6i 2. O Surgeon General's Office 0 DISEASES INFANCY AND CHILDHOOD. WEST 01 DISEASES OF INFANCY AND CHILDHOOD. Notices of the Press. In taking leave of Dr. West, we can scarcely do more than reiterate our former praise of him. We have given, we fear, but a very faint notion of the scope of his work, and of its excellent execution. It is one standing hy itself upon its important sub- ject in our language — unapproached, unrivalled. His knowledge of what others have done is equalled only by his own extensive experience ; and the re- sults of both are combined in his valuable practical lectures now offered for the guidance of others.— Brit, and For. Med.-Chirurg. Review. In conclusion we shall state that, after a careful perusal of Dr. West's work, we are convinced that it is one of the best publications ever issued upon diseases of children. Parts of it, and especially the lectures upon diseases of the respiratory organs, and some of those upon the affections of the nervous system, are deserving of the highest praise for pa- tient research, happy descriptions of symptoms, ac- curacy, and plain and sensible directions for treat- ment. The style of the author is agreeable and pleasing, and at the same time simple and perspicu- ous in a very high degree. We recommend the work to our American brethren as one which they cannot read without both pleasure and profit.— Medical Examiner. The book has about it that practical common-sense character which is always acceptable to the practi- tioner of medicine, whilst the immense experience of Dr. West, derived from his connection with the London Hospital for Sick Children, gives to him opportunities for the minute observation of the dis- eases incident to childhood, such as no private prac- tice can offer. We would especially recommend the careful study of these lectures to the medical stu- dent who is preparing himself for the general prac- tice.— Va. Med. and Surg. Journal. We must again recommend Dr. West's book as one of very high merit, and the best on the subject in the English language.—Edinburgh Medical and Surgical Journal. Every portion of these lectures is marked by a general accuracy of description, and by the sound- ness of the views set forth in relation to the pathology and therapeutics of the several maladies treated of. The lectures on the diseases of the respiratory ap- paratus, about one-third of the whole number, are particularly excellent, forming oue of the fullest and most able accounts of these affections, as they present themselves during infancy and childhood, in the English language. The history of the several forms of phthisis during these periods of existence, with their management, will be read by all with deep interest.—The American Journal of the Medi- cal Sciences. By the same Author. LECTURES ON THE DISEASES OF WOMEN. Sfoeonb %xaznfm, from t\t Staonb ITonbon ®bifton. In one neat octavo volume, of about 500 pages, extra cloth. As a sound practical treatise, based on the ex- tended experience of a close and accurate observer, whose views and acquirements are quite au niveau with the present state of medico-obstetrical science, this work is fairly entitled to the highest rank; and as such, we strongly and heartily commend it to the attention of our professional brethren.—The Dublin Quarterly Journal of Medical Science. As a writer, Dr. West stands, in our opinion, se- cond only to Watson, the "Macaulay of Medicine;" he possesses that happy faculty of clothing instruc- tion in easy garments; combining pleasure with profit, he leads his pupils, in spite of the ancient proverb, along a royal road to learning. His work is one which will not satisfy the extreme on either side, but it is one that will please the great maj ority who are seeking truth, and. one that will convince the student that he has committed himself to a can- did, safe, and valuable guide.—N. A. Med.-Chirurg. Review. We must now conclude this hastily written sketch with the confident assurance to our readers that the work will well repay perusal. The conscientious, painstaking, practical physician is apparent on every page.—N. Y. Journal of Medicine. We have to say of it, briefly and decidedly, that it is the best work on the subject in any language ; and that it stamps Dr. West as the facile princeps of British Obstetric authors.— Edinburgh Medical Journal. . We gladly recommend his lectures as in the high- est degree instructive to all who are interested in Obstetric practice.—London Lancet. We know of no treatise of the kind so complete and yet so compact.—Chicago Med. Journal. AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF .ULCERATION OF THE OS UTERI. In one small octavo volume. •'LECTURES DISEASES INFANCY AND CHILDHOOD. BY / FELLOW OF THE ROYAL COLLEGE OF PHYSICIAN'S CHARLES WEST, M. D., 3 ; PHYSICIAN TO THE HOSPITAL FOR SICK CHILDREN. FOURTH AMERICAN, FROM THE FIFTH REVISED AND ENLARGED ENGLISH EDITION. cow I PHILADELPHIA: IIEXET O. LEA. 1866. wsku PHILADELPHIA: COLLINS, PRINTER, 705 JAYNE STREET. SAMUEL STEPHENS MAELING, ESQ., OF EBLEY, NEAR STROtJD, GLOUCESTERSHIRE, THESE LECTURES ARE DEDICATED, IN ACKNOWLEDGMENT OF THE EVER ACTIVE FRIENDSHIP AND MORE THAN BROTHERLY KINDNESS WHICH HAVE MADE A LIFE-LONG DEBTOR OF HIS AFFECTIONATE KINSMAN, THE AUTHOR. 1* / PREFACE TO THE FIFTH EDITION. Twenty-six years ago the kindness of Dr. Robert Willis threw open to me the field of observation afforded by the Children's Dispensary in Lambeth, and in 1842 I succeeded him there in the office of Physician. In 1847 I gave a series of Lectures on the Diseases of Children, based on observations made at the Children's Dispensary, to the Pupils of the Middlesex Hospital; and these Lectures appeared in the " Medical Gazette" during the summer and autumn of the same year. In 1848 these Lectures were published as a distinct book; founded on the notes of 600 cases, and 180 post-mortem examinations, which I had observed at the dwellings of the poor in the district where I labored. The establishment of the Children's Hospital, in Great Ormond Street, brought me readier means of more careful observation, and the appointment within the past four years of different gentlemen to the office of Registrar, has provided for the record of cases of which want of leisure would have otherwise prevented me from preserving an account. I have thus been enabled in each successive edition to add to the preceding one, and I trust to improve upon it. The present edition embodies the results of 1,200 recorded cases, and of nearly 400 post- mortem examinations, collected from between 30,000 and 40,000 children who, during the past twenty-six years, have come under my care, either in public or in private practice. viii PREFACE. While improving, as far as I could, the substance of this book, I have not attempted to alter its form; for the fact that it has passed # through three editions in America, and through four in Germany, while it has also been translated into Danish, Dutch and Russian, and that the French translation is now in the press, may be taken as good proof that it has to a great extent met the wants of the Profession both here and abroad. A moment's satisfaction may be pardoned me in thankfully ac- knowledging these evidences that my toil has not been fruitless. But it is with no feeling of flattered vanity that I now lay down my pen. The revision in mature age of the labors of one's youth must, with most persons, minister to self-reproach rather than to self-satisfaction. The same unsolved problems meet one's eye now as met it years ago; one's deficiencies are felt more deeply; they seem graver and less ex- cusable as the time for remedying them passes by; one longs for the leisure gone, for the energies of former years, which one fancies, coupled with the soberness of advancing life, might help to add some- thing more and better to the common store of knowledge. I can for my part say most honestly, that nothing will give me greater pleasure than to see some younger man, better furnished for the task than I was, devote himself to the cultivation of that field where I have labored. No one would greet the skilled husbandman more heartily than I, nor rejoice more sincerely to see him reap, as he cannot fail to do, a most abundant harvest. CHARLES WEST. 61 Wimpole Street : June 1, 1865. CONTENTS. LECTURE PAOE I. Introductory: on the Study of Children's Diseases .... 17 II. Introductory : on the Treatment of Children's Diseases ... 27 III. Diseases of the Brain and Nervous System. General Remarks upon them, and on their Symptoms in early Life.....37 IV. Congestion of the Brain: its Causes, Symptoms, and Treatment . 45 V. Cerebral Hemorrhage, and Cephalhaematoma, or Hemorrhage ex- ternal to the Skull.........57 VI. Inflammatory Affections of the Brain. Acute Hydrocephalus: its morbid Appearances and Symptoms......69 VII. Acute Hydrocephalus, concluded : its Symptoms and Treatment . 84 VIII. Simple Inflammation of the Brain. Inflammation succeeding to Disease of the Ear. Inflammation of the Sinuses of the Dura Mater...........100 IX. Chronic Hydrocephalus . . ~ .......110 X. Hypertrophy and Atrophy of the Brain.......121 XL Hydrocephaloid Disease. Tubercle of the Brain. Hydatids and Cancer of the Brain.........130 XII. Diseases of the Spinal Cord. Irritation and Congestion. Inflam- mation of its Membranes and Substance. Trismus . . . 145 XIII. Convulsions and Spasm of the Glottis......159 XIV. Epilepsy and Chorea.........175 XV. Paralysis............198 XVI. Night Terrors. Disorders of the Mind and Idiocy .... 210 XVII. Diseases of the Respiratory Organs. General Remarks on the Re- spiratory Functions in early Life. Imperfect Expansion of the Lungs...........229 XVIII. Collapse of Lung after Birth. Induration of the Cellular Tissue . 239 X CONTENTS. LECTURE PAGE XIX. Inflammation of Respiratory Mucous Membrane. Catarrh. Coryza. Post-mortem Appearances of Bronchitis . . 250 XX. Inflammation of Substance of Lung: its Post-mortem Appear- ances. Symptoms and Treatment of Bronchitis. Influenza. 259 XXI. Pneumonia: its Symptoms and Treatment.....275 XXII. (Edema of the Lung. Gangrene of the Lung. Pleurisy, Acute and Chronic..........288 XXIII. Croup: its Varieties, Causes, Post-mortem Appearances, and Symptoms. Treatment of its early Stages .... 308 XXIV. Croup : Treatment of its advanced Stages—Tracheotomy . . 324 XXV. Diphtheria, or Angina Maligna. Laryngitis Stridula, or Croup with Predominance of Spasmodic Symptoms. Varieties of Spasmodic Cough.........334 XX VI. Hooping-cough : its Symptoms and Complications . . . 360 XXVII. Hooping-cough: its Complications, continued—Post-mortem Ap- pearances, and Treatment.......373 XXVIII. Pulmonary Phthisis: its Peculiarities, Anatomical Characters, and Symptoms in Childhood. General Symptoms of Bronchial Phthisis, and of Phthisis in early Infancy .... 390 XXIX. Phthisis, continued: its Auscultatory Signs, its different Forms, Duration and Treatment.......401 XXX. Diseases of the Heart.........417 XXXI. Diseases of Organs of Digestion and Assimilation. General Re- marks on the Diet of Infants......433 XXXII. Infantile Atrophy. Thrush. Dentition, and the Management of Children during it........445 XXXIII. Stomatitis—Follicular, Ulcerative, and Gangrenous. Cynanche Tonsillaris. Hypertrophy of the Tonsils. Retro-Pharyngeal Abscess. Cynanche Parotidea..... 453 XXXIV. Diseases of the Stomach. Indigestion. Softening of the Stomach. Hsematemesis and Melaena......, 477 XXXV. Jaundice. Constipation, and Mechanical Causes for it, as Imper- forate Anus and Intussusception .... 490 XXXVI. Diarrhoea : its Symptoms and Morbid Appearances XXXVII. Diarrhoea, continued: its Treatment, and that of its Complica- tions 506 517 XXXVIII. Peritonitis: its Acute and Chronic Forms. Tubercular Perito- nitis, Tabes Mesenterica..... c9g CONTENTS. xi LECTURE PAGE XXXIX. Intestinal AVorms. Diseases of the Urinary Organs : Albuminuria, Gravel, and Calculus. Diabetes. Incontinence of Urine . 544 XL. Abdominal Tumors. Infantile Cachexias:—Syphilis . . . 567 XLI. Infantile Cachexias:—Scrofula and Rickets.....583 XLII. Fevers: general Remarks on them. Remittent or Typhoid Fever: its Symptoms and Treatment. Intermittent Fever or Ague . 597 XLIII. Smallpox. Modified Smallpox. Chicken-pox .... 611 XLIV. Measles and Scarlatina . ... . . 621 Index to the Subjects.........641 Index to the Formulas.........655 I LECTURES 0 N T H E DISEASES OF INFANCY AND CHILDHOOD. INTRODUCTORY. On the Study of Children's Diseases.—Its difficulties, and how to overcome them.— Rules for the examination of sick children, and for taking notes of cases.—General plan and objects of the Course. Gentlemen:— It is not without hesitation that I have determined on adding another to the already numerous courses of lectures that you are called on to atteud while engaged in the study of medicine. My reasons—and I trust my justification—for so doing are furnished partly by the frequency of the diseases of infancy and childhood, partly by their fatality, but still more so by their many peculiarities. Children will form at least a third of all your patients; and so serious are their diseases, that one child in five dies within a year after birth, and one in three before the completion of the fifth year. These facts, indeed, afford conclusive arguments for enforcing on you the importance of closely watching every attack of illness that may invade the body while it is so frail; but they alone would scarcely be adequate reasons for my bringing these diseases under your notice as objects for special study. The body, however, is not only more frail in infancy than it becomes in after life, but the sympathies between its different parts are more extensive and more delicate. One organ seldom suffers alone, but the effects even of local diseases extend to the whole system, and so disorder its workings that it is often no easy matter to determine the seat of the original mischief. Nor is this all; but many important consequences result from the period of childhood, being one of un- ceasing development. In the adult the structure of the body is com- plete, and its functions are the same to-day as they were yesterday: but the child learns successively to breathe, to feel, to think; and its body is daily undergoing modifications to fit it for new duties, as well as daily growing in size and strength. Disease, therefore, not merely disturbs the present, but its influence reaches to the future ; it not only interrupts the present function of the organ that is affected, but 18 PECULIARITIES of the diseases of childken. it puts a stop for a time to the completion of the general machinery of the body, or disarranges the due proportion of one part of that machinery to another. Moreover, there are periods, namely, those of the first and second dentition, when very great changes take place in the organism of the child, and when all these dangers are especially to be feared. Disease is then frequent and serious beyond what it is at other times, and every ailment then warrants a double measure of anxiety; while, on the other hand, if these epochs are safely passed, there succeeds a season of comparative immunity from many affections that before were both common and perilous. But, if this be so, you will at once perceive that something more is essential to the successful treatment of children's diseases than to watch their advances carefully, and to adapt the strength and doses of your remedies to the tender years of your patients. It is not mere hyperbole to say that you have to study a new semeiology, to learn a new pathology and new therapeutics. Matters of such importance cannot be properly examined at the end of a course of lectures on midwifery. I have therefore preferred making them the subjects of separate consideration during the summer, when the comparative leisure of the season will, I hope, enable you to devote some of your time to the practical as well as the theoretical study of the diseases of children. I must warn you, however, of one difficulty which you will encounter at the very outset—a difficulty that disheartens many, and makes them abandon in despair the study of children's diseases. Your old means of investigating disease will here, to a great degree, fail you, and you will feel almost as if you had to learn your alphabet again, or as if, entering a country whose inhabitants you expected to find speaking the same language and having the same manners as the people in the land you had lately left, you were to hear around you everywhere the sounds of a foreign tongue, and to observe manners and customs such as you had never seen before. You cannot question your patient; or, if old enough to speak, still, through fear, or from comprehending you imperfectly, he will probably give you an incorrect reply. You try to gather information from the expression of his coun- tenance, but the child is fretful, and will not bear to be looked at; you endeavor to feel his pulse, he struggles in alarm; you try to aus- cultate his chest, and he breaks out into a violent fit of crying. Some practitioners never surmount these difficulties, and the dis- eases of children are consequently a sealed book to them. After a time they grow satisfied with their ignorance, and will then with the greatest gravity assure you that the attempt to understand these affec- tions is useless. They have fallen into this unfortunate error from not taking the pains to start aright; they have never learned how to interrogate their little patients, and hence they have never received satisfactory replies. I speak of interrogating them; for though the infant cannot talk, it has yet a language of its own, and this language it must be your first object to learn, if you mean ever to acquire the character of successful practitioners in the diseases of children. But, if you have not cultivated your faculties of observation, you cannot EXAMINATION OF SICK CHILDREN. 19 learn it, for it is a language of signs, and these signs are such as will escape the notice of the careless; if you are not fond of little children, you cannot learn it, for they soon make up their minds as to who loves them, and when ill they will express their real feelings, whether by words or signs, to no one else. There is, moreover, a certain tact necessary for successfully investi- gating the diseases of children. If, when summoned to a sick child, you enter the room abruptly, and, going at once to your patient, you begin to look closely at it, while at the same time you question the mother or nurse about its ailments in your ordinary pitch of voice, the child, to whom you are a perfect stranger, will be frightened, and will begin to cry; its pulse and respiration will be hurried, its face will grow flushed, and you will thus have lost the opportunity of ac- quainting yourself with its real condition in many respects. Besides this, the child's alarm, once excited, will not subside so long as you are present; if you want to see its tongue, or auscultate its chest, its terrors will be renewed, and it will scream violently ; you will leave the room little wiser than you entered it, and, very likely, fully con- vinced that it is impossible to make out children's diseases. Very different would be the result if you conducted this examina- tion properly; and though, I believe, where there is real love for children, the tact necessary for examining into their ailments will not be long in being acquired, still a few hints on this subject may not be out of place in an introductory lecture. The quiet manner and the gentle voice which all who have been ill know how to value in their attendants, are especially needed when the patient is a child. Your first object must be, not to alarm it; if you succeed in avoiding this danger, it will not be long before you acquire its confidence. Do not, therefore, on entering the room, go at once close up to the child; but, sitting down sufficiently near to watch it, and yet so far off' as not to attract its attention, put a few questions to its attendant. While doing this, you may, without seeming to notice it, acquire a great deal of important information; you may observe the expression of the face, the nature of the respiration, whether slow or frequent, regular or unequal; and if the child utter any sound, you may attend to the character of its cry. All your ob- servations must be made without staring the child in the face; little children, especially if ill, seem always disturbed by this, and will be almost sure to cry. If the child be asleep at the time of your visit, your observations may be more minute; the kind of sleep should be noticed, whether quiet or disturbed, whether the eyes are perfectly closed during it, or partly open, as they are in many cases where the nervous system is disordered; you may, too, if the sleep seem sound, venture to count the frequency of the respiration and the beat of the pulse, but in doing this you should be careful not to arouse the child. It should be awakened gently by the nurse or mother, and a strange face should not be the first to meet its eye on awaking. If it were awake when you entered the room, it will probably in a few minutes have grown accustomed to your presence, and will allow you to touch its hand and feel its pulse. This must always be done at as early a 20 EXAMINATION OF SICK CHILDREN. period in your visit as possible, in order that }7ou may count it while the child is undisturbed, since the pulsations of the heart vary, in young children, as much as twenty in a minute under comparatively slight disturbing causes; and any inferences that you might draw from the pulse of the child, when frightened or excited, would almost certainly be erroneous. Besides the pulse, the frequency of the respi- ration should, if possible, be noticed, since the results obtained by a comparison of the two are always more valuable than those of either taken alone. But if this be your first visit to the child, do not, for the sake of ascertaining either of these points exactly, persevere in attempts which irritate or frighten it; probably you would, after all, be unsuccessful; and even though you were to succeed, the knowledge would not repay you for the loss of the child's confidence, which it must be your grand object to acquire and to keep. With management and gentleness, however, you will comparatively seldom fail; and while you are feeling the pulse, or with the hand on the abdomen are counting the frequency of the inspirations, you will also learn the temperature of the body and the condition of the skin. Supposing your examination has thus far been pretty well borne, you may now, probably, venture to talk to the child, or to show it some- thing to amuse it—as your watch or stethoscope; and while thus test- ing the state of its mental powers, you may pass your hand over the head, and note the state of the fontanelle, and the presence or absence of heat of the scalp. The examination of the state of the abdomen, though too important to allow of its ever being omitted, will often lead to no satisfactory result unless carefully managed. If you allow the nurse to change the child's posture and to lay it back in her lap, in order that you may pass your hand over its stomach, the child will often be alarmed, and begin to cry. Its abdomen then becomes perfectly tense, and you cannot tell whether pressure on it causes pain, or whether the cries are not altogether the cousequence of fear. It is therefore the best plan to pass your hand beneath the child's clothes, and to examine the abdomen without altering its posture, while, at the same time, the nurse talks to it to distract its attention, or holds it opposite the window, or a bright light, which seldom fails to amuse an infant. If there be no tenderness of the abdomen, the child will not cry on pres- sure; or if, during your examination, the presence of flatus in the intestines should occasion pain, gentle friction, instead .of increasing suffering, will give relief. You must next examine the chest: and for this purpose immediate auscultation is always to be preferred, since the pressure of the stetho- scope generally annoys the child. If the child be not in its bedgown, it will usually be your best course to have the back of its dress un- done, and then, while it is seated in its mother's or nurse's lap, to kneel down behind it, and apply your ear to its chest. In all acute diseases of the lungs in infancy, the condition of their posterior part is a sure index to the extent of the mischief from which they are suffering; for, owing to the infant passing so much of its time in the horizontal position, the blood naturally gravitates towards the back EXAMINATION OF SICK CHILDREN. 21 of the lungs, and the secretions are much more likely to accumulate in the bronchi in that situation than elsewhere: hence, if air be heard permeating the lungs throughout the whole posterior part of the chest, and unaccompanied with any considerable amount of crepitation, it may fairly be inferred that their front parts are free from serious dis- ease, even though you should be unable to ascertain the fact by actual observation. When you have listened thoroughly to the back of the chest, you may next percuss it. You must not percuss first and' listen after- wards, as you often do in the adult; for even when practised with the greatest gentleness, percussion sometimes frets the child, and makes it cry, whereby any subsequent attempt to listen to the breathing will often be rendered unsuccessful. But you must not neglect percussion : it is of peculiar value in childhood, since auscultation is then un- avoidably incomplete in many instances, sometimes quite impractic- able. In practising it, however, there are some rules without attention to which you will very likely fail of acquiring any information what- ever. You must never, in the child, attempt to percuss the walls of the chest immediately, but should strike on your finger, and even then very gently. The chest of the child is so resonant, that, if you percuss smartly, you will fail to perceive the finer variations in sonoriety which would be readily appreciable on gentle percussion. Always compare the results obtained by percussing opposite sides of the chest, since otherwise you may overlook a very considerable degree of dul- ness. It often happens, too, that the lower lobes of both lungs are involved nearly equally; you must therefore notice the resonance of the lower as compared with that of the upper part of the chest. Some- times you are compelled, by the fretfulness of the child, or by the tenderness of the walls of its chest, to percuss so gently as scarcely to elicit any sound. It is of importance, therefore, to attend to the sensa- tion of solidity communicated to the finger, as well as to the sound of dulness that falls upon the ear, since, if your sense of touch be delicate, it will correct or confirm the evidence of hearing. Having thus examined the back of the chest, you may, if the child be likely to tolerate it, try to listen at its sides, and then in front. You can, however, scarcely auscultate the front of the chest in infancy without a stethoscope, and this you will very seldom be able to use; for, if the child be not frightened, it will probably be so exceedingly amused at what it regards as specially intended for its own diversion, that it will join in the game, and disconcert you by playing with the instrument. You will encounter this difficulty in cases of phthisis in early childhood, and will often find it no easy matter to ascertain the character of the respiration in the front of the chest. In such cases you will learn all the value of percussion, which may be practised over the front of the chest as well as the back, while the state of the breathing in the upper and back part of the chest will generally be a correct index to its condition in front. Your examination of the chest will not be complete until you have noticed the character of the breathing, whether the whole of the chest is expanded by it, or whether the respiration is merely abdominal— 22 EXAMINATION OF SICK CHILDREN. whether the child breathes as deeply as it should, or whether it makes frequent short inspirations which cannot fill the smaller bronchi. The time for ascertaining these points must vary in each case; but the earlier they are observed the better, since otherwise you run the risk of drawing your inferences, not from the child's ordinary condition, but from its state when excited and alarmed. Some of these points may be noticed though the child be so fretful that you cannot auscul- tate even the back of its chest satisfactorily. An imperfect ausculta- tion, however, is better than none; for at the very worst, during the deep inspirations that are made at intervals in a fit of crying, you may ascertain how far the lungs are permeable to air, and whether the bronchi are much loaded with mucus. Independently of auscul- tation, too, much may be learned from the cry. If its two periods be clearly marked—the long, loud cry of expiration, and the shorter, less loud, but perfectly distinct sound that attends inspiration—you may feel convinced that there exists no important ailment of the respi- ratory organs. It will still remain for you to examine the tongue, and to ascertain the condition of the gums; and it is wise to defer this to the last, since it is usually the most grievous part of your visit to the child. If dur- ing any part of your previous examination it had cried, you might seize that opportunity to look at its tongue, and, if necessary, to pass your finger over the gums; thus sparing it any further distress about the matter. If you had not this opportunity, you will generally get a good view of the mouth and throat in young infants by gently touch- ing the lips with your finger; the child opens its mouth instinctively, and then you can run your finger quickly over its tongue, and down towards the pharynx, and thus secure a perfect view of the mouth and throat. With older children a good deal of coaxing is sometimes necessary to persuade them to open their mouth: but, if once you get your finger on the gum, you can usually keep them quiet by rubbing it, and by a little address will then seldom fail in opening the mouth wide enough to get a view of the tongue. If little children be very ill, all this minute care in the order of your examination is not so much needed, because they will not notice so quickly; but gentleness of tone and manner will be even more necessary to soothe the pettishness and quiet the alarm of the little sufferer. Many of the directions that I have just given you refer to the ex- amination of infants, and become less applicable in proportion to the greater age of the patient. Minute rules for your examination of children from three years old and upwards are not needed; but patience the most untiring, and good temper the most unruffled, are indispensable. The previous history of a patient, the circumstances in which his present illness came on, and the symptoms that at first attended it, often help to remove our doubts with reference to the nature of a dis- ease, and sometimes greatly modify our diagnosis and influence our plan of treatment. Eeally trustworthy information on these points, however, is often difficult to be obtained, and the attempt to elicit it CASE-TAKING. 23 is almost sure to be unsuccessful, if the questions put to the patient are proposed at random, and without some previously well-digested plan on the part of the physician. One great object of clinical in- struction is to teach the student so to conduct this as well as other parts of his examination of the sick, as to throw from every source the greatest possible amount of light upon the nature of the disease, and thus fit himself to decide with some approach to certainty on the means most likely to effect its cure. Such instruction has been amply afforded you in the wards of the hospital; but you must allow me to detain you while I point out the subjects towards which your inquiries must be especially directed in the case of children, since they differ in many respects from the questions that you would propose if your patient were an adult. We will suppose, if you please, that a child is brought to you of whose case you wish to preserve a record. Its name, age, sex, and residence will form of course the first entry in your note-book; but your next inquiries should be as to the number of living children that the parents have had, whether any of those children have died, and, if so, at what age, and of what diseases, and as to the health of both parents, and of their immediate relatives. The object of these questions is to ascertain whether there exists any hereditary tendency to disease in the family, since that plays a most important part in many of the affections of childhood, and symptoms that in the child of healthy parents would cause you but little uneasiness, would at once excite serious alarm if you knew that some members of the family had died of hydrocephalus, or of consumption, or had been the subjects of scrofula. Many of the most serious affections of childhood occur within the period of a few years, and after a certain age are comparatively rare in their occurrence, and generally mild in their character. It is there- fore very desirable, when any ailment is coming on, the nature of which is not yet quite apparent, to know which of the diseases inci- dental to childhood have already affected your patient. With this view you would ask whether the child has been vaccinated, or has had the smallpox, and whether it has passed through any other of those affections—such as chicken-pox, hooping-cough, measles, or scarlatina—which generally come on in early life. If the child had suffered from any other disease, you should learn its nature, the age at which it occurred, and any other point of importance connected with it. In writing out your history of the case, these preliminary matters would naturally be mentioned at the beginning; and though you would not follow any very strict order in proposing your questions, yet it is always desirable to obtain information on these points at an early stage of your examination, since it may guide you in some of the questions that you afterwards propose, or may lead you to pay particular attention to symptoms which otherwise would not seem to be of much moment. Besides, if you postpone these inquiries till you have nearly completed your examination of the patient, the parents will probably apprehend that they are suggested by some doubt and 24: CASE-TAKING. apprehension in your mind as to the nature of the case, and will dis- tress themselves by causeless fears, or perhaps disconcert you by questions to which you are not prepared to return a positive answer. There are two other points which bear on the general condition of the child, to one or both of which your inquiries must, in many in- stances, be directed. If your patient be an infant at the breast, you must learn whether it lives entirely on its mother's milk, or has other food besides. If it has been weaned, you must ask its age at weaning; whether it was taken from the breast on account of any failure in its own health or its mother's, and on what diet it has since been fed. The process of dentition is the other subject for examination; and, in reference to it, you must ascertain how many teeth the child has, and which they are—whether they were cut easily or with difficulty, the age at which teething commenced, and the time that has elapsed since any fresh teeth appeared. You may now endeavor to obtain a clear and connected history of the present illness; and for this purpose it is well to begin with asking, When did the child last seem quite well? since you thus get a fixed starting-point, from which you can make the mother or nurse set out in her detail of symptoms. The date thus assigned, indeed, will often be a wrong one, the disease having begun before with some symptom that was not noticed, or its real origin having been considerably sub- sequent to its supposed commencement. But, notwithstanding this possible error, you derive much advantage from thus making sure of the symptoms being told you in something like their chronological order, since otherwise it is very likely that those only would be men- tioned which had chanced to strike the mind of the mother or nurse, while the others would be passed over in silence. Your object in the examination must not be to curtail the garrulity of the nurse, or to suppress the mother's expression of her sometimes imaginary fears, but to get as clear an account as possible of everything that has been observed. You must be careful not to underrate the value of the information they communicate, or even of the opinions they express. Both are much more likely to be correct when your patients are children, than when they are adults. A mother hanging over her sick infant, or a nurse watching the child she has helped to rear from babyhood, may sometimes see dangers that have no existence, but will generally be the first to perceive the approach of such as are real. You see the child but for a few minutes, and at distant intervals, and the excitement or alarm which your presence is so likely to occasion may greatly modify its condition during your visit. They tend the little one by day and night, notice each movement, and seize the most transient variations in its expression. I need not say much concerning the necessity of inquiring about the appetite or thirst, the state of the bowels, and the appearance of the evacuations; for these are points which you would investigate in patients of every age. I will just mention, however, that the deoree of appetite and thirst cannot be so readily determined in the infant as they may be in the adult, or even in the weaned child; for an infant may suck, not because it is hungry, but in order to quench its thirst. PROPOSED PLAN OF THE LECTURES. 25 That extreme craving for the breast, which is appeased only so long as the child is sucking, while the milk swallowed is speedily vomited, may be taken as a sign of thirst; but it is always better to record the fact than the inference. It is likewise often desirable to let the infant be put to the breast in your presence, not only for the sake of observing the above-mentioned facts, but also in order to notice the vigor with which it sucks, the ease or difficulty with which it swallows, and other similar points from which very important conclusions may often be drawn. Before you venture on drawing any inferences from the state of the child at the time of your visit, you should ascertain whether it has just before been taking food, or has been recently excited or fatigued by being washed or dressed; since comparatively trivial causes are sufficient to accelerate the pulse and respiration, and to give rise to changes which might, if unexplained, lead you to very erroneous con- clusions. Any such circumstances ought of course to be mentioned in your notes, as should also the fact of the child being asleep at the time of your visit, since that would explain even a very considerable diminution in the frequency of the pulse and respiration. But if you are carefully to observe all the points which I have mentioned, and to make yourselves thoroughly masters of a case, you must be most lavish of your time; you must be content to turn aside from the direct course of investigation, which you would pursue unin- terruptedly in the adult, in order to soothe the waywardness of the child, to quiet its fears, or even to cheat it into good humor by joining in its play; and you must be ready to do this, not the first time only, but every time that you visit the child, and must try to win its affec- tions in order to cure its disease. If you fail in the former, you will often be foiled in your attempts at the latter. Nor is this all: you must visit your patient very often, if the disease be serious in its nature and rapid in its course. New symptoms succeed each other in infancy and childhood with great rapidity; complications occur that call for some change in your treatment, or the vital powers falter suddenly, when you least expect it. The issues of life and death often hang on the immediate adoption of a certain plan of treatment, or on its timely discontinuance. Do not wait, therefore, for symptoms of great urgency before you visit a child three or four times a day; but if the disease be one in which changes are likely to take place rapidly, be frequent in your visits as well as watchful in your obser- vation. You will naturally think, that before I finish this lecture I should tell you something definite about the subjects that I mean to bring before your notice, and the manner in which I propose to treat them. The title of these lectures can, I should think, scarcely need any explanation, for by the diseases of infancy and childhood you will naturally understand all those affections which are either limited in the time of their occurrence to early life, or which, though incidental to all ages, yet in the child present many peculiarities in their symp- toms, and require many important modifications in their treatment. Some of these diseases, indeed, are usually allotted to the care of the 26 PROPOSED PLAN OF THE LECTURES. surgeon, and on their examination I will not enter, since I could tell you nothing more than has already been better said by others. They, however, are but few in number, and most of them are purely local affections; so that these omissions will not be many, and most of them not important. In the description of the diseases of children, no practically useful end would be attained by following any elaborate nosological system. I shall therefore adopt the most simple classification possible, and shall treat in succession of the diseases of the nervous system, of the respiratory and circulatory, and of the digestive systems and their appendages. There will still remain one very important class of affections, namely, fevers; and these I propose to consider last of all, because much of their danger arises from their complications, and to treat them judiciously you must be familiar with the diseases of the brain, the lungs, and the bowels. In this plan it will be easy to detect a want, perhaps too great a want, of scientific arrangement; but the one object of my endeavors will be to communicate to you, as clearly as I can, such information as may be most useful to you in the dis- charge of your daily duties. With this view I have, while composing these lectures, tried to think over the doubts I felt, the difficulties I met with, and the errors I fell into, when, now many years ago, I entered on the office of phy- sician to a large institution for the treatment of children's diseases. I have presumed that where I had encountered difficulties, there you might meet them too—that where I had made mistakes, there you would need a guide—and remembering the many anxious hours I passed when I hesitatingly adopted some course which I feared might after all be a mistaken one, it has been my aim to lay down, not only the rules for the diagnosis, but also the indications for the treatment of each disease as minutely as possible. To the task before me I now apply myself, with a deep conviction of the narrow limits of my own knowledge, but still feeling that I have contracted an obligation to impart to others what I trust experi- ence has taught me. My end will be answered, if you learn it at an easier rate than I did, and if I can be the means of saving you from some of those errors in diagnosis, and some of those mistakes in treat- ment, which, for want of some one to guide me aright, I committed. RULES FOR DEPLETION IN CHILDREN. 27 LECTURE II. INTRODUCTORY. On the Treatment of Children's Diseases.—Influence of remedies modified by the age of the patient.—Rules for the practice of depletion, for the use of mercury, antimony, and opium, and for the employment of blisters. Suggestions as to the mode of prescribing for infants and children. In the introductory lecture, I tried to point out the main peculi- arities which distinguish the diseases of early life, and to furnish you with some general rules for their investigation. It may not be time misspent if, before we begin the examination of any special class of ailments, I endeavor to give you a few general directions for their treat- ment, though in so doing I must of necessity anticipate some things which will require notice hereafter, and must occasionally presuppose the possession of that knowledge which it is the main object of these lectures to impart. The importance of great exactness in prescribing for infants and children, and the necessity for regulating the doses of our remedies according to the tender years of our patients, are self-evident. Poso- logical tables, as they are termed, are, however, of very little value for our guidance, since the susceptibility of the young to the action of differ- ent remedies varies greatly according to their nature, so that the rule which safely defines the dose of an opiate would be altogether inappli- cable as determining the strength of a purgative or of an emetic. The abstraction of blood, the use of emetics and purgatives, the employment of antiphlogistics, and the administration of sedatives are the great weapons with which we endeavor to combat the advances of acute disease. The safe use of each of these in early life implies the observance of certain precautions which I will now attempt to ex- plain, and will then try to furnish you with a few general directions that may be of service in prescribing for infants and children. The early age of our patients imposes of necessity some restriction on the mode in which depletion can be practised; for venesection in the arm is hardly ever possible before the age of three years, often not till later, in consequence both of the small size of the veins, and of the quantity of fat in which they are imbedded. In cases of ex- treme urgency the jugular vein may be opened, and I have never found any difficulty in the operation, though I believe the necessity for the proceeding very seldom arises, and the only instances in which I have had recourse to it were either instances of violent convulsions succeeded by profound coma, or else of very acute inflammatory croup. For almost all purposes of depletion in early life we are dependent on the use of leeches, and by this means, if rightly managed, we may 28 RULES FOR DEPLETION attain nearly all the ends of general bleeding. The great objection to the employment of leeches rests on the difficulty of estimating and of controlling the quantity of blood abstracted by them. This objec- tion, however, applies almost entirely to the common practice of put- ting on a comparatively small number of leeches, and trusting to the application of a poultice, or the employment of fomentations, for obtaining a sufficient quantity of blood. Instead of adopting this plan, than which nothing can be more uncertain, it is far better to apply a larger number of leeches and to allow of no subsequent bleed- ing. It may then be calculated that each leech takes about two drachms of blood, and we are thus enabled to estimate the quantity removed with a certainty little less than we are possessed of, if we employ venesection, while, further, the blood is removed in the course of fifteen or twenty minutes, instead of draining away, as in the other case, for six or eight hours, weakening the patient, and yet exercising comparatively small influence on the disease. To insure certainty and safety, however, in the employment of leeches, there are several precautions which must not be neglected. Of these, the most important is, that their application should not be left to a nurse, but that, wherever it is at all practicable, the medical attendant should himself superintend it. This is of special moment in all acute diseases in which it is desired to obtain by local bleeding the constitutional effects of general depletion, since, according to the result produced, it may, on the one hand, be desirable to put on a larger number, or, on the other, to remove some before they have completely filled themselves. The effects produced by the loss of blood often influences the character of the subsequent treatment. On this account, therefore, as well as with the view of lessening the risk of hemorrhage going on from the leech-bites unperceived, it is desira- ble to apply leeches by day, not towards evening, or at bedtime, as is commonly the practice. Attention should further always be paid to apply leeches in situations where they will not alarm the child by being within his sight, and where, also, there is a firm surface beneath against which pressure can be made, so as readily to control the bleed- ing. Behind the ears, therefore, or on the vertex, are the best situa- tions for applying leeches to the head, and under the scapulas when it is necessary to deplete from the chest; while, in many abdominal affections, all the advantages of local bleeding may be most safely obtained by the application of leeches to the anus. The above rules apply to the mode of practising depletion in early life; but, independently of the mere manner of drawing blood, there are some still more important cautions which have reference to the general principles which should govern us in resorting to depletion at all. 1st. It should be remembered that large losses of blood are worse borne by the child than by the adult; that if syncope is produced, its effects do not pass away so speedily, but leave a much more abid- ing depression. 2d. That the shock consequent on large losses of blood, shows itself, not merel/ by causing syncope, but also, not very seldom, by AND EMPLOYMENT OF MERCURY. 29 producing convulsions; and such convulsions are specially apt to be excited in cases where the previous disorder of the nervous system was considerable, even though that disorder depended on congestion of the brain which called for depletion to relieve it. It seems as if in these cases, just as in some of comparatively slight disease of the heart, if the equilibrium of the circulation is suddenly disturbed, it altogether fails to recover itself. A child of ten months old was brought to me many years ago with symptoms of cerebral congestion—a hot head, a raised fontanelle, a burning skin, and twitchings of the tendons of the arms and legs. I ordered leeches to the head, which drew freely; but the convulsions, which it was hoped they would ward off, occurred while the bleeding was still going on, and the child sank at once into a state of coma, from which it never rallied completely, and died in the course of forty-eight hours. Now, in this case, the abstraction of blood was indicated, and the appearances discovered after death showed that the depletion had not been excessive. It had, however, been too sudden ; and probably, bad I been present when the leeches were applied, I should have noticed some change in the child's condition which would have warned me to put a stop to further bleeding, and might thus have led to an entirely different result. In proportion, therefore, to the youth of our patient, must be our caution in ordering free depletion, and our care in watching its effects; and these must both be greater when marked disorder of the nervous system forms the indication for our treatment. 3d. Not only are very large losses of blood hazardous, and great shock by its too sudden abstraction also attended with danger in early infancy, but repeated bleedings are also inexpedient. The system rallies from them with proportionately far greater difficulty than in the adult, and that peculiar class of symptoms, by which exhaustion is apt to simulate congestion of the brain, is specially likely to be induced. It may be added that, to a considerable degree, the same caution holds good with reference to all other antiphlogistic remedies; that free purgation, spare diet, and depressing measures of all kinds, though often requisite, yet require most heedful watching, and gene- rally need to be soon discontinued. Among antiphlogistic remedies, the two which in the child, as in the adult, are of the greatest value and of the most general application in the treatment of acute inflammatory diseases, are antimony and preparations of mercury. Both, however, are not infrequently used in cases where they are either not needed, or are positively injurious. The peculiar influence of mercury is exerted too slowly to control the first rapid advance of some acute diseases, such as croup and pneu- monia, though in both after previous depletion, and the administration of antimony, mercury often proves most serviceable. In those forms of pulmonary inflammation, also, which sometimes occur in compara- tively weakly subjects, or in which the disease has already advanced unchecked so far as to produce consolidation of the lungs, it is on mercury that our chief reliance must be placed. Mercury, too, is our great stay in all cases of acute inflammation of the serous membranes of the chest and abdomen ; and in severe inflammation of the mucous 30 RULES FOR EMPLOYMENT OF MERCURY membrane of the large intestine, or dysentery, the disease often admits of control by no other means than by the conjoint employment of calomel and opium. In cachectic diseases its utility is far more limited. The earlier symptoms of congenital syphilis yield rapidly to the employment of small doses of mercury; but the tertiary results of the disease are often aggravated, very seldom indeed benefited, by that medicine. In the majority of disorders connected with the tubercular diathesis, mercurials are not beneficial; and in tubercular hydrocephalus in particular, in which they are so often given, I never saw even momen- tary improvement from them, apart from their occasional action as purgatives. It must, however, be confessed that, in their powerless- ness to control this disease, they do but stand on the same footing with all other medicines. There is one class of ailments, too, con- nected with tuberculosis in which the action of mercury is almost uniformly beneficial; and that is tubercular peritonitis, and those vague disorders of the functions of nutrition so commonly referred to disease of the mesenteric glands. In administering mercury to infants and young children, it must be borne in mind that evidence of the system being affected by it is seldom afforded, as in the adult, by the occurrence of salivation. So rare, indeed, is mercurial stomatitis in early life, that I have seen but one instance in which it proved fatal, and have very seldom met with it in such a degree as to be troublesome. I should therefore re- gard the production of gangrene of the mouth by the administration of mercury, as an evidence of some rare idiosyncrasy on the part of the patient, rather than of want of due care on that of the doctor. In early life, mercury, instead of affecting the mouth, usually acts very speedily as an irritant on the intestinal canal; and the green stools, which are often looked on with satisfaction as a proof of the system being brought under the influence of the medicine, are far from always having that meauiug. They prove its action as a local irritant—a result which may be most undesirable, and which often compels us to diminish its dose, sometimes even completely to suspend its admin- istration. Sometimes, too, calomel acts as an irritant on the mucous membrane of the stomach, producing nausea and vomiting, and giving rise to so great a degree of depression as to necessitate its discontinu- ance. Besides its use in those more formidable diseases to which reference has hitherto been made, mercury is also often employed as a purgative and alterative. There is no doubt but that used with either of these objects it is a remedy of great value, and the objection to its employ- ment is, not that it fails to accomplish these ends, but that it answers them at a greater expense of constitutional power than was necessary. Rhubarb, soda, the mineral acids, aloetic preparations, taraxacum, and other remedies, exert an alterative power over the secretions, without any of that depressing influence which attends the use of mercurials. In the same manner, there are many purgatives no less certain, and no less speedy in exciting the action of the bowels; so that, before prescribing calomel or gray powder, the practitioner ought AND ANTIMONY. 31 to be satisfied that there is some special end, in producing an increased secretion of bile, in controlling an excited state of the circulation, or in rapidly modifying the condition of the intestinal mucous mem- brane, which no other remedy would attain, or at any rate would not attain so certainly or so quickly. A second remedy of great value in early life is antimony, though one which also is not unfrequently misapplied. It is not as a simple emetic that antimony ought to be employed ; for, unlike ipecacuanha, its influence is not confined to inducing vomiting, but it also exerts a most powerful depressing action on the circulation, and is therefore specially indicated in acute inflammation of the lungs and air-tubes. When the object is merely to empty the stomach, to produce that revulsion which follows the operation of an emetic, and which leads us often to prescribe it at the onset of a febrile attack for the sake of the moist skin and tranquil pulse which seldom fail to succeed its ope- ration ; or when we seek simply to free the bronchi from the secretions poured into them in too great abundance, as in catarrh or in simple hooping-cough ; every end is answered by the use of ipecacuanha. On the other hand, in the onset of croup, in the early stage of acute pneu- monia or of capillary bronchitis, when disease is advancing every hour, and when its advance directly threatens life, antimony is the only medicine sufficiently speedy and sufficiently powerful in its action to keep pace with the advances of the disease, and to hold it in check. Even in these cases, however, the administration of antimony needs care, and after tolerance of it has been established we cannot, so safely as in the adult, continue its use. I shall hereafter have to explain to you the liability to collapse of the lung in early life, when feeble in- spiratory power is associated with the presence of secretion in the #ir- tubes. In this state the pulmonary tissue tends by its own elasticity to exclude the air from the air-vesicles; and, if the muscular power be reduced below a certain point, the patient's efforts fail to dilate them, and by degrees more and more of the lung becomes dense, un- aerated, and as useless, for the time, for all purposes of respiration, as if it had been solidified by inflammation or compressed by fluid. This danger is always to be borne in mind in the pulmonary affections of early"life, and the vigor of the patient's powers must be the measure of our treatment, as much as the urgency of the disease. As a mere diaphoretic, antimony, when administered in small doses, is as useful in the case of the child as in that of the adult. I am not fond of Us use, however, as an antiphlogistic in ordinary febrile af- fections; for the nausea which it is apt to produce may obscure the approach of cerebral mischief, or lead to an erroneous interpretation of the symptoms. A third great remedy in the diseases of early life is opium in its various preparations; and with it may be classed, though separated by a wide interval, other sedatives, such as hemlock, henbane, hop, and lettuce. Perhaps no remedies are so often needed in the diseases of early life as sedatives, for at no other age is the nervous system so easily disturbed. At the same time, the susceptibility to the action of narcotics and sedatives is so remarkable, and the evils which result 32 RULES FOR USE OF OPIUM from their unnecessary employment or from their administration in excessive doses are so serious, that some practitioners altogether ab- stain from their use. To do so, however, is to deprive ourselves of one of the most important classes of remedies, and of one for which no substitute can be devised. The danger which especially attends the use of opium arises partly from the employment of uncertain preparations, such as the syrup of poppies; partly from the administration of over-doses, or from their too frequent repetition: of which two errors, the latter is more fre- quently committed. In prescribing for children, preparations of defi- nite strength should always be used, as the compound tincture of camphor, tincture of opium, or Dover's powder. The weaker prepa- ration, the compound tincture of camphor, is often preferable to laud- anum, since a slight error in dispensing is of so much less moment. Sometimes the comparative tastelessness of laudanum renders it the more suitable; but if so, even though only a single dose is needed, it is wiser in the case of infants to order a mixture containing two or three doses, in order to lessen the risks of error. But mischief is more frequently done by the frequent repetition of opium than by the im- proper prescription of over-doses; and I am always averse to the common practice of giving small quantities of opium at short intervals, for the purpose of checking diarrhoea, or of soothing restlessness in young infants; and prefer, unless there be some strong reason to the contrary, to give a larger dose of the remedy once or twice in the twenty-four hours. In addition to these general precautions with reference to the mode of administering opium, special care is needed in its employment in some conditions. It must be given charily in all cases where the system has been exhausted by the previous disease or by the previous treatment; and this caution must be particularly borne in mind during convalescence from fever, where yet the patient's restlessness not seldom requires its employment. In all cases of cerebral excitement the use of opium calls for great watchfulness; sometimes it must be given rather as an experiment whereby the real nature of the disease is tested, and when so employed its results must be scrutinized with the most anxious care. In severe diarrhoea, too, the transition from a state of excitability of the nervous system to a condition of coma is often very rapid in its occurrence; an over-dose of opium may hasten or induce this catastrophe, or, even though it should not have this result, yet, without great care, we shall be at a loss to determine how far the disease, and how far the medicine has induced the symptoms. In mere restlessness, unattended by severe pain, other sedatives are often preferable to opium: thus, for instance, the feverish disquietude of a child during teething is often soothed by henbane, while that which manifests itself by a disposition to carpopedal contraction and to spasm of the glottis is mitigated by small doses of hydrocyanic acid and chloric ether as effectually as by opiates, and with far greater safety. The difficulties in the administration of internal remedies in early life have had no small share in leading practitioners to the employment AND APPLICATION OF BLISTERS. 33 of outward applications with much greater frequency than in the adult. Fomentations, poultices, and liniments of various kinds re- lieve pain, abate spasm, or serve as useful counter-irritants, in very many cases which I need not now occupy your time in specifying. But, besides these, blisters are also much used in different inflammatory affections, more particularly in those of the lungs, and air-tubes, though I think their application is more restricted and is resorted to with greater caution now than formerly; and I see far"fewer instances of unhealthy ulceration of blistered surfaces among the children of the poor now, than came under my notice fifteen or twenty years ago. In applying blisters to iufants and young children, it must be borne in mind, not only that they vesicate more speedily than in the adult, but that the vesicated surface is apt, especially in some diseases, to pass into a state of ulceration; and, further, that the amount of con- stitutional disturbance produced by blisters is considerable in propor- tion to the youth of the patient. The ordinary rule, which prescribes four hours as the longest time during which a blister should be allowed to remain on the skin in infancy, is on the whole a good one, but it must be remembered that some parts of the surface are far more sensitive than others. Thus, for instance, the skin on the front of the chest is peculiarly delicate, and a blister applied there for two hours would almost certainly vesi- cate, while it might not produce the same effect in double the time if applied beneath the scapulae. On the other hand, the scalp is re- markably deficient in sensitiveness, and a blister may be allowed to remain on it for eight hours without any risk of mischief ensuing. There are, moreover, some diseases which increase the susceptibility of the skin to the action of irritants: thus, for instance, in all the ailments which accompany or succeed to measles, and especially in the pneumonia which often complicates it, a vesicated surface is apt to pass into a state of dangerous ulceration. Nor is this the only hazard which attends their use; but the constitutional disturbance which they produce, the pain while they are drawing, the soreness of the surface while they are being dressed, and the itching and irritation which accompany their healing, often keep up an amount of restless- ness, and a state of feverish irritation, that are in every way prejudicial to the child's recovery. On these accounts, therefore, I have almost entirely abandoned the use of blisters in infancy and early childhood, and am always most careful that no extensively abraded surface shall be left by their application. Partly with this object, and partly in order to avoid the inconvenience of the blister being dislodged by the movements of the child, I make use almost exclusively of the blistering fluid, which is painted once or oftener over the surface, according as it is wished to produce a more or less considerable degree of irritation. If vesication takes place, the serum is let out by pricking with a needle, and a layer of cotton wool being applied over the surface is allowed to remain there until, healing being completed, it drops off of its own accord. In addition to the avoidance of danger and the lessening of constitu- tional disturbance by these means, we have the great advantage of 3 34 RULES FOR PRESCRIBING being able, if it should be desirable, to repeat the same proceeding in the course of three or four days, while, by the ordinary mode of em- ploying blisters, ten days almost invariably elapse before the sore left by their application is healed. In other cases, such as those of chronic pleurisy, where we are anxious to promote the absorption of the effused fluid, or in cases of consolidation of the lung, associated with signs of tubercular mischief, the application of tincture of iodine once a day over the surface takes the place most advantageously of the blisters which we should employ in the adult. The whole range of remedies might thus be gone through ; and with reference to each it might be pointed out how its employment requires to be more or less modified according to the age of the patient. But to do this would be more tedious than profitable, and the majority of details will find their fittest place when we notice the disease for the cure of which this or the other medicine is specially indicated. A few general hints may, however, be given with reference to the art of prescribing for infants and children of tender age. But first of all I must remind you of the twofold difficulty which you encounter in the treatment of the diseases of children, owing partly to the way- wardness of the little patients themselves, partly to the prejudices of their parents, while your success as practitioners will depend on the amount of tact with which you avoid coming into direct collision with either. To prescribe nauseous medicine when with a little care you could order it in a palatable form; to insist on a particular article of diet being given, or on a particular remedy being employed, which the parents fancy will not suit, unless you believe one or the other to be absolutely indispensable to your patient's cure—is needlessly to weaken that authority which in the graver maladies it is absolutely essential that you should be able to exert. As has been truly said by MM. Rilliet and Barthez, it is in the slighter much more than in the serious diseases of children that waywardness, fretfulness, and obstinate refusal of medicine are met with. In the majority of such cases nature alone suffices for the patient's cure, and, while you watch carefully the approach of any serious symptoms, you will lose nothing in the confidence of the parents, and gain much in the love of your patients, by sparing them the nauseous draught, and the agony of tears and fright and temper which they often undergo before they swallow it. The battle with a child to compel it to take medicine, to force it into a bath, or to give it an emetic, generally does far more harm than the remedy so administered can do good; and the many tears saved by it in the nursery are one of the strongest practical recommendations of homoeopathy to the public. But even the most expectant plan of treatment does not leave you without the power of regulating to a great degree the diet of the child, the temperature of its room, the nature of its amusements, and of ex- cluding bright light and loud sounds from its apartment; and nothing beyond these simple measures is needed to remove many of the mino? ailments of the young child. Many medicines, too, can be given with- out any trouble either to the child or to its attendants. A few drops of ipecacuanha wine will be unperceived in its drink, a little James's FOR YOUNG CHILDREN. 35 powder may be concealed in some arrowroot or on a bit of bread-and- butter, or a dose of scammony may pass unnoticed in a little hot and sweetened milk; while, if tonics are needed, the saccharine carbonate of iron or the steel wine will seldom be refused by the most spoilt and most wilful inhabitant of the nursery. Your own ingenuity will suggest many other remedies which may be given without exciting suspicion, or at any rate without causing disgust; and, believe me, the doctor who brings smiles rather than tears into the nursery, he whom the children love most, the parents will trust most, and that love and trust will stand him much in stead when he has to combat serious illness. As far as may be, then, it is well to avoid formal prescriptions in treating the ailments of early life. Often, however, this is not possi- ble; but something may still be done to make physic at any rate sup- portable. Let its bulk be small; two teaspoonfuls will be swallowed readily by many a child whom no persuasion could induce to take two table-spoonfuls. For the same reason, powders, except when very small, are often worse than useless; and yet one sees powdered bark or powdered calumba, or large doses of rhubarb and soda, prescribed for little children of two or three years old; and they must have been educated with far more than average wisdom, or be possessed of more than average docility, who will be prevailed on to take the nauseous compound. In the heat and fretfulness of fever, when the child would gladly drink any moderately palatable medicine, the solution of acetate of ammonia is not seldom prescribed, and the return of the time for giving each dose of medicine is but the signal for a fresh combat between the child and its attendant, in which, whoever gains the victory, the patient is sure to suffer. A few moments' thoughtfulness would avoid the trial both to the child and its parents, for nothing would be easier than to prescribe a mixture such as it would take eagerly. A solu- tion of carbonate of potash saturated with citric acid and flavored with syrup of mulberries, or a few grains of nitre dissolved in water and rendered palatable with syrup of lemons, forms a febrifuge mix- ture to which very few children would object. If it is desirable to give antimony, a watery solution of tartar emetic may be substituted for the wine, the unaccustomed taste of which might be disagreeable. If a stimulant is needed, milk well sweetened conceals to a great extent the pungency of ammonia; while the chloric ether, on account of its sweet taste, is almost always taken readily. Of course, it is not possible to make all medicines palatable, and then you must confine yourselves to giving that which is unpleasant in as small a bulk as possible. Still, if you keep this object in view, it is re- markable to how large an extent it is attainable. . The compound jalap powder is almost the only aperient powder which children very much object to, and the small bulk of the jalapine enables us to dispense even with that in the greater number of instances. Scammony, and especially its extract, can be concealed in milk; and even castor oil shaken up in a bottle with hot sweetened milk, in which a piece of cinnamon has been boiled, is so disguised as scarcely to be suspected. 36 RULES FOR PRESCRIBING FOR YOUNG CHILDREN. The addition of a little chloric ether to the infusion of senna covers its nauseous taste, almost completely, and an extra quantity of liquorice makes even the decoction of aloes palatable, while powdered aloes, occupying a small space, can often be given in brown sugar. Rhu- barb is the one medicine which nothing effectually disguises, though a little spirit of nutmeg mitigates the nauseous flavor of the infusion. Even the difficulty of administering rhubarb may often be surmounted, if we employ the extract, which is thrice as strong as the powder, Each grain of the extract may be divided into four or six tiny pills; and then, if silvered, may be given unsuspected, or at any rate quite untasted, in a little arrowroot or currant jelly. We seldom, .however, need be at a loss in selecting some of the milder laxatives; for the senna electuary, the various syrups and essences of senna, the nursery infusion of senna and prunes, fluid magnesia, and the saccharine car- bonate of magnesia, may each in turn be employed. It is not in general difficult to prescribe a tonic, which shall both be suitable for a child, and at the same time not very unpalatable. The ordinary bitter infusions, as gentian, cascarilla, and calumba are out of the question with young children; but the mineral acids can always be made tolerable, and the infusions of roses, cloves, and orange peel, though perhaps of little value except as vehicles for some other remedy, are by no means unpleasant. The decoction of logwood is very valuable as a tonic and astringent, and a little sugar and a tea- spoonful of port wine generally render the dose popular. In spite of its bitter flavor, the small bulk of quinine generally enables us to give it without much difficulty; while fortunately the cod-liver oil, dis- gusting as it seems to be, is comparatively seldom objected to, and orange syrup or orange wine usually conceals its taste very effectually. The steel wine and the saccharine carbonate of iron have been already referred to as the best chalybeates for children ; but, if iron is needed in stronger forms, the syrup of orange-peel covers the taste of the muriated tincture of iron, and even the compound iron mixture of the London Pharmacopoeia is taken readily if sufficiently diluted with almond emulsion. But enough has probably been said on these preliminary subjects. Your own experience will, every year, deepen the conviction that in dealing with the diseases of early life nothing can be considered trivial. The object of my first lecture was to show you how it is only by at- tention to little things that you will learn rightly to discriminate their nature; the purpose of this has been to teach you how necessary the same attention is to their successful treatment. FREQUENCY OF DISEASES OF NERVOUS SYSTEM. 37 LECTURE III. Diseases op the Brain and Nervous System.—Their extreme frequency in early life favored by the rapid development of the brain, and the wide variations in the cerebral circulation during childhood.—Peculiar difficulties of their study.—Symptoms of cerebral disease in the child.;—Convulsions, their symptomatic value very various—their frequency in great measure due to the predominance of the spinal system in childhood—may be excited by many causes—hence attention should always be paid to the precursors of an attack.—Description of a fit of convulsions. It can scarcely be necessary to assign many reasons for beginning this course of lectures with the study of the diseases of the nervous system. The subject, although beset with many difficulties, has always engaged much attention; partly, no doubt, from the natural tendency of the human mind to inquire most curiously into those truths that seem most hidden; but still more from the alarming nature of many of the symptoms that betoken disturbance of the nervous system, and from the frequently fatal issue of its diseases. But besides the gene- ral interest and importance of these affections, at whatever age they may occur, their extreme frequency in early life gives them an additional claim on our notice. It appears from the Reports of the Registrar-General, that 16,258 out of 91,225 persons who died in the metropolis during the years 1842 and 1845, of ascertained causes, were destroyed by the various diseases of the nervous system. But 9,350 of these 16,258 deaths took place during the first five years of existence; or, in other words, 57 per cent, of the fatal disorders of the nervous system occurred within that period.1 Even after making a very large allowance for the possible errors of statistical data, this predominance of the dis- eases of the nervous system in early life is far too remarkable to be overlooked; though some persons, not being able to account for the fact, have affected to doubt its reality. The fact is one which cannot be gainsaid; and though we do not pretend thoroughly to account for it, yet two considerations may help in some degree to explain it. The first is derived from our knowledge of the circumstance, that in an organ whose development is rapidly advancing, many diseased processes also, if once set up, will go on with proportionate activity. Now there is no organ in the body, with the exception of the preg- nant womb, which undergoes such rapid development as the brain in early childhood. It doubles its weight during the first two years of life, 1 These numbers, which yield results differing but very little from those given in the first edition, are deduced from the returns furnished in the Fifth and Eighth Reports. The returns for 184b', which are also given in the Eighth Report, are not included, since, owing to the epidemic prevalence of diarrhoea in the autumn of 1846 they would not yield average results. 38 DISEASES OF NERVOUS SYSTEM. and reaches nearly, if not quite, its maximum by the end of the seventh year. This same active state of the nutritive or vegetative processes in the brain of the child renders the organ liable to have disease set up in it by causes which would produce little or no inju- rious effect on the brain of the adult. In the second place, the brain in infancy is much more exposed to disorder than that of the adult, owing to the far wider variations of which the cerebral circulation is susceptible in early life than subse- quently. Nor is the cause of this difficult to discover. The cranium of the adult is a complete bony case, and the firm substance of the brain affords a comparatively unyielding support to the vessels by which it is nourished. It has been proved, indeed, by Dr. Burrows,1 that the quantity of blood which these vessels contain is not always the same, as some have erroneously supposed: still its variations must needs be circumscribed within far narrower limits than in the child, whose cranium, with its membranous fontanelles and unossified sutures, opposes no such obstacle to the admission of an increased quantity of blood, while the soft brain keeps up a much slighter counter-pressure on the vessels than is exerted by the comparatively firm parenchyma of the organ in the adult. If the circulation in the child be disturbed, whether from difficulty in the return of venous blood as during a paroxysm of hooping-cough, or from increased arterial action as at the onset of a fever, or during the acute inflam- mation of some important organ, the brain becomes congested, and convulsions often announce the severity of the consequent disturbance of its functions. The same causes, too, which expose the brain to be overfilled with blood, render it possible for it to be drained of that fluid more completely than in the adult. This fact, which you should always bear in mind when treating the diseases of infants, is one reason why excessive depletion induces a far more serious train of symptoms in young children than succeed to it in the grown person. It happens, unfortunately, that while there are special reasons for studying the diseases of the nervous system in childhood, their study is beset with special difficulties which we do not meet with in the adult. Disordered intellect, altered sensation, impaired motion, are the three great classes to which the symptoms of disease of the nervous system may be referred. If our patient be an adult, he tells us of his altered feelings; he perhaps experiences some disorder of his intellectual powers even before it has become observable to others, and, thus timely warned, we can often take measures to prevent the advance of disease, and to ward off that impairment of the motor powers which in his case we know usually indicates the occurrence of some grave organic lesion. In the child, things follow a very different course. 1 In his Lumleian Lectures, published in the Medical Gazette, April 28 and May 6 1842, and subsequently in his work on Disorders of the Cerebral Circulation &c 8vo ' Lond. 1846. The general accuracy of Dr. Burrows's conclusions, though' called in question by the late Dr. John Reid, in the London and Edinburgh Monthly Journal for Aug. 1846, and more recently by Dr. Hamernjk, of Prague, in the Vierteljahrschrift fur die praktische Heilkunde, vol. xvii. p. 38, seems to be placed beyond doubt bv the very careful experiments of Dr. Berlin, published in the Nederlandsche Lancet Feb. 1850, and in Schmidt's Jahrbiicher for 1851, No. 1, pp. 14-16. ' THEIR STUDY DIFFICULT. 39 At first it cannot express its sensations at all, while, long after it has acquired the power of speech, it knows too little how to shape its ideas into words to give a correct account of what it feels; and we cannot expect to learn much from the disturbance of an intellect which as yet has scarcely asserted its claim to be anything higher than the instinct of the animal. The value of the symptoms, too, is different; for disturbance of the motor power, which is comparatively rare in the adult, except as the consequence of some serious disease of the brain, takes place in the child in cases of the mildest as well as of the most serious ailments; and we may even observe convulsions recurring several times a day for many days together, apparently without adequate cause, and not leading to any serious impairment of the child's health. How, then, are we to attain in the child to anything beyond the merest guesswork in our diagnosis of diseases of the nervous system, when we are deprived to so great an extent of that information which the state of his intellect and the description of his sensations afford us in the adult? What meaning are we to attach to that symptom— the impairment of the motor power, which in the adult we look on as of such grave import, but which we meet with in the child under such varying conditions and in by far the greater number of cases? The task, indeed, is attended with difficulty, and the solution of these inquiries will need that you should devote to it some time and some careful observation ; but if you do this, you need not despair of learn- ing much about an infant's sensations and the state of its mind, and will at length become able rightly to interpret the meaning even of a fit of convulsions. It may be well to pause here for a moment, and briefly to pass in review the symptoms by which disease of the nervous centres, and espe- cially of the brain, manifests itself in infancy and early childhood. The painful sensations which the infant experiences soon show themselves in the haggard, anxious, or oppressed look, which takes the place of the naturally tranquil expression of its countenance. It often puts its hand to its head, or beats or rubs it, or, while lying in its cot, bores with its occiput in the pillow; owing to which, in child- ren who have suffered for any time from uneasy sensations in the head, you will often find the hair worn quite off' the occiput. It turns its head away from the light, and lies much with its eyes half closed, in a state of apparent drowsiness, from which it often arouses with a start, and cries. The cry, especially in inflammatory disease, is pecu- liar : it is generally a low, almost constant moan, very sad to hear— interrupted occasionally by a sharp, piercing, lamentable cry, almost a shriek. If the child be young, it will often seem relieved by being carried about in its nurse's arms, and while she is moving will cease its wail for a time, but begin it again the moment she stands still. You will sometimes observe, too, that if moved from one person's arms to those of another, or even if its position be but slightly altered, a sudden expression of alarm will pass across its features; the child is dizzy, and afraid of falling. You see, then, that even in the infant there is a language of signs 40 SYMPTOMS OF CEREBRAL DISEASE. by which we learn with certainty the existence of pain in the head, and the connection of this pain with dizziness and intolerance of light. You must beware, however, of concluding from any one set of symp- toms that the head is the seat of real disease. The child, as well as the adult, may have sick headache; and the degree of febrile disturb- ance, of heat of surface, and of heat of head, together with the state of the digestive organs, are all to be taken into account in forming your diagnosis. Something may be learned of the state of the mental powers and of the feelings even in early infancy. Have you never watched an infant on its mother's lap, and noticed the look of happy recognition with which its eye meets that of its mother ? An early result of cerebral disease is to interrupt this intercourse; the child now never seems to catch its mother's eye, but lies sad and listless, as if all per- sons were alike indifferent to it; or at other times even familiar faces cause alarm, the child apparently not recognizing those who yet have always tended it. This disturbance, however, is but momentary, and the child subsides into its former condition, and allows itself to be taken by those at whom a minute before it seemed frightened. But, these symptoms are to be interpreted by the light thrown on them from other sources, and by the information, both positive and negative, thus obtained. You fear that disease is going on in the brain ; but is the skin hot?—is there heat of head ?—are there frequent flushings of the face, and does the accession of each flush seem con- nected with an increase of agitation and distress, or followed by a deep- ening of the drowsiness ? Is the fontanelle prominent and tense, or are the pulsations of the brain to be felt with unusual force through it?—are the veins of the scalp full, or do the carotids beat with un- usual force? What is the character of the pulse?—is it not merely increased in rapidity; but even when examined under exactly similar conditions, does it afford a different result each time? Do you find it irregular in frequency, or unequal in the force of its beats, or even distinctly intermittent? Again, what is the state of the pupil?—is it generally contracted, as if to exclude light as much as possible from the over-sensitive retina? or is it usually dilated, and does it act slowly, as though disease had deadened the sensibility of the nervous system? or do the pupils of the two eyes not act simultaneously, but one more readily than the other ? Do the pupils oscillate under the light, at first contracting, then dilating, and either remaining dilated, or continuing to oscillate, though within narrower limits, and with a tendency to remain more dilated than at first? Or, lastly, do you find, when the child is roused, this oscillation of the pupil going on under the ordinary amount of light that enters the chamber? Now all of these are indications of disordered function of the brain, and many of them point to disorder of a very serious kind. But there are yet other sources from which we must not neglect to seek for information. Much may be learned from the state of the digestive functions. The bowels are almost always disturbed; usually, though not invariably, constipated; while nausea and vomiting are seldom absent. I am not acquainted with any one symptom which PRECURSORS OF AN ATTACK OF CONVULSIONS. 41 should so immediately direct your attention to the brain, as the occur- rence of causeless vomiting, and especially its continuance. At first, perhaps, the child vomits only when it has taken food; but before long the stomach will reject even the blandest fluid, and then the efforts at vomiting will come on when the stomach is empty, a little greenish mucus being rejected with no relief, the retching and vomiting soon returning. I shall have occasion to dwell again upon the importance of this symptom, which I have known continue for several days before any other indication of cerebral disease could be discovered. In children of three or four years old this occurrence would scarcely be overlooked; but the case is different with infants, who so often vomit the milk when ill, that the mother or nurse might fail to mention it to you, if you did not make special inquiries with reference to that point. The manner in which the functions of the respiratory organs are performed is also not to be overlooked. That peculiar, unequal, irre- gular breathing, to which the name of cerebral respiration has been applied, though of considerable value when present, is sometimes not observed, or not until the disease of the brain is already so far advanced that all questions of diagnosis have long been set at rest. There is, moreover, a short, hard, hacking cough, which you may sometimes hear, and the import of which you ought to be acquainted with, since it betokens disease of the brain, not of the lungs. There are peculiar sounds, too, which sometimes attend respiration, and are known as indicating disturbance of the nervous system. To these, however, I shall have to return hereafter, since they betoken a disease of a serious nature, known by the name of spasmodic croup, and which I must in the course of these lectures describe in full. I have purposely delayed, till now, speaking of the indications of cerebral disease afforded by the occurrence of convulsions. The symp- tom is one undoubtedly of great importance, since it is observed in almost every case of serious disease of the brain, at some stage or other of its progress. The very frequency of the phenomenon, how- ever, and the great variety of the circumstances in which it occurs, render it difficult for us rightly to interpret its meaning. Perhaps, it will help us to understand it, if we can bear in mind, that in a large proportion of cases convulsions in the infant answer to delirium in the adult. In early life, the superintendence of the motor power is the chief function of the brain, which has not yet attained to its highest office as the organ of the intellect. Hence the convulsions which you may observe to come on in infancy in the course of some acute diseases, such as inflammation of the lungs, do not import that any new malady has invaded the brain, but simply that the disease is so serious as to disturb the due performance of all the functions of the organism, and of those of the brain in common with the rest. Convulsions at other times take place in infancy, not as the result of any abiding disease of the brain, but simply in consequence of those anatomical peculiarities which allow of a much more sudden and more considerable congestion of the cerebral vessels than can occur in the adult. Of this kind are frequently the convulsions that come on during a paroxysm of hoop- 42 CONVULSIONS -THE SPINAL SYSTEM. ing-cough, which are induced by the impediment to the return of blood from the head, and which often cease so soon as that impediment is removed by the child taking a deep inspiration. But these two con- siderations are, it must be owned, by no means adequate to explain the very great frequency of convulsions in children, though they account for much that otherwise would be inexplicable. The grand reason of their frequency is no doubt to be found in the predominance of the spinal over the cerebral system in early life. In the adult, the controlling power of the brain checks the display of those reflex movements which become at once evident if disease heighten the excitability of the spinal cord, or cut off* the influence of the brain from the paralyzed limb, or even if sleep suspend that influence for a season. When the child is born the brain is but imperfectly developed, its functions are most humble, and convulsions are then so frequent that they are computed to occasion 73.3 per cent, of all deaths which take place during the first year of existence, from diseases of the nervous system. In the next two years the brain more than doubles its weight, and deaths from convulsions sink to just a third of their former frequency. In proportion as the brain increases in size, and its structure acquires perfection, and its higher functions become dis- played, convulsions grow less and less frequent, until from the 10th to the 15th year they cause less than three per cent., and above 15 less than 1 per cent., of the deaths from diseases of the nervous system.1 But a little observation will show you, that though convulsions are often the immediate cause of death, yet this fatal event is rare during childhood in comparison with those instances in which they pass off without any serious result; and that in proportion to their frequency they less often betoken grave disease of the brain in the child than in the adult, while any cause which greatly excites the spinal system may be attended by them. The disturbance of the spinal system which ushers in fever in the adult, shows itself by shivering; while in the child the same disturbance often manifests itself, not by shiver- ing, but by convulsions. Convulsions may be induced in early life by a constipated state of the bowels, by the"^ presence of worms in the intestinal canal, or of a calculus in the kidney, or by the pressure of a tooth upon the swollen gum—causes wholly inadequate to occasion so serious an occurrence in the grown person. Hence your first duty is, in every case, to ascertain where is the seat of the irritation which excited the nervous system to this tumultuous reaction. If the fits ' The first line in the accompanying table shows the proportion per cent, of deaths from diseases of the nervous system at different ages, to the deaths from all causes at the same ages, in the metropolis ; and the second line, the proportion borne by deaths from convulsions to deaths from diseases of the nervous system in general Under 1 year. From 1 to 3 years. From 3 to 5 years. Total under 5 years. From 5 to 10 jFrom 10 to 15 years. years. Total above 15 years. 30.5 73.3 18.5 24.9 17.6 17.8 24.3 54.3 15.1 9.9 10.6 2.4 10.4 .8 Deduced from the Fifth and Eighth Reports of the Registrar-General. CONVULSIONS—THEIR EXCITING CAUSES VARIOUS. 43 come on in an advanced stage of some serious disease, they are proba- bly only the indications that death is busy at the centres of vitality; if they occur during hooping-cough, they point to a congested state of the brain, the consequence of the impeded circulation through the lungs; if they attack a child apparently in perfect health, they proba- bly indicate that the stomach has been overloaded, or that some indi- gestible article of food has been taken; or, if this be certainly not the case, one of the eruptive fevers is perhaps about to come on; most likely either smallpox or scarlatina. To determine the cause of convulsions, you must acquaint yourself with the history of the child's health for some time before any threat- ening of them had appeared; you must learn whether the child has ever suffered from worms, whether its digestive functions have long been out of order, or whether the process of dentition, which is now perhaps going on, has been attended with much constitutional dis- turbance. But, besides all these points, your inquiries must be still more carefully directed to ascertain whether any cerebral symptoms preceded the attack, and if so, what was their nature, since it is seldom that acute disease of the brain sets in with convulsions. You will sometimes, indeed, be told that the child was well until a convulsive seizure suddenly came on ; but on inquiring minutely it will usually be found that some indications of cerebral disease has been present for days, though not sufficiently severe to attract much attention. In cases of apoplexy, of intense cerebral congestion, and of phrenitis, convulsions occur at a very early period ; but even then, extreme drowsiness, great pain in the head, and vomiting, usually precede for a few hours the convulsive seizure. When the brain is thus seriously involved, the recovery from the convulsions is very imperfect; coma perhaps succeeds to them, or other evidences of cerebral disease are so marked as to leave no doubt of the brain being affected. Tubercle sometimes remains for a long time after its deposition in the brain, without giving rise to any well-marked symptoms, till its presence is at length announced by a fit of convulsions. These convulsions are seldom at first very severe, but you will learn to dread them more than those which assume a more formidable appearance, from noticing either that one side of the body is exclusively affected, or, at least, that there is a marked preponderance of the affection on one side. It is well to bear in mind, too, that convulsions may occur from a want of blood in the brain as well as from its excess, and that the convul- sions which come on in some ill-nourished infants may indicate a state of atrophy of the brain. I must, however, have said enough already to impress upon you the importance of narrowly scrutinizing the meaning of every attack of convulsions. But though so important, there are few tasks more difficult. You have to maintain your own self-composure at a time when all around you have lost theirs; to extract truth as you best may from the imperfect, often exaggerated, accounts of anxious rela- tives; to observe not only minutely but quickly, and to come to a speedy decision : since while in those cases which require active treat- ment delay is almost synonymous with death, there is at least as great 44 DESCRIPTION OF A FIT. danger of destroying your patient by that unimia dih'genlia" to which the prejudices of the nurse and the fears of the friends will often con- spire to urge you. It is well to watch closely the first indications of that disturbance of the nervous system which will be likely to issue in convulsions. And here let me recommend you not to listen with too incredulous an ear to old nurses, who may tell you that a child has been much convulsed, while you find upon inquiry that it has not had any fit. When they say that a child has been much convulsed, they mean usually that it has shown many of the symptoms which forebode an attack of general convulsions. These forebodings are often induced by dyspepsia or by disorder of the bowels in young infants, and have been described by writers under the name of "inward fits." A child thus affected lies as though asleep, winks its imperfectly closed eyes, and gently twitches the muscles of its face—a movement especially observable about the lips, which are drawn as though into a smile. Sometimes, too, this movement of the mouth is seen during sleep, and poets have told us that it is the " angel's whisper" which makes the babe to smile—a pretty conceit of which we can scarcely forgive science for robbing us. If this condition increase, the child breathes with difficulty, its respiration sometimes seems for a moment almost stopped, and a livid ring sur- rounds the mouth. At every little noise the child wakes up ; it makes a gentle moaning, brings up the milk while sleeping, or often passes a great quantity of wind, especially if the abdomen be gently rubbed. When the intestinal disorder is relieved, these symptoms speedily sub- side; nor have we much reason to fear general convulsions so long as no more serious forebodings show themselves. There is more cause for apprehension, however, when we see the thumbs drawn into the palm either habitually, or during sleep; when the eyes are never more than half closed during sleep; when the twitching of the muscles is no longer confined to the angles of the mouth, but affects the face and extremities; when the child awakes with a sudden start, its face grow- ing flushed or livid, its eyes turning up under the upper eyelid, or the pupils suddenly dilating, while the countenance wears an expression of great anxiety or alarm, and the child either utters a shriek or sometimes begins to cry. When a fit comes on, the muscles of the face twitch, the body is stiff, immovable, and then in a short time, in a state of twitching motion, the head and neck are drawn backwards, and the limbs vio- lently flexed and extended. Sometimes these movements are confined to certain muscles, or are limited to one side. At the same time neither consciousness nor sensation is present. The eye is fixed and does not see; the finger may be passed over it without winking; the pupil is immovably contracted or dilated; the ear is insensible even to loud sounds; the pulse is small, very frequent, often too small und too frequent to be counted; the breathing hurried, labored, and irregu- lar ; the skin bathed in abundant perspiration. After this condition has lasted for a minute, or ten minutes, or an hour or more, the convulsions cease; and the child either falls asleep, or lies for a short time as if it were bewildered, or bursts into crying', CONGESTION OF THE BRAIN. 45 and then returns to its senses, or sinks into a state of coma, in which it may either be perfectly motionless, or twitching of some muscles may still continue; or, lastly, it may die in the fit. This, however, is not usual, except when the convulsions have come on in subjects exhausted by previous disease, or when they are the result of apo- plexy or of intense cerebral congestion, such as takes place occasion- ally in hooping-cough, or when they are associated with that closed state of the larynx which occurs sometimes in spasmodic croup. This preliminary examination of the symptoms of disturbance of the nervous system has placed us in a position to commence our inves- tigation of the different forms of cerebral disease; on which we will enter at the next lecture. LECTURE IV. Congestion of the Brain.—Active congestion may come on at the onset of eruptive fevers, or be induced by exposure to the sun, or may attend dentition, or be excited by various other causes.—Symptoms in each of its three stages.—Treatment.—Special rules for depletion and the application of cold.—Active measures not always appropriate.— Passive congestion may supervene on hooping-cough, or be connected with disorder of the digestive organs in weakly children, or be induced by unfavorable hygienic causes.— Its symptoms and treatment. In my last lecture, I endeavored to point out to you some of the reasons for the greater frequency of affections of the nervous system in infancy and childhood than at other periods of life. I dwelt espe- cially upon certain structural peculiarities of the brain, and of its bony case, which render the cerebral vessels liable to become overloaded with blood, under the influence of causes that would be wholly inade- quate to produce such an effect in the adult. With the advance of the ossification of the skull, and the closure of its fontanelles and sutures, these peculiarities are rendered fewer and less important; but still a remarkable liability to congestion of its vessels continues to characterize the brain through all the years of early childhood. A late distinguished German physician, Dr. Mauthner, of Vienna,1 on examining the bodies of 229 children who had died at different ages, and of various diseases, found a congested state of the vessels of the brain in 186 of the number. In some of these cases it is probable that this condition had come on only a short time before the patient's death, since in them no symptoms of cerebral disturbance had appeared during the progress of their illness; but in many it was not so; and I shall have occasion to warn you over and over again to be on the watch against congestion of the brain, as a condition which is very likely to come on in the course of affections even of distant organs. Nor 1 Die Krankheiten des Gehirns und Riickenmarks bei Kindern. 8vo., Wein, 1844, p. 12. 46 CAUSES PRODUCING is it merely as a serious complication of many other diseases that this cerebral congestion deserves your notice; its importance depends still more on its constituting the first and curable stage of many diseases of the brain, which, unless arrested at the outset, soon pass beyond the resources of our art. Neither, indeed, must it be forgotten, that although inflammation, hemorrhage, and the effusion of serum are the three results to one or other of which congestion of the cerebral vessels tends, yet the exceptions to their occurrence are by no means few, even when that congestion has been very considerable, or of long continuance; and that not only may the functions of the brain be seriously disordered, but the life of the patient may be destroyed, without the anatomist being able to discover any one of these results, or, indeed, anything more than a general repletion of the vessels of the organ.1 Any cause which greatly increases the flow of blood to the head, or which greatly impedes its reflux, may give rise to a congested state of the brain; and, according as this state is induced by the one or the other cause, it is said to be active or passive. The head symptoms which sometimes usher in the eruptive fevers depend, in a measure, upon the former cause; the convulsions which frequently occur during a fit of hooping-cough result from the latter. The brain may become actively congested at the time of teething, or from exposure to the sun, or from a blow on the head; or a state of passive congestion may be induced by some mechanical impediment to the return of blood from the organ—such as the pressure of a hypertrophied thymus, or of enlarged and tuberculated bronchial glands upon the jugular veins; or it may be merely the result of a languid circulation from the want of pure air, or of nourishing and sufficient food. Active cerebral congestion is a not very unusual consequence of the disturbance of the circulation at the outset of the eruptive fevers. Con- vulsions and apoplectic symptoms sometimes come on suddenly in a child previously, to all appearance, in perfect health, and may even terminate in death in less than twenty-four hours. The brain is found loaded with blood, but all the other organs of the body are quite healthy. Some years ago I was requested to be present at the exami- nation of the body of a boy not quite two years old, who had been in perfect health until the day before his death, which took place in such circumstances as I have just mentioned. The congested state of the cerebral vessels gave but little satisfactory information ; but the same evening, the brother of the child was taken ill with vomiting, intense fever, and sore throat. In a few hours a red rash appeared: the case was one of scarlet fever, and ran its course with considerable severity, though, happily, to a favorable termination. It is probable that the poison of the lever had affected the blood of both children, and that the consequent disturbance of the cerebral circulation was so violent as at once to destroy the life of the younger, while the elder brother survived the shock, and in him the disease soon presented its 1 Dietl's Anatomische Klinik der Gehirnkrankheiten, 8vo. Wein, 1846, contains, at pp. 53—73, a very able exposition aud defence of views concerning cerebral congestion in many respects similar to those expressed in this lecture. CONGESTION OF THE BRAIN. 47 usual features. The history of most epidemics of scarlatina would afford other instances of a similar nature.1 But, alarming though these symptoms are, it is comparatively seldom that they end in death; for when they occur at the onset of the exanthemata they generally vanish almost as if by magic on the appearance of the eruption. I was called one day to see a little girl two years old, who, until the day before, had never had an hour's illness. She had eaten a hearty dinner, and, thqugh she vomited soon afterwards, did not seem otherwise indisposed, and slept well in the night. Immediately on waking in the morning, however, she had a fit, during which she was insensible, squinted, threw her limbs about, and occasionally screamed aloud. She continued very ill through the whole day; was hot and feverish during the night, having occasional attacks of convulsions, in which she stretched out her legs, threw back her head, now and then uttered a word or two, and then relapsed into a state of insensi- bility. This was her condition at half-past 10 A. M.—about twenty- four hours after the occurrence of the first fit. I bled her to 3iij, and would have drawn more blood if it had continued to flow; and then put eight leeches on her head, employed cold affusion, and gave active cathartics during the day, but without much benefit; and at midnight she was still insensible, rolling uneasily from side to side, boring with her head in the pillow, squinting, and making automatic movements with her mouth and tongue. I now put eight more leeches on the head, which bled profusely, and the bleeding was followed by great diminution in the convulsive movements. About 4 A. M. of the next day, the child fell asleep, and dosed for a few hours. She awoke sensible, and continued so. On my visit in the morning, I found her quiet and sensible, without any sign of convulsion; her face was very pale; her head, before so hot, was now quite cool; her pulse had sunk in frequency, and lost its fulness. An eruption of a papular character had appeared on the hands, arms, inside of the thighs, and slightly on the face. This eruption was the smallpox, and the disease ran its course with no unfavorable symptom. It would not be right, indeed, to attribute the symptoms of disturb- ance of the nervous system that sometimes occur at the commence- ment of the eruptive fevers entirely to deraugement of the cerebral circulation, for something is probably due to changes in the blood itself; but we see similar results produced by other causes, the imme- diate effect of which is to disturb the circulation and to favor conges- tion of the brain. Thus, exposure to the heat of the sun, even though the head had not been unprotected from its rays, may be followed by convulsions or by other indications of an overloaded state of the brain, and these symptoms may all subside as soon as the excited circulation has recovered its wonted balance. Of this I remember a striking in- stance in the case of a delicate boy, who, when a year old, was taken 1 See Armstrong's notice of this suddenly fatal form of the disease, at p. 30 of his work on Scarlet Fever, &c, 2d edit. London, 1817 ; and Von Ammon's mention of it in his description of the epidemic of malignant scarlatina at Dresden in 1731-2, in the Analekten iiber Kinderkrankheiten, lltes Heft, p. 42. Stuttgart, 1836. 48 CEREBRAL CONGESTION. out by his nurse during one of the hottest days in June. He was quite well and cheerful when he left the house, but, after being out for some time, he began to breathe hurriedly and irregularly, and his nurse, in consequence, brought him home. I saw him about two hours afterwards. He was then restless, fretful, and alarmed; his surface generally hot, and his head especially so, the brain pulsating forcibly through the anterior fontanelle; the pulse too rapid to be counted; the respiration hurried, labored and irregular, and there were constant startings of the tendons of the extremities. The child was on the eve of an attack of convulsions; but the tepid bath re- lieved the heat of the skin, and the pulse fell, and the subsultus dimin- ished. Light and sound were excluded from the room; he fell asleep, and awoke in a few hours refreshed and tranquillized, and on the next morning a little languor was all that remained of an illness which had seemed likely to prove so formidable. Disorders of the nervous system are very frequent during the period of teething. Many of the symptoms which then occur are the direct result of irritation of the trifacial nerve, but others are the immediate consequence of congestion of the brain. Febrile disturbance almost always attends upon the process of dentition, and you can easily un- derstand that when the circulation is in a state of permanent excite- ment, a very slight cause may suffice to overturn its equilibrium, and occasion a greater flow of blood to the brain than the organ is able to bear. But I need not occupy more time in pointing out to you the vari- ous circumstances which may give rise to active congestion of the brain. Let us now pass to a more minute examination of its symptoms. Cerebral congestion may, as you have seen, come on very suddenly, its symptoms from the first being alarming, and such as to call for immediate interference; or general uneasiness, a disordered state of the bowels, which are generally though not invariably constipated, and feverishness, may have for a few days preceded the more serious attack. The head by degrees becomes hot, the child grows restless and fretful, and seems distressed by light, or noise, or sudden motion; and children who are old enough sometimes complain of their head. One little boy, nearly three years old, who died of congestion of the brain, had( seemed to suffer for some days before any alarming symp- tom came on, from severe pain in the head. He sometimes awoke crying from his sleep, or when awake would suddenly put his hands to his ears, exclaiming, "Oh, hurt! hurt!" Usually, too, vomiting occurs repeatedly; a symptom on the importance of which I have already insisted, since it is not only confirmatory of others, but also may exist before there is any well-marked indication of the head being affected, and when, though the child seems ailing, there is nothing definite about its illness. The degree of fever which attends this con- dition varies much, and its accessions are irregular; but the pulse is usually much and permanently quickened; and if the skull be unos- sified, the anterior fontanelle is either tense and prominent, or the brain is felt and seen to pulsate forcibly through it. The sleep is dis- ITS SYMPTOMS. 49 turbed, the child often waking with a start, while there is occasional twitching of the muscles of its face, or of the tendons of its wrist. The child may continue in this condition for many days, and then recover its health without any medical interference; but a slight cause will generally suffice to bring back the former indisposition. You will sometimes see striking instances of this in children while teeth- ing; the fever subsiding, the head growing cool, and the little patient appearing quite well, so soon as the tooth has cut through the gum, but the approach of each tooth to the surface being attended by the recurrence of the same symptoms. But though the disturbance of the brain may pass away of its own accord, yet we cannot reckon on such a favorable result occurring, for symptoms such as I have mentioned are often the indications of the organism generally having begun to suffer from mischief which has been going on for mouths unnoticed, and which is now about to break out with all the formidable characters of acute hydrocephalus. Or should they have no such grave import, yet congestion of the brain is itself a serious, sometimes a fatal malady. Even though no treat- ment be adopted, indeed, the heat of head may diminish, and the flush of the face grow slighter and less constant; but the#ountenance becomes very heavy and anxious, the indifference to surrounding ob- jects increases, and the child lies in a state of torpor or drowsiness; from which, however, it can at first be roused to complete conscious- ness. The manner, on being roused, is always fretful; but if old enough to talk, the child's answers are rational, though generally very short; and, murmuring "I am so sleepy, so sleepy," it subsides into its former drowsiness. The bowels generally continue constipated, and the vomiting seldom ceases, though it is sometimes less frequent than before. The pulse is usually smaller than in the other stage, and it is often irregular in its frequency, though not actually inter-. mittent. An attack of convulsions sometimes marks the transition from the first to the second stage; or the child passes, without any apparent cause, from its previous torpor into a state of convulsion, which subsiding, leaves the torpor deeper than before. The fits return, and death may take place in one of them, or the torpor growing more profound after each convulsive seizure, the child at length dies comatose. This second stage, if so it may be called, is usually of short duration ; and if relief be not afforded by appropriate treatment, death is seldom delayed beyond forty-eight hours from the first fit, •though no graver lesion may be discovered afterwards than a gorged state of the vessels of the brain and its membranes, and perhaps a little clear fluid in the ventricles and beneath the arachnoid. Occasionally, indeed, death does not so speedily follow these symp- toms; but they continue slightly modified for days, or even weeks, and, contrary to all expectation, recovery now and then takes place. This protracted course of the affection is, I believe, met with only in the case of very young children, in whom, the congestion having relieved itself by a copious effusion of serum into the ventricles, the yielding skull accommodates itself to its increased contents. The symp- 4 50 TREATMENT OF CEREBRAL CONGESTION. toms, though to a great extent the same as before, are now due to the presence of water in the brain—a disease which, though dangerous and often fatal, is yet chronic in its course, and may even admit of cure. If active congestion of the brain may come on in so great a variety of circumstances, it is evident that there can be no invariable rule for its treatment, adapted alike to every case, but that the peculiarities of each must be taken into your most careful consideration. The little girl I have mentioned in whom convulsions preceded the attack of smallpox, would most likely have died from apoplexy if she had not been bled very freely; and it is probable that in her case the depletion might have been carried still further with advantage. On the other hand, the boy who had been exposed to the heat recovered under the tranquillizing influence of a tepid bath, and there can be no doubt but that to him depletion would have been injurious. You must, then, always endeavor to make out what has been the antecedent of the attack. If violent convulsions have come on suddenly, and without apparent cause, in a child until a short time before in perfect health, inquire whether your patient has had the eruptive fevers, especially scarlatina ai*l smallpox, or whether he has been recently exposed to their contagion, and examine the arm to see whether there is a good cicatrix as evidence of successful vaccination. When head symptoms usher in the exanthemata, the danger for a time may be imminent; but you know that if you can relieve the gorged vessels of the brain, and thus ward off the immediate peril, nature herself will come to your assistance, and the outbreak of the eruption will probably be followed by the cessation of the cerebral disturbance. Or it may be that the child has greatly overloaded its stomach, or has partaken of some indigestible substance; in which case you would give an emetic, though in any other circumstances the attempt to induce vomiting would be not only useless, but dangerous. If the symptoms had succeeded to a blow, you would not lose sight of the danger of inflam- mation of the brain supervening; while if the head affection had been preceded by long-continued gastric or intestinal disturbance, or if it had come on during teething, you would bear in mind that a more cautious treatment must be pursued, lest you cause as serious mischief by doing too much, as might in other cases result from your doing too little. There are, however, but few exceptions to the rule which prescribes the abstraction of blood either locally or generally, as one of the most important remedies in cases of active cerebral congestion. If the symptoms set in violently, as they did in the case of the little girl whose history I mentioned to you, you must deplete freely, and will find that relief will follow more speedily on the abstraction of blood from the jugular vein than on venesection or the application of leeches. It is not easy to define exactly the quantity of blood which may be drawn, but two ounces are probably as much as you would ever be warranted in taking from a child a year old; and the appearance of manifest relief to the symptoms should be a signal to you for stopping its flow, even before that quantity had been obtained. The removal RULES FOR DEPLETION. 51 of too large a quantity of blood would be at least as mischievous as the abstraction of too little, while you would run some hazard of confounding the effects of loss of blood with those of its excess, and might thus be led further into error. It is, therefore, better (although children bear repeated bloodletting ill) to take but a moderate quan- tity of blood at first; to watch its effects, and to repeat the bleeding in a few hours, if it be necessary, rather than to subject the system to the shock of an excessive loss of blood. In children, under three years old, bleeding from the arm is seldom practicable; and without the case be very urgent, it is inexpedient to open the jugular vein. At this early age, however, almost all the good effects of general bleeding may be obtained by the proper appli- cation of leeches. But their proper application, in cases such as these, in which too little and too much are alike attended by most serious danger, implies something very different from ordering a certain number, and leaving the management of them to the nurse, and the regulation of the subsequent bleeding to accident; and requires that you should remain with your patient, and watch the effects they pro- duce. It is generally estimated that a healthy leech will draw about 3ij of blood, and that if the subsequent bleeding be encouraged, about as much more will flow afterwards; but it is, as I observed in the second lecture, by far the better and safer course whenever it is wished to produce a decided influence on the system, such as, in the adult, we should seek to exert by general depletion, to put on a larger num- ber of leeches at once; to remove them the moment they seem to have produced a decided effect, and not to allow of any bleeding subse- quently. Eight leeches, applied to a child one year old, will, under these regulations, do much more good, and with an actually smaller loss of blood, than will follow from half that number applied without such precautions. If on your second visit you find that the child, although manifestly relieved for a time by the depletion, is relapsing into a state of coma, or that convulsions, checked for a season, are returning, or that the head is nearly as hot and the pulse nearly as accelerated as before, and quite as hard, you may be warranted in bleeding again. You must not, however, resort to a second bleeding without the most evident necessity, nor without having tried all those subsidiary means by the diligent employment of which you will often be able to render further depletion unnecessary. Many of these means, indeed, are so simple, that their value is frequently underrated; and it is so often said, almost as a matter of course, " Keep the child quiet, and the room cool, and apply cold to the head," that it does not strike the parents how much depends upon those directions on which the doctor seems to lay so little weight. You must learn, however, that in the treatment of children's diseases none of these things are trivial, but that on their due performance often hangs the life of your patient. Do not content yourselves, then, with merely giving directions, but stay to see them attended to; and do not leave the house till the chamber is darkened, the cool air freely admitted, the cold application to the head properly 52 TREATMENT OF CEREBRAL CONGESTION. adjusted, nor till all persons who are not actually waiting on the child have left the apartment. At the outset of the affection the bowels are usually constipated, so that an active purgative is in most cases called for. You may give a dose of calomel and jalap, or the calomel may be administered alone, and followed by the infusion of senna, which may be repeated every three or four hours till the bowels act. Should the stomach be very irritable, a larger dose of calomel may be given, and after the lapse of a couple of hours, an attempt may be made to quicken its action by administering a purgative enemata, or by dissolving some sulphate of magnesia or the less nauseous phosphate of soda in the child's drink, and giving it at short intervals. In many cases the disorder will be speedily removed by this treatment, and the child, whose life had seemed to be hanging by a thread, will, in the course of twenty-four hours, be almost well. But, it may happen that though the symptoms are increasing in severity, though the convulsions are unchecked, or though coma is evidently coming on, yet the state of the pulse forbids a repetition of depletion; or it may even be that you dare not bleed at all, for fear of altogether putting out the life which is in such urgent peril. For- tunately we have another and very powerful remedy in store, which we may try in cases where, otherwise, we should be without resource; this remedy is the cold affusion. There is something, however, appa- rently so formidable in taking a child from its bed, and pouring a stream of cold water on its head for several minutes together, that you will be wise to explain what you are about to do, to the child's friends, and to obtain their consent to the experiment, lest you be compelled by their alarm to desist before you have done any real good. When you have determined to resort to it, the child must be taken out of bed, wrapped in a blanket, and laid upon the nurse's lap, with its face downwards, while you pour a stream of water from a little height upon its head. The most effectual way of doing this, though one not always practicable, is to place the child under the cock of a water cis- tern, or the spout of a pump, since you can then continue the stream uninterruptedly for five or six minutes. I have seen some remarkable instances of convulsions arrested, and of children aroused from coma by these means; but you must bear in mind that the agent is one of great power, and you must feel the pulse, from time to time, during its employment, lest you should, by its long continuance, produce too great a depression of the vital energies. But besides those cases in which you want to produce a sudden effect by the application of cold with a shock, you often need the sedative influence of cold constantly applied. A very intense degree of cold may be kept up by allowing cold water to drip constantly upon the patient's head, which may be managed, as suggested by Dr. Watson, by means of a sponge and funnel placed a little above the head. This plan is, however, objectionable on account of its being almost impossible, when it is adopted, to prevent the patient's person from becoming extremely wet; and, moreover, it is but seldom that so powerful an agent is needed in the case of children. Few methods APPLICATION OF COLD. 53 of applying cold to the head are better than that which consists in half filling two bladders with pounded ice or cold water, and placing them, each wrapped in a napkin, the one under and the other upon the child's head. By pinning the corners of the napkins to the pillow you can secure them from being displaced, and can also prevent the weight of the upper bladder from resting too heavily on the child's head, while all danger of the Bed or the dress becoming wet is avoided. Or lastly, the constant circulation of a stream of ice-cold water over the head may be obtained by the ingenious application of well-known principles, which I first saw carried out by Mr. Gee, one of our regis- trars at the children's hospital. Into the neck of a large bladder let two tubes be introduced, of which the longer afferent tube should be carried to the lower, the shorter efferent one to the upper part of the bladder. Let the one communicate with the vessel of cold water, the other with an empty vessel to receive the warmed water as it passes away; and with a little watching on the part of the attendant, a stream may thus be kept constantly flowing over the head, and separated from it merely by the thickness of the bladder. Supposing, now, that by the employment of these means you have removed the imminent danger, and that your patient is going on favorably, still it will be generally desirable to continue treatment for a few days. Free action of the bowels must be secured; for which purpose small doses of calomel may be given two or three times a day, and it may be desirable to accompany each powder with a dose of a mixture containing nitre and sulphate of magnesia.1 You must, how- ever, bear in mind that you will do less harm by allowing a child to go without medicine than by forcing on it remedies which it dislikes and resists taking. Calomel, indeed, can almost always be given; and even sulphate of magnesia will very often be taken if mixed with the drink, or dissolved in a little veal broth. But how much soever a child may resist medicine, the abstraction of blood, a spare diet, a cool and dark and quiet chamber, are remedies always at command, the value of which you must not underrate. I need not tell you that all cases do not admit of this active treat- ment. When the disease creeps on with febrile symptoms, occasional vomiting, constipation, loss of appetite, and restless nights, with com- plaints, if the child be old enough to speak, of pain in the head or limbs, or vertigo, and with a quick and variable pulse, you must treat it gently. If you deplete, it must be only by leeches, and then not in large number, while you trust much to quiet and the careful regula- tion of the diet. In such cases you will often find a tepid bath night and morning soothe the child and tranquillize the circulation far more than you might have expected from so simple a remedy. Drastic purgatives must be avoided ; but small doses of mercury and chalk, • (No. 1.) $.—Potassae Nitratis, gr. xij. Magnesiae Sulph. gj. Syr. Limonum, 3iij- Aquae destil. gix. M. gij three times a day. For a child a year old. 54 PASSIVE CONGESTION. or of calomel, either alone or combined with rhubarb, may be given with advantage once or twice a day. Half a grain of calomel, or two grains of the hydr. c. creta, with three of rhubarb, or one of the powdered extract, would be a proper dose for a child a year old. If there be much feverishness and restlessness during the day, you may give a mixture of bicarbonate of potash not quite saturated with citric acid, and containing small doses of ipecacuanha wine, if the stomach be not extremely irritable, and of the tincture of hyoscyamus; the value of which last medicine as a sedative in the diseases of children can scarcely be too highly estimated. The addition of a little syrup of mulberries will render the above mixture extremely palatable.1 You will sometimes meet with cases of cerebral congestion that appear to have been brought on by exposure to the heat of summer, and in them it often happens that the bowels are not constipated, but somewhat relaxed. You must not, however, aim at checking the diarrhoea by direct astringents, but should rather pursue an alterative plan. In most instances there is irregularity of the bowels rather than diarrhoea; the child having five or six unhealthy motions, for the most part destitute of bile, in the course of one day, and passing the succeeding twenty-four hours without any evacuation at all. In such cases you will find the treatment I have just indicated very useful. If the bowels be much disturbed, half-grain or grain doses of Dover's powder may be combined with the mercurial with advantage. There is not time to enter into more minute details with reference to the management of every variety of active cerebral congestion, but we must briefly notice those cases in which the condition exists in what may, perhaps not improperly, be called the passive state. In the paroxysms of hooping-cough, the brain becomes congested by the impediment to the return of the blood from the head; and cerebral congestion is induced in a similar manner when the larynx becomes spasmodically closed in the disease known by the name of Laryngismus Stridulus. But we likewise meet with cases where the passive suc- ceeds to the active form of cerebral congestion, or becomes more or less gradually developed out of some disorder of the abdominal viscera: or, lastly, where it supervenes towards the close of life in weakly children, whose vital powers have at length become too feeble to pro- pel the blood. In children, who have suffered long and severely from hooping- cough, you often notice a general, lividity of the face and lips, a puffed and anxious countenance, and the child makes grievous complaints about its head, while the skin is moist and cool, and the pulse soft though frequent. Many of these symptoms indicate an overloaded state of the cerebral veins; and if a paroxysm of coughing occur, and 1 (No. 2.) fy.—Potassae Bicarbonat., Aoidi Citrici, aa gr. xx. Vin. Ipecac. TT^xij. Trae. Hyosc. TT^xviij. Syr. Mori, ^iij. Aquae destill. #x. M. ^ij every six hours. For a child a year old. ITS SYMPTOMS AND TREATMENT. 55 the circulation be thus further disturbed, the child may die in a fit, or may sink after some convulsive seizure into a state of coma, which sooner or later proves fatal. In such a case you will find the vessels of the brain and its membranes universally gorged with black blood, the choroid plexuses of a deep purple color, and more bloody points than natural will present themselves on a section of the brain being- made. Both the symptoms during life, and the appearance after death, are only a rather exaggerated illustration of what occurs in all cases of passive congestion of the brain. It is not, however, always easy to explain why this condition comes on. Among the poor you often find it connected with general disorder of the digestive organs, and occurring as one of along train of ills induced by destitution and neglect. It was so in the case of a little boy four months old, whom I saw some years ago. His parents were young and healthy people, but they had already lost three children, apparently in consequence of their inhabiting one of those narrow courts so numerous in London, into which the sun never shines, and where young children pine and fade, like tender plants shut up in a cellar. When ten weeks old, this little boy was taken with pain in his bowels and diarrhoea, and at three months old he began to suffer from fits, which came on daily, some- times several times a day. No efficient treatment had been adopted when he was brought to me. He was then as large as most children of his age, and by no means emaciated; but his flesh was flabby, his face unintelligent, puffed, and livid, his head hot, the veins of the scalp and eyelids turgid, the eyes prominent, lustreless, covered by mucus, and the pupils not acting under light. He lay in his mother's lap, uttering a constant hoarse moan; his head thrown rather back, and in incessant rotatory motion; his mouth was open, his tongue red and parched, and the papillae on its surface were very prominent; his abdo- men was rather full, and his legs were constantly drawn up towards it. He vomited much; his bowels were open three or four times a day, the motions being green and offensive; his pulse was frequent, but without power. In this, as in many instances of passive conges- tion of the brain, local depletion was resorted to at first, and, benefit resulting from it, was repeated more than once. It is not, however, every case that will admit of even local depletion, whicm, whenever employed, must be practised only with the view of affording relief to the gorged cerebral vessels, not with the idea of curing the patient by bleeding. The greatest attention must in every case be paid to diet and to the state of the bowels, and you will find no means of inducing their healthy action better than the employment of smal| doses of mer- cury and chalk two or three times a day. If the child be not weaned, you may find it desirable, if there be constant sickness, to take it almost, or entirely, from the breast for a day or two, and to substitute barley- water, sugar and water, or a weak solution of isinglass, with the addi- tion of one-third of milk, which should be given in quantities of one or two spoonfuls at a time till the stomach becomes more settled. A stimulating bath, as a hot salt-water bath, or a bath into which a handful of mustard has been put, and in which the child is to be kept for four or five minutes, night and morning, will often be found a valuable 56 PASSIVE CONGESTION. auxiliary to the general treatment, as well as very useful, if combined with the application of cold to the head, in cutting short the convul- sive seizures. If the case be associated with much diarrhoea and general impair- ment of nutrition, the extract of bark, with a few drops of sal volatile, or of the compound tincture of bark, should be given two or three times a day, and you should not let the head symptoms lead you to keep the child on a low diet.1 Eemember, too, that when nutrition is much impaired, farinaceous food is not usually well digested; you must, therefore, be sparing of arrowroot, and give milk and water, or milk and water with isinglass, or veal-tea. If the broth should purge, as it sometimes does, the white decoction of Sydenham2 will form a cheap substitute for isinglass. As the child improves, the ferrocitrate of quinine will be one of the best remedies you can give,3 and through- out the whole progress of the case you will remember the tonic in- fluence of pure air; and may even find the removal to a healthier spot and a purer atmosphere absolutely necessary to the recovery of your patient. Lastly, I will just allude to the head symptoms that sometimes for a few days precede death in children who have been long ill. You may in such cases find the vessels of the brain turgid, and be disposed to reproach yourselves for not having adopted active treatment. Such self-reproach would be unmerited; the streams have stagnated, because the vital powers were all too feeble to keep them in motion. 1 (No. 3.) ty..—Extr. Cinchonae, gj. Trae. Cinch. Co. 3ij. Aquae Carui, £x. M. £j three times a day in milk. For a child a year old. The taste of the above mixture is best concealed by sweet- ening it, and mixing it with twice the quantity of milk. 2 This, the Decoction Blanche of the French Pharmacopoeia, is made by boiling half an ounce of hartshorn shavings and the inside of one French roll, in three pints of water till reduced to two, when it may be sweetened, and given either alone or with the addition of one part of milk. 3 (No. 4.) $.—Syrupi Quinae Ferro-Citrat. 3iss. Syrupi Aurantii, 5iiss. Aquae Flor. Aurantii, |j. M. 3j three times a day. For a child a year old. CEREBRAL HEMORRHAGE. 57 LECTURE V. Cerebral Hemorrhage.—The rupture of any large vessel in childhood very rare, but effu- sion of blood into arachnoid frequent—reasons for its especial frequency in new-born infants—its symptoms and treatment—Blood sometimes effused external to the skull in new-born infants—Cephalhaematoma, its characters, changes in the effused blood, and process of cure—its treatment—Hemorrhage into arachnoid in childhood—changes in the effused blood—obscurity of the symptoms—occurs sometimes in very feeble children, or in connection with changes in the blood—illustrative cases—Hemorrhage into cerebral substance in childhood extremely rare—cases in illustration of its causes and symptoms— capillary hemorrhage in connection with tubercle in the brain. When we last met, I called your attention to the very important consequences that may result from the vessels of the brain becoming overloaded with blood. I pointed out to you a train of symptoms, rising in severity, from mere pain or heaviness of the head, to convul- sions or coma, according to the degree of the cerebral congestion; and told you that death itself might take place, without any mischief being discoverable afterwards, more serious than a general turgescence of the vessels of the brain and its membranes. Simple apoplexy, indeed, is by no means rare in childhood, and the knowledge of this fact may furnish encouragement to us in cases where the symptoms of present danger are most alarming. We may hope, that if the instant peril can be averted, the blood, which has not burst its vessels, will flow again tranquilly through them, and the functions of life once more go on in their wonted course. In the adult we could scarcely indulge such an expectation, for the import of apoplectic symptoms is generally far more serious. If the patient die, we look for, and seldom fail to find, blood poured out into the brain, compressing its substance, and lacerating the delicate fibres along which the nervous influence travels. Or, even should he survive, it often is to pass through a tedious con- valescence, with palsy, and weakened senses, and impaired mental powers—the sad and standing evidence of the grievous injury which the brain has sustained. You may naturally inquire how it happens that, in the child, the very structure of whose skull favors the occurrence of cerebral con- gestion, hemorrhage into the brain is comparatively so rare; while in the adult, whose unyielding cranium and firmer brain tend to check congestion, the extravasation of blood into its substance takes place so often? The changes which advancing age induces in the structure of the cerebral vessels are probably the chief cause of this difference. In early life the arteries are yielding, and admit of being greatly dis- tended without giving way; but in the course of years they lose their elasticity, their calibre becomes diminished and unequal, and their coats grow brittle by the deposit of fatty or earthy matter in their tissue. 58 INFANTILE ASPHYXIA. But though the larger arterial trunks withstand the constantly re- curring variations in the cerebral circulation during infancy and child- hood, the smaller and more delicate vessels of the brain are very liable to give way, and capillary hemorrhage, or hemorrhage by exhalation, as it has been often, though incorrectly, termed, takes place with greater frequency than in adult age. All periods of childhood are not equally exposed to this accident, but it is oftenest met with immediately after birth, and no circum- stances can be imagined more favorable to its occurrence than those which then concur to produce it. The head of the infant has been subjected to severe and long-continued pressure during its progress through the mother's pelvis; immediately on its birth, the course of the circulation is altogether changed, and, should any difficulty occur in the establishment of the new function of respiration, a long time will elapse before the blood flows freely through its unaccustomed channels. No one will wonder that death should frequently take place during this transition to a new kind of existence. The tumid scalp and livid face of many a still-born child point to one of its most im- portant causes, since they are but the measure of that extreme conges- tion of the vessels within the skull that has at length ended in a fatal effusion of blood upon the surface or at the base of the brain. There would be reason to fear that this occurrence had taken place, if an infant, when born, were to present great lividity of the surface, and especially of the face, and if the heart were to beat feebly, and at long intervals, although the pulsations of the cord were slow and faint, or had altogether ceased. In these circumstances, death sometimes takes place without any effort at respiration being made, the beatings of the heart growing feebler and fewer till they entirely cease; but at other times the child breathes irregularly, imperfectly, and at long in- tervals. The hands are generally clenched, and spasmodic twitchings are of frequent occurrence about the face, or these twitchings are more general and more severe, and amount almost to an attack of convulsions. The symptoms, however, are by no means uniform, and probably are in some degree modified by variations in the seat as well as in the quan- tity of the effusion; for it sometimes happens, even in cases where a very large quantity of blood has been poured out into the arachnoid cavity, that the breathing is little or not at all disturbed, and that after living for a few hours in a state of weakness and torpor, with chilliness of the whole surface, the child dies without any signs of convulsion. Instances of this form of asphyxia will be sure to come under the notice of those of you who engage in midwifery practice. I need hardly remind you that the first indication to fulfil in their treatment is to relieve the overloaded vessels of the brain, by allowing of the escape of half an ounce or an ounce of blood from the divided umbili- cal cord. When the diminished lividity of the surface shows that this end has been attained, the cord should be tied, and the child may now be plunged for a minute or two in a hot bath at 100° or 102°; but prolonged immersion in a warm bath at a less elevated tempera- ture is likely to depress the nervous energy. While the body is in the bath, cold water may be dashed rather smartly on the face or chest, INFANTILE ASPHYXIA. 59 by which means the inspiratory muscles are often excited to action, or the infant may be plunged into a hot and cold bath alternately. If, however, the child do not soon begin to breathe, you must not con- tinue too long the use of these or of other subsidiary measures, such as the application of ammonia to the nostrils, tickling the throat or nares with a feather, &c.; for you would thus fruitlessly consume that time which would be much more usefully spent in making a perse- vering trial of artificial respiration. This is scarcely the place for long details with reference to the best mode of exciting respiration, or of restoring it when suspended, but it would not be right to pass unnoticed the suggestions of Dr. Marshall Hall,1 with reference to this subject. It would, indeed, appear as if the inflation of the lungs with air must needs be the simplest and most effectual mode of exciting respiration, but every one who has attempted it must have found great and unexpected difficulties in its performance. It needs a degree of dexterity for its accomplishment, such as frequent practice alone can give, and such as it is vain to look for among even the most intelligent attendants in the lying-in room, while the condi- tion of the mother herself often calls for the personal care of the doctor, and prevents him from doing more than giving directions to others as to the best means of resuscitating the child. These circumstances give all the greater value to Dr. M. Hall's plan for exciting respiration, not by forcing the air into the lungs directly, but by drawing the air into them by changes of posture which imitate the respiratory movements, but which are so simple in their nature, that they can be easily carried out by any person of moderate intelli- gence. He directs that, in the first instance, the infant should be placed on its face, in order to allow of the escape of any fluids from the wind- pipe ; and that, if sprinkling the general surface briskly with cold water should fail to excite respiration, what he terms postural respiration should then be commenced. This consists in first turning the child on its face, at the same time pressing gently on the back, and then removing that pressure, and turning it gently on the side, and a little beyond, and so on perseveringly until respiration is established. The turning the body from the prone position produces an inspiratory effort, while expiration follows of necessity when it is placed upon its face; and the repetition of these movements about thirty times in a minute introduces air into the lungs, as certainly, more safely, and in many instances more effectually, than would be done by its direct insuffla- tion into the mouth, or by means of a tube placed in the trachea. A still more efficient mode of introducing air into the lungs appears to be that suggested by Dr. Silvester, and on which a committee of the Medico-Chirurgical Society, appointed to consider the subject of suspended animation, has reported very favorably.2 " An inspiratory effect is produced by extending the arms upwards by the sides of the head, or restoring them to their original position by the side of the body; or, still better, by pressing them on the lower third of the 1 Prone and Postural Respiration, &c, by M. Hall, M. D., 12mo. London, 1857. See pp. 25 and 56. 2 In vol. xlv. of the Transactions. 60 EFFUSION OF BLOOD EXTERNAL TO THE SKULL. sternum, the expanded walls are allowed to resume their previous state, and expiration takes place, the quantity of air expelled being in proportion to that which had been previously inspired." I had opportunities of testing the success of this mode in the case of the still-born infant. It seems, however, to be indisputably superior to any other as a means of introducing air into the chest, and I should imagine could be more easily and efficiently carried out by the attendants in the lying-in room than the method of Dr. Marshall Hall. If no occurrence have taken place more serious than a very great degree of congestion of the cerebral vessels, you will generally succeed, by the use of these means, in restoring the child. Often, however, it will happen that your attempts at resuscitation will fail completely, or that after breathing imperfectly for a few hours, without having ever seemed thoroughly restored, the child will die, and you will then find blood poured out into the cavity of the arachnoid. The extravasation is sometimes limited to the neighborhood of the cerebellum, but at other times it covers a considerable part of the convex surface of the brain, and even occupies the spinal canal; as you see in this by no means exaggerated representation of a case of infantile apoplexy in Cruveilhier's great work on Morbid Anatomy.1 It fortunately happens that the overcharged vessels of the head in the new-born infant do not always relieve themselves by pouring out blood within the skull, but sometimes the capillaries of the scalp give way, and blood is extravasated into its tissue; or, at other times, the effusion of blood takes place between the bone and pericranium. When this last accident occurs it often gives rise to the formation of a tumor upon the head that presents peculiarities sufficient to call for some notice. This tumor (cephalhematoma, as it has been called, from xs^axii, head, and cdpatZua, from alfia, blood) makes its appearance within forty-eight hours after birth—often much sooner—on one or other parietal bone, most frequently on the right, as a circumscribed, soft, elastic, slightly fluctuating, painless swelling, beneath the unchanged integument. On a careful examination, it is generally felt to be bounded by a firm, ap- parently osseous ridge, which usually encircles it completely, though more distinct at one part than another. On passing the finger over the summit of this ridge, and down towards the base of the tumor, the impression is at once conveyed of the parietes of the skull being defi- cient at this point, and of the ridge being the edge of a hole in the bone. When first discovered, the tumor is usually small, but increases in the course of two or three days from the size of a marble to that of a chestnut, or of half a hen's egg. As it grows larger, it generally be- comes tenser, but still seems to cause no pain, and the child's health continues good. After it has attained its full size, it often remains stationary for a few days, and during this time a gradual increase in the distinctness of the ring which surrounds it is the only change that it undergoes. A slight diminution in the size of the tumor at length becomes perceptible, and then it slowly disappears, though its removal 1 Anatomie Pathologique, liv. xv. pi. 1. CEPHALHEMATOMA. 61 occupies a month, six weeks, or more; and a slight elevation of the skull at the point where it was situated sometimes remains even longer. The centre of the tumor generally retains its soft and fluctuating cha- racter nearly tp the last, but occasionally it loses this, and communi- cates to the finger a sensation of crackling, such as we should expe- rience if we pressed on a piece of tinsel. Although once the subject of much difference of opinion, the mode of formation of these tumors, and the nature of the changes they undergo, are now tolerably well understood. The edges of the os uteri, compressing the foetal skull during labor, just as, in this engraving,1 the hands are represented compressing it, often produce an effect simi- lar to that which you see depicted here, and occasion an oozing of blood from its surface; or the same result may follow from undue pres- sure of the foetal head against the pelvic walls. The quantity of blood thus poured out is usually small, and is then speedily absorbed without having at any time produced a perceptible swelling. If, however, it be more considerable, a tumor is formed on the exterior of the skull, and this tumor may continue to enlarge for some time after birth, owing, possibly, to the influence of causes calculated to keep up a con- gested state of the brain, and to favor the effusion of blood.2 The blood thus effused speedily coagulates, and the edge of the co- agulum sometimes conveys to the finger an indistinct sensation of a raised border surrounding the tumor. The elevated ring that is after- wards plainly felt circumscribing it is, however, mainly the result of a reparative process, in the course of which a fibrinous exudation is poured out over that part of the skull whence the pericranium has been detached, and is heaped up in great abundance just where the bone and its investing membrane come into apposition. This is proved to be its real source, by the circumstance that the ring becomes much more evident after the absorption of the blood has commenced than it is at first; while in those cases where the effusion of blood has been very considerable, no ring is perceptible during life, and it is found after death that scarcely any attempt at reparation has been made, and that the fibrinous exudation is very scanty, or altogether absent. This exudation is generally absorbed in course of time, but some- times a process of ossification is set up in it; the fibrinous ring becomes converted into an osseous ridge, and that part of the cranium over which the blood had been poured out is roughened by the formation 1 In Valleix's Clinique des Maladies des Enfants Nouveaux-nes, Paris, 1859, planche i. fig. 2. 2 The various questions relating to the mode of formation of these tumors are fully discussed by Feist, Ueber die Kopfblutgeschwulst der Neugebornen, 4to. Mainz, 1839 ; and by Burchard, De Tumore Cranii recens natorum sanguineo, 4to. Vratislaviae, 1837 ; where are likewise mentioned various exceptional cases in which the swelling formed on the parietal bone that had been directed towards the sacrum, and not, as is usual, on the bone which had been presented during labor. The investigations of Professor Levy, of Copenhagen, published in the Journal fur Kinderkrankheiten, March, 1852, show fresh exceptions to this, whioh had been supposed to be the general rule, and prove that sudden pressure, however exerted, is quite adequate to occasion this acci- dent. M. Seux's laborious essay on the subject, which forms the second number of his Recherches sur les Maladies des Enfants Nouveaux-nes, 8vo. Paris, 1863, does but confirm in all points the results arrived at by previous observers. 62 EFFUSION OF BLOOD EXTERNAL TO THE SKULL. of new bone upon its surface. The meaning of the appearances thus produced was long misunderstood, and they were thought to be owing to a process of destruction, not to one of cure. The roughened surface of the skull was looked on as the result of ulceration, by which its outer table had at one part been destroyed, and the bony ridge around it was supposed to be the edge of that part of the outer table to which the disease had not yet extended. The real nature of these changes was extremely well exemplified in a very remarkable case that came under my notice, in which blood was effused between the skull and dura mater, as well as between it and the pericranium.1 This drawing shows the processes of cure in progress. First, however, you may notice the perfect smoothness of the inner surface of the bone, in order to display which the edge of the clot is raised. Its outer as well as its inner investment had been detached from this portion of the skull by the effusion of blood beneath them, and the bone continues un- roughened, because an attempt at reparation was impossible here. At the edge of the clot, the dura mater and the bone come again into contact, and nature has here begun the cure. New bone has been deposited, and an osseous ridge has been formed precisely similar to that which in so many instances surrounds the external effusion. Nor is this all; but bony plates are beginning to be deposited between the layers of the dura mater, exemplifying the manner in which, when blood has been poured out beneath the pericranium, that membrane sometimes becomes ossified, and accounting for the crackling sensation that in these cases is felt on pressing the tumor. The characteristics of these tumors are so well marked, that they are not likely to be confounded with swellings of the scalp produced by any other cause. A hernia of the brain, indeed, may present some resemblance to them, since it forms a soft painless tumor, unat- tended by discoloration of the integuments, and the edges of the aperture in the bone through which the brain protrudes may easily be taken for the ring surrounding an effusion of blood beneath the pericranium. Independently, however, of the pulsating character of the swelling formed by hernia of the brain, its situation at one of the fontanelles, probably the posterior, or in the course of one of the sutures, will generally distinguish it sufficiently from these sangui- neous tumors, which are almost always seated on the parietal bone, and near to its protuberance. While the nature of this affection was ill understood, many practi- tioners regarded it as of very serious import, and thought that its cure could be effected only by making a free incision into the tumor, and emptying it of the effused blood, or else by applying caustic to its surface, with the view of exciting suppuration within it. There is, however, no real necessity for these severe measures, which appear in not a few instances to have caused the death of the child; for the blood will in the course of a few weeks be absorbed, and the tumor diminish and disappear of its own accord. I have even seen a tumor 1 A description of this case will be found at p. 397 of vol. xxviii. of the Medico- Chirurgical Transactions. HEMORRHAGE INTO THE ARACHNOID. 63 of larger size than my fist, which was seated on the right parietal bone, but extended considerably beyond the mesial line, disappear completely of its own accord in the course of four months. The great difficulty, indeed, that you will encounter will consist in per- suading the parents to let the swelling alone, and to wait till time effects its removal. While, however, the affection requires no treat- ment, and is generally not attended by any danger, it is yet right to bear in mind the possibility of internal as well as external effusion having taken place. In this case, as happened in an instance that came under my notice, the sudden increase of the internal effusion may be followed by apoplectic symptoms, and death; or, as in the other instance which I have just mentioned of the very large effusion, the injury inflicted on the brain may be so considerable, that the child may survive only to present every sign of hopeless idiocy. Perhaps I may be pardoned if I digress for a moment to notice the occasional pouring out of blood beneath the occipito frontalis or temporal muscle in children as the result of a blow on the head. Unlike a bruise, this effusion does not always take place at the precise spot where the injury was inflicted, but the greater size of the vessels that traverse the skull at the side seems to be the reason why a shock, such as a fall on the occiput, is sometimes succeeded by the formation of a tumor of this kind at the side of the head, and not at the part which received the blow. It has twice come under my notice in these cir- cumstances. The tumor thus formed is soft, painless, and fluctuating, and its size at first increases very rapidly, but the integuments covering it are neither hot nor discolored. It is not surrounded by so well- defined a ring as circumscribes the swelling formed by the effusion of blood beneath the pericranium; the ridge is imperfect, its edge is much less sharp, and it is often to be felt nowhere except near to the insertion of the temporal muscle. In this as in the other case nature herself is usually fully equal to the removal of the blood, and the consequent dispersion of the swelling. Cerebral hemorrhage, though at no other time so frequent as imme- diately after birth, may occur at any period of subsequent childhood, under the influence of causes that favor congestion of the brain, or even independently of any cause that we can discover. The hemor- rhage still takes place almost invariably into the arachnoid cavity, and blood is sometimes poured out there in very large quantity; but the accident is neither so invariably nor so speedily fatal as in the new- born infant. If death should follow very soon after the occurrence of the effu- sion, the blood is found unchanged, forming a more or less extensive layer upon the convex surface of the brain, and extending downwards and backwards towards the base of the organ, but seldom situated at its anterior part unless the hemorrhage have been unusually profuse. If life be prolonged, the clot speedily separates into serum and crassa- mentum, and a series of changes commences in the latter, the effect of which is to deprive it of its coloring matter, and to convert it, in course of time, into a delicate false membrane, which lies in close apposition with the parietal arachnoid. This transformation may sometimes be 64 OBSCURITY OF SYMPTOMS OF observed while in course of progress, and a central clot may then be seen gradually losing itself in a membrane that grows more and more delicate towards its periphery. If, as occasionally happens, successive effusions of blood take place at somewhat distant intervals, this mem- brane may become thick and firm, and may even present a pearly lustre; which circumstance has led some observers into the error of attributing the appearance to alteration and thickening of the dura mater. The amount of the original effusion has much to do with the rapidity of the changes in the clot. If the effusion were but incon- siderable, the serum of the blood soon becomes absorbed, and no other trace of the occurrence remains than the false membrane lining a por- tion of the arachnoid. If the hemorrhage were at all abundant, the reddish serum will, even after the lapse of a considerable time, be very evident on opening the sac of the arachnoid, and some of it will pro- bably be found entangled it} the substance of the clot. By degrees the serum loses its color, but its quantity may still continue for a long time undiminished, or the efforts of nature may even entirely fail to accomplish its absorption. The fluid in such cases is either simply contained within the arachnoid cavity, or, having remained inclosed within the clot during the changes which it underwent, appears at length to be situated within a delicate cyst or shut sac. If the hem- orrhage, in the first instance, were very considerable, or if it were to recur two or three times, the yielding cranium of the child will enlarge, the head will alter in form, and the case will assume many of the cha- racters of chronic hydrocephalus.1 All writers, even those who, like MM. Eilliet and Barthez, have thrown the most light on the anatomy and pathology of cerebral hem- orrhage in the child, concur in representing its symptoms as extremely obscure. Paralysis, which, in the grown person, is one of the most frequent results of the escape of blood from the cerebral vessels, is so rare in the child that it was observed by M. Legendre2 only in one out of nine cases, and by MM. Rilliet and Barthez3 in one out of seventeen cases. This peculiarity is doubtless in great measure accounted for by the circumstance of the blood being almost always poured out into the cavity of the arachnoid, so that the pressure which it exerts on 1 Not having had the opportunity of observing the whole series of changes said to take place in blood effused into the sac of the arachnoid, I have chiefly followed the account given by MM. Rilliet and Barthez, in their Traite des Maladies des Enfans, 2e ed. Paris, 1853, vol. ii. pp. 247-255. I am not, however, prepared to say how far this, which was the generally-received opinion as to the source of the hemorrhage and the mode of formation of the false membrane associated with it, is still to be regarded as correct. The observations of recent writers, as, for instance, Virchow, in his work Die Krankhaften Geschwulste, 8vo. Berlin, 1863, p. 140 ; and Lancereaux, in the Archives de Medecine, 1862, vol. ii. pp. 526-679, and 1863, vol. i. p. 38, tend to prove the forma- tion of inflammatory false membranes to be the first step in the morbid process, the occurrence of hemorrhage the second. I can, however, scarcely imagine that acci- dents which seem so sudden as hemorrhages into the arachnoid in children can really be due to a long train of previous morbid phenomena. The observations which have led to this conclusion were also made in the adult and in the aged. The subject seems to me to require further investigation in infancy and early childhood. 2 Recherches Anatomo-Pathologiques sur quelques Maladies de l'Eufance, 8vo. Paris 1846, p. 130. 3 Lib. cit., p. 257. HEMORRHAGE INTO THE ARACHNOID. 65 the brain is generally diffused over the surface of the organ, and is nowhere very considerable. The absence of paralytic symptoms, however, is not the sole cause of the obscurity of these cases, but the indications of cerebral disturb- ance by which they are attended vary greatly in kind as well as in degree. The sudden occurrence of violent convulsions, and their fre- quent return, alternating with spasmodic contraction of the fingers and toes in the intervals, appear to be the most frequent indications of the effusion of blood upon the surface of the brain. I need not say, however, that such symptoms taken alone would by no means justify you in inferring that effusion of blood had taken place. Many circumstances having reference to the previous history of the child, as well as to its present condition, must be taken into account in form- ing a diagnosis. Hemorrhage into the arachnoid cavity is most fre- quent in early childhood—symptoms such as have been enumerated would therefore acquire additional diagnostic importance in propor- tion to the tender age of the child in whom they occurred. The pro- bability of their betokening this accident would be still further strengthened if the child who experienced them had previously suf- fered from frequent attacks of cerebral congestion, or had been recently exposed to the sun without proper covering for the head; or had been placed in other circumstances calculated to favor determination of blood to the head. The popular notion that associates the idea of rude health and general plethora with the occurrence of apoplexy in the adult, is in many instances altogether fallacious. In the case of the child it has still less foundation, since the effusion of blood upon the brain occurs much more frequently in weakly children than in such as are robust. There seems to be reason, indeed, for supposing that the hemorrhage is sometimes of a purely passive character, and dependent on an altered state of the blood. I will relate to you a case or two as illustrations of this cachectic form of cerebral hemorrhage. Some years ago, I saw a little boy, five weeks old, the child of healthy parents, and who had been perfectly well for the first fortnight after his birth : he then, without any evident cause, grew drowsy, and vomited often, and his skin became quite jaundiced. His abdomen at this time was large and hard, and he cried when pressure was made on the right hypochondrium: these symptoms still continued when he was brought to me. A leech now applied on the right side drew a good deal of blood, and the hemorrhage was stopped with difficulty; the bowels, previously constipated, were acted on by small doses of calomel and castor oil, and in three days the child lost the yellow tinge of his skin, became cheerful, and seemed much better. He was now, however, on the 18th of July, suddenly seized with hurried respira- tion and great depression, soon followed by violent convulsions, dur- ing which he screamed aloud. At the same time it was observed that his left hand had begun to swell, and to put on a livid hue, and on the 20th, the right hand also became cedematous. His whole surface grew quite sallow, and, on the day before he died, the oedema of the left hand had much increased; the livor had become considerably deeper, 5 66 HEMORRHAGE INTO THE SUBSTANCE OF THE BRAIN. and there were small spots of extravasated blood over each knuckle. The right elbow was slightly livid; the right hand much swollen, but of its natural color; and a small black spot had appeared under the chin corresponding to the knot of the cap-string. The fits recurred very frequently, the child in the intervals lying quite still; the pupils were contracted, and the condition seemed to be one of extreme ex- haustion rather than of coma. On the 20th, the power of deglutition was lost, and after several returns of less violent convulsions the child died at 9 A. M. on July 21st; about sixty hours after the occurrence of the first fit. The sinuses of the brain were full of fluid blood ; a black coagulurn, three or four lines thick, covered the whole posterior part of both hemispheres, extending from the posterior third of the parietal bones, occupying the whole concha of the occipital bone, and reaching along the base of the skull to the foramen magnum. A little blood was likewise effused about the anterior part of the base of the brain, though the quantity was very small in comparison with what was found at its posterior part. The substance of the brain was very pale, and all the organs of the body were anaemic, except the liver, which was gorged with fluid blood, while the heart was quite empty. The ductus arteriosus was closed, the foramen ovale admitted a probe with ease, the ductus venosus admitted one with difficulty. Another instance has since then come under my notice, in which passive hemorrhage took place into the arachnoid in a child exhausted by long-continued illness, the effects of which were aggravated by poverty and want. From the age of two to that of five months the child had been under my care in consequence of frequent attacks of hsematemesis and purging of blood, and though his health afterwards improved, yet he never became strong, and his evacuations were almost always white, and deficient in bile. After he was weaned, the coarse food which his indigent parents gave him did not nourish him; he lost flesh and strength, and when almost three years old was puny and emaciated. Three days before his death an attack of diarrhoea came on, which induced great exhaustion; and while suffering from this affection, he suddenly grew comatose, cold, and almost pulseless, and his breathing became so slow that he inspired only four or five times in a minute. In this state he lay for twenty-four hours, and then died quietly. Nearly six ounces of dark coagulated blood 'were found in the sac of the arachnoid, over the right hemisphere of the brain; a little blood was likewise effused beneath the arachnoid, and there was a very small clot in the lower and front part of the right middle lobe of the brain, but no ruptured vessels could be perceived. Great anaemia of every organ, and a state of extreme attenuation of the walls of the heart, were the only other remarkable appearances. Hemorrhage into the substance of the brain, though extremely rare in infancy and childhood, does sometimes occur, and then gives rise to appearances similar to those with which we are familiar in the adult. Death, however, usually takes place too speedily in these cases for any of those changes to occur in the apoplectic effusion which are often HEMORRHAGE INTO THE SUBSTANCE OF THE BRAIN. 67 observed in the adult, and which betoken the advance that nature has made in her efforts to repair the injury of the brain. I have only twice met with distinct extravasation of blood into the substance of the brain in children. In the first case, that of a little girl 11 months old, the occurrence was evidently due to the impedi- ment to the circulation through the brain produced by the formation of a thrombus in the longitudinal sinus, and consequent inflammation of the sinuses of the dura mater. In addition to other appearances, which I shall describe in a future lecture,1 there was great venous con- gestion of the membranes covering the middle lobe of the left hemi- sphere of the brain, aud the cerebral veins were distended with coagula, and their coats were thickened. At the anterior part of the lower surface of the left middle lobe of the brain there were four apoplectic effusions, in all of which the blood still retained its natural color, and each effusion was situated close to an obliterated and distended vein. The largest clot extended for an inch into the substance of the brain, and the others were of smaller dimensions. Head symptoms, as might be expected, had existed in this little child for a long time before her death. The occurrence of the effusion was probably synchronous with a sudden attack of extreme faintness that came on forty-eight hours be fore she died, and from which she never completely rallied. The other instance of hemorrhage into the substance of the brain occurred in a girl 11 years old, the child of healthy parents, and whose own health had been quite good until she was six years of age. At that time the extraction of a molar tooth was followed by necrosis of a large portion of the lower jaw, and by the formation of abscesses in the face and head, from which bone escaped. An abscess, attended with similar exfoliation of bone, formed likewise on the right foot, and it was three years before the child had recovered completely. Though much disfigured by the disease, her health ever after conti- nued good until April 12, 1846. She was then suddenly and cause- lessly attacked by vomiting and pain in the head, for which no other treatment was adopted during ten days than the occasional adminis- tration of an aperient. During this time, however, a condition of stupor gradually stole over the child, for which, on April 21, a blister was applied to the back of her neck with great relief. On April 23 she had two attacks of convulsions, with an interval of four hours be- tween each. She struggled much during their continuance, especially with the right side; when the convulsions subsided, partial palsy of the left side remained; the child complained much of her head, and sank from time to time into a state of stupor, from which, however, she could always be roused. Very free purgation on April 24, and the application of another blister to the back of the neck, were followed by some amendment. On the evening of the 25th another fit occurred, with symptoms similar to those that had been observed on the previ- ous occasions; but it was not followed by any increase in the palsy of the left side, nor was the degree of stupor so considerable as on the former occasion. Mercurials, which had been employed from the corn- 1 See Lecture VIII. 68 CAPILLARY HEMORRHAGE. mencement of the attack, had now produced a decided influence on the mouth, and the abundant action of the bowels was again succeeded by much improvement in the child's condition. The pulse, which had varied from 60 to 70, now continued about 70, and was natural in character, and the child improved daily, though taking no other medicines than occasional aperients. The headache returned occa- sionally, though each time it was less severe than the time before; but on the evening of May 15th this amendment was suddenly interrupted by an attack of violent pain in the abdomen, which was soon followed by convulsions and coma, and the child died convulsed in sixteen hours, on the 36th day from the first attack of pain in the head. On making an examination of the head, blood was found to be effused into the subarachnoid tissue over a great part of the right hemisphere of the brain. The quantity of blood, however, was no- where very considerable, but merely occupied the sulci between the convulsions. The brain presented no remarkable appearance, except that on a level with, and just exterior to the right lateral ventricle, there was a large clot of blood, rather larger that a hen's egg, but of more irregular shape, around which the brain was softened. This effusion was perfectly black throughout, the coloring particles of the blood being equally diffused through it, and no appearance betokened that hemorrhage had previously taken place in this situation. The anterior cerebral artery ran for a considerable distance just outside the clot, but it could not be ascertained that it had given way at any point. Cerebral hemorrhage is one of the few affections of early life con- cerning the treatment of which but little can be said; for where the symptoms of a disease are so obscure, it would be idle laying down elaborate rules for its cure. The general principles, according to which you would manage a case of congestion of the brain, would still guide you if hemorrhages had taken place. It cannot, however, be necessary for me to repeat to-day the observations on that point to which I yesterday directed your attention. Before concluding, I must for a moment refer to a form of cerebral hemorrhage, which, though of no great importance, yet forms an exception to what has been stated as to the rarity of the accident in early life. In children who have been affected with tubercular dis- ease of the brain, it is by no means unusual to observe very small effusions of blood in the midst of the softened cerebral matter that surrounds the deposit. This capillary apoplexy, produced by some of the minute vessels of the brain giving way, is, however, seldom ex- tensive, and probably has but little share even in accelerating the fatal event. When next we meet, we shall pass from this subject, which, it must be owned, has more of a pathological than of a practical interest, and shall enter on the study of the inflammatory affections of the brain in childhood. INFLAMMATORY AFFECTIONS OF THE BRAIN. 69 LECTURE VI. Inflammatory Affections of the Brain—frequent in childhood, but overlooked by early writers—first noticed about a century ago—described under the name of acute hydro- cephalus by Dr. Whytt. Acute Hydrocephalus—progress of knowledge with reference to it.—The name restricted in these lectures to scrofulous inflammation of the brain, which is much more frequent than its simple inflammation in childhood. Morbid appearances in acute hydrocephalus—due either to inflammation or to tubercular deposit—alterations more apparent in the membranes at the base of the brain than in those of its convexity.—Reasons for considering granulations of the membranes as tuber- cular.—Increase of fluid in the ventricles almost invariable.—Central softening of the brain not a post-mortem alteration—frequently connected with changes in the lining of the ventricles.—Inferences to which these facts lead. Symptoms of the three stages of the disease. Few of the diseases of childhood are more serious than those in- flammatory affections of the brain on the examination of which we are now about to enter. They occasion 9.8 per cent, of all deaths under five years of age in this metropolis, while they are so especially the diseases of early life, that 81.1 per cent, of all cases of fatal inflamma- tion of the brain occur in children under five years of age, 90.2 per cent, before the age of 10, and 92.4 per cent, before the age of 15.1 But though the frequency of these affections in the young is a matter of such popular notoriety that most of you were familiar with the fact long before you were engaged in your present profession, yet if you turn to the writings of any of the old physicians, you will find in them no mention of inflammation of the brain in childhood. At first this may surprise you, but a few moments' consideration will explain the seeming oversight. Convulsions, which form a prominent symptom in most cases of inflammation of the brain occur, as I need not remind you, in the course of many other affections of the nervous system. An accident so alarming as a fit of convulsions is sure to attract attention, but much careful examination is often needed to distinguish those minor differences between the symptoms that pre- cede or accompany it, which alone would indicate its cause. It can- not, then, be surprising, that in the absence of this minute care, many diseases, though differing in most important particulars, should have long been classed together under the head of convulsions, and that inflammation of the brain should not have been recognized as a dis- tinct affection. The importance of some of those less obvious struc- tural changes which we know to be most significant of the nature of previous diseases, was not then understood, so that an alteration in the consistence of the brain, or a diminution in the transparency of its 1 Deduced from 5th and 8th Reports of Registrar-General for 1842-5. * 70 INFLAMMATORY AFFECTIONS OF THE BRAIN. membranes, often passed unnoticed; and anatomical research was not exact enough to make up for the deficiencies in clinical observation. But just as the physician's attention was fixed on the convulsive seizures which in so many cases affected his patients, so the eye of the anatomist was often arrested by the discovery of a large quantity of fluid in the interior of the brain. Sometimes this fluid had been secreted in such quantity as not only to distend the ventricles of the brain, but to occasion a manifest enlargement of the skull. In such cases the disease was essentially chronic in its course, and was called, from its most striking characters, dropsy of the brain, or chronic hydrocephalus. Speculation, however, was set afloat by the occasional notice of cases in which, though fluid was found in large quantity within the brain, yet the previous disease had been of short duration, its symptoms had been acute, and the fever, drowsiness, and cerebral disturbance which attended it had run a very rapid course to their fatal termination. Dr. Whytt was the first1 who, in the yeaj 1768, clearly pointed out the connection between these symptoms and the accumulation of fluid in the ventricles. His attention, like that of previous observers, was mainly fixed on this point, to the exclusion of other morbid appear- ances, and he was thus led to regard the disease as an acute dropsy of the brain. Little can even now be added to his description of the malady, but further observation has shown that the presence of an increased quantity of fluid in the brain, on which he laid so much stress, is not of invariable occurrence; that there is no certain relation between the amount of the fluid and the intensity of the symptoms, or the rapidity of their course; and that it is almost always associated with other very important lesions, some of which are the evident results of inflammation. Many years were occupied in the investiga- tions which led to this conclusion; so that long before Whytt's theory had been ascertained to be erroneous, people had grown familiar with the name which he proposed for the disease, and in this country it is still called hydrocephalus, or acute hydrocephalus. A most important step towards a knowledge of the true pathology of this disease was the discovery that the fluid poured out into the ventricles is not a mere dropsical effusion, but that it is the result of previous inflammatory action. A difficulty, however, appeared when it was ascertained that in those cases in which the signs of inflamma- tion of the brain were most evident during life, and its effects most marked after death, both the symptoms and the morbid appearances differed m some respects from those usually observed in Whytt's dis- ease. The almost invariable existence of a very obvious tendency to scrofula in well-marked instances of Whytt's disease, and its frequent absence in other cases of inflammation of the brain, did much towards solving this difficulty. It was next discovered that in nearly every instance in which Whytt's disease terminates fatally, tubercle is present in greater or less abundance in various organs of the body; and to the acuteness of French anatomists we owe the last step in this investiga- 1 In his Observations on the Dropsy in the Brain. 8vo. Edinb. 1768. ACUTE HYDROCEPHALUS. 71 tion, by which it has been shown that in the majority of cases the membranes of the brain themselves are the seat of tubercular deposit. We are thus led to the conclusion that inflammation of the brain occurs in early life under two different conditions. It now and then comes on in previously healthy children, but occurs much oftener in connection with the tuberculous cachexia, or as the result of tubercular deposit in the brain or its membranes. The term encephalitis may be properly used to denote the cases of simple inflammation of the brain, while we may with advantage restrict that of acute hydrocephalus to cases of cerebral inflammation in scrofulous subjects. Owing to the extreme rarity of "the former affection, it will, I think, be our better plan first to study minutely all the characters of acute hydrocephalus, and then to examine the points of difference between simple and scro- fulous inflammation of the brain. We will commence this investigation with an inquiry into the nature of the appearances found after death in cases where acute hydrocephalus has had a fatal termination. These may be divided into two classes, according as they are the result of inflammation or of the deposit of tubercle; and changes due to both of these causes are often found in the membranes of the brain as well as in its substance. The appearances which present themselves on the skull being opened are seldom very striking, for the dura mater is usually healthyj and the changes in the arachnoid are not in general of a kind at once to attract attention. Sometimes, indeed, the eye is struck by an exces- sive vascularity of the membranes, but this appearance often depends on the over-filling of the large vessels as the result of position. Atten- tive examination will enable us to distinguish between this, and that increase of vascularity which is produced by a uniform injection of the minuter vessels; and moderate pressure, while it causes the disap- pearance of the apparent vascularity in the former case, will produce no effect on the true congestion in the latter. The secretion that naturally moistens the sac of the arachnoid is altered, increased, or suppressed; but the last of these changes is the most frequent, while the first is seldom observed in cases of hydroce- phalus. The preternatural dryness of the membrane is usually con- nected with some diminution of its natural transparency; it looks dull and lustreless, and feels sticky—a state to which the French have ap- plied the term "poisseux." The dulness of the arachnoid is sometimes more considerable, and it then presents an opaline appearance, which is very evident at those parts where the membrane passes from one convolution to another. This opalescence is not often general, but is usually most marked about the upper part of the hemispheres, and in the neighborhood of the longitudinal fissure. When any considerable degree of vascularity of the membranes is evident, this is, of course, chiefly due to the injection of the minute vessels of the pia mater. Such intense injection of the pia mater is, however, far less frequent than the effusion of fluid between it and the arachnoid, and it is still less common to find the two appearances in the same subject. The effused fluid is for the most part colorless and transparent, and if present in any considerable quantity, the surface 72 MORBID APPEARANCES. of the convolutions then appears as if covered by a layer of transpa- rent jelly, though on puncturing the membrane a drop of clear serum will exude. The effusion of lymph or pus into the pia mater covering any considerable extent of the convexity of the brain is very seldom met with, but deposits of a yellow puriform lymph are not infrequently seen occupying the depressions between the convolutions, or following the course of the vessels along the sides, or at the upper surface of the hemispheres. But though the alterations presented by the membranes at the con- vexity of the brain are often comparatively trivial, the membranes at the base of the organ almost always show unequivocal traces of in- flammatory action. The predominance of the affection of the mem- branes at the base of the brain has, indeed, been regarded by some writers as pathognomonic of scrofulous inflammation of the organ;1 and though this rule is not without exception, still it holds good in the vast majority of cases. In 56 out of 61 fatal cases of acute hydro- cephalus, in which I carefully recorded the condition of the membranes, those at the base of the brain were found to be the seat of disease more or less extensive, and always more considerable than that which ex- isted at the vertex. In one of the cases in which the membranes at the base were healthy, there was a good deal of serous effusion beneath the arachnoid at the convexity; and in another instance there was some fluid in the sac of the arachnoid, and the pia mater covering the upper surface of the brain was greatly injected; but in the three re- maining cases the membranes at the upper, as well as those at the lower part of the brain, were perfectly healthy. The least considerable of the morbid changes in the membranes at the base of the brain consists in a milky or opaline condition of the arachnoid and pia mater, but chiefly of the former, sometimes extend- ing over the whole lower surface of the cerebrum, but seldom being equally apparent in that part of the membrane which invests the cere- bellum. But, besides this opacity, we usually observe much more distinct evidence of inflammatory action in the effusion of yellow lymph beneath the arachnoid. This is generally found about the olfactory nerves, which are often completely imbedded in it, while a similar effusion extending across the longitudinal fissure unites the two hemi- spheres of the brain together. A deposit of the same kind likewise reaches up the fissure of Sylvius in many cases, and connects the ante- rior and middle lobes of the brain with each other; or if poured out in less abundance, it may be seen running up in narrow yellow lines by the side of the vessels as they pass from the base of the brain towards its convexity. It is in the neighborhood of the pons Varolii however, and about the optic nerves, that the most remarkable altera- tions are met with. The opacity of the arachnoid is here particularly evident, while the subjacent pia mater is opaque, much thickened, and often infiltrated with a peculiar semi-transparent gelatinous matter sometimes of a dirty yellowish-green color. This matter is occasion- 1 On which subject, the valuable essay of M. Rilliet, De l'lnnammation franche des Meninges chez les Enfants, in the Archives de Medecine for Dec, Jan., and Feb. 1846-7 may be consulted with advantage. "" ' ' GRANULATIONS OF THE MEMBRANES. 73 ally so abundant as perfectly to conceal the third and fourth nerves, and at the same time to invest the optic nerves with a coating two or three lines in thickness; though, on being dissected off, the substance of the nerves beneath appears quite healthy. When this morbid con- dition exists in any very considerable degree it extends beyond the pons, and involves th'e membranes covering the medulla oblongata, especially at its anterior surface. It is only within the past forty years that attention has been drawn to the importance of another element, besides mere inflammation, in the production of acute hydrocephalus. The peculiar granular appear- ances which various parts of the membranes of the brain almost in- variably present in this disease, though noticed many years before, began then to engage the special attention of several French physi- cians.1 The conclusion to which we are led by their careful investiga- tion of the subject, is, that this appearance is not due to inflammation, as was once supposed, but that it is occasioned by the presence of tubercular deposits. These deposits often assume the form of minute, flattened, spherical bodies of the size of a small pin's head, or smaller, and either of a yellowish color, and rather friable under pressure, or grayish, semitransparent, and resistant, almost exactly resembling the gray granulations which are sometimes seen in the lungs or pleuras of phthisical subjects. They are likewise sometimes met with in what would seem to be an earlier stage, when they appear like small opaque spots of a dead white color, much smaller than a pin's head, and com- municating no perceptible roughness to the membrane. This appear- ance is often observed in the arachnoid covering the cerebellum, and those parts of the base of the brain where the arachnoid is stretched across from one part of the organ to another. The flattened yellowish bodies are most frequently seen at the convexity of the brain, and on either side of the hemispheres. They generally follow the course of the vessels that ramify in the pia mater, and accordingly occupy the sulci between the convolutions much oftener than their summit. The firm gray bodies are mostly seen about the pons, or imbedded in the pia mater in the neighborhood of the optic nerves, or projecting from the surface of the membranes that cover the medulla oblongata. They are also often deposited in the arachnoid lining the occipital bone, and are then sometimes collected in considerable numbers around the fora- men magnum. These bodies, sometimes of a gray, at other times of a yellow color, are likewise met with, though less frequently, in the substance of the velum interpositum, or imbedded in the choroid plexuses, and in both of these situations they are sometimes very abundant. These bodies, however, do not always retain the appearance of dis- tinct granules, but sometimes on separating two folds of the arachnoid which had seemed to be glued together by an effusion of yellow lymph or concrete pus, we find that the matter which forms these adhesions is not homogeneous, but that it consists of an aggregation of minute 1 M. Papavoine appears to have been the first who, in the Journal Hebdomadaire for 1830, vol. vi. p. 113, clearly established the tubercular nature of these granulations of the membranes of the brain. 74 TUBERCULAR NATURE OF THE GRANULATIONS. granular bodies connected together by the lymph or pus in which they are imbedded. This appearance is often met with at the con- vexity of the brain, and close to the longitudinal fissure, and rather more towards its posterior than its anterior part; a strip of this yellow matter, half an inch long by two or three lines broad, connecting to- gether the two hemispheres of the brain or the two surfaces of the arachnoid. Sometimes two or three deposits of this kind are observed at the convex surface of the brain, but they are generally more exten- sive at the base of the organ, where they occupy the longitudinal fis- sure and the fissure of Sylvius, and frequently connect opposite surfaces of the brain so closely together as to render their separation impossible without injury to its substance. But you may ask me for the proof of these granular bodies being, as I have represented them to be, real tuber- cular deposits. It would occupy nearly the whole of this lecture to detail all the arguments that have been adduced on both sides of the question, for it is a question which has been much disputed; since some persons were long disposed to regard them merely as the pro- ducts of inflammation, while the majority of French writers are so convinced of their tubercular nature, and regard their presence as so essentially characteristic of this form of cerebral disease, that, discard- ing the term of Acute Hydrocephalus, they have, almost without ex- ception, agreed to designate it Tubercular Meningitis. The reasons which appear to be conclusive, in favor of the tuber- cular nature of these bodies,1 are— 1st. That they are always associated with tubercle elsewhere. 2d. That their abundance is not in proportion to the amount of in- flammatory mischief. 3d. That they are sometimes met with in cases where no head symp- toms were observed during life, and unconnected with any sign of in- flammation discovered after death ; and 4th. That their chemical composition and their microscopic structure are identical with those of tubercle in other organs of the body.2 1 With reference to these points, see Becquerel, Recherches Cliniques sur la Menin- gite des Enfans, 8vo. Paris, 1838, p. 20; and Lebert, Physiologie Pathologique, &c, 8vo. Paris, 1845, vol. i. pp. 440-449. 2 It is perhaps scarcely necessary to give a caution against confounding with these tubercular granulations those small corpuscles, the Pacchionian bodies as they are termed, which are met with either singly or in groups upon the upper surface of the hemispheres near the falx cerebri in the early years of childhood. They are minute round excrescences of the arachnoid, either semi-transparent or of a white color, made up of dense fibrous tissue like that of lowly organized cellular tissue. The arachnoid around them.is not infrequently somewhat thickened ; but they are in no other respect to be regarded as pathological conditions, than that there appears to be some connec- tion between their development and the previous frequent occurrence of cerebral con- gestion. In the course of time they sometimes perforate the dura mater, and form little depressions in the bone in which they become imbedded. They not seldom undergo conversion into the carbonate and phosphate of lime, and yield also slight traces of silex; and are in all respects different from the bodies referred to in the text. See Luschka, in Mutter's Archiv, 1852, p. 101; a review of a thesis by M. Faivre, in Arch. Gen. de Med., Avril, 1854 ; and Rokitansky, Pathol. Anat. Wien, 1856, vol. ii. p. 407. The laborious investigations of Dr. Meyer, of Hamburgh, pub- lished in Virchow's Arcliiv, 1860, vol. xix. p. 171, 288, support the view that the development of these bodies is associated with frequent and long-standing Variations in the cerebral circulation; and my own impression is that they are discovered in SOFTENING OF THE BRAIN. 75 Notwithstanding the important nature of the changes presented by the membranes of the brain in cases of acute hydrocephalus, it was long before they attracted as much attention as the alterations in the substance of the brain itself, and especially as that distension of its cavi- ties with fluid from which the malady has derived its name. The sur- face of the brain, indeed, generally presents but few traces of disease, though sometimes the convolutions are greatly flattened, and the sulci between them almost obliterated by the pressure of the fluid from within. The cerebral substance is often healthy as low down as the centre of Vieussens, or presents no change more important than the presence of an unusual number of bloody points, the divided cerebral vessels. But, though unaltered to the eye, a diminution of consist- ence is often perceptible as the ventricles are approached. Sometimes the whole brain seems softer than natural, while at other times, though not actually softened, it is infiltrated with fluid, as though it had soaked up the serum from the ventricles. The presence of a larger quantity of fluid than natural in the lateral ventricles is of almost constant occurrence. In 59 out of 61 cases in which death had taken place under the symptoms of acute hydro- cephalus, I found an appreciable quantity of fluid in the ventricles; and in 49 of these cases the quantity was considerable, amounting to several ounces. The fluid is in general a perfectly transparent serum, resembling passive effusions poured out from other serous membranes; and such it doubtless is in many cases in which it is found distending the lateral ventricles. But, in a large proportion of instances of hydrocephalus, the increased secretion in the ventricles is associated with a very notable change in the surrounding cerebral substance. This change consists in a loss of the natural firmness of the central parts of the brain; varying in degree from a slight diminution of con- sistence to a state of perfect diffluence, in which the cerebral substance forms a pulpy mass that is easily washed away by a stream of water; or the softening may be even more considerable, and the cerebral matter may become semifluid, and closely resemble thick cream. The parts thus affected are perfectly pale and bloodless, and the adjacent substance of the brain is usually rather anaemic. The fornix, septum lucidum, corpus callosum, and posterior horn of the lateral ventricles, are the parts most frequently affected; the optic thalami, corpora striata, and lower parts of the middle and posterior lobes of the brain, rank next in this respect, while the anterior lobes are but seldom soft- ened. In a few instances the cerebellum is involved in the softening, and now and then the whole brain is found to have lost much of its natural firmness—a change, however, which is usually much more marked on one side than the other. Closely allied to this softening is the state to which I have already referred, wherein the whole brain children who have died of hydrocephalus with much greater frequency than Meyer's statement of their extreme rarity before the sixth year would lead one to anticipate, though I do not know that I could state the fact numerically. It gives, however, to these appearances that position on the border land between physiological and patho- logical products which is, I apprehend, their proper place. 76 THE RESULT OF INFLAMMATION. appears perfectly infiltrated with serum, as though it had been long soaked in it, and had imbibed it like .a sponge. A mechanical explanation has been frequently suggested to account both for this appearance and for the central softening of the brain, which you will observe is most marked in those very parts to which the fluid in the ventricles would naturally gravitate after death. Many facts, however, are opposed to this view of the cause of softening of the brain. If it were a change induced by the imbibition of fluid after death, we should expect to find it as constant as is hypostatic congestion of the lungs; but instead of this being the case, fluid is found in many instances in the ventricles without the consistence of the brain being in the least diminished. In a recent work on Acute Hydrocephalus, which embodies the results of a very large number of dissections, it is stated that central softening of the brain existed only in 47 out of 71 instances, in which the ventricles contained a quantity of serum varying from 3 to 11 ounces.1 In my records of the examination of the brain in hydrocephalus, I have preserved an accurate account of the condition of the cerebral substance in 59 cases, and find that in 22 instances there was not the least central softening, although the ventricles contained fluid in every case but one, and the quantity amounted on 13 occasions to several ounces. M. Louis, too, mentions in his work on Phthisis,1 that in 75 out of 101 tubercular subjects, each ventricle contained a quantity of fluid varying from half an ounce to two or three ounces, but yet in only 6 of these 101 cases were the central parts of the brain at all softened. And, not to dwell on any other arguments which might be adduced, it may be added that M. Rokitansky has subjected the supposed hygroscopic property of the brain to the test of experiment, and found that no change whatever was produced in slices of cerebral matter by soaking them for hours in serum. But if we reject the theory of this change in the brain being a mere post-mortem occurrence, the question still remains, to what is it due? M. Eokitansky regards it as a condition of acute oedema of the brain, often, though not invariably, associated with inflammation, since its products, pus and exudation corpuscles, are usually found in the broken down or infiltrated nervous matter. One very strong proof of the close connection that subsists between softening of the brain and an inflammatory process going on in the organ is furnished by the changes which in many of these cases may be ob- served in the lining membrane of the ventricles. My own observation would lead me to believe that in at least two- thirds of the cases these changes exist to such a degree as to be readily appreciable by the naked eye, and the microscope would, I have no doubt, ascertain their almost invariable existence. The first alteration that takes place in the membrane is the loss of its transparency, which is often, though not always, associated with a turgid state of its vessels. 1 Beobachtungen und Bemerkungen iiber den rasch verlaufenden Wasserkopf. Von K. Herrich. 8vo. Regensburg, 1847, p. 161, § 126. 2 Recherches sur la Phthisie ;. 2d ed. 8vo. Paris, 1843, p. 160, § 161. CHANGES IN LINING OF VENTRICLES. 77 At the same time it loses its polish, and next acquires an unnatural toughness, so that it can be raised by the point of the scalpel; and sometimes it is not merely opaque and tough, but greatly thickened, forming a dense firm membrane; and sometimes it presents a granular appearance, which is usually most marked over the optic thalami and corpora striata. This granular condition is sometimes so slight as to be perceptible only when the membrane is looked at in certain lights; sometimes so extreme as to present a distinct roughness to the finger. It is due to the presence" of small new-formed capillary outgrowths consisting of an accumulation of roundish cells with transparent nu- cleoli, which spring from an unevenly deposited layer of cells super- imposed on the lining of the ventricle itself. These changes, though observed in cases of tubercular meningitis, are present in their most characteristic degrees in chronic internal hy- drocephalus, and are the evidence of inflammatory action which dates back in some instances even to the time of foetal life. Now and then, indeed, the lining of the ventricles, instead of presenting the above described changes, is thickened, pulpy, and softened, so as to fray with the slightest touch; or participates in the general diffluence of the central parts of the brain. This, however, is a decidedly exceptional occurrence, and opacity, loss of polish, thickening, toughening, and granular deposit on its surface are the changes almost invariably pre- sented by the lining membrane of the ventricles. I have not been able to satisfy myself that these changes bear any certain relation to the quantity of fluid, or to the degree of central softening, though it is rare to find an extreme degree of change in the lining of the ven- tricles without a considerable quantity of fluid in their cavity, and great softening of the brain around them.2 1 See the minute researches of Dr. Loschner on this subject in his Aus dem Franz- Joseph-Kinder-Spitale, I. Theil, 8vo. pp. 48-85. Prag, 1860. 2 The subjoined note contains an analysis of my dissections of 61 cases of acute hydrocephalus, as far as respects the presence of fluid in the ventricles, the state of their lining membrane, and the condition of the cerebral substance; particulars the mutual relation of which to each other have not yet been fully investigated. In 14 of these 61 cases there is no express mention of the condition of the lining of the ventricles. In 2 the state of the cerebral substance is only imperfectly described. In 59 the condition of the cerebral substance was carefully noted, and it was soft- ened at the centre in 37, not softened in 22. Of the 22 cases in which there was no central softening— In 1 there was no fluid in the ventricles. 2 ii very little. 4 u not above 1 oz. 2 (( 1$ oz. 1 11 3oz. 2 It 4 oz. 1 a 5 oz. 1 k 6 oz. 8 « a considerable quantity. 22 In 12 of these 22 cases the state of the lining of the ventricles is expressly de- scribed. It was unaltered in 5, altered in 7. 78 SUMMARY OF MORBID APPEARANCES. It is clear that in cases of what are commonly called tubercular hydrocephalus there are two distinct elements, which have no constant relation to each other, which even are not invariably associated. The one of them manifests itself in the affection of the membranes at the It was unaltered in 1 when there was no fluid in the ventricles. " " 1 " " very little. " " 1 " " 1 oz. " " 1 " " 4oz. " 1 " " a large quantity. 5 It was altered in 7, viz :— In 1 no fluid ; tubercular granulations on choroid plexuses. 1 one ounce ; lining of ventricles tough, and thickened. 4 a large quantity; lining tough, thickened; and in 3 of the 4 finely granular. 1 four ounces of fluid; lining opaque. 7 In 18 of these 22 cases the consistence of the cerebral substance was everywhere natural; in 4 it was altered :— In 1 brain substance generally increased in firmness. 1 softening of cerebellum and of anterior parts of both posterior cerebral lobes, especially on left side. 1 softening of lower surface of both anterior cerebral lobes. 1 softening of right half of pons, which was diffluent, in a state of red softening; vessels leading to it dilated and filled with clot. 4 In 37 cases the central parts of the brain were softened; slightly in 16 cases, con- siderably in 21. In 10 of these 16 cases the lining of the ventricles was healthy. 6 tough, opaque, or granular. 16 In 12 the cerebral substance elsewhere was natural. 4 " " " " altered. 16 In 1 the surface of the cerebral convolutions generally, and the substance of the cerebellum, were softened. 1 anterior and lower half of middle lobes softened, chiefly on left side. 1 there was great vascularity of brain substance, softening of both posterior horns, much fluid in ventricles, their lining tough, lymph and hyaline mat- ter at base of brain. 1 there was softening of anterior part of left, and posterior half of right ventricle with much fluid, and granular lining of ventricles. 4 In 21 cases the central softening was considerable. In 15 cases the cerebral substance elsewhere was softened; in 10 it was not softened In 4 cases the softening existed without dis.ease of the lining of the ventricles • in 7 it was associated with it. In 1 both posterior lobes were softened, especially the right, and brain substance of yellowish-white color. 1 lower and posterior third of left lower lobe quite diffluent, and cerebellum soft. 1 great congestion of brain, and general softening of its substance. 1 great softening below centre of Vieussens, especially on left side, where gray and white matters were undistinguishable from each other. 4 In 7 instances central softening, softening of other parts of the brain, and disease of the lining of the ventricles coexisted:— MORBID APPEARANCES IN ACUTE HYDROCEPHALUS. 79 base of the brain, and is characterized by the deposit of tubercle there, as well as of the exudation products of inflammation. The other displays itself in the affection of the lining of the ventricles, in the changes which that undergoes, and in the alteration of the adjacent brain substance. It were well worth the inquiry to determine the exact connection of the two; to make out which is the earlier occurrence, which pre- disposes to the other, which contributes most to bring about the fatal event, to ascertain what symptoms betoken the one order of changes, what the other; and so to arrive, if possible, at some means of distin- guishing cases which admit of remedy, from those in which treatment is vain, and hope has no place. One sometimes hears the complaint that the field of science has been reaped so thoroughly by previous laborers as to leave but scanty gleaning for those who come after. But surely this is an idle lamenta- tion while problems such as these remain unsolved, to which it so much imports the practical physician as well as the pathologist to be able to return a correct answer. It happens sometimes that we find large patches of tubercular matter deposited beneath the membranes on the convex surface of the brain, and extending to the depth of about a line into its tissue, in children who have died of acute hydrocephalus. Now and then, also, masses of tubercle, of a spheroidal shape, and of various sizes, are found imbedded in the cerebral substance. This latter appearance, however, is not frequent; it existed only in 6 out of the 61 cases on which I have founded my remarks on the morbid anatomy of acute hydroce- In 1 there were two and a half ounces of fluid, lining of the ventricle thick and granular, brain substance generally, and that of posterior cornua specially, softened. 1 much fluid, lining opaque, general softening, optic thalami of gelatinous con- sistence for a quarter of an inch deep. 1 much fluid, lining thick and firm, increased vascularity, general softening of whole of brain. 1 much fluid, great thickening of lining, softening universal from half an inch from surface. 1 two ounces of fluid, lining opaque, much softening of both posterior lobes, especially right. 1 four ounces turbid reddish serum, lining thick and vascular; firm in some parts, soft in others, softening of anterior and middle lobes of cerebrum, not of posterior; capillary apoplexy of left corpus striatum. 1 two ounces of fluid, great turgescence of vessels in ventricles, softening of both optic thalami and corpora striata. 7 In 10 cases the lining of the ventricles was altered, but there was no softening except at the centre :— In 1 half an ounce of fluid, lining opaque, thickened, slightly granular. 2 three ounces of fluid, membrane tough, and in one of the two slightly granular. 1 four ounces of fluid, membrane granular. 2 lining tough and thickened, and lost its polish. In one of these cases there were six ounces of fluid, in the other only two. 3 there was much fluid, lining dull and thickened. 1 there were three ounces of fluid, but the lining partook of the general soft- ening of the central parts of the brain, which were almost diffluent. 10 80 ACUTE HYDROCEPHALUS— phalus; and even in these cases peculiar symptoms existed which during the lifetime of the patient led to the suspicion of the disease being something else than an ordinary attack of water on the brain. The complications of hydrocephalus consist almost entirely in the deposit of tubercle in many organs of the body, and in the various results to which that tubercular deposit may have given rise. The lungs and the bronchial glands are the parts most frequently and most seriously invaded by the tubercular deposit; the spleen, liver, mesen- teric glands, and intestines, rank next in frequency as the seat of tubercle. The complication of hydrocephalus with tuberculous ulcer- ation of the intestines is one which, though not very frequent, must not be lost sight of, since its existence may give rise to diarrhoea, and thus lead to an error of diagnosis on your part, if you look for consti- pation of the bowels as an invariable symptom of water on the brain. But let us now pass to the examination of the symptoms of acute hydrocephalus. We cannot, however, do more to-day than familiarize ourselves with the main features of the disease, and must leave all attempts at filling up the outline to our next meeting. The first or premonitory stage of the affection is attended by many indications of cerebral congestion, coupled with general febrile dis- turbance, and presenting exacerbations and remissions at irregular periods. The child becomes gloomy, pettish, and slow in its move- ments, and is little pleased by its usual amusements. Or, at other times, its spirits are very variable; it will sometimes cease suddenly in the midst of its play, and run to hide its head in its mother's lap, putting its hand to its head, and complaining of headache, or saying merely that it is tired and sleepy, and wants to go to bed. Sometimes, too, it turns giddy, as you will know, not so much from its complaint of dizziness, as from its suddenly standing still, gazing around for a moment as if lost, and then either beginning to cry at the strange sensation, or seeming to awake from a reverie, and at once returning to its play. The infant in its nurse's arms betrays the same sensation by a sudden look of alarm, a momentary cry, and a hasty clinging to its nurse. If the child can walk, it may be observed to drag one leg, halting in its gait, though but slightly, and seldom as much at one time as at another, so that both the parents and the medical attendant may be disposed to attribute it to an ungainly habit which the child has contracted. The appetite is usually bad, though sometimes very variable ; and the child, when apparently busy at play, may all at once throw down its toys and beg for food; then refuse what is offered, or taking a hasty bite, may seem to nauseate the half-tasted morsel, may open its mouth, stretch out its tongue, and heave as if about to vomit. The thirst is seldom considerable, and sometimes there is an actual aversion to drink as well as to food, apparently from its exciting or increasing the sickness. The stomach, however, seldom rejects every- thing; but the same food as occasions sickness at one time is retained at another. Sometimes the child vomits only after taking food • at other times, even when the stomach is empty, it brings up some green- ish phlegm without much effort and with no relief. These attacks of vomiting seldom occur oftener than two or three times a day; but SYMPTOMS OF ITS THREE STAGES. 81 they may return for several days together, the child's head probably growing heavier, and its headache more severe. The bowels during this time are disordered, generally constipated from the very first, though their condition in this respect sometimes varies at the com- mencement of the disease. The evacuations are usually scanty, some- times pale, often of different colors, almost always deficient in bile, frequently mud-colored, and very offensive. The tongue is not dry, generally rather red at the tip and edges, coated with white fur in the centre, which becomes yellowish towards the root. Occasionally I have seen it very moist, and uniformly coated with a thin white fur. The skin is harsh, but there is no great heat of surface; the nares are dry, the eyes lustreless, the pulse accelerated, but seldom exceeding 120 in children of four years old and upwards; not full nor strong, but often unequal in the force and duration of its beats. The child is drowsy, and will sometimes want to be put to bed two or three times in the day; but it is restless, sleeps ill, grinds its teeth in sleep, lies with "its eyes partially open, awakes with the slightest noise, or even starts up in alarm without any apparent cause. At night, too, the existence of intolerance of light is often first noticed in consequence of the child's complaints about the presence of the candle in the room. I need scarcely say that you must not expect to find all these symp- toms in every case, neither, indeed, when present, are they persistent, but the child's condition varies greatly in the course of a few minutes; cheerfulness alternating with depression, and sound sleep being now and then enjoyed in the midst of the unrefreshing dozes of the night. It will not be by a hurried visit of a few minutes that you will learn these things; you must not grudge your time if you hope ever to attain to excellence in the management of children's diseases. This precursory stage is of very variable duration, but on the average does not exceed four or five days. If the disease be not recognized, or if the treatment adopted be unsuccessful, it will pass into the second stage, in which the nature of the affection is very appa- rent, though unhappily the prospect of its cure is almost lost. The child no longer has intervals of cheerfulness, nor attempts to sit up, but wishes to be left quiet in bed, and the face assumes a permanent expression of anxiety and suffering. The eyes are often kept closed, and the eyebrows are knit, the child endeavoring to shut out the light from its morbidly sensitive retina. The skin continues dry, the face is sometimes flushed, and the head often hot; and though these two symptoms vary much in their duration, coming and going without any evident cause, yet there is a permanently increased pulsation of the carotids, and if the skull be not ossified the brain may be felt and seen forcibly beating through the anterior fontanelle. The child is now very averse to being disturbed, and often lies in a drowsy condi- tion, unless spoken to, when, if old enough to answer, it usually com- plains of its head, or of weariness or sleepiness. Its replies are generally rational, but very short; and if it need anything, it asks in as few words as possible in a quick, pettish manner, and shows much irritability if not at once attended to. At other times it lies with its face turned from the light, either quite quiet, or moaning in a low 6 82 ACUTE HYDROCEPHALUS— tone of voice, and now and then uttering a short, sharp, lamentable cry, which M. Coindet, of Geneva, regarded as characteristic of the disease, and hence termed it cri hydrencephalique ; but making no other complaint than the low moan and the occasional plaintive cry. To this, however, there are exceptions, and children sometimes scream with the intensity of the pain, or cry out "My head 1 my head!" most piteously. As night comes on there is almost always a distinct exacerbation of the symptoms, and the quiet of the day is frequently succeeded by a noisy and excited state, in which vociferous cries about the head alternate with delirium. This, however, is not by any means a constant occurrence; an increase of restlessness being often the only difference from the state of stupor in which the child lay during the day. At the commencement of this stage the pulse is quickened, sometimes very much so, and is in many cases unequal in the force and quickness of the beats. Irregularity of its rhythm, or distinct intermission in its beat, is the next change, and is usually perceived at the same time with a great diminution in its frequency, which often falls in a few hours from 120 to 90 or 80. At the same time that these changes take place in the general characters of the pulse, its power becomes manifestly diminished, while the slightest exertion, such as attends any alteration in the child's position in the bed, will often suffice to increase its frequency twenty beats or more in the minute. The child sometimes keeps its eyes so firmly closed that we can scarcely see the state of its pupils. Usually they are not much affected, but sometimes one is more dilated and acts more slug- gishly than the other, or, in other cases, strabismus exists, though perhaps in a very slight degree, or confined to one eye. It is seldom that vomiting continues beyond the commencement of this stage, but its cessation is not followed by any desire either for food or drink. The bowels usually become even more constipated than they were before, and the evacuations continue quite as unnatural, while all flatus disappears from the intestines, and the abdomen thus acquires that shrunken form on which much stress has been laid by some writers as characteristic of hydrocephalus. The transition from this to the third stage of the disease is some- times effected very gradually by the deepening of the state of drowsiness, till it amounts to a stupor, from which it is impossible to arouse the child. At other times, however, this stupor comes on very suddenly, succeeding immediately to an attack of convulsions. These convulsions usually affect one side much more than the other, and after the fit has passed off' one side is generally found partially or completely paralyzed, while the child makes constant automatic move- ments with the other, carrying the hand to the head, and alternately flexing and extending the leg. The side which is the most affected during the fit is generally, though not invariably, the most palsied afterwards. When the third stage is fully established, the child lies upon its back in a state of complete insensibility, with one leg stretched out, the other drawn up towards the abdomen. The tremu- lous hands are either employed in picking the lips or nose till the blood comes, or one hand is kept on the genitals while the other is SYMPTOMS OF ITS THREE STAGES. 83 rubbing the face or head. The head is at one moment hot, and the face flushed, and then the heat disappears and the flush fades, though usually there is a permanent increase in temperature about the occiput. Sometimes the skin is dry, and then, though the extremities are cold, a profuse sweat breaks out on some parts of the body or on the head. The pulse often loses its irregularity, but at the same times it grows smaller and more rapid, till at length it can be counted only at the heart. The eyelids now close only very partially, and in most cases there is some degree of strabismus. Light is no longer unpleasant, for the dilated pupils are either altogether motionless, or they act very sluggishly, frequently oscillating under the stimulus of a bright light, alternately contracting and dilating, till at length they subside into their former dilated condition. The child now often makes automatic movements with its mouth, as though chewing, or as though endeavoring to swallow something. It generally happens that, although sensibility is quite extinguished, the child will still swallow anything that is put into its mouth, and the power of deglu- tition is in most cases one of the very last to be abolished. An attack of convulsions now sometimes puts an end to the painful scene; but often the child lives on for days, though wasted to a skele- ton, and its features so changed by suffering that those persons who had seen it but a short time before would now scarcely recognize it. The head often becomes somewhat retracted, and the child bores with the occiput in the pillow; the eyelids are wide open, and the eyes turned upwards so as to conceal three-fourths of the iris beneath the upper lid, while the countenance is still further disfigured by a horri- ble squint, or by a constant rolling of the eyes. The pupils are now fixed and glassy, the white of the eyes is extremely bloodshot, and their surface is besmeared with a copious secretion from the Meibo- mian glands, which collects in their corners. One leg and arm are stiff* and motionless, the other in constant spasmodic movement, while the hands are often clenched and the wrists bent upon the forearm. At the same time there is frequently so much subsultus as to render it impossible to count the pulse, and the muscles of the face are thrown from time to time into a state of spasmodic twitching. Cold clammy sweats break out abundantly about the head, the breathing is labored, deglutition becomes difficult, and the child almost chokes with the effort to swallow, or lets the fluid run out at the corners of its mouth. It is uncertain how long this condition may endure; the recurrence of convulsions usually hastens the end, but sometimes many days will pass, during which death is hourly expected and earnestly prayed for, to put an end to the patient's sufferings. 84 DIAGNOSIS OF HYDROCEPHALUS. LECTURE VII. Acute Hydrocephalus, continued. Diversities in its course and in its modes of attack— insidious approach in phthisical subjects—resemblance of its symptoms to those of remit- tent fever—of simple gastric disorder—serious import of continued sickness in case of gastric disorder. Prognosis.—Disease almost always fatal—appearances of improvement often delusive—cautions against being misled by them. Duration of the disease—real nature of cases of waterstroke. Treatment.—Prophylaxis.—Treatment of the disease—rules for depletion, for use of purga- tives, mercurials, application of cold.—Diet of patients—circumstances in which opiates may be useful—when blisters are to be applied—alleged efficacy of tartar-emetic ointment as a counter-irritant. Conclusion. It can scarcely be necessary to observe that acute hydrocephalus does not always run precisely that course which I described to you at our last meeting. Almost every case, indeed, presents some slight peculiarity, either in the comparative severity of the different symp- toms, in the date of their occurrence, or in the order in which they succeed each other. Convulsions, for instance, though hardly ever absent, occur earlier in one case than in another—affect in one the whole body, in another are limited to one side—are succeeded in one instance by paralysis, in another by a stiff and contracted state of the limbs. Again, coma sometimes comes on gradually, at other times takes place suddenly; in one instance it continues long, in another is speedily followed by death. The pupils sometimes become early in- sensible to light; at other times they continue to act, though slowly, almost to the time of death; and in like manner strabismus may exist in various forms, or there may be constant rotation of the eyeball, or neither of these symptoms may be present; and yet we cannot couple these diversities in the signs of the disease with any certain differences in the morbid appearances. But, how much soever one case of hydro- cephalus may differ from another in these respects, such differences are of comparatively but little moment, since, whether these symptoms occur early or late—whether they are slight or severe—short in their duration, or of long continuance—the appearance of any one of them stamps the character of the disease too plainly for it to be mistaken, and indicates not the incipient but the fully developed evil. The de- viations from the ordinary mode of its attack are far more important, since they may lead you to mistake the nature of the disease during the only time when treatment is likely to be of much avail. The healthy and robust are comparatively seldom attacked by ]iy- ' drocephalus, and in many instances the indications of declining health precede for weeks or months the real premonitory symptoms of the disease. You may, however, be so much taken up with watching the former as to overlook the latter, or to misinterpret their meaning. Your solicitude is excited by the gradual decay of a child's strength, ITS SYMPTOMS OBSCURE IN PHTHISICAL SUBJECTS. 85 and the wasting of his flesh. You observ'3 that he becomes subject to irregular febrile attacks—that he coughs a little—that he loses his ap- petite—that his bowels are almost always disordered, and generally constipated—and that he makes frequent vague complaints of pains in his limbs, or of weariness or headache. These symptoms, which depend upon that general deposit of tubercle in the different organs of the body which almost every dissection of fatal cases of hydroce- phalus reveals, make you apprehensive lest phthisis be about to come on, and you often auscultate the chest in the expectation of discovering some signs of disease in the lungs. At length, the child seems worse —he coughs more, and is more feverish—grows heavier and more dull, but does not complain more about his head—or, at most, says that the cough makes his head ache. The parents think the child must have caught cold, and you do not see the indication of any new disorder; for, though listless and moody, he still moves about the house, and sometimes plays, though in a spiritless manner. Simple treatment seems to do a little good, and you not unnaturally hope that the aggravation of the symptoms will prove only temporary; but after an unusually restless night, a fit of convulsions comes on, or the listless- ness deepens in the course of a few hours, and without any evident cause, into profound coma, and a very few days terminate the patient's life. A little girl, nearly eight years old, was brought to the Children's Hospital one December. She was very pale, very languid, and so emaciated that she looked as if far advanced in consumption. Her mother stated that from birth the child's health had been delicate, but that she had had no disease until the previous July, when hooping- cough came on, which in a few days was complicated by the occurrence of measles, attended with diarrhoea. She recovered from these ail- ments, though they left her very thin and very weak, and the hoop- ing-cough did not completely cease until late in the autumn. From the time of the hooping-cough ceasing, the child's health improved, but her appetite was never very good, and she seemed by degrees to become more and more unable to eat the coarse food of poverty. She next was sick sometimes after taking food, and then complained occasionally of headache; and after these fresh symptoms had continued for a few days, her mother brought her to the hospital. She attended as an out-patient for nearly a fortnight, during which time no new symptom appeared; but the child grew daily weaker, and, accordingly, was received into the house on December 16. The circumstance that the auscultatory signs of phthisis which were present consisted merely in slight impairment of resonance on the left side posteriorly, with coarse breathing and loud expiratory sounds, led to the hope that the mischief in the lungs was not very considerable. She was ordered beef-tea, with a little wine, and a mixture containing the nitromuriatic and hydrocyanic acids. For a few hours the comforts of the hospital made a change in her for the better; but on the night of the 17th she slept badly, complained of headache on the following morning, and was sick after her breakfast. A single dose of calomel freely relieved her bowels, blisters behind the ears removed the headache, and the sickness was quite stopped by the 86 DIAGNOSIS OF HYDROCEPHALUS prussic acid given in an effervescing mixture. This improvement) however, lasted only for twenty-four hours. On December 20, after a restless night, she became very drowsy, refused her beef-tea, asked for nothing, complained of noth.hg, but, if much pressed, said that her head ached. A blister was put on the shaven scalp; the wine, which flushed her, was discontinued, while an attempt was made to nourish her with beef-tea enemata. The drowsiness, in spite of the blister, deepened on the next day into coma; and thus she lay, in a state of unconsciousness, with occasional convulsive twitchings of the muscles of the face for the last two days of her life, till she died quietly on the morning of December 25. On examining the body after death, there was found advanced tuber- culous disease of the bronchial glands at the left side of the trachea, but the lungs were quite free from tubercle. The ventricles of the brain contained some fluid; the arachnoid at the base was less trans- parent than natural; while a thin layer of toughish yellow lymph extended over the pons Varolii, being rather more considerable at the right than the left side. The two hemispheres of the brain were united by old adhesions along the longitudinal fissure, and the anterior and middle lobes were connected along the fissure of Sylvius; but there was scarcely any effusion of hyaline matter or any granular appear- ance between the pons and the optic commissure, where usually it is so marked. There were but few symptoms of the coming disease; for the same reason, I imagine, as that which will account for the comparatively slight appearances after death: namely, that it takes but little to ex- tinguish life, when long-standing ailments have so enfeebled all the vital powers. In cases such as this, you will, it is true, most likely be able to do little or nothing, even if you recognize the approach of hydrocephalus from the earliest indication of its coming. But you will save your patient's friends some sorrow, and yourself some reproach, if you dis- cover the danger at a distance. Now, whenever any child, especially if it be of a consumptive family, has been failing in health for some weeks or months, without evident cause, I advise you to look with much suspicion on the supervention of unusual drowsiness or listless- ness, or on any aggravation of the cough, for which you cannot find adequate reason in the information afforded by auscultation. A fre- quent, short, dry cough is not unfrequent at the commencement of hydrocephalus; but in cases where cough has existed for some time, you are very likely to refer its aggravation to mischief in the chest, and to lose sight of its possible connection with affection of the brain. Inquire, therefore, in every doubtful case, whether there has been any vomiting—for sometimes it is but slight, and occurs only after food has been taken, and then only occasionally, so that it may seem to the parents to be a symptom of little importance. Ascertain the condition of the bowels; watch the pulse most carefully; it may not be irregu- lar nor intermittent, but you will probably find a little inequality°in the force and duration of its beats: if so, you may be sure that the head is suffering; and if the head suffer in such a patient, it is in FROM REMITTENT FEVER. 87 ninety-nine cases out of a hundred from the approach of hydrocepha- lus. Do not content yourselves with seeing your patient once a day; visit him at least morning and evening, stay some time with him, watch him closely, and see how far he is capable of being amused: but if you be still strangers to that freemasonry which assures a little child that you love it, you will very likely fail of arriving at the truth. But it may happen that a child, though not robust, had yet been tolerably well till a week or two before you visited it, and that it was then attacked by febrile symptoms, with a little headache, and per- haps with vomiting and constipation. You learn that these two symp- toms were but of short duration, but that the fever has continued ever since, and that the child has been very taciturn, rather drowsy, and averse to being disturbed, though giving rational answers when spoken to. You regard the case as one of remittent fever, and treat it with- out either improvement or deterioration, till the appearance of con- vulsions or of coma corrects your diagnosis, though unfortunately too late. It must be confessed that it is sometimes a matter of great difficulty to distinguish between these two affections. It may help you, indeed, to bear in mind that remittent fever is very rare before five years of age, and is hardly ever met with in children under three; while at least half of all cases of hydrocephalus occur in children who have not completed their fifth year. But still this is not the kind of evi- dence on which,you can place much reliance in a doubtful case. There are differences in the symptoms, however, which will generally enable you to discriminate between them, if you have acquired the habit of minute and careful observation. The vomiting, on which [ have laid so much stress as a symptom of approaching hydrocephalus, is often absent even at the onset of remittent fever; it soon ceases, and is not followed by that abiding nausea which is frequent in hydro- cephalus. In remitttent fever the bowels are often relaxed from the very outset, or speedily become so, and the evacuations present no resemblance to the scanty, dark, or mud-colored motions which are voided in hydrocephalus; but are usually watery, fecal, and of a lightish color. Tenderness of the abdomen is nearly constant in re- mittent fever, and is greater in the iliac regions than elsewhere, and wind can always be felt in the intestines. The tongue is not moist as in hydrocephalus, and is seldom much loaded, but has in general only a thin coating of yellow fur at the centre and towards the root, while it is very red at the tip and edges, and becomes dry at an early stage of the disease. In hydrocephalus there is frequently a great distaste for drink as well as for food, while although the appetite is lost in cases of remittent fever, yet the patients have great desire for drink, especially for cold drink, to quench the urgent thirst. The heat of the skin in remittent fever is extremely pungent, and much greater than in hydrocephalus, in which, although there is great dry- ness of the surface, yet the temperature is seldom much increased. The pulse in remittent fever is much quicker than in hydrocephalus; it continues quick throughout, and never becomes unequal or irregu- lar, while its frequency is in direct proportion to the elevation of the 88 PROGNOSIS IN HYDROCEPHALUS. temperature of the surface. In remittent fever the child makes few complaints about its head, but delirium is of early occurrence, espe- cially at night; in hydrocephalus, on the contrary, true delirium hardly ever occurs till an advanced period of the disease, and is some- times absent altogether. In remittent fever, as its name implies, there are distinct remissions and exacerbation of the symptoms, the patient getting better towards morning, and worse again as night approaches; while, though there are many fluctuations in the course of hydro- cephalus, yet we observe no definite periods at which the symptoms invariably remit or are increased in severity. With due caution you will scarcely take a case of incipient hydro- cephalus for one of simple gastric disorder, though there are many points of resemblance between the two. Vomiting and constipation occur in both, and there is usually some degree of headache in the latter affection, though seldom severe or lasting. Mere gastric dis- order is not attended with much febrile disturbance; the face, though heavy> is not distressed nor anxious, while the tongue is usually much more coated than at the onset of an attack of hydrocephalus. The relief that follows the use of remedies in the less dangerous affection is complete as well as speedy; the sickness, will cease after the opera- tion of an emetic, the bowels will act copiously after the administra- tion of a brisk purgative, and in a day or two your patient will be quite well. The persistence of vomiting, however, in any case, which you had thought to be one merely of gastric disorder, must be looked upon by you with great suspicion, and this, even though the bowels have acted freely from medicine, and though there be no obvious in- dication of mischief in the head. I once saw a case in which the con- tinuance of intractable vomiting for more than six weeks after the cessation of a short but severe attack of diarrhoea, was the only symp- tom of illness in a boy five years of age. At length he became a little drowsy, and once or twice, when closely questioned, said that his head ached. Not quite two days after the first complaint of head- ache, the child had a violent fit of convulsions, and in the course of the succeeding week he died, having suffered during that time from all the symptoms of acute hydrocephalus, and his body presenting after death its characteristic lesions. An inquiry of little less importance than that concerning the means of distinguishing between one disease and another, respects the prog- nosis that we are to form, the inferences that we may draw, from the course of the malady, either to encourage hope or to excite anxiety. Unfortunately the prognosis in hydrocephalus is so unfavorable that we can scarcely speak of the circumstances which regulate it; for under almost every variety of condition, of symptoms, and of treat- ment, the patients die. The cases are but very few in which I have seen any other than a fatal issue follow on even the premonitory symp- toms of water on the brain. Once I saw recovery take place after the second stage of hydrocephalus had commenced, and once I watched with surprise the gradual subsidence of the disease, though convul- sions had already taken place, and had been followed by coma. In that instance the child, three and a half years old, was a member of a PROGNOSIS IN HYDROCEPHALUS. 89 phthisical family, and her younger brother had died a year before of hydrocephalus. The disease in her case ran its ordinary course, un- checked by the customary treatment. Convulsions took place, coma succeeded them, deglutition was very difficult, the pupils were dilated and almost motionless, the pulse was very feeble and very frequent, aud everything portended the speedy death which one looks for as the usual termination of such symptoms. Food was still given, as the power of swallowing was not entirely lost, and ammonia and ether were administered, which after a time were exchanged for quinine. For days unconsciousness continued, and the first return of voluntary effort was shown by the child raising her hand to steady the cup that was put to her lips. She next recovered the power of vision, but still could not move her legs, nor utter any articulate sound. The power of speech was not regained for some weeks, nor that of walking for many months; the gait long continued tottering and uncertain, and the child's manner half-idiotic. When last I saw her three years had elapsed, and recovery was then as perfect as probably it ever will be; but the child, though not deficient in intelligence, had never regained flesh, nor recovered the look of health, nor the manners of a child, but walked about unsteadily, with a weird cast of countenance, and a vacant smile, and I felt surprise that the disease, evidently still latent, had not yet returned. I am aware that other practitioners have arrived at results far more favorable than those to which my own experience has led me; but while I would gladly, if it were possible, modify my statements, I feel sure that a careful perusal of the cases of alleged recovery recorded by different writers must satisfy every one that the disease in almost every instance was not hydrocephalus at all; and that often it was some ailment bearing to it but a very slight resemblance. It is re- markable, indeed, as M. Killiet1 well observed in a very valuable paper on this subject, that almost all the instances in which recovery from hydrocephalus is stated to have taken place, occurred before the real nature of the disease was understood, while, since its tubercular nature has been recognized, not a single authenticated case of the kind has been published by any French physician. M. Guersant, of Paris, who probably had seen more than any man now living of children's diseases, gives the following statement as the result of his experience :— "Tubercular meningitis," says he, "may sometimes terminate by recovery in the first stage, though the nature of such cases is always more or less doubtful; in the second stage I have not seen one child recover out of a hundred, and even those who seem to have recovered have either sunk afterwards under a return of the same disease in its acute form, or have died of phthisis. As to patients in whom the disease has reached the third stage, I have never seen them improve even for a moment."2 1 Archives Gen. de MSdecine, Dec. 1853. 2 Diet. Med., t. xix. p. 403; quoted by MM. Rilliet and Barthez, op. cit. 1st edition, t. iii. p. 531. 90 DELUSIVE APPEARANCES OF IMPROVEMENT. The minuteness with which M. Rilliet records the history of his patient's recovery, leaves little room for doubt that the case was one of tubercular hydrocephalus in the third stage; and the bare possi- bility of error is removed by the circumstance that the child died five years afterwards under a recurrence of the former symptoms; and that on a post-mortem examination the old mischief at the base of the brain was clearly distinguishable from the effects of the recent disease under which the child had sunk. This case, however, and the few others which are scattered through the annals of medicine, can be regarded only as the exceptions which prove the rule that hydroce- phalus following the law of tubercular disease in general is almost incurable, while it proves mortal all the more frequently owing to the importance of the organ which is its seat. Since, then, the fatality of the disease is almost invariable, it may seem to you superfluous for me to say anything more with reference to the prognosis; but I am desirous of guarding you against being deceived by certain delusive appearances of improvement which are by no means unusual even in cases where the real nature of the disease has for some two or three days been clearly manifest. A few years ago, a little girl, three years old, was brought to me in a state of pro- found coma, and presenting the symptoms of the third stage of acute hydrocephalus, of which she died forty-eight hours afterwards, without having had any return of consciousness. I learned from her mother, that, fourteen days previously, the child had been attacked by vomit- ing, attended by fever and great drowsiness; but that these symptoms abated in three days, and that the child improved and was regaining her cheerfulness until the morning of the day before she was brought to me, when her mother found her comatose, and in just the condition in which she was when I saw her. A more acute observer than this child's mother would probably have seen something to make her dis- trust the apparent improvement; but it is evident that the change was great from fever and drowsiness, and frequent vomiting, to a cessation of the sickness, the diminution of the fever, and a return of cheerfulness; and yet during all this time disease was going on, and producing the very extensive softening of the central and posterior parts of the brain which was discovered after death. The cases in which you are likely to fall into error are for the most part such as have come on insidiously, unattended by very violent symptoms, and about which you perhaps hesitated some little time before you became convinced that so grave a malady as hydrocephalus could wear so mild a form. Treatment for some days produces no effect, the disease remaining stationary; but at length your hopes are raised by finding that the vomiting has ceased, and that the constipated condition of the bowels has been overcome. The heat of head has disappeared, the pulse presents much less irregularity than before, or may even have lost it altogether; the child's restlessness has subsided, and its manner is almost natural. Perhaps the child seems rather drowsy, or it may be sleeping at the time of your visit; but the account you hear of it seems satisfactory: its repose is quiet, and the mother rejoices: her little one has had no sound sleep for many days, and will, she thinks— DURATION OF ACUTE HYDROCEPHALUS. 91 and you may think so too—be much better when it wakes. It does not wake up, but it swallows well when some drink is given in a spoon, and the mother is still content. Presently slight twitchings of the face and hands are seen, but the child does not wake—you cannot rouse it: the sleep has passed into coma, and the coma will end in death. Always suspect the sleep which follows continued restlessness in a case of hydrocephalus. In other cases, although the disease did not come on so insidiously, and although it has reached a stage at which all its characters are well marked, you may yet be led for a few hours to entertain, and perhaps to express, ill-founded hopes, in consequence of the symptoms having somewhat abated, of the child having had some hours of quiet sleep, or having ceased to vomit, or no longer complaining of its head, or being visited by a short gleam of cheerfulness. You must not forget, however, that it is characteristic of hydrocephalus to present irregular remissions, that they last but for a few hours, and that at your next visit you may find every bad symptom returned, and, possibly, some fresh one superadded. Usually, too, you may be guarded from error by observing the suddenness of the change, and that the condition which has now come on is the very opposite of that which before ex- isted, preternatural excitement having been succeeded by an equally unnatural apathy, or great talkativeness having taken the place of obstinate silence, or the pulse, which before was above 130, having sunk all at once to 90 in the minute. At other times, though there is a general abatement in all the previous symptoms, yet some new one may have appeared; not more formidable, perhaps, than the occurrence of a slight degree of strabismus, which had not existed before, but still enough to indicate that the mischief is still going on, and that you must not dare to hope. A still more remarkable temporary improvement is sometimes observed, that "lightening before death," which seems, contrary to all expectation, to warrant a hope of recovery even when dissolution is impending. The only instance of it which has come under my notice occurred in a girl, aged seven years, who died on the fifteenth day of an attack of acute hydrocephalus. She had been in a state of stupor for six days, and profoundly comatose for two days, when she became conscious, swallowed some drink, spoke sensibly, and said she knew her father. She became worse again, however, in the course of an hour and a half, though she did not sink into the same deep coma as before, and in another hour she died. A few points still remain on which I must touch before passing to the consideration of the treatment of hydrocephalus. One of these is the question of its duration. The exact determination of this is not always easy, owing to the insidious manner in which the disease comes on; but, on the whole, there is less discrepancy than might have been expected between the statements of different writers. Of 117 cases observed or collected by Dr. Hehnis Green, 80 terminated within 14 days, and 31 more within 20 days. Of 28 casefe recorded by Golis,1 1 Praktisohe Abhandlungen, etc 8vo. Wien, 1820. Vol. i. 92 DURATION OF ACUTE HYDROCEPHALUS. 18 terminated within 14 days, and only 2 exceeded 20 days. MM. Rilliet and Barthez1 state the average duration of 28 cases that came under their observation to have been 22 days; and the average dura- tion of 59 fatal cases of which I have a complete record, was about 20 days. Of these 59 cases, that which ran the most rapid course terminated fatally in five days; death took place in 19 more before the fourteenth day; in 20 others during the third week, and in 13 during the fourth week. In the remaining 6 cases indications of cerebral disturbance had existed for four, six, or eight week; but death took place in every instance in less than 21 days after the appearance of well-marked symptoms of hydrocephalus, and in one on the eighth day from their becoming clearly manifest. We are, then, warranted in stating that the disease usually runs its course in from two to three weeks. The late celebrated Dr. Golis, of Vienna, proposed the name of water-stroke for some cases in which the head symptoms were of such short duration as not to exceed 24 or 48 hours. Such a rapid course, however, is not observed in true tubercular hydrocephalus; but the name of water-stroke has been applied to a great variety of cases which have presented little in common except the presence of head symp- toms, and their rapidly fatal termination.2 The appellation has been sometimes bestowed on cases of intense cerebral congestion ; at other times on cases of simple meningitis. In a few instances the name may have been given to cases of true hydrocephalus in which the rapid course of the disease has been apparent rather than real, owing to its having succeeded to chicken-pox, or having come on in the course of that febrile disturbance which vaccination sometimes excites, or which attends upon dentition. In such circumstances it often happens that the manifestations of cerebral disease are mistakenly attributed entirely to the previous cause of irritation in the system, so that when the signs of serious mischief force themselves upon the notice, the hydrocephalus has well nigh run its course. In describing this disease I divided it into three stages, but did so simply for convenience. Many physicians, however, have attached much greater importance to this division, regarding the first as the stage of turgescence; the second as that of inflammation; the third, that of effusion. Again, the first has been characterized as the stage of increased sensibility; the second, of diminished sensibility; the third, of palsy. Lastly, Dr. Whytt proposed a division that has been much followed, based on the variations of the pulse, which is usually quick and regular in the first stage, slow and irregular in the second, and quick in the third. There are too many exceptions, however, to the order of these changes, for it to be right to make them the foun- dation of any division of the disease into different stages; and the same remark may be made with reference to any arrangement founded on the variations in the sensibility of the patient. I have said that the phenomena of the pulse are not constant; I 1 Op. cit., vol. iii. p. 497. 2 In proof of this statement, see Golis, lib. cit. Cases 1 to 9. PROPHYLACTIC TREATMENT OF HYDROCEPHALUS. 93 need scarcely %add that the slow irregular pulse is no proof of the oc- currence of effusion ; neither is the dilated pupil a proof of it; it is a proof of great mischief having been inflicted on the brain; so are the strabismus and the rolling of the eyes which frequently accompany it; but you cannot connect these symptoms with injuries of a special kind, or involving particular parts of the brain. Although a disease of childhood, acute hydrocephalus is by no means most frequent in early infancy. In only 5 of 61 fatal cases in which the diagnosis was confirmed by a post-mortem examination, were my patients under a year old; 15 were between 1 and 3 years of age; 30 between 3 and 6; 5 between 6 and 9 ; 2 between 9 and 10; 1 between 10 and 11; and 1 between 12 and 13 years old.1 From all that I have told you about hydrocephalus, you have, I doubt not, already deduced the practical inference that the only treat- ment likely to avail much is the prophylactic; and that, if you would hope ever to save a patient, you must treat the mere threatenings of his disease, and not remain inactive until you see the malady fully developed before you. The prophylactic treatment of hydrocephalus must be in the main the prophylactic treatment of consumption, since not only is tubercle in- variably present in the various organs of children who have died of hydrocephalus, but the disease itself often supervenes on more or less definite phthisical symptoms, as is shown by the fact that the previous health of the children was indifferent in more than two-thirds of the cases that came under my notice. The influence of hereditary pre- disposition to phthisis, in favoring the development of hydrocephalus, on which almost all writers have insisted, is illustrated by the circum- stance, that in twenty out of twenty-seven instances, in which the health of the relatives was made the subject of special inquiry, it was ascertained that either the father, mother, aunt, or uncle had died of phthisis. In any case where several children of the same family have already died of hydrocephalus, or have shown a marked tendency to the dis- ease, the mother should for the future abstain from suckling her infants, and they should be brought up by a healthy wet-nurse. In such circumstances, too, it is desirable that a child should always live in the country; should be warmly clad, and should wear flannel next its skin. Its diet should be simple, and any change in it should be made with the greatest caution, while milk should for a long time form one of its chief aliments; and it would be desirable not to wean it until after it had cut four molar teeth, as well as all the incisors. As it grows up, over-exertion, either of mind or body, must be most 1 This statement as to the time of life at which hydrocephalus is most frequent is fully borne out by the Fifth and Eighth Reports of the Registrar-General, from which it appears that while only 7 per cent, of the total deaths under one year old in this metropolis resulted from cephalitis and hydrocephalus, these diseases caused 12.5 per cent, of the deaths between 1 and 3 ; 12.5 per cent, of those between 3 and 5 ; 11.1 per cent, of those between 5 and 10; and 5.9 per cent, of those between 10 and 15. 1 must, however, add, that since at the Children's Hospital only few and exceptional cases are admitted under two years of age, the figures given above understate the fre- quency of hydrocephalus in early infancy. 94 PROPHYLACTIC TREATMENT OF HYDROCEPHALUS. carefully avoided; and on this account, though free exercise in the air is highly beneficial, gymnastic exercises are by no means to be recom- mended. The child must be watched carefully during the whole period of dentition, and every precaution must be taken to shield it from the contagion of measles, hooping-cough, or scarlatina; since these diseases, which tend to excite the tuberculous cachexy, would be likely greatly to aggravate the disposition to hydrocephalus, or even to bring on an attack of the disease. The condition of the bowels must be most carefully watched; constipation must not be allowed to exist even for a day, and the least indication of gastric disorder must be regarded as a serious matter. It is not desirable that calomel should be used as a domestic remedy; but if the simplest aperients (such as castor oil, or the infusion of senna, or of rhubarb1) do not act, the child should be immediately placed under proper medical care. If at any time there should be heat of head, and the child appear squeamish, you must be at hand with your remedies, and those well chosen. Any bulky remedy would probably be rejected; but the stomach is almost sure to bear a grain or two of calomel with sugar, and you may follow this up with small quantities of the sulphate of magnesia2 every hour until the bowels act freely. A small dose of mercury and chalk, or of calomel, may be continued every night for two or three times; and if any feverishness remain, or the bowels be disposed to be constipated, the sulphate of magnesia may still be given twice or thrice a day. Leeches should not be applied to the head without very obvious necessity, nor then in large numbers, for strumous children do not bear the loss of blood well; and your endeavor should therefore always be, not simply to cure, but to cure at the smallest possible expense to the constitution. After attacks of this kind, children sometimes recover their health very slowly, and much good may then be effected by a judicious use of tonics. The infusion of calumba,3 with small doses of rhubarb, is a very suitable medicine, and one which children generally take tolerably well. Or you may give the ferro-citrate of quinine in orange-flower water, and sweetened with the syrup of orange-peel,4 while you secure the healthy action of the 1 (No. 5.) ty.—Potassas Sulphat. gr. xij. Inf. Rhei, gvss. Trae. Aurant. ^ss. Aquas Carui, gij. M. |ss for a dose. For a child three years old. * (No. 6.) I£.—Magnes. Sulphat. 3ij- Syr. Aurantii, £ij. Aquas Carui, 3vj. M. 5ij every hour till the bowels act. For a child three years old. 3 (No. 7.) fy —Inf. Calumbae, §ij. gij. Inf. Rhei, Sivss. Trae. Aurantii, giss. M. giij twice a day. For a child three years old. 4 See Formula No. 4, p. 56. TREATMENT OF THE ATTACK—DEPLETION. 95 bowels by a grain or two of hyd. c. creta, combined with five or six of rhubarb, administered every night, or every other night. If threatenings of head affection have frequently occurred, an issue should be inserted in the back of the neck ; for the keeping up a con- stant discharge from the neighborhood of the head is certainly very serviceable in many instances as a means of warding off hydrocephalus. A most remarkable instance of this is recorded by Dr. Cheyne, who mentions that all the children in a numerous family were carried off by water on the brain, with the exception of one, in whose case the precaution was adopted of putting a seton in the back of his neck. But the opportunity may not be afforded you of adopting this pro- phylactic treatment; and when you first see your patient, the existence of headache, vomiting, constipation, and a quickened pulse, with per- haps a very slight inequality in its beat, may leave you but little doubt as to the formidable nature of the disease with which you have to contend. In doing this, there are three remedies on which practitioners commonly rely, namely, depletion, purging, and the administration of mercury. With reference to depletion, you must not forget that the disease in which you are about to employ it, although of inflammatory nature, is inflammation in a scrofulous subject, and is in many cases grafted on previous organic disease; such as those tubercular deposits in the membranes of the brain which I have already described to you. You cannot, therefore, hope to cut short the affection by a large bleeding, but your object must be to take blood enough to relieve the congested brain, and no more than is necessary for that purpose. Avoid pre- cipitancy in what you do, and do not let your apprehensions betray you into that over-activity which is sometimes more fatal to a patient than his disease. If you feel any doubt as to the necessity of deple- tion, visit your patient again before determining on it, but do not delay that visit long. Order a dose of calomel, to be followed by some sul- phate of magnesia, if, as is most probable, the bowels be confined, and return again in three or four hours. You may then find that the bowels have acted, and the sickness has ceased; that the head is cooler, and aches less; and that the depletion is, for the present at any rate, un- necessary. Or the child's state may be the same, and you may still feel uncertain as to the right course. In that case, at once obtain the assistance of some other practitioner. This is the season when advice may be really useful, for it is only at the outset of the disease that its cure is possible; when convulsions have occurred, or coma is coming on, your treatment matters comparatively little, for the season of hope and the opportunity for action have then fled. Though you may have determined on the propriety of depletion, it will seldom be found, even at the outset of the disease, that the cha- racter of the pulse is such as to warrant venesection. Local bleeding will generally answer every purpose, and, indeed, the application of leeches may, as I have already mentioned to you,1 be so managed in the case of infants or young children, as to answer every purpose of 1 See Lecture IV. p. 50. 95 DEPLETION—PURGATIVES. general depletion. One caution may not be out of place with refer- ence to the part of the head on which leeches should be put in chil- dren ; since, though the reasons for it are obvious, it nevertheless is often forgotten. They should be applied to the vertex, because, if put on the temples, they hang down over the eyes and terrify the child; if behind the ears, they are very likely to be rubbed off as it rolls its head from side to side. I will not say that this depletion is never to be repeated, but I believe that in by far the greater number of cases you will do no good whatever by its repetition, and the exceptional cases will generally be those in which, very marked relief having fol- lowed the first bleeding, the same symptoms of congestion of the brain appear to be returning twenty-four or thirty-six hours afterwards. If you do not see the child until the second stage of the disease is far advanced—till general convulsions have occurred, or till twitchings of the limbs, or of the muscles of the face, an appearance of extreme alarm, or a state of alternate contraction and dilatation of the pupils, show them to be impending—you must be exceedingly careful in ab- stracting blood. In such circumstances, I have seen convulsions, to all appearance induced, and the fatal course of the disease accelerated, by a rather free, though by no means immoderate, loss of blood. The value of purgatives in the treatment of hydrocephalus can scarcely be overrated; but they must be given so as not merely to obtain free action of the bowels, but to maintain it for some days. After having once overcome the constipation, you will secure this end best by giving small doses of a purgative every four or six hours. The administration of a strong cathartic every morning will not answer this end nearly so well; for, independently of the chance of its being rejected by the stomach, you will find that the dose which sufficed the first time will not be large enough the second, and that there will be a constantly increasing difficulty in obtaining an evacuation. The nausea and vomiting which at first stood in the way of your administer- ing any medicine, are often so much relieved by depletion, that the stomach will almost immediately afterwards bear a dose of calomel and jalap, or calomel and scammony, which may be repeated every three hours, until it acts, while you at the same time endeavor to quicken its operation by the administration of a purgative enema. There is no use, however, in persevering with these medicines if they excite sickness, and it is then better to give a single large dose of calomel in some loaf sugar, and to follow it up by a solution of sul- phate of magnesia, which should be repeated at short intervals. When a free evacuation has been obtained, the same salt, in combination with the nitrate of potash, will often keep up a free action of the bowels as well as stimulate the kidneys to increased activity. These remedies may be either mixed with the child's drink, or be dissolved in water flavored with syrup of lemon or of orange-peel.1 Mercurial preparations, and especially calomel, have long had a high reputation in all the cerebral diseases of early life. Unhappily my own experience does not bear out the common practice, and 1 put no 1 See Formula No. 1, p. 53. LOCAL APPLICATION OF COLD. 97 faith in calomel, nor in the production of salivation, as a means of curing hydrocephalus. I have seen children die whose mouths had been made sore by mercury, without any influence appearing to have been thereby exerted on the disease; and I recollect two, who, at the time of their death, were in a state of most profuse salivation. What- ever good I have seen in these cases from calomel has been when it was given in combination with purgatives, or when it produced a pur- gative effect. Let me, however, again remind you that you may have hydroce- phalus combined with tubercular ulceration of the intestines, and that in such a case diarrhoea may exist from the outset, or may come on after a mild dose of some aperient. Now and then, too, without such a cause, constipation is absent, while diarrhoea comes on occasionally in the advanced disease. You must not, therefore, draw inferences as to the state of the patient too exclusively from the condition of the bowels. There is still one remedy, the iodide of potassium, to which some practitioners cling with a sort of half faith in its specific virtues, and its proved utility in various forms of scrofulous disease furnishes, with- out doubt, an argument in its favor. I myself give it likewise, and think that I have seen good from its employment, while in one in- stance of what seemed to be advanced tubercular hydrocephalus, under the care of my friend and former colleague, Dr. Jenner, recovery took place under its employment. No other case of equal success has come under my own notice, and I can therefore by no means indorse all that has been said in its favor, though I have seen symptoms of a very threatening kind subside under its continued use; and this, especially in those cases which were the least active in their character. After the bowels have been freely relieved, and with due care still to keep them daily acting, I give about two grains of the iodide of potass every four hours to a child three years old; either alone, or if the child seems feeble, and the case is one whose symptoms seem to occupy the boundary line between true and spurious hydrocephalus, in combina- tion with a third of a grain of the sulphate of quinine; and I can re- commend this practice as yielding results, on the whole, more encou- raging than any other with which I am acquainted. I insisted much on the local employment of cold when speaking about the management of cases of cerebral congestion. It is likewise a very valuable agent in the treatment of hydrocephalus, but its application requires to be judiciously regulated. You will generally find it of service after depletion, for you have abstracted blood on account of the febrile disturbance, and heat of head, and other indications of con- gestion of the brain, all of which cold will be a powerful auxiliary in subduing. So long as the signs of active congestion of the brain are present cold will be of service, but it should not be employed inde- pendently of the symptoms which betoken the existence of that condi- tion; nor can you hope to see any benefit result from cold applications to the head in the advanced stages of the disease. I need scarcely say that the application of cold with a shock, or the pouring cold water from a height upon the head, though a very valuable means of arousing 7 98 USE OF NARCOTICS—USE OF BLISTERS. the child from the state of coma into which it sinks in some cases of intense cerebral congestion, it is wholly inapplicable in the coma of hydrocephalus. The functions of the brain are here not merely in- terrupted by the excess of blood in the organ, but they are abolished by the disorganization of its tissue, or the compression of its substance by the effusion of fluid. In the management of children attacked by hydrocephalus you must not forget that for the most part they are of feeble constitution, and that they will not bear too rigorous a diet. Just at first, indeed, while the febrile symptoms run high, and the bowels are unrelieved, or the sickness is urgent, the less the patient takes the better. Afterwards, however, it is desirable that he should be supplied with as much light and unstimulating nutriment as he will take; such, for instance, as arrowroot, or veal, or beef tea, either of which will often remain on the stomach when most other articles of food or drink would be rejected. In the treatment of many diseases you see physicians destroy the sense of pain by narcotics, and the question naturally suggests itself to you whether you may not sometimes venture, in the management of hydrocephalus, to mitigate by their means your patient's sufferings. The inquiry is one not very easy to reply to satisfactorily. I think, however, that there are two conditions in which you will be justified in trying the experiment of giving them. Sometimes the disease sets in with great excitement, and a condition closely resembling mania in the adult, symptoms which may have been ushered in by convulsions. In such a case, although the heat of the head and the flush of the face may have disappeared after free depletion and the copious action of purgative medicine, and though the pulse is feeble as well as frequent, yet the excitement may be scarcely if at all diminished. Here an opiate will sometimes give the relief which nothing else will procure; your patient will fall asleep, and wake tranquillized in the course of two or three hours. In other cases, which did not set in thus violently, jestlessness, talkativeness, and a kind of half-delirious consciousness -of pain in the head, become very distressing as the disease advances, being always aggravated at night, so that the patient's condition seems one of constant suffering. But he is not able to bear any more active treatment, and, indeed, you have already emptied your quiver of such weapons. In these circumstances 1 have sometimes given a full dose of morphia, and have continued it every night for several -nights toge- ther with manifest relief. Another inquiry that you may put is, when are you to employ blisters? Certainly not at the beginning of the disease, when they would increase the general irritation, and do more harm than good. At a later period they may be of service, when the excitement is about to yield to that stupor which usually precedes the state of complete coma. They should then be applied to the nape of the neck or to the vertex; and I am disposed to think the latter the better place, since, when applied to the nape of the neck, they often become displaced bv that boring movement of the head which the child in many instances keeps up unconsciously. It is well, too, to remember that the skin in hydrocephalus is very inapt to vesicate, so that a blister will require TREATMENT IN THE LAST STAGE OF HYDROCEPHALUS. 99 to be kept on for ten or twelve hours; contrary to what ought to be your usual practice with children. Cases enough are on record prov- ing the utility of blisters thus applied, to render it your duty not to neglect this means. I have made a few trials of a very energetic counter-irritant which has been strongly recommended by a German physician,1 but my ex- perience does not induce me to recommend its adoption. Dr. Hahn employs an ointment composed of one part of tartar emetic and two parts of lard; of which a portion, the size of a hazel-nut, is to be rubbed on the shaven scalp over a surface some two and a half inches in circumference, every two hours, till an abundant pustular eruption is produced. The sores which follow this inunction are remarkably intractable, requiring sometimes many months for their cure; but Dr. Hahn asserts, and gives some cases in proof of the assertion, that even in an advanced stage of hydrocephalus, and after the supervention of coma, recovery has often taken place under the use of this remedy. Many of the cases that he relates, however, are clearly not instances of hydrocephalus at all, while the theory which he propounds of the ex- istence of a sort of antagonism between tubercular meningitis and certain pustular eruptions of the skin, and on which he founds the assumption of a sort of specific virtue in the tartar-emetic ointment, is a mere hypothesis, of the correctness of which, as a general law, we have no sort of evidence. In the cases in which I tried it, it produced most formidable ulcerations of the scalp: it did what a very energetic counter-irritant might be expected to do, but nothing more, and it was difficult to convince bystanders that a large black-looking wound did not increase the suffering of patients whose disease it certainly failed to arrest. Need I say that you must not think of treating a case of hydro- cephalus throughout just in the same way as you did at its commence- ment? There is, if the disease do not run a very rapid course, a stage of weakness and exhaustion, often associated with a half-comatose condition, though sometimes attended with a considerable degree of suffering, which frequently precedes the signs of approaching death. The bowels are now sometimes relaxed, though oftener they continue constipated, because the nervous energy which kept up the peristaltic movements of the intestines is worn out. The powers of organic as well as those of animal life are palsied. This is the time for the administration of quinine, for the employment of nutritious broths and jellies, and even of wine. You may perhaps be disposed to ask me what I think of this remedy or the other, which has at different times been boasted of, as having done good when other means had failed. Now you must not infer from my silence that I do not believe that other medicines besides those which I have spoken of have been of service; but to attempt to canvass the respective merits of each would, I fear, be a tedious task, and one from which you would derive but little profit. Besides, let me remind you of what Sydenham says: "* * * In eo 1 De la Meningite Tuberculeuse, etc., par H. Hahn. 8vo. Paris, 1835. 100 SIMPLE INFLAMMATION OF THE BRAIN. prsecipue stat Medicina Practica, ut genuinas Indicationes expiscari valeamus, non ut remedia excogitemus quibus illis satisfieri possit; quod qui minus observabant, Empericos armis instruxere, quibus Medicorum opera imitari queant." LECTURE VIII. Simple Inflammation of the Brain—its difference from hydrocephalus—occasional extreme rapidity of its course—cases in illustration—morbid appearances—frequent connection with meningitis of the cord—extreme rarity as an idiopathic affection—treatment. Inflammation of the Brain succeeding to Disease of the Ear—digression concerning otitis—its symptoms—distinctions between it and inflammation of the brain—treatment —chronic otorrhcea, with disease of the temporal bone—case. Phlebitis of the Sinuses of the Dura Mater—circumstances in which it occurs—it some- times succeeds to large collections of pus in distant organs—case in illustration. We have been engaged at our last two meetings with the study of one form of inflammation of the brain in the young subject. We found hydrocephalus to be an affection almost exclusively confined to chil- dren whose previous health had been indifferent, who had shown some indications of phthisis, or in whose family phthisical disease existed. We observed its development to be gradual, its progress often tardy and attended with irregular remissions, but its issue almost always fatal. The alterations of structure discovered after death were seen to be slight at the convexity of the brain, but very obvious at its base, where, in addition to the effects of inflammation, the membranes often present a peculiar granular appearance. The fluid contained in the ventricles of the brain is almost always transparent, and tubercle is discovered in some, often in many, of the viscera. But we sometimes meet with cases in which inflammation of the brain has given rise to changes that contrast remarkably with those which true hydrocephalus produces. We find the cerebral membranes intensely injected, the effusion of lymph or pus abundant, especially about the convex surface of the brain, where it sometimes forms a layer concealing the convolutions from view. Moreover, the fluid that occupies the cavity of the arachnoid, as well as that within the ventricles, is turbid and mixed with lymph, while the membranes present no trace of that granular appearance so remarkable in true hydrocephalus, and the various organs of the body are free from tubercle. If we inquire as to the symptoms by which this disease was attended during the lifetime of the patient, we shall most likely find that they present fresh reasons for distinguishing between it and hydrocephalus. We shall learn that the attack came on in a previously healthy child, that it was either ushered in by convulsions, or that they soon occurred, that they returned often, and probably that they continued with but little intermission until death took place. We shall be told, moreover, SIMPLE INFLAMMATION OF THE BRAIN. 101 that the disease set in with violent vomiting and intense febrile excite- ment; and that having commenced thus severely, it advanced rapidly, and without remission, to its fatal termination, which may have arrived in the course of a few hours, and is seldom delayed beyond the first week. Some cases of this simple encephalitis are recorded by Golis, under the name of Water-stroke: I will select one of them, as affording a good specimen of the most acute form of the disease.1 "A little girl, 14 months old, who was healthy and strong and fat, was suddenly seized at 5 o'clock in the morning, after a restless night, with violent fever and frightful general convulsions. Medical assist- ance was at once obtained, and in less thau thirty minutes from the commencement of the attack four leeches were applied behind the ears, which drew three ounces of blood: calomel and other remedies were administered internally, and mustard poultices were applied to the soles of the feet. These measures soon alleviated the symptoms, but the relief lasted for but a very short time; the fever returned as intensely as before, convulsions came on again, attended with opistho- tonos, and the child became comatose. Hemiplegia succeeded; the pupils became extremely contracted; complete loss of vision, and spasmodic twitchings of the muscles of the face, soon followed, and, thirteen hours after the first convulsive seizure, in spite of most appro- priate and energetic treatment, the little child died. " The vessels of the scalp were loaded with blood, and the skull was so intensely congested as to appear of a deep blue color. The sinuses were full of coagulated blood mixed with lymph, and all the vessels of the brain and its membranes were enlarged and turgid with blood. " A large quantity of coagulated lymph covered the convolutions of the brain and the corpus callosum like a false membrane, and fur- nished a delicate lining to the lateral ventricles, whose walls were softened and in part broken down. The ventricles contained about three ounces of turbid serum, and there was a considerable quantity of lymph at the base of the brain." As I have never seen an instance of this most rapid form of menin- gitis, I will draw for another illustration of it upon that valuable storehouse of facts, Dr. Abercrombie's work on Diseases of the Brain.8 " A child, aged 2 years, 21st May, 1826, was suddenly seized in the morning with severe and long-continued convulsion. It left her in a dull and torpid state, in which she did not seem to recognize the per- sons about her. She had lain in this state for several hours, when the convulsion returned, and during the following night it recurred a third time, and was very severe and of long continuance. I saw heron the morning of the 23d, and while I was sitting by her she was again attacked with severe and long-continued convulsion, which affected every part of the body, the face and the eyes in particular being fright- fully distorted. The countenance was pale, and expressive of exhaus- tion; the pulse frequent. Her bowels had been freely opened by 1 Praktische Abhandlungen, etc., vol. i. Case 2. * Case 10, p. 52. 102 SIMPLE INFLAMMATION OF THE BRAIN. medicine previously prescribed by Dr. Beilby, and the motions were dark and unhealthy. Farther purging was employed, with topical bleeding, cold applications to the head, and blistering. After this attack she continued free from convulsion till the afternoon of the 23d; in the interval she had remained in a partially comatose state, with frequent starting; pulse frequent but feeble; pupils rather di- lated ; she took some food. In the afternoon of the 23d the convulsion returned with greater severity; and on the 24th there was a constant succession of paroxysms during the whole day, with sinking of the vital powers; and she died early in the evening. "On removing the dura mater, the surface of the brain appeared in many places covered by a deposition of adventitious membrane betwixt the arachnoid and pia mater. It was chiefly found above the openings between the convolutions, and in some places appeared to dip a little way between them. The arachnoid membrane when detached ap- peared to be healthy, but the pia mater was throughout in the highest state of vascularity, especially between the convolutions; and when the brain was cut vertically, the spaces between the convolutions were most strikingly marked by a bright line of vivid redness, produced by the inflamed membrane. There was no effusion in the ventricles, and no other morbid appearance." It would not answer any useful purpose to multiply the recital of cases, since though there are great varieties in the duration of the dis- ease, yet its general features are the same in almost every instance, and will, I think, readily be recognized by you as betokening an affection very different from ordinary hydrocephalus. The morbid appearances are sometimes found to vary both in their degree and in their extent, without any corresponding difference being observed in the symptoms. With the exception of its course being more rapid, Golis's case differed but little from that recorded by Aber- crombie. I believe that in the majority of instances the lining of the ventricles is affected; and it is certainly more common for the mem- branes at the base of the brain to be involved in the disease, than for it to be entirely limited to those at the convexity. It may also be doubted whether the membranes of the spinal cord are not also affected in the greater number of cases; but unfortunately the histories of but few post-mortem examinations contain complete details with reference to their condition. I have had the opportunity of examining five fatal cases of acute meningitis in infants or children, and in three of these there was not only abundant deposit of lymph on the surface of the convolutions, but it was effused copiously at the base of the brain; the ventricles contained turbid serum intermixed with flakes of lymph, and the membranes of the spinal cord were inflamed, and coated in many parts with lymph and pus. In all of these three cases the chil- dren were under a year old, and the disease came on without any assign- able cause, as it did also in the case of another little boy, ao-ed 13 months. In that instance, however, no lymph was effused anywhere; the ventricles contained only a small quantity of transparent fluid and the most remarkable appearance consisted in an intense injection of the pia mater of the convexity and of the surface of the convolu- INFLAMMATION BEGINNING WITHOUT THE SKULL. 103 tions for about two lines in depth, the cerebral substance in that situa- tion being softened, so that portions of it were removed when the pia mater was stripped off. In another instance, where all the symptoms of encephalitis succeeded to an injury of the,neck and head, the mem- branes at the convexity of the brain, and also the choroid plexuses and the velum interpositCtm, were intensely red; there was much effusion in the sub-arachnoid tissue; not much in the lateral ventricles, though their lining was considerably thickened. The substance of the brain was injected and much softer than natural, especially towards the centre of the organ at its left side. In both of these cases the mem- branes at the base of the brain were perfectly healthy, but the spinal cord was not examined. I have seen two other cases in which I believe that inflammation existed of the membranes both of the brain and spinal cord, but in which I had no opportunity of making an examination after death. These seven cases constitute the. whole of my experience in this formidable disease. Acute inflammation of the brain or its membranes is fortunately of very rare occurrence in childhood, except as the result of fracture of the skull, or of injury to the head or neck. Exposure to the heat of the sun has been known to induce it; sometimes it comes on in children who are apparently recovering from scarlatina; and at othec times it occurs without our being able to trace it to any definite cause. In the treatment of this affection, our remedies must be, in the main, the same as we should employ to combat the acute inflammation of any other vital organ. Bleeding, purgatives, mercurials, and the appli- cation of cold are the grand means on which we must rely; and these must be used with an unsparing hand if we would have any chance of saving our patient. Our prospect of success, however, depends almost entirely upon our seeing the patient at the very outset. The case which I quoted from Golis showed you what extensive mischief may occur in thirteen hours, and instances are on record in which a greater amount of injury has been discovered after a still shorter train of symptoms. Even in those cases which do not run this extremely rapid course, and in which the mischief found after death is not so considerable, there is little less need for speedy as well as active inter- ference, for if life be prolonged for a day or two without the disease being overcome, the patient often sinks into an exhausted condition, in which active treatment can no longer be ventured on. Formidable though these cases are, yet, if seen early, and treated actively, they may be regarded more hopefully than those in which the brain and its membranes become inflamed in consequence of the extension to them of disease beginning without the skull. You will occa- sionally see instances of this occurrence in children who have suffered from scrofulous disease of the cervical vertebras, when a life of suffering is terminated by a most painful death; or inflammation of the brain, proving very quickly fatal, may come on in a child who has long had discharge from the ear, with occasional attacks of earache. Vague threatenings of mischief in the head may perhaps have existed for some time, just sufficient to excite your apprehension, but not so 101 INFLAMMATION OF THE INTERNAL EAR. serious nor so definite as to call for decided interference; and yet, when death takes place, you will find it almost impossible to reconcile the existence of lesions so extensive and of such long standing as a post-mortem examination discovers, with the long-continued absence of definite cerebral symptoms. In Dr. Abercrombie's work on Diseases of the Brain,1 an account is given of a boy, aged 14 years, who had been affected for two months with headache and discharge of matter from the right ear. A week before his death the pain increased, and was accompanied by great debility, giddiness, and some vomiting. He continued in this state, without stupor or any other remarkable symptom, until the day of his death, when he was suddenly seized with convulsions, and died. An abscess was found in the middle lobe of the right hemisphere of the brain, and another in the cerebellum, and there was extensive caries of the pars petrosa, with effusion of three ounces of fluid in the ventricles. I have quoted this case in order to impress upon your minds that every, even the slightest, indication of cerebral disturbance is to be looked on with the greatest anxiety in children who have suffered from chronic otorrhcea. Your solicitude must be redoubled if the dis- charge from the meatus had ever been attended with the formation of abscesses at the back of the ear, or burrowing between the cartilage and the bone, since they would render it extremely probable that caries of the bone had existed, and that the membranes of the brain had been reached by the advance of the disease. Inflammation of the brain occasionally supervenes on disease of the internal ear, even though there had been no actual exposure of the dura mater by destruction of the bone, and though attacks of otitis have not been of frequent occurrence. Attacks of otitis, indeed, are of importance, not merely on account of the occasional supervention upon them of inflammation of the brain, but also on account of the severe suffering by which they are always attended. In many instances, too, needless alarm may be excited by the symptoms of inflammation of the ear being supposed to betoken that the brain itself is the seat of the mischief; and hence it is very desirable to become familiar with the diagnostic marks that distinguish the less from the more dangerous affection. The name of Otitis has been applied to inflammation of very different parts of the organ of hearing, and in common parlance no adequate distinction has been drawn between the affection of the external audi- tory canal, and that of the more deeply-seated parts of the ear, poste- rior to the membrana tympani. The earache of infants and young children is sometimes due to inflammation of one, sometimes of all of these structures. It is more frequent in all its forms in early life than in adult age, and it is the more deserving of mention since the amount of suffering by which it is attended is by no means a certain criterion by which to judge of its importance. When limited to the external auditory canal, the inflammation, though apt to recur from slight causes, and though very painful, seldom leads either to permanent dis- 1 Page 37; quoted from Mr. Parkinson, in London Med. Repository, March, 1817. INFLAMMATION OF THE INTERNAL EAR. 105 charge from the ear or to permanent impairment of hearing. Inflam- mation of the mucous membrane lining the cavity of the tympanum, when occurring as an acute idiopathic affection, is usually associated with affection of the external auditory canal, and then often greatly aggravates the child's sufferings. It does, however, often run a com- paratively chronic course attended with uneasiness rather than with severe pain, but which betokens the progress of mischief within the ear such as is likely to lead to abiding dulness of hearing. The deaf- ness that follows measles and scarlatina is due to inflammation, which terminates in secretion of pus within the cavity of the tympanum, whence it escapes through the membrana tympani; a mischief either repaired as the inflammation declines by the closure of the opening, or rendered altogether incurable by the detachment of the bones of the ear. In strumous subjects, too, the evil which thus originated may become chronic, may involve the petrous portion of the temporal bone, and may thence eventually extend to the brain. The same result may also follow on long-standing purulent discharge from the ear de- pendent on chronic inflammation of the external meatus; and it is this circumstance which gives to otorrhcea in childhood its most grave sig- nificance. The full detail of the symptoms and management of these various affections comes rather within the province of the aural surgeon1 than within mine. I must not, however, pass them entirely without men- tion. Attacks of earache are most frequent before the completion of the first dentition, and are by no means rare in young-children who are perfectly unable to point out the seat of their sufferings. The at- tack sometimes comes on quite suddenly, but usually the child is fret- ful and languid for a period varying from a few hours to one or two days before acute pain is experienced. In this premonitory stage, however, it will often cry, if tossed or moved briskly, noise seems un- pleasant to it, and it does not care to be played with; while children who are still at the breast show a disinclination to suck, though they will take food from a spoon. The infant seeks to rest its head on its mother's shoulder, or, if lying in its cot, moves its head uneasily from side to side, and then buries its face in the pillow. If you watch closely, you will see that it is always the same side of the head which it seeks to bury in the pillow, or to rest on its nurse's arm, and that no other position seems to give any ease except this one, which, after much restlessness, the child will take up, and to which, if disturbed, it will always return. The gentle support to the ear seems to soothe the little patient; it cries itself to sleep, but after a short dose some fresh twinge of pain arouses it, or some accidental movement disturbs it, and it awakes crying aloud, and refusing to be pacified, and may con- tinue so for hours together. Sometimes the external ear is red, and the hand is often applied to the affected side of the head; but neither of these symptoms is constant. The intensity of the pain seldom lasts 1 Two papers by Mr. Toynbee may be consulted with advantage: the one a pam- phlet on Otorrhoea and Otitis, the other in vol. xxxiv. of Med.-Chir. Transactions, on "Those Affections of the Ear which produce Disease in the Brain;" and also chap. xiv. of his work on The Diseases of the Ear, 8vo. London, 1860. 106 TREATMENT OF OTITIS. for more than a few hours, when in many instances a copious discharge of offensive pus takes place from the ear, and the child is well. In some instances, indeed, the subsidence of the disease on one side is followed by a similar attack on the opposite side, and the same acute suffering is once more gone through, and terminates in the same man- ner. Sometimes, too, this complete cure does not take place, but the earache abates, or altogether ceases, for a day or two, and then returns; no discharge, or but a very scanty discharge, taking place, while for weeks together the child has but few intervals of perfect ease. In in- fants earache seldom follows this chronic course, though I have occa- sionally seen it do so in older children; and the disease is in these cases seated within the cavity of the tympanum. In children who are too young to express their sufferings bywords, the violence of their cries, coupled with the absence of all indications of disease in the chest or abdomen, naturally lead to the suspicion of something being wrong in the head. There are three circumstances, however, which may satisfy you that the case is not one of ordinary hy- drocephalus; the child does not vomit, the bowels are not constipated, and there is but little febrile disturbance. The loud and passionate cry, the dread of movement, and the evident relief afforded by resting one side of the head, are evidences of the ear being affected; while in many instances the movement of the hand to the head, and the redness of the external ear, with the swelling of the meatus, concur to make the diagnosis easy. Sometimes, when in doubt, you will be able to satisfy yourselves that the cause of suffering is in the ear, by pressing the cartilage of the organ slightly inwards, which will produce very evident pain on the affected side, while, if practised on the other side, it will not occasion any suffering. The treatment of this painful affection is very simple. In many instances the suffering is greatly relieved by warm fomentations, or by applying to the ear a poultice of hot bran or chamomile-flowers. A little oil, to which some laudanum has been added, may be dropped into the ear, and repeated from time to time; while if the pain be ex- tremely severe, or have continued for several hours, it may be wise to apply a few leeches to the mastoid process. If the earache return frequently, a small blister should be applied behind the ear, or slight vesication may be produced by means of the acetum cantharidis. The possible supervention of inflammation of the brain must of course be borne in mind, and any indication of its approach must be immediately combated; but fortunately this occurs less frequently as a complication of otitis than as a sequela of long-continued purulent discharge from the ear, which has probably been attended with con- stant though not very severe pain in the head. A little boy, four years old, was for some time under my care, who had suffered for eighteen months from purulent discharge of a very offensive charac- ter from both ears. After this discharge had continued for six months, an abscess formed behind the left ear, which, on being opened, gave issue to lij, of very fetid pus. A month afterwards a large portion of the mastoid process of the left temporal bone was exfoliated, and for several weeks after this occurrence the left side of the face was INFLAMMATION OF SINUSES OF DURA MATER. 107 frequently thrown into a state of twitching movement, which showed that some of the branches of the portio dura had been involved in the disease. This symptom disappeared after the lapse of nine months, but the discharge continued as fetid as ever, though much more pro- fuse from the right than from the left ear; and long after abscess had ceased to discharge, a fistulous opening still continued leading down to the diseased bone, and the little boy was in almost constant suffering from headache. Sometimes the pain was very severe, and quite pre- vented his sleeping, and then it abated for several days or weeks with- out any evident cause. On giving up my appointment at the Child- ren's Infirmary, I lost sight of the child; there can, however, be little doubt but that sooner or later an acute attack of inflammation of the membranes of the brain will come on, and prove quickly fatal. In those cases where offensive puriform discharge from the ear has been of long continuance and the matter is sometimes tinged or streaked with blood, astringent injections must be used only with the greatest care, while their employment is not at all advisable if exfoliation of bone have taken place, since in such a case not only is the internal ear disorganized, but the dura mater has very probably become ex- posed. Attention to cleanliness, by frequently syringing out the ear with warm water or with a solution of gr. j or gr. ij of the acetate of lead in an ounce of water, constitutes all the topical treatment on which it would be safe to venture, while the most sedulous attention must be paid to the general health of the patient. It still remains for me to notice one singular form of cerebral dis- ease, which, though not confined to children, is seen much oftener among them than among adults; namely, phlebitis of the sinuses of the dura mater. In grown persons it usually succeeds to some injury of the head, but in the child it has generally been observed as a conse- quence of long-continued purulent otorrhcea, combined with disease of the temporal bone, or it has been connected with disease of the frontal sinuses, or has followed an abscess of the scalp. In one or two instances, also, it has seemed to be excited by the presence of large collections of pus in distant parts of the body. M. Tonneld, who has written a very valuable paper on inflammation of the sinuses of the dura mater in children,1 records one instance in which it coin- cided with a pleuritic effusion; and a somewhat similar case has come under my own notice, which I will relate, partly on account of its rarity, partly because it illustrates exceedingly well the morbid appear- ances observed in cases of this description. A healthy little girl was attacked by scarlatina when eight months old. The attack was not severe, but, after it had passed away, she did not regain her previous health, but continued restless and feverish; she was sometimes sick, and her eyelids were often slightly swollen. A fortnight after the rash appeared, she had one or. two violent con- vulsive seizures, but they ceased after her gums were lanced, and did not appear to be in any way connected with her subsequent illness. She continued out of health until she was 10^ months old, when her 1 Journal Hebdomadaire, vol. v. p. 337. 1825. 108 INFLAMMATION OF SINUSES OF DURA MATER. mother noticed, in addition to the puffiness of the eyelids, a swelling of the legs and abdomen, for which she came under my care when eleven months old. The legs were then very cedematous, and fluctu- ation was distinctly felt through the parietes of the abdomen, the urine being scanty and high-colored. In the course of about three weeks her condition had improved considerably, the urine having increased much, the anasarca having greatly diminished, and the abdomen being 1| inch less in circumference. A fit of convulsions now came on without any apparent cause, but no other symptoms of cerebral mischief followed it, and the convulsions did not return. After the lapse of another week a discharge of seropurulent fluid took place from the umbilicus, and continued for several days in quantities of from a quarter to half a pint daily. The discharge was attended with an improvement rather than a deterioration in the child's health ; but after it had continued for eleven days, fever and dyspnoea suddenly came on, with dulness on percussion over the right side of the chest, and absence of respiratory murmur in that situation. The discharge ceased for a week during the urgency of the thoracic symptoms, but then reappeared, though scantily. The child now grew thinner and weaker, and sank into a state of hectic. No new symptom came on till she was suddenly seized with extreme faintness, amounting to almost perfect syncope. She rallied, however, under the use of stimu- lants, but forty-eight hours afterwards the faintness returned, and terminated in death, without any convulsion having preceded it, just five months and a half after the attack of scarlatina, and two months after she came under my care. On an examination of the body after death, pleurisy of the right side was discovered, with about Ivj of pus in the right pleura, and peritonitis, with Oiij of pus in the abdomen; the passage being still traceable through which the fluid had escaped at the umbilicus. The dura mater adhered firmly to the skull, along the posterior half of the longitudinal sinus, at the torcular Herophili, and along the left lateral sinus; but elsewhere it was easily detached from the cranium. The siuuses on the right side were healthy, but the blood within them was almost entirely coagulated. The posterior half of the longi- tudinal sinus, the torcular, the left lateral and left occipital sinuses, were blocked up with fibrinous coagulum, precisely such as one sees in inflamed veins, and the clot extended into the internal jugular vein. The coats of the longitudinal and of the inner half of the lateral sinus were much thickened, and their lining membrane had lost its polish, was uneven, and presented a dirty appearance. There was some congestion of the arachnoid, a considerable quan- tity of fluid in the ventricles, and sections of the brain presented more bloody points than natural, especially on the left side. The base of the brain was perfectly healthy on the right side, but there was great venous congestion beneath the middle lobe of the left hemisphere; the cerebral veins in that situation were distended with coagulum, and their coats were thickened. Towards the anterior part of the left middle lobe were four apoplectic effusions, in all of which the blood retained its natural color. Each of these effusions was connected with INFLAMMATION OF SINUSES OF DURA MATER. 109 an obstructed and distended vein. The largest clot extended an inch into the substance of the brain; the others were of smaller extent. I cannot speak to you of any symptom as pathognomonic of this occurrence: it usually comes on, as in this instance, in much debili- tated children, and though it generally follows some injury or disease in the neighborhood of the brain, you will bear in mind the possibility of its occurrence whenever large collections of pus exist in any part, and will draw a very unfavorable prognosis in the event of head symptoms coming on in such circumstances. It is now many years since I observed this case, and made with reference to it the above remarks. No other instance of this affection has come under my notice, but it has been described by several recent writers, who have brought to bear on it the light which the researches of Virchow have thrown on clot formation in the bloodvessels. The most elaborate essay on the subject is that of Von Dusch,1 who divides all cases of "Thrombosis of the Cerebral Sinuses," into two classes, according as they are the result of inflammation in the neigh- borhood, or as they depend on the indirect influence of general de- bilitating causes. The effects of local injuries to the skull, and the extension of disease of the internal ears, illustrate the former mode of its production; but the latter would seem to be much the more fre- quent in early life, and in many instances of it, in addition to the influence of general debilitating causes in its production, there was superadded some condition or other obstructing the respiration, and thus preventing the right side of the heart from emptying itself pro- perly, thereby retarding the current of the blood. Neither the researches of Yon Dusch, nor the observations of other writers indicate any symptoms as pathognomonic of this affection, and the only conclusion at which we can arrive with reference to it is, that when head symptoms set in suddenly in previously debilitated subjects, and do not run the course of any ordinary form of cerebral disease, such symptoms will probably be found to be due to the forma- tion of thrombus in the sinuses. 1 The essay of Von Dusch, on Thrombosis of the Cerebral Sinuses, is translated in vol. xi. of the publications of the New Sydenham Society, 8vo., London, 1861. Seve- ral interesting cases have been contributed by Dr. Loschner, of Prague, in the Prague Vierteljahrschrift, and in the Jahrbuch fur Kinderheilkunde, vol. iv., Analecten, p. 49, who dwells especially on the absence of any characteristic symptoms during life, and a case with remarks by Dr. Langenbeck, of Gottingen, will also be found in the Journal fur Kiudeikiankheiten, vol. xxxvi., 1861, p. 75. 110 CHRONIC HYDROCEPHALUS. LECTURE IX. Chhonic Hydrocephalus—various conditions under which fluid collects in the skull—divided into the external and the internal—symptoms of both nearly identical—changes in form and size of the head—and their mode of production—course of the disease—termination almost always fatal. Internal Hydrocephalus—important questions involved in its pathology—frequent connec- tion with malformation of brain—but also follows inflammation of lining of ventricles— description of post-mortem appearances—case illustrative of its connection with inflam- mation—process of cure usually mere arrest of disease. External Hydrocephalus—circumstances in which it exists—its relation to hemorrhage into the arachnoid.—Treatment of both forms of the disease.—Importance, but difficulty, of distinguishing curable and incurable cases.—Golis's plan.—Compression.—-Puncture.— Cases suited for each mode of treatment. We have now completed our examination of the acute inflammatory affections of the brain, and with them we may consider that we have dismissed the most important class of diseases of. that organ. Before we pass, however, to those in the production of which inflammation bears no part, we must study one malady which forms a kind of con- necting link between the two. Chronic Hydrocephalus, or Dropsy of the Brain, is a morbid condi- tion met with in children at various ages, and coming on in a great variety of circumstances. Sometimes it is congenital, and is then often, though by no means invariably, associated with malformation of the brain. In subsequent childhood, an excess of blood in the brain, or its deficiency, or the existence of some impediment to the circulation through the organ, are conditions all of which have been found to give rise to the effusion of fluid into the cavities of the brain, or upon its surface. Instances of chronic hydrocephalus are on record, which have succeeded to hemorrhage into the sac of the arachnoid; others, that have been connected with wasting of the brain, in consequence of the supply of blood being inadequate to its due nutrition, or in which obliteration of the sinuses by disease, or the pressure of a morbid growth upon some of the vessels of the brain, has interfered with the due performance of the cerebral circulation. In many cases, however, I believe, as do MM. Eokitansky and Vrolik,1 that the dis- ease is not a mere passive dropsy, nor simply a consequence of arrested cerebral development, but that it is the result of a slow kind of in- flammation of the arachnoid, especially of that lining the ventricles which may have existed during foetal life, or may not have attacked the child until after its death. I may further add that each year leads me to estimate more highly the share of inflammation of the lining of the ventricles in the production of hydrocephalus. ii. p. 754 ; Vrolik, Handboek der Ziek- o. pp. 514-537. SYMPTOMS OF CHRONIC HYDROCEPHALUS. Ill According to the situation in which the fluid collects, a division has been made of chronic hydrocephalus into the external and the internal; the former term being applied to cases in which the fluid collects in the sac of the arachnoid; the latter, to those in which it accumulates in the ventricles of the brain. The two conditions sometimes coexist, but generally they are independent of each other; the internal hydro- cephalus being the more frequent and the more important; and to it we will therefore first direct our attention. The early symptoms of the disease vary. When it is congenital, in- dications of cerebral disturbance are generally apparent from the infant's birth. These are sometimes serious—such, for instance, as convulsions, recurring almost daily ; at other times they are compara- tively slight; and consist in nothing more than strabismus, or a strange rolling of the eyes, unattended by any very definite sign of affection of the brain. The size of the head generally attracts attention before long, and causes importance to be attached to symptoms which other- wise might have given rise to but little anxiety. In some instances, however, the increased size of the head is not very obvious until the child is a few weeks old, although well-marked symptoms of mischief in the brain existed from its birth. Enlargement of the head, indeed, is by no means invariably the first indication of chronic hydrocephalus. In 12 out of 45 cases, fits, returning frequently, had existed for some weeks before the head was observed to increase in size; in 6, the enlargement of the head succeeded to an attack resembling acute hydrocephalus; and in four other instances it had been preceded by some well-marked indication of cerebral disturbance. In the remain- ing 23 cases no distinct cerebral symptom preceded the enlargement of the head; but in almost every instance the child's health had been noticed to be failing for some time, although the cause of its illness was not apparent. In whatever way the disease begins, impairment of the process of nutrition is sure to be one among its earliest symptoms. The child may suck well, and, indeed, may seem eager for food, but it loses both flesh and strength; and often, although the head has not yet attained any disproportionate size, the child is unable to support it, either losing the power it had once possessed, or never attaining that which, with its increasing age, it ought to acquire. The bowels are usually, though not invariably, constipated. Sometimes diarrhoea comes on for a day or two; but, under either condition, the evacuations are almost always of an unhealthy character. Thus far, indeed, there is but little to distinguish the case from any other in which a young infant is imperfectly nourished; but, even though no well marked cerebral symptom be present, occasional attacks of heat of head will be observed, attended with pulsation or tension of the anterior fonta- nelle, while crying and restlessness often alternate with a drowsy con- dition, though the child almost always sleeps ill at night. In many instances, too, the open condition of the fontanelles and sutures ex- cites attention long before any enlargement of the head becomes perceptible. By and by, however, the increased size of the head grows very 112 COURSE AND TERMINATION OF THE DISEASE. manifest, and the child's physiognomy soon assumes the distinguish- ing features of chronic hydrocephalus. As the disease advances, the unossified sutures become wider, the fontanelles increase in size, their angles extend far into the sutures in which they terminate, while the fluid, pressing equally in all directions, tends to impart a globular shape to the receptacle in which it is contained. Some of the casts upon the table afford striking illustrations of this change in the form of the cranium, which would be still more remarkable were it not for the very unequal resistance of different parts of its parietes. The bones at the vertex of the skull are much less firmly fixed than the others, and ossification is nowhere so tardy as at the anterior fontanelle, and along the inner edges of the parietal bones. Hence it results that the great increase in the size of the head is effected by enlargement of the anterior fontanelle, and by widening of the sagittal suture. The os frontis consequently becomes pushed forwards, the parietal bones are driven backwards and outwards, and the occipital bone downwards and backwards. The displacement of the bones is vei-y obvious in this hydrocephalic skull, but it is still more striking in the two engravings which I here show you.1 You notice the great pro- minence of the forehead, and the alteration in the position of the parietal bones, which are driven backwards as well as outwards, so that the natural relations of their protuberances are altogether changed; while in this remarkable case of a man named Cardinal, who, though hydrocephalic from his infancy, lived to the age of 29 years, the occi- pital bone lies almost completely in a horizontal position. You will observe, too, another remarkable alteration produced by the yielding of the orbitar plates of the frontal bone, which are driven by the accumulating fluid from a horizontal into an oblique direction. Some- times, indeed, they become nearly perpendicular, when, by contract- ing the orbits, they give to the eyeballs that unnatural prominence, and that peculiar downward direction, which constitute one of the most remarkable features in cases of chronic hydrocephalus. Few objects are more pitiable than a little child who is the subject of far-advanced chronic hydrocephalus. While the skin hangs in wrinkles on its attenuated limbs, the enlarged head appears full, almost to bursting, owing to the stretching of the scalp; and the scanty growth of hair does not at all conceal the distended veins that run over its whole surface. The size of the skull, too, appears greater than it really is, since the face not only does not partake of the en- largement, but retains its infantile dimensions much longer than natural. The eyes are so displaced by the altered direction of the orbitar plates that the white sclerotica projects below the upper lid, and the iris is more than half hidden beneath the lower. Often, too, there is a considerable degree of convergent strabismus, or a constant rolling movement of the eyeball, which the child is unable to control; or the pupil is dilated, and quite insensible to light. The symptoms of cerebral disturbance that attends the advance of 1 Baillie's Morbid Anatomy, fasc. x. plate iii. fig. 1, and the drawing of Cardinal's skull, in Briglit's Reports, vol. ii. part 2, plate xxxv. PATHOLOGY OF CHRONIC INTERNAL HYDROCEPHALUS. 113 the disease differ much in severity. Sometimes there is little besides a state of uneasiness and restlessness, aggravated at intervals when the head grows hot and the fontanelle becomes tense. In other cases convulsions occur very frequently, being induced by extremely slight causes, or corning on without any. In several instances I have ob- served spasmodic attacks of difficult breathing, attended with a crowing sound in inspiration, and those symptoms which constitute spasmodic croup, seizures of which sometimes come on even before there is much enlargement of the head. But, whether the cerebral symptoms are slight or severe, almost every case of chronic hydrocephalus has pauses in its course, during which the child seems to enjoy a compa- rative immunity from suffering, and gains flesh, while its head ceases for a time to enlarge. Nothing, however, can be more variable than the frequency of these pauses, or their duration.1 Though almost every case of chronic hydrocephalus is fatal, yet death takes place in very different ways. Childreu who are the sub- jects of the disease are almost always very weakly: hence, they often give way under the first serious illness that attacks them, and are carried oft' by maladies totally unconnected with their head affection; while many others sink into that state of atrophy, by which the dis- ease of the brain is often accompanied, and die exhausted. Others are carried off" suddenly by convulsions, or fall victims to some severe paroxysm of spasmodic croup: and there are other instances in which the disease seems lighted up again after a pause, by the irritation of teething, or by some trivial accident, and death is preceded by the indications of acute cerebral mischief. The pathology of chronic internal hydrocephalus involves questions not merely of scientific interest, but of great practical moment; for if we come to the conclusion at which some observers of high authority have arrived, that it is almost invariably the effect of arrest of the development of the brain, all therapeutical proceedings must be worse than useless. The early date of the occurrence of its symptoms, in the great majority of cases, lends support, indeed, to the opinion that the causes to which it is due must generally have existed before birth ; for I find, on examination of the history of 54 cases, 18 of which came under my own observation, that some indications of it were observed in 50 of this number before the child was six months old ; that in 11 of these its symptoms existed from birth; and that in 21 more they appeared before the completion of the third month. The knife of the anatomist, too, has discovered evidences of congenital malformation of the brain, in some instances in which no sign of hy- drocephalus was apparent until several weeks after the child's birth; a fact which still further deepens the dark colors in which this malady has been portrayed. 1 I make no reference to the results of cerebral auscultation in this or other affec- tions of the brain in early life. M. Roger's essay, Sur l'Auscultation de la TSte, in vol. xxiv. of the Memoires de l'Academie de Medecine, has completely settled the imaginative character of MM. Fisher and Whitney's discovery. I have myself list- ened, without success, for the cerebral souffle in several cases of chronic hydroce- phalus. 8 114 INTERNAL HYDROCEPHALUS—MORBID APPEARANCES. Still, large as is the proportion of cases in which symptoms of chronic hydrocephalus have existed from birth, I am disposed to believe the exceptions to this not to be so extremely rare as some imagine, and am further of opinion, that, even in cases of congenital hydrocephalus, inflammation of the lining of the lateral ventricles, such as produces it after birth, may, in many instances, have excited it during foetal life. In seven post-mortem examinations of children affected with cronic internal hydrocephalus, who died at the respective ages of 16 months, 3 years, 8 months, 19 months, 2 years, 3£ and 3 J years, I found the corpus callosum perfect in every instance. In all, also, the fornix was present; thrice it and the septum lucidum were thickened and tough; twice they were found torn and softened, acute hydrocephalus having supervened on the chronic disease. Once the septum lucidum was absent, and once both it and a large portion of the fornix also were wanting. In one case the state of the membranes lining the ventricles was not noted; in the other six it was thickened, four times very re- markably; and twice it was roughened and granular, presenting an exaggerated degree of that condition which is also so often met with in fatal cases of acute hydrocephalus, and to which I directed your attention when speaking of that disease. In some cases—as, for instance, in this drawing by Professor Vrolik1 of the brain of a young man who died of chronic hydrocephalus at the age of 20—a false membrane is found in the interior of one or other ventricle, and may even occlude the foramen of Monro; an accident which, by interrupting the communication between the two sides of the brain, may serve to account for the unequal distension of the two ventricles, and the great want of symmetry occasionally observed in hydrocephalic skulls. The marks of inflammation of the membranes at the base of the brain are, moreover, in many instances, very evident; and there is often an extremely abundant effusion of that hyaline matter in the meshes of the pia mater, to which I called your attention when speaking of acute hydrocephalus. Lastly, I may remark, that the observation, in a large number of instances, that the cerebral substance has been simply unfolded by the accumulation of the fluid in the ventricles, so that even when of extreme tenuity the gray and white matter could still be distinguished, proves not merely that the brain was not melted down by the action of the fluid, but also that its accumulations could not, in these instances, be due to the arrest of cerebral development. Besides the evidence which post-mortem examinations often furnish of the connection of chronic internal hydrocephalus with previous inflammatory action, the history of the patient's illness sometimes affords distinct proof of its occurrence. A striking instance of this has been published by M. Rilliet, of Geneva,2 in the case of a little girl 10J years old, in whom the symptoms of acute cerebral inflammation were succeeded by those of chronic disease in the brain, which termi- 1 Traite" sur la Hydrocephalic Interne, 4to. plate iii. Amsterdam, 1839. 2 Archives Gen. de Medecine, Dec. 1847. INTERNAL HYDROCEPHALUS—MORBID APPEARANCES. 115 nated fatally at the end of four months. Ten ounces of transparent but highly albuminous fluid were contained in the lateral ventricles, the lining membrane of which was nearly half a line thick, having a gelatinous appearance, as if softened, but being in reality so tough that it could be torn away from the cerebral substance in long strips. Though in the following history the connection between the acute and the chronic evil is far less striking than in M. Rilliet's case, yet I think few will refuse to admit the injury to the head and the subse- quent cerebral symptoms as the first steps in the chain of morbid pro- cesses which led to the distension of the ventricles of the brain with fluid, and to the development of all the symptoms of chronic hydro- cephalus. A little girl, the child of healthy parents, was healthy when born, and continued so until she was five months old, when she fell out of the arms of the person who was nursing her, and on the same day was taken in a fit, and lay stupid and senseless for some hours. She was leeched and blistered for these and other head symptoms which the parents were unable to describe very accurately, and to all appearance recovered. When a year old, however, head symptoms returned, and for several weeks convulsions were of extremely frequent occurrence; but at length ceased. About that time, the child being then 15 months old, her mother first noticed that her head was beginning to enlarge, since which time she had had no return of fits, but the head continued to increase in size down to the time when I first saw her, she being then just three years old. Her countenance presented all the peculiarities of chronic hydro- cephalus in a very marked degree: her head was large, measuring 20 inches in circumference, and 13^ from one meatus auditorius to the other; her forehead was prominent, and her eyes were directed down- wards, while her body was very ill nourished. Her bowels were regular, her bodily functions generally natural, and she was very voracious. She was by no means stupid, but on the contrary showed much shrewdness, though she was noisy and almost constantly chattering. I had not seen her above once or twice when she was attacked by measles, on the second day of which convulsions came on, and she sank into a comatose state interrupted only by convulsive twitchings of the limbs, and died in this condition on the fourth day of her illness. The head was examined 48 hours after death. The bones of the head were quite firm and hard; the posterior fon- tanelle was closed, but the anterior was open; its diameter in either direction being about 3J inches. There was no fluid in the sac of the arachnoid, nor morbid condition of the membranes either at the vertex or base of the brain. A very small quantity of fluid was in the sub-arachnoid tissue, and a pint of perfectly transparent serum in the lateral ventricles. The convolutions of the brain were quite flattened ; its cortical sub- stance was of natural thickness, the white substance very thin, and expanded around the ventricles, which were dilated to four times their natural size. 116 EXTERNAL HYDROCEPHALUS — MORBID APPEARANCES. The white substance of the wall of the ventricles was quite firm, and separable into a thin tough layer, leaving the substance of the brain quite natural beneath. The septum lucidum was tough and membranous, and much thickened. The edges of the fornix were firmly adherent to the upper surface of the optic thalamus, and in- cluded between them a portion of the choroid plexus. The membrane lining the ventricles was universally thickened; where it covered the corpora striata, the optic thalami, the commis- sures, and the floor of the fourth ventricle, it was not only peculiarly tough, but granular, and presented an appearance just like shagreen. The size of the head in this case had been increasing but slowly, and probably, had the child not been cut off by the intercurrent attack of measles, the effusion of fluid would at length have come to a stand still, and the hydrocephalus would have been cured; at least, as much as hydrocephalus usually is. Strictly speaking, however, there is in general no cure of the affection, but merely an arrest of its progress; no more fluid is poured out, but that already effused is un- absorbed; the sutures and fontanelles become ossified, and the enor- mous size of the head attracts less attention, not because there is any diminution in its dimensions, but because the disproportion between the cranium and the face becomes less striking, owing to the develop- ment of the latter as the child grows older. In some instances, indeed, Professor Otto1 is of opinion that a real cure is effected by an increased activity of the nutrition of the brain, producing hypertrophy of the organ; the fluid being absorbed, and nerve matter deposited in its stead. This, however, is in all probability a purely exceptional occur- rence; and the majority of hydrocephalic patients who survive the advance of the disease still have their lateral ventricles distended with fluid. This was all that occurred in the well-known case of Thomas Cardinal, whose bust I here show you. Having being hydrocephalic from infancy, he yet lived to tta age of 29, in the possession of a tolerable amount of bodily and mental activity. On examination of his body after death, between seven and eight pints of fluid were found in his cranium. In the greater number of instances symptoms exist during life which show clearly enough that the arrest of the disease differs widely from its cure, or that the malady of the brain which it produces, or with which it was associated, is irreparable; for the in- tellectual powers are generally feeble, and the temper very irritable while the child is often unable to walk, and its sight is very imperfect. The presence of a large quantity of fluid in the sac of the arachnoid, constituting what is called external hydrocephalus, may arise from several causes. 1st. The commissures of the distended brain may yield, and a por- . tion or the whole of the fluid which it contains may escape into the cavity of the cranium. This seems to have taken place in the case of Cardinal, whose skull contained seven or eight pints of fluid, while " the brain lay at its base, with its hemispheres opened outwards like the leaves of a book."2 1 Rokitansy's Pathologische Anatomie, 1st ed. vol. ii. pp. 749-769. i Bright's Reports, vol. i. part 1, p. 433. TREATMENT OF CHRONIC HYDROCEPHALUS. 117 2d. An atrophied condition of the brain may exist, and fluid may be poured out to fill up the vacuum thus produced in the skull; and such cases are generally of a very hopeless kind, the defect of cerebral development being almost always the result of congenital malforma- tion or of intra-uterine disease. 3. A large quantity of fluid is sometimes found in the sac of the arachnoid, as the result of hemorrhage into its cavity, and of the changes subsequently undergone by the effused blood. MM. Rilliet and Barthez, who have most ably investigated the subject of hemor- rhage into the arachnoid, believe that chronic hydrocephalus frequently has this origin. I have seen a few cases which I suspect were of this nature, but have never had the opportunity of confirming my suspicion by a post-mortem examination. In cases of this last kind, more may be expected both from nature's own reparative powers, aud from the resources of art, than in any other form of chronic hydrocephalus. Unfortunately, their symptoms so closely resemble those of the other less hopeful varieties of the disease, that their diagnosis is attended by much difficulty and uncer- tainty, and must be founded, in great measure, on the previous history of the patient. "It is never congenital, but generally begins about the tenth month; that is to say, about the time when the teeth begin to appear. The head, indeed, enlarges gradually, but does not acquire so large a size as in internal hydrocephalus: while, lastly, it is always preceded by repeated convulsions, or by some other form of active cerebral disturbance, which marks the date of occurrence of hemor- rhage."1 The observation has often been made, that the reputed means of cure of any disease are generally numerous in a directly inverse pro- portion to its curability; and to this rule chronic hydrocephalus certainly forms no exception; "its remedies have been derived," as Golis says, "from all the kingdoms of nature, and include almost every kind of surgical contrivance and pharmaceutical compound." It would be an almost endless task to attempt estimating the comparative value of them all; and I think it more useful to direct your attention to a few points of real importance. First of all, I would have you bear in mind that there are some cases in which you can do no permanent good, but in which treatment must fail, not because it is improper, but because the malady does not admit of cure. Such cases are those in which the accumulation of fluid within the brain is associated with extensive congenital disease, or malformation of the organ. If aware of its existence, our treat- ment would, of course, be simply palliative, and our efforts would be limited to securing euthanasia, since we could not hope to avert death. We should suspect the affection to be incurable, if, though the head were large, and its ossification very imperfect, the forhead were low and shelving; if a considerable degree of paralysis were present, if convulsions occurred daily and causelessly, and especially if these or 1 Legendre, Recherches Anatomo-pathologiques, p. 135. See also Rilliet et Barthez, op. cit. 2d ed. vol. ii. p. 259. 118 COMPRESSION OF THE HEAD. other indications of serious cerebral disorder had existed almost from birth. Unfortunately, these hopeless cases are by no means invariably characterized by peculiar symptoms, and the amount of functional disturbance often affords but a very incorrect index to the extent of organic lesion: your prognosis, therefore, must always be most guarded, and even when you see every reason to expect success, you must yet be prepared for failure. On the other hand, you must not regard a case as hopeless, and abstain from remedial measures, merely on account of the head having been larger than natural at birth, or its ossification having been less advanced than usual, since we have evidence of perfect recovery from chronic hydrocephalus in cases where many circumstances had ap- peared to indicate that the disease was congenital. The state of the cerebral functions must influence your prognosis as much as the size of the head, or even more. In either form of chronic hydrocephalus, the success of treatment must depend, to a great degree, upon its being adopted early, but in no stage of the disease can good be expected from violent remedies; rough measures would be likely to destroy the patient rather than the malady. I do not know of any plan, on the whole, more likely to be of service, than that which Professor Golis, of Vienna, recom- mended as the result of many years' experience, though I fear I must add that my confidence in it is by no means on the increase. He advises that the head of the child be shorn, or its hair cut close, and that one or two drachms of the mild mercurial ointment be rubbed daily into its scalp. As the same time the head is to be kept con- stantly covered with a flannel cap, to prevent the risk of the perspira- tion being checked by the cold air, and gr. \, or gr. ss of calomel, should be given twice a day, unless diarrhoea come on, when the in- unction alone must be employed. This plan should be persevered in for thirty or forty days, when, if the patient appear improving, the remedies may be very gradually diminished, but the cap should be still worn even after the inunction has been discontinued. Should no great improvement appear after a lapse of six or eight weeks, some mild diuretic may be conjoined with the other remedies, and a couple of issues may be inserted in the occiput. For this measure, however, I have always substituted the frequent application of blisters to the back of the neck. The woollen cap, recommended by Golis, often seems agreeable to the child, but sometimes I have had to discontinue it in consequence of the heat of head which it produced. In most cases, too, you will be compelled to resort to occasional leeching, in order to subdue the attacks of heat of head and restlessness which are exacerbated from time to time, and often attended with other symptoms that threaten the supervention of acute disease. The observation that in some cases where the spontaneous cure of chronic hydrocephalus takes place, the ossification of the head, previ- ously so imperfect, makes rapid advances, and the bones become early united, led Mr. Barnard,1 of Bath, to imitate nature's processes, and to 1 Cases of Chronic Hydrocephalus, &c, by J. H. Barnard, 8vo. London, 1839. COMPRESSION OF THE HEAD. 119 bandage the head so as to prevent its yielding to the accumulating fluid. He has related several cases of the successful adoption of this practice, though, like many other persons, he rides his hobby rather too hard, and advocates his mechanical method to the exclusion of all other treatment. It is, however, a valuable adjunct to other treatment in some cases. Unless you apply it well it will be of little service, and the plasters by which the compression is exerted will come off'. You cannot do better than follow M. Trousseau's rules for their application.1 He uses strips of diachylon plaster about one-third of an inch broad; and applies them—1st, from each mastoid process to the outer part of the orbit of the opposite side; 2d, from the hair at the back of the neck along the longitudinal suture to the root of the nose; 3d, across the whole head, in such a manner that the different strips shall cross each other at the vertex; 4th, a strip is cut long enough to go thrice round the head. Its first turn passes over the eyebrows, above the ears, and a little below the occipital protuberance, so that the ends of all the other strips shall project about one-fourth of an inch below the circu- lar strip. These ends are next to be doubled up on the circular strip, and its remaining two turns are then to be passed over them just in the same direction as the first turn. By this means you secure a firm, and equal, and very powerful pressure on the head. You must watch the results of this proceeding very carefully, and loosen the plasters if symptoms of compression appear, since it once happened to M. Trous- seau, from neglect of this precaution, that the fluid acted on the base of the skull, detaching the ethmoid bone from its connections, and thus occasioned the infant's death. You will naturally inquire whether pressure is applicable to every case, and if not, when it should be employed ? I regret that I cannot answer these inquiries so satisfactorily as I could wish. It is my be- lief, however, that cases of external hydrocephalus, which have suc- ceeded to previous hemorrhage into the arachnoid, will be found better adapted than any others to treatment by mechanical means; while I am quite sure, from actual experience, that when there is any appearance of active cerebral disease pressure will not do good. Puncture of the cranium, and the evacuation of the fluid, is another proceeding which has been occasionally resorted to from a very early period in the history of medicine, and which is even at the present day strongly advocated by some writers, not merely as a palliative measure, or as an adjunct to other remedies, but as a means of effect- ing the radical cure of the disease. Opinion, however, is much divided as to the propriety of this practice, the statistics of which certainly do not yield any very encouraging results. Fifty-six cases, the particu- lars of which I published many years ago,2 as I found them recorded in various publications, yielded a proportion of fifteen alleged reco- veries; but on subjecting these cases to a rigid analysis, it appeared that in only four of this number were the particulars recorded with sufficient accuracy, or had the interval since the performance of the 1 Journal de Medecine, April, 1843. 2 In the Medical Gazette, April, 1842. 120 CASES SUITED FOR PUNCTURE. operation been long enough, to warrant our admitting them as perma- nent cures. The very unfavorable conclusions which 1 then expressed with reference to this operation were afterwards criticized by M. Du- rand Fardel,1 a gentleman whose opinion on any question connected with cerebral disease is entitled to very great weight. He observed, that while it is admitted that in a few cases puncture of the cranium has been followed by complete and permanent cure, its failure on other occasions was often manifestly due to the existence of utterly incurable malformation of the brain; while in many instances, though the ope- ration failed to effect a cure, yet the very frequency with which it was repeated proved that in itself it is not usually attended with any con- siderable danger. Since, then, it may do good—since, if it should fail, its failure is often due to causes which no remedy could remove— since, even if it should do no good, yet in the majority of instances it will do no harm, while if left to itself the course of the disease is almost invariably to a fatal result, he advocates its performance in cases of chronic hydrocephalus. Though I cannot but fear that this gentle- man rather underrates the amount of immediate risk attendant on the operation, yet I think that his authority ought at least to have so much weight with you as to prevent your looking upon its performance as altogether unjustifiable, and the rather since there is good reason for believing that the accumulation of fluid in the ventricles is frequently the result of previous inflammation of their lining membrane, and that puncture of the cranium may therefore contribute to the cure of dropsy of the brain, just as tapping the abdomen does to the cure of ascites.2 I should regard any case as favorable for the operation, which, on the whole, there was good ground for believing to be one of external hydrocephalus, or in which the enlargement of the head had not been attended by indications of active cerebral disease. Though less pro- mising, I should not reject the operation simply because enlargement of the head had been congenital; while I should always be more ready to operate if nutrition were well performed than if the child were emaciated. I would not, however, have you operate simply because the head is large; for it does not appear that diminution in its size has resulted from the puncture, but only arrest of its enlargement: and if the disease be at a standstill, and the cerebral functions tolerably well performed, you would risk much with the chance of gaining but very little. The proper situation for the puncture is the coronal suture, about an inch or an inch and a half from the anterior fontanelle. A fine trocar and canula are the best instruments; and care must be taken not merely to withdraw only a very few ounces of fluid at a time, but to keep up pressure both during the escape of the fluid as well as afterwards. 1 In the Bulletin Generale de The'rapeutique, vol. xxiii. p. 190. 2 See, moreover, some remarks on this operation, and cases of its successful per- formance, in the Oesterr. Med. Jahrbucher, vol. xxii. p. 27, by Dr. Schopi-Merei, late of Manchester, and previously the distinguished director of the Children's Hospital at Pesth. HYPERTROPHY OF THE BRAIN. 121 LECTURE X. Hypertrophy op the Brain—usually associated with general disorder of nutrition—symp- toms and course—seldom directly fatal—nature of change in brain—alterations in form of skull, and difference from chronic hydrocephalus.—Treatment.—Partial hypertrophy. Atrophy of the Brain—case illustrative of its defective development.—Wasting of the brain in protracted illness.—Temporary retrocession of mental powers in children after long illness.—Case of partial atrophy. The anxiety of parents is sometimes needlessly excited in conse- quence of an infant's head being larger than common, and even though the child's health be good the relations are apprehensive lest it should be affected with water in the brain. Now you must not be too ready to take up this cry, which is one often raised by nurses and ignorant persons, or to suppose that every large head is therefore unnatural; for one child may have a bigger head than another, just as it may have a bigger hand or foot. But it may be that the child's head is not only larger than natural, but that well-marked symptoms of cerebral dis- turbance are present, and you may feel yourselves compelled to adopt the opinion that the case is one of incipient chronic hydrocephalus. The subsequent history of the patient may in many respects confirm your original diagnosis, so that great will be your surprise, on exa- mining the body after death, at not finding a drop of serum in the ventricles, although, when you opened the skull, the cerebral convo- lutions had appeared flattened, as if the brain were greatly distended with fluid. Individual cases of this kind had been mentioned by medical writers at different times, but Laennec1 was the first who drew attention to hypertrophy of the brain as a condition resembling chronic hydrocepha- lus in many of its symptoms, and liable to be mistaken for it. It has since then been frequently noticed, and I am not sure that an undue importance has not sometimes been attached to it, as though it were of much more common occurrence than you will really find it to be in practice. I have placed upon the table a cast taken from the head of a child who was affected with hypertrophy of the brain, and whose very remarkable case is related by Dr. Watson.2 He came under the care of the late Dr. Sweatman when two years old, and his head, which had been gradually increasing from the age of six months, was then so large as by its weight to prevent the child from continuing long in the upright posture. The boy was active and lively, though thin. He had never any fit or convulsion, but occasionally seemed uneasy, 1 Journal de Medecine, Chirurgie, et Pharmacie, 1806, t. xi. p. 669. 8 Lectures, 4th ed. vol. i. p. 425. 122 HYPERTROPHY OF THE BRAIN. and would then relieve himself by laying his head upon a chair. He had never squinted, nor was he subject to drowsiness or starting during his sleep, and his pupils contracted naturally. His appetite was good, and all the animal functions were well performed. The case was supposed to be one of chronic hydrocephalus; but no urgent symptoms being present active remedies were not employed. About six months afterwards the child died of inflammation of the chest, and Dr. Sweatman examined the head. It measured 12 inches from ear to ear over the vertex, 13 inches from the superciliary ridges to the occipital, and 21 inches in circumference. The anterior fontanelle, which was quite flat, measured 2\ inches by 1| across its opposite angles; the posterior fontanelle was completely closed, as was the frontal suture. The skull generally was increased in thickness; the morbid appearances in the membranes of the brain were quite trivial; the ventricles were empty, not dilated; the convolutions were per- fectly distinct, and retained their proper rounded shape. The medul- lary matter, however, presented a very unusual vascularity. It is not merely on account of the great size which the head attained that I have quoted this history, but because it affords an in- stance of the overgrowth of the brain unconnected with any general disorder of the processes of nutrition. Such an occurrence is very rare, for hypertrophy of the brain is usually only one manifestation of a deep-seated disorder of the nutritive process, and is met with, in connection with rickets or scrofula, in the narrow lanes of a crowded city, or in the unhealthy valleys of mountainous districts, where goitre and cretinism are endemic. The majority of cases of hypertrophy of the brain that have come under my notice in London have occurred in infants about six or eight months old. Their history had usually been, that without any definite illness, the children had lost their appetite, and grown by degrees dull and apathetic, though restless and uneasy. Notwith- standing the general apathy, this restlessness is often very considerable, though it does not show itself in cries so much as in a state of general uneasiness, and in frequent startings from sleep. Short gleams of cheerfulness occur when the children are awake, but these are usually very transient. The head seems too heavy to be borne, and even when its size is not much greater than natural it hangs back- wards, or to one side, as if the muscles were too weak to support it. If placed in its cot, a child who is thus affected bores with its occiput in the pillow, while its head is almost constantly in a state of profuse perspiration. Convulsions sometimes occur without any evident cause, but threatenings of their attack are much more frequent than their actual occurrence, the child awaking suddenly with a start and a pecu- liar cry, like that of spasmodic croup, the surface turning livid, and the respiration becoming difficult for a few moments, and the symp- toms then subsiding of their own accord. Such attacks may issue in general convulsions, which may terminate fatally; but infants thus affected do not by any means invariably die of the cerebral disorder; but, being weakly, they are often cut off by the first malady which attacks them. DIAGNOSIS FROM CHRONIC HYDROCEPHALUS. 123 If life be prolonged, it becomes more and more evident that the process of nutrition is imperfectly performed: the child loses flesh and looks out of health, and enlargement of the wrists and ankles shows the connection between this disease and rickets—a connection which becomes more evident in the second and third years of the child's life. When the child survives infancy, or when, as occasionally happens, the symptoms of hypertrophy of the brain do not come on until denti- tion has been in a great measure accomplished, convulsions are of very rare occurrence. Complaints of headache, however, are frequent and severe; and, though drowsy in the daytime, the child generally rests ill at night, and often awakes crying and alarmed. Besides these symptoms, too, the child has occasional attacks of feverishness, with great increase of the headache, and giddiness, which last for a few hours or a day, and then subside of their own accord, while it grows by degrees more and more dull and listless, and its mental powers become obviously impaired. It happens, in some cases, that, as the child grows older, these symp- toms become less and less severe; the health improves, the rickety deformity of the limbs gradually disappears, and the infant who had excited so much solicitude becomes at length a healthy child. There is a termination in complete idiocy, which I have never seen in this country, but some years ago I observed some instances of it in the Hospital for Cretins, which then existed near Interlachen; and I be- lieve that the association of cretinism and idiocy with hypertrophy of the brain is by no means of unusual occurrence. Death is not often the direct result of the affection of the brain, but generally takes place owing to the supervention of some other disease. The affections, how- ever, which prove most fatal are those which favor cerebral congestion, such as hooping-cough, or the eruptive fevers, especially scarlatina. You must not infer that hypertrophy of the brain has existed in every instance in which the organ may appear to be large, and its convolutions somewhat flattened, although the ventricles are free from fluid. The weight and apparent size of the brain are much influenced by the quantity of blood contained within it, and it may appear too large for the skull, simply because the vessels are over-full.1 In true hypertrophy, on the contrary, the brain is generally pale and anaemic, unless death should chance to have taken place as the result of an attack of cerebral congestion. Neither, indeed, is the process one of mere increased growth, but the nutrition of the organ is modified in character as well as increased in activity. The gray matter of the brain is but little involved in it, and, with the exception of its color being somewhat paler than natural, it shows scarcely any alteration. The white matter, on the contrary, is both paler and firmer than in a state of health; and Professor Rokitansky2 states, as the result of many microscopical examinations, that its augmented bulk is not produced either by the development of new nervous fibrils, or by the enlargement of those already existing, but by an increase in the inter- 1 See Mauthner's elaborate tables of the weight of the brain in various circum- stances, lib. cit. sect. v. 2 Lib. cit. 3d ed., Vienna, 1S56, vol. ii. p. 430. 124 DIAGNOSIS OF HYPERTROPHY OF THE BRAIN. mediate granular matter, most probably due to an albuminoid infil- tration of that structure.1 These changes, too, do not affect indifferently all parts of the brain, but are confined to the hemispheres, and do not implicate either the base of the organ or the cerebellum. Chronic hydrocephalus is the only affection with which hypertrophy of the brain is liable to be confounded; the diagnosis between the two affections is often by no means easy, though it is of much import- ance with reference both to our prognosis and our treatment, for we shouW have more hope of the recovery of a child whose brain is merely hypertrophied, than of one whose brain is distended with fluid, while the means, by which we should endeavor to effect a cure, would differ widely in the two cases. The history of the patient would afford some help towards determining this question; for the symptoms of chronic hydrocephalus generally come on earlier, and soon grow much more serious than those of hypertrophy of the brain, and the cerebral disturbance is throughout much more marked in cases of the former than in those of the latter kind. The form and size of the head, too, present peculiarities by which you may often be enabled to distinguish between the two conditions. Both diseases are attended by enlargement of the head, and in both the ossification of the skull is very tardy, but the head does not attain so large a size in hyper- trophy of the brain as in chronic hydrocephalus, neither are the fon- tanelles and sutures so widely open. The skull, likewise, presents some peculiarities in form, which are so remarkable as to have attracted the attention of- several observers. The head not merely shows no tendency to assume the rounded form characteristic of chronic hydro- cephalus, but its enlargement is first apparent at the occiput, and the bulging of the hind head continues throughout especially striking. The forehead may, in the course of time, become prominent and over- hanging, but the eye remains deep sunk in its socket, for no change takes place in the direction of the orbitar plates, such as is produced by the pressure of fluid within the brain, and which gives to the eye that unnatural prominence, and that peculiar downward direction, which are so striking in cases of chronic hydrocephalus. In hydro- cephalus the anterior fontanelle is tense and prominent, owing to the pressure of the fluid within, but when the brain is hypertrophied there is no prominence, but an actual depression in this situation. I have more than once observed this condition in a very remarkable degree, the depression not being limited to the anterior fontanelle, but being observable at all the sutures; and you may notice something of the kind in this cast. When hypertrophy of the brain occurs in the adult, the symptoms that arise are in great measure due to the compression which the organ undergoes from its bony case being too small to contain it. These symptoms are of course obscure, while, even if the nature of the af- fection could be recognized, its cure must be hopeless. In the infant, however, and the child whose head is incompletely ossified, the imme- 1 See Jenner's valuable Lectures on Rickets, Lect. Hi., in Med. Times, April, 28, 1860, p. 415. TREATMENT OF HYPERTROPHY OF THE BRAIN. 125 diate consequences of the evil are far less serious, while some benefit may be expected from the judicious employment of remedies, since over-development of the brain in childhood is almost always associated with general disorder of the processes of growth and nutrition. We are not, indeed, acquainted with any means by which we can directly check the morbid increase of the brain, but all our efforts should be turned towards improving the general health, while we interfere directly with the cerebral symptoms only in so far as their urgency- may render it absolutely necessary. The child, therefore, must not be dosed with calomel merely because its head is affected, though the deficient secretion of bile may often render the employment of small doses of mercurials necessary. Similar restrictions would apply to depletion, for we have seen that the hypertrophied brain is character- ized by a want of blood rather than by its superabundance; but, nevertheless, occasional attacks of cerebral congestion may render local depletion necessary, and the exacerbations of headache, with vertigo and fever, will, if severe, be often benefited by its employment. I have now and then tried counter-irritation by means of the tartar- emetic ointment rubbed into the back of the neck, with much relief to the head symptoms, in the case of children who were suffering from the indications of hypertrophy of the brain, but I should fear to have recourse to this measure in infants. In them, indeed, one of our first efforts must be to relieve the brain from the constant irritation to which it is exposed when the child is in the recumbent posture, and the head rests on the yielding and imperfectly ossified occiput. For this pur- pose, we cannot do better than follow the suggestion of a German physician, Dr. Elsasser,1 and have a small horsehair cushion prepared for the child's head to rest on, a piece being cut out of it large enough to receive the occiput. In cases both of hypertrophy of the brain and of chronic hydrocephalus, I have seen the adoption of this simple contrivance, followed by almost immediate cessation of the rotatory movement of the head, and by quiet sleep in its cot, to which perhaps for weeks before the child had been a stranger. It is not desirable that a child who suffers from this affection should sleep entirely without covering to the head. The profuse perspiration of the head is more effectually checked by a thin linen cap, which may be changed once or twice in the night, while at the same time the child is saved from the danger of catching cold. While these hygienic proceedings, which have special reference to the head, are attended to, the child should be daily sponged with salt and water, or with sea water, if it be possible to remove it to some place on the coast, such as Brighton ; or it would probably be benefited by immersion in a tan-bath, in which it should remain for several minutes.9 1 Der weiche Hinterkopf, 8vo., p. 205. Stuttgart, 1843. 2 The tan-bath, which I have employed with very marked benefit in the case of weakly and rickety children among the poor, is prepared, as directed by Dr. Elsasser, by boiling three handfuls of bruised oak bark, tied up in a linen bag, in three quarts of water for half an hour, and adding the decoction to the water of the child's bath. These baths should be applied tepid, and their use should be continued every day for several weeks. 126 ATROPHY OF THE BRAIN. The remedies under the continued use of which I have seen the most good result are the extract of bark, from which you may pass to the preparations of iron—such as vinum ferri, or the ferrocitrate of quinine.1 I have not made much trial of the iodide of potassium, since in all the cases that I have seen some more decided tonic appeared necessary. I have, however, given the syrup of the iodide of iron sometimes with advantage; and in cases where the tendency to rickets was well marked, I have observed a most decided improve- ment follow the use of the cod-liver oil, in doses of a drachm twice a day for a child of three years old. I may just mention that, notwith- standing its nauseous taste, this medicine is usually readily taken by children, some of whom even become fond of it. With reference to diet, it will probably be desirable, if the child be not weaned, to obtain for it a healthy wet nurse; while, after weaning, a diet of milk, with an egg once or twice daily, will often agree better than any other food. In cases of this kind, and, indeed, in all where the digestive powers are feeble, a preponderance of farinaceous food is not desirable, while the child may with safety be allowed a little veal-broth or beaf-tea daily, or even a little meat if it have cut some of its molar teeth. Cases of partial hypertrophy of the brain are on record, in which one hemisphere alone was affected, or in which some one or more of the central parts of the brain greatly exceeded the natural size, whilst the rest of the organ deviated in no respect from its normal condition. An instance of the kind you see represented in this drawing of Dr. Mauthner's,2 in which the right optic thalamus was as large as a hen's egg in a girl of three years old. In cases of this sort sometimes no symptoms are present, and the anomaly is only accidentally discovered after death; whilst in others, although there are indications of cerebral disturbance, yet they are not such as to enable us to determine the nature of the evil of which they are the expression. There is a condition of the brain the direct opposite of that which we have been examining, in which the organ falls below the natural size, or in w^iich atrophy of the brain exists. I do not refer here to those cases where the brain is imperfectly formed, the head exceed- ingly small, and the child idiotic from birth ; but this state of micro- cephalus appears sometimes to come on afterwards, owing probably, as has been suggested, to premature closure of the fontanelles and sutures. Such a case I saw several years ago, when a woman brought to me her boy, who was three years old, the elder of two children of perfectly healthy parents, none of whose relatives had ever shown any sign of consumption, idiocy, or mental derangement. When born, this boy was perfectly well formed, neither did he present any pecu- liarity till he was six months old, when his mother began to observe that he did not look any one in the face, and that he seemed to take but little notice of anything. When eight months old, he began to have fits, which had since returned about once a week, being preceded 1 See Formula Nos. 3 and 4, at p. 56. 2 Lib. cit., plate i. and p. 189. ATROPHY OF THE BRAIN. 127 by extreme restlessness for a day or two. The fits lasted for a quarter of an hour; they were attended by convulsive movements of both sides, and followed by drowsiness, which continued for some days. The child ate and drank, though not heartily, and he never seemed anxious for food. He did not distinguish between what was nice and what was nasty, swallowing all things with the same readiness, though deglutition appeared to be difficultly performed. H#had cut all his teeth, he seemed tolerably well nourished, and his body and limbs were well formed. He was, however,quite unable to stand; he passed his urine and feces under him without appearing to take the slightest notice of it, and he seemed destitute of every glimmering of under- standing. His mother said that his head was smaller than that of her infant which was only six months old. It measured 17 inches in cir- cumference around the parietal protuberances, and 11 inches across the head from the centre of the meatus of one ear to the same point on the opposite side. The forehead was extremely narrow, and the head shelved upwards quite in a sugar-loaf shape. All the sutures and fontanelles were firmly ossified, but I have unfortunately omitted to record at what age they became so. I never saw this boy again, but several similar cases have since come under my notice, in which there did not seem to be any direct relation between the smallness of the skull and the low development of the intellectual faculties. The poor children who some years ago were exhibited in London as Aztecs, furnished a remarkable illustration of the effects of training in bring- ing out in the case of idiots who were at the same time remarkable microcephali some of the lower forms of intelligence and that imitative faculty with which idiots are often singularly endowed. I have nothing more to say about such cases, for their cure is manifestly quite hope- less, and, therefore, though they may interest us as pathologists, they scarcely concern us as practical physicians. Of much higher practical importance are those instances in which the brain of children wastes during long-continued illness. The scalp in such cases will usually be found bloodless, the fontanelles collapsed, and the process of ossification will be seen to have been unusually tardy. Fluid will be found within the sac of the arachnoid, and effused into the subjacent pia mater. The brain will be far from fill- ing up the cavity of the skull, so that a knife may be passed in many places between it and the cranial walls. The sulci between the con- volutions appear unusually deep, and fluid will be found both at the base of the brain and iu the ventricles, as well as in the pia mater. The cerebral substance is pale, and its texture firmer than usual. The important point about such cases is, that cerebral symptoms and frequently recurring convulsions may be observed in a child whose brain is nevertheless not diseased, but too feeble and too wasted to perform its functions. If, then, you find indications of cerebral disturbance come on in infants who have been exhausted and emaci- ated by previous illness, you must not interpose too hastily with remedies directed against a supposed disease of the brain, but bethink you whether these symptoms may not be merely the signs of the brain having become unequal to its duties from its having been im- 128 PARTIAL ATROPHY OF THE BRAIN. perfectly nourished: and do not, without consideration, abandon the tonic plan of treatment which you had been previously pursuing. It is only in infants that accidents of this grave nature are likely to ensue from the imperfect nutrition of the brain consequent on pro- tracted illness: but symptoms arise in older children, in similar cir- cumstances, well calculated to excite the apprehension of parents. In children who have but lately learned to talk, I have sometimes known loss of speech follow a long illness, the child being too weak to talk, just for the same reason as it is too weak to walk. Occasionally, however, the child apparently regains its previous health, and yet makes no efforts to articulate, even for two or three months. In cases of this kind I have seen parents thrown into great anxiety from the fear lest the child's continued silence should be the result of the intel- lect having become impaired during its illness. I imagine that in many of these cases the child has forgotten during its illness much of its newly-acquired knowledge, and that it is some time before it again feels equal to the mental effort of shaping its ideas into words. Usually, however, when it begins to make the effort, it recovers its speech rapidly; and you may therefore console the parents with this prospect. Even a manifest retrocession of the intellectual endowments should not be regarded with too much anxiety, when it has followed some long-continued disease, for it may be the result of mere weakness; the vacant look, the unmeaning laugh, and the silly manner gradually dis- appearing as the child gains strength. The brain seems to regain its lower powers, and to perform its humbler functions, before it resumes its nobler office as the organ of the mind. Partial atrophy, like partial hypertrophy of the brain, may occur we know not why, and may be discovered, after death, where the existence of cerebral disease had never been suspected; or we may find the explanation of a number of anomalous symptoms, which had existed during life, in a wasted condition of some portion of the organ. This state may be the result of original conformation, or it may come on as the result of disease, in which latter case the substance of the wasted portion of the brain is usually found to be much firmer than natural. We are greatly in the dark as to the nature of the process by which this change is effected; but it is thought in some cases to be the remote consequence of hemorrhage into the cerebral substance, and in others to be induced by a slow kind of inflammation. One case of this kind has come under my own notice, which, for its rarity, I will relate to you. The patient was a little girl, aged three years and ten months, the child of phthisical parents, but whose health, though delicate, had never been interrupted by any serious illness until she had an attack of remittent fever in the early part of the spring of "1845: she recovered from it without any bad symptom, and seemed doing pretty well for about a month, when she became sleepy and heavy, and feverish, for which symptoms she was brought to me on May 19th. After being under a mild antiphlogistic treatment for a week, she got better, and was beginning to walk about again, when she awoke one morning with her face drawn to one side—a condition, however, which did not PARTIAL ATROPHY OF THE BRAIN. 129 continue. When she attempted to walk, it was noticed that she halted very much on her left leg, and that it sometimes gave way under her, so that she fell down on that side, and then turned round upon her back. She had, besides, but little power with her left hand and arm, so that she could not grasp anything firmly, nor hold it steadily. The child's bowels were at that time constipated: I purged her freely, aud sent her into the country, whence'she returned in the beginning of August, much improved in every respect, though still limping a little with the left leg, and using her right arm in preference to the left. At the end of September I saw her again, she having then a bad impe- tiginous eruption on the scalp, which was treated with warm poultices and water dressing; when, on October 6th, she began to limp with her right leg, just as she had previously done with her left; though in other respects she continued pretty well. On October 17th the affec- tion of the right leg was a good deal less marked; but the child now became unwilling to walk, ofteu turning giddy, and always catching hold of something by which to steady herself. When attempting to walk she often fell down into a sitting posture; and then would sit on the floor, laughing loudly. Fits of uncontrollable laughter often came on without any cause, and the face began to assume an idiotic ex- pression. There was occasionally slight inward strabismus of both eyes, but the pulse was soft and undisturbed; the bowels were regular and the evacuations natural, and the child rested well at night, though her head was often rather hot. A week afterwards there was no new symptom, except that the child kept her neck quite stiff, as though she feared to move it. Her head grew hotter, and she began to have a fre- quent teasing cough, while her power of walking varied almost every day; she now, too, grew more restless at night. On the morning of the 27th frequent convulsive twitches of the muscles of the face and extremities came on, and the left eye became permanently turned inwards. She had no sleep in the night; general convulsions came on at 8 A.M. on the 28th, and she died convulsed two hours afterwards. I found some deposit of tubercle in the bronchial glands, but none in the brain, where I had expected to discover it. The left hemisphere of the cerebellum, however, was, as you see both in this drawing and in the preparation itself, fully a third smaller than the right; thus presenting an additional instance in confirmation of Schroder van der Kolk's statement1 as to the greater frequency of unilateral atrophy on the left side of the brain ; it was of extremely firm consistence, quite 1 In his essay on Atrophy of the Brain, published in vol. xi. of the New Sydenham Society's publications, he states that in 17 out of 29 cases the affection was situated on the left side of the brain. In his case, however, while the left hemisphere of the cerebrum was wasted, the right half of the cerebellum and the right half of the cord were atrophied. In his case the right side of the body was atrophied ; in my case no wasting of any part of the trunk or extremities was observed, the child's inability to regulate her movements being apparently the chief result of the affection of the cerebellum. S. van der Kolk, in his elaborate essay, regards the affection not as the result of congenital malformation, but as the probable consequence of inflammatory action, occurring sometimes before birth, at other times in early infancy; and the change of consistence of the brain substance observed in my case bears out the same opinion. 9 130 HYDROCEPITgLOID DISEASE. leathery, and, on making a section of it, its surface presented a rose tint. The halves of the pons and medulla oblongata were of equal size, as were the two hemispheres of the cerebrum. It was evident, too, that this condition was not congenital, since the two halves of the skull were of equal size, and the elevations and depressions in the interior of its base were precisely similar on both sides. There was a little fluid at the base of the brain, but none in the ventricles; a state of general congestion of the brain and its membranes being the only other remarkable appearances. The spinal cord could not be examined. There was no trace of any old effusion of blood in the substance of the cerebellum, though the symptoms that occurred in May, and the subsequent gradual improvement of the patient, are not ,easily expli- cable on any other supposition than that hemorrhage had at that time taken place into the substance of the brain. The history of the case presents another difficulty, in the circumstance that the disease was seated on the same side as that to which the symptoms had been chiefly referred. Another problem which I cannot pretend to solve is, why the paralysis should in the first instance have affected the left side, while, on the occurrence of the relapse in October, the right leg was palsied. I must therefore content myself with the bare relation of this history. LECTURE XI. Hydrocephaloid Disease—often succeeds to sympathetic disturbance of brain in course of various affections—supervening on diarrhoea, pneumonia, and cerebral congestion—diag- nosis in each of these circumstances.—Prophylaxis, and treatment. Tubercle of the Brain—its frequency in childhood—its anatomical characters.—Symp- toms—occasionally absent—generally very obscure—symptoms of premonitory stage, their great diversity—symptoms of acute stage also various—diversity in these respects cannot be altogether explained by the morbid appearances.—Occasional recovery where symptoms of cerebral tubercle have long existed.—Treatment. Hydatids and Cancer of the brain. Closely connected with the state of atrophy of the brain, which we examined in the last lecture, is that condition which is induced if the organ be somewhat suddenly deprived of its usual supply of blood. Even in the adult a profuse loss of blood is followed, as you well know, by extremely severe headache, and by various other cerebral symptoms. In the child, whose brain needs for the due performance of its functions a proportionably larger quantity of blood, the symp- toms that follow its excessive loss are of a corresponding gravity. Often, indeed, they present a striking similarity to those which betoken inflammation of the brain; a fact implied in the name of the hydroce- phaloid disease, by which Dr. Marshall Hall, who was among the first to HYDROCEPHALOID DISEASE. 131 call the notice of the profession to this affection, has proposed that it should be designated. "This affection," says he, in his admirable essay on the subject,1 " may be divided into two stages: the first, that of irritability; the second, that of torpor. In the former there appears to be a feeble attempt at reaction; in the latter, the powers appear to be more pros- trate. These two stages resemble in many of their symptoms the first and second stages of hydrocephalus respectively. " In the first stage the infant becomes irritable, restless, and feverish; the face flushed, the surface hot, and the pulse frequent; there is an undue sensitiveness of the nerves of feeling, and the little patient starts on being touched, or from any sudden noise; there are sighing and moaning during sleep, and screaming; the bowels are flatulent and loose, and the evacuations are mucous and disordered. " If, through an erroneous notion as to the nature of this affection, nourishment and cordials be not given, or if the diarrhoea continue, either spontaneously, or from the administration of medicine, the exhaustion which ensues is apt to lead to a very different train of symptoms. The countenance becomes pale, and the cheeks cool or cold ; the eyelids are half closed; the eyes are unfixed, and unattracted by any object placed before them, the pupils unmoved on the approach of light; the breathing, from being quick, becomes irregular, and effected by sighs ; the voice becomes husky ; and there is sometimes a husky teasing cough; and eventually, if the strength of the little patient continue to decline, there is a crepitus or rattling in the breath- ing. The evacuations are usually green; the feet are apt to be cold." In early infancy symptoms of this kind sometimes succeed to pre- mature weaning, especially if that be followed by an unsuitable diet; but afterwards they are generally induced by some definite attack of illness, either exhausting in itself, or for the cure of which active measures had been necessary. It is important too to bear in mind that they are not equally apt to come on in the course of all diseases, but that those in the early stages of which considerable cerebral irrita- tion has existed, are much more likely to assume the characters of this spurious hydrocephalus when the bodily powers are exhausted. There is no disorder in which the two conditions of considerable sympathetic disturbance of the brain, coupled with rapid exhaustion of the vital powers, are so completely fulfilled, as in infantile diarrhoea, and in no other affection do we meet with such frequent or such well- marked instances of the supervention of the hydrocephaloid disease. Some time since a previously healthy boy, aged 18 months, was brought to me suffering from vomiting and diarrhoea, which had existed for three days. After treatment had been continued for two days the purging ceased, but the child seemed to have a distaste for all nourishment, and refused both milk and arrowroot, and the mother made but few attempts to overcome this repugnance; so that for 1 Republished in his work "On the Diseases and Derangements of the Nervous Sys- tem," 8vo. chap. v. sect, iii., London, 1841. It can scarcely be necessary to refer to Dr. (rooch's Paper " On Symptoms in Children erroneously attributed to Congestion of the Brain," for another most graphic account of this disorder. 132 SYMPTOMS OF HYDROCEPHALOID DISEASE. twenty-four hours the child took hardly anything except water and barley-water, and those in small quantities. On the afternoon of the sixth day the child became faint, and seemed so feeble during the * night that the mother became much alarmed, and came again to me on the morning of the seventh day. The child's face was then sunken and very anxious; it lay, as if dozing, with half-closed eyes; breath- ing hurriedly; suddenly waking up from time to time in a state of alarm and restlessness, and then in a few moments subsiding into its former condition. The skin was dry but cool; the extremities were almost cold; the lips were dry and parched, and some sordes had col- lected about the teeth ; the tongue was dry, red, and glazed, and coated in the centre and towards the root with yellowish fur. The pulse was extremely feeble. There was very great thirst. The bowels had not acted for twelve hours. I ordered the child a tablespoonful of equal parts of milk and barley-water every half-hour, with the addition of fifteen drops of brandy every hour, and directed that some strong veal broth should be prepared and given every two hours. At the same time, a draught containing ten grains of aromatic confection, half a drachm of the corn- pound tincture of bark, and six drops of sal-volatile, was given every three hours, and a grain of Dover's powder was directed to be taken at bedtime. Within six hours after the commencement of this treatment the child began to improve; it slept tolerably well in the night, and the next day was lying tranquilly in bed, looking about and smiling cheer- fully; the extremities were warmer, and the skin had lost its harsh- ness; the tongue was no longer dry, and the pulse had increased in power. The stimulants were gradually withdrawn; no further bad symptoms came on, and the child was soon convalescent. It is of great importance rightly to interpret the meaning of the symptoms which attend the first stage of this affection, and to dis- criminate between the cerebral disturbance of approaching exhaus- tion, and that which implies the existence of real mischief in the brain. A little girl was seized with diarrhoea on August 8th, which at first was severe, but soon yielded to treatment, and she was again conva- lescent; when, on the 15th, vomiting and purging returned with great violence, and were attended with much febrile disturbance. On the following day she was still worse in all respects, but was not brought to me again until the 17th. She then looked exceedingly ill; her face was sallow, but with a flush on each cheek, and her eyes were deeply sunk. She lay in a half-dozing state, with her eyelids half closed, and the eyeballs turned upwards, so that nothing but the sclerotica was visible; but from this condition she awoke frequently and suddenly in a state of great alarm, and looking as if she were about to have a fit of convulsions. Her skin was hot and very dry; her pulse very frequent, but not strong; and there was some subsultus of the tendons of the wrist. The abdomen was rather tympanitic; the tongue red, coated with white mucus; the thirst was great, the vomiting very fre- quent, and the bowels acted two or three times in the course of an hour, the evacuations having the appearance of dirty water. SYMPTOMS OF HYDROCEPHALOID DISEASE. 133 The child was immediately placed in a tepid bath; an enema containing five drops of laudanum was next administered, and the abdomen was covered with a large bran poultice. The extreme irri- tability was almost immediately relieved by the warm bath, and still further soothed by the enema. The bowels ceased to act so frequently, and the stomach began to bear small quantities of barley-water and other drinks, which were given cold. In a few hours the imminent clanger had passed away, and the child recovered in the course of a few days. If, in a case of this kind, you fall into the error of regarding the cerebral symptoms as the signs of active disease, and withhold the Dover's powder, or the opiate enema that might have checked the diarrhoea and soothed the irritability, while you apply cold lotions to the head and give the child nothing more nutritious than barley-water in small quantities, because the irritability of the stomach which re- sults from weakness seems to you to be the indication of disease in the brain, the restlessness will before long alternate with coma, and the child will die either comatose or in convulsions. But it is not only in the course of diarrhoea that errors of this sort may be committed. The early stages of pneumonia are often attended with so much sympathetic disturbance of the brain, as to throw the other symptoms into the background. The child vomits, it refers all its suffering to its head, and possibly has an attack of convulsions almost at the outset. You not unnaturally assume the case to be one of cerebral congestion, and treat it accordingly with free local deple- tion. On the next day the indications of disordered respiration are more apparent; you think your former diagnosis was incorrect, and probably apply more leeches to the chest to combat the pneumonia you had overlooked. The urgency of the symptoms may be relieved by these means, or, if that be not the case, still the reaction will diminish with the diminished power, and the child for a short time seems to suffer less. But soon the restlessness of exhaustion comes on, and then follow the soporose condition and the apparent coma: you condemn yourself for having overlooked the cerebral mischief, of which you fancy you now have most convincing proof: you renew your antiphlogistic measures, to arrest, if it be not too late, this ima- ginary hydrocephalus, and your patient dies. Something of the same kind too may happen in cases where the brain has really been congested, and where the depletion, which you practised somewhat too freely, was in reality indicated, though to a smaller amount. The restlessness and heat of head may have been diminished by your treatment, and the bowels may have been relieved by the purgatives you administered. In a few hours, however, rest- lessness returns, though not to so great a degree as before, the child moans sadly when awake, and thit> suffering, state alternates with, a drowsy condition, while the stomach, irritable before, now rejects everything almost as soon as swallowed, though the child still seems eager for drink. The previous arrest of very similar symptoms, though but for a few hours, by active treatment, seems to you to indi- cate the propriety of continuing the same plan, but nevertheless, the 13-4 TREATMENT OF THE AFFECTION. drowsiness deepens into coma, and the child dies, of hydrocephalus, as you suppose—in reality of the nimia diligentia medici. "Forewarned, forearmed," says the old proverb. When head symptoms come on in the infant, do not judge of their import simply from the present condition of the child, but ascertain its previous history. Learn whether any other members of the family have had hydrocephalus or been consumptive. Inquire whether this infant has thriven at the breast, or whether it has for some time been drooping; if already weaned, ascertain on what it is now fed, whether signs of declining health soon followed on the change of diet, while it throve so long as it was suckled. Ask what signs of disorder of the bowels there have been, and observe at what times the vomiting comes on; whether only after sucking or taking food, or whether efforts to vomit occur when the stomach is quite empty. In a case where the symptoms of cerebral disturbance, and those of disordered respiration, comes on almost at the same time in a pre- viously healthy child, and so alternate with each other as to render your diagnosis difficult, you will do well to remember that pneumonia often sets in with much sympathetic disorder of the nervous system, and that the disease is much more likely to be seated in the lungs than in the brain. In most cases auscultation will enable you to decide the question, and if you once accustom yourselves to listen to a child's chest as invariably as you would look at its tongue or count its pulse, you will but seldom have to reproach yourselves for the uncertain diagnosis and the vacillating treatment into which, in cases of this description, you will otherwise be too often betrayed. In a child suffering from diarrhoea, you will be prepared to meet with sympathetic disturbance of the brain, and will not allow the oc- currence of its symptoms to deter you from adopting the treatment which the diarrhoea requires. If doubt cross your mind as to their signification, and you fear'lest mischief be really going on in the brain, it will usually suffice to watch the symptoms closely in order to detect a want of correspondence between them, which would not exist if true cerebral disease were present. Attention to this point will guard you from error during the stage of excitement, as well as in that of ex- haustion and stupor, which simulates the last stage of hydrocephalus. In no circumstances are mistakes more easily committed, and never are their results more mischievous, than when real congestion of the brain has been somewhat over-treated, and the consequent symptoms of exhaustion are supposed to be those of advancing disease. In such a case, however, it will usually be observed that great faintness had been induced by the first depletion, and that the quiet which succeeded it was that of exhaustion as much as of mitigated suffering. If so, the returning restlessness will probably be the index of the feeble power of the brain, no longer adequate to the performance of its wonted func- tions, rather than the evidence of active disease of the organ. Nor will the Jjistory be the only safeguard from error, but the fontanelle sunk below the level of the cranial bones, instead of being tense and pulsating, the cool surface, and the pulse presenting no other charac- ters than those of frequency and feebleness, will all point to the real TREATMENT OF SPURIOUS HYDROCEPHALUS. 135 nature of the case. You do not need to be told that to deplete in such circumstances would be to destroy your patient—that food is needed, not physic. The sunken powers of life are to be rallied, and as their strength returns, the functions of the brain will again go on harmoni- ously. Although the diagnosis of this affection is sometimes attended with difficulty, the rules for its prevention and its cure are happily very simple. Bearing in mind the possible supervention of the hydrocephaloid dis- ease, you would never keep an infant from the breast, nor put a young child on a spare diet for several days without most absolute necessity; you would pay especial attention to its food if the disease from which it suffers be, like diarrhoea, such as interferes directly with its nutri- tion. Again, you would not trust depletion of a young child, espe- cially if suffering from head affection, to a nurse, but would yourselves exercise the supervision of it. And lastly, in the treatment of every disease, you would at once suspend the antiphlogistic measures that you had previously been adopting, and resort to the use of stimulants and tonics so soon as any of the symptoms that we have been exa- mining make their appearance. The state of general restlessness and irritability that attends the early stages of exhaustion is often greatly soothed by the tepid bath, continued for not more than five minutes, for fear of still further de- pressing the infant's powers. While you secure a free access of air, too, you must be extremely cautious to maintain the room at a suffi- cient temperature, for the power of generating heat is diminished in a very remarkable degree in young animals who from any cause are insufficiently nourished. The irritability of the stomach is best over- come by giving nourishment in extremely small quantities—as a des- sert-spoonful of asses' milk for an infant, or of veal tea for an older child, given by little and little every half-hour. If the symptoms have succeeded to weaning, a healthy wet-nurse should, if possible, be at once obtained; but as the effort to suck seems sometimes to exhaust the child, and, probably, thereby to favor vomiting, it is sometimes better at first to give the nurse's milk by a teaspoon. If the exhaustion be very great, and a state analogous to coma be impending, a hot mustard bath is sometimes serviceable in rousing the child, while, at the same time, a few drops of sal-volatile, or of brandy, may be given every few hours. It is desirable, however, to suspend the use of the more pow- erful direct stimulants so soon as it can safely be done, though a nu- tritious diet will be necessary for some time. Tonic medicines, like- wise, are often of much service, few of which are preferable to the extract of bark, which, dissolved in caraway water, mixed with a few drops of the tincture, and well sweetened, will be taken very readily by most children. The addition of a little milk to the medicine when taken still further covers any unpleasant taste.1 Those cases in which the brain becomes the seat of various morbid growths still remain for us to consider, before we pass to the study of affections of the spinal cord. 1 See Formula No. 3, at p. 56. 136 TUBERCLE OF THE BRAIN. In the child, as in the adult, the brain may become the seat of hy- datid cysts, or of cancerous tumors, or of tubercular deposits; but I should not detain you long with their study, if it were not that the last of these three morbid conditions, though exceedingly rare in the adult, is by no means unusual in the child. Thus, while M. Louis met with only a single case in which the brain contained tubercle out of 117 examinations of adults who had died of phthisis; MM. Rilliet and Barthez discovered tubercle in the brain of 37 out of 312 children, between the ages of 1 and 15, in some organ or other of whose body this morbid deposit existed. You will remember that I am not now speaking of cases where tubercle is present merely in the membranes of the brain, producing that granular appearance to which I called your attention when treating of acute hydrocephalus; but my remarks refer to separate deposits of tubercular matter in the substance of the brain. These deposits are for the most part distinctly circumscribed, of a rounded form, and varying in dimensions from the size of a millet- seed to that of a split pea, or of a bean, or even larger. The largest mass that I ever met with in the brain of a child was almost as big as a sugared almond, but they have been seen three or four times as large. Sometimes there is but a single deposit in the brain, but in the majority of cases there are three or four small deposits, of the size of a millet-seed or rather larger, as well as a single mass of greater magnitude. Sometimes, though not often, the deposits of tubercle are limited to one hemisphere of the brain ; but it generally happens that there is a marked preponderance of the affection on one side. The situation of these deposits varies greatly, and they have been found in all parts of the brain, both on its surface and in its interior. The smaller deposits are, I think, most frequently observed on the con- vexity of the brain, and they are then found closely adherent to the pia mater, to which they remain attached if that membrane be stripped off. They seem, however, to have some connection with the cerebral substance besides mere juxtaposition, since a thin investment of it clings to them, and the place where they were situated may be seen after their removal to be quite uneven. Even when situated at the base of the brain, or in the cerebellum, they often retain this relation to the pia mater; and those larger masses, which generally appear more deeply seated, will often be found, if the convolutions be un- folded, to have been in reality not far removed from the surface. Now and then a distinct, firm, fibrous capsule may be found investing the deposit; but this is oftener absent, or at any rate so delicate as not to be clearly perceptible. I have never seen these deposits prtsenting throughout the characters of the gray semi-transparent tubercle fre- quently noticed in the lungs, but once I found the exterior of a small deposit in this stage, while its central part had undergone the trans- formation into the ordinary friable, yellow tuberculous matter—a condition which Rokitansky has also occasionally met with. Softening sometimes goes on in cerebral tubercles; the process beginning in the centre, and gradually extending towards the periphery—a condi- tion which I have observed in 4 out of 21 cases. The brain around the softened deposits is almost always of a rose tint, aud more or less TUBERCLE OF THE BRAIN — MORBID APPEARANCES. 137 softened, though this alteration seldom extends for a distance of more than two or three lines; and once I observed the cerebral substance perfectly unchanged around a small tubercle, in which the process of softening was already considerably advanced. As a general rule, the brain around deposits of* crude tubercle still retains its natural characters; but to this I have seen one exception. If death usually occurs before the process of softening has taken place in the tubercular deposits, still rarer is it for life to be so pro- longed as to give opportunity for the occurrence of that cretaceous transformation by which the disease in other organs is sometimes arrested. MM. Rilliet and Barthez have observed it only twice out of 37 cases of cerebral tubercle; and but one instance of it has come under my notice, in a boy 3| years old, in whom but one deposit existed, of the size of a large pea, situated in the left hemisphere of the cerebellum. The change was in this instance incomplete, when death took place from acute hydrocephalus, succeeding to the sudden cessation of otorrhcea. Had the child lived, however, it is probable that the disease would have been altogether cured, for no tubercles were present in any other organs of the body, with the exception of the bronchial glands; and in them the same curative process was going on. Cerebral tubercle does not invariably affect the rounded form, but it occasionally extends as a patch, half an inch or more in length, by two or three lines in breadth, immediately beneath the pia mater, and not reaching above one or two lines deep into the cerebral substance, which is usually slightly softened beneath it. Now and then, too, the deposit takes place, not in distinct and isolated masses, but in the form of infiltration into the tissue of the brain, which, in this situation, is of a rose-red color, and extremely soft. This condition has come twice under my notice, and was associated on both occasions with abundant tubercular deposits in almost all the viscera. These tubercular deposits in the cerebral substance are very often, but by no means invariably, associated with that granular state of the membranes which I described to you as occurring in many cases of hydrocephalus. Thickening of the membranes, and effusion of hya- line matter into the pia mater at the base of the brain—the evidences, in short, of meningitis—are often present, as well as abundant effusion qf fluid into the ventricles, and softening of the central parts of the brain. Sometimes, however, the signs of inflammation of the mem- branes exist without any effusion into the ventricles; and in a few instances the ventricles contain an abundance of fluid, but no softening of the central parts of the brain exists, nor any sign of inflammation of the membranes. I know of no instance in wrhich tubercle was limited to the brain in childhood; but if present there, it always exists in other viscera, and is but one of the results of that general cachexia which may show itself in any of the various forms of scrofulous or phthisical disease. At the same time there is no uniform connection between the presence of tubercle in the brain, and the existence of advanced general tuberculosis. This is a fact all the more to be borne in mind, 138 SYMPTOMS OF TUBERCLE OF THE BRAIN. since, unless we remember that a condition of good general nutrition of the body does not preclude the deposit of cerebral tubercle, we may run some risk of misinterpreting the symptoms which otherwise would excite our apprehension. I am unacquainted with any special cause that renders the brain more liable to this disease in childhood, than in adult age, or even in youth. It certainly is not owing simply to the intensity of the tuber- culous cachexia, and the consequently greater abundance of the mor- bid deposit, for I have met with many instances of far more extensive tubercular degeneration than existed in those cases where the brain had become its seat. Cases are not yet recorded in numbers sufficient for us to determine accurately the time of the greatest liability to this affection; or whether difference of sex exerts any real influence in predisposing to it. Of my own 21 cases, 11 were male and 10 female; 5 were under 2 years of age, 3 between 2 and 3; 5 between 3 and 4; 1 between 4 and 5; 3 between 5 and 6; and of the remaining 4, one was 6J; one 8; and two 10 years of age.1 We come now to the examination of a very difficult question— namely, that of the symptoms of this affection. The difficulty arises from many sources; for sometimes the disease gives rise to no symp- toms at all, and its existence is not discovered till after death: and even when symptoms are present, neither their character nor their intensity bears any invariable relation to the extent of the local mis- chief or its seat; while, lastly, the symptoms that usually betoken tubercle of the brain sometimes exist where no such morbid growth occupies the organ. Cases in which no symptom whatever marks during life the pre- sence of the morbid deposit in the brain, are very unusual, and have never come under my own observation. Much less rare, though still constituting exceptions to the general rule, are the instances of com- plete absence of premonitory indications of cerebral disorder; symptoms of disease of the brain manifesting themselves suddenly and with violence, and carrying off in the course of a few days, or perhaps even a few hours, the child in whom tubercle has for months been develop- ing itself. No reason can be assigned for the complete latency of the affection in some instances, or for the sudden supervention of cerebral symptoms in others, after the deposit has existed for a long time without giving rise to any indications of its presence. It is true that the brain in the immediate neighborhood of the tubercular deposit does not, to the best of my knowledge, present any sign of softening 1 The cases recorded by Dr. H. Green, in vol. xxv. of the Medico-Chirurgical Trans- actions, by MM. Rilliet and Barthez, in vol iii. of their work, and by Professor Hirsch, of Konigsberg, in a dissertation De Tuberculosi Cerebri, 8vo., 1847, added to my own, made up a total of 69, which may be thus arranged:— Male. Female. From 6 months to 5 years ..... 23 14 From 5 years to 10 years ..... 9 14 From 10 years to 15 years ..... 4 5 36 33 SYMPTOMS OF TUBERCLE OF THE BRAIN. 139 in those cases which have been characterized by absence of all pre- monitory signs of cerebral disturbance, and that the tubercle itself always appears in the crude state. This fact at once suggests a plau- sible explanation of these cases, founded on the assumption that the symptoms, when observed, do not depend simply on the presence of tubercle, but rather on the changes in the surrounding brain. Such an hypothesis, however, is contradicted by the fact, that the cerebral symptoms sometimes occur in cases where no perceptible disorganiza- tion of the brain has taken place either around the tubercle or else- where. In most instances some kind of premonitory symptoms manifest themselves before the commencement of the child's fatal illness; but these are very variable in their character, and often very difficult of interpretation. Dr. Hennis Green, in his very valuable paper, "On Tubercle of the Brain, in Children," mentions pain in the head as having been present in 17 out of 20 cases; but this symptom attends upon so many other affections, that taken by itself its diagnostic value is but small. In young children who are unable to describe their sensations, we cannot be certain of the existence of headache; but must be content to infer it from causeless fretfulness, drowsiness, or listlessness. One or other of these indications of disorder of the sensorium was present, however, as the most marked premonitory symptom, in 11 out of 16 cases in which forewarnings of mischief preceded the child's fatal illness.1 1 In the following note I have endeavored to bring together the more important points in the history of the 21 cases of cerebral tubercle on which my remarks are founded. There were no premonitory symptoms of head affection in 5 cases. No. Sox. Age. Previous history. Fatal illness. Duration. 1 M. 2 ' M. 3 1 F. 4 ! F. 5 ] M. 4 years 1 yr. 5 mos. 2 " 6 " 19 " 0 " 1 " 0 " Convalescent 3 weeks from measles Cough for 2 months Tabes mesenterica, 4 mos. Constipation debility, 2 mos. Phthisis, 5 months Tubercular meningitis Fits, coma, died in fits Fits, coma, died comatose Typhoid symptoms, no fits Drowsiness, fits, coma, fre-quent fits 19 days 6 " 5 " 9 " 7 " More or less marked signs of cerebral disturbance existed in the remaining 16 cases, namely:— No I S.'x. A po. yr. mo. Premonitory Symptoms. i Duration. Fatal Illness. Duration. M. 2 0 Fretfulness 8 days 1 Fit, coma 99 hrs. 2 F. 3 3 Great drowsiness succeed- 6 weeks ing cynanche parotidea i Fits, for some hours, re-turned in 5 days, then fre-quent, drowsy in inter-vals, coma 24 days. 3 F. 0 6 Dull, drowsy, suppressed 1 mo. Deepening stupor, fit, coma 6 " eruption on scalp 4 M. 8 0 Drowsy, listless, feverish 14 days Stupor, coma, ptosis of right eyelid, dilatation of right 1 week. ! pupil, no fit 5 M. 1 9 Otorrhoea 6 weeks, pain in 14 " Vomiting followed by coma, 83 hrs. head, crying at night fits, death comatose 140 SYMPTOMS OF TUBERCLE OF THE BRAIN. When headache is present it is yet but seldom that any connection can be traced between the seat of the tubercle and the situation of the pain, which is, for the most part, referred to the forehead. It is often very severe, so that during its continuance the child is entirely taken up with its suffering, and shrieks with the severity of the pain ; but it does not continue with this intensity for more than a few hours, and on the next day the child will be found to be no worse than usual. Vomiting in many instances attends these exacerbations of pain ; and, when this is the case, the absence of any gastric disorder sufficient to account for it will lead you to suspect the presence of tubercle in the brain. In some cases, however, the headache, though severe, does not present this remarkable intensity, while there is so much perma- nent impairment of the general health, that an occasional attack of sickness does not surprise you. On the other hand you will meet with delicate children in whom attacks of violent headache, sometimes accompanied by vomiting, come on from very slight causes, or appa- Age. No. Sex. M. yr. 3 mo. 6 Premonitory Symptoms. Duration. Fatal Illness. Duration. 6 Otorrhoea 9 months, pain in 7 days Several fits, furious deli- 3 days. head on its sudden cessa- rium, coma tion, and excited manner 7 F. 6 6 Headache, sickness, consti-pation 2 mo. Supervention of acute hy-drocephalus, fits 16 " 8 M. 3 6 Habitual rotary motion of head, pain in forehead, feverish 2 " Symptoms of acute hydro-cephalus, fit 5 hours be-fore death 13 " 9 F. 3 0 Fit, leftside affected, return in 4 days, twitching of left side 13 days Symptoms of acute hydro-cephalus, pneumonia su-pervened, and caused death 35 " 10 M. 1 11 Epileptic fits from 7th mo. drowsiness from 15th mo. 16 mo. Slight fit, followed by coma 24 hrs. 11 M. 2 0 Head hung to left side since measles 4 " Two fits, stupor, automatic movement of right side, death comatose 5 days. 12 F. 3 3 Sudden twitching of right hand, arm, and leg, torti-collis, paralysis of right portio dura, last two symptoms disappeared, others improved, no head-ache 9 " Head heavy 10 days, deep-ened into coma, death comatose from effusion of blood at base of brain 10 " 13 F. 5 4 Fit, followed by paralysis of right side, 5 months be-fore, and impairment of intellect, febrile attack 3 months, almost constant convulsions 6 weeks 5 " Increase of convulsions, deepening of coma, death comatose 6 weeks. 14 F. 5 1 Headache after measles 4 months, ptosis of right eyelid 1 month 4 " Increase of headache, con-vulsions 5 days' before death comatose 14 days. 15 M. 10 0 Pain at back of head, and occasional vomiting, ema-ciation 6 weeks Increase of symptoms, but death su'dden in sleep. Tubercle 1\ inches in dia-meter in centre of cere-bellum 17 " 16 F. 5 0 Fit, followed by paralysis of 4 mo. Fever, frontal headache, 24 " left side of face. Nothing paralysis extending to more tongue, gradual occur-rence of coma SYMPTOMS OF TUBERCLE OF THE BRAIN. 141 rently without any cause at all, and return at irregular intervals for years together, till they gradually subside as the health becomes more robust, and cease altogether at the age of puberty or sooner. In a doubtful case, the existence of irregularity of the pulse would to some extent govern your decision ; though its occurrence in cases of cerebral tubercle is not constant: while I have known children in whom every attack of gastric or intestinal disorder was accompanied by this symp- tom in a very marked degree. In infants, and in children under two years of age, we of course lose the evidence which is afforded by the patient's complaints of headache, and can only infer it to be present from the occasional loss of cheerfulness, and the attacks of fretfulness and crying. Sometimes too the suffering of the brain shows itself in other ways besides headache. The temper becomes wayward and passionate, or a general dulness steals over all the faculties, and the child grows quite indifferent to what is going on around it. One little boy, aged two years, whom I watched for some weeks before his death, never made any complaint of headache. He was fretful, and cried if moved, but was perfectly quiet if allowed to remain in his chair, where he would sit half dozing for hours together. Affections of the motor system are often among the early indications of this disease, but neither are they so definite as to present anything pathognomonic of cerebral tubercle. A boy who died at three and a half years old, and in the left hemisphere of whose cerebellum there was a tubercle as large as a pea, had been subject from his earliest infancy to an almost constant and involuntary rotatory movement of the head when in the recumbent posture. Aud in another boy, who was two years old at death, the head had hung for four months towards the left shoulder before any other symptom of mischief in the brain appeared: convulsions then suddenly came on, and the child died in 72 hours. Sometimes paralysis of a limb comes on gradually; or, though actual paralysis does not exist, yet the power over one side becomes greatly weakened, and the child drags one leg, or is observed invariably to use one arm in preference to the other. Convulsive movements, however, are the most frequent of the affections of the motor system, and paralysis of a limb, or impaired power over it, usu- ally succeeds to their occurrence, and but seldom takes place inde- pendently of them. Eegular epileptic seizures, attended with equal affection of both sides during the fit, and followed by no impairment of power over any part, are decidedly unusual, and have only once come under my notice; but the convulsive movements generally assume one of two characters. Either they are occasional in their occurrence, attended with insensibility, though the movements are confined to one side of the body or to one limb, the same being affected on each occasion; and these attacks are usually of compara- tively short duration, varying from a few minutes to a few hours;— or the intellect is unimpaired, but movements like those of chorea affect one limb or one set of muscles constantly. Of this I saw a striking instance in a little girl who died from hemorrhage beneath the arachnoid at the base of the brain when 3\ years old, and in whom numerous tubercles were present in the left optic thalamus, and one 142 SYMPTOMS OF TUBERCLE OF THE BRAIN. in the right hemisphere of the cerebellum. Nine months before her death she was seized, when apparently in perfect health, by twitching tremulous movements of the right hand, which in 14 days extended to the arm, and in a month to the leg, so as to prevent her walking. In 2 months the head was drawn to the left shoulder, and in 4 the mouth to the left side. In 3£ months the head was held straight, and in 5 months the mouth was no longer drawn awry. The tremulous movements diminished, the child began to walk about, and continued to improve till 20 days before her death. She then grew dull, and the tremor returned. In 10 days she became comatose, and continued so, with occasional convulsions, in which for the first time both sides were affected, till she died. This case illustrates another fact perhaps worth notice; namely, that convulsions affecting one side only are sometimes seen, although tubercle is present in both hemispheres; or in other instances both sides are affected by the convulsions, and yet the deposit is found only in one hemisphere of the brain. Lastly, it may be added, that when convulsions, whether general or partial, attended with insensibility, have once occurred, they are seldom absent for many days together, though to this there are occasional exceptions, in which a pause of many months ensues after the first convulsive seizure; the general health, indeed, being impaired, but no sign clearly indicating the special mischief that exists in the brain. The transition from the premonitory to the acute stage sometimes takes place gradually, the convulsions becoming more and more fre- quent, the other cerebral symptoms more serious, and the intervals of freedom from suffering shorter; or the change takes place suddenly, and without such previous increase in the severity of the child's suffer- ings as to make you anticipate its approaching death; and yet we can- not always discover such differences between the morbid appearances in the two cases as suffice to explain the dissimilar course of the dis- ease. In the 21 cases of which I have preserved a record, the dura- tion of the acute stage varied from 24 hours to 42 days: being under a week in 8 instances; between one and two weeks in 5; between two and three in 4; twice extending to 24; once to 35 days; and in one instance convulsions were of perpetual recurrence for six weeks, when at last the child died. In four instances the acute stage was attended by the ordinary symptoms of acute hydrocephalus; once death took place from apoplexy dependent on effusion of blood at the base of the brain ; one boy died in his sleep so quietly, that the nurse watching in the ward was unaware of it; once the child gradually sank into a typhoid condition, and died without any convulsion; and twice coma stole on gradually, death again being unpreceded by convulsive move- ments. In the remaining 12 cases, convulsions took place, though obeying no definite rule as to the frequency of their occurrence, or the intensity of the coma by which they were succeeded. Wide as the differences are between the effects mentioned as pro- duced by cerebral tubercle in one case from those which are observed in another, and impossible as it is completely to account for them, they are yet, perhaps, not so altogether inexplicable as at first sight DIAGNOSIS OF TUBERCLE OF THE BRAIN. 143 they may appear. The size or position of the deposit, or the rapidity of its growth, may in one case produce pressure on the brain, occasion the effusion of fluid, and thus cause the patient's death; or the acci- dental congestion of the brain following the arrest of some discharge, or the healing of some eruption, or attending on some intercurrent febrile disorder, may render it sensible of the presence of the morbid deposit which it had endured quietly for weeks or months, and all the indications of serious cerebral irritation may at once become apparent. In another case softening may take place in the tubercular mass, and, extending to the adjacent tissue, inflammation of the brain may be lighted up; or the deposit not being limited to the brain itself, but affecting its envelopes also, tubercular meningitis may supervene, as it often does, and destroy the patient. These considerations may serve to explain cases where the tuber- cular deposit has been found external to the substance of the brain, merely pressing on it, but in no way altering its tissue. Such a case I once saw in the person of a little girl, 10 years old, who for five months had suffered from strumous disease of the knee-joint, but had never manifested any head symptom during her six weeks' stay in the Middlesex Hospital. She was taken home at the end of this time, but had not left the hospital many hours when convulsions of the right side came on, which were succeeded by coma: and this deepened, till in the course of forty-eight hours it became absolute. Convulsions occasionally returned, always affecting the right side, which from the first continued paralyzed in the intervals between their occurrence. She lay thus for eight days without any sign of amendment, and then died. There was a large quantity of clear serum in the lateral ven- tricles, and much escaped from the spinal canal. There was no dis- ease of the brain, nor any important morbid appearance in the spinal cord; but there was disease about the odontoid process and its articu- lation with the atlas, with a collection of tubercular matter around it, forming a tumor which, situated in the mesial line, encroached some- what on the occipital foramen, though pressing but very slightly on the cord. Jn the quiet of the hospital this disease had produced no symptom ; the excitement of her return home kindled the spark, and destroyed the patient. Bearing these things in mind, too, we can account for the sudden death of a child, in whom a solitary tubercle in the brain had already passed into the cretaceous state, but where habitual otorrhcea had ceased suddenly; and we can understand the reason for the inter- mittent character which the symptoms of cerebral tubercle so fre- quently assume.1 I do not wish for one moment to exaggerate the difficulties that attend the diagnosis of this affection; but, at the same time if we assume that we have to do with an incurable disease, we are less likely to use efficient means of treatment than if we felt that there is still some room for hope. While, therefore, I would have you bear in 1 See, with reference to the various effects of cerebral tubercle, and the different ways in which it may prove fatal, the excellent chapter on tubercle of the brain in Dietl's work, already referred to pp. 346-356. 144 TREATMENT OF TUBERCLE OF THE BRAIN. mind that the symptoms which we have been passing in review, espe- cially if associated with indications of tubercle in other organs, render the presence of tubercle in the brain in the highest degree probable, they yet do not afford absolutely certain evidence of it; and further, that the occasional observation of cerebral tubercle which has under- gone the cretaceous change, shows that recovery from the disease is not absolutely impossible. Headache aggravated at intervals, and associated with occasional convulsive movements of one limb, and even with attacks of an epileptic character, may occur in children who yet after a time recover, and show, by the robust health they subse- quently attain to, that some cause of a less abiding nature than tuber- cular deposit must have given rise to the disturbance of the brain; or, on the other hand, though serious cerebral disease may exist, and such as gives rise at length to a fatal result, yet it may appear* after death that it was such as would have been mitigated, if not cured, by appro- priate treatment. You must not, then, be merely passive spectators of these symp- toms; and if you watch cases of this kind with attention, 3'ou will generally find that they afford you some clue to the treatment that you should follow. Either there is manifest gastric and intestinal disorder, or there are indications of a state of general debility, or there are signs of inflammatory disease in the brain. In the first case, the regulation of the bowels and the careful management of the diet are obviously indicated; in the second, iron may be given with advantage, and the shower-bath may be cautiously tried, and, if it do not alarm the child, it may often be continued with much benefit. In those cases where there seems to be some slow mischief in the brain, I have once or twice seen recovery take place, contrary to all my anticipations, from the employment of small doses of mercury night and morning, persevered with for many weeks. In such cases, too, counter-irritation by means of the tartar-emetic_ ointment rubbed into the back of the neck is often followed by the happiest effects. A little girl, 14 months old, was some time since under my care for the frequent recurrence of convulsive attacks of a very anomalous cha- racter. So long as a discharge was kept up from her neck by the tartar-emetic ointment, the fits did not occur; but if the discharge ceased for two or three days they were sure to return. These are the principles by which your conduct must be governed; but you will find that each case will present some special peculiarity, and will need to be studied and treated for itself. Tumors of other kinds may exist in the brain in childhood, though they appear to be more frequent in the middle-aged or the old.1 I once saw a case in which hydatids had formed in the substance of the brain in a girl of seven years old; and once also I saw cancer affecting the brain and its membranes in a boy two and a half years old. But, though such occurrences are interesting from their rarity, I do not 1 Of the 34 cases of non-tuberculous tumors in the brain, which form the basis of Friedereich's elaborate " Beitrage zur Lehre von den Geschwiilsten innerhalb der Scha- delhohle," 8vo., Wiirzburg, 1853, none occurred in children under 10 years old; and only 4 in young persons between the ages of 10 and 20. DISEASES OF THE SPINAL CORD. 145 know any circumstance, except the absence of the signs of tubercular disease in the patient, by which you could determine during life that certain cerebral symptoms arose from hydatids, or cancer of the brain, and not from tubercle in that organ. LECTURE XII. Diseases op the Spinal Coed—their study rendered more difficult by the tender age of children. . Irritation and Congestion of the Cord. Inflammation of the Membranes of the Cord—sometimes epidemic—not common as a sporadic affection. Illustrative cases.—Inflammation of the Substance of the Cord —extremely rare in its acute form—in its chronic form gives rise to symptoms similar to those which occur when bones of the spine are diseased. Cases. Trismus—extremely rare in this country—symptoms—post-mortem appearances.—Causes of the disease—influence of vitiated air—treatment almost hopeless. At the commencement of these Lectures I called your attention to the predominance of the spinal over the cerebral part of the nervous system, as constituting one of the grand characteristics of early life. Since then, our daily course of inquiry has brought before us numerous confirmations of this truth, and has shown us how slight a disturbance of the functions of the brain may suffice to destroy the harmony of those which belong to the spinal cord. To-day we pass from the consideration of those cases in which the brain is the original seat of disorder, and the spinal cord suffers only secondarily, to the study of others, where that organ is primarily affected. I need not remind you how much obscurity hangs over the ailments of the spinal cord at all periods of life; but in the young < subject this is not a little increased by the difficulty that attends the observation of some of those symptoms which would be obvious enough in the adult. Thus, for instance, while impairment or loss of the locomotive power in the grown person could hardly escape our notice for a moment, it might fail to attract much attention in a young child, who often totters in his gait, or even becomes unable to walk, if from any cause his health should fail. Or, again, the impaired sensa- tion, or the vague pains in the limbs, which the adult would be sure to tell us of, would be but ill described by a child, even though it had long been able to talk, while terror might cause it to cry if any attempt was made to examine its back, and might thus prevent our ascertain- ing the presence or absence of tenderness of the spine. These are difficulties, however, which patience and tact will overcome; for not onlv the diseases of the spinal cord, but the symptoms by which they manifest themselves, are much the same at all ages, the chief difference being that in the one case they strike the eye even of the careless, while in the other careful observation is necessary for their detection. 10 146 IRRITATION AND CONGESTION OF SPINAL CORD. Irritation of the cord, however produced, gives rise in the child, as well as in the adult, to impairment of the motor power. A little boy, between two and three years old, remarkably strong and healthy, was observed, without any obvious cause, to fail in his general health, and at the same time to totter in his gait, to become indisposed to move, and, at last, almost entirely to cease walking; and this impairment of his power of walking was quite out of all proportion to the signs of ill health by which it was attended. After watching him for a time, it was discovered that the child had become addicted to the practice of masturbation. This was put a stop to, and he soon regained his health, and with it his power of walking. In this instance the cause of the irritation of the cord, and of the consequent impairment of its functions, was obvious enough, but cases now and then occur in which symptoms of disorder of the spinal cord manifest themselves without our being able to discover on what they depend. Such cases, too, are all the more important from the circum- stance that the symptoms which attend them simulate serious disease, and are likely to lead us into the unguarded expression of a very unfavorable prognosis as to their issue. On the 30th of December, a few years ago, I saw a delicate boy, between four and five years old, who had been drooping in health, though without any definite symptom, for a week or two; but had complained of stiff neck for the first time on the previous Christmas Day. This ailment, however, had disappeared and recurred more than once between then and the 28th; since which last date it had been constant, though not always the same in degree, being less marked in the morning, more so towards night. The child looked out of health, and seemed very languid; he moved very cautiously, as if afraid of the slightest jar; his shoulders being raised, his head thrown rather back, and kept most carefully motionless; while he complained bit- terly of any attempt to bend his neck, and said that pressure on the upper part of the cervical spine occasioned him much pain. The boy's appearance and manner were precisely those of a patient/suffering from disease of the cervical vertebras; and a most experienced surgeon, who saw the case with me, expressed himself as very apprehensive that the case was a bad one, though whether the disease was in the spinal cord or in the vertebras he considered to be uncertain. I certainly took a most unfavorable view of the affection; and was much surprised to learn subsequently that, after the application of four leeches to the back of the neck, the child went to sleep, slept during the night, and awoke the next morning with the most complete power over the muscles of the neck, showing no pain in moving his head, complain- ing of no tenderness of the spine, nor did any such symptoms manifest themselves at any subsequent period. I have since met with several cases of a somewhat similar kind which I believe to be of rheumatic origin. The symptoms come on too rapidly to be due to disease of the cervical vertebras, while they are not sufficiently severe to be attributed to inflammation of the spinal cord, or of its membranes. Headache is not present, nor any distinct evidence of cerebral disturbance. Rest in bed, attention to the bowels MENINGITIS OF THE SPINAL CORD. 147 diaphoretic medicines, and warm applications, and stimulating lini- ments to the back of the neck, of which there is none better than the Linimentum Belladonnas of the new Pharmacopoeia, have sometimes removed in a couple of days symptoms that seemed most threatening. In such cases, as in many others, the results of treatment yield a most important help towards the formation of a correct diagnosis. Whether in the instance above related the affection was a rheumatic one I do not know, or whether there was some unusual congestion of , the vessels of the cord, which the local depletion at once removed, and thus cured the patient. That such a condition existed in the following instance is still more likely, for here there was a local injury amply sufficient to produce it. In May, 1845, a little girl, four years old, was brought to me by her mother, who said that ten days before, the child had had a fall on her back, while left in the charge of a servant; that on the following morning she was unable to stand or move, unless supported; and that she had ever since continued in the same condition. Her appearance was rather anxious; her face was slightly flushed; skin warm and dry; tongue slightly furred ; pulse frequent, and with power. If placed on her feet, she clung hold of her mother, sank down into a stooping, half-squatting posture, and immediately began to cry. She could walk if firmly supported, but hurriedly and unsteadily, stepping on her toes, her legs moving in a semicircle with her toes turned inwards, and one foot being put down just in front of the other. On examining the spine, the integuments from the tenth to the twelfth dorsal vertebra presented a little puffiness, and there was very great tenderness of the spine in that situation; and even when not touched, the child com- plained of pain in her back. There was no appetite, but great thirst; the bowels were constipated ; the appearance of the urine was natural, and neither feces nor urine were voided unconsciously. She was cupped on the loins to 3iv, and on the following day was much relieved, moving her legs more readily, and suffering much less from pain in the back. On the 17th she was able to stand, and could walk a little without suffering. Attention was paid to keep the bowels open, and in a few days she was quite well. Besides cases of this kind, however, in which there is some un- certainty as to the cause of the functional disorder of the spinal cord, others are sometimes met with of a more formidable, though of a less obscure kind. Such are the cases, fortunately by no means common, in which the spinal cord or its membranes are the seat of inflamma- tion. Inflammation of the membranes of the spinal cord prevailed epidemi- cally in many parts of France from 1842 to 1844. The victims of the disease, which proved very fatal, were almost entirely youths a little past the period of puberty. An epidemic of a similar kind was lately prevalent in many of the hospitals and workhouses of Ireland; but in that country boys under twelve years of age were almost the only persons who suffered from it. The arachnoid of the spinal cord was found in every instance to be the part chiefly affected, though in most cases the membranes of the brain seem to have been slightly involved 148 MENINGITIS OF THE SPINAL CORD. in the disease. Notwithstanding the great extent of the inflammation of the membranes of the cord, and the effusion of lymph beneath them, the nervous substance appears to have been comparatively seldom attacked by it, and never with much severity. The disease generally came on very suddenly, and its course was often extremely rapid, some patients dying in twenty-four hours, while few survived the fourth day. Severe pain in the abdomen, attended with vomiting and purging, and a condition of general collapse, marked the outset of the affection. A state of reaction soon succeeded, the surface in the course of a few hours becoming hot, the pulse full, and its frequency varying from 120 to 140, while the face assumed a tetanic expression, and the head was retracted and firmly fixed. General convulsions, or coma, succeeded to this condition, and failure of deglutition, with a slow and labored pulse, followed as the immediate precursors of death. I must refer you to Dr. Mayne's account of this epidemic, which is contained in the Dublin Quarterly Journal for August, 1846, for I have not seen the disease in any other than a sporadic form, and even then but seldom. Perhaps, therefore, I shall convey to you a more truthful impression of the general characters of inflammatory affections of the spinal cord and its membranes, by relating to you a few of those instances that have come under my own notice, rather than by attempting to draw a general portraiture of them from too small a number of examples. A boy, aged 11 years, of a phthisical family, who seven months previously had had severe and long-continued attacks of headache, was greatly distressed by hearing of the sudden death of a relation. On the following day he had slight nausea, with pain in the head; but in a day or two he suffered more from pain in his limbs, especially in the calves of the legs, and also shooting from the situation of the coccyx to the middle of the back. He complained, moreover, of a constant pain at the epigastrium, which, as well as that about the lower part of the back, was always much aggravated when the bowels acted; they being, however, usually constipated. These symptoms were associated with great weakness of the legs, which he dragged when walking, and he reached the Children's Infirmary, from which his home was about a mile distant, with much difficulty. On the fol- lowing day I visited him, and ascertained, on examining the spine, that there was considerable tenderness on pressure from about the middle of the dorsal vertebras to the apex of the sacrum, but greatest about the lumbar region. There was no intolerance of light, but very distressing sense of giddiness, complete loss of appetite, constant sen- sation of sickness, and a nasty taste in the mouth. The intellect during the whole illness was only once affected, and then but for a few hours; and the child was remarkably acute, and described his different sen- sations with great exactness. The pain in the loins was relieved by cupping; but on the next day the headache was increased in severity, and there was some subsultus of the tendons of the forearms, and a good deal of twitching of the hands. This symptom disappeared after the boy had been depleted copiously by leeches to the head, and after his gums had begun to MENINGITIS OF THE SPINAL CORD. 149 be affected by mercury, which was freely administered to him; but his pulse, which during the whole of his illness never exceeded 75, sank to 60 in the minute, and its beat became irregular. As the mouth became decidedly sore, first the shooting pains in the back and limbs ceased; then the pulse became regular, and rose in fre- quency; then the epigastric pain disappeared, and was succeeded for a time by a sense of weight there. By degrees the tenderness of the spine diminished, and finally ceased, and the headache grew less; but his legs long continued weak, so that he could not tread firmly, and the slightest noise, or any kind of over-exertion, brought on an imme- diate increase of his sufferings. A seton was put in the back of his neck, and the influence of mercury on the system was cautiously maintained for four months before the boy appeared sufficiently well to justify the discontinuance of remedies. But the disease may run a more acute course, and to a less favorable termination. A little boy, one year old, who had cut four incisor teeth, and whose health had been habitually good, was brought to me by his mother after three weeks' illness. She told me that he had been suddenly seized with great fever and heat of skin, accompanied, after a lapse of four days, by violent screams. At the outset of his illness he had been cupped at the back of his neck, and leeches had been applied to the head without amendment, and for a week before I saw him all treatment had been discontinued. The child then lay in his mother's lap, frequently crying with a low distressed whimper; his face was usually pale, but occasionally flushed; his head was thrown back, so that the occiput and the back of the neck were nearly in contact with each other. The sterno-mastoid muscles were rather rigid, though there was no trismus. The hands were clenched, the thumbs drawn into the palm, and occasional attacks came on, in which he uttered a scream, and then bent his body back into an arch. The child sucked eagerly, but frequently dropped the nipple as if in pain; the pupils acted naturally; the pulse was frequent, small, and hard. In the course of the succeeding day frequent convulsive twitchings and start- ings of the limbs took place, affecting the left arm more than any other part. His face grew habitually pale and more sunken, and the spine became habitually, though slightly, curved forwards, notwithstanding which, occasional attacks of opisthotonos still occurred. The pupils still acted well, but a new symptom appeared, in the labored breathing, which sometimes became so difficult that the child seemed almost choking, while phlegm collected in his throat, which he appeared unable to get rid of. This dyspnoea would almost imply that the inflammation had been gradually travelling upwards till it began to involve the origins of the cerebral nerves—a supposition still further confirmed by finding two days afterwards that the eyeballs were in a state of constant convulsive rotation. After this, which was the fifth day from that on which I first saw the child, he was not again brought to me; but, though this case is incomplete, yet it helps to fill up the portraiture of the disease. To complete it, however, I must relate one 150 MENINGITIS OF THE SPINAL CORD. instance more, in which the results of examination after death con- firmed the diagnosis. Some years ago, I saw a little boy, five months old, of whom his mother gave me the following history: A month before, he had been attacked by shivering (an unusual occurrence in a young child) and, in the night following this seizure, had many fits, during which he screamed much and became very stiff. After they had continued for three days, returning at intervals of an hour or half an hour, a little diminution in their severity followed the use of some medicine pre- scribed for him by a surgeon; but, even when I saw him, ten or twelve often occurred in the twenty-four hours, though a day would now and then pass without any. The fits were described as presenting the cha- racters of opisthotonos, though in a less marked degree than when they first came on. The retraction of the head by which they were attended at first subsided as they passed off'; but in the course of two or three days the tendency to keep the head thrown back became constant, and for a fortnight the head had never been brought out of that position. The mother thought, too, that the child had been blind for that period. The child appeared well grown and well nourished, and the face was not expressive of particular suffering, but the head was drawn back so that the occiput rested between the shoulders, while the back was bent forward in a state of perfect emprosthotonos; the legs were drawn up towards the abdomen, the palms of the hands turned back- wards and outwards, the fingers clenched, and the thumbs drawn into the palm. On turning the child round on its face, the body formed a complete arch resting on the chin and knees. The whole spine was very tender, and this tenderness was greatest about its upper part. The pupils were dilated and immovable; suction was difficultly per- formed, though there was no trismus, but the child vomited everything it took almost immediately. The pulse was at this time too rapid and too feeble to be counted, and the child died in a fit of convulsions twenty-four hours afterwards. On examining the body, blood was found effused, though not in any considerable quantity, within the spinal canal, but external to the dura mater, from the third cervical to the third dorsal vertebra. A thick layer of white lymph was present both under the arachnoid and in its cavity along the whole posterior surface'of the lumbar and dorsal por- tions of the cord, and likewise existed in the cervical portion, though in a less degree. Anteriorly, blood and lymph occupied the whole cervical portion of the sac of the arachnoid, and were effused beneath the membrane; but in the remainder of the front of the cord there were merely patches of lymph beneath the arachnoid. The substance of the cord was apparently healthy. On lifting up the cerebellum, a considerable quantity of serum, with flakes of lymph, escaped from the base of the skull, and the whole under surface of the cerebellum had a uniform coating of white lymph at least a line and a half in thickness, which extended over the medulla oblongata, and was con- tinuous with the deposit of lymph along the spinal cord. The lateral ventricles of the brain were much distended with fluid, in which large irregular masses of yellow lymph were floating. The corpora striata INFLAMMATION OF THE SPINAL CORD. 151 and the fornix were much softened, but the rest of the brain and the membranes at its convexity were quite healthy. It can scarcely be necessary that I should comment on these cases, either to point out to you the many respects in which inflammation of the spinal cord differs from that of the brain, or to insist on the absolute necessity of active antiphlogistic treatment being adopted at the very outset of the disease. But besides those (feses in which the affection of the spinal cord and its membranes so greatly preponderated, and in which the rapid course of the disease served further to impress on it a peculiar character, others are occasionally met with where the course of the disease is slower, where the symptoms are less exclusively those of disease of the spinal cord, and concerning which it seems almost doubtful whether the membranes of the spinal cord suffer from extension to them of in- flammation beginning in the lining of the lateral ventricles, or whether, as indeed I believe to be the case, mischief beginning about the cord is thence propagated upwards. Such cases are of importance, because, if seen only when far ad- vanced, and considered without reference to their previous history, they often present few points to distinguish them from the more hope- less tubercular meningitis, while at the same time their course is slower, their nature more purely inflammatory, and therefore their treatment may be undertaken with some prospect of success. A little girl, 20 months old, rather backward in her physical develop- ment, and having cut only seven teeth, the last of which appeared at the age of 18 months, was admitted into the Children's Hospital on April 4th. Two months previously, while cutting her seventh tooth, her right arm became somewhat stiff, and the power over it rather im- paired, a condition which, though improved, had not altogether dis- appeared at the time of her admission. On March 24th she vomited, became hot and restless, ceased to talk, and left off all attempts at standing, though her legs did not become stiff', nor were they paralyzed. Her neck became stiff", though she could move her head ; she swallowed without difficulty, but had little appetite; her bowels were disposed to be relaxed; her abdomen was not shrunken, her pupils contracted well under light; her pulse was frequent but regular, and there was no return of vomiting after the first day or two of her illness. On admission the child was in a state of great apathy, but not of coma; the surface was not hot, but the pulse 168, though regular. She kept her head somewhat thrown back, but could move it about in any direction, and even bend it forwards. The belladonna liniment was applied constantly to the neck, small doses of the iodide of potas- sium were given, and the child was fed with beef-tea. For a week improvement appeared to take place in her general con- dition, but on April 11th the symptoms became aggravated without apparent cause; the pulse sank to 104 aud became very irregular in rhythm; divergent strabismus of the left eye became apparent, and the left pupil was more dilated than the right. The child occasionally stretched out her limbs and trunk for a moment quite stiffly, almost 152 INFLAMMATION OF THE SPINAL CORD. like a passing fit of tetanus; but the features were not affected, there was no trismus, and the head was not fixed, though usually retracted. The pulse sank on the 12th to 80, and its irregularity became more marked, the strabismus varied in degree, the pupils became gradually dilated, and the left usually more so than the right. The application of a blister to the back of the neck was succeeded by an increase of consciousness, and the addition of half a grain of quinine to each dose of the mixture was followed by a still greater apparent amendment, which lasted till the 20th. It was noticed, however, that the stiffness of the right arm rather increased, that the right leg was moved rather less freely than the left, that there was partial paralysis of the left side of the face, and the rectus externus muscle of the left eye, while the left pupil was more dilated than the right. On the 25th the symptoms had increased. On May 2d the child had lost both flesh and strength; her pupils acted scarcely at all, though they were not extremely dilated, and the strabismus persisted though it did not increase. On May 4th a convulsive seizure occurred, which lasted for a quarter of an hour, affecting both sides equally. On the morning of the 7th convulsions returned, chiefly affecting the left side, accom- panied with much movement of the eyeballs, though with but little distortion of the face. These convulsions lasted for 4| hours, and in them the child died. There was no congestion of the vessels of the convexity of the brain. The sac of the arachnoid was dry, the convolutions of the brain were much flattened, and the enormously dilated lateral ventri- cles contained six ounces of transparent serum. Their lining mem- brane was coated with a thin layer of very soft greenish lymph, which was already far advanced in fatty degeneration. This lymph was most abundant on the left choroid plexus, and on the walls of the posterior cornua, while in some places it was so thin that it could be made visible only by scraping a considerable surface. The ventri- cular lining beneath it was perfectly natural, smooth, not thickened, not softened, not extra vascular. In both descending cornua, how- ever, where there was more lymph than elsewhere, it was rather more adherent to the subjacent membrane, and when removed seemed to leave a rather rough surface, on which it was not easy to raise a membrane. There was but very slight softening of the central parts of the brain. At the base of ihe brain, from the optic commissure backwards, there was much thick greenish puriform exudation, passing over both crura cerebri, and encasing both lobes of the cerebellum in a thick layer of puriform material, extending also over the inferior surface of the pons Varolii, and both surfaces of the medulla oblongata. There was how- ever, no softening of the brain substance. From the third cervical to the second dorsal vertebra there was much extravasation of blood external to the theca of the cord. On opening the dura mate^ there was a thick layer of lymph of ACUTE INFLAMMATION OF SUBSTANCE OF CORD. 153 the same kind as in the brain, which invested the whole cord, from the medulla oblongata to the cauda equina. In the cervical region the substance of the cord was much softened; but it could not be ascertained whether this softening was greater before, behind, or to one side. Below this point the softening of the cord was inconsiderable. There was no tubercle in any organ of the body. Now I have seen other cases, in some of which the extent of lymph deposited on the cord was less considerable, and the affection of the ventricles of the brain and of its base also less. Some of these cases, too, have run a slower course, extending over three, four, or even six months. In these the spinal symptoms have been more marked, and those of cerebral disturbance have come on more slowly; convulsion's have often occurred, varying in frequency and severity, though usu- ally not of long duration, unattended by much distortion of the features, not limited to one side, not succeeded by paralysis, nor by abiding coma; while even when the children took the least notice of surrounding objects, their condition was one rather of indifference than of insensibility. The above case, and these observations, will probably suffice to pre- vent your misinterpretation of these rare instances of cerebrospinal meningitis, when they come before you in their less rapid forms. I have not met with any instance of acute inflammation and conse- quent softening of the substance of the spinal cord, although there are many such on record. It has been supposed that paralytic symptoms usually attend this affection, while stiffness and spasm of the muscles characterize spinal meningitis; but though this is probably true in many instances, yet it does not by any means hold good in all. Three cases are related by MM. Rilliet and Barthez, where the disease ran its course with symptoms of tetanus and trismus, which continued up to the time of the patient's death. In one of these cases the child died in 36 hours; in the second, in 96 hours; but in the third, a temporary remission having occurred, the patient survived for thirteen days. I select from Dr. Mauthner's valuable treatise on the Diseases of the Brain and Spinal Cord in Children, a very characteristic case of acute inflammatory softening of the spinal marrow.1 A girl aged 11 years, whose occupation as a sempstress compelled her to remain for many hours daily in a sitting posture, with her head bent forwards, while she was at the same time much exposed to cur- rents of cold air, was seized, after she had followed this employment for three weeks, with dragging and tearing pains in the back of her neck. As these pains grew more severe, voluntary power over the arms became impaired, and the paralysis increasing rapidly in spite of the application of leeches to the back of the neck, she was admitted into the Hospital for Children at Vienna, under Dr. Mauthner's care, on December 26th. Both arms were at that time completely palsied, flaccid, cool, and almost insensible; the lower extremities still obeyed the will, but the girl was unable to stand firmly. The mind was per- 1 Lib. cit., p. 421, case 117. 154 CHRONIC INFLAMMATION OF SUBSTANCE OF CORD. fectly clear, the appetite good, deglutition easy, and pulse natural; and in these respects her condition continued unchanged to the very last, except that the pulse became very frequent on the day of the child's death. On the 28th the legs were palsied, and the urine was passed iuvoluntarily. On the 29th, voluntary power over the hands and feet was likewise completely lost, and sensation in them was imperfect. On the 30th, sensation was perfectly lost in all extremities. The child had desire to pass feces, the bowels not having acted for three days, but she had not power to do so. On the 31st, the sphincter ani was likewise paralyzed, and opened to the size of a shilling. On January 4th the hardened feces began to fall out of the gaping anus; the respi- ration was feeble, articulation difficult. On the 6th the child was in much distress, and for many days had scarcely slept at all; the whole left side of the body was completely paralyzed, and only the right side of the chest moved in respiration. Her exhaustion was so extreme that her voice was scarcely audible, but the muscles of the face still retained the power of motion and sensation perfectly, and the intellect was quite clear, though the child died the same night. The spinal cord presented the only morbid appearance; the mem- branes being perfectly healthy. The medulla oblongata was as soft as butter, of a yellow color, not retaining a trace of its natural organi- zation ; and the same condition existed in the whole of the spinal cord as low as the cauda equina, where it once more resumed its natural appearance and characters. The chronic form of inflammation of the cord will much oftener come under your notice as one of the consequences of caries of the vertebras. You will remember, too, that this serious result, and the paralysis to which it gives rise, are not produced simply by the distortion of the spine and the mechanical compression of the cord, but rather by ex- tension to it of inflammatory action. You have, then, in these cases, a double danger to combat; both that which arises from the disease in the spinal column itself, and that which depends on the probable extension to the cord of the disease which began in the bones. The symptoms of the two affections present likewise so many points of resemblance in their early stages that you can never feel sure that the cord is uninvolved. Of this we have ample proof in those rare cases in which chronic softening of the cord occurs independent of any affection of the bones of the spine. You will find a case that illus- trates this fact very well in M. Louis's valuable paper, " On the Condi- tion of the Spinal Marrow in Cases of Caries of the Vertebras;"1 and I will relate to you another still more remarkable instance of it, which came under my notice. On March 31, 1846, a little girl aged three years and a quarter, the strumous child of unhealthy parents, in whose family phthisis was hereditary, was brought to me by her mother. Nine months pre- viously, her^ father having taken her in his arms and tossed her, she suddenly cried out that she was hurt, and for several days afterwards 1 " Memoires, ou Recherches Anatomico-Pathologiques," 8vo. Memoire viii Observ i. p. 411. Paris, 182b". CHRONIC INFLAMMATION OF SUBSTANCE OF CORD. 155 refused to walk, and seemed unable to stand, sinking down on her hams if set on her feet. She made no definite complaint, however; no injury was anywhere observable, and in about three weeks she seemed to have recovered her health, and continued well until the middle of March, when her frequent complaints of pain in the neck attracted her mother's attention. The appearance of the little girl, when first placed under my care, was very remarkable; for though the face wore no expression of suffering, yet the neck was so much bent as to give an unusual prominence to the seventh cervical vertebra, and the head was constantly directed downwards. No part of the spine seemed particularly tender; but any attempt to raise the head was forcibly resisted, and seemed to occasion considerable pain. The child walked, though with a tottering gait, and if left alone for a few minutes sank down upon her knees to play. Her constant complaint was of being tired and drowsy, notwithstanding which she slept ill; her appetite was bad, and her bowels were constipated. I regarded the case as one of incipient disease of the cervical vertebras, and was anxious to make an issue in the back of the neck, but the parents refused to consent to this proceeding. Medical treatment, therefore, was confined to the administration of the cod-liver oil, and afterwards of the syrup of the iodide of iron; but though no fresh symptoms appeared, the child gradually lost strength. On the 12th of May she was able to walk a distance of nearly half a mile; but on the 14th, though not worse in other respects, she was unable to raise her hands, and was forced to be fed by another person. In the evening she com- plained of her eyes aching, but nevertheless slept tolerably well till 1 A. M. She then awoke crying and fretful; but on being taken up passed an evacuation, and on lying down again, after a few efforts to vomit, which soon subsided, spoke a few words to her mother, in whose arms she was lying. After breathing in a sighing manner for a few moments she seemed to fall asleep, and in this sleep died so quietly, that her mother was ignorant of it until awakened by her daughter's corpse beginning to grow cold. On examining the body after death the brain was found to be quite healthy, with the exception of some venous congestion of the arachnoid. The muscles of the back and the bones of the spinal column were per- fectly healthy; but on laying open the vertebral canal, the spinal cord, from a level with the third down to the seventh cervical vertebra, bulged considerably, so as completely to occupy the canal, though above and below this its size was natural. In this situation the two layers of the arachnoid of the cord were firmly connected together by numerous filamentous adhesions, and the membrane itself was opaque and thickened. The cord in the situation of this bulging had a shining gelatinous appearance, not unlike turbid and badly-made jelly, with a yellowish lymph-like matter infiltrated into it. This softening involved the posterior columns of the cord much more than the anterior; the bulging, too, seemed due to the posterior columns, though the anterior presented some degree of softening. Three apoplectic effusions were discovered in the spinal cord. The 156 INFANTILE TRISMUS—ITS SYMPTOMS. first was situated just below the calamus scriptorius, and was about the size of a lentil; the nervous matter all around being perfectly healthy. The second, which was larger, was just at the commence- ment of the swelling of the cord, and partially extended into the sound parts. It just showed through the surface of the cord as big as half a pea, but on longitudinally dividing the cord, was seen to be of the bigness of a kidney bean; and the third effusion just above the termination of the swelling of the cord, was about as large as a big pea. Besides these there were several small ecchymosed spots in the softened parts of the cord, but all the effusions of blood were strictly limited to the posterior columns of the cord. This case presents many points of interest. The scrofulous diathesis in the family; the probable injury to the spine, followed for a short time by impairment of the motor power, the subsequent occurrence of pain in the bended neck, and the fixed position of the head, all seemed to warrant the opinion that the vertebrae were diseased; but all resulted from inflammatory softening of the spinal cord, while the bones were perfectly healthy. The softening of the posterior columns of the cord, and the extravasation of blood into their substance, while the anterior columns were in a state of comparative integrity, are occurrences very remarkable when coupled with the impaired motor power.1 Cases such as this are warnings to us to avoid hasty gene- ralizations on physiological subjects; they show us how hard some of the Sphinx's riddles are to read. There still remains one affection which we must notice in connection with the diseases of the spinal cord, although it is one whose pathology is by no means thoroughly understood. The trismus or tetanus of new- born children is a malady which, though frequent in the West Indian Islands, is seldom seen in this country. Four instances of it have come under my own notice, three of which occurred in the Dublin Lying-in Hospital, while for the opportunity of observing the fourth I am indebted to the courtesy of Mr. Stone, of Christ's Hospital. The disease may come on within twelve hours after birth, or, on the other hand, may not occur for several days, but it very rarely makes its appearance after the lapse of a week. I once saw it attack a child fifteen hours after its birth, but in the other cases it came on upon the fifth day in one instance, and the sixth in the other two. Though it runs a rapid course, yet its onset is gradual; one of the first things that attracts the mother's notice being, in general, that the child does not take the breast when put to it, but utters a whimpering cry, and if the mouth be then examined, it will be found more or less firmly fixed. Sometimes general convulsions come on suddenly, and usher in the other symptoms, but they more frequently follow than precede the trismus. When fully developed, these fits, which come on in paroxysms, are ushered in by a screech, or are attended by some im- pairment of the respiration, and during their continuance the whole surface becomes livid. The hands are strongly clenched, the feet 1 It is almost impossible in so young a subject to ascertain accurately the state of sensation, but there was no obvious indication of its impairment in this case. TRISMUS — ITS PATHOLOGY DOUBTFUL. 157 forcibly flexed on the ankles, and the toes bent, and remain so during the fit, and the trunk is curved backwards in a condition of opistho- tonos: the mouth is generally drawn slightly open, and the lower jaw firmly fixed. When the fit subsides, the muscles do not become gene- rally relaxed, but the child still lies with its hands clenched, and its thumbs drawn into the palm, the legs being generally crossed, and the great toe separated widely from the others, while the head is thrown back, and the opisthotonos continues, though in a diminished degree. The condition of the mouth is peculiar and characteristic. The jaws at first are slightly open, and the corners of the mouth drawn down- wards and backwards; but as the disease advances the jaws become quite closed, the corners of the mouth even more drawn down, and the lips firmly compressed against the gums. The power of sucking is early lost, but for some time the child continues able to swallow; at length, however, it accomplishes this with great difficulty, a convulsion sometimes following the attempt, while even that fluid which had ap- parently been swallowed is for the most part speedily regurgitated. The child dies either during some paroxysm of convulsions, or, seem- ing much exhausted, it sinks into a comatose condition, and so expires. There are few affections that run so fearfully rapid a course as this; its fatal termination almost always taking place within thirty-six, often within twenty-four hours from the appearance of the first symptoms. The most frequent post-mortem appearance in these cases, and that which I found in the bodies of all the four children whom I observed, consists of effusion of blood, either fluid or coagulated, into the cellular tissue surrounding the theca of the cord. Conjoined with this there is generally a congested state of the vessels of the spinal arachnoid, and sometimes an effusion of blood or serum into its cavity. The signs of congestion about the head are less constant, though much oftener present than absent, and sometimes existing in an extreme degree, while in one instance I found not merely a highly congested state of the cerebral vessels, but also an effusion of blood in considerable quan- tity between the skull and dura mater, and also a slighter effusion into the arachnoid cavity. In spite, however, of the striking nature of these morbid appear- ances, I formerly hesitated in referring the symptoms of trismus with certainty to this apoplectic condition of the cord. My hesitation arose from the circumstance that, on examining the bodies of infants who died soon after birth in the Dublin Lying-in Hospital, I very frequently found great fulness of the vessels of the cord, and a gelatinous matter, which was frequently deeply tinged with blood, effused around its theca. It therefore became a question whether appearances such as are met with in cases of trismus might not in reality be due to the position in which the bodies had been allowed to remain, resting on the back, and thus be rather the result of simple gravitation than the consequences of the disease. These doubts, however, have been set at rest by the very excellent observations of Dr. Weber, of Kiel,1 who placed the 1 " Beitrage zur pathologischen Anatomie der Neugebornen," 8vo. part i. pp. 7, 63, and 73. Kiel, 1S51. 158 , CAUSES OF TRISMUS. bodies of infants in various positions before examining them, and thus was able to discriminate between morbid and pseudo-morbid appear- ances, and who, moreover, although he on every occasion placed chil- dren who had died of trismus upon their face immediately after death, yet always found intense injection of the minute vessels of the cord and its membranes, extravasation of blood external to the theca, and other appearances similar to those which I have just described to you. There are few diseases respecting the cause of which opinions so various have prevailed as with regard to trismus. Bearing in mind the frequency of external injury as a cause of locked-jaw in the adult, some writers have sought to find in every case the history of a blow or other injury to which it might possibly be attributed; while others have conceived that it depended on awkward management of the navel- string, or on injury of some kind or other inflicted on it. This last opinion has appeared to derive support from some cases in which the umbilical vein has presented the signs of phlebitis; but further obser- vation has shown these appearances to be anything but constant, and though carefully sought for, they were not found in any of the cases which came under my notice. Moreover, a German physician, Dr. Mildner, of Prague,1 who has recorded the results of 46 cases of fatal inflammation of the umbilical vessels in children born in the Lying in Hospital in that city, states that convulsions occurred in only 5 of the number, and that in no instance had these convulsions the least resem- blance to those which characterize trismus. Congestion of the liver, impairment of its functions, and icterus, were among the symptoms which attended it, as well as, in many of the cases, peritonitis, inflam- mation of the abdominal integuments, purulent infection of the blood and the formation of abscesses in the joints, which occurred 33 times while in 4 cases hemorrhage took place from the umbilicus. We may, then, fairly conclude that the connection between this disease and tris- mus is merely an accidental coincidence. The remarkable frequency of the disease in hot climates, where the heat of the day is succeeded by intense cold at night, favors the opi- nion that interruption of the function of the skin by sudden alterna- tions of temperature, is a powerful cause of the disease. In an epide- mic of this disease in the Lying-in Hospital at Stockholm, in 1834,2 there seemed also to be a most marked connection between the periods of its greatest prevalence and the fluctuations of temperature. No- thing, however, can be more satisfactorily proved than the tendency of a vitiated state of atmosphere to produce it. Where such a condi- tion exists, there trismus abounds, be the peculiarities of climate or temperature what they may. It is freqttent among the children of the negroes in the slave States of America; it is depopulating the island of St. Kilda, and 64 per cent, of the infants born in Westmannoe, a small islet off the coast of Iceland, die of it between the fifth and twelfth day from birth.3 Dirt and defective ventilation are probably almost 1 "PragerVierteljahrschrift,"v. 2, 1848; and Schmidt's " Jahrb.,"No. 7,p. 64,1848. 2 Cederschjold, in Busch's " Zeitschrift ftir Geburtsk.," x. 345. 3 See a very interesting notice in the " British and Foreign Medico-Chjrurgical Re-' view" for April, 1850, of a woik by Dr. Schleisner on the Sanitary Condition oAceland. ACUTE FORM OF CONVULSIONS. 159 the only points in common between the dweller in the southern States of North America and the inhabitants of Northern Europe and the Arctic Regions. But if any further proof were needed that to this cause, and not to some fancied displacement of the cranial bones,1 this disease is really to be attributed, we are furnished with it in the re- cords of the Dublin Lying-in Hospital, which point out both the evil and its remedy. Sixty years ago, every sixth child born in that in- stitution died within a fortnight after birth, and trismus was the cause of the death of £$ of these children. Dr. Joseph Clarke adopted means to secure the efficient ventilation of the hospital, and the mortality of the children fell at once to 1 in 19J; and during Dr. Collins' master- ship from 1826 to 1833, was only 1 in 58J; and but little more than the ninth part of that mortality depended on trismus.2 But though we may hope by wise hygienic measures to avert this disease, yet, when once it has become developed, our prospects of cufe are so slender that I may almost say the task is hopeless. I have not seen leeches employed, out, bearing in mind the post-mortem appear- ances, should certainly be disposed to apply them freely at the outset of the disease. I have seen the hot bath used with temporary relief; but though I have witnessed the employment of calomel and of antispas- modics, as assafcetida, and the administration of an enema of gr. iij of tobacco infused for half an hour in 3viij of water, yet I have never known any of these means followed by even a temporary pause in the symptoms; and the endeavor to excite the action of the skin is the only measure that in the cases which I witnessed seemed to be of the slightest service. LECTURE XIII. Convulsions, independent of organic cerebral disease—their two forms. The acute form, how distinguishable from those dependent on disease of the brain—practical importance of the distinction—rules for their treatment. The chronic form—relation to them of Spasm of the Glottis—import of this spasm—one of several signs of disorder of nervous system. Relation of these convulsions to processes of development in teething—but ex- citing causes various. Symptoms—description of carpo-pedal contractions—ways in which death is produced. Treatment—rules for diet and for the regulation of the bowels— caution with respect to lancing the gums—occasional necessity for free depletion—case in illustration.—Suggestions as to general management, and prevention of an attack. Use of chloroform. Remarks on some anomalous forms of convulsion, and on the Eclampsia Nutans. In the third of these Lectures, when passing in review the different signs of disorder of the nervous system I made some remarks on the subject of convulsions. I tried to show you how their import varies 1 A theory propounded by Dr. Sims, of Alabama, in the "American Journal of the Medical Sciences" for 1846, and further expanded in the same journal for July and October, 1848. 2 Collins' " Treatise on Midwifery," p. 513. 160 ACUTE FORM OF CONVULSIONS. in different circumstances; how at one time they betoken real disease of the nervous centres, at another only betray their irritation from some cause which, if death occur, may yet leave behind no trace such as the skill of the anatomist can discover. Cases of the former kind have hitherto exclusively engaged our attention, but we must not quit the study of disorders of the nervous system without some consideration of the latter. In the adult, fits sometimes occur independent of obvious cerebral disease; the patient falls to the ground struggling and insensible; but after a time convul- sion ceases, consciousness returns, and the patient recovers. Our anxiety in such cases is much less for the present than for the future; death in the fit is a rare accident, but what we dread is the recurrence of the fits, the weakening of the intellect, the slow impairment of the health which epilepsy brings with it. In the child our apprehension is twofold; for the frailer machinery is more readily brought to a stand-still, and the risk of death in the fit is far greater than in the adult; while should the child survive, the convulsions of infancy may issue in the epilepsy of riper years; and, in fact, seem to do so in a very large number of instances. The convulsions of infancy and early childhood generally assume one of two characters. Either they are sudden in their onset, violent in their character, frequent in their return, or they come on gradually, and after various forebodings, present less violence, occur at longer intervals, but are not therefore by any means devoid of peril. Cases of the first kind run some risk of being overtreated, from their sup- posed dependence on active cerebral mischief; cases of the second kind often excite less apprehension than they really warrant, until their symptoms have become manifest in their full intensity. Some of the most marked examples of the sudden access of violent convulsions which have come under my notice have been in children in whom they succeeded to the sudden drying up of an eruption on the scalp. Even in many cases, however, where we might most readily suspect some direct influence on the brain, the character of the fits is widely different from that which we observe in instances of real cere- bral disease. The illness preceding them is neither very marked nor of long duration, while, when the fits come on, instead of only one side of the body, or one set of muscles being affected, sometimes one side is convulsed, sometimes the other, or both are involved equally. Even after the fits have frequently returned, paralysis does not succeed to them, and often neither sleep nor coma, while frequently consciousness returns, even before the convulsive movements have completely ceased, and the pupils, though dilated during the fit, act again almost or quite as well as ever as soon as it has passed oft'. Vomiting does not pre- cede nor accompany the attack; nor an obstinately constipated state of the bowels; and the abdomen is often much distended with flatus, the endeavor to get rid of which produces troublesome hiccough, while the inspiration is often accompanied by a peculiar crowing sound. There is at no time the burning heat of the head which is observed in active inflammatory disease of the brain; there are not the piercing cry, nor the constant wail, nor the tearless eyes, nor the ACUTE FORM OF CONVULSIONS. 161 shrunken abdomen, nor the automatic movements of one side, and the contraction of the limbs on the other, which attend upon tubercular hydrocephalus. These characteristics are such as ought to prevent the by no means unusual error of regarding the attack as symptomatic of active disease of the brain; and under that impression depleting the child freely, dosing it with mercury in large quantities, and at short intervals; a course of proceeding by which all chances of recovery are frustrated, and hopes, small at first, are altogether destroyed. The state of the child before the occurrence of the fits, and the amount of apparent congestion of the brain, must in cases of this kind determine the question of depletion. Moderate depletion once is often well borne, but the persistence of the fits must not be thought neces- sarily to indicate the propriety of its repetition. If the attack suc- ceeded to the rapid disappearance of some eruption on the scalp, an attempt may be made to reproduce it by rubbing in every three hours an ointment composed of one drachm of powdered ipecacuanha to an ounce of lard; which generally produces an abundant papular eruption in the course of from twelve to twenty-four hours. If a purgative be indicated, a single dose of calomel has the advantage of acting surely and speedily, but mercury, given in any other manner or with any other object, is out of place. The flatus by which the intestines are distended rt got rid of better by an assafoetida enema than by any other means; while the application to the abdomen of a cloth dipped in a stimulating liniment (such, for instance, as a drachm of oil of turpentine, five drachms of the simple camphor liniment, and six drachms of olive oil), and that covered by a light linseed meal poultice, both serves as a counter-irritant, prevents the reproduction of the flatus, and relieves that spasm of the abdominal muscles which in many of these cases adds very painfully to the infant's sufferings. These measures having been adopted, you may now, according to the general condition of the patient, prescribe either some carminative medicine with small doses, of ether, or of the fetid spirits of ammonia, or a single dose of Dover's powder, if restlessness and excitability have out- lasted the other symptoms; or a simple saline, as the citrate of potash, with small doses of the tincture of henbane; or the hydro- cyanic acid with a little chloric ether at short intervals—a sedative which, whenever there is a doubt as to the expediency of employing direct narcotics, has always seemed to me of especial value. Within certain limits, this treatment must of course be modified according to the exact nature of the case, but enough has already been said to mark out the general principles upon which your treatment should be conducted; while even if the attack had seemed at first to present some obscurity as to its cause, a few hours will suffice for its removal, will develop the signs of cerebral inflammation, if that were impending, or will bring to light the character of the fever which is making this stormy onset. So long as, notwithstanding the frequency of the return of the fits, recovery is complete after each, so long as the power of deglutition subsists, and the natural hue of the lips and face announces the oxygenation of the blood to be well performed, you 11 162 CAUSES AND SYMPTOMS OF may give on the whole a favorable prognosis, though always guarding it by admission of the possibility of the child dying in a fit from that spasm of the glottis, and consequent arrest of breathing, which is the great source of danger in infantile convulsions. This Spasm of the Glottis is, indeed, one of the most remarkable features in many convulsive affections of infancy and childhood ; though more especially of that variety to which I have referred as coming on gradually and pursuing a somewhat chronic course. So prominent a feature, indeed, is it of this latter class of convul- sions, that attention has been very generally directed to this one symptom, almost to the exclusion of the other signs of disorder of the nervous system by which it is accompanied, and the various terms, spasmodic croup, child-crowing, spasm of the glottis, and laryngismus stridulus, show how great has been the disposition to regard it as a distinct and independent disease. Hence has resulted the inconveni- ence, that attention being directed exclusively to the affection of the respiratory function, local causes have been too much sought for to account for the local symptom; defective, if not erroneous explana- tions of its occurrence have been proposed, and sufficient regard has not been paid in its treatment to the great diversity of conditions under which it may supervene. The sobbing breathing,, or the sense of choking, so characteristic of the hysterical patient, are but instances of spasm of the respiratory muscles, similar to those which we observe in the infant, and equally due to the great excitability of the nervous system. In the hysterical girl, fits are frequently superadded to the affection of the respiratory muscles; and in the child, spasm of the muscles of the extremities, giving rise to the drawing of the thumb into the palm, and to the separation of the great toe from the other toes, or to the forcible ex- tension of the foot upon the ankle, is seldom absent; while general convulsions often supervene under slight causes, or even without any apparent reason. In both cases the affections are usually attendant upon important processes of development, since while in the former instance they generally come on about the period of puberty, they oftenest occur in the latter during the time of teething; and this with so great frequency, that in 31 out of 37 cases of which I have pre- served a record, the symptoms manifested themselves between the age of 6 months and 2 years, or just at that time when the process of dentition is going on with the greatest activity. The direct irritation of the trifacial nerve in teething has no doubt a great share in the production of the symptom at that time, but I apprehend that we should be in error if we confined our attention entirely to the local cause, and attributed this, more than any other form of convulsive affection, which occurs at this time, simply to the mechanical irritation of the teeth pressing on or cutting through the gum. The period of teething, like that of puberty, constitutes one of the great epochs of life; it is a time when great changes are going on in the whole or- ganism—-when the animal machine, being in a state of increased activity, its parts are more than usually apt to get out of order. New diseases appear, or such as were before of rare occurrence become SPASM OF THE GLOTTIS. 163 frequent; catarrhal affections and disorders of the intestinal mucous membrane are extremely prevalent, and the brain grows more than ever liable to congestion of its vessels. In these circumstances, the various spasmodic affections, of wr/ich spasm of the glottis is the most striking and the most important, often occur as the secondary rather than as the primary result of dentition. The child has cut some of its teeth without any symptom of^isorder of the nervous system making its appearance, but at length it suffers an attack of diarrhoea, or the bowels are allowed to become constipated, or signs of cerebral congestion show themselves. A crowing sound now becomes audible with the inspiration, and with it some or all of the whole train of con- vulsive symptoms which I shall presently describe make their appear- ance. It may be that the gums are not swollen, nor any tooth near the surface just at the moment when the signs of disturbance of the nervous system occurred, but their connection with the process of denti- tion is not the less undeniable. In many instances, too, though these symptoms may subside as the health improves, yet so great is the nervous excitability of the patient, that they return when he cuts another tooth, and this even without a recurrence of that general dis- order which attended them on the former occasion. The various sources of irritation, however, that give rise to these affections are not limited to the period of teething; and hence they may be met with before the commencement of that process as well as after its termination. By no one has this fact been more clearly stated, or the mode of action of the various exciting causes more successfully explained, than by the late Dr. Marshall Hall. " Spasm of the Glottis," says this distinguished physiologist,1 " is an excitation of the true spinal or excito-motory system. It originates in I. 1. The trifacial, in teething. 2. The pneumogastric, in over- or improperly fed infants. 3. The spinal nerves, in constipation, intestinal disorder, or catharsis. These act through the medium of II. The spinal marrow, and III. 1. The inferior or recurrent laryngeal, the constrictor of the larynx. 2. The intercostals and diaphragmatic, the motors of respiration." In illustration of these observations as to the various causes on which these symptoms depend, I may mention that I have seen them in a child ten weeks old as a consequence of improper feedino-: in another, aged nineteen months, they followed the sudden suppression of long-continued diarrhoea; while in a third, aged two years, they came on during an attack of purging with severe pain in the abdomen. In another child, aged two years and a half, they seemed to depend on a state of cerebral congestion which succeeded to habitual consti- pation; in a fifth, aged nine months, they supervened in the course of chronic hydrocephalus; and, not needlessly to swell the list, in a sixth child, who died when two months old, convulsions occurred for a period of six weeks, and eventually occasioned its death, without 1 Lib. cit., p. 171. 161 CAUSES AND SYMPTOMS OF its having been possible to discover, either from the symptoms or from the appearances found on examination of the body, any cause to which they could be attributed. But this principle admits of a wider application. Not only are the convulsions which occur during dentition symptomatic of something more than the undue pressure of a tooth against the gum, but in by far the greater number of instances, we have to look deeper than the local cause to which at last the signs of disturbance of the nervous system were due, and find that it is only on the removal of some influence which acted injuriously on the whole constitution that the liability to convulsions ceases. Thus, for instance, in the child brought up by hand, the commencement of teething is ushered in by convul- sions, a wet nurse is procured, the convulsions cease; or medical care has failed to relieve the infant resident in London—it is removed to the country, and the fits previously so frequent disappear. In spite, however, of the illustration of this fact which the action of remedies affords, it is yet too often lost sight of. The defective nutri- tion which shows itself in the bowed limbs, and distorted form of the rickety patient, is attended in early life by special proneness to con- vulsions. A German physician1 thought that he had discovered, in the tardy ossification of the skull in such children, an adequate ex- planation of their liability to disturbance of the functions of the imper- fectly protected brain, and putting a part for the whole, wrote by a very pardonable, but not the less mistaken synecdoche, an essay on " The soft Occiput." Again, one of the commonest manifestations of the tuberculous diathesis is glandular enlargement; and the late Dr. Hugh Ley3 propounded a theory which explained the symptoms of spasm of the glottis by an assumed pressure of the enlarged cervical glands on the recurrent laryngeal nerve. Still, more recently, we find a practitioner of considerable experience struck by the connection of spasm of the glottis3 with enlargement of the liver, and framing a mechanical explanation of the trouble of respiration by the impedi- ment to the descent of the diaphragm which is occasioned by the great size of the organ. Of the frequent coexistence of the enlarged and fatty liver with spasm of the glottis there can be no doubt; but it does not therefore follow that we are to accept the mechanical expla- nation of the fact which Mr. Hood suggests. Some years ago, my friend and former colleague, Doctor Rolleston, now Linacre Professor at Oxford, wrote a paper which I wish that his modesty had not with- held from publication, in which he shows that this same fatty liver is present in many instances of the hydrocephaloid disease of early infancy; the extreme anaemia, the feeble powers, the rapid sinking under slight ailments, the supervention of signs of disorder of the nervous system (among which spasm of the glottis is by no means necessarily present), being found associated with this grave defect in nature's great alembic, and consequently with imperfect depuration ' "Derweiche Hinterkopf," etc., von Dr. C. L. Elsasser. 8vo. Stuttgart, 1843. 2 "On Laryngismus Stridulus," 8vo. London, 1836. » " On Scarlet Fever and Crowing Inspiration." 8vo. London, 1857. SPASM OF THE GLOTTIS. 165 and depraved character of the blood. But modern physiology1 gives a still graver import to this, as to other morbid conditions of the liver in connection with those disorders of the nervous system in early life which are associated with anaemia or with deranged nutrition. The liver would seem to be not merely a purifyer, but an actual generator, of the blood ; its disease, therefore, interferes immediately with sanguifi- cation, and prevents the best devised tonic remedies from exercising that influence which otherwise they would not fail to produce. It follows then, with reference to all the disorders of the nervous system in early life, that while the mode in which they manifest them- selves varies from slight and unimportant causes, and while local accidents may account for their assuming this or the other special form, we must in all instances endeavor to look beyond them to the constitutional ailment, sometimes of one kind, sometimes of another, to which, as their ultimate occasion, they are due. Bearing in mind now what I have just said with reference to the import of Spasm of the Glottis—how it is but one of many signs of the general disorder of the nervous system—we may proceed to exa- mine the conditions under which it usually manifests itself; the symp- toms by which it is generally attended. It is a disorder that almost always comes on by degrees; and its early symptoms are seldom such as to excite the alarm of non-professional persons. It does not often occur in perfectly healthy children; but an infant who is attacked by it has usually been observed to be drooping for some time previously, to have lost its appetite, to have become fretful by clay and restless at night, and to present many of those ill-defined ailments which are popularly ascribed to teething. At length, after these symptoms have continued for a few days or weeks, a slight crowing sound is occa- sionally heard with the child's respiration. The sound is something between the hoop of hooping-cough and the stridor of true croup; it must be heard to be known, but when once heard will easily be recog- nized. Usually it is first noticed on the child awaking out of sleep, but sometimes it is perceived during a fit of crying, or comes on while the infant is sucking. Now and then the first crow is very loud, and, by its resemblance to the sound of croup, at once alarms the family: but this is not generally the case; and its loudness usually increases in proportion as its return becomes more frequent. The spasm may have been excited by some temporary cause, and the sound which is its token may in that case not be heard again; but generally it returns after the lapse of a few hours, or of a day or two. It will soon be found, as its return becomes more frequent, that certain conditions favor its occurrence; that the child wakes suddenly from sleep with an attack of it, that excitement induces it, or deglutition, or the effort of sucking; so that the child will suddenly drop the nipple, make a 1 Funke, "Lehrbuch der Pbysiologie," vol. i. 2d ed. 8vo. Leipzig, 1858, says in § 35, on the metamorphosis of the blood in the liver: " It is the more correct view to regard the liver as an organ the special function of which is the formation of new blood cells, and to consider the change of the materials which during, and probably in consequence of, that new formation are excreted from the blood into bile, only as its secondary duty." See p. 147. 166 CAUSES AND SYMPTOMS OF croupy sound with its breathing, and then return to the breast again. Throughout the whole course of the affection its attacks will be found to be more frequent by night than by day; and to occur mostly either soon after the child has lain down to sleep, or towards midnight, when the first sound sleep is drawing to a close. At first the child seems, during the intervals of the attack, in as good health as before—except, perhaps, that it is rather more pettish and wilful; but it is not long before graver symptoms than the occa- sional occurrence of an unusual sound with inspiration excite atten- tion, and give rise to alarm. Fits of difficult breathing occasionally come on, in which the child throws its head back, while its face and lips become livid, or an ashy paleness surrounds the mouth, slight convulsive movements pass over the muscles of the face; the chest is motionless, and suffocation seems impending. But in a few seconds the spasm yields, expiration is effected, and a long, loud, crowing inspiration succeeds, or the child begins to cry. Breathing now goes on naturally; the crowing is not repeated, or the crying ceases; a look of apprehension dwells for a moment on the infant's features, but then passes away; it turns once more to its playthings, or begins sucking again as if nothing were the matter. A few hours, or even a few days, may pass before this alarming occurrence is again observed; but it does recur, and another symptom of the disturbance of the nervous system is soon superadded, if it have not, as is often the case, existed from the very beginning. This consists in a peculiar contrac- tion of the hands and feet; a state which may likewise not infrequently be noticed, during infancy, unattended by any spasmodic affection of the respiratory organs, though it is often overlooked, since, unlike the peculiar noise in breathing, it does not force itself on the attention even of the most unobservant. It differs much in degree; sometimes the thumb is drawn into the palm by the action of its adductor mus- cles, while the fingers are unaffected; at other times the fingers are closed more or less firmly, and the thumb is shut into the palm; or, coupled with this, the hand itself is forcibly flexed on the wrist. In the slightest degree of affection of the foot, the great toe is drawn a little away from the other toes; in severer degrees of the affection this abduction of the great toe is very considerable, and the whole foot is forcibly bent upon the ankle and its sole directed a little inwards. Affection of the hands generally precedes the aff'ection of the feet, and may even exist without it; but I have never seen spasmodic contrac- tion of the feet when the hands were unaffected. At first this state is temporary, but it does not come on and cease simultaneously with the attacks of crowing inspiration, though generally much aggravated during its paroxysms. Sometimes a child in whom the crowing inspi- ration has been heard will awake in the morning with the hands and feet firmly flexed, although he may not have had any attack of difficult breathing during the night. At other times, though but seldom, this state will subside during sleep, while very often it is impossible to as- sign any reason for its cessation or return. The hands may often be unflexed by bending the fingers, but they will resume their former position on the withdrawal of the force, and such attempts are painful SPASM OF THE GLOTTIS. 167 to the child. When the contraction is but slight, children still use their hands; but when considerable, they cannot employ them, and they sometimes cry, as if the contraction of the muscles were attended with pain. Coupled with these carpopedal contractions, the back of the hand and the instep are sometimes swollen, tense, and livid, and occasionally there is slight puffiness about the face. This condition is sometimes more general, and on two successive years the same child was brought to me, in whom these attacks of crowing inspiration were accompanied by a state of tense anasarca of the whole body.' The swelling of the hands and feet may be due merely to the impediment to the circulation presented by the continuous spasm, and will then subside of its own accord as the spasm abates. The general anasar- cous condition, of which I have now seen several instances, depends on a different cause. The urine in these cases, if it can be collected, will be found to be albuminous, and underlhe employment of diuretic and diaphoretic medicines, the removal of the dropsy and the abate- ment or disappearance of the spasmodic symptoms will take place together. When the disease has reached a high degree of intensity, a slight crowing sound often attends each inspiration, and the paroxysms of difficult breathing are much more severe; they last longer, and some- times terminate in general convulsions. The breathing now does not return at once to its natural frequency, but continues hurried for a few minutes after the occurrence of each fit of dyspnoea; and it is some- times attended with a little wheezing, from the accumulation of mucus in the trachea and larger bronchi during the paroxysm. When this wheezing is permanent, I do not apprehend that it usually constitutes any essential part of the disease, but regard it either as due to an ac- cidental complication with catarrh, which is so frequent during the period of dentition, or as the result of the affection being associated with tubercle in the lungs or bronchial glands, or it may, perhaps, be owing to a degree of pulmonary congestion, such as takes place in hooping-cough in consequence of the frequent interruption to the regular performance of respiration. The slightest cause is now suffi- cient to bring on an attack of difficult breathing; it may be produced by a current of air, by a sudden change of temperature, by slight pressure on the larynx, by the act of deglutition, or by momentary excitement. The state of sleep seems particularly favorable to its occurrence, and the short fitful doses are interrupted by the return of impending suf- focation. The general condition of the child varies much during the existence of these symptoms, but is always widely removed from a state of health. The bowels are almost invariably disordered, constipation being more frequent than diarrhoea. The mouth is sometimes hot, and the gums are swollen—the child is evidently suffering from the process of teeth- ing; and this is the state with which spasm of the glottis is perhaps most frequently associated. Sometimes there is evident congestion of 1 This case presented a remarkable similarity to one described by Dr. M. Hall, at p. 185 of his work on the Diseases and Derangements of the Nervous System. 8vo. Loud. 1841. 168 TREATMENT OF SPASM OF THE GLOTTIS. the brain, and the face is flushed, the head hot, and the pulse frequent; but these flushes of the face are usually temporary, and the skin is ge- nerally pallid. When the aff'ection has continued for some weeks the countenance often assumes a haggard, miserable aspect; and though it may come on in children apparently in good health, I have never known the health continue good after the disease, even in a mild form, has lasted for any time. Death sometimes takes place during one of the paroxysms of dys- pnoea, the child being suffocated by the long continuance of the spasm ; or at other times the often-repeated difficulty of breathing induces a state of permanent cerebral congestion; general convulsions occur, and the child dies convulsed or comatose, serous effusion having taken place into the ventricles of the brain. Should the child escape both these dangers, and should no tubercular disease of the lungs or bron- chial glands exist, recover^ is almost sure eventually to take place, though the convalescence is often very protracted, and the attack is apt to return under the influence of the same causes as originally ex- cited it. The treatment of spasm of the glottis must be regulated by the nature of its exciting cause; and this, as you have already seen, varies much in different cases. In infants, before the period of dentition, it is usu- ally induced by over-feeding, or by food of an improper kind. Our inquiries, therefore, must at once be directed to ascertain bow the infant is fed; and, supposing it to be still suckled, it will be wise to interdict any other food than the mother's milk—or, at most, to allow only a little barley-water. Spasm of the glottis, however, occurs much oftener in infants who are brought up by hand, or in those who have been weaned, than in children still at the breast. In such cases, much pains are sometimes necessary, in order to ascertain precisely the kind of food that best suits the infant. Two parts of milk and one of barley-water, sweetened with a little loaf-sugar; or equal parts of milk and of a solution of isinglass, made.of the thickness of barley- water, generally agree very well; but much caution must be used in the introduction of farinaceous articles into the child's diet. Asses' milk, which forms the nearest approach to its natural food, must sometimes be given till the child has decidedly improved; while, if it be puny, and do not appear to thrive, and the crowing inspiration continue undiminished, it may become absolutely necessary to restore it to the breast. The state of the bowels requires no less attention than the regulation of the diet. The tendency to constipation must be combated, not by drastic purgatives, but by mild aperients. Castor oil often answers the purpose very well, but sometimes each dose of it nauseates a child for several hours, and then it is not desirable to employ it if a daily aperient should be needed. Both senna and manna are apt to gripe; and if they be found on trial to produce this effect, their use must not be persevered in. E'ew medicines act more mildly or more certainly in children than aloes; and the bitter of the compound decoction may be much concealed by extract of liquorice. The bulk of a medicine, however, often opposes a great difficulty to its employment in infancy ; TREATMENT OF SPASM OF THE GLOTTIS. 169 and if that be the case, the powder may be substituted for the decoc- tion. If slightly moistened, mixed with a little coarse sugar, and placed on the tongue, it will often be swallowed very readily. The habitual use of mercurials to overcome the constipation is not desi- rable: their employment is better limited to those cases in which the bowels are not only sluggish, but the evacuations unnatural in cha- racter. The action of the bowels may be encouraged by rubbing the abdo- men twice a day, with a liniment composed of equal parts of soap liniment and tincture of aloes; or the bowels may sometimes be induced to act regularly in young infants, by the daily employment of a small soap suppository. Enemata, consisting either of warm water or gruel, may also be given for the same purpose. Sedulous attention to the diet and the state of the bowels will some- times effect a cure; but in many instances tonics may be employed with advantage, and probably none with such decided benefit as the preparations of iron. Kemoval to the pure air, however, or to the sea-coast, is often a tonic of greater power in these cases than all the contents of the laboratory, and one which you will find in some instances to be absolutely indispensable to the child's cure. All these cases are not less needed in children in whom the process of dentition has already commenced. In them, however, the irritation to teething is often the exciting cause of the aff'ection, and lancing the gums is frequently needed in addition to the other treatment. The relief thus afforded is sometimes very striking; and the frequent repetition of the operation may be necessary to diminish the swelling and tension, and to ease the pain of the congested gum. It is not, however, a proceeding to be adopted, irrespective of all other con- siderations, simply because the child had begun to cut his teeth when the attack of spasm of the glottis came on. Dentition does not go on continuously from the time when the first tooth is cut until the com- pletion of the whole set, but there are regular pauses in the process, during which its advance is suspended for several weeks together. Thus, for instance, after the appearance of the incisors, there is a pause for several weeks or months before the first molar teeth appear, and then there is another cessation in the process before the child begins to cut its canine teeth. The spasm of the glottis, therefore, may come on during one of these pauses, and be excited by some cause quite unconnected with dentition. Lancing the gums, too, is not well borne in every case, even when it may have appeared to be indicated; and I have more than once been compelled to discontinue it, on account of the pain and alarm which it excited, bringing on a violent spas- modic seizure whenever I attempted to practise it. In some instances the spasm of the glottis is associated with mani- fest uneasiness in the head. It has been suggested that, in some of these cases, the brain is kept in a constant state of irritation, owing to the deficiently ossified skull being too thin to define it from injury, while at the same time it affords no adequate counter-pressure to check the over-distension of the cerebral vessels. There is no doubt but that rickety children are peculiarly liable to this aff'ection ; and though 170 GENERAL MANAGEMENT OF the constitutional condition of such children has certainly much to do with its production, yet the imperfect bone formation of the cranium probably has a share in such cases in aggravating it. I have seen many instances in which the recommendation that a horsehair cushion should be made for the head to rest on, having a hole in its centre, so as to relieve the occiput from all pressure, has been acted on with manifest advantage. The supervention of attacks of spasm of the glottis, in a case of well-marked chronic hydrocephalus, would call for little change in the treatment, though it must evidently add much to the danger of the patient. Symptoms of cerebral congestion are sometimes associated with this condition. They are seldom such as to call for active interference; but the tepid bath and neutral salines, with small doses of hyoscyamus,1 are often of much service in quieting the general excitement of the circulation, while the occasional application of a leech to the head may be beneficial, especially if general convulsions are beginning to super- vene on the attacks of dyspnoea. It is possible that you may meet with a case in which active deple- tion is indicated, and you must not allow the consciousness that, as a general rule, it is inappropriate, to prevent you from having recourse to it in such exceptional instances as the following. In this case, indeed, it was found necessary to carry depletion beyond that point which is in general expedient in so young a child. Some years since I saw a little boy, 1\ years old, who had already suffered from several attacks of spasm of the glottis. A return of the affection had taken place about seven weeks before, though not attended by any very alarming symptoms until after the lapse of a month, when a general convulsive seizure occurred. From this he recovered, and he had for some days appeared to be convalescent from the spasmodic attacks, when his bowels became disordered, and a good deal purged, and after they had been so for two or three days his mother noticed one afternoon that his thumbs were forcibly drawn into the palm of his hands. With the exception of this contraction of his thumbs, however, he seemed as well as usual and had a tolerably good night; but immediately on awaking at six o'clock on the follow- ing morning he had a paroxysm of stridulous breathing, in which he crowed so loudly as to be heard over the whole house. His face at the same time became greatly flushed, and his hands and feet con- tracted, as they were when I visited him three hours afterwards. His face was then much flushed, his head hot, his pupils rather dilated, his pulse full and bounding; his thumbs were drawn across the palm; the fingers were not closed, but the hands were forcibly flexed on the wrist; the great toe was drawn far apart from the other toes, which were flexed, and the whole foot was stiffly bent on the ankle. The child was then breathing quietly, and seemed drowsy; but he screamed out the moment he was touched, as if the least disturbance of his limbs gave him pain. Eight leeches were applied to his temples, and drew much blood, 1 See Formula No. 2, p. 54. CASES OF SPASM OF THE GLOTTIS. 171 but without producing any amelioration of his condition. A croupy sound continued to attend his respiration, and he had a fit of urgent dyspnoea, with loud stridulous breathing, between my first visit at 9 in the morning and my second at five in the evening. I now bled him from the arm to |vj, which subdued the fulness of the pulse, blanched his lips, and diminished the flush of his face, though it did not cause actual fainting. I ordered cold to be applied to the head, and saw him again at 1\ P. M., when I found that he had been lying quiet ever since I left him, and had had some tranquil sleep, without any crowing sound attending the breathing. His pulse was less full, the flush of his face was diminished, the heat of the head was gone, and the contractions of the hands and feet were both less, and less firm. A powder with gr. j of calomel and gr. viij of rhubarb, which had been given in the morning, and had produced one evacuation, was now repeated. The child had some sleep in the night, and no access of dyspnoea returned, nor did the croupy sound again accompany the inspiration. In the course of the day the spasmodic contractions of the hands and feet greatly diminished, and the child became cheerful. In five days from this formidable attack he was quite well, and continued so for a year, when a slight return of spasm of the glottis took place, in the course of a severe impetiginous eruption on the scalp. Before concluding this lecture, I will suggest a few cautions, appli- cable alike to all cases of spasm of the glottis. Sudden excitement, and especially a fit of crying, are likely to bring on the attack, and since there is a possibility of any one of these attacks proving fatal, the greatest care must be taken in the management of the child to avoid all unnecessary occasions of annoyance or distress. Although the benefit that accrues from fresh air, or from a change of air, is often very great, yet it is very important that the child should not be exposed to the cold or wind, for I have seen such exposure followed by a severe attack of dyspnoea, or by the occurrence of gene- ral convulsions. The hazard of such an occurrence is greater in pro- portion to the severity and long continuance of the aff'ection; and, in such cases, the excitability of the spinal cord and the irritability of the surface, seem sometimes to become as great as they may be ob- served to be in frogs when narcotized, whom you may then throw into convulsions by merely shaking the table on which they are placed. It is possible that this condition in the infant may be due to a cause not unlike that which produces it in the lower animal. In the latter, it is manifestly due to the influence on the nervous system of blood impregnated with opium; in the former, a similar influence may be exerted by blood the proper depuration of which has been prevented by the frequent recurrence of spasm of the glottis. There is also another reason for caution in exposing the child to cold or wind, namely, that the occurrence of catarrh is almost sure to be followed by an aggravation of the spasmodic affection. On more than one occasion I have seen the supervention of catarrh convert a 172 PECULIAR FORMS OF CONVULSION. very mild into a very serious attack, and once the exacerbation of the symptoms thus produced was the cause of the iniant's death. The parents should in every instance be made fully aware of the uncertainty that attends this affection—of the possibility of death taking place very suddenly and unexpectedly. In the paroxysm itself but little can be done. Cold water may be dashed on the face, and the fauces may be irritated, or the finger passed down into the pharynx, so as to bring on, if possible, the effort to vomit, while at the same time the legs and lower part of the body may be placed in a hot bath. The remarkable observations of MM. Braun and Chiari1 on the em- ployment of chloroform in puerperal convulsions, and a short paper by Dr. Simpson, of Edinburgh,2 on its utility in the convulsions of children, drew my attention to it, and I have tried it extensively, and in many instances with advantage. In cases where depletion is inad- missible, where the convulsions are not obviously due to organic dis- ease of the brain, while they are both severe in their character and are returning with frequency, the inhalation of chloroform sometimes altogether arrests them. It is also of service in attacks of a more chronic kind, in which, though convulsions are less violent, yet the irritability of the nervous system is extreme, and every change of pos- ture, and every attempt at deglutition, are followed either by threat- enings of a fit, or by actual convulsions. Its efficient use, however, is not easy to secure, since it requires the constant presence in the house of some one competent to administer it; while if intrusted to the pa- rents or to a nurse, the fears of the former and the want of intelligence of the latter generally render its employment merely nominal. Even when most skilfully administered, too, the efficacy of the remedy soon ceases, if, from the return of the convulsions, the necessity should arise for its being given at very short intervals. In these circumstances the narcotism soon becomes very partial, and the fits recur altogether unmitigated by it—a result which I have also observed in puerperal convulsions. I have never seen mischief follow from its use; but its power of doing good seems usually to be more evanescent than that of other sedatives. There are still a few points connected with the derangements of the nervous system in early life which require a brief notice before I close this lecture. And first, with reference to cases, happily rare, of violent, causeless, and fatal convulsions in early life, independent of disease of the brain. Such attacks are very unusual after the completion of den- tition; sometimes they occur without anyapparent exciting cause, but more frequently they follow on some slight error in diet, or on slight exposure to the heat of the sun, or on the drying up of some cutane- ous eruption, or of some long-existing strumous sore. They are cha- racterized by the violence of the convulsive movements, by the depth of the coma which succeeds to them, and by the very rapid failure of the child's powers. I think, too, it may be said, that convulsions • Klinik der Geburtshiilfe, etc., part ii. p. 249, 8vo. Erlangen. 1853. 2 Obstetric Works, vol. ii. p. 470, from Ed. Monthly Journal, January, 1852. ECLAMTSIA NUTANS. 173 attended by such circumstances warrant more serious apprehension in children of three or four years old than in infants of a year or eighteen months. For this the reason doubtless is, that at an age when the nervous system is less susceptible than in infancy, an attack of this kind implies a graver disturbance, and one less likely to pass away. Death in these seizures seems to take place, not from sudden asphyxia, as in spasm of the glottis, but from the slower influence of the perpetual disturbance of the respiratory process, or from exhaustion of the ner- vous powers, just as one sees it do in cases of puerperal convulsions; the skin becoming colder, the pulse more feeble after each attack, and complete collapse being induced within twenty-four, sometimes within twelve hours from the first seizure. With reference to the share which is borne by the imperfect aeration of the blood in destroying the pa- tient in some of these cases, M. Trousseau1 makes some remarks, dis- tinguished by his usual acuteness. He notices that the state is not dissimilar from that of a person on whom tracheotomy has been per- formed in the extreme period of croup. The obstacle to the entrance of air may have been removed by the operation, but the consequences of the previous long-continued interruption to the aeration of the blood remain, and they gradually destroy life. Just in the same way the often-repeated convulsions bring with them great disturbance of respi- ration and circulation, and scarcely is one fit over when a second and a third return, and leave no time for breathing and the heart's action to resume their regular course. " Thus it happens that when at length a state of calm succeeds to the attack, even though respiration may seem to be regular, it is a delusive calm, and the child dies some hours later without any fresh convulsion, without marked oppression, with- out the appearance of any new symptom of importance. He dies, if I may be allowed to say so, not of actual asphyxia, but of the results of asphyxia." Far less hopeless are cases, with which we also meet occasionally, of the exceedingly frequent recurrence of convulsions; five, ten, or more taking place every day, for days or weeks together. Such attacks are seldom or never met with after the completion of denti- tion. The danger to life seems to lessen with the frequency of their recurrence, but there is hazard lest they should end by becoming habitual; while, further, there seems to be a very decided relation between the liability to convulsions in early infancy, and the develop- ment of epilepsy in subsequent childhood. One word, in conclusion, with reference to that peculiar form of convulsion, to which, from the movements that characterize it, the name of Eclampsia Nutans,2 or the Salaam convulsion, has been given, and in which some observers have thought they recognized the signs of a special disease. Infants and children affected by it bow the 1 Clinique Medicale de l'Hotel Dieu de Paris, vol. ii. 8vo. Paris, 1862, p. 95. 2 Four cases of this affection were described by Mr. Newnham in the British Record of Obstetric Medicine, March, 15, 1849 ; two are related by Dr. Faber, in J. f. Kinderkr., vol. xiv. p. Hb'O ; two by Dr. Ebert, Annalen der Charite zu Berlin, 1850 ; one by Dr. Willshire at a meeting of the Westminster Medical Society, March, 1851; and prob- ably others may be found in the medical journals. 171 PECULIAR FORMS OF CONVULSION. head and bend the body slightly forward, a movement which is repeated with great rapidity, sometimes twenty, fifty, or even a hun- dred times, and then ceases, but returns once or oftener in the twenty- four hours. During the attack the child seems bewildered, but com- plete consciousness returns as soon as the movements end; and in one case which was under my care, the infant seemed relieved, and quite bright and happy the moment that the movements ceased. In con- nection with these attacks, there is a general failure of health, and enfeebling of the mental powers, but they do not tend to destroy life, nor are they connected with any special form of cerebral disease, nor have they any invariable issue. Their tendency, however, unquestionably is, to pass into confirmed epilepsy; and the bowing of the head seldom lasts for more than a few weeks without some other convulsive movement becoming asso- ciated with it. Often it is a slight convulsive movement of one or other arm, but attacks of general convulsions occasionally intervene, and at last they take the place almost or altogether of the previous bowings of the head, and the case becomes one of ordinary epilepsy, with in general very considerable impairment of the intellect. Just the same course, however, is observed to be followed by other partial convulsions, though such convulsions seldom attract attention by their singularity to the same extent as the Eclampsia Nutans. Some years ago, however, I saw an infant, seven months old, in whom attacks of an oscillatory movement of the head from side to side came on just in the same manner, and associated with the same impairment of the general health, as usually attends the Salaam convulsion. The rarity of the latter affection, too, consists not in the nature of the movement, but in its frequent repetition, and I have often observed the first sign of incipient epilepsy in the child to be a sudden bowing downwards of the head, instantaneously recovered from, and just attracting notice by the bruising of the forehead, which had struck against a table or chair. Next this bowing ceases to be confined to the neck, and the child falls forwards on the ground, though still the attack is so momentary, that it rises again immediately, and it sometimes is not until after an attack of general convulsion has awakened the anxiety of relatives, that any meaning begins to be attached to what was long supposed to be merely the effect of a child's heedlessness, or of its not having thoroughly learnt to walk. Such cases are but a few illustra- tions of the fact so often-insisted on, that in the study as in the treat- ment of the diseases of early life, nothing is too trivial to notice—that the slightest occurrences often have the gravest import. CAUSES OF EPILEPSY. 175 LECTURE XIV. Epilepsy—its causes—illustrative tables—its general character and influence on the mind. Circumstances which must regulate our prognosis. Treatment—futility of specifics— general management—employment of belladonna. Chorea—not exclusively a disease of childhood—causes which influence its occurrence— its relation to rheumatism. Symptoms, prognosis, and treatment. Partial chorea. We yesterday studied the convulsions of early childhood in their gravest aspect, as immediately threatening life: but a painful interest attaches to them independent of the anxiety which they excite lest they should prove immediately fatal. There is the dread of their persistence, or of the child being left with his nervous system so shaken that fits may recur at some later period; that convulsions in infancy or childhood may issue in epilepsy in youth or manhood. Nor, indeed, does this seem to be a groundless fear, for of 68 cases which form the basis of M. Herpin's1 elaborate work on epilepsy, 17 or 25 per cent, date from the first five years of existence; and of 63 cases that came under my own observation in young persons under the age of 14 years, 38 dated back to the first four years of life, 20 occurred between the ages of 4 and 10, and 5 between 10 and 12. TABLE, Showing Age of Patients at Commencement of Attacks of Epilepsy. Age at Commencement. Male. Female. Total. Under 6 months 4 4 8 Between 6 and 12 months 5 3 8 " 1 " 2 years 6 6 12 2 " 3 " 2 5 7 " 3 " 4 " 2 1 3 " 4 " 5 " 2 3 5 " 5 " 10 " 7 8 15 " 10 " 12 " 3 2 5 - 31 32 63 In the above table the alleged age at the commencement of epilepsy does not represent that at which some isolated convulsion may have occurred, but the age since which there had been a succession of fits coming on at intervals more or less regular, and without the inter- vention of any fresh exciting cause. It will be seen that in nearly a fifth of the eases the attacks date back to very early infancy, to a time when the ordinary exciting causes of epilepsy have as yet not come into play, when we must seek for the origin of the disorder in some 1 Du Pronostic. etc., de l'Epilepsie, Svo. Paris, 1852, p. 336. 176 CAUSES OF EPILEPSY. conditions profoundly affecting the general nutrition, not in such as specially act upon the nervous system. But the gravity of those apparently causeless convulsive seizures which sometimes occur in very early infancy is still further seen, if we bear in mind that in many other cases where epilepsy is stated to have come on during dentition, or even at some later period of childhood, it will be found, on close inquiry, that many of the patients had suffered from convul- sions in early infancy, although a period of months or even of years may have passed without their return ; and the very fact may have been forgotten until your inquiries recall it to the parent's recollection. In 6 of the cases hereditary tendency to epilepsy was admitted to exist;1 and I have no doubt but that its real frequency is far greater than the friends of our patients admit; and in not a few instances, especially of the earliest occurrence of epilepsy, a strict inquiry will elicit that other children have had fits during teething, or have suffered from chorea, or that mental peculiarities, more or less remarkable, have been observed in different members of the family. A distinct exciting cause for the attack was assigned in 1 only of the 12 cases in which the fits dated back from the first six months of life; and in that instance they were said, with what truth I know not, to have fol- lowed inflammation of the brain. In 33 of the remaining 51 cases, or in about two-thirds of the num- ber, the attacks were said to have been induced By fright . . . . . . . . in 3 instances. ' injury to the head......2 " 1 a fall........1 " ' weaning ....... 1 " ' errors in diet ...... 1 " gastric disorder ..... . 2 " vaccination ....... 1 " ' scarlatina coming on during convalescence . 2 " 1 anger ........ 1 " ' first dentition ......18 " ' second dentition . ..... 1 " In one of the above cases the epileptic attacks which came on during the first dentition ceased with its completion, and did not recur until the commencement of the second dentition, when they returned frequently and severely. The statement of the alleged causes of epilepsy is imperfect, to a great degree no doubt inaccurate, but still the coincidence of the attacks in 18 of the 33 cases with the active progress of teething deserves to be borne in mind as a fresh illustration of the peculiar excitability of the nervous system at that important period of development. In the cases on which my remarks are founded I have not included instances of mere epileptic idiots, in wjhom the occurrence of fits was only a subordinate and often a secondary manifestation of the general disorder of the nervous system. In childhood, however, as surely and even more speedily than in the adult, the return of epileptic 1 Herpin, op. cit., p. 328, estimates the frequency of epilepsy at from four to five times greater in the family of epileptics than in the population at large. CHARACTERS OF EPILEPSY IN CHILDHOOD. 177 attacks impairs, and at length even completely abolishes, the mental powers. In 5 boys and 5 girls the weakness of the mind amounted to idiocy, which in the case of 1 girl was associated with occasional attacks of maniacal excitement; and in 2 other girls epilepsy coexisted with peculiarities of manner and disposition, such as appeared to me to justify their being regarded as an instance of moral insanity. In 17 other cases the child was either duller than the average of children of the same age, or, more painful still, the early dawn of intellect was becoming gradually overclouded with the recurrence of the epileptic seizures, and in 3 of these 17 cases the blunting of the mind was associated with perversion of the character with violence or obstinacy. Though these cases are unselected, it is yet possible that they present a darker prospect, with respect to affections of the mind in connection with epilepsy in early life, than reality will warrant; but even though it be so, there is yet enough in them to justify us in regarding this disorder with the greatest anxiety and apprehension. There is, indeed, one peculiarity in the mind of children which should never be lost sight of, when we endeavor to estimate the in- fluence of disturbing causes upon it; namely, that it is undeveloped, and that having but partially and imperfectly acquired its powers, it is consequently more easily obscured than in subsequent life. In 6 of the 14 cases in which the affection of the mind was most considera- ble, the attacks commenced within the first year, in 7 within the first three years; and in 1 only was the child turned 7 years of age when she became subject to epilepsy. In 4 of the 13 cases in which the mind was less gravely affected, the attacks began under the age of 1 year, in 2 under the age of 2 years; 4 children were 4; 1 was 8, and 2 were 9 years old when the epileptic attacks commenced. I may add, that none of the children of whom I am speaking had reached the age of 14 years. It seems, indeed, as if the inference which these facts suggest held good to even a greater degree than one might at first imagine; and as if we might state as a general rule that, in pro- portion as epilepsy comes on early, will the chances of its being asso- ciated with serious disorder of the mind be increased. M. Cazauvieilh,' in his elaborate essay on the connection between epilepsy and insanity, states as the result of a comparison between 26 female epileptics in whom the disease preceded menstruation, and 26 in whom its occur- rence succeeded it, that in 19 of the former, and in only 10 .of the latter, it was associated with insanity. This fact is always to be borne in mind when consulted about a case of epilepsy in early life, since it obviously must exercise a great influence upon our prognosis. To the best of my knowledge, the general characters of epilepsy in childhood agree closely with those which it presents in after life. I have observed the petit mal, as it is termed, continue in children for a period of several months, and finally issue in regular epileptic seiz- ures. In the child, I have sometimes noticed the loss of consciousness during the seizure to be imperfect, and this in spite of very marked convulsive movements; fits, with complete insensibility, occurring 1 Archives Gen. de Medecine, Janvier, 1826, p. 43. 12 178 CHARACTERS OF EPILEPSY IN CHILDHOOD. occasionally in the same patient, and being of longer duration, though not attended with a greater amount of convulsion, than those in which the loss of consciousness was incomplete. In one instance, attacks of apparently causeless alarm, accompanied by much excitement and incoherent talking, passed in the course of a few months into regular epileptic seizures; in another instance, a girl who came under my care at the age of 10 years and 10 months, had had an attack of general convulsions when 8 years old, for which no cause could be assigned. Since that time she had been liable to occasional attacks of strange excitement of manner; and these had for six months been attended with a sort of cataleptic condition, in which she stood motionless for a minute or two, wildly staring at vacancy, and uttering a few inco- herent words, which apparently had reference to some object she saw, though she could not be induced to describe her imaginings. Eleven months after the commencement of these attacks their peculiar charac- ter disappeared, and she began to have regular epileptic seizures, while, in the intervals, her actions and manner, though often rational enough, were frequently those of an insane person. In a boy aged 9, in whom for a year epileptic fits had occurred causelessly, and with a rapidly increasing frequency, until at length three or four came on weekly, and sometimes more than one in a day, a sort of maniacal excitement seized him occasionally, in which he struck other children, though they had given him no provocation. These manifestations of mental disorder are precisely analogous to the momentary delirium observed in the epileptic adult, during which the patient commits some act of gross impropriety, or attacks his friends or attendants, or some bystander, with savage fury, and recovers his consciousness a minute or two afterwards, to learn with horror the act which he has committed.1 They are, as might be expected, most observable in cases in which epilepsy has not come on till about 5 or 6 years of age, or somewhat later:—the convulsions which date from early infancy lead to a more complete obscuring of the mind, and the cases in which they have occurred often present themselves to us as instances of idiocy complicated with epilepsy, rather than as cases of epilepsy producing disorder of the mind by their frequent return. I do not know that the age of the patient makes any important difference in the characters of the epileptic seizure. They seem to be the same, in all essentials, in the child as in the adult. The aura epileptica is often described of their own accord by children ; though many are of course too young to explain their sensations, and others, with the strange tendency to exaggeration which one often observes in early life, seeing that their story is listened to with attention, will dress it up with such details as to their young imagination seem almost wonderful. In some cases the attacks begin invariably with convulsive movements of one limb. Thus, in a little boy who was some time since in the hospital, 1 With reference to the relation between epilepsy and affection of the mind, there are some important observations by M. Trousseau in his Clinique Medicale, vol. ii. pp. 23 and 28; and by M. Falret, in Archives de Med., 1860, vol. ii. p. 661; 1861, vol. i. p. 461, and vol ii. p. 421. PROGNOSIS IN EPILEPSY. 179 the attacks always began with painful convulsive movements of the right hand, which he seized with the left and endeavored to keep still. In a few seconds or a minute these movements ceased ; the tonic spasm came on, and then the general convulsive movements as in an ordinary epileptic seizure. These peculiarities seldom last for very long: some- times for a season one limb is habitually the first to be affected, some- times another; or the fits invariably predominate on one side, and then, with no other changes in the patient's condition, the attack will com- mence in another limb, or predominate on the other side. Stupor more or less continued, or a heavy sleep, usually follows the attack, but now and then a state of excitement precedes the sleep; a noisy delirium which, but for the tender age of the patient, would be identical with the temporary mania which sometimes follows the epileptic seizure in the adult, and renders him for the time one of the most dangerous class of insane patients. The question is often put to us in practice as to the probability of fits terminating in epilepsy; or, on the other hand, as to the ground for hope in any case that epileptic attacks which have already fre- quently recurred will evidently cease. With reference to neither of these inquiries, however, are we in possession of data such as to enable us to give an answer with much certainty. I do not think that those fits of which spasm of the glottis is a prominent symptom, often pass into confirmed epilepsy; long-continued struggling is not a character- istic of them, but more often drowsiness or stupor immediately succeed- ing to the fits, and heaviness and dulness continuing for some hours after them. It is not the violence of a single fit, nor even the frequent return of fits for a limited time, which warrants the gravest apprehen- sion. It is the recurrence of fits, when all observable cause of irrita- tion has passed away; it is their return when the patient is otherwise apparently in perfect health; and hence it is that the statement has been made that attacks of the petit mal warrant a graver prognosis than the violent convulsion. As to the prospect of epileptic seizures ceasing at puberty, I fear that the hope is a very groundless one. It is scarcely to be expected that a new period of development should be attended by anything else than a fresh excitement, and an increased disturbance of the nervous system; so that there is more reason for anticipating a deterioration in the patient's condition, than for ex- pecting an improvement from the changes of puberty. It is true, that if epileps}' comes on while dentition is in active progress, we may hope for, though we cannot with certainty calculate on, amendment when teething is accomplished; and though I have no statistics bear- ing on the subject, yet my impression is, that I have oftener known epilepsy cease spontaneously between the fourth and sixth years than at any other period. In the same way, if epilepsy occur during the changes that usher in puberty, we may look forward with some degree of cheerfulness to the time when all of those changes shall have been completed. In each of these cases, however, it is not the period of excitement, but the season of repose, on which our hopes are founded ; while, to leave the case untreated, in the vague expectation of what at a certain critical epoch of life the healing power of nature may be 180 TREATMENT OF EPILEPSY. able to effect, would be to trifle alike with our own reputation and with our patient's prospects of recovery. The first point in every case is obviously to make out, if possible, the cause on which the fits depend; or to ascertain, by the most minute observation and inquiry, the peculiarities of health with which their occurrence is associated. The diet, the bodily exercise, the mental pursuits, all need the most rigid investigation f the condition of the bowels, the state of the evacu- ations, require to be most carefully examined ; and the fact of the first dentition having been accomplished is no adequate reason for omitting to watch the process of teething most sedulously. I have seen one or two instances in which convulsive attacks of an epileptic character attended the cutting of the permanent molar teeth ; and illustrations of this fact (to which Dr. Ashburner1 was the first to call attention) are to be found in all our medical journals. In proportion as the fits admit of being traced with probability to causes of a remediable character, may our prognosis be favorable. The severity of the fits is a matter of less importance with reference to prognosis than the frequency of their occurrence; and the oftener they recur, even in a mild form, or the more frequent their forebodings, such as dizziness, or momentary stupor, the less is the prospect of their cessation. In forming our prognosis, also, regard must be had to the state of the child's mind in the intervals between the fits; and the less the intellect seems to be dulled, or the moral faculties perverted, the more encourag- ing may be our opinion. In judging of this last point it is well to bear in mind that a child who has been liable to any such affection is almost sure to be backward in learning; very likely to be wayward in temper, for his friends will have been afraid to overtax him with work; and they will probably, from fear of crossing him, have indulged many of his caprices. We must judge of his intellect, less by the child's amount of actual knowledge, than by his power of answering simple questions concerning things familiar to him; and must draw our conclusion as to the state of his moral faculties from his general childlike character, his fondness for the same pursuits, his showing the same dispositions, manifesting similar attachments, having similar good and bad qualities to those which we observe in other children of his own age, or a few years younger. With reference to the treatment of epilepsy, I know of no specific for it; and the much-vaunted oxide of zinc has proved as powerless in my hands as in those of most who have tried it on the strength of the high encomiums bestowed on it by M. Herpin. I fear, indeed, that it will not be in the search for specifics that we shall light upon the appropriate treatment of a disorder which depends upon causes so almost numberless as epilepsy. We meet every now and then with cases in which some profound impression on the nervous system has been followed by temporary cessation of the fits, and with others in which they seem under the influence of such a cause to have been permanently cured; but the difficulty is how to apply such observa- tions in practice. A girl aged ten years, was admitted into the Child- 1 In his work " On Dentition and its Coincident Disorders," 12mo. London, 1834. TREATMENT OF EPILEPSY. 181 ren's Hospital, suffering from epilepsy, fits of which occurred about seven times in a week. These fits were said to have affected her -for a considerable time, though the history given of her was very imper- fect. After a month's stay in the hospital, during which time twenty- four fits occurred, she was attacked by typhoid fever of a mild charac- ter, accompanied by abundant rash, but which ran its course in twenty-one days, unattended by any complication. During the whole course of the fever the fits completely ceased; but on the thirty-first day from the first complaint of frontal headache and first accession of fever the fits returned, assumed their former severity, and returned afterwards with their former frequency. A boy, ten years old, suffered from occasional attacks of petit mal in February. In the following August the attacks became regular epileptic seizures, which increased in frequency, and in the succeeding March returned several times in a day, and were accompanied by marked impairment of his mental powers and by an unsteady and tottering gait. After a two months' trial of various remedies, and the insertion of a seton in the back of his neck, he left the hospital worse than on his admission. On June 13th he fell in, a fit, and struck his occiput a violent blow. A large abscess formed there, which burst of its own accord, continued dis- charging for a few days, and then healed up. It is just two years since this accident happened, and from that time to the present there has been no return of fits; the boy has regained his power of walking, and has all the intelligence and cheerfulness that befit his years. These cases are of interest, they forbid us to despair even when there seems least ground for hope; but I fear they give us little help in our search after remedies, for how are we to obtain any therapeutic agent as far reaching as the poison of typhoid fever, which yet exerted but a tem- porary influence, or how can we safely imitate the profound shock of the accident concerning which, too, we do not know whether its salu- tary influence was due to the blow or to the suppuration that followed it? There is of course the most ground for hope, and the fairest opportunity for treatment, when the attacks can be referred to any obvious, or even probable exciting cause. Our first attempts must be directed to its removal; and according to its nature, depletion may or may not be indicated; or the administration of alterative or purga- tive medicines may be desirable, and now and then some wisely chosen remedy may in these circumstances remove, almost as if by magic, the cause and its effect together. Unfortunately, howeverjn a large number of instances, no definite cause is discoverable, and we are thrown en- tirely upon general principles for the regulation of our conduct. As violent and sudden excitement of any kind will often bring on an epi- leptic seizure, so the influence of the opposite condition in warding off its attacks is very remarkable; and on several occasions I have received patients into the Children's Hospital, who were reported to have epi- leptic seizures several times in a week, and who nevertheless remained a fortnight or more in the institution without any attack coming on. The qu?et, however, which suits the epileptic is not the quiet of list- less, apathetic idleness, but the judicious alternation of tranquil occu- pation and amusement. The mind must not be left to slumber, from 182 TREATMENT OF EPILEPSY. the apprehension of work bringing on a fit, but the work must as far as possible be such as to interest the child. It is an observation often made, that adult epileptics who follow dangerous trades, as that of a bricklayer, for instance, scarcely ever have attacks when occupied in their pursuit; and children are rarely seized when at play, but oftenest either when in bed at night, or before getting up in the morning, or when sitting quiet in the evening, tired and unoccupied. The good results, too, which I hear have followed the introduction of gymnastic exercises among the epileptic patients at the Bicetre, in Paris, point in the same direction. In the occupations of epileptics, therefore, such pursuits as not merely employ the mental faculties, but also give work to the hands, such as gardening, carpentering, or the tending of animals, are especially to be recommended; and if by these the mind can be kept awake, the grand object of teaching is answered, and backwardness in reading, writing, or those kinds of knowledge which other children at the same age have acquired, is of very little moment. Many epileptics have an indistinct articulation, and almost all have a slouching gait and an awkward manner. The former can often be corrected to a considerable degree by teaching the child simple chants, which are almost always easily acquired, and practised with pleasure. The latter may be rectified by drilling, not carried into tedious minutiae, but limited to simple movements, and the irksomeness of drill is almost completely done away with by music; while I believe that the accustoming a child to the strict control and regulation of all its voluntary movements is of very great importance indeed as a cura- tive agent. Many of these measures could be much better carried out in class than by the child alone, and whatever may seem at first to be the objections to the association of epileptics, I have no doubt but that they would be more than compensated for by its advantages. Epileptic children cannot be educated with such as are healthy—partly for the sake of the latter, but at least equally so for their own; since the different regulations to which they must be subjected, the differ- ence in their education, their amusements, and often in their diet, would be to them a source of ceaseless distress. If educated alone, however, not only do they lose all the advantages of association with other children, though both intellectually and morally this is of great moment, but also they become, far too obviously for their own benefit, the centre around which everything in the household turns, while rules become doubly irksome when apparently made for themselves alone, and not part of a general system to which others besides have to submit. These advantages, however, are not at present to be ob- tained, and we are compelled to put up with the more imperfect carry- ing out of our directions, either at the patient's home, or, still better, under the superintendence of some competent person who devotes the whole of his time to the care of the child. The diet should be mild, nutritious, but unstimulating, and, as a general rule, should include meat comparatively seldom, and in small quantities. I have certainly seen epileptic fits increased both in fre- quency and severity by an abundant meat diet, and diminished in TREATMENT OF EPILEPSY. 183 both respects when a diet chiefly of milk and vegetables was adopted.1 This diet, however, must not be adopted invariably, nor in disregard of the patient's general symptoms. In feeble children with cool skin, soft pulse, languid manner, and deficient energy, a generous diet with wine, and the mineral acids with quinine, or small doses of zinc or iron, have certainly proved of service, not only in improving the gene- ral health, but even in lessening the frequency of the occurrence of the fits. When the approach of a fit has been usually preceded by stupor, or headache, or drowsiness, I think that I have sometimes warded off its occurrence by putting a few leeches on the head ; but epilepsy is not to be cured by systematic bleeding, nor by systematic purging, nor, I may repeat, by any of the various medicines which at different times have been employed for its cure, and the very number of which is perhaps the best proof that could be adduced of the inefficacy of all. There is one remedy, belladonna, which must not, however, like the rest, be passed over without especial notice, for all the more recent writers have agreed in its praise. M. Trousseau says that he has been " less unsuccessful with it than with any other remedy ;" and the great acuteness and profound study of Dr. Brown-Sequard yet taught him nothing better than the one unvarying prescription of'belladonna, or of its equivalent atropine, in the treatment of epilepsy. I cannot, in- deed, say that I have met with any successes from its use, though I think I have seen the frequency of the return of the fits somewhat diminished, but then I have never had the opportunity of continuing its employment steadily for several months, or even of keeping a child for any long period under my observation—an evil which attaches almost invariably to what is called consultation practice in London, and makes it, in spite of one's best endeavors, so barren in results. Trousseau attaches importance to the remedy being continued not for months but for years, to its being given daily at the same time, either in the morning or in the evening, according as the attacks are more frequent by day or by night, to its gradual increase until exces- sive dilatation of the pupils and great dryness of the throat indicate that a dose has been reached beyond which it will not be wise to pass. The rate of increase of the dose must be determined by the patient's power of bearing the remedy, and if that be but slight, it must be in- creased only every two, three, or four months. " When the attacks appear to be somewhat influenced by the remedy, the dose last given is to be continued for some time, then to be dimi- nished slowly and by reversing the scale according to which it was originally increased. An attempt may then be made to suspend it for 1 My attention was first drawn to the importance of abstinence from a meat diet in epileptics by Dr. Maxwell, formerly resident physician to the Asylum for Idiots. This caution, too, gains still greater weight from the testimony of Dr. Jackson, of Boston, in America, who, in his " Letters to a Young Physician," 12mo. Boston, U. S., 1855, p. 67, insists very strongly on its importance. As already stated, I have little faitli in the influence of mere drugs; but I have a yearly increasing confidence in the influence of diet, judicious management, aud mental and moral as well as physical hygiene in epilepsy occurring in early life, independent of hereditary predisposition, and unconnected with approaching puberty. 184 TREATMENT OF EPILEPSY. a time, resuming it once more after an interval, the length of which must depend on the persistence of the patient's improvement. " I cannot repeat to you too often that patience, on the part alike of doctor and patient, is the capital condition of success. A whole year is sometimes scarcely long enough to make us acquainted with the influence of belladonna, and if in the second year some amendment should appear, we must persevere for two, three, or four years, accord- ing to the rules which I have laid down, and so as to bring the nerv- ous system completely under the influence of the remedy."1 But if the cause of epilepsy is so deeply seated that it yields even in the most favorable cases only to months or years of the employment of the most powerful remedy, it may be inquired whether there are no means of mitigating the severity, or warding off' the occurrence of individual attacks. Something, though I fear not very much, may be accomplished. It suffices occasionally, in attacks of the petit mal, to call to the patient in order to cut short at once the condition which might otherwise last for half a minute, and even after actual convul- sions have begun to characterize the epileptic fit, I have, in children, seen it equally arrested in the same way. A certain attitude in bed will sometimes bring on a fit on the child waking from sleep, and its careful avoidance will postpone the occurrence. The principles im- plied in suddenly arousing the attention, and thus stopping the fit, may be carried further, and the immediate application of a tight liga- ture, as a twisted handkerchief, for instance, around the arm or leg, will sometimes entirely arrest a commencing fit, though more fre- quently it will only postpone it for a few minutes. It is on the same principle that cold water, thrown in the face, will sometimes retard a fit, or even prevent it, and so long as any of these measures check or mitigate the attacks, they may be persevered in. A trial of chloroform naturally suggests itself to us as a means of mitigating the severity of the attacks. Its influence is too slow to prevent the seizure, for, as you know, to the momentary bewilderment succeeds the tonic spasm, and on that follows the convulsion with the imperfect respiratory movements that attend it, during which the lungs are filled but imper- fectly, and the inhalation of chloroform must be very incomplete. Usually, therefore, a convulsive attack would pass away of its own accord long before the influence of the anaesthetic had been produced. In long-continued convulsions, however, I know of no objection to its use, and it certainly is something gained if we can control the violent convulsions, and secure thereby the better performance of respiration —ends which we can usually attain, though I have found that with each repetition of the chloroform its influence becomes harder to pro- duce, and tends to pass away more quickly. Almost every lecture has furnished some fresh illustration of that connection between the development of an organ or a set of organs, and their liability to disorder which characterizes the diseases of early life. The growing brain is readily overfilled with blood, readily emptied of it; cerebral congestion, cerebral hemorrhage are frequent, 1 Trousseau, op. cit., p. 41. CHARACTERISTICS OF CHOREA. 185 and so is the opposite state of anaemia, producing, as we have seen, the signs of spurious hydrocephalus. The balance is so easily dis- turbed between the different parts of the nervous system, that con- vulsions occur with a frequency proportionate to the tender years of the patient, assuming all sorts of strange forms; now threatening life in one way, now in another, destroying the child suddenly by spas- modic closure of its glottis, or exhausting it by their violence and their ceaseless return; or lastly, working a change so subtle, that the knife of the anatomist cannot detect it, and yet so serious, as to induce their perpetual recurrence, and to convert the once bright and hopeful child into the dull and all but hopeless epileptic. But we have not yet completed our survey of this class of affections, for there are various forms of impairment of the motor power which are still unnoticed, ailments which indeed rarely threaten life or per- manently disturb the mental faculties, but which are yet tedious in their progress, often distressing in their character, and difficult of cure. I shall reserve for another lecture, those cases in which there is mere loss of power over a limb, or over some of its muscles, and will now notiee those in which that power is imperfectly exercised, in which the will no longer exerts its full control, but the muscles of some parts are left in a state of involuntary activity, though still performing imperfectly their proper duties. The characters just enumerated are those which mark a disorder with which you are doubtless all familiar, the Chorea Sancti Viti, or St. Vitus's dance. It is, however, by no means one of the most frequent affections of early childhood ; but its occurrence coincides, as the sub- joined table1 shows, rather with that period of development which intervenes between the second dentition and the completion of the changes that attend on puberty. Age Female Total At or under 4 years .... More than 4, but not exceeding 6 years " 6 " " 10 " " 10 " " 15 " 4 22 64 87 Total 177 6 11 142 220 379 10 33 206 307 556 It must also be added, that the liability to chorea does not cease entirely with the completion of the changes that accompany puberty, but that it has been computed that a fourth of all cases of it occur during adult life. I believe, indeed, though I cannot prove, that this estimate of the frequency of chorea in the adult is exaggerated, while, when it does occur in the grown person, it is probably due either to the influence of some grave internal inflammation, such as pericarditis 1 Deduced from the cases reported by Dr. Hughes, in Guy's Hospital Reports, Second Series, vol. iv., 1846 ; by M. Rufz, in Archives de Medecine, February, 1834 ; and from the statistics of M. Wicke, as reported by Romberg, Nervenkrankheiten, vol. ii. part 2, p. 177. 186 INFLUENCE OF AGE AND SEX. or endocarditis, or to that peculiar state of the constitution which gives rise to rheumatism, or to both these causes combined. The reason of the greater rarity of chorea in early childhood than subsequently is, I apprehend, to be found in the circumstance that with the progress of growth and the increase of strength the nervous system becomes less impressionable, and the causes which in the infant would have produced a fit, or would have given rise to that more chronic form of convulsive disorder, of which spasm of the glottis is a common accompaniment, no longer produce such grave results. They do not endanger life, they do not even abolish consciousness, but they shake the control of the will over the voluntary movements, and produce chorea. As the boy grows older, his liability to all con- vulsive diseases diminishes; and as the girl grows older, hers lessens too, but not to the same extent. In her, disorders of a milder kind show themselves with a frequency from which the boy's hardier frame altogether defend him; and chorea occurs only as one form of disturb- ance of the nervous system, having reference to an earlier stage of development than that at which hysteria commonly appears, when, in connection with the first performance and first consciousness of new functions and a new destiny, the mind and the emotions participate in disorders previously limited to the motor powers. TABLE, Showing the Age and Sex of 422 patients brought to the Children's Hospital suffering from Chorea. Age Male Female Total Between 3 and 6 months ..... 1 2 3 " 6 " 12 " 1 4 5 " 12 " 18 " 1 1 2 " 18 " 2 years . 1 3 4 " 2 " 3 " 3 3 6 " 3 " 4 " 6 5 11 « 4 " 5 " 4 16 20 " 5 " 6 " 7 23 30 " 6 " 7 " 18 30 48 7 " 8 " 17 34 51 " 8 " 9 " 17 41 58 " 9 " 10 " 23 57 80 " 10 " 12 " 23 81 104 122 300 422 The attack of chorea is often excited by a violent shock to the ner- vous system, such as a fright, a blow, or some sudden, violent emo- tion ; but even in those cases it is comparatively seldom that it occurs in children previously in perfect health. For the most part, whether one can point to a distinct exciting cause or no, there has been some previous failure of the general health; such as at an earlier age would have ushered in a fit of convulsions, or an attack of spasm of the glot- tis. In many instances, too, a minute inquiry into the child's previous history, or into that of his family, will show a special liability to exist CHOREA — ITS SYMPTOMS. 187 to convulsive affections, to chorea, or to epilepsy. The preponderating frequency of its occurrence in girls is but another expression of the same fact, namely, of its association with special excitability of the nervous system. Just as hysteria, too, comparatively seldom occurs in the robust, but is usually connected with some marked disorder of nutrition, such as anaemia or chlorosis, so, as I have stated, in almost all cases of chorea the commencement of its symptoms is preceded by failing health, by constipation, or by some other form of disorder of the digestive sys- tem, or even by some disease intimately connected with defects in the blood-formation, as rheumatism, or one of the eruptive fevers, most frequently the former. The existence of a distinct relation between rheumatism and chorea has already been indicated by several writers; but M. See1 was, to the best of my knowledge, the first who proved its intimacy, and who ad- duced figures in support of his statement. He alleged that of the 109 cases of rheumatism admitted into the Hopital des Enfans, 61 were complicated with chorea. Subsequent observers have not confirmed this statement to its full extent, and some have even thrown grave doubts on its accuracy. Thus, the late lamented M. Rilliet2 observes, that while rheumatism is very common at Geneva, chorea is extremely rare; that while he had seen many children suffering from rheumatism during the previous ten years in his private practice, only two cases of chorea had come under his care in that time, and neither of the pa- tients had, or ever had had, rheumatism. M. Lombard, too, during twenty years' extensive practice in that city, had seen the complication of rheumatism with chorea only once. My own opinion, too, was formerly in opposition to these statements; and the fact that rheumatism occurs among the patients at the Chil- dren's Hospital with exactly the same frequency in the two sexes, while chorea is more than twice as frequent in the female, throws doubt on the alleged relation being as close as M. See imagines. M. Blache3 also makes a statement which points still more in the same direction. At the Hopital des Enfans, the boys affected with rheuma- tism were to the girls as 2\ to 1, but chorea occurred in the proportion of only 1 boy to 3 girls. I must confess, however, that the relation is very real, and that since the appointment of a medical registrar to the Children's Hospital, one has found in his more accurate histories evi- dence of a connection between the two diseases much more frequently than heretofore. Of 33 cases of chorea in children under 12 years of age, 11 presented a history either of distinct rheumatic fever, or of fever accompanied with pains in the limbs, and therefore, no doubt, of rheumatic character. In 9 of these 1L cases the chorea either came on during the second week of rheumatism, or developed itself during convalescence from it. In one case rheumatism preceded the chorea by six months; and in another, a first attack of chorea, at 6 years old, was followed by rheumatism at 7; and a second attack of rheumatism 1 In Memoires de l'Academie de Medeoine, vol. xv. 1 Maladies des Enfants, vol. ii. p. 585. 3 Meuioires de l'Aoadjinie de Medecine, vol. xix. p. 608. 188 CHOREA. at 9 years of age was followed nine months after by a second choreic attack. Be the exact relation, then, what it may, it does seem that rheumatism, or the rheumatic diathesis, is a very powerful predispos- ing cause of chorea. The approaches of the disorder, when it does not follow on some sudden and violent shock to the system, are for the most part very gradual. It is first noticed that the child has certain awkward, fidgety move- ments, which it seems unable to check; or which, at any rate, it re- peats almost constantly, though they may cease for a few moments. On closer watching, it is next observed that these movements are almost or altogether confined to one side, and generally to the arm, the leg being at first almost always unaffected. In a few days, how- ever, the leg becomes the seat of these movements also, and the child in consequence stumbles or falls occasionally in walking. Now, too, if not previously, the muscles of the face participate in the irregular movements, and the child almost constantly makes the strangest grimaces, and soon the affection ceases to be limited to one side, but both legs and both arms, and at length all the muscles of the trunk, become involved. It is almost impossible to describe the condition of a chorea patient exactly, so much does it vary according to the intensity of the disease in different cases, and so much also in the same case at different times. Excitement increases the movements, fixed attention to any object usually quiets them, while even when severe they generally, though not invariably, cease during sleep. In some instances the ailment never passes beyond a comparatively mild form; inability to hold objects steadily in the hand, or to keep one or both arms from an occasional twitching movement, with slight momentary distortion of the muscles of the face, or spasmodic motion of the head, being all that is apparent. If the disorder be more severe, both sides are almost invariably affected; the patient is unable to grasp any object, or holding it for a moment or two, drops it from the hand, which with the greatest effort of will he is yet unable to keep closed. At the same time his gait is so unsteady that attempts to walk are dangerous, or sometimes the power over the legs is so im- perfect that the child is quite unable to stand. The face is not merely constantly distorted, but, if the child is desired to show his tongue, he puts it out with difficulty, hurriedly, and imperfectly, while, owing to the affection of its muscles, articulation is stammering and almost unintelligible, and deglutition is also performed difficultly and by sudden gulps. The movements still continue even when the child is lying in bed; those of the lower extremities, indeed, are often most marked in the horizontal position. In the worst cases the intellect is generally dulled, and the child's manner almost idiotic, while if the illness, though not very severe, be yet of long continuance, there is often an imbecility of manner over and above what may be due to the child's inability to control its movements or to articulate with dis- tinctness. My own impression is, that in almost all cases, those alone excepted in which the attack is slight and of very short duration, ITS SYMPTOMS. 189 there is a temporary dulling of the intellect, and instances are some- times met with where the weakness of the mind is quite out of pro- portion to the severity of the movements.1 Now and then the patient's condition is most distressing. It was so in a little girl whom I saw some years ago in the Children's Hospital at Paris. All the muscles of her body were affected; her spine was often bent back -in an ex- treme degree of opisthotonos, while her movements were so violent and so incessant, that it was necessary to place a board three feet in height around her bed to keep her from throwing herself over its edge, and by the violent grinding of her jaws together she had forced almost all her teeth from their sockets. Among the frequent accompaniments of chorea, modern science has made us acquainted with the signs of disease or of disorder of the heart. These signs consist either in irregularity of the rhythm and inequality of the force of the heart's beats, sometimes associated with a systolic murmur at its apex; or in the murmur alone which varies much at different times in force and intensity; or lastly, in the distinct evidences of endocarditis or pericarditis. I do not think that there is any connection between the presence of the first two of these phenomena and any special severity of the chorea; and in one of the only two fatal cases of chorea that have occurred under my care, there were no signs of disordered function of the heart during life, nor was any trace of disease of that organ discovered after the patient's death. These sounds are, doubtless, often what have been termed Dynamic cardiac murmurs; they "cannot be referred to inflammation or organic change of the mitral valve; they have not the usual accompaniments of a haemic murmur, but they do seem plausibly ascribable to disordered , action of the muscular apparatus connected with the valve."2 Often, indeed, these sounds continue for a considerable time, and though eventually disappearing, yet outlast the choreic movements. Some- times, too, the sounds are persistent, or at any rate they have continued for a period of many weeks, during which the patients remained under my observation, and the reasonable presumption is, that in these cases they were symptomatic of some organic affection of the valves of the heart. Even in these instances, however, the supervention of the murmur was not attended by any proportionate increase in the inten- sity of the choreic movements; and I imagine that wre should err if we were to apply to cases of chorea, in the course of which cardiac murmurs become perceptible, the same grave inferences as are fairly 1 See with reference to the mental state of patients suffering from chorea, the dis- cussion in the Academie de Medecine on occasion of a paper on the subject by M. Marce. The hallucinations and the maniacal delirium with which that gentleman appears sometimes to have met, are probably in part due to his field of observation having been a peculiar one, in the Bicetre and the Salpetriere, in part to the coexist- ence of hysteria in some of the cases. My own impression, however, coincides very closely with the opinion of M. Trousseau, who regards disturbance of the intellectual powers as occurring in the greater number of cases of chorea. (Bulletin de l'Academie, 1861, April 12, July 5 and 19.) See also Trousseau's Clinique Medicale de I'Hotel Dieu, vol. ii. p. 139. < 2 Walshe, On Diseases of the Lungs, Heart, &c, 2d Ed. London, 1854, crown 8vo. p. 243. 190 CHOREA. deducible in cases of heart disease, which in their progress become complicated with choreic movements. At the same time I must admit that I have met with some few instances of the supervention of a murmur during the course of chorea, which remained permanent, which became accompanied by all the evidences of disease of the mitral valve, and was followed by an obvi- ous dilatation of the heart. In one case, too, a girl 9 years old, who was admitted with chorea and very slight aff'ection of the mitral valve, dilatation of the heart increased with great rapidity, and the symptoms due to it threw those of the chorea completely into the background. The child died suddenly five weeks after admission into the hospital, and the heart was found after death enormously dilated. Some other somewhat similar cases have come under my notice, in which disease of the heart has advanced during the course of chorea; even when there was no previous rheumatic history of the patient. Two questions suggest themselves as deserving consideration; first, whether under the influence of the peculiar state of the circulating fluid, special dis- position to endocarditis may exist; and secondly, whether the disorder in the heart's movements may not favor its dilatation under the influ- ence of an extremely small amount of valvular disease. Even in the severest cases of idiopathic chorea, a fatal issue is most unusual. When it does occur, it seems to be due to exhaustion pro- duced by the violence and ceaselessness of the movements; is preceded by a sudden failure of the vital powers, by delirium, or failure of intelligence, and at last by a comatose condition, which seldom lasts longer than a few hours. In such circumstances there does not appear to be anything constant in the appearances discovered after death; and, though congestion of the vessels of the spinal cord and the effu- sion of blood or of a bloody fluid around the theca of the cord are generally discovered, yet the presence of these conditions is by no means,constant, and in some instances a post-mortem examination discovers absolutely nothing to explain the patient's death.1 Two instances only of fatal idiopathic chorea have come under my notice. In one, the sudden death of the patient appeared to be due less to the chorea than to the disease of the heart by which it was accompanied; the other case was that of a girl aged 7 years, who died on the 42d day of her first attack of the disease, and on the 23d of her being under my care. The attack, which was causeless, did not present any symp- toms of gravity at the time of the child's admission into the hospital; she was unsteady in her gait, and could not keep her hands quiet,-but there was but little distortion of the features, and she could protrude her tongue steadily. Her state, however, deteriorated, and a fortnight after her admission the child could scarcely walk, and she protruded her tongue with difficulty. She next became unable to feed herself, her countenance lost all expression of intelligence, which was replaced by a vacant stare; her powers manifestly failed, and her body was bathed in abundant perspiration. During the last week of her life 1 Leudet, Sur les Chorees sans Complication, terminces par la Mort • in " Archives de Medecine," 1853, vol. ii. p. 285. ITS SYMPTOMS. 191 her coudition became worse and worse; the day before she died the movements affected the whole trunk as well as the extremities, so that the child lay writhing in bed; her face was dusky and livid, the small superficial capillaries were congested, the lips dry and bleeding from her incessantly biting them; her face was quite unintelligent, and her pupils were much dilated. Her skin was very hot, but not dry; the heat of her head was especially marked. On turning her round to examine her spine, she shrank when pressure was made in the lower cervical and upper dorsal regions. This tenderness was relieved, and the child's condition seemed improved by the application of a few leeehes to the spine. She became more conscious, asked for drink, and passed a much quieter night than she had done for some time. The next morning, however, her exhaustion seemed extreme, and early in the afternoon she died in a comatose condition, the choreic movement having almost ceased for some hours before her death. On examining the body, the muscles of the back were found to be turgid with blood, which flowed out abundantly on dividing them. On laying open the spinal canal and exposing the cord, a large quan- tity of blood was seen external to the theca, from about the fifth cervical to the eighth dorsal vertebra, but most abundant in the dorsal region. Along the dorsal portion of the cord, too, there was beneath the semi-coagulated blood a thick layer of a gelatinous matter of a yellowish color, and resembling lymph or broken-down fibrin. The external surface of the dura mater appeared perfectly healthy beneath this deposit; and although a large quantity of transparent serum escaped on opening the membranes, yet there was no increase either of their vascularity or of that of the cord, and the only point which could be noticed was that the substance of the cord was a little firmer than natural. There was no excess of fluid in the ventricles of the brain, nor any other important appearance either in the brain or else- where. The morbid appearances in this case were almost identical with those which are met with in the trismus of new-born children. It is, indeed, unusual to meet with evidences of mischief so considerable about the spinal cord; but, at the same time, in instances of idiopathic chorea, some degree of congestion, often intense vascularity of the cord or its membranes, is the most frequent of all the changes which an examination after death reveals. I believe, then, that chorea falls into the same category with the majority of the convulsive affections of early life; that its phenomena depend on irritation, direct or indirect, of the spinal cord; and that, consequently, the intensity of its symptoms, and the danger that attends them, are greatly influenced by the exciting cause to which they are due. Idiopathic chorea is therefore almost always less serious than the symptomatic, and the disorder which is excited by some momentary shock to the nervous system generally calls for far less anxiety than that which manifests itself during the course of aqute rheumatism, or of inflammation of the heart or pericardium. It is with the former class of cases only that I here concern myself, 192 TREATMENT OF CHOREA. and in the majority of them the question fortunately is less one of whether the patient will recover, than within what time recovery may be expected. The disease is essentially slow in its course, and the average of 117 cases, as reported by M. See,1 is 69 days; the extremes either way, however, vary considerably, for while recovery in the less severe cases is sometimes complete in a month, the convulsive move- ments persist in others for a period of several months, or longer. Cases of very chronic chorea are, however, usually of the partial kind, the affection having either involved only one limited set of muscles from the outset, or remaining in them after other parts had ceased to be its seat. Not only is chorea slow in departing, it is also very apt to return, and the attacks have been known to recur as often as six or seven times in the same patient, though generally with a progressive diminution in their severity. The treatment of chorea depends much on the general condition of the patient, and on the severity of the symptoms. In the milder, more chronic, and happily more usual forms of the disease, it is under the employment of a combination of aperients and tonics that the patients generally improve the most speedily; for even though the convulsive movements have come on as the result of some sudden shocli, the state of the system in which they occur is almost invariably one of debility. Tonics, indeed, can seldom be given alone; for in almost all cases the bowels have a great tendency to constipation, even though the functions of the digestive organs be not otherwise disor- dered. Purgatives are, therefore, almost always indicated, and this not merely at the commencement, but throughout the whole course of the disease. At first it is often necessary to administer the more active purgatives, such as scammony; and now and then we meet with instances where purgatives alone, frequently repeated, suffice to cure the ailment. This, however, is unusual, and the frequent repe- tition of drastic medicines is not in general expedient, but the due action of the bowels, when they have been once fully relieved, is after- wards best secured by some of the warm aperients, such as the powder or compound decoction of aloes. Tonics, however, must go hand in hand with aperients, and by common consent the ferruginous preparations are regarded as of peculiar value in this affection. Though much has been said about the virtues of the carbonate of iron, I do not apprehend that any one preparation has a decided superiority over the others: but having continued one for a time, it will usually be desir- able to substitute for it another form of the remedy. SometimoiB the iron altogether falls, and the sulphate of zinc may be tried in gradu- ally increasing doses; while in obstinate cases, in which both of these remedies have been given unavailingly, success has followed the use of the liquor arsenicalis. Of this latter remedy, however, I cannot speak from personal experience. I have of late years employed, and am doing so with a growing confidence in its value, the nux vomica and strychnine in cases of chorea. The condition in which this remedy has seemed to me to be most serviceable is that state of loss 1 Op. cit., p. 408., TREATMENT OF CHOREA. 193 of power in which the limbs cannot be exerted without the irregular movements being at once induced; although those movements are comparatively slight so long as the patient remains perfectly quiet in bed. In such circumstances the strychnine seems often to effect much more than iron, or any other form of tonic, but I have never had recourse to it so long as the movements were violent and incessant, or during what may be called the acute stage of chorea. The remedy should be begun in small doses, and increased gradually and cau- tiously ; the increase not being made oftener than every third day. M. Trousseau, with whom this remedy is a favorite, insists, very pro- perly, on looking out for the physiological effects of the drug, the stiffness of the jaw and of the muscles of the neck, and the tetanic contraction of the muscles as indicating that the remedy must not be carried further. On two or three occasions—whether from want of due care on the part of the nurses I cannot say, or from the difficulty in ascertaining the existence of some of these symptoms in young children—I have known a fit of convulsions come on during a course of strychnine, apparently unpreceded by any of the ordinary physiolo- gical effects of the remedy. I mention the fact as an additional reason for great care in its administration. With reference to the form in which it is best given, I used to employ the extract of nux vomica, but have of late given the liquor strychniae of the British Pharma- copeia, two drachms of which contain one grain of the strychnia. I begin with five minims of this solution, or one twenty-fourth part of a grain of strychnia, every six hours for a child of seven years old, and increase gradually up to double that dose. I believe it may be safely carried further, but in the cases where I have employed it I have been satisfied with the results obtained by the doses which I have mentioned. In addition to internal treatment there ar§ certain external measures which may sometimes be employed with great advantage. Foremost among these stands the shower-bath. Its use, however, must be begun with care; the child must not be frightened by being subjected all at once to too copious or too cold an affusion, but if you begin with but a small quantity of water, and that tepid, you will generally be able, in the course of a few days, to employ the bath in such a manner as shall be really efficacious. But, even with all these precautions, there are difficulties in the case of young children in employing the shower- bath such as we do not meet with, or at any rate need not regard, in the case of older patients. The sudden affusion of the water causes alarm to many children, even when in good health, and in chorea the nervous excitability is so much increased, that the shower-bath not infrequently occasions extreme terror, and compels us to desist from its use. The late M. Baudelocque, and some other French physicians since his time, have recommended as equally efficacious, and as un- questionably free from all these objections, the use of warm sulphur- baths. These baths are prepared by dissolving 6^ ounces of the sul- phuret of potass in an ordinary bath, which is to be heated to 90° Fahrenheit, and the patient must remain in it for at least an hour daily. 13 194 TREATMENT OF CHOREA. It is alleged by M. See,1 who is a great advocate for this measure, that improvement generally becomes apparent in the course of two or three days; that the average duration of treatment does not exceed twenty- two days; and that it proved efficacious in 50 out of 57 cases—a re- sult, however, which one cannot but fear is more favorable than can be generally expected. My own experience of it is limited to two cases, but in neither of these was it possible long to continue its use, for the offensive sulphurous smell so disgusted the children that it was found impossible by any persuasion to induce them to remain in the bath for more than a very short time. There is another mode of proceeding which has been strongly ad- vocated in cases of chorea, and which, to say the least, is well worth a trial as a subsidiary measure—namely, the employment of gymnastics. These exercises should begin with simple movements; they should be regulated by a simple tune or chant, in which the child takes part, and should never be so prolonged as to cause fatigue. At first, stand- ing upright, flexing and extending the arms, bending and straighten- ing the knees, and marking time, are all that should be attempted; but, by degrees, walking, running, and even leaping, may be practised. I havcnever had the opportunity of putting these exercises fully to the test, out have seen so much benefit even from their very partial us^at the Children's Hospital, that I feel sure great good would result from their employment when convalescence has once commenced, and can well imagine that they may, in many instances, as M. S6e alleges, have been sufficient of themselves to effect a cure. A more important use than that of a mere subsidiary aid to conva- lescence has, indeed, been made of gymnastics, in the treatment of chorea, and the results,*as described by M. Blache,2 are very remarka- ble. A total number of 108 patients, 8 of whom were suffering from a relapse of chorea, 100 from a first attack, were subjected to this plan, which was not associated with any other medical treatment. In 31 of the cases, the chorea was of moderate severity, in 74 of extreme vio- lence. All of the first class of cases recovered in an average period of 26 days, and after 18 series of exercises. Of the remaining 74, 68 got well in 45 days, and after 31 series of exercises, and the remaining 6 in 122 days, and after 73 series of exercises. These results, if com- pared with the ordinary average duration of chorea, must be regarded as very successful, since MM. Rilliet and Barthez estimate it at from 6 weeks to 2 months, and M. See fixes it at 69 days. The mode of proceeding in these cases was as follows: The child being on its back in bed, the teacher of gymnastics, with the help of three or four of his most intelligent pupils, begins by holding him per- fectly motionless in that position for from 10 to 15 minutes. He then begins a series of kneading or shampooing movements with the open hand upon the limbs, and over the chest, and afterwards along the back of the trunk, and chiefly the back of the neck, and the muscles on either side of the spine, and these movements are followed by brisk 1 Op. cit.,p 485. 2 Memoires de PAcademie de Medecine, vol. xix. pp. 598-608. TREATMENT OF CHOREA. 195 frictions of the parts. About an hour is occupied by these proceed- ings, and they are repeated every day for three or four successive days, and the child is said to experience great comfort, and to sleep much better after them. Without completely discontinuing this shampoo- ing, the child is next made to execute a series of regular and perfectly rhythmical movements for a considerable time together. Thus, while the child is still lying on his back, with his arms extended by his sides, he is laid hold of by the wrists, the forearm is bent on the arm, the arm raised, the forearm extended, and then by a succession of the same three movements the arnis are once more replaced by the side of the trunk; and these movements are repeated in the same order again and again. In the same way the leg is bent on the thigh, and the thigh on the pelvis; and then, these two movements being reversed, the legs are once more stretched out straight, and then submitted once more to the same movements with the same regularity. At the end of 10 or 12 days the children are usually sufficiently recovered to go down into the gymnasium, where, under the lessons of the teachers, their im- provement becomes perfected. I have on a few occasions found the choreic movements, even when very violent, controlled to an unexpected degree by proceedings simi- lar to those described by M. Blache, and have been prevented only by the absence of a gymnasium and of a competent teacher, from giving his plan a thorough trial, just as I may add that the want of proper bath rooms has hitherto interfered with my making such use of the sulphur-baths as would alone enable me to form a conclusive opinion as to their value. I trust, however, that when funds allow of the re- construction of the Children's Hospital, both these wants will be sup- plied. Of course, while pursuing any form of tonic treatment, the general management of the child must be in harmony with it. Residence in the country, sea-air and seabathing, a well-regulated but nutritious diet, from which even wine is not always to be excluded, will, when combined with the avoidance of over-excitement in any form, often do as much as medicine, or even more, for the restoration of your pa- tient. The above remarks refer to the treatment of chorea in those forms in which it usually presents itself to our notice, but sometimes it as- sumes an extreme degree of severity, and is attended by movements of such extreme violence as to call for whatever means can most speedily control them. In all cases of severe chorea it is of importance to confine the patient to bed, for long before the power of walking is lost, each attempt at locomotion is attended by distress, and by most marked exacerbation of the violence of the movements. It is equally important, too, that every cause of excitement should be removed, and that none but the necessary attendants should be about the child, for one may often have occasion to observe how the speech previously tolerably distinct becomes at once inarticulate, and how all the move- ments are immediately aggravated the moment that a stranger enters the room. In addition, however, to these general precautions, there are two remedies which seem to have a special influence in controlling 196 TREATMENT OF CHOREA. the violence of choreic movements. Antimony is one of these reme dies, belladonna the other. Idiopathic chorea, when it assumes the acute form, is almost always associated at its commencement with some degree of febrile disturbance, with an exceedingly dry and unperspiring condition of the skin. In these circumstances antimony is of special service, showing its influence, not merely by exercising its customary diaphoretic action, but also apparently by directly controlling the movements. There is, however, a relation between the two, and it has been found that the influence of the antimony is rendered still more decided by combining with it the daily use of the hot air-bath, so as to obtain very profuse diaphoresis. In some instances, rest in bed, with the hot-air bath and a dose of antimony at night, suffice in a very few days to restrain the violent movements; but commonly it is expe- dient to give the antimony every four hours in what would usually be nauseating doses. It will commonly be found, however, that the ordi- nary doses do not nauseate until the violence of the movements has begun to abate, but that simultaneously with the improvement of the disorder the tolerance of the medicine ceases. I do not know who first recommended the use of this remedy; it came to my knowledge only at second or third hand, though 1 have now employed it in many instances. It is evidently not applicable in all cases, and generally all the good which it is capable of accomplishing is effected in four or five days; but I believe, that as a means of controlling the violence of chorea in its early stage, the remedy is one of very great value. The employment of antimony in still more heroic doses has been advocated in cases where the movements are uncontrolled by other means, and I believe, from a very limited trial, that in some cases of exceptional severity the practice is deserving of adoption. M. Gillette suggested, and M. iloger has adopted, the plan of giving three grains of tartar emetic the first day of treatment, six the second, nine the third; then allowing a pause of from three to five days; and recom- mencing with four grains the first day, eight the second, twelve the third, and so on for three series. I recently tried these large doses in a child of 11, in whom the violent movements were unchecked by other means. The antimony controlled their severity. I did not push it beyond nine grains daily, for any larger dose caused vomiting, but this dose was twice given for three days without producing serious depression. Having obtained this end, I discontinued the remedy, in consideration of the child's general weakness, but the movements never acquired their former intensity. Belladonna is another very serviceable medicine. Its use is not limited to the early stage of chorea, and indeed is, I think, rather more manifest in cases where the movements have already continued for some time, either not diminishing, or even actually increasing in severity ; chalybeate medicines either being contraindicated, or having been employed without benefit. In such cases the belladonna should be given in moderate doses, repeated every four or six hours, and should be persevered with, for ten days or a fortnight, since its good effects are often not immediate, and seldom show themselves so PARTIAL CHOREA. 197 speedily as does the improvement which follows the employment of antimony. Neither of these remedies is spoken of as a specific for chorea, but both are referred to as applicable at certain stages, and in certain cir- cumstances, and as preparing the way for that plan of treatment which has already been detailed as suitable to the majority of cases, and during the greater part of the course of the disorder. In the great majority of cases of chorea you may, as I have already mentioned, assure the friends of your patient that the disease will ultimately subside, though it may last for several weeks. You cannot, however, speak with the same confidence with reference to a kind of partial chorea that you will occasionally meet with, and in which some muscles only are affected. Some years ago, I saw a young lady, 9 years old, whose health had never been robust, and who had often suffered from headache and gastric disorder. When 7 years of age, she began, without any spe- cial cause, to have frequent twitchings of the muscles of the face ; and almost ever since, some muscles, either of the face, neck, mouth, or extremities, had been similarly affected, though it had scarcely ever happened that two sets of muscles were thus disturbed at the same time. She had been under the care of several practitioners, and by some had been leeched and mercurialized with manifest disadvantage. Some benefit had been derived from large doses of carbonate of iron, and when in the country during the summer before I saw her, the involuntary movements almost entirely ceased. She had not long re- turned home, however, when a slight twitching began about the mus- cles of the lower jaw; but this ceased in a few weeks, and, instead of it, there was now a convulsive twitching of the head towards one or other shoulder. A month afterwards she began to have occasional contractions of the muscles of the right hand, so that the pen would drop from her hand while writing, and the fingers would be gathered up into the hand. On the last time that I saw her, the contraction of the fingers had ceased to occur; the spasmodic movement of the neck was much less frequent, and was slighter, but there were slight move- ments of the back. The child's bowels had been disordered and con- stipated, and her general condition was weakly. I regulated the bowels, gave the ferro-citrate of quinine, and afterwards other prepa- rations of iron, and, when the spring came on, sent her into the coun- try, where, as I afterwards heard, she became quite well. The danger in these cases, and one which you cannot even with the most judicious management always guard against, is, lest some one or two muscles should become permanently affected by this spasmodic movement—an occurrence which, though not otherwise of importance, is very distressing, especially if the patient be a girl. 198 INFANTILE PARALYSIS. LECTURE XV. Paralysis—sometimes congenital—often follows very slight and temporary symptoms of cere- bral disturbance—most frequent during period of dentition.—Its Symptoms and Diag- nosis.—Prognosis not very favorahle.—Consequences of its persistence.—Treatment—aids to walking—modes of exercising the limbs—internal treatment. Facial Hemiplegia in new-born infants. Neuralgia in infancy and childhood. Disturbance of the nervous system shows itself in children as well by loss of the motor power as by the occurrence of involuntary move- ments; and such an accident as the palsy of a limb naturally occasions parents the greatest anxiety. In the adult, a paralytic seizure is gene- rally the result of very serious disease either in the brain or spinal cord, and the sign of the commencement of a series of morbid pro- cesses which issue sooner or later in the destruction of the patient's life. Non-professional persons are aware of this fact, and often sup- pose that the same rule holds good in the case of the child as in that of the adult; but you may in most instances quiet their fears with the assurance that paralysis in infancy and childhood seldom betokens any peril to life, though the aff'ection is often very slow in disappearing, and sometimes is quite incurable. Paralysis in childhood occasionally dates from so early a period that there seems every reason for believing it to be the result of some original defect of conformation. In such cases the power over both extremities on one side is greatly impaired, and the limbs on that side are much smaller and less well-nourished, and sometimes the defective growth and want of power are evident on the whole of the same side of the face and body. Some years ago, I saw a girl, 18 years old, in whom not only were the left extremities much shorter and smaller than the right, but the left half of the face and body was so likewise. The parents of the girl stated that this inequality in size of the two halves of the body had existed from earliest infancy, and that the de- fective power over her limbs had not succeeded to a fit, nor to any other indication of acute cerebral disease. The left side was weak, and motion imperfect, but sensation seemed to be unimpaired. The patient in this case was rather deficient in intellectual endowments. In another instance the body was well-formed, but the patient, a girl of 8 years of age, had had from her earliest infancy but very imperfect use of her right side. She limped with her right leg as she walked, always treading on her toes, with the heel raised considerably above the ground, and turning the foot inwards at every step. She had but very incomplete power over her right arm; the fingers of that hand were constantly flexed and drawn into the palm; and though by a great effort she could extend them, yet the moment her attention was withdrawn they returned to their former flexed position. Sensation CAUSES OF PARALYSIS IN CHILDHOOD. 199 was as perfect in the right limbs as in the left, but their wasted con- dition and smaller size, as compared with the left extremities, showed that their nutrition had been but very imperfectly carried on. It is almost needless to observe that, in cases such as these there is no room for treatment other than the employment of whatever mechanical means may be best calculated to relieve inconvenience or to diminish deformity. Real congenital paralysis, however, is a much less frequent accident than the occurrence of partial or complete loss of power over certain limbs or muscles at a subsequent period. In many instances its com- mencement can be traced to some attack, though often a very brief one, of cerebral disturbance, which showed itself perhaps by nothing more than a single convulsive seizure, or by an unusual heaviness of the head that lasted for a day or two, and then subsided of its own accord. In the majority of cases, indeed, the cerebral disturbance that precedes infantile paralysis is neither severe nor long-continued; and only two instances have come under my notice in which there seemed to be reason for supposing that it was associated with abiding mischief in the brain. It is therefore of importance to examine an infant care- fully, even after a very mild convulsive seizure, in order to make sure that it moves its limbs as freely as before, or that, if its power over them be impaired, appropriate treatment may be at once adopted. Paralysis sometimes comes on independently of any evident cerebral disturbance, seeming to be induced by the irritation of dentition, or supervening on the long continuance of a constipated state of the bowels, or appearing in connection with all the indications of general debility, or succeeding to a short feverish seizure which came on sud- denly when the child was in bed at night, and left it with one limb palsied in the morning. The local action of cold sometimes produces paralysis. I have met with one or two instances in which, after sitting on a stone step, a child has lost power over one leg; and paralysis of the portio dura is doubtless in some cases produced by cold air, though I do not at this moment recall an instance of this having been the case in children. The whole subject of paralysis in early life calls for, and would well repay, a thorough investigation. Unfortunately, however, the diffi- culties which beset any inquiry into the subject are numerous; and are the least easy to overcome, since they arise in great measure from the chronic nature of the ailment, which renders it almost impossible adequately to test the value of remedies, or to estimate the changes which time may bring about, either in improving or deteriorating the patient's condition. Of the large number of cases which 1 have seen, few have continued for more than a few weeks under my observation; so that I am unable to answer, with reference to them, more than a few of the questions which suggest themselves as deserving a reply. From a comparison of forty-three cases of which I have a record, we learn, with reference to the patient's sex and age at the time of the attack that— 200 CAUSES OF PARALYSIS IN CHILDHOOD. In Male Female 0 2 the paralysis was congenital. 0 2 paralysis occui red at 3 months 0 1 a a 5 " 3 1 ii l< 8 " and not more than 1 year 9 5 II (( 1 year u ii 2 " 3 6 (1 It 2 " II a 3 " 3 3 a a 3 " (( a 4 " 1 0 a it 4 " (I tt 5 " 1 . 1 a a 7 " !< « 8 " 2 0 it (( 8 " « « 9 " 22 21 In twenty-seven out of forty-three cases, or in more than half of the cases, the paralytic symptoms came on between the age of eight months and three years, or, in other words, during the time when the process of dentition is going on most actively. In many of these cases, indeed, it was not preceded by any of the local signs of difficult dentition, but still it is quite apparent that the changes which are going on in the constitution during that important period of develop- ment powerfully predispose to it, as to so many other affections of the nervous system. In twenty-one out of the forty-one cases which were not congenital, no indication of cerebral disturbance either occurred before the paralysis, or came on afterwards, while there were but four instances in which the signs of affection of the brain were other than exceedingly transient. With reference to the parts affected, in only 2 instances 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 both deltoid muscles, and over the flexor muscles of both thumbs. Six times none of the limbs were palsied, but the affection was con- fined once to the portio dura of the left, and five times to the portio dura of the right side; but in one of these instances, though there was no actual paralysis, the patient's gait was feeble and tottering. In almost all instances, those of facial paralysis excepted, in which the loss of power is at first almost complete, a certain small amount of voluntary power over the affected side remains after the seizure. Thus, if the arm is paralyzed, the child can move it a little, though with difficulty, and not so as to answer any useful purpose; or if the leg is affected, the child can flex and extend it when lying in bed, or, perhaps, can make some slight attempt at progression if the weio-ht of its body is supported by some one else; and this even though it be wholly unable to stand for a moment without assistance. Owino- to this circumstance, the date of the occurrence of paralysis of the lower limbs is very apt to be overlooked in infants who have not be°-un to DIAGNOSIS OF INFANTILE PARALYSIS. 201 walk, so that the affection may not attract notice until it is in reality of several months'duration. But though the existence of this affection may for a time be altogether overlooked in early infancy, diagnosis is not otherwise attended with much difficulty, for the history of the case and the pain- lessness of the affected limb will at once show that the loss of power over it is "not the result of any injury. Often, however, sensation in the affected limb appears to be exalted when the paralysis is recent, the degree of hyperaesthesia in the early stage being in such cases proportionate to the completeness of the loss of power which after- wards is apparent. In some instances the exaggerated sensibility continues for several weeks, though this is unusual; but when this is the case, the leg being the seat of the aff'ection, and the paralysis in- complete, the existence of hip-joint disease may very likely be sus- pected. In such a case the child bears all its weight on the healthy limb, turns the foot of the affected side inwards when walking, and stands with the toes of that foot resting on the dorsum of the foot of the healthy side. Still it will usually be found that the exaggerated sensibility of the paralyzed limb varies greatly at different times, while that extreme increase of suffering produced in cases of hip- joint disease, on striking the head of the femur against the acetabulum by a blow upon the heel, and the fixed pain in the knee of the affected side, so characteristic of disease of the hip-joint, are absent; and these points of difference will enable you to distinguish between the two affections. One other important means of diagnosis is furnished by the presence or absence of an increased temperature over the sus- pected joint. The value of this easy observation in determining the presence or absence of inflammation about any particular spot is dwelt on by Mr. Hilton,1 in his lectures delivered recently at the College of Surgeons. I cannot refer to them without recommending them to your most careful perusal, or without expressing my con- viction that, more than almost any work which has recently appeared on subjects connected with our profession, they bear the stamp of original thought, and of that simplicity which characterizes real genius. Another important question is, how we may distinguish between forms of paralysis, such as I am here speaking of, and those more serious cases in which the palsy is a sign of organic disease in the brain. In many cases the history of the patient will of itself be sufficient to guard us from error; for if paralysis occur suddenly, affecting both limbs on one side, and be neither preceded nor attended by any cerebral symptom, it is almost certain that it does not depend on serious organic disease of the brain. Our decision will be more difficult if the loss of power has been gradual, and especially if only one limb is affected ; but if the brain is diseased, we shall rarely find a mere weakening of the motor power: for connected with it there will usually be occasional involuntary tremor or nervous twitching of the limb, or contraction of the fingers or toes, and that independent 1 Lectures on Rest and Pain, 8vo. London, 1863. See p. 64. 202 PROGNOSIS. of the general wasting of the affected limb which takes place in all cases of long-standing essential paralysis, and is then accompanied with contraction, owing to the predominance of the flexor over the extensor muscles. When the paralysis succeeds to convulsions, the case will be still more obscure. In most cases of simple paralysis, however, the palsy comes on after a single fit; while, if it depends on some local mischief in the brain, it is generally preceded by several convulsive seizures, during each of which the limb that afterwards becomes palsied is in a state of peculiar movement, or is sometimes the only part where convulsive movements occur. I do not know that one can lay down any decided rules with refer- ence to prognosis in these cases as deducible from the sudden or gradual access of the paralysis, though it is my impression that the former, which is the more common mode of onset of paralysis at the time of dentition, warrants a more hopeful view of the case than the latter. The duration of infantile paralysis, indeed, in whatever circumstances it may have come on, is extremely variable. In those instances in which recovery is most complete, amendment generally manifests itself within a few days, and this sometimes wholly independent of treat- ment, though it oftener occurs under the employment of some simple remedy directed against the symptoms of constitutional disorder with which it was accompanied; so that the same medicine suffices at once to remove the child's indisposition and to cure its paralysis. In other cases, even though all signs of disordered health may pass away with the same rapidity, the child may continue for weeks or months with the power over one side of its body, or over one-half of its face, or one of its limbs greatly impaired; or this condition may persist through the remainder of its life. The evils resulting from the persistence of the paralysis are also much greater in childhood than in after-life, for the disfigurement which it produces is far more serious. In the course of time the muscles of a paralyzed limb become almost always wasted, and the sinking of its temperature attests its imperfect nutrition; but in child- hood the growth of the part also is arrested, or retarded, so that in the course of a year or two the affected limb will be half or three- quarters of an inch shorter than the corresponding member on the opposite side. A little girl became paralyzed with her left leg at the age of 1 year and 9 months, after a febrile attack accompanied with pain, and which seemed to have been of a rheumatic character. At the age of 6 years, she having recovered power over her left leg suffi- cient to walk without a crutch or other support, a line drawn from the anterior superior spine of the ilium to the external malleolus measured 20J inches on the right side, 19 on the left; the circumference of her right calf was 8J, that of the left 6f inches; while, owing to the re- laxation of the ligaments about the ankle-joint, a line drawn obliquely from the internal malleolus to the end of the heel measured 2| inches on the left side, 2| on the right. Two years later, a similar disparity between the two limbs still existed; the measurements on the left side yielding 20, 7J, and 3 inches respectively, those on the right side 22, 8|, and 2| inches. The arrest of growth, too, had affected the foot as PROGNOSIS IN INFANTILE PARALYSIS. 203 well as the leg, for while the right measured 6J inches from toe to heel, corresponding measurements of the left foot yielded only 5| inches. The relaxation of the ligaments mentioned in this case some- times exists in even a much greater degree, and tends to increase the deformity and to diminish the usefulness of the limb; and this is generally most marked when the upper extremity is affected. On three occasions I have seen the arm completely dislocated, owing to long-standing paralysis, the ligaments about the shoulder-joint having become so relaxed that the head of the humerus hung quite out of the glenoid cavity; and on measuring the distance from the acromion to the tip of the finger in one of these cases, I found that an apparent elongation of the paralyzed limb to the extent of three-quarters of an inch had thus been produced. The deformity in these cases, however, depends not simply on the wasting of the muscles and the relaxation of the ligaments, but also on the greater power of the flexor and adductor muscles of the limbs, which by their constant involuntary action produced distortion, and often necessitate the interference of orthopaedic surgery. Thus in some cases of long-continued paralysis of the lower extremities, the thighs are kept permanently close together by the overpowering action of the adductor muscles; while contraction of the hamstring muscles, preventing the straightening of the knee; and of the gastrocnemii, occasioning one form of club-foot, are of still more frequent occur- rence. The same overpowering action of the flexor muscles leads also, in some cases, to undue arching of the foot, and keeps the toes constantly bent, so as to interfere most seriously with progression.1 It must also be borne in mind that the deformities just referred to are not merely the occasional consequences of very serious or very protracted paralysis, but that there is a tendency to their occurrence in every instance; and that the restoration of a very large measure of power to the affected limb furnishes no guarantee against their taking place. From this it follows that in every case of paralysis in infancy or childhood the patient will require the most careful watching during the whole process of recovery—a proeess not infrequently prolonged over several years; and this the rather, since so long as one set of muscles continues feebler than another, one most influential cause of deformity of the limbs is constantly in operation. But even though treatment be adopted early, and continued long, it must still be owned that the prospects of recovery in these cases are far from being cheer- ing. In only 11 out of the 43 cases did a complete cure of the paralysis take place, and in 3 of this number the limb remained somewhat wasted, and club-foot existed or some contraction of the tendons, though probably remediable. In 3 of these 11 cases the portio dura alone was affected, in two others the paralysis of both leg and arm 1 There are some remarks on this source of deformity in Dr. Little's work On De- formities of the Human Frame, 8vo. London, 1853, p. 120. But by far the fullest observations on this subject are to be found in the valuable essay of Dr. Heine, Ueber Lalnnungszustande der untem Extremitaten,etc.,4to. Stuttgart, 1840, and in his more recent work, Spiuale Kinderliihmung, Svo. Stuttgart, 18U0. 201 TREATMENT OF PARALYSIS. was incomplete, aud was associated with a state of general debility; while in one instance the loss of power over one leg had come on after the child had been sitting for some hours on a stone door-step. In 7 of these cases treatment was commenced within two or three days after the occurrence of the paralysis, and continued uninterruptedly until the patient's recovery. Once the treatment was begun after the lapse of nearly three weeks, and in another instance, though begun immediately, it was afterwards discontinued for several weeks. In 14 more cases, in spite of the employment of medical treatment, and steady perseverance with it for some months irr all instances but one, the improvement was but very partial. In the remaining 16 cases but very slight improvement took place in the patients' condition, and it is deserving of note that in 9 of these cases either no treatment at all was adopted, or not till after the lapse of six months or more from the occurrence of the paralysis. It would be difficult to find a more cogent argument than these facts furnish, to enforce the necessity for the early adoption of appropriate treatment. Two observations, however, must be made here: first, that a certain amount of spon- taneous amendment takes place in almost every case, beginning within the first week or two after the occurrence of the paralysis, being at first very obvious, afterwards going on very slowly, or coming to a complete stand-still; and, next, that while a very large number of these cases come annually under my notice, I see them usually but once or twice, and then only those in which the spontaneous improvement has been arrested. I believe that more cases of infantile paralysis get well speedily of their own accord than my individual experience would have led me to suppose, and I believe, further, that the cases in which permanent palsy or deformity irremediable by orthopaedic surgery is left behind are less numerous. The nature of the treatment must of course vary according to the circumstances in which the affection comes on, and these, as we have already seen, differ very widely; paralysis in one instance occurring during dentition ; in another, following one of the eruptive fevers; in a third, succeeding to rheumatic symptoms. Very soon, however, a time comes with all when every sign of acute ailment has passed away, and little remains besides the loss of power to engage our notice. Sometimes no disorder of the general health is present, while in the majority of instances in which any such ailments exist they are limited to a constipated state of the bowels and a condition of general debility. Hence purgatives and tonics are the internal remedies which are most usually indicated, and of these the gentle aperients are more suitable than those of a drastic kind: and preparations of iron are usually of greater service than other tonics. There is, however, one tonic which has, and not altogether undeservedly, a special reputa- tion in cases of paralysis, and that is the nux vomica, the employ- ment of which has seemed to me to have been succeeded, in many bad cases, by a rise of the temperature of the limbs, and an increase in power over them. I have never yet given it to infants, but with child- ren of four years old I begin with an eighth of a grain of the spirituous extract, three times a day, increasing the dose by degrees to a sixth, a quarter, or a third. I have not seen it produce those twitchings of TREATMENT OF PARALYSIS. 205 the limbs which attend on the administration of strychnine in the adult, but I have seen general and rather severe convulsions come on during its employment—which were followed by no evil consequences, though I cannot say they were unattended with danger. In one of these instances great amendment had at first succeeded to the use of the nux vomica, but the child's condition had been stationary for some time before the fits occurred; and a return to its employment was not followed by any further improvement. Be the purely medical treatment what it may, unceasing efforts must be made from the very first to bring the palsied limb once more into use, while, when the power is most impaired, we must seek, by the regular employment of passive exercise, and by friction of the limb, to prevent that wasting of the muscles which is sure to follow on long-continued inaction. If the leg be affected, a child who has not very long learned to walk will be taken completely off its feet, while even after power has returned, quite sufficient to enable it to make some attempts at walking, it will be deterred from the effort by its sense of insecurity, will cry even though carefully supported by its nurse, and will refuse to make the slightest movement. The attempts thus evidently distressing the child are discontinued, and in the hope, too often a vain one, that in the course of months the child will gain more power, much valuable time is thrown away: the muscles waste, and permanent deformity of the limb results. In these cases, two very simple means are often of great service in preventing this untoward occurrence. The Baby-jumper, which all infants delight in, exercises the legs most effectually, while as soon as there is even a very moderate return of power in the legs, the Go cart is of great use, since it completely removes all sense of the risk of falling, and the little one, thus convinced of its safety, soon begins to walk again. The Go-cart, however, has this disadvantage, that it exaggerates the disposition to lean very much forward in walking, which is observable in all children even for some time after they have learned to walk pretty well: and thus renders the gait very unsteady. So soon, then, as the child can walk tolerably in the Go-cart, it is as well to discon- tinue its use, either entirely or in great measure, and to substitute for it the following contrivance. A little jacket, made of some stout mate- rial, lined, and padded under the armpits, is put on the child. To it are attached a couple of straps, of stout webbing, one end of which is fastened to the front, and the other to the back of the jacket. The straps are of sufficient length to be conveniently held by the child's attendant, and by means of them its weight is supported more or less completely, while in walking the child is not thrown forwards as when stepping in a Go-cart. Feeling perfectly safe, the child now perseveres in walking: many of the worst consequences of paralysis are avoided, and a more speedy and more complete recovery is obtained than could at first have been anticipated. If the child be old enough to be taught to walk with crutches (and at five or six years old the lesson is soon learned), it is desirable that as soon as possible it should be furnished with them, for it will certainly make greater and surer progress if entirely dependent on itself, than if its weight is borne, or the possi- 206 TREATMENT OF PARALYSIS. bility of falling prevented, by a nurse or attendant. With all this care, however, it is yet quite possible that a disposition to contraction of the adductor or flexor muscles of the leg may manifest itself, calling for employment of splints or other contrivances, or even for surgical interference. When the arm is affected, the principles just laid down are of equal importance, though the mode of carrying them out must, of course, differ. Passive exercise must be strictly carried out: the sound arm must be tied up, either altogether or for a considerable part of the day ; coaxing, bribes, aud all the inducements which move a little child's heart, must be brought into play as rewards for using the feeble limb. Raising a weight by means of a rope passing over a pulley, is a mode of exercising the arm which can be put in practice even in very young children; while in those who are older, trundling a hoop with the feeble arm is a capital plan for joining work and play. I need not say that much care and much patience are needed in carrying out any of these suggestions, and not a little of that intuitive love for children which teaches those who are its possessors how to extract fun and merriment from what might in other hands be a most irksome task. In many cases, however, something more is needed than even the best directed attempts at exercising the paralyzed limb will supply, and this, either from the completeness of the paralysis, or from its long continuance. In these circumstances we generally find the nutrition of the limb greatly impaired, its temperature very low, and its sensi- bility less acute than natural. In such cases, while rubbing the limbs, and other forms of passive exercise, must be most sedulously perse- vered in, I think that I have seen benefit from the warm douche to the lower limbs and the sacral region once or twice a day, when steadily continued for weeks together. One objection to the employ- ment of blisters is, that they of necessity preclude perseverance with the douche; and a similar objection, though not to the same extent, applies to the employment of stimulating liniments. In cases of this kind, however, we constantly find that one remedy, though serviceable for a time, ceases at length to be of benefit: so, when improvement under the douche seems to be at a stand-still, a stimulating liniment may be tried for a season. I usually employ a croton-oil liniment, or one containing the tincture of cantharides in quantity sufficient to produce a rubefacient effect, but not to blister. Blisters not merely cause much distress by vesicating, but have also seemed to me of more transient benefit than liniments. Galvanism is another remedy from which much good is often derived, but its proper application requires an expenditure of time which it is not always easy to bestow, as well as a tact in its employment scarcely attainable except by long practice. Between the results which follow the ordinary rough mode of employ- ing galvanism and its more scientific application by means of that "localized galvanism," for a knowledge of which we are indebted to Duchenne,1 the difference is immense, and I look forward to an 1 For an account of his researches, as well as for most valuable practical informa- tion on this subject, Dr. Lawrence's little work on Localized Galvanism, 12mo. Lon- don, 1858, may be consulted with advantage. FACIAL HEMIPLEGIA. 207 increased dexterity in the use of the latter as to a means by which we may remedy conditions that hitherto we have been accustomed, and not without reason, to regard as all but absolutely hopeless. Of late years much has been said about the so-called Swedish Exer- cises as a means of restoring the usefulness of paralyzed limbs; and though, unfortunately, the direction of them has fallen into the hands of persons not the most likely to maintain the reputation of our profession, we must not on that account undervalue the benefit which they are capable of affording. Two principles seem involved in their employ- ment: the one, the devising of such movements as shall best bring into play those muscles the power over which is deficient; the other, the calling forth the active exercise of the will in determining them. Of the efficacy of the will, as a subsidiary means of restoring power to the partially paralyzed limb, I have no doubt whatever. Of course in the child, whose will is feeble, and liable to be distracted by very trivial causes, this power is far less energetic than in the grown person; but still it is a power well worth cultivating, and the steady perse- verance in it exercised from childhood up to adult age will, I am sure, do more towards the recovery of a paralyzed limb than would ever be imagined from its casual employment on one or two occasions. It would be useless to go into details as to all contingencies in these cases, or to furnish you with rules for the management of each dif- ferent degree or stage of this affection. The remarks I have already made will at any rate put you in possession of the principles by which your conduct must generally be regulated.1 I may just add one word with reference to cases of paralysis of the portio dura. In the child, as in the adult, they usually improve very much; often, indeed, get quite well in the course of time and under treatment directed to the state of the patient's general health. You must bear in mind, however, the possibility of the nerve having under- gone pressure from some enlarged gland; and if you find reason for believing this to be the case, you may apply a leech in the situation where the nerve passes out of the skull—a proceeding which I once adopted with advantage. Lastly, I may just mention, that infants are sometimes born with facial hemiplegia as the result of injury to the nerve from application of the midwifery lbrceps, or, as has in one or two cases been observed, from injury received during the passage of the head through the pelvis without any instruments having been employed. Such occurrences are rare, but it is well that you should be aware of the possibility of their being met with independent of any injury to the brain. The paralysis, in these cases, generally disappears in the course of a few 1 I have not spoken at all of those rare cases of paralysis attended by fatty dege- neration of the muscles, and, as Cruveilhier has shown, by wasting of the anterior roots of the spinal nerves; since they are by no means confined to early life, nor de- pendent on causes with which the patient's age has anything to do. The treatise of Dr. Roberts, on Wasting Palsy, 8vo. London, 1858, contains a very good abstract of our knowledge concerning this disease, for our first acquaintance with which we are indebted to Cruveilhier. See his essay "Sur la Paralysie musculaire progressive atrophique," in the Archives de Medecine for May, 1853. 208 HYPERESTHESIA AND NEURALGIA. days or weeks.1 In the only instance of the kind which has come under my own observation, the distortion of the face, though very great at birth—one eye being wide open, and the corresponding side of the face powerless, so that the child was unable to suck—had already greatly diminished within forty-eight hours, and disappeared com- pletely in a week. Perhaps it would not be right to take leave of this class of subjects, without a brief reference to the occasional occurrence of hyperesthesia and neuralgia in early life. It is certainly singular, when one con- * siders the extreme liability of infants and children to disorders of the nervous system, that cases of exalted sensibility, frequent as they are in the adult, should in them be so rare. Still I have met with these ailments on several occasions; sometimes preceding the loss of power in limbs which subsequently became paralyzed, and then almost in- variably lasting for only one or two days, though I have known ex- ceptions to this, and have observed a state of extreme sensitiveness of the lower part of the spine and of both legs to continue for several weeks, and then gradually to pass away, but leaving the power over the limbs much diminished. Besides these cases, however, I have twice observed in children during teething a state of increased sen- sibility of the whole surface, but chiefly of the lower extremities, so excessive as to render it almost impossible to move them for the pur- pose of washing or dressing. For many weeks one of these children could not be moved out of the horizontal position on account of the severe suffering which any change of position occasioned; while the other was thrown into an agony of crying whenever its legs were touched, either to wash them or to put on or take off' its stockings. Both of these children, of whom one was ten and the other twenty months old at the time of their coming under my care, were much out of health, suffering from severe odontitis, with bleeding and spongy gums, and in proportion as their general condition was ameliorated, the excessive sensitiveness lessened, and in the case of the youuger infant disappeared in about three months. In the case of that child the symptoms had existed only about a month; in the case of the other, more than three months before it came under my notice. When I last heard of him, he was 1\ years old, greatly improved in health, having cut all his teeth, and his gums having become nearly sound. His limbs had for two months ceased to pain him, and he had began to sit up for an hour at a time, though he had not made any attempt to walk. In both instances, iron, quinine, and the chlorate of potass were employed, with a moderate use of wine; and it was under this treatment that the improvement, tardy though it was, took place. Intense neuralgic pain, like that of tic douloureux in the grown per- son, coming and going without apparent cause, is extremely rare. I know, however, of one instance of its occurrence in a little girl aged 10 years, forcing from her shrieks of agony when the paroxysm of pain in her heel came on, but finally ceasing, and leaving behind no impairment of power over the limb, no tenderness on pressure, nor 1 See Kennedy's Observations on Apoplexy, Paralysis, &c, of New-born Infants, in Dublin Journal of Med. Science, 1836; and Laiidouzy, Sur rHemiplegie facial chez les Eufants nouveau-n.s. 8vo. Paris, 1839. HYPERESTHESIA AND NEURALGIA. 209 any evidence whatever of disease. Once, too, I saw a little girl, 7 years old, in whom, after a few days of what seemed like a mild attack of remittent fever, agonizing pain in the head came on, with extreme intolerance of light and sound. The symptoms had been regarded by some medical men who had seen her, as those of hydrocephalus, and treatment in accordance with that supposition had been adopted with- out benefit; but it had not escaped the notice of the very intelligent practitioner who had the chief charge of the child, that vomiting had not preceded, nor obstinate constipation accompanied, these symptoms; that the cries were too vociferous, the suffering too iutense, and the occasional intervals of ease too complete to accord with what might be anticipated if organic disease of the brain were present, while, though the treatment had aggravated rather than improved her condition, no additional sign of cerebral mischief had appeared in the course of four or five days, but pain continued, as at first, to be the only symptom. Regarding the condition as neuralgic, quinine was substituted for the previous antiphlogistic medicines, and the child was at once removed to Tunbridge Wells. Even on the journey the pain lessened in severity, and in a few days had altogether ceased, and the child rapidly regained her health. Two or three cases of a similar kind have also come under my notice in the Children's Hospital, and the symptoms have got better under good diet, perfect quiet, and the employment of quinine. The intensity of the pain, the completeness of its cessation, the persistence of the symptoms, with their non-progressive character, the absence of constipation or of permanent heat of head, as well as of that rapidly advancing emaciation which is rarely absent when active tubercular disease is going on in the brain or its membranes, will generally help us to a correct diagnosis. I have on more than one occasion, when in doubt, experimented for twenty-four hours with quinine, giving a full dose of it every four hours, and have had the satisfaction of finding the experiment succeed, and the symptoms which had seemed to bode such ill, abate, and at last disappear under its continued use. But while cases such as the above are very rare, it is by no means unusual for children to have attacks of headache, often of considerable severity, and attended with temporary intolerance of light and sound as the result of slight gastric disorder, or produced by slight over- fatigue or over-excitement. Such attacks closely resemble the sick headache, or the hysterical headache, to which delicate women are liable. They come on suddenly; they do not last above twelve, or at the utmost twenty-four, hours; they cease spontaneously (though a mild aperient or an alterative dose of mercury accelerates their depar- ture), and, except a little languor, they leave behind them no sign of indisposition. Anxious parents are often solicitious about these attacks, lest they should portend disease of the brain; their very suddenness and their frequent recurrence, however—circumstances which awaken the alarm of non-professional persons—may serve rather to allay your apprehensions when taken in connection with the speedy cessation of each attack, and the absence of any abiding evidence of cerebral ail- ment in the intervals. 14 210 NIGHT TERRORS. LECTURE XVI; Night Terrors—usually depend on intestinal disorder, not on primary disease of the brain —their symptoms not to be mistaken for those of incipient hydrocephalus—sometimes continue to occur for many weeks. Treatment. Disorders of the Mind in childhood—knowledge of them very imperfect—misuse of the term Cretinism. Mental peculiarities in childhood, how they are obvious in its disorders, which partake of nature of moral insanity ; and why they do so. Hypochondriasis and Malingering in children—illustrative cases—suggestions for their management. Moral Insanity—conditions resembling it sometimes arise from over-exertion of mind—case in illustration, and principles of treatment.—Cases of more aggravated character, and independent of that cause. Mode in which intellect becomes dulled in such cases. Idiocy—difference between idiocy and backwardness, how to be distinguished from each other. Deficiency of our knowledge on the subject of idiocy—its frequency as a con- genital condition overstated.—Characteristics of idiocy in early infancy and as the child grows up. Objects of education of idiots—its difficulties, and principles which should direct it. It happens sometimes that a child who has gone to bed apparently well, and who has slept soundly for a short time, awakes suddenly in great terror, and with a loud and piercing cry. The child will be found sitting up in its bed, crying out as if in an agony of fear, "Oh dear! oh dear! take it away! father! mother!" while terror is depicted on its countenance, and it does not recognize its parents, who, alarmed by the shrieks, have come into its room, but seems wholly occupied with the fearful impression that has aroused it from sleep. By degrees consciousness returns; the child now clings to its mother or nurse, sometimes wants to be taken up and carried about the room, and, by degrees, sometimes in ten minutes, sometimes in half an hour, it grows quiet and falls asleep. As the terror abates, the child in some in- stances becomes quiet at once, but frequently it bursts into a fit of passionate weeping, and sobs itself to rest in its mother's arms. In some instances a quantity of limpid urine is voided as the fit passes off', but this occurrence,is by no means constant. Usually, the remain- der of the night is passed in tolerably sound sleep, and the following night the child may rest quite undisturbed; or the terrors may again return, and with precisely the same symptoms as before. The attack usually comes on after the child has been from half an hour to a couple of hours asleep; and two attacks do not generally occur in the same night. They are always more or less distinctly associated with the impression of some object which occasions alarm—as a cat or dog, which is fancied to be on the bed; and this illusion continues even after the child has recognized those who are around it. The condition is not one of delirium, for the child has no other hallucinations, but the attack may return night after night with precisely the same charac- ters. The previous sleep sometimes seems sound, and though often uneasy, yet talking in the sleep does not usually occur, and after the NIGHT TERRORS. 211 child has been pacified it generally sleeps heavily, perhaps till morning, or till a second, usually slighter, attack comes on; but this scarcely ever happens until after sleep has again lasted for an hour or longer. Seizures of this kind may come on in a great variety of circum- stances, and, according to the cause whence they have arisen, may continue to return for many weeks together, or may occur but a few times. As far as I have had the opportunity of judging, they are never the indications of primary mischief in the brain, but are always associated with some disturbance of the intestinal canal, and more or less obvious gastric disorder. Some years ago I saw a little boy, aged 11 months, in whom the process of dentition was just beginning, and who for ten days had had slight diarrhoea, with dark and slimy evacuations. He then awoke one night, though before apparently sleeping soundly, with a sudden start, and a scream so violent that all the people in the house heard it. When taken out of bed he continued crying loudly for some minutes, but by degrees grew quiet and fell asleep again, sweating profusely. This sleep was as heavy as it had been before, though the eyes were not always closed during it; but after an uncertain interval of from half an hour to two hours he would again wake with the same loud and terrified scream, and again in a few minutes sink into slumber. The first of these attacks had taken place six days before the child was brought to me: they were increasing in frequency, as many as seven or eight having occurred in the course of a single night, and even during his sleep in the daytime the child was not free from them. He was cheerful, however, at other times; he sucked well, did not vomit, his head was not hot, and the anterior fontanelle was depressed rather than prominent; but the abdomen was rather full, and some- what tender; the gums were much swollen, and the tongue was rather furred. The gums were lanced, the child was put in a tepid bath every night; a powder containing one grain of hydr. c. creta, and one of Dover's powder, was given daily at bedtime, and 3j of castor oil every morning, and the attack subsided. Cases of this kind illustrate a point of practice which, though im- portant in the adult (you will find it insisted on by Andral in his Clinique Medicale) is still more so in the child. It is, that in many affections of the brain there is a stage quite at the commencement in which depletion may be out of place, but opiates or sedatives will allay the irritation, which, if let alone, would issue in dangerous or fatal congestion, or inflammation. In the majority of cases of these night terrors, the condition of the bowels is one of constipation, not of diarrhoea. Sometimes, after gas- tric disorder has continued for a few days, in the course of which, perhaps, vomiting may have occurred, an attack of this nocturnal alarm may throw the parents into a state of great apprehension lest hydrocephalus should be impending. I have seen a very severe attack of jaundice come on with these symptoms; and in such a case it is important to bear in mind the difference between the sudden, sympathetic disturbance of the brain, and the more gradual approach 212 TREATMENT OF NIGHT TERRORS. of hydrocephalus with the drowsiness the child experiences, and yet the difficulty it has in going to sleep, the restlessness all night long, or the unquiet slumber, with the moaning and startling which I pointed out to you when speaking of that disease. If, then, bearing in mind these facts, you find that the child who has bad this attack in the night yet does not complain of intolerance of light, or of much or any headache, and that while the head is cool and the pulse regular, the abdomen is full and hard, and perhaps slightly tender, you will scarcely take the less for the more dangerous affection. But these symptoms may last for weeks or months together, neither diminishing nor much increasing in severity, so that they seem almost to constitute an independent disease; a view which Dr. Hesse, of Altona,1 who has written a very good pamphlet on it, is disposed to take somewhat too generally. Such a case was that of a delicate boy, seven years old, who during the previous twelve months had been cutting his first permanent molar teeth, and for the whole of that time had suffered from attacks of night terrors, which usually came on about half an hour after he had fallen asleep. He then started up with a wild and terrified look, and loud outcries, appearing not to know any one for some time, then begging to be taken up, and becoming pacified after being carried about for half an hour in his father's arms. As the seizure passed off' he used to void a large quantity of limpid urine, and having fallen asleep again, never but once had a second attack of it in the same night, while sometimes none occurred for two or three nights together. In other respects he seemed to be tolerably well, and was a lively and intelligent child, though for about fourteen days before he was brought to me his health had appeared less good, and there were evident in- dications of gastric disorder. I never saw this child but once again, so I cannot tell you his subsequent history; but his case affords a good illustration of the occasional persistence of these symptoms for a long time without the supervention of any really serious disease. Although these symptoms may be the result of sympathetic affection of the brain through the medium of the abdominal viscera, still you should watch a child in whom they had frequently occurred with especial care, knowing that long-continued irritation of the nervous centres may, under the influence of comparatively trivial causes, issue in serious disease. Your chief attention, however, must be directed to the removal of the disorder of the intestinal canal; and this should be attempted by gentle means—by a careful regulation of the diet, and the judicious combination of aperients and tonics, rather than by drastic purgatives. At the same time, too, it is right that the child should not be left in the dark, or alone; the aff'ection resembles night- mare, and in childhood dream-images seem to mingle with the waking impressions much more than in adult age. A light burning brightly in the room, and a familiar face meeting the child's eye at once on waking, will do much towards breaking the spell, and towards allay- ing its fears. Harshness in such cases is quite out of place, and few 1 Ueber das nachtliche Aufschrecken der Kinder im Schlafe. 8vo. Alterberg, 1845. DISORDERS OF THE MIND IN CHILDHOOD. 213 pieces of cruelty can be greater than forcing a timid little child, in whom threatenings of these attacks have occurred, to go to bed in the dark, or to lie there without a candle, while its active imagination conjures up before its eyes, out of the bed-curtains or other objects in the room, the outlines of all sorts of terrific forms. I have noticed this aff'ection, not merely on account of its own im- portance as the occasion of much distress to the child, and sometimes also of much anxiety to its parents, but also because from it we may pass by a very fit transition to the brief consideration of some other forms of disorder of the highest functions of the brain in early life. My remarks on these subjects must of necessity be very fragmen- tary and imperfect; so much so, indeed, that if I knew to what authors to refer you for information concerning them, I should feel that, by sending you to consult their writings, my duty would be best dis- charged. But books will not help you here: and I will try to tell you the little that I know, in the hope that it may at least prevent you from going into practice with the impression that perversion of the intellect may not occur in the child as well as in the adult; or from supposing, if you do meet with a case too striking to be over- looked, that you have done all which can be expected of you in the way of diagnosis when you have pronounced the child an idiot; or all that is possible in the way of treatment, when you have provided for its safe custody. The first step towards a better knowledge of these affections was taken when that form of idiocy which is endemic in certain localities, and is connected with various disorders of physical development, began to attract general attention. To Dr. Guggenbiihl unquestionably belongs the merit of having given the first impulse to this study by his observations on cretinism, though it is to be regretted that his subsequent career has neither conduced to his reputation as a physi- cian nor to the support of his character as a philanthropist. Cretinism is, however, but one of many forms of disordered development of the intellect; and there seems to be some risk of our being led into error by the extension of this term to a very large number of cases of idiocy occurring under conditions which have but a very slight resemblance to those which induce the endemic form in Alpine districts. But not only are the causes of idiocy various, and the characters which it pre- sents very different in different cases; but perversion of the intellect or of the moral faculties, as distinguished from mere feebleness of mind, is met with in childhood as well as in adult age, and deserves to be regarded and to be treated as insanity no less in the one case than in the other. In the first of this course of lectures, I pointed out to you the pecu- liarities impressed on the diseases of early life by the circumstance that childhood is a period of development. The peculiarities of the mind in early life are, however, more numerous and more important than even those of the body, and impart their characters to its dis- eases. A child's experience is small, his ideas are few, and those are gathered from the world around him, not from his own reflections, 214 DISORDERS OF THE MIND IN CHILDHOOD. while one impression succeeds another with greater rapidity than his feeble memory can hold fast. Hence, in disorders of the mind in early life, we do not meet with the distinct hallucinations, the fixed ideas, which characterize insanity in the adult. But though the intellectual powers are imperfectly developed, the feelings and the impulses are stronger, or, at least, less under control, than they become with advancing years; and one great object of education is to bring them into proper subordination. Mental disorders, then, show them- selves in the exaggeration of those feelings, the uncontrollable char- acter of those impulses; in the inability or the indisposition to listen to that advice or to be swayed by those motives which govern other children. The affection, in short, is of that kind to which the name of moral insanity is usually given. With this state of mind, however, the child is of course less teachable than others—less able to apply to any form of learning; while tits of passion or of sullenness sometimes for days together put a stop to every attempt at instruction. The disorder of the moral faculties thus reacts upon the intellect; the child learns but little, and consequently grows up ignorant, as well as ungovernable; till at length either the evidences of insanity become with its advancing years unmistakable, or the mind, growing more obtuse from long want of culture, the case sinks down into one of mischievous idiocy.1 Now it is my belief that practitioners in general have not their atten- tion sufficiently alive to some of these forms of mental disorder in early life. They are familiar with the idea of the idiot, as a being incapable of learning anything, unfit to take care of himself, still pleased with the toys of babyhood; but with a heart as stainless, and affections as overflowing, as the infant's. They are acquainted, too, with the general characters of cretinism, where the mind and body are alike dwarfed and misshapen by the influence of an unhealthy dwelling; but cases such as I have just referred to scarcely attract their notice. They are passed by as anomalies, as painful instances of some extreme badness, or of ungovernable temper, or of strange oddity about the child, from the study of which there is nothing to be learned, and for its remedy nothing to be suggested. Many of these anomalous cases are, I believe, instances of a kind of mental disorder especially liable to issue in confirmed insanity. I have already assigned reasons for the opinion that affections of the mind in childhood must oftener display themselves in perversion of the moral faculties than in disorder of the intellectual powers; and bearing this in mind, I would always watch with close attention those cases of extremely bad disposition, of unconquerable stubbornness, or unma- nageable fury, of which sorrowing parents sometimes tell us, though with but little hope of our suggesting anything that may remove or mitigate their bitter grief. 1 My remarks refer to those slighter forms of mental unsoundness which present themselves to the notice of the ordinary practitioner. The subject of insanity in early life will be found specially noticed by Dr. Connolly in " Medical Times," March and April, 1852 ; and by Brierre de Boismont, " Annates d'Hygiene," 2d Series, vol. x. 1858, p. 362. HYPOCHONDRIASIS AND MALINGERING. 215 One of the least serious, though by no means of the least puzzling of these perversions of the moral faculties in childhood, is the disposi- tion occasionally noticed to exaggerate some real ailment, or to com- plain of some ailment which is altogether imaginary. It is difficult to assign any sufficient reason for this conduct; mere indolence seems sometimes to be the chief motive for it; often vanity; the sense of importance in finding everything in the household arranged with ex- clusive reference to itself appears to have led to it—a feeling which may sometimes be*observed to be very powerful, even at an exceed- ingly early age. In many instances a morbid craving for sympathy is mingled with the love of importance, and both these sentiments are not infrequently gratified and exaggerated by the conduct of a fool- ishly-fond mother. Real illness, however, in almost all of these cases exists at the commencement, though the child persists in complaining of its old symptoms long after their cause has disappeared. Not very long since I met with a case which illustrates these remarks extremely well. A lad, aged 13, whose family were not very healthy, and who himself had at no period been robust, fell ill, nine months before I saw him, with headache and other vague cerebral symptoms, his illness having apparently been brought on by grief at the death of a favorite sister. This sister, too, had died of some disease of the brain, as had two other members of the family previously, and the anxiety about himself, which a knowledge of these facts naturally excited, was still further increased by his mother's desponding tone, and by the anxiety often expressed by her in his hearing lest he should likewise fall a victim to the same disease. From the very commencement his symptoms had presented a nearly uniform character, and had varied but little in intensity. They con- sisted of headache, with extreme sensibility to sound, even more than to light, so that if an organ was played in the street he would some- times rush into another room and bury his head in a pillow to be out of hearing of the noise. Coupled with these was extreme sensitiveness of the scalp and of the hair, so that for several months he had not allowed his hair to be brushed, combed, or washed; but this sensibility did not extend to the face or the spine. The boy's appetite was very bad; he not infrequently suffered pain after eating, and for some four months had complained of pain and tenderness in the right hypochondriac and iliac regions; his bowels were constipated, his urine scanty, with considerable deposits of lithates, and occasional pain in voiding it, and erection of the penis sometimes took place during the act of micturition. The boy was rather small for his age, ill-nourished but not emaci- ated, his upper lip slightly swollen, his abdomen soft and not at all full, and though he said that he had pain in the right hypochondrium, yet the abdomen was quite as soft there as elsewhere. His pulse was about 113, and very feeble; his tongue moist, slightly coated; respi- ration was quite good in both lungs. As he came into the room the lad stooped; he walked feebly and with a slouching gait, but seated himself opposite the light without any apparent discomfort, and answered questions intelligently, though 216 CASES OF MALINGERING. bis speech was a little thick and hesitating; and there were slight twitchings of his face as he talked. The question raised in this case was, whether the symptoms which I have just enumerated did or did not depend upon organic disease of the brain. I believe that no disease existed; for in spite of the long continuance of the symptoms, the boy was confessedly no worse than he had been many months before. Moreover, the absence of any fit, of any paralytic aff'ection, or of impaired power over any limb; the fact that vomiting had never occurred, and that the pulse presented no other character than that of extreme feebleness, negatived, in my opinion, the supposition that disease of the brain existed. Besides, though he complained of so much tenderness of the scalp that the slightest touch of his hair caused extreme distress, yet on several occa- sions, when the hand had been laid gently on his head without his being aware of it, he made no complaint till he saw the hand. His father also said that he walked better when not noticed than when he was aware of any one's presence; that though he was unable to read, he yet was very fond of playing at cards, and that of an evening, when so occupied, he often seemed quite cheerful, and like other children; and moreover, his sleep at night was in general tolerably good. In these circumstances—the intervals of ease, the quiet sleep, the manifest influence of notice in increasing his ailments, and of amusement in re- moving them—there seemed to be further and conclusive reasons against the supposition that the symptoms depended on organic cere- bral disease. Treatment of various kinds having been long pursued without any benefit, I recommended the complete discontinuance of all medicines with the exception of the cod liver oil, to which the boy showed no repugnance, while the very imperfect manner in which he was nour- ished seemed to furnish a good reason for its employment. His health having previously somewhat improved at the sea-side, I advised that he should go thither again, but to a fresh place, and unaccompanied by his mother; that while there all obvious reference to his head, either in-general management or medical treatment, should be sedu- lously avoided, while an endeavor should be made, by fresh occupation and fresh amusements, to turn his thoughts into a new channel. This advice was not completely carried out, for an appearance of medical treatment was still kept up, though no active remedies were any longer employed. The boy, however, was sent to the sea-side, and without his mother; and three months after, I heard of him as being in no respect worse, and in many better, than when I saw him; and eventually he perfectly recovered. Another case of a somewhat similar kind may also deserve a brief notice. A little girl, aged 10J years, whose mother, though a woman of considerable talent, had shown many peculiarities of character, came under my care on account of attacks of headache of the most intense severity. She had suffered from convulsions when 18 months old, and a slight illness at the age of 3 was attended by their return. When 6 years old, she began to suffer from a peculiar spasmodic cough, succeeded in the course of some months by considerable tender- CASES OF MALINGERING. 217 ness of the epigastrium. During the course of treatment for these ailments, she began to experience attacks of headache, which, from the age of 8 years until the time of her coming under my care, were reported to have returned frequently and without cause. Apparently nothing could be more arbitrary than the occurrence of these head- aches; present at one time with excruciating severity, absent at an- other for weeks together. A constipated state of the bowels, and a capricious appetite were the only abiding symptoms of ill-health which existed; but there did seem to be some connection between her occa- sional residence in a damp situation, and an increase in the frequency and intensity of her headaches. The first time that I saw her, her countenance was anxious and ex- pressive of intense suffering. She sat with her hand to her head, cry- ing out vociferously, and asserting her inability to move from one room to another; though on being told decidedly that she must walk, she at once rose from the chair where she was crouching, and walked easily and firmly into another apartment. The child's pulse was rather feeble, but otherwise natural; her tongue a little coated, but there were no symptoms of serious illness about her. Sometimes she lay all night grievously complaining of headache; sometimes she slept well, and her sleep was usually more sound if she took some stimulant at bedtime. Accompanying the complaints of headache, there was a loss of interest in all childish pursuits, a waywardness and irritability quite unnatural in a girl of her age; and though now and then roused by some occurrence which interested her, she soon relapsed into her former condition. Sometimes she would rise before six o'clock in the morning, and go for a walk with her maid ; while at other times she would lie in bed till a late hour. Her appetite was never large, but there were times when she took food moderately well, while at others she rejected it; and at last absolutely refused to feed herself; so that it became necessary to feed her like an infant. She clung to her mother during the whole of this time with the most exaggerated pro- testations of affection, but it was obvious that her complaints were always louder and more constant in her mother's presence; and when accidental circumstances took her mother for a few days from home, there was a marked improvement in the child's condition. If I came into the room unexpectedly, the child was often found at cheerful play; but the moment she perceived me, her hand was reapplied to her head, and her moan recommenced. Treatment of the most differ- ent kinds had been tried for years; the mother's conviction in the existence of some very serious disease was strengthened by the inu- tility of medicine, and her sympathy with her child, and lamentations over her sufferings, were often expressed in the child's presence. My opinion that no serious disease existed, that the complaints were exag- gerated, that the mind needed discipline more than the body did medi- cine, that the child's cure would be difficult, if not impossible, so long as she remained with her mother, was unpalatable, and was considered unkind. To turn the attention into new channels; to lay aside ordi- nary tasks, such as hitherto, when apparently well enough to engage in them, she was set to; to give her the charge of live animals, and 218 CASES OF MALINGERING. to endeavor, by teaching her something of their habits, or something of plants and flowers, which a country residence would have rendered easy—did not seem to be the rules that a doctor was expected to give. Physic was what the mother came to me for, and as I could not under- take the child's cure by drugs, she was soon removed from under my care. She returned home, and in a few days well-marked globus hystericus was added to her other symptoms; she next had general convulsions, though not accompanied by complete loss of conscious- ness, then hysterical dysphagia, during the continuance of which she was nourished chiefly by enemata of beef-tea; and at last these symp- toms assumed the character of complete hydrophobia: the appearance of water in a cup caused her to shudder, and the attempt to swallow any fluid produced an attack of general convulsions. This condition lasted for several days; by degrees its worst features subsided, the child regained health, and six months afterwards, when I heard of her, she was galloping about the country on her pony, and cured for the present of all her ills. Now in cases of this description, and in others of a similar kind which have come under my notice, it is much less the state of the body than that of the mind which excites my apprehension. The constant watching its own sensations, the habit of constantly gratify- ing every wayward wish and temper under the plea of illness, and the constant indulgence which it meets with in this from a mother's overkindness, exert a most injurious influence on the child's character, and it grows up a juvenile hypochondriac. It is well to be on our guard against the possibility of this occurrence in all the more pro- tracted diseases of childhood; to warn the parents of it, in order that they may join with us in the endeavor to keep the child's mind healthy during the long illness of its body. It is but seldom that this condition comes to be so marked as in the cases which I have related, without very injudicious management on the part of the parents or friends. In such circumstances we often find it necessary to use great caution in conveying to their minds the suspicion which we entertain, and the expression of which they will be disposed to regard as a most unkind and unfounded libel on the child. Another phase of mental disorder in childhood sometimes presents itself to us as the result of over-tasking the intellectual powers. This over-work, too, is by no means in all cases due to the parents unwisely urging the child forward, but is often quite voluntary on its part. Sometimes, too, the friends of the child are so alive to this risk, that they limit the hours of work—a precaution which nevertheless often proves inadequate, from the want of some due provision for turning the thoughts and energies during play hours into some perfectly dif- ferent channel. In many of these cases nature happily takes matters into her own management. For a year or two, or more, the mind has grown appa- rently at the expense of the body; the parents take a fearful joy in their darling's acquirements; and if it should but live, think they, of what remarkable talents will it not be the possessor! By degrees, the extreme quickness of intellect becomes less remarkable; but the body MORAL INSANITY. 219 begins to increase in robustness; and a year will sometimes suffice to transmute the little fairy, so quick, so clever, but so fragile, into a very commonplace, merry, rosy, romping child. I may add, that it is well to bear in mind the converse of this; to remember that body and mind rarely grow in equal proportion at one time; that the incor- rigible little dunce, though not likely to prove a genius as he grows older, will yet very probably be found at twelve or fourteen to know as much as his playmates. A dull mind and a sickly or ill-developed frame, may make us anxious; but if the physical development is good, the mind will not be likely to remain long below the average standard. But sometimes the overtasked mind leads to mischief which nature cannot rectify; an attack of cerebral inflammation comes on—often partakes of a tuberculous character, and destroys the patient; or if not, the child sinks under almost any accidental disease. In other instances, however, neither of these results takes place, but the whole nervous system seems profoundly shaken, and the moral character of the child seriously, and even permanently, injured. A little girl, of whom her mother gave me the following history, came under my notice when seven years old. Never very robust, but quick and clever, her governess took pleasure in urging her for- ward, though never at the expense of what was supposed to be suffi- cient rest from study, and amusement suited to her years. However, when 5| years old, the first signs of over-taxed brain appeared in frequent extreme irritability, and occasional causeless attacks of fury, amounting almost to madness. A few' weeks after the commencement of these symptoms, the child began to suffer from chorea, affecting both sides of the body, though not severely; and at the same time she occasionally stumbled, and even fell when walking, though not from the violence of the spasmodic movements; and made complaints of frequent headaches, which were attended with great heat of head. The chorea disappeared, the child improved altogether, though still having occasional headaches, and retaining much irritability of man- ner. Her improvement took place during a quiet residence at the sea-coast, and a return to London was followed by an attack of influ- enza and an aggravation of her symptoms, with the exception of the chorea, which did not return. Revisiting the country, she once more improved, but a return to London, and the resumption of her educa- tion, even in the most careful manner, were followed by increased headache and more ungovernable temper; and it was in these circum- stances that she came under my observation. She was a fair-haired, delicate-looking child; but with the excep- tion of slight contraction of the left orbicularis palpebrarum muscle, there was nothing remarkable in her appearance. Her pulse was rather feeble; and her mother stated that she was soon tired, and that every day she needed quiet rest upon a sofa for a couple of hours. Occasionally, whether at work or play, she would be attacked with very severe headache, which never lasted for more than a few minutes, but during its continuance incapacitated her, by its intensity, for any- thing. Equally sudden, and almost equally causeless, were the attacks of fury which she now and then manifested, and which a word, a look, 220 MORAL INSANITY. or her favorite companion entering a room before her, or stepping before her up the stairs, would suffice to bring on. At one time she had vented her anger in blows; but though she did not now strike those who offended her, she would burst forth into the most violently abusive language, though seldom uttering above a sentence or two. Sometimes she denied, and her mother believed with truth, that she knew what she had said; at other times she seemed aware of it, and throwing her arms round the person whom she had so addressed, would express her sorrow and beg to be forgiven. There was still some dis- position to fall when walking, though nothing like a fit had ever been observed; and if anything was given to her to hold or to carry, she would not unfrequently let it fall. The child's general disposition was amiable; she was very intelligent in her manner, but was morbidly solicitous about her health, and disposed to exaggerate every ailment— a disposition, however, which had been most judiciously controlled by her mother. In this case, while conceding the possibility that the occasional stumbling in her walk might be the prelude of epilepsy, and that the fits of fury might issue in abiding disorder of the mind, I yet was disposed to entertain a more favorable prognosis—and this, founded in no slight degree on the great good sense with which the child's mother recognized these dangers, and applied herself to guard against them. As the return to her previous pursuits, even though attempted with the greatest care, was followed on each occasion by a deterioration in the child's condition, I advised that for a time they should be com- pletely laid aside; that she should go into the country; that for French, and music, and history, should be substituted botany, the keeping and managing of pet animals, the studying their habits, and all that class of quiet occupations which the country offers, especially to those whose friends, as was the case with this little girl, have the intelligence to derive from them the full measure of advantage which they can be made to yield. I believe the recognition of the real danger, and the adoption of a proper plan of management, to be of the greatest possible importance in these cases ; and yet the doing so is attended with great difficulty. Not merely is the danger at which we hint so fearful, but the idea of permanent disorder of the mind occurring in childhood seems to the parents so strange, even so improbable, that they are disposed too often to think the risk an imaginary one, and to reject the counsel we offer concerning the best manner of its avoidance. Moreover, the recommendation, which I believe to be a sound one, that in almost all of these cases the child should be separated from its parents, while it adds to their distress, diminishes at the same time the probabilities of their compliance. I am certain, however, that the parents are very rarely the best persons to carry out the management of the child; often, that they are the very worst to whom it could be intrusted. The very motives which, in the proper relation between parent and child, are the most cogent to induce the latter's obedience, are not of a kind to be exposed to the wayward caprices of that child when its CASES ILLUSTRATIVE OF INSANITY IN CHILDHOOD. 221 moral faculty is perverted. With the most undeviating kindness, there is yet necessary in the management of such a patient a complete impassibility, if I may use the word. " You grieve me," " You make me sad by this or that conduct, by this wilfulness, or this fit of fury," is in these cases too often but an announcement to the child of a never- failing mode of annoying those whom he may wish to vex, and the discovery of this power is alone sufficient to weaken their authority and control. Moreover, the steady undeviating pursuit of a certain plan for weeks, or months, can scarcely be intrusted with safety to persons so deeply interested in its issue, so apt prematurely to rejoice in its success, and to diminish their precautions, or equally prema- turely to despair of benefit, and therefore to relax in their vigilance, as the parents of the suffering child. Besides, all the thousand re- collections of infancy, which link together parents and children, instead of strengthening, do but fetter their hands if they undertake this office. I should not have thought it necessary to add, that a school is not the place for such children, if I had not sometimes known them to be sent thither, under the vain expectation that the society of other chil- dren would amuse, and the necessary regulations of the place would control and amend them. Ordinary school discipline, however, is intolerable to them ; occasions of anger constantly abound there, while the frequent outbreaks of fury, characteristic of this condition, can neither be passed over without notice, nor subjected to controlling influence of the proper kind. The houses of those who receive imbecile and idiot children are, however, not fit places for this class of patients. Their intellect is active enough; they are revolted by the stupidity of those around them, and find a mischievous pleasure in tormenting and annoying them, while no rules can be laid down suited for the management of cases so different as the idiotic and the insane. I believe that children in this condition do best as the only inmates of a quiet family, under the constant control and supervision of some person competent to enter into their pursuits, and to share their pleasures; to whom they may become attached, but whose relation to them will not be so intimate as to place it in their power, even when most wayward, to cause serious vexation or distress. At intervals, as the child improves, it may be allowed to associate with other children; at first in their play, as in dancing, for instance, or in some out-of-door amusement—afterwards at other times, and with fewer restrictions; but a course of education apart from other children, different in its manner and its objects, is, I am sure, desirable till the mind has quite recovered its balance, and the power of self-control has been developed and strengthened. The cases that I have hitherto related were instances of only the slightest degrees of a condition which, if not remedied, may pass into confirmed insanity. I believe the gradations to be almost imperceptible by which the one state passes into the other, and I know of some cases in which the ungovernable temper and occasional fury of the child have changed after puberty to complete mania, which rendered the 222 CASES ILLUSTRATIVE OF INSANITY IN CHILDHOOD. patient the inmate, and, I fear, the permanent inmate, of a lunatic asylum. One more history I may add, to show some of the steps by which the change from bad to worse takes place. A girl, .12 years old, an only daughter, pretty, clever, but very vain and very fond of dress, the object of her parents' doating fondness, which she returned with equal affection, was urged by the love of display, and the desire of praise, beyond her powers. She grew wilful, unmanageable, ungovernably passionate; but in spite of this, her expressions of attachment to her mother became stronger and stronger, and on the occasion of her mother's illness it was almost impossible to keep her from the sick room; and she gave way to fits of fury if ever of necessity denied ad- mittance. She was now, by medical advice, sent to school, in spite of her most earnest entreaties to the contrary. She remained there two months, during which time she had been extremely unhappy, and returned decidedly worse. The first indication that she showed of positive in- sanity consisted in lacing her stays as tight as possible over her abdo- men, and in tying a handkerchief tight round her body for the same purpose. For this she assigned no reason, but' became furious if pre- vented from accomplishing this purpose. Soon afterwards she had another delusion with reference to the state of her bowels, which she was always trying to relieve, spending sometimes several hours together running up and down stairs to and from the water-closet. Under a very partial adoption of a plan such as I have mentioned, combined with due attention to the state of her bowels, which were very constipated, considerable improvement took place, and continued for nearly a year. By degrees, however, the ungovernable temper returned, the child's paroxysms of rage became frightful in their vio- lence, and lasted sometimes for hours together, and the desire to be perpetually on the water-closet became as strong as ever. In this con- dition, about two years from the date of her first showing signs of mental disorder, she died; but of what disease, or in what special cir- cumstances, I am unable to tell. But it is not only in these circumstances that moral insanity pre- sents itself to us in children. Mental disorder in childhood seems, as I have already stated, almost invariably to assume this character, whatever be the condition in connection with which it comes on. I once saw a little girl, six years old, who from the age of one year had been subject to fits of an epileptic character, which sometimes were severe, and lasted for several hours, but did not seem to exercise any abiding influence on her general health. They recurred at uncer- tain intervals of from two to seven months, and though sometimes apparently induced by sudden alarm, often came on independent of any obvious exciting cause. But besides the fits, there were some mental peculiarities about the child which excited her parents' appre- hension, and the more so, since the older she grew the more striking did they become. When I saw her she was a tall, fair-haired, blue-eyed child, and the abiding expression of her countenance was pleasant. She walked DISTINCTION BETWEEN BACKWARDNESS AND IDIOCY. 223 awkwardly, however, with her head very much bent down; and when she stood, she kept up an almost unceasing mechanical movement of her hands up and down the front of her dress, or tossed them about not unlike a child with chorea, except that the movements were less violent. Her manner was tolerably intelligent, indeed not without a certain precocious shrewdness, but she laughed once or twice unmean- ingly, and on my refusing to give her a toy to keep, which she had amused herself by playing with, she at once struck me. She was decidedly backward in knowledge as compared with other children; but, owing to her condition, had never been taught much. Her parents said that she was quick if she could be induced to apply, but that she never would apply to anything for more than a few minutes. She was said to show a fondness for music; and, though unable to write, it was a favorite amusement with her to scribble over paper in imitation of the writing of her elder sisters. In disposition she was said to be either an angel or a demon; though fond of her sisters, she would strike them on the slightest provocation, and she had occasional fits of most ungovernable fury. The advice which I gave with reference to the management of this child was similar to that which I have already given you. It was partially adopted, and with some improvement in her condition, though I do not know what was its ultimate issue. My object in relating the case, was to add another illustration to those already given, of the peculiar character which disorder of the mind assumes in early life, and of the differences between it and mere idiocy or feebleness of in- tellect. The earlier these symptoms manifest themselves, and the more aggravated their form, the greater will be their influence on the intellectual powers, and the more, completely will they interfere with the education of the child, who may in consequence sink in the course of time as low in intelligence as the most hopeless idiot. Idiocy is unquestionably of much more frequent occurrence in child- hood than are those affections of the mind which have hitherto engaged our attention. The term idiocy, however, is a very wide one, include ing conditions differing remarkably from each other, both in kind and in degree, while not seldom it is misapplied to cases in which there is mere backwardness of the intellectual powers. Backward children enfants arrieres, as the French call them—consti- tute a class by no means seldom met with. They generally attain their bodily development slowly, and the development of their mind is equally tardy. They cut their teeth late, walk late, talk late, are slow in learning to dress and to wash themselves, are generally dull in their perceptions, and do not lay aside the habits of infancy till far advanced in childhood. When the time comes for positive instruction, their slowness almost wears out every one's patience; and among the poor, indeed, the attempt at teaching such children is at length given up in despair, and growing up in absolute ignorance, it is no wonder that they should be regarded as idiots. Still, dull as such children may be, and duller still they must needs become if allowed to grow up untaught to manhood, there is a difference between them and idiots, 224 DISTINCTION BETWEEN BACKWARDNESS AND IDIOCY. and one which I cannot better describe than in the words of M. Seguin,' who has both written and worked so well on this very subject. "The idiot," says he, "even in the slightest degree of the affection, presents an arrest of development both of body and mind; the back- ward child does not remain stationary, but his development goes on more slowly than that of other children at his age; he is behind them in the whole course of their progress, and his delay increasing every day, places at length an enormous distance between him and them—a distance which, in fact, is insurmountable." In some of its minor degrees, even this backwardness not unfre- quently excites the solicitude of parents. I have observed it in chil- dren who had been ill nourished in infancy, or who had been weakened by some serious and protracted illness, even though unattended by any special affection of the brain; but I have also observed it in other instances independent of any such cases. Be the history, however, what it may, the ground on which you rest your opinion that the case is not one of idiocy is this;—that though, at 4 years old, the child may not seem to be intellectually superior to most children at 2, yet in manners, habits, and intelligence, it does agree with what might be expected from the child at 2; less bright perhaps, less joyous, but still presenting nothing which, if it were but younger, would awaken your apprehension. It is well, in all cases of unusual backwardness, to ascertain the condition of the sense of hearing, and of the power of speech; for I have known the existence of deafness long overlooked, and the child's dulness and inability to speak referred erroneously to intellectual deficiency; and have also observed mere difficulty of articulation, partly dependent on malformation of the mouth, lead to a similar mis- apprehension. In both the instances referred to, the complete inability to keep up intercourse with other children, or the great difficulty in the attempt, had cast a shadow over the mind; and the little ones were dull, suspicious, unchildlike. A similar effect is not unfrequently produced by serious illness, even after the time of infancy is passed. The child will for months cease to walk, or forget to talk, if these had been but comparatively recent acquirements; or will continue dull, and unequal to any mental effort, for weeks or months together, and then the mind will begin to develop itself once more, though slowly; possibly so slowly as never altogether to make up for lost ground. In idiocy,2 however, there is much more than this; more even than the mere arrest of the intellect at any period. The idiot of eight years old does not correspond in his mental development to the child at six, or four, or two; his mind is not only dwarfed, but deformed; while feebleness of will is often as remarkable as mere deficiency of power of apprehension. Numerous questions suggest themselves to us with reference to this subject; to many of which I can attempt no ' Traitement Moral, etc., des Idiots, p. 72. 12mo., Paris, 1846. 2 It is almost needless to observe, that idiocy is here spoken of independent of that peculiar variety, endemic in certain localities, and which, under the name of cretin- ism, has attracted so much attention of late years, and has been the subject of seve- ral reports, both to the Sardinian, Austrian, and Swiss Governments. CAUSES OF IDIOCY. 225 answer whatever, to none of which can I return anything like a satis- factory reply. The causes of idiocy, the influence which our know- ledge of them should exercise on our prognosis, the relations of epi- lepsy and of paralysis to it, and the extent to which their existence should modify our opinions, are only some among several very im- portant questions to which I can do no more than refer as requiring elucidation. I trust that before long those regulations of the Idiot Asylum, which close its doors against medical men for the purpose of study, may undergo some modification ; or, at least, that the medical officers of the institution may feel it to be their duty, and may find it to be within their power, to furnish some information on subjects so important and so little understood; and to our knowledge of which they have hitherto contributed absolutely nothing. Down to the present time, the only systematic attempt with which I am acquainted to collect and arrange information on the subject of idiocy, is that which has been made by Dr. Howe, of Boston, by authority of the Legislature of Massachusetts.1 Valuable, however, as such an inquiry is in many points of view, its results can never yield more than mere approximations to truth, and cannot be regarded as positive medical facts. For instance, Dr. Howe states,2 as the result of his inquiries, that in 420 out of 574 cases the condition of idiocy was congenital; but these numbers, if received as absolutely correct, would, I am sure, lead to a very considerable over-estimate of the frequency of congenital idiocy ; and it is admitted, indeed, that all cases have been classed as congenital in which the affection dated from infancy, or early childhood. It is quite certain that a very large number of cases of idiocy date from early infancy; but a sense of hopelessness attaches to congenital disease, which renders it very desirable that this impression should not be adopted hastily; and though my opinion is necessarily founded on a comparatively small number of cases, I must nevertheless express my decided conviction that instances of really congenital idiocy actually form a minority of the cases of that condition. The distinct evidence, however, of the really congenital character of idiocy is not by any means sufficient ground for regarding a case as absolutely hopeless, so far as obtaining a very considerable amelio- ration of the patient's condition is concerned; and no one who saw the children that were exhibited a few years ago in London, as Aztecs, need despair of being able to teach much even to those whose cerebral conformation is most imperfect. The history most commonly obtained on closely questioning the relation of idiot children, is to the effect that their health having been good up to a certain period, which usually falls within the first year of life, they then had one or more fits, or perhaps a succession of them, recurring at uncertain intervals for one, two, or three years, or even becoming habitual; and that from this date their mental development was retarded in all respects, 1 Report made to the Legislature of Massachusetts upon Idiocy, by S. G. Howe, Chairman of the State Commission. 8vo. Boston, 1848. 2 See pp. 57 and 95 of the Report. 15 22b CHARACTERS OF IDIOCY. completely arrested in some; while the signs of idiocy have since then become more marked with each succeeding year. The cessation of these fits, even though once very frequent, does not seem to be by any means generally followed by improvement in the patient's condition; nor as far as I know, are epileptic idiots, even when the fits date from a very early period, those whose intellectual powers are by any means invariably the lowest. This, however, is but one of the modes in which idiocy comes on; in other instances there is no point in the child's history which can be laid hold of as marking the commence- ment of this condition, but as the body grew the mind remained stationary ; till by degrees the painful conviction that it was an idiot forced itself on the friends. In other instances some serious cerebral disease which threatened life at two, three, or four years old, or later, has left the mind obscured and weakened; while once or twice I have seen the mind reduced to a state of imbecility from habitual mastur- bation; but neither of these cases can perhaps with strict propriety be regarded as instances of idiocy. Even in earliest infancy there is usually a something in the idiot child which marks him as different from babies of his own age. He is unable to support his head, which rolls about from side to side almost without an effort on his part to prevent it: and this often awakens a mother's anxiety long before any other circumstance has excited her apprehension. Next it is perceived that the child does not notice, that his eye does not meet his mother's with the fond look of recognition, accompanied with the dimpling smile, with which the infant, even of three months old, greets its mother. Then it is found to have no notion of grasping anything, though that is usually almost the first accomplishment of babyhood; if tossed in its nurse's arms there seems to be no spring in its limbs; and though a strange vacant smile sometimes passes over its face, yet the merry ringing laugh of infancy, or the joyous chuckle of irrepressible glee, is not heard. As time passes on, the child shows no pleasure at being put down—' to feel its feet,' as nurses term it; if laid on the floor, probably it cries, but does not attempt to turn round, nor try to crawl about, as other babies do. If it learns to stand or walk, it is late, awkwardly and imperfectly, while not unfrequently the power of the adductor muscles of the thigh so predominates in the feeble limbs, that the legs are crossed immediately on the child assuming the erect posture; and this infirmity may continue for years. The teeth are cut late; often they appear irregularly, and out of their usual order; not unfrequently the incisors begin to decay even before the molar teeth have made their appearance, while the excessive secretion of the salivary glands, and the constant dribbling of the saliva, are a very frequent and very loath- some characteristic of many idiot children. Disorder of the process of dentition is often one of the earliest indi- cations of deranged physical development which we met with in the idiot. The jaws do not grow in proportion as the teeth appear; and generally a high roof to the mouth, narrow jaws, and crowded teeth, are met with in these cases. Growth everywhere goes on but slowlv, and in spite of the aspect of premature old age which his face often MENTAL FACULTIES OF IDIOTS. 227 presents, were we to judge from the height and size and general con- formation of the idiot, we should imagine him to be some years younger than his real age.1 Just as the idiot is slow to notice, slow in learning to grasp any object in his hands, or to stand or walk, so he is late in learning to talk; often acquires but few words, aud those with diffi- culty, often using the same to express many different ideas, generally articulating them indistinctly—often, indeed, so imperfectly, as to be almost unintelligible. There is a class of idiots who make no progress, who remain all their lives below the level of the brute; but the majority more or less slowly and painfully make such advances as I have described; and then with • each succeeding year the peculiar characteristic of their idiocy becomes more and more apparent. Some one faculty of the mind seems often to be partially exempted from the dulling of the rest; one child shows a perception of tune, another a fondness for some mechanical occu- pation ; a third manifests an idea of numbers; and it is of great im- portance to seize in each case on these peculiarities, since they indicate the direction in which efforts must be made to raise through them the other mental powers from their state of weakness. Even those facul- ties, however, which are least obscured, are generally far inferior to the same in other children; real mechanical dexterity, or musical power, or numerical skill, are very rare. They strike us by contrast with the other powers of the child; of themselves they are usually most humble.2 It is well to bear this in mind in order to avoid disappointment at the results which may be obtained at any institution for the education of idiots. To teach cleanliness, order, and neatness; to impart know- ledge enough to enable the idiot to take care of himself; to develop his affections; to enable him to read and write; to practise some easy handicraft; to partake of some simple pleasures; is an object well worth some trouble to accomplish. Exaggerated expectations will not contribute to its realization. Two great difficulties interfere with every attempt to teach the idiot. One of these is presented by his habitual indolence ; the other by his inability to fix his attention. I am not speaking here of those cases of almost utter absence of all intellectual power, in which safe custody of the unfortunate is all that can be attempted; but of those instances concerning which your advice may be asked, where some powers of memory, some degree of teachableness, evidently exist. In such cases, however, you must not fix your expectations too high, or you will inevitably meet with disappointment; for the child who, by careful education, has been brought to answer certain simple questions, and who to your first inquiry will give a correct reply, will yet be unable to command his attention sufficiently to answer the second; although a few moments after he will, if the question be repeated, 1 Dr. Howe, in the most interesting tables appended to his Report, has some facts corroborative of the above statement; his measurements, however, refer to the adult, not to the idiot in the years of childhood. 2 Assuming the sensibility to musical sounds in o:dinary persons to be as 10, Dr. Howe found it to be as 6.3 as the average in 574 idiots; skill in language as 5; and numerical skill as 3 to 10. See p. 41 of the Appendix to the Report. 228 EDUCATION OF IDIOTS. answer it quite correctly. The lower we descend in the scale of intellectual power, the more striking does this inability to fix the attention become, until at length we reach a point in which the per- ceptive powers also being dull, the child may sit for hours together noticing nothing. It is in a grade above this that we meet with that perpetual restlessness so characteristic of some idiots, who are con- stantly in motion, examining every object within their reach, but not stopping above a few seconds at any; and this mental infirmity con- stitutes one great bar to their improvement. The habitual indolence of the idiot, the dislike to exertion of any kind, bodily or mental, is almost invariably manifest in all; and its existence is quite compatible with the restlessness, the sort of busy idleness, which I have just mentioned as so often characteristic of his condition. Both of these evils are extremely difficult to combat successfully, even with the best endeavors, so long as a child remains at home with his parents; and I am therefore disposed always to recommend the sending such a child to an institution specially set apart for the instruction of idiots. Another reason for this course is furnished by the circumstance that the imitative faculty, which is usually very strongly marked in the idiot, furnishes one great means of his improvement, while besides there are many of his moral powers which cannot be brought out except in the society of other children of his own age, and not differing too widely from him in mental power. To obtain, however, all that is possible in the education of idiots, it is of great importance that they should be classified with great care; that the hopeless idiot should not be associated with those who are capable of improvement; that insane children should not be inter- mingled with the idiotic; and that children of very different degrees of mental capacity should not be thrown together at their work, nor even, without much care and oversight, in their amusements. Im- portant, too, as reading, writing, and a knowledge of numbers unquestionably are, the time at which it is expedient to teach them varies greatly in different cases. Mere verbal memory, too, is by no means a fair index of a child's mental condition; for the idiot may often be taught, parrot-like, to repeat many things of the meaning of which he has not the slightest notion. This sort of acquirement, too, while it exercises but very little influence on the general mental con- dition, is lost very speedily so soon as the constant teaching is interrupted, and therefore, though not without a certain utility, does not rank by any means among the first objects to which the attention should be turned. There is not time, however, nor indeed have I the experience, to enable me to enter into so wide a subject as that of the education of idiots. I must content myself with having pointed out to you the general characteristics of their condition—the objects towards which your endeavors must be chiefly turned in any attempt at its improve- ment. I can wish for nothing better than that before long the labors of others shall render these observations of mine as superfluous as I know them to be imperfect. DISEASES OF THE RESPIRATORY ORGANS. 229 LECTURE XVII. Diseases op the Respiratory Organs, their frequency and fatality.—Peculiarities of the respiratory function in early life—causes of the rapid pulse and quick breathing in infancy —feebleness of inspiratory power, and consequent tendency to collapse of the lung. Imperfect Expansion op the Lungs—sometimes congenital.—Appearance of the lung— influence of inflation upon it—its causes and symptoms.—Case of its fatal termination— case of recovery from it.—Diagnosis from congenital phthisis.—Treatment. We now come to the examination of the diseases of those two grand systems of the organism by which the blood is kept in motion, the re- quisite changes in it are effected, and the animal heat is maintained. Your attention was lately called to the fatality of the diseases of the nervous system in early life as one grand reason for their attentive study; but this argument is still more cogent if applied to the maladies of the organs of respiration and circulation, since they destroy a far greater number of children, and occasion a mortality almost equal to that produced by diseases of the nervous and digestive systems toge- ther. It appears, indeed, from our tables of mortality, that very nearly a third of all deaths under five years of age are due to the diseases of the respiratory organs; while not above one child in four dies under that age from diseases of the nervous system, and not above one in seven from those of the digestive system.1 While the study of these diseases is of paramount importance, we meet with inducements to their investigation which in a great measure failed us in the case of diseases of the nervous system. Peculiar diffi- culties then attended us, and the truth was veiled in so much obscurity that we often saw it but indistinctly—sometimes, perhaps, altogether failed to perceive it. The same means, however, as have enabled us to bring medical knowledge, with reference to the diseases of the chest in the adult, almost to the state of one of the exact sciences, still stand us in stead here; and care and patience will enable us to discover the condition of the lungs with nearly as much certainty in an infant as in a grown person. Nor is the greater facility of their diagnosis the only circumstance 1 Tahle showing the proportion per cent, of deaths from different causes in child- hood, in the metropolis, as compared with subsequent life. [Deduced from the 5th and 8th Reports of the Registrar-General, for 1842 and 1845.] Under 1 year. Between Between1 tt_j„_ a land 3 3andojDnder5 5 to 10 10 to 15 At all ages above 15 From Diseases of the Nervous do do Respiratory System do do Digestive System . 130.5 26.9 17.5 18 5 39.5 12.8 17.6 24.3 33.0 1 32 8 5.5 14.1 15.1 29.5 6.5 10.6 30.7 8.8 10.4 3S 0 7.7 230 PECULIARITIES OF RESPIRATORY ORGANS IN EARLY LIFE. that lightens their study, but a feeling of hopefulness attends their in- vestigation which we often missed in the subjects that have lately en- gaged our attention. They, indeed, furnished us with interesting pathological studies; we stood around the sick bed, and watched na- ture's struggles with disease that was irremediable, and we traced its effects afterwards as we examined the dead body; but the diagnosis of the affection was in many instances but the sentence of the patient's death, and we often felt, that as practical physicians, there was but little for us to do. We shall, it is true, meet with some such affections in our study of diseases of the chest, but happily they are few in com- parison with those which, in addition to much that would interest the mere pathologist, present still more that will give ample scope for all the skill of the practical physician. At first sight, it may seem to you that there can be little in the organs of respiration and circulation in early life different from their condition in riper years. And it is true that the part they play is as important at the first hour of existence as in the most advanced old age, and that their structure and functions undergo no such changes as we have noticed taking place in the brain during infancy and child- hood ; but nevertheless they present some important peculiarities in the young with which you must be acquainted before you can hope to treat their diseases with success. The condition of infancy is one of unceasing development; all the organs of vegetable life have, so to speak, double work to do—not ' merely to supply the daily waste, and to remove effete and useless matter, but to build up that wondrous edifice, the human body. It is probably in great measure on this account that the blood in infancy and childhood runs its course more rapidly, and that the lungs vivify it more frequently than in adult age. We shall probably not be far wrong if we estimate the average frequency of the pulse in the grown person, when making no exertion, at 75, and of the respirations at 12 in the minute.1 In infants not above a week old, the average frequency of the respiration is 39, and of the pulse 102; but the former may rise to 84, and the latter to 140, as the result of some transient excitement or disturbance, and wholly independent of disease. Until the sixth year the average frequency of the pulse continues at 102, and though that of the respiration diminishes, yet it does not fall below 30. The variations between their maximum and minimum frequency are now, however, circumscribed within limits which grow narrower as the child approaches manhood.2 Although the rapid pulse and quick breathing of early life are pro- bably in great measure due to the activity of the vital processes, yet the wide variations in their frequency induced by very slight accidents 1 This result is afforded by the numerous and careful observations of Professor Vierordt; see his article Respiration, in Wagner's Handworterbuch der Physiologie, Part 12, 8vo. Brunswick, 1845, p. 874. 2 The chief authority for the statements in the text is the valuable essay of M. Roger, De la Temperature chez les Enfants, 8vo. Paris, 1844. The more recent researches of M. Seux, Sur les Maladies des Enfants Nouveau-Nes, 8vo. Paris, 1855, do but confirm, in the main, the results already arrived at with reference to the wide variations in the frequency of the pulse in new-born infants. FEEBLENESS OF THE INSPIRATORY POWER. 231 lead to the suspicion that this is not their only cause, but that both phenomena are to a certain extent indications of the infant's weak- ness. This suspicion is still further strengthened by our knowledge of the fact, that the quantity of carbonic acid exhaled at each expira- tion diminishes in proportion as the expirations are more frequent;1 so that it is plain that the rapidity of the respiratory movements is not of itself a measure of the activity of the respiratory process. But still stronger proof of this fact may be adduced. Animal heat is gene- rated almost entirely by respiration. If, therefore, the activity of the vital processes were in proportion to the rapidity of the breathing, the new-born infant should be warmer than the child, and the child than the youth. But this is not so, for M. Roger has found, as the result of many most elaborate investigations, that the temperature of the child at six years of age exceeds that of the infant of a week old by more than half a degree of Fahrenheit, although the respiration is nearly a fourth less frequent.2 There seems, then, good reason for believing that the rapid breath- ing of the child is to some extent the result of its more delicate frame, rendering it unable, at a single effort, to inspire as deeply as the more robust adult, so that it is compelled, by the frequent repetition of its efforts, to make up for their comparative feebleness. Quite in keeping with this is the small power of resisting cold, or of maintaining an independent temperature, which is a distinguishing peculiarity of early life. If the young of any warm-blooded animal be exposed to a low temperature, its respiration at first increases in frequency, but if not soon restored to a warmer atmosphere, the nervous energy that should set the respiratory apparatus in motion becomes still more depressed; air enters the lungs imperfectly, the inspirations grow less frequent, and the warmth of the body sinks rapidly down to that of the sur- rounding medium. Nor is this all; but it often happens, if a young infant has been thus exposed to the cold, and especially if this has been done before the respiration had become properly established, that no subsequent removal to a warmer atmosphere will suffice to raise the temperature, or to set in proper activity the respiratory pro- cess. But not merely is the respiratory apparatus more delicate in the child than in the adult, for so are all the organs in early life, but it is feebler, as compared with the work it has to do, with the difficulties it has to overcome : and this constitutes a most important peculiarity in the physiology of respiration in early life, and greatly modifies its pathology. The interesting researches of Mr. Hutchinson3 have shown us that in the case of the adult "the resistance to the ordinary breathing force independently of the elastic power of the lungs, is equal to lifting more 1 See Vierordt's experiments on this subject, loc. cit., p. 887. * The researches of Dr. v. Barensprung, published in Miiller's Archiv, 1851, p. 125, do not confirm the above statement, but they are too few in number to invalidate it, aud therefore it is still retained in the text. See § 5 of v. Barensprung's essay. 3 On the Respiratory'Functions, in vol. xxix. of the Medico-Chirurgical Trans- actions. 232 IMPERFECT EXPANSION OF THE LUNGS. than 100 lbs. at every ordinary inspiration." The elasticity of the walls of the chest which present this resistance, is, in proportion to the size of the thorax, nearly as great in the infant as in the adult; but how much smaller is the muscular power by which this resistance is to be overcome! You see proof of it in the ordinary mode of re- spiration of a young infant, which presents something almost of diffi- culty. The breathing is quick and short, then after a few seconds there succeeds a pause, and then the hurried respiratory movements begin again, while the slightest disturbance, or the most trivial excite- ment, will at any time raise the frequency of the inspirations by ten or twelve in the minute. This respiration, too, is almost entirely abdominal; the chest moves but little, its walls are but little expanded, and the ear detects in the respiratory murmur little or nothing of that clear loud sound which is so characteristic of a subsequent period of childhood, and with which you are all familiar by the name of puerile respiration. This peculiarity of the breathing in early infancy, to which M. Trousseau was, I believe, the first to call attention, is another token of the feebleness of the inspiratory power. As the child grows older, and its strength increases, and its muscular system becomes more developed, the chest expands with each inspiration, and the faint respiratory murmur is succeeded by the loud puerile breathing which is heard as the air enters into the smaller air-cells. The resistance of the walls of the throat, however, is not the only obstacle to be overcome at each inspiratory effort, but the lungs them- selves are furnished with an elastic fibrous investment, processes of which dip down into their substance, and form the parietes of the different lobules. If you blow air forcibly into the lungs after their removal from the body, the resiliency of their tissue will expel a large proportion of the air the moment your effort at inflation is suspended. This elasticity of the lungs, then, which has been estimated as offering in the adult male an obstacle to each inspiration equal to 150 lbs., and in the female equal to 120 lbs. avoirdupois, is constantly tending to empty them of air, and constantly resisting the introduction of more.1 The want of breath, however, puts the respiratory muscles into play; the man takes a deep inspiration, and by this effort he unconsciously overcomes the resistance of the chest and the elasticity of the lungs. The new-born infant feels the same want, and makes the same effort, but its muscular power is small, and its inspirations are often so feeble as to draw the air in some parts only into the larger bronchi, while many of the smaller air-tubes remain undilated, and much of the lung continues in its foetal state. The blood being thus but imperfectly aerated, all the processes of nutrition go on imperfectly; the vital powers languish, the inspiratory efforts become more and more 1 The investigations of Professor Donders, and of Mr. Hutchinson, into the amount of this elasticity of the lungs, though carried on independently, conduct to very simi- lar results : the former estimating it as equal to £ix 3* avoirdupois per square inch as a maximum; the latter estimating it on the average at Ibss per square inch. See the researches of Prof. Donders, in the Nederlandsche Lancet, Dec. 1849 ; and Schmidt's Jahrb., Dec. 1850 ; and article Thorax, by Mr. Hutchinson, in Clyclopsedia of Anatomy and Physiology, vol. xiv. p. 1058. IMPERFECT EXPANSION OF THE LUNGS. 233 feeble, the temperature sinks, and the infant dies. But not only may this state persist as the result of imperfect respiration at birth, but cold, or the want of sufficient food, or any other cause that impairs the already feeble muscular power, favors its supervention. As the power of the inspiratory muscles is impaired, the air no longer pene- trates into the lungs so far as it once did, while the residual air is gradually driven out of the pulmonary cells by the elasticity of the lung, and portions once permeable to air become, in the course of time, altogether useless. Or, an increase of the ordinary resistance to the entrance of the air will have the same effect; and if the pouring out of mucus into the bronchial tubes should much obstruct them, large portions of lung will by degrees become emptied and collapsed, the dyspnoea will grow urgent, and the child will die from symptoms such as, in the adult, result only from most serious structural disease. The possibility of a large portion of the respiratory apparatus re- maining useless from birth, or becoming so afterwards without any serious disease of these organs, is a most important element in the pathology of infancy and early childhood. It warns us to be on our guard during the course of various maladies, against a danger which, in more advanced life, we have not to apprehend; while, at the same time, it teaches us that the dyspnoea, the hurried breathing, and many other symptoms which, in the adult, would call for most active treat- ment, may result, in infancy, from simple weakness, and require stimu- lating rather than depletory measures. Before we proceed to study the diseases of the respiratory organs in infancy and childhood, we must make ourselves thoroughly ac- quainted with this state of imperfect expansion of the lungs. It presents itself to us in two different circumstances. 1st. As a congenital condition : a more or less considerable portion of the lung never having become penetrated by air, but having re- mained in its foetal state. 2d. As an acquired condition : portions of the lung which once were freely traversed by air ceasing to admit it; and this not from alteration of structure, but from a simple collapse of the pulmonary tissue. It is now thirty }?ears since Dr. Edward Jorg gave the first clear description of the former of these two conditions, to which he applied the rather cramp name of alelektasis, from a-ee^f, imperfect, and ixtaois, expansion.1 We will first study this, since it is the simpler form of the affection, and we shall thereby obtain a clue to the understanding of the second form. If you examine the body of a new-born infant, or of one that has survived its birth but a few days, you will sometimes find patches of the lung of a dark red color, and depressed below the surrounding tissue, thus giving to the surface of the organ an uneven appearance. These darker portions, which exactly resemble foetal lung, are solid to the touch, do not crepitate at all under the finger, and sink imme- diately if thrown into water, while no minute air-bubbles are inter- 1 In his dissertation De pulmonum vitio organico. &c. Lips. 1832; and afterwards more fully in his work Die Fbtuslunge im gebomen Kinde, 8vo. Grimma, 1835. 234 EFFECTS OF INFLATION ON COLLAPSED LUNG. mingled with the small quantity of reddish serum which pressure causes to exude from their divided substance. They are not friable nor easily torn, their cut surface is perfectly smooth, closely resembling a piece of muscle, and, if examined under a lens, the pale collapsed air-tubes are seen intersecting their substance, and scarcely distin- guishable from the small vessels, which are almost devoid of blood. If air be blown into a lung, some lobules of which have this appear- ance, it will permeate the collapsed air-tubes; the pulmonary vesicles will by degrees become distended, and the solid lobules will rise to a level with the rest of the lung, will acquire the same color and con- sistence, and, like other parts of the organ, will float in water. A sin- gle inflation, however, is by no means sufficient to render this change permanent, but the moment the tube is withdrawn the air will escape, and the recently distended lobules will again collapse, and sink below the rest of the lung; their color, too, will become dark, though less so than before. Even if, after you have distended the lung to the utmost, you pass a ligature round the bronchi, and allow the lung to dry, a difference will still in general be very perceptible between the size of the air-vesicles which had been inflated by your efforts, and of those which had been distended during life by the natural process of respiration. The force required thus to distend the collapsed portions of the lung is very variable; sometimes it requires all the force you can possibly exert, and continued for some minutes. If the child had survived for several weeks, the air will penetrate only very imperfectly into the collapsed globules, while in some parts the resistance will be greater than it can overcome, and the most forcible inflation will be followed by no effect. The situations in which this condition is most frequently met with, are the languette and lower edge of the upper lobes, the middle lobe of the right lung, and the posterior part and lower edge of the lower lobes; and inflation restores these parts to a natural con- dition much less easily than it does any patches of the same kind in other situations. Whether the impermeability of some collapsed lobules is owing to adhesions having taken place between the oppo- site surfaces of the minuter bronchi, as has been suggested, I cannot pretend to say, but the supposition is plausible, and microscopical researches, according to which the bronchi of a portion of collapsed lung lose their lining of tessellated epithelium, lend it a still further degree of probability.1 It is usual to find, in connection with this state of the parenchyma of the lungs, that the pulmonary vessels contain less blood than usual, that the foramen ovale is unusually open, and the ductus arteriosus but very imperfectly closed. If the child have survived its birth but a short time, the brain is frequently found congested; but otherwise there is often nothing observable more than anaemia of all the organs, together with a general state of atrophy. Sometimes bronchitis attacks a lung thus affected, and, besides the presence of mucus in the air- 1 See a paper on this subject by Prof. KGstlin, in Schmidt's Jahrbucher, 1850. No. 1, p. 28. CAUSES OF IMPERFECT EXPANSION OF THE LUNG. 235 passages, there is then very often a state of congestion of the lungs, which renders the contrast between the collapsed and the healthy lobules less striking. The causes of this condition are not clearly made out. Dr. Jorg has attributed great importance to precipitate labor as a frequent cause of its occurrence, and has suggested a somewhat fanciful theory to explain its mode of production. He conceives that one grand use of the uterine contractions is gradually to enfeeble the circulation through the pla- centa, and thus to induce in the foetus that besoin derespirer which shall excite the complete establishment of respiration immediately on its birth. If, however, by the very rapid course of labor, the child should be born while the fcetal circulation is still going on with unim- paired vigor, the want of air will not be experienced by the child, and its attempts to breathe will be feeble and imperfect. It is probably better, instead of indulging in speculations of this sort, to content our- selves with the simple statement that when, from any cause whatever, the establishment of respiration at all has been attended with difficulty, there is a very good probability that its establishment will never be complete, but that some lobules only will receive the air, while it will not penetrate into other parts of the lung. The probability of this occurring, too, will be still greater if the children be weakly or ill- nourished when born, or if they be exposed soon after birth to cold or other unfavorable hygienic influences, such as are calculated to interfere with the due performance of respiration. Cases in which this condition of the lungs exists usually present the history of the child having been apparently still-born; and, though resuscitated after a time, yet still continuing unable to utter a strong and loud cry like that of other children. Even after breathing has gone on for some time, such children usually appear feeble; and though they may have attained the full term of fcetal life, yet they can scarcely suck, although they often make the effort. An infant thus affected sleeps even more than new-born infants usually do; its voice is very feeble, and rather a whimper than a cry; and the chest is seen to be very little, if at all, dilated by the respiratory move- ments. The temperature falls, the skin becomes pale, and the lips grow livid, and often slight twitching is observed in the course of a few hours about the muscles of the face. The difficulty in sucking increases, the voice grows weaker and more whimpering, or even altogether inaudible, while respiration is attended with a slight rale, or an occasional cough ; and the convulsive movements return more frequently, and are no longer confined to the face, but affect also the muscles of the extremities. Any sudden movement suffices to bring on these convulsive seizures ; but even while perfectly still the child's condition is not uniform, but it will suddenly become convulsed ; and during this seizure the respiration will be extremely difficult, and death will seem momentarily impending. In a few minutes, however, all this disturbance ceases, and the extreme weakness of the child, its inability to suck, its feeble voice, and its frequent and imperfect inspirations, are the only abiding indications of the serious disorder from which it suffers. But the other symptoms return again and again, 236 CASES ILLUSTRATIVE OF ITS SYMPTOMS. till at length, after the lapse of a few days, or a few weeks, the infant dies. But I will relate a case which may serve to impress these charac- teristics on your memory. A little boy, three weeks old, was brought to me at the Children's Infirmary, on March 13, 1846. He was puny, emaciated, with a cold surface and bloodless conjunctivae. His face, which was wizened like that of an old man, was occasionally distorted by slight convulsive twitches; and these fits, as the mother termed them, were, according to her account, sometimes much more severe. The abdomen was tympanitic, and it alone was seen to move during respiration, there being hardly any lateral expansion of the chest. The ear applied to the chest heard but little air entering; and the cry was a stifled whimper, in which none of the inspiratory sound, the reprise of French writers, was distinguishable. The child sucked with difficulty, and had wasted ever since its birth, though no diar- rhoea existed, but the bowels, on the contrary, showed a tendency to constipation. The chest was rubbed twice a day with a stimulating liniment, and a mixture was given containing some ammonia and the compound tincture of bark. Under this treatment the child appeared to improve; it began to breathe less rapidly and in a less labored manner, and its cry became louder. The parents, however, were miserably destitute, the mother in an ill state of health, so that her milk afforded but a very imperfect sustenance for the child. From the beginning of April he grew less well, and began to have occasional attacks of general convulsions, in one of which he died on April 26, 1846. On examining the body, large portions of both lungs presented the appearances which I have described as characteristic of their imper- fect expansion; but inflation restored them to a crepitant state. Some patches, however, though they admitted air and assumed the same color as the rest of the lung, yet could not by any effort be dilated so completely as to rise to a level with the surrounding tissue. The foramen ovale was open, the margin of the valve for fully half its cir- cumference not being adherent, although the valve was sufficiently large for its closure. The ductus arteriosus also was quite permeable, although of considerably less calibre than during fcetal life. This case affords a very good specimen of one way in which the affection leads on to a fatal termination; but sometimes, and probably in those instances in which the affected portion of lung is not so con- siderable, a less formidable train of symptoms usher the fatal event. Convulsive twitchings, such as I have before mentioned, do not occur, nor are periodic exacerbations of the symptoms observed; but the child is merely feeble and its breath is short, and it has an occasional cough. It sucks, though with difficulty, but it loses flesh, the bowels become disordered, and medicine is unable to restrain the diarrhoea. The unchecked diarrhoea increases the emaciation and exhaustion of the child, which dies at length worn out and wasted to a skeleton. Sometimes, too, we meet with cases in which the child eventually recovers, and it is then very interesting to watch the gradual diminu- tion in the frequency and violence of the paroxysms of dyspnoea, while OF IMPERFECT EXPANSION OF LUNG. 237 the respiration grows by degrees more equable, and the cry louder, the power of sucking increases, and the child at length attains to per- fect health. A little boy, four months old, was placed under my care by his mo- ther, who informed me that the child had presented in some unnatural position during labor, so that manual interference was required to effect her delivery; and when born, the infant appeared dead, and was recovered only after very great difficulty, and after the occur- rence of convulsions; the convulsions had since returned almost every day—sometimes, indeed, they occurred several times in the same day—and always came on with greater frequency by day than by night. The attempt to suck often induced them, as did also any rapid movement about the room, or any sudden change of posture. During the fits the child did not struggle much, but he always turned extremely livid about the face and mouth. No fit ever lasted longer than five minutes, and during the intervals between them the child seemed pretty well, except that he often suffered from a suffo- cating cough. He appeared tolerably well-grown and well-nourished, and the tem- perature of the suriace was nearly natural. The respiration, however, was very hurried, and was almost entirely abdominal, the chest being hardly at all expanded. The cry, moreover, was feeble, and without reprise. There was a considerable want of resonance of both sides of the chest posteriorly, and deficient entrance of air into the back of both lungs. Both the dulness and the scanty admission of air were more obvious in the left than in the right infrascapular region, and some mucous rale was heard in the former situation. The child was placed in a hot bath, and an emetic was given it every night; the chest, both in front and back, was rubbed twice a day with a stimulating liniment, and the face was ordered to be sprinkled with cold water whenever any threatenings of the fits came on. At the end of five days the child was better, and the cry louder, though without any distinct reprise. Small doses of the ferro-citrate of quinine were now combined with the other remedies, while the eme- tics were discontinued, as on some occasions they had appeared to ex- cite the convulsions.- First the cry grew louder, then the appearance improved and the manner became more cheerful, then the cough was less troublesome and the breathing less habitually wheezing, and at the same time the chest began to expand more, and the marked dul- ness of its lower parts gradually diminished. At the end of five weeks the child was discharged with increased flesh, invigorated strength, and with no ailment more serious than a slight degree of wheezing respiration. The history of this patient may serve to show us that even very serious symptoms should not lead us to despair of recovery, while it illustrates the importance of forming an accurate diagnosis between this affection and congenital phthisis (the only malady with which it is likely to be confounded), lest we either cherish unfounded expecta- tions, or discourage hopes that might reasonably be entertained. A little care will usually suffice to enable us to distinguish between 288 IMPERFECT EXPANSION OF LUNG. these two affections, notwithstanding some general points of resem- blance between them. The symptoms of the imperfect inflation of the lungs date from the infant's birth; but it scarcely ever happens that tuberculous disorganization of the lung is so extensive in the new- born child as to interfere with the establishment of the respiratory function. But not only do not the symptoms of phthisis appear so early, but they likewise seldom advance so rapidly as those of atelek- tasis. Phthisis, too, is not from the beginning attended with the same debility, nor with difficulty in sucking, while it is associated with a febrile action which is quite wanting in atelektasis. The head symp- toms, which in so large a number of cases attend the imperfect infla- tion of the lungs, are absent in phthisis; while, lastly, auscultation would furnish some clue to the real nature of the case; in the one instance there would, in general, be simply a deficiency of air; in the other, respiration, accompanied with rales, and often with bronchial breathing. The treatment required by this affection need not detain us long. The importance of maintaining an equable temperature around every child in whom respiration is not duly performed, cannot be too much insisted on; and the power of generating heat being, as you know, much diminished, this temperature ought not to be below 70°, and in bad cases may be even 10° higher. Besides attending to preserve this warmth around the child, benefit often accrues from the employment of the hot bath once or twice every day, at a temperature of 100° Fah- renheit, to which mustard may be added to render it more stimulating to the surface. The child should not be allowed to remain longer than five minutes in the bath, aud should be enveloped in hot flannels immediately afterwards, to prevent its taking cold. The back and chest should be rubbed twice or oftener every day with a stimulating liniment, as camphor or soap liniment, which may be diluted with a little oil if it be too irritating to the skin. If the child be very feeble, stimulants may be given, of which there are none better than the com- pound spirit of ammonia or ether, or the spiritus ammonias succinatus, the unpleasant pungency of which remedies is concealed by milk better than by any other menstruum. The daily employment of a gentle emetic of ipecacuanha has, in some instances, appeared to be of ser- vice, not merely by relieving the air-tubes of any mucus that may have accumulated there, but by inducing several deep inspirations, and thus aiding the complete establishment of respiration. As the child improves the more directly stimulating medicines may be with- drawn and tonics substituted for them, among which few are better than the extract of cinchona.1 It has the great advantage of not dis- ordering the bowels, a point of no small importance in any case in which diarrhoea is likely to occur. In some cases there is a sluggish- ness of the bowels, and a deficiency in the secretion of bile; very minute doses of the hydr. c. creta, will often remedy the latter, and the use of a soap suppository will frequently render the internal em- ployment of any purgative needless. The child should be put to the 1 See Formula No. 3, p. 56. COLLAPSE OF LUNG AFTER BIRTH. 239 breast unless it be very feeble, but in that case should not be allowed to exhaust its strength in fruitless attempts to suck. It will be better to draw the breast, and give the child its mother's milk by means of a spoon or from a bottle, which latter plan has this advantage, that while it costs the child but little effort to get its food, we avoid the risk of its forgetting how to suck, an inconvenience which attends the use of the spoon if continued for any length of time. Artificial feeding is not at all desirable in such cases, though sometimes, if the child be very weak, it may be necessary at first to give a few drops of brandy in its milk every three or four hours. This plan of treatment must be patiently persevered in, nor must the supervention of symptoms of an apparently acute character induce too wide a deviation from it. The head symptoms in particular must be combated cautiously, lest by too great a solicitude to overcome them we destroy the patient rather than the disease. LECTURE XVIII. Collapse of Lung that has once been Expanded—described as lobular pneumonia by various writers—its characters—symptoms and differences from true pneumonia—Obser- vations of Bailly and Legendre.—Is not to be regarded as a post-mortem occurrence.— Illustrative cases.—Instances of its occurrence in the adult.—Similar causes tend to pro- duce it at all periods of life—hence very frequent in old age. Induration of the Cellular Tissue—its characters—remarkable reduction of tempera- ture that attends it—appearances after death—condition of deficient expansion, or of collapse of the lung, noticed by many observers, though misunderstood by mos£, is pro- bable cause of the induration or oedema of the surface. The condition of the lungs, which we were occupied in examining at the last lecture, is of importance, even if regarded merely as a con- genital state, the result of nature having failed in the attempt to estab- lish respiration, and to fit the child thoroughly for the new mode of existence to which it is destined after birth. But its claims on our attention are still greater when we bear in mind the possibility of its occurrence in consequence of a variety of causes operating after birth, so that lungs once permeable to air may cease to admit it, and death may at length occur from apncea without any serious structural change having taken place in the organs of respiration. Appearances supposed to be the result of pneumonia had long attracted the notice of writers on diseases of children, by the wide dif- ferences which they presented from those which inflammation of the lungs give rise to in the adult.1 It had been observed that infants and children under five years of age often died after presenting some of 1 In the "British and Foreign Medico-Chirurgical Review" for October, 1853, is a very clear and intf resting sketch, by Dr. Willshire, of the progress of knowledge with reference to pneumonia, and condition of the lung resembling it in early life. 240 COLLAPSE OF LUNG AFTER BIRTH. the symptoms of inflammation of the lungs, such as cough and difficult breathing, together with more or less extensive dulness of the chest on percussion, and some or other of the auscultatory signs of solidifi- cation of the lung. In such cases these peculiar morbid appearances were especially well marked. But while they seemed to prove that these changes in the lung were the consequences of pneumonia, it hap- pened not unfrequently that the fever and the pneumonic symptoms underwent a great abatement before any sign of approaching death appeared, or that children, who had seemed to die worn out from va- rious causes, and during whose lifetime no indication of inflammation of the lungs had existed, presented the supposed anatomical evidences of pneumonia in a most remarkable degree. The frequency of occur- rences of this kind led to the assumption that pneumonia was an ex- tremely frequent concomitant of almost all the diseases of infancy and early childhood; that this pneumonia was very often latent (that is to say, that it did not manifest its existence by those symptoms which usually attend it); and lastly, that owing to causes which were differ- ently stated by different observers, it gave rise to alterations in the lung very dissimilar from those which it occasioned in the adult. One of the most remarkable peculiarities of this supposed infantile pneumonia led to its receiving the appellation of lobular pneumonia, as expressive of the fact that it did not attack a large tract of lung, or the whole of a lobe, at one time, but that it affected isolated lobules, which might be seen of a dark color, solid, often depressed below the surrounding parts, and sinking in water if detached from the healthy tissue in the midst of which they were situated. Sometimes the affec- tion was strictly limited to a single lobule, the boundaries of which could be exactly traced; and though it often happened that a cluster of lobules was thus hard, and dark, and solid, still there was no gradual shading-off from the darker to the lighter parts; so that it was evident that, in whatever way the disease extended, at any rate it did not advance by mere continuity of tissue. Sometimes almost the whole of one lobe was thus affected, a few lobules only still re- taining a healthy aspect, and crepitating under the finger; and it often happened that the bronchi leading to it were full of mucus or pus, while at other times there was marked congestion of the lung; and in the midst of this congested tissue were two or three solid hepatized patches. All these circumstances, as it may be conceived, variously modified the morbid appearances. In the last case the lobular pneu- monia was thought to be becoming generalized; or, in other words, the inflammation originally limited to certain lobules were supposed to have begun to extend to the adjacent tissues, constituting a kind of transition state between lobular and lobar pneumonia. The lower edge of the different lobes, the whole of the middle lobe of the right lung, and often a very considerable portion, or the whole of one or other lower lobe, were also sometimes found in a state to which, among other names, that of carnification was applied, on account of its close resemblance to a piece of muscular tissue. A portion of carnified lung showed the closest possible similarity to a lung that had been COLLAPSE OF LUNG. 241 compressed by effusion into the pleura. It was dark, tough, solid, contained no air, presented a smooth surface when cut, yielded a small quantity of bloody serum when pressed, and, indeed, seemed almost like a piece of flesh; in all which respects it resembled a portion of lung hepatized by lobular pneumonia, and differed from the lung of the adult when that has been rendered solid by inflammation. The course of the disease in many of these cases during the lifetime of the patient, and the results of medical treatment, tended to enhance the difficulties which the above-described anatomical peculiarities placed in the way of referring lobular pneumonia to the same cate- gory of affections with the pneumonia of the adult. Venesection, leeches, and mercurials, the ordinary antiphlogistic apparatus in the pneumonia of the adult, often appeared to hasten the child's death; blisters rarely effected any good, and the blistered surface often showed a remarkable indisposition to heal. On the other hand, emetics and rubefacients were frequently of service: a stimulant plan of treatment was almost always necessary at an early period, and sometimes seemed to be required nearly from the outset of the affection. The rapidity of the changes that took place in the physical condition of the lung was another peculiarity which rendered the nature of the affection still more obscure; for where air was heard entering freely on one day, none would be perceptible on the morrow, but percussion of that part of the chest would yield a sound of complete dulness. On the other hand, it happened sometimes, though much less often, that dul- ness was succeeded just as quickly by resonance on percussion, and that breathing became distinctly audible where on the previous day no sound of air was to be heard. Nothing can show more forcibly the influence of a name, than the fact that this condition of the lungs should have been described by all writers as lobular pneumonia, and that its symptoms should have been attributed to inflammation, while yet it was evident from the con- current testimony of every one that neither in its progress nor in its results was it similar to inflammation of the lungs in the adult, much less identical with it. Having, however, once been called pneumonia, every person continued to call it so, though often with a full recogni- tion of its peculiarities. Even the close resemblance which the lung presented to fcetal lung, or to those undilated portions which are characteristic of atelektasis, was noticed and discussed by myself, and by many far better observers, apparently without a suspicion that both states were identical. But while the peculiarities of lobular pneumonia were thus gener- ally commented on, it seems strange that no one should have had recourse to the experiment of inflation in order to obtain a solution of some of the difficulties that existed with reference to its nature. This oversight seems the more extraordinary, when we call to mind that this very means had cleared up so many doubts concerning appearances in the lungs of new-born infants, which had once been supposed to be the result of pneumonia in the foetus, or of some arrest of development. At length the experiment was tried by MM. Bailly 16 242 COLLAPSE OF LUNG. and Legendre,1 and though, as in the old tale of Columbus and the egg, the thing seems so obvious that there is some risk of our under- rating the merit of those who were the first to do it, it must not be forgotten that^by that simple means, they have thrown more light on the affections of the lungs in infancy and childhood, than all the writers of the previous ten years together. MM. Bailly and Legendre state, as the result of their observations, that the appearances to which the name of lobular pneumonia has commonly been given are in reality produced by an occlusion of the pulmonary vesicles. This occlusion, say they—and the correctness of their opinion is now universally admitted—is due to the inspiratory power having been inadequate to overcome that elasticity of the lung, which I described to you in my last lecture as constantly tending to empty the pulmonary vesicles of air, and constantly impeding its entrance. Coupled with this, however, there is another cause, the full influence of which had not been recognized till dwelt on by Professor Gardiner, of Glasgow,2 namely, the presence of the secretions in the bronchi, and the obstacle which they present, sometimes at one point, and sometimes at another, to the admission of air. The child inspires, and the secretion, which it could neither expectorate nor expel by coughing, closes the entrance to some small bronchial tube. With the succeeding expiration, a little of the air retained behind this obstacle escapes, and on the next occasion a little more, till at length, no single inspiratory effort having been strong enough to surmount the obstruction, while with each expiration the quantity of air behind it is lessened, the vesicle collapses, and its situation is betrayed by the small, dark, depressed spot which may be seen on the surface of the lung, and felt solid or non-crepitant beneath the finger. In bronchitis, where this secretion is abundant, perhaps excessive, the obstacle to the entrance of air which thence arises becomes, in the case of young children, a very serious source of danger, and the possible occurrence of collapse of the lung must make you very guarded in the expression of your prognosis, even when the symptoms do not appear to be formidable. In such cases, too, the congestion of the pulmonary tissue, and the consequent pressure of the gorged vessels on the air-cells, both favor their collapse and impede their expansion.3 But besides these cases, in which the collapse of the lung becomes a grave, perhaps even a fatal complication of disease already existing, there are others in which this condition occurs independently of any affection of the air-passages, and destroys life suddenly and unex- pectedly. If from any cause the inspiratory powers be very feeble, the obstacle in the air-tubes need be but very slight in order to pro- 1 Nouvelles Recherches sur quelques Maladies du Poumon; in the Arch. Gen. de Med., Jan., Fev., Mars, 1844. * Ou the Pathological Anatomy of Bronchitis, &c. : reprinted from the Monthly Journal of 1850 and 1851. •» With reference to this point, there are some conclusive experiments of MM. Rilliet and Barthez, recorded in vol. i. p. 427, note, of the second edition of their work on Children's Diseases. CASES OF COLLAPSE OF THE LUNG. 243 duce collapse—need, certainly, be nothing more than may be presented by the gradual accumulation in the bronchi of their natural secretions ; while in some instances, such as the one which I will now relate to you, the collapse of the lung may be considerable, though the bronchi may contain no appreciable amount of secretion. A little girl was attacked, when a month old, by very severe diarrhoea, which lasted for three weeks, and then left her greatly exhausted and much emaciated. No return of the purging occurred, and the child lived, though in a state of great weakness, till she was five months old. For the last five weeks of her life she was under my care, and sometimes she seemed, for a day or two, as if she were gaining strength and might recover ; but these signs of improvement were never of long duration. Three days before she died, her breath grew suddenly hurried; the dyspnoea was not attended with any cough, but, from the time of its coming on, the child's exhaustion increased, and her respiration grew more rapid until her death. No organ showed any sign of disease, but all presented a most re- markable degree of auaemia. Two-thirds of the upper, and almost the whole of the lower lobe of the right lung, were dark, solid, and non-crepitant; and a few lobules of the left lung presented the same appearance. Inflation restored them to exactly the same state as the rest of the lungs. The bronchi were preternaturally pale, and contained no secretions. It is not possible to say why the child's inspiratory power grew too feeble to fill the lungs at one moment rather than at another, but few will doubt that it had become so just at the time when the dyspnoea occurred. A portion of the lung having become collapsed, the elastic ribs tended to render abortive any faint effort to draw in more breath, and thus the vital flame went out for want of air to feed it. Sometimes the occurrence of this condition is long preceded by indications of the imperfect performance of the respiratory functions, but yet they go on sufficiently to keep the machinery of life in motion, till some trivial, perhaps some inappreciable cause—a draught of cold air, a little over-exertion, the horizontal posture too long continued, the customary food delayed an hour beyond the usual time—sinks them so low, that they soon cease, for ever. Some time ago I saw a little girl ten months old, who had lost her mother soon after her birth, and had been indebted to a stranger for what should have been a mother's cares. She never throve; her chest presented that peculiar malformation commonly called pigeon-breast, and that circular constriction around the base of the thorax, which used to be regarded as due to the direct action of the diaphragm draw- ing in the receding parts at each contraction; but which Dr. Jenuer's careful observations have shown to be produced by atmospheric pres- sure acting on the chest-walls just above the upper margin of the liver, spleen, and stomach.1 But though she was a backward child, and 1 The commonly-received explanation of the mechanism by which this deformity of the chest is produced is given by MM. Rilliet aud Barthez, op. cit., vol. i. p. 45. The careful observations of Dr. Jenner are contained in his Lectures on Rickets, in Med. Times, March 17, 1860, p. 262. 244 CASES OF COLLAPSE OF THE LUNG. though her respiration was always almost as abdominal as that of a new-born infant, there was no definite evidence of disease till she was nine months old. She then lost flesh rapidly, and began to cough without having had any previous catarrh. Her case seemed to be one of bronchial phthisis. Four days before she died her breath suddenly became much oppressed, and her cough far more severe than it had been before. The dyspnoea rapidly increased, but her cough soon grew less frequent. A few hours before her death her lips were quite livid; she was breathing from 80 to 86 times in the minute, the abdominal muscles acting most violently, but the chest being scarcely at all expanded. Auscultation detected nothing more than some rather large mucous rale in the lung. After death no tubercle was found in any organ, but large portions of both lungs presented the undilated condition, which disappeared entirely on inflation. The bronchi were pale, and contained very little mucus, but the right side of the heart was greatly distended with coagulated blood, which its thin, pale, and flaccid substance had evi- dently been unequal to propel with the requisite vigor. The imperfect respiration had here for some time manifested itself; the vital powers had long been feeble; nutrition had been ill performed, and the heart itself had shared in the general feebleness, till at length the secretion of a comparatively small amount of mucus presented an obstacle to the free entrance of air, which, though slight in itself, was greater than the child could overcome; and the whole machinery of life was thus suddenly brought to a stand-still. In both of these cases the feebleness of the inspiratory power was one chief cause of the collapse of the lung. The result is the same, however, if the obstacle be increased, as if the power be diminished ; and hence, as I have already mentioned, the supervention of this state of lung becomes one of the most perilous, while it is one of the most frequent complications of infantile bronchitis. A little girl, previously quite healthy, was seized when ten months old with symptoms of acute bronchitis, suffocative cough returning in paroxysms, and sometimes followed by the rejection of a muco-purulent fluid. The symptoms throughout did not seem to allow.of depletion; but ammonia, with decoction of senega and tincture of squills, and other expectorants of a stimulating kind, were given with temporary amendment. The child did not, however, appear to have undergone any marked change, either for better or worse, except that she had certainly lost both flesh and strength, when coldness, faintness, and exceedingly labored respi- ration suddenly came on, and continued till her death, which took place in the course of twenty-four hours. A few recent adhesions were found on each side of the chest, between the costal and pulmonary pleura. The trachea contained a large quantity of muco-purulent matter, and the same secretion abounded in the bronchial tubes, many of which were filled by it, while nowhere did air-bubbles appear intermixed with it. There was some congestion of both lungs, especially posteriorly; the upper and posterior part of the upper lobe of the right lung, the whole of the COLLAPSE OF THE LUNG IN THE ADULT. 245 middle lobe, and the posterior part and lower edge of the lower lobe, were dark, solid, non-crepitant, and depressed below the adjacent tissue. The same state existed in the whole inferior third of the upper lobe, and the lower edge of the lower lobe of the left lung. On inflating the lung, most of these parts were restored to a perfectly natural condition, but some patches still remained less dilated than the others, and some of the darker, almost violet-colored portions of the lower lobes appeared but little affected by it. But you may naturally inquire whether any occurrence of a similar kind is ever met with in the adult, since there is certainly no such peculiarity in the structure of the lung in childhood as should render it then exclusively liable to a morbid process from which at all other ages it is exempt. My own experience would not have enabled me to answer this question; but my lamented friend Dr. Baly communicated to me some years ago the particulars of three cases in which he found large portions of the lung in the adult presenting the characters that we have been studying in the child, and, like it, resuming a natural appearance on the insufflation of air into the bronchi. The patients in all of these cases died of fever, attended with dysenteric symptoms; and for some days before their death were in a state of great exhaustion, such as appeared to indicate the free employment of stimulants. In two instances distinct dyspnoea occurred some days previous to death; but though the chest lost its resonance in the situation of the affected parts of the lung, and the breathing there was deficient, yet the minute crepitation of pneumonia was not detected in either case, but merely some mucous rale. In addition to extensive disease in the intestines, this collapsed condition of portions of the lung was found, unconnected with any disease of those organs in one of the cases, combined with the effusion of tenacious mucus in the bronchi leading towards the collapsed portions in a second, and associated with true pneumonia and a state of red or gray hepatization of other parts in a third.1 But these are by no means isolated cases; for it would seem that in some diseases which are attended by much depression of the vital power, this collapse of the lungs is by no means unusual. To adduce but one illustration of the fact, it may be mentioned that M. Louis* found in nineteen out of forty-six post-mortem examinations of patients who had died of typhoid fever, a condition of the lungs which he calls 1 The minute accuracy of Dr. Baly's description induces me to subjoin the following particulars of one of the examinations : " No effusion ; lungs healthy, except in lower and posterior fourth of right inferior lobe, which is of a dark purple color, is depressed somewhat below the level of other parts, does not crepitate, feels solid, but flexible and tough, almost leathery, and sinks quickly in water: the part having these characters is distinctly defined by boundaries of lobules. The whole lung being inflated, the part just described receives air with greater difficulty than the other parts, but at length becomes distended lobule by lobule, and assumes the same pale red color as the rest of the lungs. The change takes plac£, as has been stated, lobule by lobule, separate lobules appearing suddenly of the paler color, not merely at the margins of the dark mass, but also in its centre. On cutting through the lungs and tracing the bronchi, it is found that the ramifications of those tubes which go to the dark, contracted, and condensed parts are filled up with tough mucus, from which those going to other parts are free." 2 Recherches sur la Gastro-enterite. 8vo., tome i. pp. 361-364. Paris, 1829. 246 COLLAPSE OF THE LUNG IN THE AGED. "carnification," and which it is evident (although he did not try the effect of inflation) was identical with the state so frequent in the child. He describes the parts thus affected as of a deep purple-red, having lost the natural suppleness of the lung, being solid and sinking in water: they were, moreover, tougher than healthy lung; if divided, the section became covered with a reddish fluid, perfectly destitute of air, while the tissue neither resembled that of healthy lung, nor pre- sented the peculiar granular appearance characteristic of lung in the second stage of pneumonia. More recently, too, Professor Gairdner, in his very important essays on the pathological anatomy of bronchitis, already referred to, has mentioned this condition of the lungs as having been of frequent occurrence during the epidemic fever of 1847. It is true, however, that in these cases the condition of the lung was merely superadded to other lesions in themselves adequate to occasion the patient's death; and hence, though interesting to the mere patholo- gist, it yet loses much of its value in the eyes of the practical physician. But it will not seem to you that too much stress has been laid on this state, if it should appear that whenever the power of the inspiratory muscles is much diminished there is a tendency to its supervention, so that it alone may be the cause of death; and this, which I have put hypothetically, really does occur in old age. The term "second childhood" is not a mere figure of speech, expressive solely of the decay of the mental powers, by which the evening of life is obscured and made like the twilight of the mind in early infancy, but it is in many points the statement of a physical truth. Thus, as old age creeps on, and the nutrition is no longer adequate to supply the waste, the respiration loses the character which it presented in the adult, and the extremes of life in this respect pre- sent a close resemblance to each other. The muscles of the chest grow too feeble to dilate it fully; the diaphragm becomes, as it was in early infancy, the principal inspiratory muscle, and the vertical diameter of the thorax is that in which its chief enlargement takes place. The ear applied to the chest no longer detects the puerile breathing of youth, nor the clear vesicular murmur of manhood ; but the respiration is coarser, sometimes almost bronchial. There is not occasion, as in infancy, for more rapid breathing to maintain the high activity of the vital processes, but the worn-out machinery needs to be put in motion more frequently than in the adult, in order to obtain oxygen enough to support existence; and, accordingly, MM. Hourman and Dechambre1 found the average frequency of the respiration in 255 old women at the Salpe*triere to be 21.79 in the minute, while in some whose frame seemed most decayed, it was far more rapid. Just as in infancy, too, so in old age, these respiratory movements are most irregular. Sometimes the parietes of the thorax continue for a long time motionless, and then there succeed a series of rapid movements, while at other times the intervals between the inspirations are irregu- lar, but the inspiratory movements are of the same intensity and dura- 1 The above facts with respect to the respiration in the aged are derived from the interesting papers of MM. Hourman and Dechambre, in the Arch, de Med. for 1835 and 1836. See especially the number for Nov. 1835. INDURATION OF THE CELLULAR TISSUE. 247 tion. Here, then, without pursuing the comparison further, we have ample proof of the many points of resemblance between the physio- logical condition of the respiratory function in early life and in old age. The respiratory organs, too, in their pathological state, present, as might be expected, the same resemblance; and, accordingly, MM. Hourman and Dechambre1 notice a state in which the pulmonary parenchyma is of a very deep, sometimes almost of a blue color, or nearly black, non-crepitant, and presenting a smooth surface on a section of it being made. The lung thus altered is often remarkably tough, almost like India-rubber; while under pressure, a viscous fluid, generally of a reddish color, and containing no air-bubbles, exudes from it. The idea of inflating the lung had not occurred to these observers; but they remark, that, if portions of lung presenting these characters be dried, the air-cells have a tendency to reappear without having undergone any other change than a well-marked contraction. I have dwelt long on this pathological condition, though I think not longer than its importance demands; because we shall find that in some form or other it presents itself, modifying the symptoms, determining the prognosis, and influencing the treatment of almost all the affections of the lung in early infancy. We shall pass to the study of some of these diseases at the next lec- ture ; but, before doing so, may notice an affection about whose nature much controversy has arisen, but to which, thanks to the researches of MM. Bailly and Legendre, we may now assign a place as one of the results of the imperfect expansion or subsequent collapse of the lungs, and of the consequently incomplete performance of the respira- tory function. Though very rare in this country, induration of the cellular tissue is extremely common in the foundling hospitals of the Continent, where so many causes contribute to depress the new-born infant's feeble powers. The children in whom it occurs are usually weakly, not seldom premature, and its first symptoms generally appear between the first and fifth day after birth, though occasionally they do not come on till later. In many instances a livid redness of the whole surface is obvious from birth ; but the appearance of a circum- scribed hard spot on one other extremity, or on some prominent part of the face, as the end of the chin, or the cheek bone, is the first sign of the commencement of this affection. Other spots of a similiar kind are soon discovered on different parts of the surface; and the body generally, and the hardened spots in particular, are found to present a temperature much below the natural warmth of the body. It appears, indeed, from M. Roger's researches,2 that a general reduction of the temperature precedes the induration, or, at least, exists in a very marked degree, while the induration is still extremely slight. Some- times, too, the premonitory loss of temperature3 may be perceived in weakly children without being succeeded by the appearance of spots ' Op. cit., Mars, 1836, p. 272. 2 Op. cit., pp. 124-151. s Hervieux, Sur l'Algiditg progressive des Nonveaux-Nes, in Arch. Gen. de Med., Nov. 1855. See also an essay by Dr. Loschner, of Prague, ou the same subject, in the Jahrbruch fiir Kinderheilkunde, vol. i. p. 91. 248 ITS CAUSES. of induration. This, however, is exceptional, and in the majority of instances the sinking of the temperature and the extension of the in- duration advance together, and the warmth of the surface may eventu- ally fall from 100° to 90°, 80°, or even lower. If the induration become very extensive, it affects the integuments of the chest and the abdomen, as well as the extremities, and the body feels cold and stiff, as though it were frozen. This condition is, as might be expected, attended with great impair- ment of the general health, and with a very remarkable degree of emaciation.1 Children suffering from it are extremely weak, often too weak to suck; their pulse is very small, their respiration abdominal, and their cry is faint and whimpering, wholly unlike that of a healthy infant. In some of the worst cases, too, a bloody fluid is discharged in considerable quantity from the nose and mouth. If the indurated parts be punctured, a small quantity of reddish serum escapes from them, though generally without much diminution of their previous hardness. If the induration be at all general, death almost invariably takes place; and so great is the fatality of the affection, that, including even slight cases, five-sixths of those children who are attacked by it in the hospitals of Paris, die. In very slight cases, however, if the infant be at once placed in favorable circumstances, recovery need not be des- paired of. The hardness of the surface still persists after death, and the absence of any peculiarity in the effused serum, or of any sign of active dis- ease, left writers generally in much perplexity as to its cause. The venous system is usually found gorged with fluid blood, and this con- gestion is often apparent in the cerebral vessels, as well as in those of the abdominal viscera, particularly the liver. Both the thorax and abdomen also frequently contain a quantity of serum, often tinged with blood—effusions which are evidently of a passive nature, since they are unattended by any trace of inflammation either of the pleura or peritoneum. None of the viscera present any morbid appearances of half so much importance as those which are met with in the lungs, a very great part of which displays those changes to which your attention has already been directed as characteristic of their deficient expansion.* This condition of the lungs had been noticed and most 1 In a paper by M. Elsasser, of Stuttgard, reprinted in the Archives de Medecine for May, 1853, from the Archiv. f. physiolog. Heilkunde, are some very interesting facts with reference to the loss of weight in the course of this affection. The average loss of weight in 53 fatal cases, was f of a pound ; the extremes each way being six ounces and two pounds. 2 The observations of J. A. Troccon, in his dissertation " Sur la maladie connue sous le nom d'endurcissemeiit du tissu cellnlaire," 4to. Paris, 1814, are especially remarkable, since he not only described with accuracy the physical condition of the lungs, but even tried the experiment of inflating fhem, in order to prove that they were not, as had been erroneously supposed, in a state of gangrene. He says—"J'ai insuffle ensuite de Pair dans les poumons par la trachee : aussitdt la couleur noire qui etait a leur base s'est changee en une couleur rouge claire, laquelle s'est etendue de proche en proche a mesure que je continuais ces insufflations." After removing a ligature which he had applied around the veins, and allowing the escape of the blood with which the heart and lungs were gorged, he.resumed the inflation of the lungs, TREATMENT OF INDURATION OF CELLULAR TISSUE. 249 carefully described many years ago, as one of the most striking at- tendants on induration of the cellular tissue. It was thought by some of those who described it to be the result of pneumonia; while other observers, justly insisting on the absence of the other effects of in- flammation of the pulmonary tissue, yet drew the attention of patho- logists too much away from the chest, where the clue to the solution of the question as to the cause of the affection was to be found, had they but known how to use it. We, however, are aware that those appearances once thought to be the result of pneumonia, are in reality due to the unexpand^ed condition of the lung; and we can understand how it may happen, if children be exposed to cold immediately after birth, and then transferred to the ill-ventilated wards of a foundling hospital, and there fed with food far other than that which nature destined for them, that respiration may be but very imperfectly estab- lished ; that their temperature may consequently fall, and the blood flowing in part through the unclosed fcetal passages may stagnate in its course, may give rise to passive effusions into the great cavities of the body, and to an anasarcous swelling of the surface. There are, it is true, some peculiarities in this form of oedema, but not such as to invalidate the above explanation of the cause to which it is due. The treatment of this affection implies the removal of every cause likely to induce it. Hence warmth stands foremost both as a curative and as a preventive measure. The warm bath may be resorted to as a means of raising the child's surface to a proper temperature, provided its extreme weakness do not contra-indicate that measure. Gentle friction with warm oil is a means which has been tried for this pur- pose with advantage. The child should be nourished with breast-milk, even if it be too feeble to suck, and stimulants, of which white-wine whey is a very good one, will in many instances be needed. Defective respiration being the ultimate source of all the symptoms, the main principles of all your treatment must be the same as have already been laid down for your guidance in cases of atelektasis of the lung; and these it can hardly be necessary to recapitulate. I should have said more about this affection, its nature and treat- ment, if it were one with which you were likely to meet often ; but, in consideration of its extreme rarity in this country, I may perhaps be excused for passing it over with this cursory notice. and " les organes de la respiration ont ete presque de suite dans un etat absolument naturel,et aussi beaux que ceux que l'onvoitpendus devantnosboucheries."—pp. 37-8. It seems strange that neither M. Troccon nor subsequent observers perceived the full bearing of these experiments till similar ones were instituted by MM. Bailly and Legendre. 250 INFLAMMATION OF RESPIRATORY MUCOUS MEMBRANE. LECTURE XIX. Inflammatory Affections of the Respiratory Mucous Membrane—comparative rarity of catarrh during the first weeks of life—Coryza—simple and pseudo-membranous or malignant—identity of latter with nasal diphtheria.—Catarrh, causes adding to its im- portance in early life—its treatment—danger of bronchitis or pneumonia. Post-mortem appearances of Bronchitis—redness of the membrane—nature of the contents of the bronchi—dilatation of their cavity.—Extension of the inflammation to the lining of the pulmonary vesicles, producing vesicular bronchitis. State of the lungs in bronchitis—frequency of congestion—carnification of some lobules— possible extension of inflammation to the pulmonary tissue, producing lobular pneu- monia—suppuration of these patches producing vomicae. Although two lectures have already been devoted to the pathology of the respiratory organs, yet, until to-day, we have not been able to commencethe study of their special diseases. They may be divided into the three grand classes—of the inflam- matory, the nervous, and those which result from morbid deposits. We will examine these in the order in which I have enumerated them. At every age inflammatory affections of the respiratory mucous mem- brane exceed all others in frequency; and even when the pulmonary substance becomes eventually involved, it is often by the extension to it of mischief which began in the mucous membrane. But in infancy and childhood this is pre-eminently the case, for the delicate and highly vascular lining of the respiratory organs resists but feebly the influence of noxious impressions from without, while it sympathizes most acutely with many morbid processes within. This extreme susceptibility of the mucous membrane of the respi- ratory organs' in childhood renders its disorders of very frequent occurrence, while we are compelled to study closely the signification of symptoms that may betoken disturbance from such various causes. Something of this sympathy with the affections of other parts exists even in the adult, as we may see exemplified in the cough that attends upon affections of the liver, but in the child the sympathetic disorder of the respiratory mucous membrane is vastly more frequent; and nurses, taught by experience, will speak to you about a tooth-cough, a stomach-cough, a worm-cough; while you will soon find for your- selves that the intestinal mucous membrane is seldom affected without that of the respiratory apparatus suffering too. It is a curious fact, however, to which Professor Jorg, of Leipsic,1 was the first person to call attention, that this extreme susceptibility of the lining of the respiratory apparatus does not exist to the same degree during the first month or two of life as it does afterwards. 1 Handbuch der Kinderkrankheiten, 8vo. Leipsig, 1836, p. 531. INFLAMMATION OF RESPIRATORY MUCOUS MEMBRANE. 251 The exposure of an infant two or three weeks old to a low temperature or to a vitiated air, will be followed by disturbance of the functions of the liver, and the occurrence of jaundice; or, perhaps, by such depression of the muscular power as to render the child incapable of taking a full inspiration, so that its lungs collapse, aud it dies from disorder of the respiratory organs, but without the cough or bronchitic symptoms, which would not fail, if it were a little older, to announce the irritation of the mucous membrane of the air-tubes. Why this is so I do not know, but I suppose it to be the result of the generally feeble vitality which renders the lining of the bronchi less susceptible ; just as that of the intestine also seems to be at the same period; since, while constipation is frequent, diarrhoea is comparatively rare during the first two months of life. The mucous membrane of the nares, however, has not by any means this insensibility, the coryza is an affection most frequent, and most important, during the first two months of life, when the other forms of catarrh are comparatively rare. This affection, in its most frequent form, is a source of discomfort rather than of danger. Its most prominent symptom has given rise to its vulgar name of "the snuffles;" for, the mucous membrane of the nares being swollen, the child is no longer able to breathe through its nose as it was wont to do, but is compelled to breathe likewise through its mouth, and its difficult inspirations are attended by a peculiar snuffling noise, which, during sleep, sometimes amount to a complete snore. As in common catarrh, the secretion from the mem- brane is at first suppressed, afterwards it flows in an increased quantity, and then at length it is altered in character, and becomes thicker and puriform; and then it sometimes dries and forms crusts about the nostrils, which interfere greatly with free respiration, and cause the child much annoyance. At the outset there is often a degree of heat of skin and febrile disturbance, but these symptoms soon subside, and, with the exception of the snuffling respiration, the child seems quite well. If the attack be more severe, however, it may occasion a good deal of suffering, for if respiration through the nose be very much impeded or altogether prevented, the child is rendered unable to suck, and so soon as it has seized the nipple and begun to draw the milk, it is compelled to leave it in a state of threatening suffocation. Its distress, too, is further increased by the circumstance that its mouth, being constantly kept open in order to breathe, the tongue and throat become extremely dry, and deglutition, even when the child is fed with a spoon, is often attended with difficulty. Any such severity of the disease, however, is very unusual, though such cases do sometimes occur, and even prove fatal; the difficulty of breathing and sucking, together, wearing out the patient. In the great majority of instances indeed, when this event occurs, something more exists than a simple inflammation of the Schneiderian membrane, since it either secretes a very tenacious mucus in extreme abundance, or becomes coated with false membrane, which sometimes extends even to the tonsils and palate. Cases of this kind are usually asso- ciated with extreme depression of the vital powers, and have received 252 CHRONIC CORYZA AND CATARRH. on this account the name of coryza maligna. I have no doubt of their identity with diphtheria, of which they constitute the form known as nasal diphtheria, though some twenty years ago, when diphtheria was a comparatively unknown disease, their real nature did not strike me then as it does now. I shall, therefore, leave them out of consideration at present, and confine my remarks to that simple coryza, which as I have stated, is usually a source of discomfort rather than a cause of danger. This simple coryza calls for but little treatment, and, indeed, treat- ment appears to exert but little influence over it. It is desirable, however, if there be much difficulty in breathing, that the child be taken from the breast, though it may still be fed with its mother's milk by means of a spoon, since the fruitless efforts to suck aggravate its distress, and should therefore be prevented. If heat of skin and other indications of fever attend its onset, some mild diaphoretic medicine, with a few drops of ipecacuanha wine, may be given;1 attention must be paid to the state of the bowels, and in the course of ten days or a fortnight the infant will be found again breathing quietly, and the disease will have subsided. As the secretion becomes thicker, care must be taken to prevent its accumulation and drying at the opening of the nostrils, by which it would cause serious discomfort to the child. Cases are sometimes met with in which coryza, though not of a se- vere kind, is troublesome by its continuance for weeks together. This chronic coryza is, I believe, almost always connected with a syphilitic taint. I have on several occasions met with it when there were not above one or two spots of copper-colored eruption to mark its charac- ter ; and a few instances of it have come under my notice in which no positive evidence of venereal taint, either past or present, could be ob- tained, but which nevertheless got well under the use of small doses of the hydrarg. c. creta. With the increasing age of the infant there is a growing liability to catarrh, and during the period of dentition the susceptibility of the mucous membrane of the respiratory organs appears to have attained its maximum. Slight variations of temperature now induce catarrhal seizures; or even, independently of any such exciting cause, the mere approach of a tooth towards the surface of the gum often gives rise to its symptoms, which subside when the source of irritation ceases. Such attacks often alternate with attacks of diarrhoea, or the two co- exist; the symptoms of disturbance of the intestinal mucous membrane predominating at one time, those of disturbance of the respiratory membrane at another. The preponderance of one or the other aff'ec- tion seems much to depend on atmospheric causes; and children who 1 (No. 8.) R.—Liq. Am. Acet. gj. Vin. Ipecac. ttbxvj. Pot. Nitratis, gr. viij. Svr. Tolutan. 3ij- Mist. Amygdalae ad gj. M. a teaspoonful every four hours. For a child six months old. CATARRH — ITS IMPORTANCE IN EARLY LIFE. 253 during the months of June, July, August, and September, would suffer from diarrhoea, will, in precisely similar circumstances, in the earlier months of spring or the later months of autumn, suffer from catarrh. From the extreme susceptibility of these two great surfaces arise a large proportion of the ailments, and many even of the serious diseases of infancy. Morbid as well as reparative processes go on most rapidly in early life; the flux of to-day may to morrow be attended with dy- senteric symptoms; the catarrh of to-day may to-morrow have put on the grave features of acute bronchitis. Now these two circumstances taken together—the extreme suscep- tibility of the respiratory mucous membrane, and the rapidity with which its trivial disorder sometimes becomes a grave disease—give to the catarrhal affections of infancy an importance such as in more ad- vanced life they do not possess. This importance, too, is still further increased by the tendency of the lung to become collapsed when the entrance of air into its minuter cells is impeded even by a compara- tively trivial cause; while in other cases, or even in connection with the collapsed condition of the lung, the inflammatory process may invade the pulmonary cells and the general tissue of the lung, and that which had seemed a slight cold may grow to a dangerous bron- chitis, or a still more dangerous pneumonia. Of catarrh itself and its general characters little need be said. Allow- ing for the difference between the ages of the patients, its symptoms are the same as in the adult. Sneezing and running at the eyes and nose, and cough, a hot skin and quickened pulse, attend it. In some children the febrile disturbance with which even a common attack of cold sets in is very severe for the first twenty-four hours or more, and then the more threatening symptoms subside, and the true nature of the aff'ection becomes apparent. At other times, when catarrh is ex- tremely prevalent—epidemic in short—this severe onset is usual, and the affection closely resembles, or is probably identical with, influenza. Often, too, you will find the commencement of an epidemic of hoop- ing cough preluded by an unusual prevalence of catarrh, the cough by degrees assuming in more and more numerous cases the paroxys- mal character and peculiar sound of pertussis. It is unnecessary to allude to the catarrhal symptoms which precede measles; but bearing in mind that that which seems to be a mere cold may turn out to be the first stage of a very serious malady, you are furnished with an ad- ditional reason for not slighting it. Lastly, you must not forget that the frequent return of attacks of catarrh, is sometimes an indication of that irritable state of the bronchial membrane which the abundant de- posit of tubercle in the lungs occasions; and this, again, yields another argument for not neglecting an apparently trivial ailment. While it is your duty, however, on so many grounds, to watch closely every child, although its indisposition may not seem to be more than a simple catarrh, yet in the way of actual medical treatment Very little is required. The child must be kept in one temperature; and, if the nursery be an airy room, it is desirable that it be confined to that apartment. If already weaned, it may be well to withdraw some of the more solid articles of diet; if not, care must be taken that 254 TREATMENT OF CATARRH—BRONCHITIS. the child does not, in consequence of its thirst, suck too much, and a little barley-water should therefore be given it from time to time. A warm bath at night will do much to allay the heat of skin; and, if the febrile disturbance be considerable, a couple of grains of James' pow- der, with half a grain of calomel, may be given to a child a year old, at bedtime. During the day a mixture, containing a few drops of ipecacuanha and antimonial wine, with a little of the compound tinc- ture of camphor, if the cough irritate by its frequent return, may be given with advantage; and, as the fever subsides, the spirit of nitrous ether may be substituted for the antimonial wine.1 The danger, however, in these cases, is of a more grave disorder of the air-passages coming on; and this brings us to a subject which we cannot pass over hurriedly—namely, the bronchitis and pneumonia of infancy and childhood. The study of these affections in childhood is beset by some diffi- culties which we do not meet with in the adult. The points of diffe- rence between bronchitis and pneumonia are sufficiently well marked in the adult for all purposes of practical utility, although many inquiries may be started with reference to the intimate nature of the morbid processes, which we may be unable to answer satisfactorily. Besides, whether the capillaries, or the pulmonary cells, or their parietes, be the structures first attacked, it is clear that they are all involved in pneumonia from a very early stage of the disease; and hence we find it attended from the outset with peculiar symptoms, such as do not occur in bronchitis. Pneumonia similar to that of the adult is sometimes observed even in early childhood; but it often happens that, though the pulmonary substance becomes eventually a partaker in the disease, yet it is not so at first; but the inflammation, beginning in the larger air-tubes, has passed along them to the smaller bronchi, and then at length involving the tissue of the lung, the case comes to be one neither of pure bronchitis nor of pure pneumonia, but a mixture of the two, which has not inaptly been termed broncho- pneumonia. Another source of difficulty in the study of these affec- tions, as well as an occasion of the great peril that attends them, is the tendency which we have already observed in the lung during early life to become collapsed, and no longer to admit that air without which the changes in the blood cannot take place, and the absence of which naturally aggravates the mischief that the inflammatory disease itself tends so immediately to produce. I must beg you, therefore, to pardon me if I enter rather more minutely than is my custom into the description of the morbid appear- ances produced by inflammation of the lungs and air-tubes in infancy and childhood. 1 (No. 9.) (No. 10.) ty.—Vin. Ipecacuanhas, nix. R.—Vin. Ipecac, TTix. Vin. Ant. Pot.-Tart., irixxx. Oxym. Scillae, rr^xl. Tinct. Camph. co., ttixx. Spir. ^Eth. Nitr., rt\,xx. Mist. Amygdala?, ^vij. Tinct. Camph. co.,Tt\,xx. M. two teaspoonfuls every four hours. Aquae Anisi, 3viss. M. two teaspoonfuls every four hours. For children of one year old. MORBID APPEARANCES OF THE BRONCHI. 255 t An increased degree of redness of the mucous membrane of the bronchi is almost constantly observed in the case of children who have died of inflammation of the lungs or air-tubes. There are three sources of error, however, which it is essential to guard against when examining the bronchi with reference to this point. The first is the occasional disappearance of redness after death, even where the presence of an abundant muco-purulent secretion in the tubes bears evidence to the activity of the inflammatory process; the second is the apparent red- ness of the smaller tubes in cases where the lungs are congested or inflamed, and which may be due, not to the increased vascularity of the bronchi themselves, but to their transparency allowing that of the subjacent tissue to be seen through them. The third is the occasional staining of the mucous membrane, owing to the transudation of the blood through the coats of the vessels after death. With care, how- ever, none of these circumstances will lead you astray. The redness of the bronchi varies much both in degree and extent, and in some cases which have approached to the character of pneu- monia rather than of bronchitis, is sometimes limited to the inflamed lobes. In cases, however, in which much bronchitis has existed, very marked redness generally begins about an inch above the bifurcation of the trachea, and pervades all the bronchi, being deeper in the secondary than in the primary tubes, and retaining nearly as great an intensity even in the tertiary branches. It may stop here, or it may extend even into the ultimate ramuscules, or into the pulmonary cells themselves. In the majority of cases no other change besides this intense redness is perceptible in the mucous membrane, but sometimes it appears'both thickened and softened; and on one occasion in which a fatal attack of acute bronchitis supervened on a long continuance of the chronic stage of the disease, the bronchial mucous membrane was intensely red, and so thickened as to have an almost villous appearance, and closely to resemble red velvet. Ulceration of the mucous membrane of the trachea and larger bronchi, which is occasionally met with in the bronchitis of adults, I never observed but once. In that case, a little boy, twenty months old, who had suffered from a not very severe attack of bronchitis, in the course of which, however, he had had oc- casional difficulty in deglutition, with return of fluids by the nose, died rather suddenly. The only remarkable appearance besides a general redness of the bronchial tubes consisted in the presence of several small excavated ulcerations or erosions in the upper part of the larynx, just above the chordee vocales. Associated with the changes in the mucous membrane of the bronchi there is an alteration in the character of their secretion. At first, no doubt, this secretion is suppressed, just as we see that furnished by the Schneiderian membrane to be in a common cold; but afterwards it is poured out abundantly, and next ceases to present its natural charac- ters of a glairy mucus; becoming opaque, thick, puriform, or actually purulent, while in'a few less common instances the secretion assumes the form and consistence of false membrane, constituting a true croup of the bronchi. Any traces of blood are but very seldom observed in 256 MORBID APPEARANCES OF THE BRONCHI. the secretion, and the quantity of air-bubbles intermingled with it is usually in inverse proportion to the thickness of the secretion and its abundance. But not only are the contents of the air-tubes altered in character, and for the most part, increased in quantity, but the tubes themselves often undergo a marked alteration in their calibre, and become greatly dilated. This dilatation is usually observable from the secondary bronchi to the minutest air-tubes; the branches often being as large as the parent trunk, or even larger: but that fusiform dilatation which is met with in the adult has never come under my notice. On one occasion, however, in addition to a general cylindrical enlargement of the tubes, many of them presented a marked dilatation about half an inch from their termination; the tube expanding into a cavity big enough to hold half a nut. The interior of these cavities was not per- fectly smooth and regular, but its thickened lining was in many parts thrown into folds or wrinkles. The case in which this appearance was observed was the one already mentioned, where the mucous mem- brane of the bronchi presented so extraordinary a degree of thickening. Dilatation of the bronchi was once supposed to be the purely me- chanical effect of the accumulation of the secretions within them. There is, however, no constant relation between the quantity of the liquids within the bronchi and the degree of their dilatation, and we must look to two other circumstances as being the primary causes of the occurrence. The first of these is the weakening of the muscular fibres of the bronchi by the inflammatory action; the other, the loss of the ciliary epithelium which lines the air-tubes when in a state of hearth, and contributes by the incessant vibration of its cilia to keep them free for the access of air. Whenever bronchitis has reached such an intensity as to give rise to the abundant pouring out of thick fluid into the air-tubes, so that the air can no longer permeate them with facility, while this difficulty is still further increased by the loss of the ciliary epithelium, and by the weakening of the contractile power of the bronchi, which would have helped to keep them free, it often happens that the feeble inspi- ratory power of the child becomes wholly inadequate to fill the lungs; large portions of them collapse, and bronchitis thus becomes the indi- rect cause of carnification of the lung. In some cases, the inflammation of the respiratory mucous membrane extends further than usual along the smaller bronchi, until it involves their extremities and the pulmonary vesicles themselves, when it pro- duces an appearance almost peculiar to childhood, and which has been described under the names of vesicular pneumonia or vesicular bronchitis. A lung, or a portion of a lung, thus affected, no longer contains any air—it is dark in color, and feels tough, though solid ; its surface is beset by a number of small, circular, yellow, slightly prominent spots, of the size of a millet-seed, or smaller, which, on a hasty glance, pre- sent a very great resemblance to crude tubercles. A very little atten- tion, however, suffices to distinguish between them; for not only do these yellow spots differ from tubercle in their favorite seat being along the lower margins of the different lobes, but on puncturing any CONGESTION OF THE LUNG. 257 of them with the point of a scalpel, a drop of pus will exude, and the yellow spot will disappear. Sometimes too, a minute bronchus may be traced running to its termination in one of these little sacs. It hns been suggested that this appearance may be due to the secretions formed in the air-tube being forced by the column of air which enters in inspiration into the smaller bronchi and pulmonary vesicles, the cavities of which thus become mechanically distended. The opinion that the secretions which occupy these parts are produced at the spot where they are discovered, by inflammation of the ultimateramuscules of the bronchi, is, however, generally entertained, and is supported by very conclusive evidence. Bronchitis often exists unattended with this peculiar appearance; and on the other hand, vesicular bronchitis is met with independent of general inflammation of the air tubes, while, though usually partial, and often limited to the lower border of one or other lobe, it is sometimes very extensive, and occupies nearly the whole of the lower lobe on either side, constituting the most important of the morbid appearances discovered on examining the chest. It may, and unquestionably often does, happen that children die of bronchitis alone, and without any notable affection of the pulmonary tissue. But it is much more frequent for the pulmonary substance to bear a part in the morbid process; and this share may either be limited to mere congestion, or may rise in degree until it produces all those consequences which we find attendant on inflammation of the tissue of the lung in the adult. Some degree of congestion of the lung is almost constant if bronchitis be at all severe, for the circulation through the organ is disturbed, the blood flows less freely than natural, and its changes take place more slowly. It stagnates first in those depending parts whence position renders its return most difficult, and the portions of the lung thus affected become by degrees more and more extensive. Dark, solid, non-crepitant patches may be often seen in the midst of a lung thus congested; and until the results of inflation showed that a wrong interpretation had been given to the appearance, these patches were regarded as the centres whence the inflammation was extending to the surrounding tissue. You do not need to be reminded that these are lobules which have collapsed, and become impervious to air; and portions of lung in which this occurrence has taken place seem to have but little disposition to become the seat of active inflammation, and to pass into a state of red or gray hepatization. At the same time, it must be borne in mind that this indisposition to active inflam- mation does not by any means amount to actual immunity from it, and that carnified lung may sometimes become softened, or even infil- trated with pus. It does, however, happen now and then that the lung is found in a condition which may justly be called lobular pneumonia, as the result of the extension to the surrounding tissue of inflammation beginning in air-tubes. Patches of lung will then be interspersed through the surrounding pulmonary substance, of a vivid red color, of various sizes, from that of a pea to that of an almond, irregular in shape, and not circumscribed exactly by the margins of lobules, as in the case with 17 258 TRUE LOBULAR PNEUMONIA. portions of carnified lung. This process going on in a number of different situations, the affected parts may at length coalesce, and a pneumonia at first lobular, may thus eventually become generalized. Or, though this should not occur, the inflammation may yet go on in the isolated portions of lung to the infiltration of pus into its substance, or the actual destruction of its tissue, when a portion of the lung will appear riddled with small distinct abscesses seldom larger than a pea, irregular in form, and communicating more or less evidently with a minute air-tube. They may be distinguished from the vomicae pro- duced by softened tubercle, partly by the absence of tubercular de- posits in other parts of the body, and by their being almost always limited to a single lobe of one lung. Their own characters, however, are sufficiently well marked, for they are altogether destitute of those solid walls which the tubercular deposit forms around a .phthisical cavity; though the yellow lymph which often lines them may be mis- taken by the inattentive observer for tubercle. MM. Rilliet and Bar- thez mention having found the pulmonary substance healthy, except in the immediate periphery of these abscesses ; but no instance of this kind has come under my own observation, the pneumonia having in each instance become generalized. The appearances we have been hitherto considering are due almost exclusively to inflammation of the air-tubes; and many of them are peculiar to infancy and childhood. We might next proceed to study the symptoms that betoken their existence; but on the one hand, they seldom exist quite alone, and on the other hand their symptoms pre- sent so many points of resemblance to those of pneumonia strictly so called, that it may be better to complete our survey of the morbid appearances that result from inflammation affecting either the air-tubes or the parenchyma of the lung, before we pass to the study of the symptoms that attend the one or the other during life. The completion of this subject, however, must be postponed to the next lecture. LOBAR PNEUMONIA — NOT UNUSUAL IN CHILDHOOD. 259 LECTURE XX. Inflammatory Affections of the Tissue of the Lung—Lobar Pneumonia—More com- mon in early life than has been supposed—Its general characters the same as in the adult —Some morbid appearances deserving especial notice, viz., sub-pleural ecchymoses, pneu- monic abscess, and emphysema of the uninflamed portions of the lung. Frequency and causes of inflammation of the respiratory organs—Influence of age—of previous attacks—of various diseases. Bronchitis—its Symptoms ano Treatment—A more serious disease than in the adult, and why—Symptoms of capillary bronchitis—Illustrative case—Results of auscultation. Treatment of bronchitis—Change in the epidemic constitution of diseases, and inexpediency of very active measures—General rules for treatment—Treatment of bronchitis in its chronic stage. Influenza—its peculiarities and treatment in early life. We were occupied during the last lecture with the examination of some of the results of inflammation of the respiratory organs in early life, and considered more especially those changes which inflammation produces in the air-tubes. You were told on that occasion that the disease does not always remain limited to the bronchi or pulmonary vesicles, but that it sometimes involves the substance of the lung, and thus gives rise to the appearance of a number of small circumscribed patches interspersed throughout its tissue, either red, hard, and solid, or gray from the infiltration of pus; while, if the mischief advance one step further, it may lead to the destruction of the parenchyma of the organ at these points, and thus produce numerous minute abscesses, a condition which has come four times under my own observation. Cases of this kind, constituting true lobular pneumonia, though some- what less rare than in the adult, are yet of very unfrequent occurrence. It is almost needless to remind you that the contrary opinion resulted from persons not having learned till very lately to distinguish between that solidity of the lung which is produced by inflammation, and that which results from the mere collapse of its air-cells. The exaggerated estimate of the frequency of lobular pneumonia, and the peculiar character of the field presented at the Hospital for Children at Paris, in which the most diligent and most successful students of children's disease labored, led to an underrating of the frequency and importance of lobar pneumonia such as is met with in the adult; and hence you will find but little said concerning it in many most valuable works of our continental neighbors. Lobar pneu- monia, however, is often met with in early life both as an idiopathic and a secondary affection, giving rise to the same morbid appearances as in the adult, and requiring a very similar treatment. Not only are the physical characters of the lung in lobar pneumonia the same in childhood as in adult age, but the three stages of engorge- ment, of red and of gray hepatization, are observed with much the 260 LOBAR PNEUMONIA —NOT UNUSUAL IN CHILDHOOD. same frequency at the one period of life as at the other. I find that after rejecting all cases in which pneumonia occurred as a complication of phthisis, or of acute pleurisy, and in which the results might be modi- fied by the disease to which the inflammation of ttte lung succeeded, I have a record of 94 cases in which the condition of the inflamed lung was carefully noticed. In 15 of these cases the 1st and 2d stages of pneumonia coexisted. » 4 » " 1st and 8d " " « 25 " " 2d and 3d " « 14 " " all 3 " " " " 13 " " lung was in the 1st stage only. " 13 " " lung was in the 2d " » 10 " " lung was in the 3d " 94 This result does not differ very widely from that obtained by M. Grisolle,1 on an examination of 40 cases of pneumonia in the adult. In 4 cases the 1st and 2d stages of pneumonia coexisted. " 3 " 1st and 3d " " " " 16 " 2d and 3d " " " 2 " all 3 " " " " 7 " lung was in the 2d stage only. " 8 " lung was in the 3d " 40 It will be seen, on a comparison of these tables, that the third stage of pneumonia occurs not very much less often in children than in adults, having been met with in the former in the proportion of 56.3, in the latter in the proportion of 72.5 per cent.; and the main differ- ence between the two consists in the greater frequency with which all three stages of pneumonia coexist in the young subject. This pecu- liarity of pneumonia in childhood is probably due to the tendency which the disease then displays to involve a large extent of pulmo- nary tissue; and to the same cause we must attribute the frequency of double pneumonia in early life, which, in the cases that came under my notice, preponderated greatly over those wherein only one lung suffered. The well-known law, according to which pneumonia of the right lung is more common than pneumonia of the left, holds good in childhood; nor is the frequency of concomitant pleurisy much, if at all, less in the child than in the adult. The contrary opinion arose from the error to which reference has so often been made, of regarding cases of collapsed lung, either with or without bronchitis, as instances of red hepatization of the pulmonary substance. Instead of inflammation of the lungs being less active in the child than in the adult, there are some facts which would seem to lead to a directly opposite conclusion. Such are the frequency with which, in fatal pneumonia in children, ecchymoses are found beneath the pleura 1 Traite de la Pneumonie, 8vo., 2d ed., p. 17. Paris, 1864. PULMONARY ABSCESS. 261 covering the inflamed lung, the more common occurrence of pulmo- nary abscess in early than in adult life, and the very extensive emphysema which is often observed in those parts of the lung to which the inflammation has not extended. The sub-pleural ecchymoses appear to result from the rupture of some of the minute capillaries of the lungs in consequence of the great disturbance of the circulation through them. They are usually small like petechias, but occasionally they attain a large size, and now and then they even extend a little way into the tissue of the lung, consti- tuting little spots of pulmonary apoplexy, about the size of millet- seed, or even a little larger. They are most numerous on the posterior surface of the lungs, and especially in parts where the lung has become hepatized, though by no means confined to those situations. The termination of pneumonia in abscess of the lung is so rare an occurrence in the adult, that Laennec did not meet with it above five or six times in the course of several hundred examinations of persons who had died of inflammation of the lungs. In the child, however, the case is otherwise, for abscess of the lung has come under my qbservation in four out of ninety-four examinations of cases of pneu- monia, on which my present remarks are founded. In one of these cases, that of a boy, aged twenty months, who died on the fourteenth day after the commencement of an illness which resembled remittent fever in many of its symptoms, but was associated from the outset with the indications of pneumonia, the following appearances were observed: The upper and middle lobes of the right lung were con- nected to each other, and to the walls of the chest, by adhesions which were chiefly recent. Nearly the whole of the upper lobe was solid, and sank in water. It was of a mottled reddish-gray color, in which gray predominated ; it broke with a granular fracture, and was readily reduced to a dirty putrilage. Near the apex was a portion the size of a walnut which was already soft and in a state of quagmire. The upper two-thirds of the middle lobe were in the same condition as the upper lobe; the lower third was emphysematous. In the centre of the middle lobe was a cavity the size of a bean, irregular in form, intersected by the remains of some vessels lined by a thin layer of yellow lymph, and surrounded by lung in the third stage of pneu- monia; but neither in that lobe nor in any part of the pulmonary tissue was there the least trace of tubercle, and the only indication of phthisical disease consisted in one bronchial gland having become converted into tubercle which had undergone the cretaceous transfor- mation. The lower lobe of the right lung was in the first stage of pneumonia; the left upper lobe was quite healthy; the left lower lobe was in a state of mingled red and gray Jiepatization. Two cases occurred in children who had suffered for some weeks from hooping- cough, and in both the lungs contained numerous semi-transparent, gray, tubercular granulations. One of the children was a boy, five years old; the other a little girl, aged two years. In the case of the former, the abscess, as large as a walnut, was situated at the lower border of the upper lobe, extending a little into the lower lobe. In the latter it was of the size of an unshelled almond, and occupied a 262 EMPHYSEMA. similar position with reference to the right upper and middle lobes. The characters of the abscess were the same in both instances, being situated almost immediately beneath the pleura; from which a wall of lung not above two lines in thickness separated it. Its cavity was partly filled with a yellowish, puriform, very tenacious fluid, like very tenacious pus, and which did not bear any resemblance to softened tubercle. It was not lined by any membrane; there was no appear- ance of tubercular deposit in the hepatized lung in its immediate vicinity, which was generally in the second stage of pneumonia, nor was it situated near to, nor in communication with, any large bron- chial tube. In the fourth case, that of a boy aged eleven years, who died of pyaemia, consequent on exposure to cold and wet, the purulent deposits were not limited to the lung substance, although they were associated there with general pneumonia, and with several patches of pulmonary apoplexy. The lung in childhood shows a much greater tendency to pass into a state of gangrene than in adult age. It maybe doubted, however, whether this gangrene is the result of the intensity of the inflammation so much as of some peculiar change in the blood which favors the occurrence of mortification. The occasional prevalence of gangrene of the lung and of other parts, as an endemic affection in the Hopital des Enfants at Paris, favors the latter supposition, with which the only instance of it that has come under my own observation in the child is quite in accordance. The emphysematous condition of the uniuflamed portions of the lung, in cases of fatal pneumonia in early life, seems to be connected with the rapidity of the advance of the disease. It is usually most obvious at the anterior part of the upper lobes of the lungs and at the margin of the other lobes, and always bears a marked relation to the shortness of the patient's illness, and the extent of lung which has been rendered unavailable for purposes of respiration. The cases, however, which terminate most rapidly are not those in which the direct results of inflammation are the most extensive, but rather those in which collapse of a considerable portion of lung has taken place; and the emphysema, which is met with also in many cases of vesicular bronchitis, is conse- quent less on the inflammation than on the collapse by which it is accompanied. Its occurrence in those circumstances affords therefore an illustration of that modification of the inspiratory theory of emphy- sema so clearly propounded and so ably supported by Professor Gairdner, of Glasgow ;x and which regards the over-distension of the air vesicles of one part of the lung as a necessary compensation for their collapse, and the consequent diminished bulk of another part, while the enlargement and the capacity of the thorax during inspira- tion remain the same, or at any rate are but slightly modified.2 1 On the Pathological Anatomy of Bronchitis, &c, 8vo., Edinburgh, 1850; and Edinburgh Monthly Journal, vol. xiv. 2 In the second and third editions of these lectures I stated that the amount of emphysema bore a " marked relation to the shortness of the patient's illness, and the extent of lung which had been invaded by the inflammation." A careful re- examination of the accounts of my post-mortems of cases of pneumonia and bron- chitis, convinces me that the statement as now modified is more correct in point of CAUSES OF PNEUMONIA. 263 The causes which give rise to inflammation of the lungs and air- tubes are, to a great extent, the same at all periods of life ; so that we need not devote much attention to the special study of those which tend to produce it in childoood. It should be borne in mind, however, that the fluctuations in temperature, or the biting wind, or the cold weather, which may be encountered with impunity by the robust adult, may prove most deadly when they act on the feeble frame and delicate organs of the child. Hence it is, in great measure, that inflammation of the respiratory organs is so much more frequent, and so much more fatal, in childhood than in adult age, and in infancy than in childhood. The fact is well shown by the Reports of the Registrar-General for the years 1842 and 1845, from which it appears that 67.1 per cent, of the total mortality from inflammation of the lungs and bronchi, in the metropolis, took place in persons under fifteen years of age; 63.2 per cent, under five; 57.1 under three; and 28.7 per cent, under one year. But the tendency to these affections, as is shown in the following table, is not greatest in the first month of life, diminishing in proportion as the child advances in age and increases in strength; but the time when they are most prevalent coincides exactly with the time when the susceptibility of all the mucous membranes is at it? highest point, namely, the period of den- tition. Table, showing out of 299 cases of children dying from various diseases, in whom I carefully examined the thoracic viscera, the number of in- stances in which the lungs, bronchi, and pleura presented no signs of recent inflammation, and also those in which signs of it were dis- covered. [The first line represents the former, the second the latter class of cases.] Under From From From From From From From From From From From From From From Total 1 mth. 1-6 (J-12 12-18 18-2 yrs. 2-3 3-4 ■1-.-) 5-6 6-7 7-8 8-9 9-10 10-11jll-12 5 13 17 15 6 22 17 8 12 5 11 5 4 3 2 145 3 10 15 18 23 16 15 13 8 10 11 3 4 5 154 This table illustrates the fact mentioned in the last lecture, that when the child is first born, the mucous membrane of the respiratory organs is endowed with but little of that susceptibility which it after- wards acquires, and that accordingly those diseases whose point of departure is from that membrane are far less frequent during the first six months of life than they become during the succeeding eighteen months; while from the completion of the second year up to the time of puberty, they go on diminishing in frequency and fatality. And fact, while at the same time it harmonizes perfectly with Dr. Gairdner's theory of emphysema. That theory however is, I am convinced, applicable only to one class of cases, while of another equally numerous, Dr. Jenner's expiratory theory (see his paper in vol. xl. of the Medico-Chirurgical Transactions) offers the true solution. To this reference will be made when the subject of hooping-cough comes for con- sideration. 264 SYMPTOMS OF BRONCHITIS. there are important practical inferences which may be deduced from the facts we have just mentioned. They teach us not only that a catarrh is a much more serious thing in infancy than in adult age, but also that it is more serious at one period of infancy than at another, and they warn us to guard a child, during the time that the process of teething is going on, with double care against all causes that are likely to excite inflammation of its respiratory organs. There are some diseases which, after having occurred once, confer on persons an immunity from subsequent attacks. This, however, is far from being the case with bronchitis or pneumonia in early life, but the susceptibility of the respiratory organs appears to increase in exact proportion to the frequency with which they have already suffered,' and a child who has once been attacked by inflammation of the lungs or air-tubes is more likely to have a second attack brought on by a slight change of temperature than another who had never suffered from it would be to experience a seizure from a much graver cause. With advancing age this susceptibility seems to wear out— the child outgrows it; but we should act most unwisely if we were to sanction exposure to the cold with the view of hardening a child against its influence. The importance of inflammatory diseases of the respiratory organs depends not merely on the frequency of their occurrence as idiopathic affections, but also on their tendency to supervene in the course of other maladies. This tendency, though very evident at all ages, is especially remarkable in early life, as is apparent from the fact that in only 25 per cent, of the cases enumerated in the table was the inflammation an idiopathic aff'ection. When we come to the subject of measles, hooping-cough, croup, diarrhoea, and remittent fever, it will be necessary to study these secondary attacks of bronchitis and pneumonia with attention, since they constitute frequent and serious complications of those diseases against which it behooves us to be most anxiously on the watch. We will now pass to the study of the symptoms of bronchitis, and will commence with the examination of the most simple form of inflam- mation of the air-tubes—namely, that which develops itself out of ordinary catarrh. In such a case the child has for some days seemed to suffer from nothing more serious than a common cold; but by degrees, instead of the cold and cough subsiding, the heat of skin becomes more considerable, the cough tighter, more frequent, and more painful, the child sometimes crying after each cough: the pulse becomes more rapid, the respiration wheezing, hurried, and often somewhat irregular. These graver symptoms in many instances steal 1 In a tract on Pneumonia in Children, published two-and-twenty years ago in the British and Foreign Medical Review, I mentioned that of 78 children who came under my care for inflammation of the lungs, 31 were stated to have had previous attacks of the disease ; 21 once; 4 twice ; 2 four times ; and 4 were said to have had it several times, though the exact number of seizures was not mentioned. Of these 31, 10 were under two years of age, 10 between two and three, and the remaining 11 between three and six. The same fact is noticed by the most recent writer on pneumonia in child- hood, Ziemsen (Pleuritis und Pneumonie ira Kindesalter, 8vo., Berlin, 1862, p. 153), though his numbers do not represent it of quite such frequent occurrence. SYMPTOMS OF BRONCHITIS. 265 on very gradually, and among the poor it by no means seldom happens that the disease has already attained an advanced stage, and the con- dition has become one of very considerable peril, before the parents, never very observant of those ailments that are not attended with acute suffering, take the alarm. The flush of the face and the heat of the skin become increased, the respiration grows more labored, and the cough more troublesome towards evening; and the first hours of the night are usually very restless, but the child then falls asleep, and often dozes tranquilly for some hours; it then generally awakes with its respiration very oppressed, for the secretions have been accumu- lating in the smaller bronchi, and have now begun to impede the entrance of the air. An attack of cough probably comes on, which very likely ends in vomiting and the rejection of some mucus$ and then by degrees the breathing becomes more easy, and the child may for a short time seem comparatively cheerful. The temperature of the surface, though increased, is variable; and, if the disease continue for several days, perspiration will be observed occasionally to break out on the body, while the pulse, though quickened, is not very much accelerated, and the tongue continues moist throughout. The ear detects nothing in the chest besides a mixture of rhonchus, sibilus, and largish crepitation; the dry sounds preponderating at the upper, the moist at the lower part of the chest, and being vastly more abundant behind than in front. Now in the adult a condition such as this would excite but little apprehension, but in the child it must be borne in mind that nothing more is needed than a copious secretion of mucus in the bronchi, or a feeble condition of the vital powers, to prevent the air from freely entering the pulmonary vesicles, and thus to induce the collapse of a large portion of the lung. Thus it is, at least as I apprehend, that we must explain many of the instances in which urgent dyspnoea, and all the symptoms of serious pulmonary disease, have developed themselves in the course of a few hours out of what had seemed to be nothing more than a rather severe cold, or a bronchitis of moderate intensity. This too accounts for the oc- casional sudden supervention of dulness on percussion, and of bron- chial respiration in the child; so that you may discover them in the morning in a situation where over-night the percussion was good, and no sound was heard of graver import than large crepitation; changes which, unlike those dependent on solidification of the lung from inflam- mation, you may find, as has been remarked by Dr. Gairdner, un- accompanied by an exacerbation of the febrile symptoms. This rapid change in the auscultatory phenomena has been noticed by Dr. Stokes as occasionally happening in the phenomena of the adult.1 That dis- tinguished physician offered no explanation of the occurrence; but we can now understand what is its true import, and what the reasons are for its being met with so much oftener in the child than in the adult. But, notwithstanding this danger, which is great in proportion to the youth of a child, most cases of idiopathic bronchitis that come on gradually, developing themselves out of previous catarrhal symptoms, 1 On the Diseases of the Chest. 8vo. Dublin, 1837, pp. 311 and 327. 266 SYMPTOMS OF CAPILLARY BRONCHITIS. have a favorable termination; and, as a general rule, it may be stated that an attack which is long in arriving at its acme is seldom very dangerous in its character. Pure idiopathic bronchitis occurring in an otherwise healthy child, usually subsides in the course of a few days, leaving the patient with an increased susceptibility to the influ- ence of those causes which brought on the first attack, and perhaps with a degree of debility, the recovery from which may be protracted for many weeks. There is, however, a form of acute bronchitis which is often, though not always, idiopathic, that runs its course with much rapidity, and generally tends to a fatal termination. In this, the suffocative catarrh of some writers—the capillary bronchitis of others—the smaller air- tubes throughout the whole or a considerable portion of the lungs are attacked either in connection with the larger bronchi, or independently of them; and the inflammation, which is very intense, usually termi- nates in the abundant secretion of pus, or in the formation of false mem- brane that nearly obliterates its cavity, or, involving the pulmonary vehicles themselves, it gives rise through a considerable extent of the lungs to those appearances which have been described under the names of vesicular pneumonia and vesicular bronchitis. Its attack is sometimes sudden, though in the great majority of cases it is preceded for a few days by the ordinary symptoms of catarrh, or it supervenes on that condition of bronchial irritation which accompa- nies or follows one or other of the eruptive fevers. In these latter circumstances there is either a progressive though rapid increase in the severity of the bronchitic symptoms, or there is a sudden outbreak of fever and dyspnoea, and the cough becomes all at once frequent, short, and hacking. The disease soon attains a very considerable in- tensity; the face becomes anxious and oppressed, the eyes heavy, the manner depressed; the respiration very hurried, generally irregular, and interrupted by the cough, which frequently seems to occasion pain. The restlessness is often extreme, and the position which the child assumes very variable; but, in whatever attitude it may have placed itself, it does not like to be disturbed, and endeavors at once to return to its former posture. If spoken to, the child's answers are hurried, and its manner impatient, as though it were too much taken up with its suffering, or with the business of respiration, to be able to reply to questions. Sometimes it will say that it feels stuffed, or will complain of distress about the sternum, or of pain at the epigastrium; while pressure on the abdomen, by interfering with the free descent of the diaphragm, always produces much discomfort. There is no appetite; and, though at first the thirst is very considerable, yet the child soon ceases to take much drink, for it wants breath to swallow fluids in any quantity, and therefore does little more than moisten its lips. At the same time the tongue is moist, and either differs but little from its condition in health, or it'has a thin coating of yellowish fur; the bowels are usually constipated, and not only is nausea or vomiting seldom present, but emetic remedies often fail of their ordinary effect when given in the course of this affection. As the disease advances the cough becomes less hacking, though it continues very frequent; it ILLUSTRATIVE CASE. 267 sometimes puts on a paroxysmal character, and returns in fits some- what like those of hooping-cough, except that each fit of coughing is shorter, does not terminate with a whoop, and is seldom attended with expectoration. Even if the cough be accompanied by expectoration, it is seldom that anything is spit up more than a little mucus tinged with blood, or now aud then a little pure blood, while in a few instances small shreds of false membrane are intermingled with the mucus. For a time the respiration grows more and more hurried, and parox- ysms of dyspnoea continue to occur at irregular intervals almost to the last. In these paroxysms the child's distress and restlessness are ex- treme, and it sometimes throws itself wildly about the bed. The breathing does not, however, go on increasing in rapidity until the patient's death; but, after the disease has reached its acme, the respi- ration often grows less frequent, though more irregular and more va- riable. The face loses its flush, and, instead, acquires a livid hue; the cough becomes smothered, and occurs less often; the pulse gains in frequency and fails in power; and though there is often a diminution of the restlessness, yet, if able to talk, the child will generally say that it is no better. As death approaches, though the respiration grows labored and more abdominal, yet the child's suffering generally dimi- nishes, or a state of somnolence gradually steals over it, in which it lies till roused by an attack of cough or by a paroxysm of dyspnoea, and then, after a struggle for breath, it subsides into its former drow- siness. The struggles for breath grow feebler with each returning paroxysm, the drowsiness becomes more profound, and the patient dies. It may be worth while to fill up what is wanting in this brief sketch of the disease, by the history of a case that displayed many of its most characteristic features. A little boy, aged 7.V years, after suffering for a few days from gene- ral feverishness, with a constipated state of the bowels, was attacked on the 6th of April with incessant short cough and hurried breathing, for which symptoms he was ordered to be bled to six ounces, although only two ounces of blood were obtained. Twelve leeches were applied to his chest, and powders containing two grains of calomel and a quarter of a grain of antimony were given him every four hours. The leech-bites bled profusely, and afforded some relief to the dys- pnoea; but, notwithstanding this, the child passed a very restless night. The next morning he was found lying on his back, with his knees drawn up towards the abdomen, his face anxious, his eyes heavy, his skin dry; breathing at the rate of 78 inspirations in the minute, his respiration being often interrupted by a short hacking cough. His pulse was 138, and sharp. He complained of no pain, except when the abdomen was pressed on; but seemed then to suffer considerable uneasiness about the epigastrium. Percussion of the front of the chest occasioned so much pain that it could not be practised satisfac- torily, and behind it did not elicit any difference between the two sides. Throughout the whole of both lungs sub-crepitant rale was heard ; it was smallest in the inferior dorsal region, but was nowhere so small as true pneumonic crepitus. The boy was cupped to five :68 CAPILLARY BRONCHITIS. ounces between the shoulders, and tartar emetic was ordered in quarter of a grain doses every ten minutes until free vomiting should be pro- duced, after which the powders were to be resumed. He took two grains of the tartar emetic without the slightest effect being produced ; and on the 8th his respiration had risen to 98, and his pulse to 144. On the 9th, his respiration had sunk to 72, but the pulse had risen to 156. The cough was usually short and hacking, but attacks of it, which resembled paroxysms of hooping-cough, now came on at in- tervals. The tartar emetic was now given in doses of half a grain every two hours, but with no effect beyond that of producing a feeling of nausea, and occasioning very slight vomiting twice. For an hour or two early on the morning of the 10th he seemed somewhat better: but this improvement soon passed away, and he began to complain of great pain in the chest; whereas his answer previously to all in- quiries had been, "I am so stuffed." His cough was more severe, and the mucus which he now and then expectorated with it was some- times tinged with blood. He passed another night of distressing rest- lessness, but on the morning of the 11th grew quieter, and, when not disturbed, lay on his right side dozing. If spoken to, he gave intelli- gent answers, and said, "I am no better," though, if left alone, he made no complaint. He continued drowsy all through the day. To- wards evening he had a few minutes of cheerfulness, and spoke of his own accord to his father. His mother lay down by his side: he slept, and seemed to breathe gently: she slept too; and when she awoke at 4 A.M. on the 12th, her boy was dead: life had fled so quietly, that, though her arm was round him, she had not been disturbed. I need not detail to you the appearances found on dissection of the body, since they were such as have been mentioned as characteristic of capillary bronchitis; though the air-tubes, notwithstanding their intense injection, contained neither pus nor false membrane, and very little mucus. The case illustrates the remarks already made on the symptoms of the disease, and illustrates too the remarkable results which percussion and auscultation yield in this affection, since sub- crepitant rale continued to be heard to the last, unmixed with bron- chial breathing or pneumonic crepitus, while, so long as percussion could be practised, it failed to elicit a dull sound anywhere. Though the indications afforded by auscultation and percussion are often sufficiently characteristic of this disease, yet there are some cir- cumstances which may occasionally render their information doubtful. The child is sometimes so extremely alarmed, and the sensibility of its surface so much increased, that we have much difficulty in percus- sing the chest: but we shall usually be able to distinguish this from the painfulness of the walls of the thorax which attends pleurisy by finding that it is not limited to one half of the chest, but that it is felt equally on either side, and as much in front as behind. If we can succeed in percussing the chest, however, it will be found to yield a natural, sometimes even an increased degree of resonance, while little, if any, difference can be discovered between the sound afforded by the upper, and that given out by the lower part of the chest; or, should such be perceived, it is generally due to pneumonia having supervened. TREATMENT OF BRONCHITIS. 269 The ear detects a scanty transmission of air, attended at first with rhonchus and sibilus, but soon with a universal sub-crepitant rale, heard most distinctly on the child making a deep inspiration. By the term sub-crepitant rale, it can hardly be necessary for me to say that a sound is meant smaller in character than large mucous rale, but larger than the true small crepitation of pneumonia. As the disease advances, the only change that takes place consists in this sub-crepitant rale being replaced by a large mucous rale, the result not of any improvement in the child's condition, but of the air scarcely penetrating beyond the larger bronchi; for you will still hear the smaller sound during the deep inspiration that follows the attack of cough. This form of bronchitis is one not only very dangerous, but likewise very rapid in its course to a fatal issue. One little girl in whom it came on while convalescent from an attack of measles fourteen days before, died within forty-eight hours; and the boy whose case has been just related died in less than four days from the appearance of any serious symptom. Those, however, were instances of a rather unusual rapidity in its course; and from five to eight days, which is the estimate of its duration formed by M. Fauvel, who has written a very valuable essay on the disease,1 is probably not far from the true average. But we may now pass to the treatment of bronchitis, and in recon- sidering the rules which I shall lay down for your guidance, I am struck by the different conclusions to which five and twenty years of the practice of my profession have led me from those which I adopted at the outset of my career. It is, I believe, but rarely, at the present day, that depletion is indicated in bronchitis or pneumonia; and tar- tar emetic needs to be given more sparingly than in former years, and acts with less certainty in cutting short at its very outset the inflam- matory action. And yet, when looking back on the records of cases where I abstracted blood freely, and gave antimony in large doses, I cannot admit that my practice then was a mistaken one, that the recoveries which then took place were the result of accident, or that, in counselling now a different course, I am merely following the fashion or the prejudices of the age. "If any one," says M. Trousseau, with reference to this very subject, "reads with attention the remarks of Sydenham and of Stoll on the changes in the treatment of disease which the'differences in the epi- demic constitution of successive years rendered necessary, he will be sure to arrive at two conclusions: first, that any physician must have but a very narrow view of his art, who, in spite of the change of con- stitution, continues still to treat all diseases in the same way; and next that the change of epidemic constitution exerts an immense influence on the action of the same remedies in a disease whose local mani- festations continue unchanged." "You will now understand, gentlemen, why it was, when I told you at the beginning of this lecture, that the necessity, nay even the utility, 1 Recherches sur la Bronchite Capillaire, etc. 4to., Paris, 1840 ; republished in a more extended form in vol. ii. of the "Memoires de la Societe Medicale d'Obser- vation," bvo., Paris, 1844. 270 TREATMENT OF BRONCHITIS. of depletion in*pneumonia did not seem to me well established, that I made a point of adding just at present. I did so, because it so happens that now for the past several years we are in the midst of an epidemic constitution in which diseases do not require this remedy, though for- merly they did require it, and though in the course of time they will no doubt stand in need of it again."1 But besides, I believe that with advancing years all practitioners become disposed to attach more importance to the hygiene of the sick room ; to the temperature of the air which the child breathes, to the perfection of the ventilation, to the posture of the patient in bed, to the regulation of the diet, the avoidance of all causes of irritation and dis- tress; and the favorable issue of the case not seldom justifies the appa- rent over-caution in these respects to which experience seems to lead. The confidence sometimes expressed in nature's healing power is, however, altogether misplaced, unless accompanied with every care to place the patient in the most favorable conditions for that power to be exercised. These conditions once secured, the severity of the attack of bronchitis must govern the further treatment. In a healthy child, at the outset of a bronchitic seizure of moderate intensity, small doses of calomel, antimony, and ipecacuanha, given every four hours for the first twenty-four or thirty-six hours, are often extremely useful. This combination usually acts on the bowels slightly as well as on the skin, and often notably abates the febrile disturbance. The mercurial should then be discontinued, but small doses of antimony or of ipeca- cuanha should still be continued in a saline mixture. In addition to these means, the breathing is often much relieved by the application of a large warm linseed poultice to the chest, or of a large piece of spongio-piline wrung out of hot water; either of which may be made more stimulating by the addition of a third or fourth part of mustard to the poultice, or by sprinkling some stimulating liniment over the spongio-piline.2 These applications should be frequently renewed, and should be continued for twenty-four or thirty-six hours together, while any marked increase of difficult breathing must be controlled by the application of a mustard poultice between the shoulders, or to the front of the chest; a proceeding which has this great advantage over the use of a blister, that it will admit of frequent repetition. After the first day or two the abundance of the secretion poured out into the bronchi not only increases the discomfort of the child, but is a positive source of danger, inasmuch as it tends to favor the occurrence of pul- monary collapse. An emetic once or twice a day is the great means of relieving this discomfort, and warding off' this danger. The emetic selected should be one of ipecacuanha in preference to antimony; or 1 Clinique Medicale. vol. i. p. 607. 2 (No. 11.) R.—Lin. Camph. co., gj. Tinct. Lyttae, 3ij. Tinct. Opii, 5ij. M. Ft. Linimentum. The pungency of liniments often compels us to employ them to the posterior part of the chest only, or to rub the front of the chest with a much weaker liniment than that which is used for the back. TREATMENT OF BRONCHITIS. 271 even the sulphate of zinc if the ipecacuanha, as happens sometimes, while it fails to vomit, should act upon the bowels. Your attention has more than once been called to the remarkable tendency of the nervous system in early life to sympathize with the affections of other parts. This tendency is often very evident in in- flammation of the respiratory organs; and accordingly you must not always take the degree of dyspnoea in a case of infantile bronchitis as a measure of the severity of the disease, since it may be only an evi- dence of the sympathy of the nervous system. In a majority of in- stances, it is towards evening that this acceleration of breathing comes on, accompanied with a state of general restlessness, and usually with an increase, though not to an extreme degree, of the heat of skin ; but yet if you listen carefully to the chest you will find no deterioration in the results of auscultation. In the infant, too, you will probably perceive in the half-closed eyes, and in the thumbs drawn into the palm, indications of the disturbance of the nervous system. The evening warm bath often relieves this symptom very much, and if the amount of the secretion in the bronchi is not so consider- able as to contraindicate its use, a dose of Dover's powder given after- wards will soothe the child and obtain for it a few hours of quiet sleep. The emetic and the mustard poultice will in other cases be followed by the same result, while it must be borne in mind that a constipated state of the bowels on the one hand, or the irritation of teething on the other, may give occasion to a hurry of respiration, which will at once cease on the administration of a dose of castor oil, or on lancing the gums. The combination of a direct sedative with each dose of the medi- cine which the child takes must be had recourse to cautiously, and must have reference rather to the relief of the irritating cough than to the control of any very marked symptoms of nervous dyspnoea, since, whenever in these cases the blood is imperfectly aerated, risk attends the frequeut employment of narcotics. On this account the chloric ether is often so useful an adjunct to the cough mixture; while of the more direct sedatives the compound tincture of camphor is preferable to any other preparation of opium, and the tincture of henbane is perhaps still safer; the Dover's powder in a fuller dose being reserved for the evening exacerbation of dyspnoea. After the first few days, sometimes even very early in the attack, comes the necessity for supporting the child's strength, and for watch- ing carefully against that collapse of the lungs which in infancy is the grand source of danger. Ammonia must now be added to the expec- torant mixture which the child was previously taking, or it may be given in combination with the decoction of senega1 and tincture of squills, if secretion in the bronchi is very abundant, while once or ' (No. 12.) R.—Decoct. Senegae, !§ij. 3V- Ammon. Sesquicarb. gr. xij. Tinct. Scillae, ™.xvj. Syr. Tolutan 5iij. M. A dessert-spoonful every four hours. For a child from two to three years old 272 INFLUENZA, OR EPIDEMIC CATARRH. twice in the twenty-four hours the attempt must be made to unload the air-tubes by the administration of an emetic. The maintenance of the child's strength by food, and often by sti- mulants, becomes now, too, a matter of the greatest moment. Veal broth or beef-tea, given alternately with white wine whey, or brandy added in a small quantity to all the food which the child takes, be- comes necessary so soon as feebler pulse, or diminution of temperature of the extremities, or a more labored respiration with an increase of mucus in the air-tubes, accompanied by a diminution or suppression of the cough, give tokens of failing power. One troublesome symp- tom, very apt to supervene in this condition, and which sometimes frustrates all our endeavors, is an obstinate diarrhoea, that exhausts as well as distresses the child. The chalk mixture with tincture of catechu sometimes suffices to check it, but, should this fail, an opiate enema will very generally succeed in arresting it, provided it has not been allowed to continue unrestrained for more than a few hours. During the patient's convalescence, great care is needed to avoid a relapse, which is the more apt to recur and the more likely to be serious in proportion to the tender age of the child. In the case of teething children, it is by no means unusual for a fresh attack of bron- chitis to occur just as each tooth approaches the surface; a circum- stance which renders it specially important to watch over the period of convalescence with the greatest care. If the season of the year admits of it, a change of air has more decided influence in removing the remains of any bronchitic attack than medicine, though for the most part the cough will gradually cease, and the child regain its health, under the influence of preparations either of bark or of iron. Sometimes, however, bronchitic symptoms continue for a long period, the expectoration being copious and puriform, while the child loses flesh, and the relatives become not unnaturally apprehensive lest it should be phthisical. Their fears may be well-founded, but at the same time that you would recommend change of climate to some warmer country in the winter, or to the sea-coast during the summer, you would, as I shall hereafter point out to you when speaking of phthisis, be warranted in taking a much more favorable view of such cases in a child than in the adult. Before concluding this lecture, it may be as well to say a few words on the subject of influenza, or epidemic catarrh, as we observe it among infants and children. Catarrhal epidemics, indeed, not unfrequently occur among the young at a time when there is no general prevalence of the same class of ailments in the adult population, and they do so especially just before the commencement of an epidemic of measles or hooping-cough, and for a short period after its outbreak. Such catarrhs, however, are not in general very severe, and are important chiefly as forewarnings of the more serious disorder by which they are often succeeded. This affection assumes on the other hand a more serious character when influenza is generally prevalent; and children are attacked, not especially, but in common with persons of all ages. It is then often very severe, and in many instances presents notable peculiarities, with INFLUENZA, OR EPIDEMIC CATARRH. 273 a description of which I prefer occupying your time to repeating over again the description of how ordinary catarrh assumes by degrees the graver features of bronchitis, and the bronchitis, in its turn, becomes associated with pneumonia. Of course, in every epidemic of influ- enza, there are many instances of this occurrence, and, in every case, we need watch most carefully for its indications. But the anomalous forms of influenza are of no less moment. Of these, one of the most remarkable is characterized by the intensity of the febrile disturbance as contrasted with the comparative unimportance of the chest symp- toms, so that the ailment sometimes runs its course more like a severe attack of ephemera than like an affection in which the organs of respi- ration are implicated. In such circumstances I have even known con- vulsions occur in very susceptible children, and be followed by a state of intense overpowering drowsiness, which, though unaccompanied by other signs of cerebral disturbance, continued for twenty-four hours, and then gradually subsided, being succeeded either by a slight feverish condition or by the ordinary catarrhal symptoms, and those not always of great severity. The convulsive seizures are, in- deed, exceptional, and of decidedly rare occurrence; but the burning skin, the extremely frequent pulse, and the irresistible drowsiness, are by no means unusual; a child going to bed a little ailing, sleeping heavily during the night, seeming unable to get up in the morning, and continuing apparently overpowered by the disorder for the ensu- ing twenty-four hours, but then recovering with great rapidity. It is not, however, by any means constant for the disorder of the nervous system to be thus limited to the sensorium ; for, in very many instances, the respiration is greatly disturbed; and with the burning skin and heavy head there are associated acceleration of breathing, and imperfect aeration of the blood such as we may often observe in hooping-cough. This disorder of breathing too will often be found to be utterly out of proportion to the gravity of the auscultatory signs, which generally consist in a large diffused rhonchus, equally audible over the whole of the chest. The danger, indeed, frequently consists less in the occurrence of pneumonia or in the advance of bronchitis than in the supervention of a state of collapse, such as in epidemics of influenza not unfrequently carries off the aged. In the influenza of 1856, many instances of this kind came under my notice, by no means exclusively among infants, but at least as often among children between two and three years of age, in whom the attack set in with considerable nervous dyspnoea and heat of skin (symptoms which on some occasions had undoubtedly been treated with over activity before the patient came under my notice), but in the course of two or three days the fever suddenly dis- appeared, and was succeeded by a state of extreme depression, with a cool moist skin, a very feeble pulse, and labored respiration. In this condition the children, though quite conscious when roused, lay gene- rally dozing, while, though the somewhat livid hue of the lips and surface seemed to imply the existence of some serious mischief in the lungs, there was often nothing to be heard but a large moist rale. When this state was well marked, the symptoms of exhaustion usually 16 274 INFLUENZA, OR EPIDEMIC CATARRH. went on increasing, in spite of the free employment of stimulants, and terminated fatally on several occasions in the course of forty-eight hours, and within a week from the commencement of the illness. One more point deserves notice, and that is the frequent tediousness of the convalescence from influenza; an irregularly remittent febrile condition, with complete loss of appetite, and much impairment of strength, often remaining behind. These symptoms, however, disap- pear, and sometimes rapidly, under the beneficial influence of change of air and preparations of quinine. The cautions to be borne in mind in the treatment of influenza are sufficiently apparent from the remarks which have just been made. The danger in these cases is oftenest that of doing too much; of mis- interpreting the nervous element, which plays so important a part in the production of the symptoms; and of regarding the dyspnoea, the hurried breathing, and the rapid pulse, as the necessary evidence of active inflammation of the lungs or air-tubes, calling for vigorous treatment to subdue it. As a general rule, both depletory measures and the employment of large doses of antimonials are out of place, and the indications are best answered by maintaining a uniform warm temperature in the room, by giving gentle diaphoretics, with small doses of ipecacuanha, and of some opiate, such as the compound tinc- ture of camphor, or Dover's powder, if the cough is very troublesome or the nervous dyspnoea considerable. Counter-irritation by large mustard poultices to the chest will often relieve any great access of difficult breathing; and the evidence of auscultation should be very decided to justify a recourse to stronger measures, while it must be borne in mind that the necessity for ammonia, ether, and wine, is by no means unlikely to occur, and that the first appearance of those signs of exhaustion which I have just described must be taken as an indication for their immediate employment. SYMPTOMS OF THE FIRST STAGE OF PNEUMONIA. 275 LECTURE XXI. Pneumonia, its Symptoms and Treatment.—Symptoms of Pneumonia frequently present a mixed character when it supervenes on bronchitis—Idiopathic Pneumonia—approach of first stage generally gradual—characteristic peculiarities in mode of sucking and of respi- ration—attack sometimes sudden. Symptoms of second stage—results of auscultation— reasons for rarity of true pneumonic crepitus. Symptoms of third stage—convulsions often precede death—their import—occasional imperfect recovery—auscultatory phenomena of this stage. Nature of modifications in symptoms produced by association with bronchitis. Diagnosis from bronchitis—pleurisy—hydrocephalus—remittent fever—intestinal disorder during denti- tion. Treatment—Expectant treatment—Depletion—Tartar emetic—limitations as to its use. Mercury—its importance—danger of salivation very slight. Diet—antiphlogistic in the early stages—caution as to sucking—stimulants often needed in advanced stage. Blisters not desirable. It was stated in the last lecture, that the supervention of inflamma- tion of the substance of the lungs constitutes one of the chief dangers of infantile bronchitis. Pneumonia, however, is not to be regarded as being invariably a secondary aff'ection; for, in some cases, while the disease of the air-tubes is but trivial, the pulmonary substance is the seat of serious inflammation; and in other instances the air tubes are altogether unaffected, or at least are involved only in common with the other constituents of the lung. In either case, there are peculiari- ties enough, both in the symptoms observed and in the treatment re- quired, to render the separate study of pneumonia indispensable. When pneumonia supervenes, as it by no means seldom does, on previous catarrhal symptoms, the disease often comes on insidiously, and develops itself so gradually out of the preceding trivial ailments that it is not possible to determine the exact date of its attack. At other times, indeed, there is a sudden and well-marked increase of the fever and dyspnoea, and an aggravation of all the symptoms, sufficient clearly to point out the date of the supervention of the pneumonia. But, even though this should be the case, yet, if there were much bronchitis previously, the aff'ection of the air-tubes will often mask that of the lung to some degree; and the case not presenting the symptoms either of pure bronchitis or of unmixed pneumonia will assume some of the characters of each, and merit, both by the phe- nomena attending it during life, as well as by the appearances found after death, the name of bronchopneumonia. Cases of this mixed character occur most frequently during the period of teething, when the mucous membranes are especially susceptible. We will return to notice some of these peculiarities hereafter, but we will first examine the symptoms that attend a case of idiopathic pneumonia, where the pulmonary substance has been affected from the outset, and has not 276 SYMPTOMS OF THE FIRST STAGE OF PNEUMONIA. merely become involved by the extension to it of mischief commencing in the bronchi. In almost all of these unmixed cases, a condition of general feverish- ness, exacerbated towards evening, with fretfulness and pain in the head, precede the more marked symptoms. The child is either rest- less at night, or, if it sleep, its repose is unsound; it talks in its sleep, or wakes in a state of alarm. Sometimes from the very commence- ment, at other times soon after the appearance of these febrile symp- toms, cough comes on; at first, short and hacking, frequently not causing the child any uneasiness, and so slight as scarcely to excite the notice, and not at all to awaken the anxiety, of the parents. Loss of appfttite and increase of thirst are early observable : the bowels are usually constipated, and vomiting is not unfrequent, especially in infants at the breast. The tongue and lips are at the same time of a florid red ; the tongue is less moist than usual, and is generally coated in the middle with a thickish white fur. In these symptoms, indeed, there is but little to mark the real nature of the case, or to point to the organ whose disease has kindled the fever in the system; for the slight cough, if not overlooked, may yet be attributed to irritation of the bronchi, sympathetic with derangement of the stomach or intes- tines. The respiration too is not always much hurried at this early period; while, in the young child, both its frequency, and that of the pulse, are much modified by position; and the results of auscultation are not uniform, and may sometimes afford no information at all. Even now, however, there are some signs which to the attentive ob- server will convey much information, and information all the more valuable from our being furnished with it chiefly in those young infants in whom the diagnosis of the disease is attended with most difficulty. The seat of the mischief is shown to be in the respiratory organs by the child no longer breathing through the nares, while the tongue is applied to the roof of the mouth as in health; but by its breathing through the open mouth also, whence the tongue early acquires an unusual degree of dryness. This same inability to respire comfortably through the nares causes the child to suck by starts: it seizes the breast eagerly, sucks for a few moments with greediness, then sud- denly drops the nipple, and in many instances begins to cry. As the disease advances, these peculiarities in the mode of sucking and of respi- ration often become more striking; but it is at its onset that they are most valuable, since then we have fewer indications to lead us right. It is not, however, thus gradually that pneumonia always comes on; for sometimes a child who has gone to bed well, or merely a little poorly, wakes in the night in a state of alarm, refusing to be pacified, with a flushed face and burning skin, and hurried breathing and short cough. This sudden supervention of pneumonia is not so often met with among infants at the breast as among children from two to four years old. Often, though not always, this severe onset of the disease has appeared to depend on the pneumonia being asso- ciated with extensive inflammation of the pleura; but sometimes the symptoms which at first seemed so threatening soon subside, and the SYMPTOMS OF THE SECOND STAGE OF PNEUMONIA. 277 affection, in its subsequent stages, presents no peculiarity, and is not by any means remarkable for its severity. Th\sflrst stage of pneumonia passes, for the most part, by degrees into the second, in which the nature of the aff'ection is generally obvious to all. The momentary cheerfulness which before existed has now passed away; infants now no longer wish to be removed from the cradle, or from the recumbent posture in their nurse's arms, and older children have quite lost all interest in their play ; they become drowsy, ask to be put to bed, and cry if taken up. The hurry of the respiration is now abundantly evident; the aloz nasi are dilated with each inspiration, the abdominal muscles are brought into play to assist in its performance, and any change of posture renders the breathing more labored and more hurried. The cough has become much more frequent; it is still hard, sometimes is evidently painful, so that the child cries with each cough; at other times it is an almost constant short hack. The bright flush of the face, and the florid tint of the lips, are gone, but the heat of skin continues; for the persistence of an almost unvarying high temperature throughout its course is, as M. Roger has shown, one of the characteristics of the pneumonia of the child as well as of that of the adult. It is a pungent heat, which becomes more sensible the longer the hand is kept in contact with the surface; and sogreat is the elevation of temperature, thatM.Rogerfound it average almost 104° Fah. in ninety-seven experiments, while in some cases it greatly exceeded this degree. Though so intense, however, this heat is unequal at different parts—the extremities being cool, or even cold, while the body is hot; but there is no moisture on any part of the skin. The face now assumes a puffed, heavy, but anxious appearance, and when the child is very young, or the pneumonia very extensive, the lips put on a livid hue, which is also very evident around the mouth, while the face generally is pale. The thirst usually con- tinues very urgent, but children at the breast still vomit the milk. This is apparently owing to their thirst being so urgent as to lead them to suck too greedily, and thus overload their stomach, since, while they generally vomit almost immediately after leaving the breast, they do not reject small quantities of fluid given them from a cup or a spoon. The disease of the lungs now betrays itself most strikingly in children at the breast, for as often as they attempt to suck, the respiration becomes at once greatly hurried ; they drop the nipple, panting, from their mouth, or, having seized it, have not breath sufficient to make the vacuum necessary to bring the flow of milk. The results of auscultation, though variable, are now sufficiently obvious. Crepitation is now heard, often in both lungs, and generally in their lower and posterior parts—seldom, however, the minute crepitus such as we hear in the pneumonia of the adult, but that sound known as the sub-crepitant rale. The comparative rarity of true pneumonic crepitus in inflammation of the lungs in infancy is a point not to be lost sight of: often, however, if you keep your ear to an infant's chest, and wait till it takes an unusual deep inspiration, you will hear the true crepitus of pneumonia just for a moment when the 278 SYMPTOMS OF THE THIRD STAGE OF PNEUMONIA. air enters the pulmonary vesicles; and then again you will lose it when the child breathes as it was doing before, and you will hear only the sub-crepitant rale. If the inflammation have attacked only one lung, you will perhaps be struck by the loud puerile breathing in the healthy organ, which is thus compelled to perform a double function. If both be involved, you may almost overlook the disease, since you have not the aid afforded by contrast; unless, as sometimes happens, the mischief on the one side is so far advanced as to cause bronchial breathing, while on the other side crepitation alone is audible. This bronchial breathing is sometimes heard associated with thesub-crepitant rale, or with large crepitation, while at other times the ear detects nothing but the whiff'of air through the larger air-tubes; and often this alone is audible on an ordinary inspiration, while on a deep breath being taken the sub-crepitant rale will be at once perceptible. In the child we lose all the information which, in the adult, is afforded by the different modifications of the voice sound; for the shrill or querulous tone of a suffering child, and the words often uttered in different keys, afford, even when the child is old enough to talk well, results far too uncertain to be trustworthy. Percussion sometimes yields a very manifest dulness on the affected side; and this dulness is usually most evident in the infra-scapular region. At other times, however, no such marked results are afforded, but the lower parts of the chest give a somewhat duller sound than the upper, and the impression communicated to the finger is that of greater solidity below than above the scapula. This last sign is often very valuable, since it may be perceived at a time when the ear cannot clearly detect actual dulness on percussion. Death may take place in this, the second stage of pneumonia, if a very extensive portion of lung have been involved in the disease, or if it be associated with much inflammation of the pleura, or if the pneumonia have been grafted on severe bronchitis. The pneumonia which supervenes on measles, or which comes on in a child debilitated by previous illness, sometimes terminates unexpectedly in this stage, and on an examination of the body after death the lung is found scarcely to have passed beyond the first stage of pneumonia, except in a few portions of but limited extent; though still larger tracts will probably be found in the state of collapse, and to the sudden super- vention of this condition the fatal event is probably in great measure due. It is important, too, to bear in mind that in weakly children, a pneumonia of even very small extent will often prove fatal: hence the great importance of watching most sedulously against all those intercurrent affections of the lungs which come on in the course of diarrhoea, measles, remittent fever, &c. But the pneumonia may be free from any of the above-named com- plications, and then, if unchecked by treatment, it will pass into the third stage. The respiration now becomes more labored, and though its frequency is sometimes diminished it will be found to have become irregular; several short and hurried inspirations being followed by one or two deeper, and at longer intervals, and these again by hurried breathing. The cough sometimes ceases altogether, or if not, it is less frequent, and looser, since it is now produced by the child's efforts to RESULTS OF AUSCULTATION. 279 clear the larger airtubes from the accumulating secretions. The voice is often lost, the patient speaking only in a hoarse whisper; while children who were just learning to talk will frequently maintain com- plete silence, as if conscious that they have no breath to waste in words. The face looks sunken, the extremities are cold, and, though the trunk retains its high temperature almost to the last, yet the skin often loses somewhat of its previous dryness, and clammy sweats break out, especially about the head. The pulse is extremely frequent and small, and the beats so run into each other that it is almost impossible to count them. The child is sometimes very restless at intervals, tossing about from side to side as much as its reduced powers will permit; but it usually lies in a state of half consciousness, though sensible when spoken to, and fretful if disturbed. If raised hastily from the recumbent posture, or if put to the breast, the great increase of dys- pnoea which is immediately produced shows how seriously the respi- ratory organs are affected. In many cases, too, the livid hue of the face and of the nails is a further proof of the great impediment which exists to the decarbonization of the blood; and once I saw purpurous spots appear on the arms and hands thirty-six hours before the death of a previously healthy child of a year old, in whom an attack of idiopathic pneumonia terminated fatally on the seventeenth day. This condition seldom lasts above two or three days; for either life becomes gradually extinct, without the supervention of any new symptom, or convulsions occur, which are followed by fatal coma, or the child re- covers from it for a few hours only to suffer a second attack of con- vulsions, and return of coma, in which it dies. It can scarcely be necessary to remind you of what was said some time since with refer- ence to the import of convulsions, and to their being in many cases merely a token of disturbance of the functions of the brain, such as delirium is in the adult. The former symptoms in the child, and the latter in the adult, betoken in a case of pneumonia that the brain is suffering from the circulation through it of imperfectly aerated blood. The third stage, however, does not always advance thus uninter- ruptedly to a fatal issue, but a kind of imperfect recovery sometimes takes place. A diminution is obvious in the more alarming symp- toms ; the patient begins to express some desire for food as well as for drink, and even has occasional gleams of cheerfulness. The cough, which in many instances had almost or altogether ceased, returns, but is short and hacking, although there is sometimes a good deal of mucus in the larger air-tubes. The dyspnoea is no longer urgent, though the breath is habitually short. The skin is hot, dry, and harsh, and evening exacerbations of fever often occur; the tongue is red, dry, and sometimes chapped, or presents small aphthous ulcers at its edges; diarrhoea is not infrequent; the child wastes daily, and dies in the course of a week or two, worn out and exceedingly ema- ciated. The auscultatory signs of this third stage of pneumonia are in the main those of the second stage, except that the bronchial breathing usually becomes both more distinct and more extensive, occupying situ- ations where either the sub-crepitant rale, or even large crepitation, 230 BRONCHIO-PNEUMONIA. had previously been heard. As it extends, too, it becomes audible in front as well as behind, and both it, and dulness on percussion, may be perceived in the infra-mammary as well as in the infra-scapu- lar region, to which at first they are almost always limited. This bronchial breathing is generally much more extensive on one side than on the other, and sometimes it is heard throughout the whole posterior part of one side of the chest; but it is exceedingly unusual to find bronchial breathing confined to the upper part of one lung, except in cases where there existed previous tubercular disease of the organ, and then the pulmonary tissue may become solidified under the influence of an amount of disease which otherwise would be inade- quate to produce this result. The symptoms that attend the third stage of the disease usually are the result of the lung having passed into the state of suppuration. I say usually, for sometimes recovery eventually takes place even from a condition apparently desperate, and in such cases the degree to which disorganization of the lung had actually advanced must always remain uncertain. The results of auscultation do not help us, any more than in the adult, to determine with certainty the amount of injury that the lung has sustained, while we are deprived almost entirely of that information which in the grown person is afforded us by the changes in the ap- pearance of the sputa. In some cases of rapidly fatal pneumonia I have seen a frothy secretion collect about the mouth; but this was evidently not furnished by the air-tubes, but was merely the saliva which the child was unable either to spit out or to swallow. The cough of pneumonia being generally short and not paroxysmal, we have not so much chance of seeing the sputa as in the case of acute bronchitis, and children even of five or six years old seldom spit out the matters that they expectorate, but almost always swallow them. When resolution of hepatized lung takes place, the changes in the physical signs of the disease are much the same as are perceived in the adult. I have not, however, in any instance detected a return of true pneumonic crepitation, but sub-crepitant rale in most cases became audible, and in a few instances large crepitation. In either case mucous rale was eventually heard, and it often continued for many days after the lung had in other respects recovered its natural con- dition ; apparently much as, in the pneumonia of the adult, prolonged expiration often persists for a long time after all the other signs of disease have disappeared. At the commencement of this lecture reference was made to cases in which the symptoms of pneumonia are modified by those of the bronchitis with which it is associated. In such cases there is from the very outset a marked degree of dyspnoea and distress, and the face presents from the first a livid hue. The cough is less short than in simple pneumonia, but it comes on in paroxysms which greatly distress the patient: the respiration is more hurried and more irregular, and this irregularity comes on at an earlier stage of the disease. Large crepitation and sub-crepitant rale are generally heard very extensively in both lungs, but true pneumonic crepitation is unusual. A prepon- BRONCHIO-PNEUMONIA. 281 derating affection of the lower lobes is seldom perceptible; and since these cases usually tend to a rapid termination, death sometimes takes place before either dulness on percussion, or bronchial breathing, has become distinctly audible. Such are the characters generally presented by pneumonia in early life, and these are usually so well-marked as to render it impossible either to overlook the disease or to mistake its symptoms for those of some other malady. This, however, is not invariably the case even when the inflammation of the lungs occurs as an idiopathic aff'ection, while in those instances in which it comes on in the course of other diseases, it very often remains latent, and much acuteness of perception, as well as much patient observation, is necessary for its detection. We will pass over, for the present, the consideration of secondary pneu- monia, since to understand all the varieties that it presents would require a previous acquaintance with those diseases in the course of which the inflammation of the lungs supervenes. When we come to the study of hooping-cough, croup, measles, remittent fever, &c, I will endeavor to point out the period at which, in each of these maladies, pneumonia is most to be apprehended, and the symptoms that indicate its attack; but to-day we will confine our notice to those cases in which the inflammation of the respiratory organs occurs as an idio- pathic affection. The points of difference between pneumonia and bronchitis have already been dwelt on so fully as to render it unnecessary to recapitulate them. In many cases they are too obvious to admit of your falling into error, but in others they are so shaded off that it is difficult to determine whether the characters of one or of the other predominate; and we are forced to conclude that the two exist together, the one obscuring the otherwise well marked features of the other. In the child, as in the adult, some degree of pleurisy exists in a large proportion of cases of pneumonia, though sometimes so slight as to be scarcely noticed; whilst in other cases, though a little friction sound may be heard for a short time, yet it is evident that the danger to life is occasioned by the mischief in the lung, and not by the affec- tion of the pleura. Sometimes, however, inflammation of the pleura is the chief, if not the sole cause of the patient's danger, and hence it is desirable to know even at the outset, whether the lung or its invest- ing membrane is the part chiefly affected. An attack of pleurisy is much oftener marked by complaint of severe pain in the chest, than is an attack of pneumonia; or if the child be unable to express its feelings, the seizure is not unfrequently announced by violent and continued screaming. Sympathetic disturbance of the brain is more frequent and more severe at the onset of an attack of pleurisy than of pneumonia, and the attendant restlessness is greater. Auscultation, too, fails to discover the crepitant or sub crepitant rale which characterizes pneumonia, but air enters the lung on the affected side much less freely than on the other, and a friction sound may perhaps be distinguished ; though this is by no means invariable, and even when present it may easily be mistaken for rhonchus. It may be laid down as a rule, subject to but few exceptions, that when- 282 DIAGNOSIS OF PNEUMONIA. ever a child is suddenly seized with symptoms which, while they indicate some aff'ection of the lungs, are yet unattended with the aus- cultatory signs of pneumonia, the disease from which it is suffering is pleurisy; and this probability is rendered almost a certainty, if, while the child bears percussion on one side of the chest, it cries and strug- gles on the slightest attempt at percussion on the opposite side. The error of taking a case of pneumonia for one of pleurisy, how- ever, or the opposite, is of comparatively little moment; but there are other diseases for which pneumonia may be taken, in which the error of diagnosis will lead to serious, and perhaps fatal mistakes in treat- ment. These mistakes, too, may be made at almost any stage of the disease. At the commencement pneumonia may be taken for incipient hydro- cephalus. The vomiting, the pain in the head, the restless nights, with talking in the sleep, which attend the onset of almost all the acute affections of childhood, the fever, and the constipated state of the bowels common to both diseases, lead to this error. The cough in some cases of pneumonia is so slight as scarcely to be noticed, while even if pre- sent it may be taken for that sympathetic cough which is sometimes present in the early stages of hydrocephalus; and the child, if ques- tioned, may complain of his head, and of nothing else. But still there are circumstances which would lead the attentive observer, inde- pendently of auscultation, to detect the real nature of the case. The vomiting that ushers in an attack of pneumonia, though sometimes violent, seldom continues long, and is unattended with that permanent nausea and irritability of the stomach which are so marked in the first stage of hydrocephalus. The evacuations in pneumonia are natural; the tongue is of a much more vivid red than in hydrocephalus; the pulse is much more frequent, its beats are not irregular, the heat of the skin far greater, far more constant and more remarkable on the trunk than about the head, and the thirst is generally urgent. If these indications, however, be overlooked at the commencement of the attack, and if auscultation, by which the error might still be set right, be neglected, it is probable that each subsequent occurrence will be misinterpreted, and that the real nature of the disease will not be understood until it is revealed by the post-mortem examination. More or less sympathetic aff'ection of the head is seldom wanting in pneumonia to confirm the preconceived, erroneous notion; while as the child grows worse, the difficulties in the way of making a careful auscultation increase. Convulsions sometimes occur even several day8 before the patient's death, and the head symptoms may appear, espe- cially to a prejudiced observer, to be much more striking than any which indicate affection of the lungs. It sometimes happens that the sympathetic disturbance of the stomach and bowels is so considerable as to obscure the chest symptoms, and the case is taken for one of enteritis; or perhaps, if the heat of skin and sensorial disturbance be considerable, for one of remittent fever ; and this latter error is especially likely to be committed if the upper lobes of the lung are the seat of the inflammation. The vomiting at the outset of the disease, the pain referred to the abdomen, with the DIAGNOSIS OF PNEUMONIA. 2S3 evident increase of discomfort on pressure, the red tongue, with its disposition to dryness, and the diarrhoea that exists in these rather exceptional cases of pneumonia, are the circumstances which tend to lead into error; and this error may be confirmed on the practitiouer finding that at least temporary relief follows the application of leeches and poultices to the abdomen. With reference to the complaint of pain in the belly, which seems often to have a large share in inducing this error, it must be remembered that the statements of children with reference to the seat of pain are very vague, and that they frequently speak of the belly when they mean the chest; while the impediment to the descent of the diaphragm occasioned by pressure on the abdo- men, especially if this pressure be either sudden or considerable, will almost always excite expressions of uneasiness when the organs of ► respiration are in any way affected. It is in careful auscultation that your chief safeguard against these mistakes will consist; but you will find besides, that by accustoming yourselves to look not at one or two prominent symptoms only, but at the relation which each bears to the other, many of the chief difficulties in the way of forming a correct diagnosis will disappear. It may perhaps seem to you that much of this is very dry and rather needless detail; but unfortunately my own case-books would enable me to illustrate each of these errors of diagnosis against which it is my endeavor to guard you. One more caution I would offer you, and that is, not to overlook the pneumonia which sometimes comes on in children while teething. Unless you be on the watch for it, its early symptoms will probably fail to excite your apprehension, since they will be regarded as the result of that sympathetic irritation of the air- tubes which so often accompanies dentition, and the time for action will thus be allowed to pass unemployed. The disease comes on most frequently in weakly children, is unattended by much constitutional reaction, and often runs a somewhat chronic course ; while its nature is further obscured by the tendency to diarrhoea which exists during dentition, and which is now excited by the thoracic affection. The purging often becomes the most striking symptom, and all means are employed to suppress it, and to check the vomiting which generally attends it. These efforts, however, are unavailing; the child wastes daily, and its skin hangs in wrinkles about its attenuated limbs, while the abdomen becomes tumid from the collection of flatus in the laro-e intestines, and tender on pressure, and the tongue grows red, dry, and chapped, or covered with aphthous ulcers. The cough now perhaps attracts notice; but both it and the bronchial breathing in the lun^s are probably looked on as indications of phthisis, and the doctor con- soles himself with the belief that he has failed to cure the disease because it was irremediable. At last the child is worn out, and dies, and great is the surprise to find no tubercle in any part of the body, no disease in the intestines, but pneumonia, with purulent infiltration in both lungs—a disease which ought to have been detected, and which probably might have been cured. When speaking of the treatment of bronchitis in early life, I felt it to be my duty to explain to how large a degree changes in the charac- 284 TREATMENT OF PNEUMONIA. ter of disease had led to a modification of my practice. But in the case of the treatment of pneumonia we have to consider even more than this, and to decide whether the adage " optima est medicina, medicinam non facere" does not include, as some have contended, all that we need know with reference to it. This allegation has been made: it has been asserted that in the young the tendency to recovery from uncomplicated pneumonia is so invariable, that the physician has nothing more to do, after having established his diagnosis, than to watch how nature brings about the cure, and to abstain from disturbing processes which his interference can only mar.1 Dr. Barthez2—a name which we cannot mention without stopping for a moment to pay the tribute due to the memory of his worthy fellow-laborer, Eilliet, who passed away so suddenly, so prematurely for science, if not for his own fame—addressed a communication to the Academy of Medicine of Paris in April, 1862, the object of which was to vindicate the expectant treatment of pneumonia in early life. In this paper he states, that of 212 cases of lobar pneumonia occurring between the ages of two and fifteen, in the course of seven years, at the Hopital Ste. Eugenie, two only had a fatal termination, although no approach to active treatment was adopted in more than a sixth of the number. M. Grisolle, so deservedly high an authority on the subject, seems inclined to accept the conclusions of M. Barthez for children above the age of four, and for young persons up to the age of five-and-twenty, but demurs to its applicability at a more advanced age: or in other words, where his own largest experience commences, and his own personal responsibility weighs upon him most heavily, he hesitates to stand by a mere spectator of the combat between dis- ease and nature for the mastery. M. Barthez sums up his conclusions very decidedly, though with just moderation, and it is fairest to state them in his own words: " The only positive rule which I am anxious to lay down is this; that it is scarcely ever useful, and still less is it necessary, to employ very active treatment in the idiopathic pneu- monia of children, and that it is especially important to abstain as much as possible from the repeated abstraction of blood, since its evi- dent effect is to weaken the children uselessly, and to protract their convalescence considerably." Now I have no statistical data to oppose to the statements of M. Barthez. I meet with idiopathic pneumonia in an early stage much more rarely now than I did formerly, when I was physician to the Children's Dispensary in Lambeth, or when I had charge of some of the out-patients of the Children's Hospital; and in the case of most of the patients who are admitted with pneumonia, the disease has long since passed the stage in which active treatment would have been admissible. The same, too, applies to the cases that have come under my notice in private consultation; though at the same time it must be allowed that the rarity with which idiopathic pneumonia has fallen ' For the history of opinion with reference to the expectant treatment of pneumonia, Bee Grisolle, La Pnenmonie, 2d ed. Paris, pp. 558-573. « Reported in the Bulletin de Therapeutique, 8vo. Paris, 1862, vol. 62, pp. 368-374. TREATMENT OF PNEUMONIA. 285 under my observation, in private, says much for its tendency to«spon- taneous subsidence when the patient is placed in favorable hygienic conditions. But I confess that I cannot forget the good results which I saw years ago from the abstraction of blood at the outset of an attack of pneumonia in previousfy healthy children, in whom fever, short cough, and hurried breathing had come on suddenly, and unpreceded by catarrhal symptoms. It is conceded, by writers even at the present day, that depletion employed at an early period lessens heat of skin, abates hurry of breathing, and relieves distress; and to these admis- sions I should be disposed to add that, in some instances, it cuts short the disease. I do not, however, think that after the first twenty-four or thirty-six hours this result will be obtained, and should not advise depletion at a time when small crepitation has become generally dif- fused, still less when dulness or bronchial breathing is perceptible; nor should I advocate a repetition of bleeding in any case when the good which it appeared to have effected had passed away. But if I cannot admit that the abstraction of blood in the early stage of pneumonia is never indicated, still less can I allow that antimony is in no case to be employed, even though the symptoms do not seem to justify depletion, or though the time for having recourse to it may have passed away. So long as the breathing has not become bronchial, or the heat of skin and hurry of respiration continue, and the vital powers of the child are manifestly unimpaired, even though the diffu- sion of small crepitation through the lungs proves the inflammation to be very general, I believe that antimony is likely to prove of essen- tial service. I mean here antimony employed for its own specific action, and not merely given as an adjunct to other treatment. Given in a dose of gr. I every ten minutes till vomiting is produced, in the case of a child of two years old, and continued afterwards every two hours for a period of twenty-four or thirty-six hours, it subdues the fever and abates the dyspnoea in a most remarkable manner; the minute crepitation becomes larger, and, as M. Trousseau says, "there is no stage of convalescence;" the child dangerously ill yesterday is all but well today; and nothing but our experience of the real im- portance of the previous symptoms would satisfy us that we had not misread their meaning, or over-estimated their gravity. But I must add that antimony thus employed usually accomplishes its purpose in twenty-four, or at the most in thirty-six hours; and that with the establishment of its complete tolerance comes the signal for its discontinuance, or at least for a change in the mode of its administra- tion, and the results of auscultation must now in great measure deter- mine our subsequent conduct. Should that inform us that the physical condition of the lung has greatly improved, as well as the general state of the patient, the use of the remedy may be persevered in at longer intervals, as every four or six hours. If the signs of in- flammation are advancing, and have become perceptible in portions of lung previously free from disease, mercury must be employed, which may be combined with small doses of antimony, while large doses of that remedy may still be given to combat any sudden increase 286 EMPLOYMENT OF MERCURIALS. of fever or dyspnoea that may chance to supervene. If, notwithstand- ing a manifest diminution of the fever and reduction of the dyspnoea, bronchial breathing should have become distinctly audible, mercurials must at once be substituted for the antimony ; and the existence in any case of extensive or well marked bronchial respiration should be regarded as of itself contradicting the antimonial plan of treatment. It is not my intention to say, that after the supervention of bronchial respiration antimony ought never to be given, but only that it should not be employed except in small doses, and in combination with other remedies. In cases where the symptoms do not set in with such violence as to indicate the necessity for very large doses of antimony, or in which the disease has passed that stage where antimony so given is likely to be beneficial, mercurials may be used with great advantage. In cases of the former kind, from two-thirds of a grain to a grain of calomel, combined with two grains of James's powder, may be given every six hours to a child two years old. If the case be of a graver kind, and bronchial breathing have become perceptible, notwithstanding depletion and the administration of tartar emetic, the calomel must be given more frequently—as every four or three hours, combined with small doses of Dover's power and tartar emetic, if the child be not so depressed as to render the use of the latter medicine inexpedient. Sometimes the combination of antimony with the mercurial is at first well borne, but afterwards it becomes desirable to discontinue it on account of the sickness that it produces, or on account of the debility of the patient. The diarrhoea which the calomel excites may usually be checked by increasing the quantity of the Dover's powder, or by an occasional dose of chalk mixture. There are some troublesome cases, however, in which the stomach and bowels are so irritable that scarcely any medicine can be borne; and in them, as well as in cases of neglected pneumonia where the proper time for active treatment has been allowed to pass by, and the child has become exhausted, while a large extent of lung is impervious to air, much benefit some- times follows the persevering use of mercurial inunction, or the em- ployment of that convenient substitute for inunction, the mercurial belt, on which the ointment should be renewed every twelve hours. In infants and children under five years of age, the gums hardly ever become affected by mercury, even though most energetically employed; and it has only once occurred to me to meet with an instance of pro- fuse salivation, or of dangerous ulceration of the gums, as the result of the employment of mercury in pneumonia. Such accidents, how- ever, do now and then occur, and have been known to terminate in fatal gangrene of the cheek, or in necrosis of the jaw. On this account, therefore, you must watch the condition of the gums in infants and children to whom you are administering mercury, just as you would do in the case of the adult, and diminish or discontinue the remedy on the first indication of their being affected. The diet of children in the early stages of pneumonia should be Sparing; and infants not weaned should have some less nutritious food than the mother's milk, which their thirst will otherwise lead STIMULANTS — BLISTERS. 287 them to take more abundantly even than when they are well. If the pneumonia be severe, it is better to give even the mothers milk with a spoon, rather than to allow the infant to suck, since the very act of sucking is injurious, and taxes to the utmost the respiratory function, the organs of which it is desirable to keep in as unexcited a state as possible. But though the treatment of inflammation of the lungs requires a strict antiphlogistic regimen in the early stages of the disease, yet in many, perhaps in most cases there arrives a period in which a spare diet is no longer suitable—in which your main efforts must be directed to support the constitutional powers, rather than to subdue the inflam- mation. If you forget this, it may happen to you to overcome the mischief in the chest, but to lose your patient from carrying too far, or from continuing too long, the very treatment which, within proper limits, was most salutary. No point in the management of the disease is more difficult than the seizing the exact moment when the employ- ment of stimulants becomes necessary; and no general rule can be laid down for regulating their use. If, however, the patient were beginning to be much purged, if the respiration were growing more labored and irregular, though diminished in frequency, and if the pulse were becoming more frequent, and above all, smaller and smaller, it is high time to resort to their use. Wine is indispensable in such cases in the pneumonia of the child as in that of the adult; and it may be necessary to give it even to infants at the breast. Ammonia may also be advantageously administered in this stage of the disease, either in a mixture with the decoction of senega,1 or dissolved in milk, which conceals its disagreeable pungency better than any other vehicle. If diarrhoea do not exist, strong beef-tea or veal-broth is the best form in which nutriment can be given; but if the bowels be relaxed, arrowroot, or the decoction blanche2 of the French hospitals, should be substituted for it. In conclusion, it may be well to offer a caution with reference to the employment of blisters—a measure to which we often have re- course with advantage during the resolution of pneumonia in the adult, but which is not advisable in young children whose lungs have been solidified by the disease. Stimulating liniments3 may be em- ployed with advantage; they produce very evident good, and are unattended by the risk that always accompanies making a breach of the surface in a young child exhausted by previous illness. The risk of such sores taking on an unhealthy character appears to be greater after inflammation of the lungs than after almost any other disease; and it may be added, that the risk is still greater in those cases of secondary pneumonia that supervene on measles. » See Formula No. 12, p. 271. 2 See Note, p. 56. 3 See Formula No. 11, p. 270. 288 CEDEMA OF THE LUNGS. LECTURE XXII. (Edema of the Lungs—occasionally comes on in the course of scarlatinal dropsy—severity of the symptoms and their sudden accession—Difference between characters of ©edematous and hepatizecl lung—treatment—importance of venesection—occasional exceptions to its use—Chronic oedema, or carnification. Gangrene of the Lung—Case illustrative of the disease—is not the result of mere intensity of inflammation—unattended by any pathognomonic symptom. Pleurisy—its symptoms and morbid appearances similar to those observed in the adult— auscultatory signs of it, and their changes as recovery advances—it occasionally simulates other diseases, as affections of the head, and of the abdomen—Evidences of auscultation less conclusive than in the adult, and why. Latent Pleurisy—occasional sudden death in these cases—various modes in which pleurisy proves fatal—other terminations of the disease—deformity of the chest from pleurisy, pontaneous opening in chest, its tendency to remain fistulous. Treatment in the acute state, importance of depletion and antiphlogistic measures ; manage- ment in subsequent stages—Question of paracentesis considered—management of pleural fistula—of deformity of chest after pleurisy. Before we proceed to the examination of some other forms of in- flammatory disease of the respiratory organs, it may be convenient to notice two conditions of the pulmonary tissue, which, though not the direct results of inflammation, yet are closely connected with it. One of these conditions is acute oedema of the lung ; the other is gangrene of its substance. It is unnecessary to occupy your time with any detailed account of that anasarcous state of the lungs which is sometimes met with in con- nection with general dropsy of long standing, or with some old disease of the heart and great vessels. In such cases, the oedema of the lungs is a secondary affection, and has very little share in producing the patient's death. But it occasionally happens that children are attacked by intense dyspnoea, and other symptoms of disorder of the respiratory organs, which terminate rapidly in death; while it is discovered, on an examination of the body, that the thoracic viscera generally are free from disease, but that the tissue of the lungs is loaded with serous fluid. Laennec1 refers to such an accident as probably accounting for the occasional sudden supervention of extreme dyspnoea in children recovering from measles; but the late much lamented M. Legendre2 was, to the best of my knowledge, the first person who clearly proved the connection between the symptoms observed during life, and the state of extreme oedema of the pulmonary tissue after death. This oedema of the lungs, though it sometimes destroys life very speedily, is seldom, if ever, a purely idiopathic affection, but occurs 1 On the Diseases of the Chest, translated by Dr. Forbes, 4th edition, p. 164, London, 1834. 2 Recherches sur quelques Maladies de l'Enfance, 8vo. pp. 324-352. Paris, 1846. CHARACTERS OF EDEMATOUS LUNG. 289 generally as one of the complications of that acute anasarca which not unfrequently succeeds to scarlatina; and even then it is not of very common occurrence. M. Legendre records only four cases, all of which were observed in children who were suffering from anasarca afer scarlatina; but several instances of it have come under my notice since the publication of his observations, in all of which it supervened during scarlatinal dropsy. In some of these cases it came on while the children were laboring under a great degree of anasarca; while in others the dropsy had greatly abated before the thoracic symptoms appeared. Indications of slight mischief in the chest, such as frequent dry cough, some degree of dyspnoea, with rhonchus and sibilus, or scanty crepitation, preceded the more serious symptoms for two or three days. The patient, in short, had seemed to be suff'ering from a bronchitis of moderate intensity, when suddenly extreme difficulty of respiration supervened, attended with very hurried breathing, or- thopnea, and most tumultuous and violent action of the heart, though with a feeble pulse. The cough continued, being still short, and quite unaccompanied by expectoration. Auscultation, in such circum- stances, does not seem to give account of mischief sufficiently serious to explain the alarming nature of the symptoms. It may be thought that air enters the lungs less freely than it should do; but the crepita- tion heard is scanty, bronchial respiration is not perceptible, neither is the resonance of the chest on percussion diminished unless fluid has at the same time been effused into the pleura. Nevertheless, if relief be not soon afforded, the child's sufferings in a few hours amount to perfect agony; the difficulty of respiration and the tumultuous action of the heart continuing; the lips and face becoming perfectly livid, but the intellect remaining clear, and the child complaining of great distress referred to the heart or epigastrium ; till, at length, death takes place suddenly, which it sometimes does within twenty-four hours from the appearance of these alarming symptoms. At other times, the approach of the disease is more gradual, the dyspnoea being augmented in paroxysms, but, on the whole, increasing with the increase of the general anasarca, and proving fatal in the course of five or six days. On examining after death the bodies of children who have died of this acute oedema of the lungs, some transparent serum is usually found in the chest, and a few deposits of lymph on the surface of the lung sometimes betoken the existence of slight inflammation of the pleura. The lungs themselves are of a deep-red color, firm, and destitute of air through a great extent of their substance, not breaking down so easily as lung in a state of true hepatization would do, but giving exit when cut into to a most abundant quantity of reddish serum, mixed with very few air bubbles. If the lung be punctured, the fluid will, by degrees, drain out, and the organ will recover much of its natural flaccidity, while, if the air be blown into the bronchi, the pulmonary tissue will completely resume its light color, and will crepitate as in a state of health. These experiments show that the fluid is not actually incorporated with the substance of the lung; and M. Legendre ex- 290 TREATMENT OF 02DEMA OF THE LUNG. plains the sudden occurrence of alarming dyspnoea in some instances by the assumption that it is due to compression of the air vesicles by the rapid pouring out of fluid into the cellular tissue by which they are surrounded. The supposition, however, that the fluid is in these cases entirely external to the pulmonary vesicles does not appear to be well founded, for watery fluids1 will pass by endosmosis from one part of the lungs to another, and will even transude through the pleura. The general effect, however, is the same, whether the chief accumulation of fluid be within the air-cells, or external to them, for in either case the free entrance of air is impeded; while the severity of the symptoms depends upon the rapidity with which the oedema has taken place almost as much as upon its degree. In cases where it comes on towards the close of some chronic affection, there is often no dyspnoea nor any aggravation of the patient's sufferings to mark its occurrence, wliile, when it takes place suddenly, not only are the symptoms most urgent, but the right auricle and ventricle are found after death enormously distended with coagulated blood—a token of the difficulty with which the heart had discharged the functions to the performance of which it at length became wholly unequal. In every case of anasarca after scarlatina, the possibility of the supervention of this condition must be borne in mind, and every endeavor must be made, by the employment of diaphoretics and anti- monials, and by the use of the hot air bath, to maintain the action of the skin, and to relieve thereby the congested kidneys. If in spite of care, or, as far oftener happens, from want of it, these symptoms should occur, your course of treatment must be governed by the child's general condition. If its employment be not absolutely contraindicated, free venesection will be found to bring the same remarkable and imme- diate relief which it affords to those most urgent symptoms that follow the escape of air into the pleura; and the relief is probably in both cases brought about in the same manner. After depletion, large doses of tartar emetic should be given, since there is no other remedy that so speedily or effectually reduces the urgent dyspnoea. In the subse- quent management of the case, just such remedies are required as would be best calculated to relieve the general dropsy; and as that decreases, the oedema of the lungs will likewise diminish and dis- appear. Very often, however, especially among the poor, the oedema of the lung comes on after long neglect of the patient's symptoms, or after some course of treatment altogether inefficient has been adopted; and the cold extremities, the livid surface, and the feeble pulse forbid all depletory measures, and render the use of any depressing remedy, such as antimony, altogether inappropriate. In such circumstances, a directly opposite plan must be adopted: a large mustard poultice must be applied to the chest; stimulants must be given abundantly, such as the nitrous or sulphuric ether, wine or brandy; and sometimes it is necessary to continue these measures for several days, while some 1 See the remarks and experiments of M. Barthez, in a note at p. 188 of vol. ii. of his and M. Rilliet's work .on Diseases of Children. CHRONIC 03DEMA — GANGRENE OF THE LUNG. 291 mild diuretic, such as the tartrate or citrate of potass, or the benzoic acid, is the only medicine which we can venture to employ. On one or two occasions I have found reaction speedily follow the use of the stimulants, and have even been able in six or eight hours not only to discontinue them, but have even ventured to take blood from the arm; and the relief which followed justified the wisdom of the course. These, however, are exceptional cases, and care is often needed, on the other hand, lest the child should sink from the too early withdrawal of the Btimulants. It would be wrong, perhaps, to leave this subject without some notice of the views of M. Baron1 with reference to certain alterations in the lungs, and in other parenchymatous viscera, which he believes to be due to chronic oedema of their tissue. He describes a state of carnification in which the substance of the organ becomes dark, firm, and compact, as if from compression; but instead of these changes being attended by any diminution of its bulk, its size is actually increased. This alteration, though observable both in the liver and spleen, is naturally most striking when it exists in the lung, and was found by M. Baron, in all instances, either coexisting with dropsical effusions, or present in cases where such effusions had previously existed. He believes it to be due to long-standing oedema, to depend on changes in the tissue which the infiltration of fluid brings about in the course of time. The tendency of this condition when the lung is the part affected by it is to compress the air-cells, and interfere with the entrance of air; but nevertheless in many cases there were no symptoms announcing its existence during life, and air was found in the pulmonary vesicles after death, a fact which goes far to substan- tiate the correctness of Dr. Gairdner's opinion, that positive obstruction of the bronchial tubes is necessary to prevent the entrance of air into the lung; that the mere elasticity of its tissue, or congestion of its vessels, is not adequate to occasion this result. I will not, however, dwell further on these opinions, which involve questions of morbid anatomy more than of practical medicine, and the rather since I have no observations of my own bearing on the subject. My experience of gangrene of the lung in childhood is extremely limited, for only one case of it has come under my notice. The par- ticulars of it, however, may be worth relating, since they illustrate very well the symptoms which the disease usually presents, and the circumstances in which it generally occurs. A little girl, three years old, the child of healthy parents, who had previously had good health, with the exception of a severe attack of inflammation of the lungs when two years old, began to droop in health, to cough, and to have shortness of breath, on February 11, 1843. No treatment was adopted until the child was brought to me on the 15th. Her breathing was then more oppressed, her general condition more cast down, and her strength more reduced than is usual in so short a time from the commencement of an attack of pneumonia, 1 In the Gazette Medicale for 1851; and republished in the Journal fur Kinder- kraukheiten, vol. xviii., March, 1852. 292 GANGRENE OF THE LUNG. which had not set in with very severe symptoms. Four leeches were applied beneath the right scapula, and half-grain doses of calomel and Dover's powder were given every three hours. Slight relief succeeded to the bleeding, but this was of short duration ; and the child did not seem to be either better, or seriously worse until the 19th, when she appeared to be losing strength. The mercury was now discontinued, and ammonia and nourishing diet were freely given. On the 20th, the gums both of the upper and lower jaw began to swell; by the next day they were ulcerated; the breath became very fetid, and a discolored, stinking fluid, ran from the mouth. The thoracic symptoms continued much the same, not at all increasing in intensity, and the cough growing looser than before; but the child became paler and more exsanguine, and continued to lose power. The ulceration of the gums extended to the fold of the lower lip, and three of the incisor teeth fell out before the disease was finally checked, on Feb. 26, by the application of the pure nitric acid. The child did not appear to suffer pain, but was very restless, and continually harassed by efforts to vomit, during which she rejected nothing but an offensive mucus. She was extremely indisposed to take either wine or any nourishment for four days before her death, which took place, apparently from exhaustion, on March 1, nineteen days after the commencement of her illness. On an examination of the body after death, the left lung was found perfectly healthy, with the exception of some emphysema of its upper, and considerable congestion of its lower lobe. The right lung, which consisted of only two lobes, was universally solid and non-crepitant, with the exception of about a fourth of the upper and inner edge of the upper lobe, which was emphysematous. The two lobes were connected together by a layer of yellow lymph. The exterior of the lung generally was of a dark grayish-red color, with irregular patches of yellow deposit beneath the pleura, some of which were nearly half an inch in length and a quarter in breadth; besides which many small purulent deposits were contained within the pul- monary vesicles, as in vesicular bronchitis. The upper part of the upper lobe, and a small portion near the diaphragmatic surface of the lower lobe, felt soft and boggy to the touch. On cutting into the upper lobe, a cavity was opened as large as a hen's egg, very irregular in form, intersected in various directions by the tubes and vessels that crossed it; from which, as well as from the walls of the cavity, por- tions of lung hung in shreds. The cavity contained a small,quantity of dirty, grayish-yellow putrilage, which exhaled a most fetid odor. The substance of the lung in the immediate neighborhood was in a state of far advanced purulent infiltration, and other parts of the lobe were in an earlier stage of the same condition; besides which, small collections of puriform fluid, not bigger than a split pea, were found in various parts of its substance. The state of the lower lobe on the whole resembled that of the upper, but the cavity in it was not larger than a marble, and contained a small quantity of yellow pus, of a less fetid character than that in the upper lobe. The bronchial * GANGRENE OF THE LUNG. 293 glands w?re swollen, soft, of a homogeneous aspect, and a gray color; but neither in them, nor in either lung, nor in any organ of the body, was there the least trace of tubercular deposit. Although there was in this instance a larger amount of inflammatory disorganization of the lung than is usually met with in connection with gangrene of its substance, yet the symptoms noticed during the patient's lifetime were precisely such as are generally observed in cases of this description. The child was attacked by symptoms of pneumonia, which, however, were far from being severe; but, nevertheless, by the fifth day from their commencement, the greater part of the right lung had become impervious to air, and percussion over the right part of the chest, on February 15, yielded an almost entirely dull sound. Even then the child's strength seemed much reduced, and in the course of a few days more she sank into a state of great weakness. Through- out the whole course of the disease, there was the same absence of striking indications of the extent to which the respiratory organs had suffered, and this even after a large portion of the lung was completely disorganized. The most remarkable phenomena were those which betokened the general loss of power in the system, while the appear- ance of gangrenous ulceration about the gums tended to prove the correctness of the opinion which refers the disease to some peculiar alteration of the circulating fluid rather than to the violence of the inflammatory action. Another circumstance which tends to support this opinion is, that gangrene of the lung much more frequently su- pervenes on the pneumonia that comes on in the course of the exan- thematous fevers, than on idiopathic inflammation of the lungs. The disease, too, occurs far more rarely in children who are well fed, and who live in pure air, than in those who are surrounded by unfavorable hygienic conditions. Hence it results that this, as well as other forms of gangrene, are met with in the Children's Hospital at Paris with far greater frequency than elsewhere, and that they sometimes show a tendency to become epidemic in that institution. There is no symptom that can be mentioned as of constant occur- rence in gangrene of the lung in children, and as pathognomonic of the disease. That peculiar fetor of the breath on which so much reliance is placed in cases of gangrene of the lung in the adult, some- times loses its value in the child, as it did, in the case just related, by the coexistence with it of gangrene of the mouth. It happens, too, not unfrequently, that the characteristic odor of the breath is altogether absent in cases of gangrene of the lung—a circumstance for which it is not easy to account; though of the fact there can be no doubt, since it rests on the authority of MM. Rilliet and Barthez. Should you meet with any case in which you apprehend that this condition of the lung is present, you would adopt a tonic and stimu- lant plan of treatment, as affording the only chance, and that a very slender one, of saving the patient's life. Dr. Stokes's suggestion, too,1 for the administration of chlorine, in the form of the chloride of lime or soda, should not be forgotten, since if the remedy did nothing else, 1 Op. cit., p. 359. 294 POST-MORTEM APPEARANCES, it might diminish that fetor of the breath, which is a source of very great suffering to the patient. Pleurisy, or inflammation of the investing membrane of the lungs, is a disease which received until comparatively lately much less attention than its importance deserves. Some writers on the diseases of children, indeed, have left it altogether unnoticed on account of its supposed extreme rarity in early life; though this opinion is cer- tainly erroneous so far as regards that secondary pleurisy which comes on in the course of pneumonia, and which is almost, if not quite, as frequent in childhood as in adult age. It is true, that acute idiopathic pleurisy, unconnected with pneumonia, or in which the inflammation of the lung bears but a very small proportion to that of the pleura, is an uncommon affection during the first years of child- hood; and that as a cause of death its rarity is extreme. According to the Eeports of the Registrar-General of 202 fatal cases of pleurisy that occurred in London in the years 1842 and 1845, only 14, or 6.3 per cent., took place in children under five years old; while you will not have forgotten that 63.2 per cent, of all fatal cases of pneumonia are alleged on the same authority to have befallen children aged less than five years. It may be doubted whether this statement, which rests only to a comparatively small extent on the results of post- mortem examination, does not under-estimate the frequency of idiopathic pleurisy in early life. But, be this as it may, the rarity of the disease unquestionably diminishes after the first years of infancy are passed; while its importance as an occasional complication or sequela of other affections, and more particularly of scarlet fever and the frequent obscurity of its symptoms, are reasons for devoting to it more than a passing notice. In fatal cases of pleurisy in childhood, the appearances found after death are precisely the same as are met with in the adult. Adhesions between the costal and pulmonary pleura, and between the different lobes of one or other lung, associated sometimes with very intense redness of parts of the membrane, are hardly ever wanting, and in connection with them a small quantity of transparent serum, often of a reddish tint, is sometimes effused into the cavity of the chest. In other cases the effused matters are entirely solid, and both the surface of the lung and the interior of the thorax are coated with a distinct investment of lymph; or, in addition to the deposit of lymph on the lung, fluid is poured out into the chest—no longer transparent serum, but either a sero-purulent fluid in which flakes of lymph are floating, or more rarely, healthy pus. The most frequent complication of pleurisy is with inflammation of the lungs; besides which, it occa- sionally happens, when the left pleura has been the seat of inflamma- tion, that the disease extends from it to the pericardium, which on four such occasions I have found lined with lymph, partially adherent to the heart, and containing a sero-purulent fluid.1 1 In 80 cases in which the above-mentioned consequences of recent inflammation of the pleura were observed after death in non-phthisical subjects, they existed in the following combinations:— •4 AND SYMPTOMS OF ACUTE PLEURISY. 295 The main symptoms that attend the disease, as well as the physical signs of its existence, are the same at alLages. There are, however, some circumstances peculiar to early life, which, unless you are on your guard, may serve to obscure the real nature of the affection. The history of a case of acute pleurisy in childhood is generally something to this effect: A child previously in perfect health is suddenly attacked by pain referred to the chest or to the upper part of the abdomen, so severe as to occasion it to cry aloud; perhaps attended at first by vomiting of a greenish fluid, accompanied with fever, a rapid pulse, and hurried respiration interrupted by frequent short cough, which evidently occasions pain, and which the child labors, though in vain to suppress. After a few hours the severity of the pain subsides; but the fever, hurried respiration, and cough, continue, and the child, though usually it looks heavy and seems drowsy, yet becomes extremely restless at intervals—cries and strug- gles, as if in pain, and violently resists any attempt to alter its position, since every movement brings on an exacerbation of its sufferings. The posture which it selects varies much: sometimes its breath seems disturbed in any other than an upright position; at other times it lies on its back, or on one side; but, whatever be the posture, any alteration of it appears to cause much distress, and is sure to be re- sisted by the patient. The probabilities are, that, if you auscultate the chest of a child in whom these symptoms exist, you will hear good breathing through the whole of one lung. On the other side, the motion of which in breathing will be seen to be less extensive, and performed in a slightly jerking manner, the air will be found to enter less freely, though un- accompanied by any moist sound, perhaps unattended by any morbid sound at all; or, possibly a rough sound like a rhonchus may be audi- ble on this side, and for this you may very likely at first take it, though with more attention it will be discovered to be a friction sound. A day or two later you will detect a sound like that of bronchial Redness of the pleura existed alone.......1 " " with recent adhesions and deposit of lymph. . 26 Serous effusion existed alone ........ 17 " " with adhesions, or deposits of lymph . . .12 Sero-purulent effusion..........11 Effusion of pus...........13 80 In 34 of the above 80 cases, the affection of the pleura, though sometimes consid- erable, appeared to be secondary, and subsidary to that of the lung itself. In the remaining 46, the pleura was the chief seat of the mischief, the lung being eilher simply compressed by the quantity of the effused fluid, or its inflammation being secondary in extent and importance to that of which the pleura bore evidence. In 8 of the above 46 cases, the affection of the pleura was idiopathic ; 21 times it succeeded to scarlet fever ; four times to pericarditis, and endocarditis; once to typhus fever; thrice to diphtheria : twice it succeeded to peritonitis, and once it was associated with ascites, and cirrhose liver. In one instance it followed inflammation of the sinuses of the dura mater ; and once fatal hydrothorax supervened in a case of general dropsy, which, as far as could be ascertained, had not been preceded by any of the exanthematous fevers. 296 DIAGNOSIS OF PLEURISY breathing,1 as you pass your ear from above downwards along the posterior part of the chest, while the friction sound, if it had previously been audible, will have disappeared; and still lower there will be an utter absence of all sound. In most instances, however, no friction sound is to be heard at the commencement of the attack, though it becomes perceptible on its decline, but a bronchial character of the respiration will be perceived as one of the earliest auscultatory signs of the disease. The walls of this side of the chest, if their tenderness do not prevent your trying percussion, will yield a much less resonant sound than usual; while, at the same time, a distinct sense of solidity will be communicated to the finger, and the vocal fremitus will either be indistinct, or altogether absent. The first auscultatory evidence of improvement is often furnished by the reappearance of friction sound, or by its beginning to be heard for the first time. It is usually perceived first about the upper and back part of the affected side, and descends by degrees in proportion as the air enters with more freedom, and as the thin layer of fluid which had been poured out becomes absorbed. This process of ab- sorption obeys no rule as to the time which it occupies; so that a « friction sound may be heard in some cases only for a few days, in others for several weeks. The very long persistence of a friction sound, however, always raises the suspicion that tubercular deposit has taken place on the surface of the pleura. It is very rare for a friction sound not to be heard over at least some small extent of sur- face, but in some instances, when very little fluid has been poured out, the costal and pulmonary pleura speedily become adherent, and in such cases little or no friction sound may be heard. With the gradual return of the pleura to a healthy state the rubbing sound passes away; but for some time after all other traces of the attack have disappeared, a somewhat harsher character of the breathing, and a marked dulness on percussion continue. The dulness on percussion, too, far exceeds that which the disparity between the amount of air admitted into the two lungs would seem to account for, and has, to the best of my knowledge, never yet received a thoroughly satisfac- tory explanation. The symptoms by which an attack of acute pleurisy is ushered in, point sometimes rather to the head than to the chest. The child is seized with vomiting, attended by fever and intense headache: it either cries aloud, or is delirious at night, or screams much in its sleep, and, when morning comes, complains much of its head, but denies having any pain whatever in its chest, while the short cough and the hurried breathing may be thought to be merely the result of the cere- bral disturbance. Sometimes, too, the cough is altogether absent, and the acceleration of the breathing so slight as not to suggest the idea that serious mischief is going on in the chest. Under the impression that the child is suff'ering from cerebral disease, auscultation is omitted, or at least practised hastily and superficially, and consequently serves 1 Rilliet and Barthez were the first to insist on the constant occurrence of bronchial breathing as one of the earliest auscultatory signs of the existence of pleurisy in child- hood. See vol. i. p. 554 of the 2d edition of their work. FROM CEREBRAL AND ABDOMINAL INFLAMMATION. 297 but to confirm the erroneous diagnosis. It often happens, indeed, that in these cases no friction sound is perceptible, and that you have no other indication to guide you aright besides the feebleness of the respi- ratory murmur on the affected side. The child, too, fearful of taking a deep inspiration, fills neither lung completely, so that the information usually gained by comparison of the breathing in one lung with that in the other is in great measure lost. Still the presence of feeble respiratory murmur at the lower part of one lung, when coupled with the sudden access of acute febrile symptoms in a previously healthy child, points almost invariably to the existence of acute pleurisy ; while a careful consideration of the patient's history and general condition will, even irrespective of the results of auscultation, go far towards preventing you from falling into error. The onset of the illness has been far too acute, attended with far too much febrile disturbance, for a case of tubercular hydrocephalus, while many of the signs of cere- bral mischief which might be expected in a case of simple encephalitis have not presented themselves. The heat of head is not greater than that of the rest of the surface: the cries with which the disease set in have not ended in coma. It happens but seldom that convulsions mark the commencement of the disease; but, if they had occurred on the onset, they have not since returned: neither twitching of the muscles, nor strabismus, nor retraction of the head, is present; and though the child may cry (as children when ill and fretful often do) at the curtain being undrawn and the candle brought near it, yet there is no real intolerance of light, while, in spite of its fretfulness, the intelli- gence is not otherwise perverted. Error indeed is easy, but to avoid it requires in this, as in most instances, not so much great acuteness as great care and great patience. The pain which with pleurisy sets in is sometimes referred not to the chest, but to the abdomen; and its commencement may be attended with vomiting and purging. This mode of onset of the disease is especially likely to be observed in cases of diaphragmatic pleurisy, and more particularly if the inflammation be seated on the right side; and in this latter case, bilious vomiting is often one of the most marked of the early symptoms. Pressure on the abdomen, too, not only in these, but frequently also in other cases, occasions a considerable increase of suffering; and you may thus be led to overlook the exist- ence of the pleurisy, and to allow your attention to be entirely directed to the abdominal symptoms. Not very long since a boy seven years of age was admitted into the Children's Hospital in the sixth week of a pleurisy of the right side, which had terminated in empyema, for which paracentesis was afterwards successfully performed. He was reported to have had inflammation of the bowels, and the marks of recent leech-bites in his^ right iliac region bore witness to the diag- nostic error which auscultation would have avoided. In any such doubtful case, it is well to bear in mind, that children, long after they can talk, describe the nature and seat of their sufferings very inaccu- rately ; and if, as often happens in these cases, they refer the pain to the right hypochondrium, you should not forget that pain in that situ- ation is at all ages much oftener connected with inflammation of the h 298 DIAGNOSIS OF PLEURISY FROM PNEUMONIA. pleura than of the peritoneum; and, lastly, that the increase of dis- comfort produced by pressure on the abdomen may be due to the additional impediment thereby offered to the already laboring respi- ration. The careful auscultation, which I need not say should never be neglected, will generally save you from error, but in a case of dia- phragmatic pleurisy you are rather left to infer the nature of the disease from the non-correspondence of its symptoms with those of any other ailment, than enabled to decide upon its character from any positive sign of mischief in the chest with which your ear makes you acquainted. The heat of skin, the frequency of the pulse, and the hurry of the breathing, are such as to exclude the suspicion of almost all affections of the abdomen while not only do not the general characters of the attack tally with those of acute peritonitis, but there is no such tenderness upon even slight pressure, no such tension of the abdominal walls, no such dread of the slightest movement, as characterize that disease. Your great safeguard will be found, in such a case, in the right interpretation of the general symptoms, and in the recognition of the fact, that, when attended wiih acute febrile symptoms, the mere imperfect entrance of air into the lung is itself a valuable indication of inflammation of the pleura. The danger, in cases of pleurisy in early life, is, however, not simply that of over- looking the existence of mischief in the chest, but also of referring that mischief to a wrong cause. The fever, and cough, and dyspnoea, may be so marked as to render the former mistake impossible; but auscultation, unless you rightly interpret the information it affords, may not guarantee you against the latter. It is not by any means a matter of indifference whether you take a case of pleurisy for one of pneumonia, or whether, in a case of bronchitis, which may for some time have been under your care, you recognize the in- flammation of the pleura which may have supervened, or see in the increased urgency of the chest symptoms merely an exacerbation of the previous ailment. The error, indeed, is one not likely to be com- mitted in a case of idiopathic pleurisy that you may have watched from the commencement, but it is one into which you may very probably fall in those instances where pleurisy succeeds to the exan- themata, especially to scarlet fever, and less often to measles. Cough and hurried breathing, and rhonchus, with some crepitant rale, may have already existed for some time, and in these circumstances, a fric- tion sound, even if it should become audible, is very likely to be un- noticed. But, besides this, the unequal breathing so characteristic of early life, as the result of which air may seem one hour to enter one lung imperfectly, while a few hours subsequently the deficient respi- ration may appear to be on the opposite side, naturally leads you to undervalue the importance of mere deficient respiration. But, if the bronchial character of the breathing forces itself on your attention, the probability is, that, without any further consideration, you may put that down as an unequivocal proof of the advance of pneumonia, and alto- gether overlook the pleurisy of which in this instance it is an indication. It is the more important to bear in mind the possibility of error, since some of the means of distinguishing between pleurisy and pneu- LATENT PLEURISY. 299 monia on which we rely much in the adult are less available in the child. It is so difficult to induce children to speak several words con- secutively in the same tone, and their voice is often so feeble, as to deprive us in great measure of the information which the diff'erent resonance of the two sides of the chest would otherwise afford. For the same reason, too, the difference of vocal vibration, as perceived on applving the hands to either side of the chest, is often by no means so manifest in children as in grown persons. The experiment, however, is one which should never be omitted, since the information which it yields, provided it do not fail altogether, is as valuable in the one case as in the other. Two more hints may perhaps be of service in helping to keep you from error: first, that the limitation of the physical signs of affection of the chest to one side, of itself raises a presumption that that affection is inflammation of the pleura, not of the lung; and second, that the bronchial breathing which is perceived at an early period of an attack of acute pleurisy is attended by diminished resonance on percussion rather than by that absolute dulness which is perceived when the substance of the lung itself has passed into a state of hepa- tization. But there are also cases of latent pleurisy in the child as well as in the adult: cases in which there are vague symptoms of feverishness, with perhaps a little cough, and nothing more; nothing to call special attention to the chest, nor even to suggest the existence of grave ail- ment anywhere. In young children the symptoms are attributed to teething, in those who are older to worms, or to gastric fever; terms which cover a large amount of carelessness, ignorance, and indolence. I know of no means infallibly to preserve from error, besides those simple rules which have grown almost wearisome by frequent repe- tition. Bear in mind, with reference to teething, that there are pauses in the evolution of the teeth; that it does not follow because a child has not yet cut all its teeth, that dentition must therefore at any par- ticular moment be in active progress. Next, that how much soever the presence of worms may interfere with a state of perfect health, febrile symptoms are not indicative of their presence: and in the third place, that with the exception of the exanthemata and of ague, typhoid fever is the only essential fever to which children are liable. In other words, the fever is symptomatic of disturbance somewhere; it behooves you by careful examination to make out where; and in order that you may not fail to discover the seat of the disturbance you must never omit auscultation. A little girl, two years and two months old, had slight cold and a cough, which seemed so trivial that medical care was not sought for; and when at the end of a fortnight a purulent discharge took place from the right ear, that was looked on but as another evidence of the dependence of the ailment on dentition. At the end of three weeks, as she did not recover her customary health, a doctor was called in, who found her breathing quietly, with no cough, but looking worn and ill. She slept well during the night, and the following day seemed much the same, except that she was rather more fretful, so that she would not allow of any attempt at auscultation, and her pulse had 300 SUDDEN DEATH IN PLEURISY. suddenly fallen from 120 to 72 beats in the minute. She slept pretty well during the night, but the next morning when taken up as was her wont, she laid her head on one side against the nurse's bosom, and died without a struggle or convulsion. I was present at the post-mortem examination, which disclosed no morbid appearances whatever in the brain. There were, however, nearly six ounces of reddish serum in the cavity of each pleura, though without any deposit of false membrane on their surface. Some por- tions of the lung were in a state of collapse; there were some white clots on the right side of the heart, while the left side wras empty and contracted. Few symptoms had here called attention to the condition of the child, who at length died suddenly in consequence of the effusion into its chest, and probably from the sudden change of posture on assum- ing the sitting position. This case has a twofold interest, partly from the latency of its symp- toms, partly from the suddenness of its termination;1 and the possible sudden termination of a case of pleuritic effusion is perhaps less borne in mind than it should be. A little boy, not quite three years old, whose health had never been very robust, was brought as an out-patient to the Children's Dispen- sary in Lambeth on June 11, 1847, on account of a chronic impeti- ginous eruption on his scalp. On the night of June 12, he suddenly became hot, and his chest was much oppressed, but on the following day he was well enough to be out at play in the garden, and on the 15th was drawn a mile and a half in a perambulator to and from the Dispensary when I saw him for the first time. He looked pale and ill, was feverish, and breathed with a wheezing noise, but there was nothing about him indicative of serious mischief; and in the hurry of prescribing for a large number of patients, I regarded him as probably a phthisical child, who had caught cold recently. I ordered some simple medicine for him, and at one P. M. he returned home. At three o'clock the same afternoon he suddenly became much worse, was very faint, breathed with extreme difficulty, and died at eight o'clock the next morning. Some serous fluid was present in the abdomen, and about six ounces in either pleura, by which the lower lobes of both lungs were so compressed as to be almost destitute of air. But again, death may, as in the first case, be almost immediate; and this sudden death, be it observed, takes place chiefly in instances where the inflammatory action has not been intense, and where the effusion is simple serum. A little boy, aged eight years, was attacked by moderately severe scarlatina. Slight anasarca appeared on the 19th day, which had somewhat increased, but was accompanied by no urgent symptom on the 22d day, when he walked a distance of two miles without suffering serious fatigue. After a rather restless night he rose to relieve his bowels, and there was so little suggestive of danger in his condition that his mother left him for a few minutes alone. On her return, his bowels had acted scantily, aud he seemed 1 See, with reference to this subject, Trousseau, Clinique, etc., vol. i. p. 137. TERMINATION OF PLEURISY IN EMPYEMA. 301 faint. He was replaced in bed, when he immediately began to struggle feebly, and in a few minutes was dead. The lungs were compressed by abundant serous effusion in each pleura, and the pericardium also contained four ounces of fluid, but there were no other morbid appearances except some congestion of the kidneys. This very sudden death is unquestionably a rare result of pleurisy, but nevertheless, the disease in early life is by no means unattended with danger; and my own impression is that a fatal termination of acute idiopathic pleurisy is by no means of such rare occurrence in early as in adult life. In most of those cases, however, which I have seen terminate fatally, the disease, though it began in the pleura, did not continue limited to it, but extended either to the pulmonary sub- stance or to the pericardium. The serious nature of the latter com- plication is obvious, and hence it happens that in by far the greater number of cases of fatal unilateral pleurisy the disease was seated in the left side. I have, indeed, in these circumstances known a case of pleurisy prove fatal within four days from the first appearance of its symptoms. Besides these cases, others require notice in which the pleurisy neither proves immediately fatal nor terminates on the other hand by speedy recovery. Here the effusion which takes place produces an even greater degree of deformity of the chest in the child than in the adult, since its more yielding walls give place more readily. The immediate consequence of the effusion is of course to produce an en- largement of that side of the chest into which the fluid is poured out, while at the same time the respiratory movements on that side are almost entirely abolished, and the intercostal spaces are bulged out- wards, or at least are raised to a level with the surface of the ribs; though in the child the amount of fat beneath the integuments renders this less obvious than in the adult. As the one side, however, is expanded by the effusion of fluid, the other also increases very appre- ciably in the course of ten days or a fortnight, as the result of the extra work thrown on the healthy lung, which has to perform its func- tions not for itself only, but also for the other, whose action is impaired or it may be almost completely arrested. With the commencement of the absorption of the fluid the affected side begins to shrink- and in the*course of time from being half an inch to an inch larger than the healthy side it becomes at least as much smaller; it grows flatter in the infra-clavicular region ; the spine itself yields, its upper con- vexity being directed towards the healthy, its lower convexity towards the contracted side. The hypertrophy of the healthy lung produces a bulging of the corresponding side, the shoulder of which is thrown up, while the other is proportionately depressed, and a very remarkable degree of deformity is thus produced. Gradually with the lapse of time, a sort of restorative process seems to be set on foot, the steps of which have not been sufficiently studied; but by it the spinal curva- ture and the flattening of the upper and front part of the chest are lessened, in proportion as air permeates the lung more freely; and in many instances a comparatively slight degree of deformity remains 302 TERMINATION OF PLEURISY IN EMPYEMA. the only evidence of what had seemed to be almost irremediable mis- chief. This, however, is a result, which it does not seem possible to calculate on with any certainty, for there can be no doubt but that in the large majority of cases of acute pleurisy in early life in which effusion takes place, either pus is poured out at once, or the fluid very speedily becomes purulent, and consequently inapt for absorption, though by no means incapable, as was once imagined, of being absorbed.1 In these circumstances, we usually find the chain of occurrences to be somewhat as follows. After the first acute attack which has terminated in the effusion of fluid, the more active symptoms abate, the fever subsides, and the child enters on a state of semi-convalescence. This, however, does not last above a week or ten days, when without any fresh access of acute symptoms, the child begins to suffer from notable dyspnoea, grows unable to lie at all except on the affected side, while the superficial veins on that side become greatly enlarged, the integu- ments somewhat cedematous, and the whole surface so tender that even the gentlest percussion cannot be tolerated. These symptoms indicate that the matter is about making its way outwardly, which it does usually by perforating the chest-wall, though the empyema now and then empties itself into a bronchus, of which I have seen two instances; and has been known to burst through the diaphragm into the abdominal cavity, and thus to produce fatal perionitis. In by far the majority of cases the matter is discharged externally through the chest-wall, almost invariably through the anterior wall of the chest, and mostly in the fourth or fifth interspace, and a little outside the nipple. Increase of tenderness of the chest-wall, and then bulging of the integuments in one or other intercostal space, precede the dis- tinct pointing of the abscess, which, whether opened or allowed to burst of itself, will almost invariably continue fistulous for a great length of time; the profuse discharge exhausting the patient, and the rapid contraction of the side producing great and often remediless deformity. This external opening, too, is not unfrequently an indirect one, the matter having burrowed between the pleura and the chest- wall for some distance before it escaped externally. Thus in the case of a boy, aged eight years, who died eighteen months after the first symptoms of pleurisy on the left side, and four- teen months after the formation of a pleural fistula; between the first and second bones of the sternum, which remained open till his death, and another between the sixth and seventh rib, which ceased to dis- charge nine months before that event; a post mortem examination disclosed the following state of things:— The old sinus between the sixth and seventh rib did not extend for more than a quarter of an inch, and terminated without entering the chest. That between the bones of the sternum opened at once into a ' In Mr. Hilton's work, already referred to, will be found many instances of the absorption of the contents of abscesses. Perhaps the most interesting is that related at p. 375, in which the small amount of solid residuum found on the patient's death after the lapse of some months, was ascertained by chemical examination to be abso- lutely identical with the constituents of pus. TREATMENT OF ACUTE PLEURISY. 303 number of sinuses which led for at least an inch upwards and down- wards in several directions, and then pierced the chest-wall to run along in a similar manner in the substance of the costal pleura, which was like cartilage in appearance, and at least three-fourths of an inch in thickness; and all these sinuses were filled with pus. To sum up, then. Speedy recovery when little fluid has been poured out; tardy recovery when it has been more abundant; and followed in most instances by deformity which time tends gradually and im- perfectly to remove; occasional sudden death when serous fluid has been poured out rapidly and in large quantity; escape of the fluid in most instances when purulent through the chest-walls, in obedience to the laws which govern the course of an abscess, wherever situated: such are the different issues of pleurisy in early life. How these facts bear upon our treatment of the disease is the question that we have next to consider. The causes which have already been referred to as modifying in very important respects the treatment of bronchitis and pneumonia, have also exercised their influence over the treatment of pleurisy. But, nevertheless, I am fully convinced that considerable activity in the early stage of the disease best averts danger, and most economizes the patient's strength. In almost every instance, indeed, that has come under my observation, where the issue of acute pleurisy has been unfortunate, either all treatment had been neglected until the children were past hope, or the nature of the complaint had been mistaken, or the treatment followed had not been sufficiently active. The same statement, too, may be made with reference to those cases in which paracentesis of the chest became necessary. By active treatment, I imply depletion in all cases in which the child's previous health has been good, in which pleurisy is idiopathic, the symptoms are at all urgent, and the patient is seen before the occurrence of effusion. In children of five or six years old, general depletion is to be preferred, and the relief to the breathing may be taken as the indication for stopping the flow of blood. If after the lapse of four or six hours the pain and dyspnoea return, leeches should be applied to the affected side, and four or six leeches will seldom fail to give permanent relief. In the case of younger children, local depletion alone will suffice, but that should not be practised too timorously, since the most relief is procured when the abstraction of blood answers to some degree the purpose of a general bleeding. After depletion, our chief reliance is to be placed on calomel, which should be freely given in combination with opium or Dover's powder; and an attack of pleurisy thus treated will often be cut short in thirty-six or forty-eight hours. In many instances, however, the child's previous health does not warrant, or the severity of the symptoms is not such as to indicate, these very active proceedings. In these circumstances a mustard poultice to the chest will often give immediate ease; and on its removal a lin- seed poultice may be applied, and renewed every four hours, so as to maintain the effect of a gentle counter-irritant. At the same time the iodide of potassium may be given in combination with a saline and 304 TREATMENT OF PLEURISY. diuretic,1 and continued steadily for several days; while its action may be seconded by a small dose of mercury, given once or twice a day, as one grain of calomel, or three of gray powder, for a child of six years old. The mercurial may be discontinued at the end of a week, but the iodide of potass may be persevered with for two or three weeks; the abatement of all febrile action, and the diminution of the effusion, indicating the time when it may be given with less frequency. Often, however, after the symptoms have subsided, the affected side remains dull, and the respiration scanty for several weeks together; and now is the time when the use of blisters, or still better the paint- ing the side with tincture of iodine, seems to be of much service in promoting the absorption of the fluid; while cod-liver oil, given twice a day, is a useful means of maintaining the nutrition of the child, and of counteracting that tendency to the development of tubercular dis- ease which is so apt to manifest itself in cases where pleurisy has passed into a chronic stage. Sometimes, indeed, in spite of remedies perseveringly employed, one side of the chest continues full of fluid; and the question then comes before us whether it will not be expedient to let out that fluid by mechanical means. I do not feel in a position at present to lay down decisively the indications for the performance of paracentesis; but the following suggestions represent the opinions which I entertain, subject to their correction by wider experience. I believe, then, that so long as the child's health is improving, or at least not deteriorating, as the dyspnoea is not urgent, as the chest-walls have not become a tender, nor the superficial veins notably enlarged, and there is no indications of pointing anywhere, while careful measurement of the chest proves the effused fluid not to be on the increase, we may persevere in the employment of the means already indicated. I believe, however, also, that we shall best consult the interests of our patient by evacuating the contents of the pleura, so soon as any of the above-mentioned favorable conditions cease, and that we shall err if we delay until the supervention of intense dyspnoea leaves us no choice, or until the pointing of the empyema externally allows us to do no more than anticipate by a very few days, the completion of the process which nature herself has undertaken. In twenty-four out of fifty-three post-mortem examinations, in which fluid was found in the pleural sac, that fluid was purulent; and if the cases were excluded in which either the fluid was very inconsiderable in quantity, or in which its effusion was secondary to scarlatinal dropsy, we should find that in almost every instance the pleura con- tained pus. In eleven out of thirteen of my cases in which paracen- 1 (No. 13.) R.—Potassii Iodidi, gr. xij. Potassse Nitratis, gr. xxx. Spt. Mth. Nitr. 2[j. Liq. Taraxaci, giij. Tinct. Scillee, n\xxx. Tinct. Digitalis, TTLXxiv. Syr. Aurantii, i|iv. Aquae, ad ^iv. M. ft. Mist. A tablespoonful every four hours. For a child six years old. QUESTION OF PARACENTESIS. - 305 tesis of the chest was performed the fluid was purulent. In one of the two exceptional cases the effusion followed scarlatinal dropsy, in the other it succeeded to measles; and it is my belief that in every instance of idiopathic pleurisy in which fluid is poured out in con- siderable quantity, that fluid either is originally purulent or becomes so very speedily. The possibility of the absorption of pus is indeed no longer disputed, but at the same time pus is inapt to be absorbed, and its absorption is sure to be tedious; while the longer the lung continues compressed by it, the more likely is it to become bound down permanently by lymph, to become altered in texture, and in- capable of being again permeated by air. If to this we add the con- stitutional symptoms which never fail to become excited by the presence of a large abscess; the risk of pyaemia inseparable from it; and the great probability, nay the almost certainty, that in the course of time nature herself will decide the point, and make an opening in an undesirable situation which will empty the pleura but imperfectly, while it will remain fistulous for months or years, difficult to close, aggravating the deformity of the chest, wearing the strength by the constant drain of matter; we have, I think, a number of reasons more than sufficient to justify the comparative early performance of paracentesis. I know indeed that the question is not a simple one; that in the first place art cannot safely make the puncture at the lowest part of the purulent collection any more than nature does, who, when the matter is left in her hands, commonly selects a situation at or near the fourth costal interspace, and a little to the outside of the nipple. Further, the continuance of a copious drain of pus exhausts the strength more than the mere presence of the purulent collection in the pleural sac; while, lastly, the almost inevitable admission of air through the wound, almost always converts the previously healthy pus, into a highly offensive sero-purulent discharge. But still, while fully recognizing all these facts, there is, I think, a preponderance of evidence in favor of adopting the course which I have indicated. Thirteen cases have come under my care in which the chest has been tapped. Of these 13, 5 permanently recovered; 2 passed from under observation on the 53d and 77th day respectively, so much im- proved as to leave no doubt of their eventual recovery, though the puncture was still unclosed ; 1 was removed from the hospital 22 days after the first tapping, 4 days after the third, decidedly relieved, but still in a doubtful state from pneumonia of the opposite side, which already existed at the time of the child's admission. One case is still under my care while these sheets are passing through the press, with, as far as I can see, every prospect of eventual recovery. Of the four fatal cases, one was that of a child, who was moribund at the time of the performance of the operation for the relief of serous effusion into the chest, coming on in the course of scarlatinal dropsy; one died of gangrene of the mouth and pneumonia of the opposite lung; one in whom it was performed for empyema following measles, sank from the effects of the measles rather than from the pleurisy or the tapping; and a fourth, who had likewise recently had measles, died of pyasmia, 20 306 PARACENTESIS OF THE CHEST IN PLEURISY. 34 days after the puncture. If to these 13 cases we add 33 collected from various sources, to which references are given by Dr. Ziemmsen,1 we have a total of 46 cases, which yield 34 recoveries more or less complete, and 12 deaths, or about one death in every 4 cases. Some points deserve attention which concern the manner of per- forming the operation; such as the importance of excluding the air even in cases where the fluid let out is purulent, and the comparative advantages of frequently repeated tapping, or of keeping the wound open so long as fluid remains within the pleura. Further, we must endeavor to lay down rules for the management of cases in which the opening after puncture continues fistulous, and of those in which a spontaneous opening remains unclosed, and discharge more or less profuse continues; and lastly, we must consider the best means of pre- venting the occurrence of deformity. The precautions insisted on by different writers for the exclusion of air from the pleural cavity, have had reference to those cases in which the fluid being serous the wound was closed immediately after its evacuation, and remedies were employed in the hope of insuring the complete absorption of what remained behind. It has not, how- ever, seemed to me that the immediate closure of the wound, or its accidental reunion speedily after the evacuation of purulent fluid, has had a good result. The matter, in many instances, has reaccumulated with great rapidity, reproducing all the distress and dyspnoea which had led in the first instance to the performance, of the tapping, and necessitating the speedy opening of the wound, or the repetition of the puncture. All this has seemed to depress the patient more than the uninterrupted continuance of the discharge from the wound. I have not been accustomed to take any special precaution to prevent the admission of air in these cases: but have just introduced a small tent between the edges of the wound to keep it from closing; and have then covered the side with a linseed poultice. Some pus has always escaped into the poultice, and a more copious outflow has taken place daily on the removal of the tent; and it has happened once or twice that the discharge has diminished rapidly as the lung expanded ; and that at the end of two or three weeks the opening has been per- manently closed. But to this more fortunate course there are, it must be confessed, frequent exceptions; the pus has often speedily become fetid, thin, and irritating; and hectic symptoms have supervened. In these circumstances I have washed the chest out with tepid water every day; and have employed a solution of iodine, which, when it has failed to check the discharge, has almost always had the effect of greatly lessening the fetor. It still, however, remains a question whether, if air could be perfectly excluded from the pleura while pro- vision is made for the escape of the matter, a much more certain and a speedier recovery might not be insured. A case where my colleague, Dr. Buchanan, by means of a canula fixed in the wound, the end of 1 Op. cit., p. 148. It can scarcely be necessary to do more than refer to Trousseau's lecture on paracentesis of the chest in his "Clinique de I'Hotel Dieu," vol i. p. 617. He does not, however, consider the operation with any special reference to its perform- ance in early life. DEFORMITY OF CHEST FROM CHRONIC PLEURISY. 307 which was opened once a day, and the pus removed by Bowditch's exhausting syringe, and which had a remarkably favorable issue, ap- pears to me to invite further trials in the same direction. There are some difficulties in the details of any plan with this object, but they might, I think, be overcome. There are other cases which call for notice, where the wound made in tapping continues fistulous, or where the opening made by nature remains unclosed. In two cases of this kind I tried the system of drainage as recommended by Dr. Goodfellow.1 The result, however, was not quite satisfactory, for the presence of the tube seemed to pro- duce increased irritation, and to render the discharge more profuse, while the posterior wound in both cases became unhealthy, and com- pelled the removal of the tube. Considering that the great elasticity of the chest-walls in early life, while it favors the occurrence of de- formity has the counterbalancing advantage of facilitating the escape of matter, I have employed on two occasions a silver-gilt canula adapted to a broad shield, which has admitted of the ready outflow of the pus, and has allowed of the washing out of the pleura with tepid water, and the injection of iodine solution into it. I have begun with one part of tincture of iodine to seven of water; and have increased its strength to one in four; but have always allowed the injection to flow out immediately. In several cases this has had the effect of re- straining the discharge of pus; I think I may say of arresting its secretion, and I have in no instance seen harm result from its em- ployment. Lastly, there remains the question of the best means obviating that deformity of the chest which follows in cases of chronic pleurisy on the hypertrophy of the sound lung, and the shrinking of that side on which the effusion was situated. These changes in the chest call for a more attentive study than they have yet received, for time seems to play a considerable part in removing much of the deformity which seems to threaten soon after paracentesis has been performed. This, no doubt, is due to the gradual expansion of the compressed lung, which takes place to a greater extent than,-judging from the case in its earlier stages, one would have thought possible. Still, whenever the contraction seems to be steadily on the increase, I should recom- mend the employment of Tavernier's belt, with a crutch under the arm of the contracted side; a contrivance which has seemed to me to arrest the progress of the deformity, and to give opportunity for na- ture to restore in, great measure the symmetry of the two sides of the trunk. 1 Medico-Chirurgical Transactions, vol. xlii. p. 231. 308 TWO DISEASES INCLUDED LECTURE XXIII. Chottp.—Reasons for not studying it earlier in the course—discrepancy of opinion with refer- ence to it—two distinct though allied diseases included under the name. Laryngeal Croup ; or Cynanche Laryngea.—Causes of the disease—its frequency in child- hood, in the male subject, in northern climates, in rural districts. Post-mortem appearances—variations in the extent of false membrane in the air-passages— changes associated with it—affection of the fauces and soft palate. Symptoms—occasional sudden onset—catarrhal stage, general course of a fatal case—occa- sional delusive appearances of amendment.—Evidences of auscultation—changes in tracheal sound. Duration. Prognosis. Treatment—importance of abstraction of blood—directions for its performance, and for the administration of tartar-emetic—when and how mercurials are to be employed. Modifi- cations in treatment produced by alterations in epidemic constitution. Importance of not exaggerating them, and of not confounding in their treatment croup and diphtheria. In strict propriety the very important disease which we are about to investigate to-day ought to have engaged our attention immediately after we had completed our study of infantile bronchitis. Two reasons, however, independent of mere convenience, have led me to postpone till now the consideration of the subject of croup. One of these rea- sons is, that its gravity is often greatly increased by the association with it of inflammation of the lungs—a complication the importance of which it was essential that you should thoroughly understand; the other is, that croup, though an inflammatory disease, is not without a very evident spasmodic element in every case; so that it may very appropriately form a sort of transition between the inflammatory and the spasmodic diseases of the respiratory organs. It can scarcely be necessary to tell any of you that croup is the English name for the disease designated by scientific writers cynanche trachealis, or cynanche laryngea. It consists in inflammation, generally of a highly acute character, of the larynx or trachea, or of both, which terminates in the majority of cases in exudation of false membrane more or less abundantly upon the affected surface. The formidable nature of the symptoms by which it is attended, and the rapidity with which it tends to a fatal issue, have'led many of the ablest physicians to devote much time and attention to the study of croup. It might, therefore, be anticipated that our knowledge of a disease which betrays itself by very manifest and highly characteristic symptoms, and which gives rise, when fatal, to changes easily appre- ciable after death, should, by this time, be very definite and settled. "With reference to many of the more important points in the history of the malady, writers are now, indeed, pretty well agreed; but croup, like many other diseases that depend to a great extent on atmospheric and telluric causes, is modified in many of its symptoms by peculiari- UNDER COMMON NAME OF CROUP. 309 ties of air, water, and situation. The affection assumes one character among the poor of a crowded city, and another among the children of the laborer in some rural district.1 If, therefore, you find that my account of the disease varies in any respect from the description given by some other writers, or from the 1 I have preserved a record of 23 cases of croup that came under my notice at the Royal Infirmary for Children between May, 1839, and April, 1849. Of these 23 cases, 11 were idiopathic, 12 secondary ; five of the former and two of the latter recovered. In two of the idiopathic cases that recovered, a scanty formation of false membrane was observed upon the velum and tonsils, but no such appearance existed in the other idiopathic cases. Three of the six fatal idiopathic cases were examined after death; in two the false membrane was confined to the larynx ; and there was but little injec- tion of the trachea or bronchi; in the third case there was great redness both of the trachea and bronchi, and a large quantity of purulent secretion in both, and ulcera- tion of the mucous membrane of the larynx, but no false membrane. Of the twelve secondary cases, one supervened in the course of pneumonia; in the other eleven, croup appeared as the sequela or concomitant of measles, and ten of the twelve ter- minated fatally. In the cases which recovered, and in three of those which termi- nated fatally, there was no false membrane on the velum or fauces, but in the other seven false membrane was present in those situations as well as in the larynx, and twice this false membrane extended into the oesophagus. Six of the fatal cases were examined after death; in one there was no false membrane anywhere, but intense redness of the larynx, trachea, and bronchi, with an uneven granular appearance of the larynx, and ulceration about the epiglottis. In the other five cases the larynx contained more or less false membrane, and its surface was ulcerated ; and in four of the cases the palate and tonsils were inflamed and coated with false membrane. In all these five oases, pneumonia existed in both lungs, and four times it was found to have reached in some parts the stage of purulent infiltration. These results, which differ in so many respects from the conclusions of many most excellent observers in this country, approach much more nearly to those obtained in the Hopital des Enfans Malades at Paris. The district in which my observations were made is low, with defective sewerage, open drains running close to many of the houses; and most of the patients were the children of poor parents, who occupied only one room, and who consequently were placed in most unfavorable hygienic conditions. I may further add, that with the change of my field for observation since the open- ing of the Children's Hospital in 1852 a more sthenic form of the disease came under my notice; and in some of the fatal cases which occurred in that institution under my care, a complete false membrane not only lined the trachea, but extended even into the tertiary bronchi. This state of things continued for some five years, and then once more the disease assumed an asthenic character as it increased in frequeucy; and became associated with diphtheria, in which latter disease it has almost com- pletely merged. The following abstract from the tables of the Children's Hospital is not without interest as illustrative of these changes in the epidemic constitution of the time since it was opened. I need not say that it is not to be taken as illustrative of any other fact. Total Admissions ate. of In-Patients. Cases of Croup. Cases of Diphtheria. $52 143 0 0 3 187 4 0 4 251 2 0 5 263 8 0 ? 309 15 0 325 11 5 8 380 4 6 9 411 4 5 60 384 0 3 1 577 10 15 2 543 7 17 3 571 2 23 Total 4344 67 74 310 DIFFERENCES OF CROUP AND DIPHTHERIA. results of your own observation hereafter, do not too hastily assume either that your teacher has been mistaken, or that your own obser- vation has been incorrect. The difference may be nothing more than a fresh exemplification of the old story of the shield, silver on the one side and golden on the other, about which the knights in the fable quarrelled. There are, indeed, two diseases which have often been included under the common name of croup, though the points of difference between them are at least as numerous and as important as are those in which they resemble each other. Of these two diseases, the one is almost always idiopathic, the other is often secondary; the one attacks persons in perfect health, is sthenic in its character, acute in its course, and usually proves amenable to antiphlogistic treatment; the other attacks by preference those who are out of health or who are sur- rounded by unfavorable hygienic conditions, and is remarkable for the asthenic character of the symptoms which attend it. The one selects its victims almost exclusively from among children, is inca- pable of being diffused by contagion, is governed in its prevalence by the influence of season, temperature, and climate, but rarely becomes, in the usual acceptation of the term, an epidemic; while the other attacks adults as well as children, is propagated by contagion, and though it occasionally occurs in a sporadic form, is susceptible of wide- spread epidemic prevalence. The one is developed out of catarrh, and the amount of disease of the respiratory organs is the exact measure of the danger which attends it; while the other affects the organs of respiration secondarily, its peril is often altogether out of proportion to the degree in which they are involved, and death itself may take place although they are altogether unaffected. In this latter ailment, too, a long train of sequelae not unfrequently remains after the local symptoms have been dissipated: the evidence of its affinity to the class of blood diseases rather than to that of simple inflammations. Cynanche Trachealis, Cynanche Laryngea, are the appellations of the former; Home1 and Cheyne,2 and Albers,3 its historians; Angina Maligna, the Garotillo, Morbus Strangulatorius, Diphtherite or Diphtheria, the synonyms of the latter; Severinus,4 Bard,5 Starr,6 Rumsey,7 Breton- neau,8 Trousseau,9 and Jenner,10 some of the writers who have most carefully described it. 1 An Inquiry into the Nature, Cause, and Cure of the Croup. 8vo. Edinburgh, 1765. 2 On the Pathology of the Larynx and Bronchi. 8vo. Edinburgh, 1809. 3 De Tracheitide Infantum. 4to. Lipsiae, 1816. 4 De psedanchone maligna, &c. in De recondita abscessuum natura, p. 513, 4to. Lugd. Bat., 1724. 5 An Inquiry into the Nature, &c, of the Angina Suffocativa, in Transactions of American Philosophical Society, 4to. vol. i., 2d ed. Philadelphia, 1789, p. 388. 6 An Account of the Morbus Strangulatorius, in Philosophical Transactions, vol. xliv., 4to. London, 1752, p. 435. 7 Transactions of a Society for the Improvement of Medical and Surgical Knowledge, vol. ii. 8 De la Diphtherite. 8vo. Paris, 1826. 9 Clinique Medicale, etc., vol. i. p. 312-450. 10 Diphtheria, its Symptoms and Treatment. 12mo. London, 1861. CAUSES OF CROUP. 311 Different, however, as the two diseases are, there are yet between them points of similarity no less striking— Facies non una, nee diversa tamen, and the diagnostic difficulties which are thus almost inevitable, are still further enhanced by the not unfrequent simultaneous prevalence of both affections. It will be my endeavor to describe, first, that disease which used at least to be the more frequent in this country, and then to give the best account in my power of that other malady, which is a yet more formidable visitant, and one less within the power of medicine to control. Croup, or Cynanche Laryngea, in the form whioh it usually assumes in this country,- is essentially a disease of early life; for it appears from the Fifth Report of the Registrar-Greneral, that while 1,022 out of 98,391 deaths in the metropolis and twenty-four town districts, took place from croup, 1,013, or 99.9 per cent, of those deaths occurred before the age of fifteen; and 879, or 87.9 per cent, before the age of five years. Of thirty-nine cases of croup occurring among the in-pa- tients of the Children's Hospital, thirty-two took place in children under five years of age, and only seven in children between the ages of five and ten. Twenty-four of the patients were males, fifteen females. It has been attempted to explain this great frequency of croup in early life by the imperfect development of the organ of the voice before puberty. This, however, cau scarcely be admitted as a valid expla- nation, since it does not at all account for the extreme rarity of the disease after five years of age. The preponderance of male over female children among those who are attacked by croup, is another fact which, though confirmed by the experience of all observers, has never received any adequate explanation.1 Croup appears to be influenced by peculiarities of climate and locality much more than most diseases of the respiratory organs. Though not entirely confined to northern climates, it prevails but seldom in the southern parts of Europe, and is even less frequent in the southern than in the northern counties of England. In Kent, Surrey, and 1 From the Fifth Report of the Registrar-General, it appears that, while the deaths of males under 15 from all causes, are to the deaths of females from all causes as 11 to 10, the deaths from croup are as 15 to 10. Of 249 cases that came under Golis' observation at Vienna, 144 occurred in males, 105 in females; at Geneva, under Jurine's observation, 54 males and 37 females died of croup, between the years 1791 and 1808 ; and the relation of the sexes at Berlin among the deaths from croup between 1838 and 1849, was, as nearly as possible, as 5 to 4; the actual numbers being 545 male to 459 female children. See Honerkopff iiber die Anwendung des schwefelsauren Kupferoxyd's gegen Croup. 8vo. Leipzig, 1852. It may be noticed as a point of difference between croup and diphtheria that no such special liability of the male subject to its attacks is observed in the case of the latter disease. The proportion, indeed, would seem from the 24th Report of the Registrar- General to be almost reversed, since while 2,321 male deaths, and only 2,076 deaths of females, took place from croup in 1861 throughout England ; 2,453 female deaths, and only 2,0i>4 male deaths occurred from diphtheria. M. Roger, in his valuable essay on diphtheritic paralysis, notices the same fact, of the equal liability of both sexes to diphtheria, or that if any difference exists between the liability of the two sexes to diphtheria, it is the female sex which suffers the most; in the proportion of about 5 to 4. See p. 462 of vol. i. of the Archives de Medecine for 1862. 312 MORBID APPEARANCES IN CROUP. Sussex, the deaths from croup are to the deaths from all causes in the proportion of .9 per cent.; while in the four northern counties, Durham, Northumberland, Cumberland, and Westmoreland, which contain an equal population, the deaths from this cause are in the proportion of 1.6 per cent. It is endemic in particular localities; and residence near the sea, proximity to the mouths of large rivers, a moist soil and a damp atmosphere, have been enumerated as greatly predisposing to the disease. The influence of these local peculiarities has probably, in some instances, been overrated; but still it cannot be denied, for a most striking illustration of it is afforded by the comparative rarity of croup in towns, and its frequency in rural districts. In the county of Surrey, exclusive of the metropolitan districts, the mortality, from all causes, under five years of age, is little more than a third of the mor- tality in Liverpool, and little more than half the mortality in London. But the total mortality under five years of age, from croup in the county of Surrey is to that in Liverpool nearly as 3 to 2, and to that in London as 2 to 1; so that out of 100 children dying under five years of age from all causes, more than four times as many will have died from croup in Surrey as in Liverpool, and exactly four times as many as in London. Variations in the condition of the atmosphere, and peculiarities of situation, not only influence the frequency of the occurrence of croup, but they likewise greatly modify its character, and determine to a considerable extent the nature of the lesions which it produces. The chief morbid appearances, however, are always discovered in the larynx, trachea, and air-tubes. They consist of redness of the mucous mem- brane, which is oftened thickened, sometimes abraded or ulcerated, and very generally covered with a more or less abundant exudation of false membrane. This exudation, however, though so generally met with as to have suggested to medical writers the terms angina polyposa, angina membranacea, as appropriate designations of croup, is neither invariable in its occurrence, nor of a uniform extent in all cases. It is found in the larynx oftener than in the trachea, and in both more frequently than in the bronchi. Nevertheless, in many instances, the secretion of false membrane is so extensive as not only to line the larynx and trachea, but even to reach into the minuter air- tubes, forming a complete cast of many of their ramifications. There appears to be some connection between the circumstances in which children become attacked by croup, and the extent of false membrane in the air-passages, which a post-mortem examination reveals. In rural districts, where the disease wears throughout a sthenic character, false membrane is deposited in greater abundance, and over a greater extent of surface than is usually observed in the case of the poor in this metropolis: while on the other hand, we find in London a con- dition of unhealthy ulceration about the larynx; ulceration, and the deposit of false membrane about the tonsils and palate in many in- stances, appearances which are seldom met with in children placed in circumstances more favorable to health.1 1 It is open to question how far one is justified in classing such cases with true croup; whether they do not approach more nearly to diphtheria, or whether at least they do not form a sort of connecting link between the two diseases. MORBID APPEARANCES IN CROUP. 313 In cases of croup that have come under my own observation, the formation of false membrane in the larynx has seemed almost inva- riably to precede its deposit in the trachea; and not unfrequently it has been found constituting a tough, continuous membrane in the former situation, but growing less tenacious in the upper part of the trachea, and passing gradually into a thick, puriform mucus, inter- spersed with shreds of lymph. I have usually observed the false membrane lining the whole of the larynx, and reaching down to the lower edge of the thyroid cartilage, while the trachea contained nothing else than a puriform matter, or glairy mucus, sometimes of a reddish color. In some instances the false membrane has been confined to the upper part of the larynx, lining the lower surface of the epiglottis, blocking up the opening of the sacculus laryngis, and covering the chordse vocales, but not extending any further. When first secreted, the false membrane is firmly adherent to the mucous lining of the air-passages, but after a time a secretion of a puriform character is generally poured out, which detaches the membrane from its connec- tions ; and it is after this occurrence has taken place that tubular pieces of false membrane have sometimes been expectorated. This detachment of the false membrane from the subjacent surface takes place more frequently and more completely from the interior of the trachea than from that of the larynx. On removing the false mem- brane from the trachea, the lining of the tube is seldom found to pre- sent any change other than an increase of its vascularity, which, though sometimes very considerable, does not bear any certain rela- tion to the amount of false membrane present. The greater difficulty in removing the false membrane from the larynx depends upon the more extensive alterations which the lining of that part of the air- tubes is usually found to have undergone. It is generally red and swollen, especially about the edges of the rima glottidis and the ary- tenoid cartilages, and the opening of the sacculus laryngis. Small aphthous ulcerations are also frequent in the two former situations; and occasionally, the ulceration being more extensive, the whole of the larynx, on detaching the false membrane that lined it, presents a worm-eaten appearance. It seldom happens that the bronchi are perfectly free from disease; but even though the trachea contain no false membrane, and present but few signs of inflammation, they are almost always much congested, and contain a muco purulent or purulent secretion ; though false mem- brane is seldom found in them, except when it is continuous with a similar adventitious structure in the trachea. Pneumonia, in all its stages, is far from being unusual, and is a com- plication especially to be feared in those cases where croup occurs as a secondary aff'ection in the course of measles. The cavity of the mouth, and the fauces, do not present any inva- riable alteration in cases of croup. Congestion about the fauces and soft palate is of frequent occurrence, sometimes coupled with a scanty deposit of false membrane in those situations, or the tonsils are found in a state of ulceration. In that form of croup which succeeds to measles, there is moreover in many instances a condition of unhealthy 314 SYMPTOMS OF CROUP. inflammation, and aphthous ulceration of the mouth and gums; a slight speck of ash-colored false membrane covering each little ulcer. In many of these cases I apprehend that the laryngeal affection does not come on in consequence of extension to the air-passages of disease beginning in the mouth, but that the disease is the same in both situa- tions; though the accident of the locality renders that a serious dis- order, when seated in the larynx, which is but a trivial ailment when affecting the mouth. Cases of this last kind have been called cases of ulcerative laryngitis: they have always come under my notice asso- ciated with the exudation of false membrane, and between them and croup I can discover no essential difference. Whatever be the circumstances in which croup comes on, the symp- toms resulting from disease obstructing the channel of the larynx and trachea by false membrane, or inducing a spasmodic closure of their aperture, must always be to a great extent the same. Its mode of outset, however, is very variable. Sometimes, especially in those forms of croup that prevail among healthy children living in the country, the disease is announced by few, if any, premonitory symp- toms: but the affection of the larynx is apparent from the very outset, and attains in the course of a few hours to a high degree of intensity. Some years since I saw a little boy, about seven years old, living at some distance from London. He had overheated himself at play during the afternoon of a hot day in August, but went to bed appa- rently well at eight o'clock, and soon fell asleep. At ten, he began to breathe with the peculiar noise characteristic of croup, and presented all the symptoms of the disease before midnight. In his treatise on croup, Professor Golis, of Vienna,' relates the case of a little boy four years old, previously in perfect health, who having gone out of an overheated room into the open air, during an extremely cold winter's day, was seized while walking with all the symptoms of most violent croup, which proved fatal in fourteen hours. This sudden onset and rapid course of the disease, however, are of rare occurrence, and croup generally comes on gradually, attended in its first stage by but few symptoms that could distinguish it from ordi- nary catarrh. Slight fever, drowsiness, suffusion of the eyes, and defluxion from the nares, attend it. The respiration is not perceptibly disturbed, and the cough, though frequent, presents no peculiar char- acter. There is, beside, occasional complaint of slight sore-throat, or of uneasy sensation about the larynx, but so slight as scarcely to attract attention, and not sufficient to cause any alarm. The duration of this stage is very variable: nor is there any regu- larity in the mode of its transition into the second stage. In the majority of cases, indeed, the transition takes place gradually; but thirty-six hours seldom pass without the supervention of some symptom which, to the well-schooled observer, would betray the nature of the coming danger. Most symptoms may continue unchanged, perhaps scarcely aggravated, but a slight modification takes place in the character of 1 De rite oognoscenda et sananda Angina Meinbranacea, 8vo. Viennse. Observ. iv. p. 141. SYMPTOMS OF CROUP. 315 the cough, which now becomes attended with a peculiar ringing sound, difficult to describe, but when once heard not easily for- gotten. This peculiarity in the cough very often precedes any change in the respiration, and may sometimes be so slight as scarcely to attract the parent's notice at the time, and to be remembered only when the full development of the disease leads to inquiries as to how the attack came on. Soon after this modification of the cough has become per- ceptible, or even simultaneously with it, the respiration undergoes a change no less remarkable. The act of inspiration becomes prolonged, and attended with a stridor as difficult to describe, but as characteristic of the disease, as the tone of the cough. It oftens happens that these two pathognomonic symptoms first come on, or at least first excite attention, in the night, and that a child who at bedtime was supposed to ail nothing, or at most to have a slight cold, awakes suddenly with ringing cough and stridulous breathing, frequently in a state of alarm and with marked dyspnoea. Through the whole course of the disease, indeed, an obvious tendency exists to nocturnal exacerbations, and to remissions as the morning approaches. In whatever manner these symptoms may have come on, they will not continue for many hours without being attended by increase of fever, by acceleration, and soon by difficulty of respiration. The skin becomes hot and dry, the face flushed, the breathing hurried, the cough frequent, the pulse full and quick, the child dull, fretful, and passionate. For a few minutes, indeed, it may appear cheerful, may turn to its playthings, and breathe more naturally, though the peculiar respiratory sound never ceases altogether. Soon, however, the dyspnoea returns with increased intensity: the whole chest heaves with the inspiratory effort, which is more prolonged aud attended with great stridor. During it, perspi- ration breaks out at every pore, and the veins of the neck and face become greatly distended. Short and forcible expiration follows, and after this state of dyspnoea has lasted for some minutes, an interval of comparative ease succeeds. The child now often falls asleep exhausted; but during sleep, the sound attending respiration is heard in an exaggerated degree. Though the drowsiness is great, sleep is uneasy, and frequently interrupted by violent startings, in spite of which the child may still sleep on. After some minutes he awakes in a state of terror, to pass through another paroxysm similar to the preceding one, though more severe. The cough does not increase in severity in proportion as the disease advances; it is unattended by expectoration, or at most a little mucus is spit up, but without any relief. Although the paroxysms of dyspnoea are not dependent on the cough, they are sometimes provoked by it, and the two or three inspirations next following an effort of coughing are often attended with increased stridor. From the first appearance of the more marked symptoms, the voice is hoarse, cracked, and. whispering, or in young children is either totally suppressed, or, if their voice be not actually extinct, at least their disinclination to speak is so great, that they will reply to questions only by signs, and cannot be induced by any persuasion to utter a word. There is almost always much eagerness for drink, and deglutition 316 SYMPTOMS OF CROUP. is generally well performed. The fauces are often red, though their redness bears no direct proportion to the intensity of the croupal symptoms; and there is frequently considerable tenderness of the larynx. The tongue is red at the tip and edges, but coated in the centre and at the back with thick white fur; the bowels are rather constipated, and the appetite for food is entirely lost. As the disease advances, the paroxysms become less marked, or rather, the intermissions grow less distinct, and the child is constantly engaged with the effort to respire. The cough now sometimes ceases altogether, and the breathing frequently becomes sibilant rather than stridulous. The child throws its head back as far as possible, in order to increase the capacity of the trachea; the chest is heaved violently at each effort to inspire, during which its lateral region becomes flattened, and all the soft parts of its parietes recede, indicat- ing the inadequacy of the attempt to fill them; and the larynx is de- pressed forcibly towards the sternum, while the abdominal muscles co-operate energetically in expiration. The face is heavy and anxious, the eyes are dull, the lips livid, the skin dry, and the extremities cold; or clammy sweats bedew the surface. The respiration is hurried, un- equal and irregular, and the pulse is very frequent and very feeble. Though no remissions now occur, there are frequent exacerbations, in which the child throws itself about, and puts its hand to its throat, as though to tear away some obstacle to the admission of air, while help- less, hopeless agony, is depicted on its countenance. In the midst of these sufferings the patient dies, or coma or convulsions come on, and close the scene. It is not always, however, that the last stage of croup is attended by such distressing symptoms. The treatment employed may seem to have mitigated the severity of the disease; the restlessness may give place to ease, the burning skin may grow moist, the respiration may become tranquil, the cough loose with but little clangor; expectoration may be easy, and a wheezing, attended with a very slight croupy sound, may be the only indication of the dangerous disease under which the patient is suffering. This apparent amendment may con- tinue for a few hours, and then be succeeded, without any assignable cause, by the return of all the former symptoms, and soon be followed by death; or the mitigation of the disease may be accompanied with great drowsiness, which, however, does not excite alarm, since it is very naturally attributed to the exhaustion, produced partly by the disease, partly by the remedies. During sleep, the respiration is deep and tranquil, like that of a persou in a sound slumber; it is, indeed, attended by a kind of wheeze, but presents little of the croupy stridor; and when awake the child is quite sensible, and even cheerful. After a time, however, it becomes difficult thoroughly to rouse him; his pulse grows more rapid, the moisture on his skin changes almost imperceptibly to a cold clammy sweat, and convulsive twitchings of the angles of the mouth occasionally disturb the repose of his features. Silently, but surely, the exudation has been making progress, and when the alarm is taken, it is too late; the stupor deepens, and the child dies comatose, or rouses only to spend its last hours in the AUSCULTATION IN CROUP—ITS DURATION. 317 vain struggle for breath, and embittered by all the painful circum- stances which ordinarily attend the suffocative stage of croup. Auscultation yields us information in cases of croup with reference to two important points: namely, the amount of obstruction to the entrance of air into the lungs, and the extent of disease of the air-tubes or substance of the lungs which accompanies it. At first, air is heard entering the chest freely, and unattended by any morbid sound other than that stridor which is produced in the larynx. If the lungs should continue unaffected, no other morbid sound will be heard; but, as the disease advances, the same negative results will be obtained from auscultation as are yielded by it in cases of emphysema—a feeble res- piratory murmur belying the loud resonance on percussion. Often, however, respiration is attended from the commencement with the sonorous rhonchus of the first stage of bronchitis, though masked to some extent by the croupy noise in the trachea. Even in cases where the disease is originally confined to the larynx or trachea, inflammation almost always extends to the bronchi; often, also, to the substance of the lungs, so that mucous or sub-crepitant rale generally becomes perceptible during its course, often attended by impaired resonance on percussion over the lower part of the chest. Air, however, may enter so imperfectly as not to fill the smaller bronchi; and these sounds may be quite unperceived, unless the auscultator listen at the moment when the child makes an unusually deep inspiration, such as often follows a fit of coughing. The pneumonia, too, in all cases that I have observed was double, and the resonance consequently nearly equally diminished on both sides of the chest. Hence the importance of comparing the sound elicited by percussion of the upper with that given out by the lower part of the chest—a point to which you will remember that your attention has already been called on several oc- casions. The changes in the tracheal sound which attend the progress of the disease may be traced with great distinctness by applying a stetho- scope to the larynx. Some writers have thought that they recognized in its variations the indications of the formation of false membrane, and that these changes also afford a means whereby to judge of its extent. I believe that usually when false membrane has been exten- sively formed in the larynx, the tracheal sound becomes less stridulous and more sibilant; but I noticed on one occasion those alterations in the tracheal sound which are supposed to indicate the presence of a very extensive deposit of false membrane, although no false membrane was either expectorated during the patient's lifetime, or discovered in the inflamed larynx and trachea after her death. We must conclude, therefore, that the changes in the tracheal sound do not afford abso- lutely certain evidence of the existence of false membrane, and that still less can they be regarded as safe criterions of its extent. It is difficult to state with precision the duration of a disease such as croup, since its premonitory symptoms vary greatly, and its fatal termination is often in great measure due to the concomitant or consecutive bronchitis or pneumonia. When the laryngeal affection goes on to destroy life, it is seldom that more than forty-eight, 318 PROGNOSIS—DANGER OF RELAPSE IN CROUP. or at the most seventy-two hours elapse from the full development of the croupal symptoms to the fatal event; and, allowing the ordinary duration of the premonitory stage to be about thirty-six hours, the disease will be found to run its course in from four to six days. Twice I knew death take place within thirty six hours from the occurrence of the first croupal symptoms; and on a third occasion within thirty-seven hours; but these are instances of unusu- ally rapid termination of the disease. Treatment sometimes partially subdues it: but it returns, and the relapse, in the course of a few hours, proves fatal. Now and then the acute symptoms subside, and the disease assumes a chronic character; but this has but very rarely come under my notice in idiopathic croup, though it is more common in that form of the disease which we shall have hereafter to notice as constituting a serious complication of measles. The prognosis of croup must always be guarded, and is generally unfavorable, since the disease is unquestionably one of the most dangerous to which childhood is liable. Much depends upon the patient being seen at an early stage of the disease; and the prospect of recovery is generally very small if no treatment should have been adopted until after the full development of the symptoms. The presence of bronchitis, and, still more of pneumonia, adds greatly to the dangers of the affection, and would induce us to form a very unfavorable opinion of the chances of recovery. A second attack of the croup is generally less serious than the first; and cases in which catarrhal symptoms have preceded the seizure for several days are more amenable to treatment than those in which the premonitory stage has been short, or altogether absent. Diminution of the dyspnoea in the intervals of the cough—a louder and looser cough, attended with expectoration or vomiting of muco-purulent matter, intermingled with shreds of false membrane—a less suppressed voice, less anxiety, and less restlessness—all indicate that the disease is abating. Much caution, however, must be exercised in drawing a favorable conclusion from a diminution of the severity of the symp- toms, until such improvement has continued for twenty-four hours at least. In all but the most acute cases of croup the remittent character of the disease is very apparent; and it is well to bear in mind that the fatal termination usually takes place with extreme rapidity, when an exacerbation of the symptoms follows soon after a manifest remission of their intensity.1 It can scarcely be necessary to remind you that extinction of the voice, suppression of the cough, the change from stridulous to sibilant breathing, and increased difficulty of respiration, all show death to be surely and speedily approaching. The danger of being lulled into security by the apparent improve- ment of a child who has been attacked by crourj, is so serious, that before proceeding to consider the treatment of the disease I will relate to you a case by way of caution. On the 25th of June, a little girl, four years old, became hoarse and lost her appetite, though she did 1 " Mox post symptomatum remissionem recidivantes, brevi ac certa morte demun- tur."—Golis, lib. cit., p. 164. TREATMENT OF CROUP. 319 not appear otherwise ill. On the 27th, she seemed less well, and in the night was very restless, and had difficulty of breathing. On the 28th respiration was more difficult, and though she had but little cough, she seemed sometimes in danger of choking. In the night a croupy sound accompanied her breathing, and violent attacks of dyspnoea were of frequent occurrence. On the 29th she was taken to a surgeon, who gave her some medi- cine, after each dose of which she was sick, and this sickness was followed by much relief, and by an almost complete cessation of the croupy sound. This improvement was thought to have continued during the 30th ; the child slept quietly during the night, and was considered so much better by her parents that she was brought by them to the Children's Hospital at 9 A.M. on July 1st. As she lay in the lap in a sitting posture, her countenance was pale and livid, her respiration was sibilant, her surface cool, her pulse very frequent and feeble, but there did not appear to be any of the distress usual in the advanced stages of croup. At 6 A.M. she was admitted: at 6 P.M. she died; though no great distress or violent struggle for breath preceded her death. The extensive deposit of false membrane in the trachea and bronchi showed that, in spite of her apparent amendment for a season, disease must all the time have been advancing, unsuspected by her friends, overlooked even by her medical attendant. In no disease is the prompt employment of appropriate treatment more important than in croup, since in none does the use of remedies sooner become unavailing. Even in cases where the attack is merely apprehended, but where catarrh exists, attended with a slight ringing cough, such as often indicates the commencement of croup, the patient should be watched most sedulously, and visited not merely by day- time, but also late in the evening; and attention should be particu- larly directed to the character of the respiration during sleep as well as in the waking state. The child should at once be placed in a warm bath, be confined to bed, be placed on a spare diet, and should take an emetic of ipecacuanha and antimony, to be followed by some mild saline medicine, containing slightly nauseating doses of antimonial wine.1 At the same time the air which the child breathes should be both warm and moist, the temperature of the room being steadily kept up at 65°, while the moisture of the air is easily maintained, by a ket- tle boiling on the fire, with a long roll of paper, or, still better, a tin tube attached to its spout, which serves to direct the steam into the apartment. These simple precautions, useful in diminishing the irri- tability of the air-tubes when croup is merely threatened, are, I need scarcely say, of still greater moment when the disease is fully devel- « No. 14. R.—Potassse Bicarbonatis, gr. xl. Acidi Citrici, gr. xx. Vin. Ant. Pot.-Tart. giss. Vin. Ipecac, tt^xx. Syr. Limonum, giiss. Aquae, giiss. M. ft. Mist. A dessert-spoonful every 3 or 4 hours. For a child two years old. 320 TREATMENT OF CROUP — DEPLETION. oped.1 By these measures, which should be observed with especial care if the premonitory symptoms of croup appear in a child who has previously suffered from the disease, or in whose family a liability to it exists, you may often succeed in warding off' the attack. A far more energetic plan must be resorted to if the disease set in with violence, or if, the indications of its approach having been either overlooked or unchecked, the symptoms should have attained their full development before the patient came under your notice. The abstraction of blood, and the administration of tartar emetic, are the two measures on which your main reliance must be placed; and you must bleed largely, and give tartar emetic freely, remembering that if relief do not come soon it will not come at all—that there is not dan- ger only, but death, in delay. I have never met with an exception to the rule which prescribes the free abstraction of blood in every case of severe idiopathic croup, when seen at an early period, and before the purple lips and livid countenance, and failing pulse, announce the long-continuance of a serious obstacle to the free admis- sion of air into the lungs. Even in very young children local deple- tion forms in these cases but a poor substitute for general bleeding, for it is not merely the abstraction of a certain quantity of blood that is needed, but its removal in such a manner as most speedily to pro- duce an effect on the system. Bleeding from the jugular vein is pre- ferable in these circumstances to venesection in the arm, since the latter often fails in children under three years old; and the blood never flows so freely as when taken from the jugular vein. It is not easy to state in figures the exact quantity to be abstracted, since the child's previous health, the intensity of the symptoms, and the effect produced by the flow of the blood, must all be taken into account in determining when to stop. Dr. Cheyne says, "The removal of three ounces of blood from a child between one and two years of age, or of six ounces from a child from eight till ten, generally appears to make a sufficient im- pression on the disease;" and this is a sufficiently near approach to a correct estimate of what is usually needed. The effect of free vene- section is often very striking, and as the blood flows, the respiration may be seen to become notably easier. But though the relief thus afforded is very great, it proves but temporary; and unless followed by other remedies, the symptoms will often regain their former inten- sity in the course of four or six hours. I have not seen any instance in which the repetition of general bleeding appeared indicated, but many of you will probably meet with such cases in the country. Local depletion I have occasionally employed with advantage a few hours after the general bleeding; but if you follow up the first loss of blood by the free employment of tartar emetic, you will often be spared the necessity for further depletion. It has been recommended that leeches should be applied to the top of the sternum rather than to 1 At the Children's Hospital, so much importance is attached to the maintenance of a warm and moist atmosphere around the croup patient, that we are accustomed to inclose the bed with woollen curtains, and to introduce within them the rose of an apparatus constructed like that sometimes employed as a vapor bath, by which means uniformity of temperature and moisture can be maintained for days together. EMPLOYMENT OF ANTIMONY. 321 the windpipe, since difficulty may be experienced in arresting their bleeding if applied in the latter situation, as children are very intole- rant of pressure in that neighborhood. The caution is worth bearing in mind; but if you superintend the application of the leeches your- selves, which in such a case you certainly ought to do, the advantage of drawing the blood as nearly as possible from the affected part will more than make up for the risk of some slight difficulty in stopping its flow. To accomplish any real good by means of the tartar emetic it must be given in doses of an eighth, a quarter, or half a grain every ten minutes until vomiting is produced; and the same doses should after- wards be continued every half hour, until decided and permanent relief has been afforded. The dose that at first caused vomiting may, after it has been repeated a few times,«ease to excite it, in which case we must increase it, and not rest satisfied with tolerance of the medi- cine having been established, since its utility appears to be closely connected with its emetic power. Nauseating doses of antimony have not seemed to me to check the disease so surely, while they cause a greater depression of the system, and thus mask the approach of the fatal event. A striking illustration of the superiority of emetic over nauseating doses of medicine is given by M. Valleix,1 who states that, in thirty-one out of fifty-three cases of true croup, ipecacuanha and antimony were employed in full doses as emetics, and of these thirty- one cases fifteen recovered; while of the twenty-two cases in which their use was but sparingly resorted to, only one recovered. If, after antimony has been thus administered for four or six hours, no satisfactory measure of improvement should have appeared, local depletion may be resorted to; or possibly a repetition of general bleeding may in some cases be ventured on. If the croupal symp- toms, on the other hand, should have begun to abate, the antimony may be given at longer intervals; but you cannot be too much on your guard against being misled by temporary improvement, and abandon- ing the medicine too soon. Its use likewise is not to be relinquished by gradually diminishing the dose and substituting a quantity suffi- cient only to induce nausea for that which caused vomiting, but a full dose should be given every hour or two hours, instead of every half hour, and if amendment continue, the interval may be prolonged to three, four, or six hours. It is now, after the severity of the disease has been subdued by antimony, that the time has come for the ad- ministration of calomel. From the very commencement of the attack, mercurial inunction may be had recourse to every two or three hours; or a flannel bandage, on which two drachms of mercurial ointment have been spread, may be swathed around the abdomen of the patient; but the action of mercurials is far too slow to overtake at its outset, a disease which tends so rapidly to a fatal issue. At this period, however, calomel seems to have a twofold utility; it counteracts the tendency to the formation of false membrane in the air-passages, and prevents or subdues that inflammation of the lungs which is so fre- 1 Bulletin General de Therapeutique, Oct. 1843, p. 246. 21 322 CROUP AND DIPHTHERIA quent and so fatal a complication of the disease, I usually employ it in doses of half a grain or a grain in children from two to five years old every hour or two hours, in combination with minute doses of ipecacuanha, but interrupting its use at intervals in order to give an antimonial emetic. The appearance of any exacerbation of the croupal symptoms, however, would lead me at once to discontinue the calomel, aud to return to the emetic employment of antimony. It is not unintentionally, nor from any oversight, that I have allowed my observations on the treatment of true croup to remain unaltered; expressing the opinions which I formed, and the practice which I adopted five-and-twenty years ago. Both indeed have been modified, just as the treatment of bronchitis and pneumonia has been modified, by the changes in the epidemic constitution of disease which recent years have brought with them, and which have been especially marked since the second epidemic prevalence of cholera in this country in 1848 and 1849. But with every allowance made for these changes, I still believe that a decided antiphlogistic treatment (by which I mean the employment of antimony in emetic doses, the subsequent administration of calomel, and if the case be seen at the very outset, the recourse to actual depletion), is indicated in almost all cases of acute idiopathic croup. I have full notes of eighty-two cases of croup or diphtheria, though very many more have come under my observation in consultation, when I have seen them one, two, or three times. The earliest date borne by these notes is July, 1840, and for the first ten subsequent years all cases, with the exception of those secondary to measles, were treated by me with uniform activity, in accordance with the prin- ciples laid down by Dr. Cheyne, and to which reference has already been made.1 About this time, however, I find from my notes evidence of a gra- dual falling off in the activity of my treatment, and this in spite of my field of observation having shifted to a district in which disease gene- rally, and croup among the rest, presented a more sthenic character than it wore in the low-lying district to the south of the Thames. I notice less frequent employment of depletion, and at the same time recourse to cauterization of the throat, a proceeding to which I was led in a measure by Dr. Horace Green's remarks on cauterization of the larynx in croup, and which therefore had by no means constant refer- ence to the presence of false membrane about the fauces. For some years past I have given up the charge of out-patients at the Children's Hospital, and almost all the cases of croup which I see in private I see in consultation, and consequently when some symptom of special gravity has already arisen. It may perhaps be due in part to these circumstances that I have met wifh no occasion for depletion during the past five years. I have, however, met with not a few instances of idiopathic laryngeal croup, which, in the hands of younger 1 The peculiarities of this form of secondary croup, and its relation to the then so- called diphtheritic, were noticed by me, and illustrated by cases in the Medical Gazette Aug. 25, 1843. NOT TO BE CONFOUNDED IN THEIR TREATMENT. 323 practitioners who thought of nothing but diphtheria, were being plied with stimulants and sesquichloride of iron, and were saved by anti- mony, by emetics, and the use of mercurials. In Germany, in spite of the prevalence of diphtheria there as well as here, the old form of inflammatory croup still prevails; and some of the older practitioners1 have raised their voice against the tendency to ignore its existence, to assume that diphtheria is the one only form of croup, that the observers of five-and-twenty or fifty years ago com- mitted a mistake in supposing that antiphlogistic treatment was ever called for, or that stimulants could possibly be out of place. My object is to warn against the same errors, to insist on the differ- ence in character between cynanche trachealis and diphtheria, and, as a consequence, on the necessary difference between their treatment. There is, however, one point which it is important to remember in the management of the severer cases of croup, lest you fall into the error of over-treating your patient; an error not less hazardous than the opposite one of too great inertness. The disease, as you know, has a marked tendency to exacerbations and remissions, even inde- pendently of any physical change in the condition of the respiratory organs. You must not, therefore, allow the return of more difficult breathing, after a period of comparative tranquillity, to lead you at once to the inference that the child is worse, and that necessity exists for renewed and increased activity of treatment. It is very possible that the increased dyspnoea may be merely spasmodic; that immersing the child in a hot bath will give immediate and most signal relief; and that if you auscultate the chest afterwards you will find the air enter- ing the lungs in as large a quantity as before, and unattended by any increase of morbid sounds. The administration of calomel is not necessary in every case of croup, for when seen early, and treated with due activity, its symp- toms are sometimes completely removed in the course of a few hours. But though we may sometimes be warranted in suspending all active treatment for a season, yet we must watch our patient with most un- tiring care for some days after the decline of the acute croupal symp- toms, and at each visit our attention must be directed to the condition of the lungs, in order that we may at once put a stop at its very com- mencement to that inflammation of the smaller bronchi and of the pulmonary substance which so often disappoints the fairest prospects of recovery. Its treatment does not differ from that of ordinary bronchitis or pneumonia, except that depletion is not generally indi- cated, and that it not unfrequently becomes necessary to support the patient's strength, even from a very early period. Your own good sense will suggest to you the care and watching which are required during convalescence from croup; the necessity of withdrawing your remedies cautiously, and of awaiting the complete disappearance of all hoarseness, and the cessation of all cough, before you allow the child to breathe the external air. In cases where the 1 Among them is especially deserving of notice a short paper by Dr. Clemens, of Frankfort, in "J. f. Kinderkrankh." vol. xxxvi., June, 1861, p. 359. 324 TREATMENT OF SECOND STAGE OF CROUP. peculiar croupal sound continues with slight cough, long after every other sign of mischief about the larynx has subsided, you will often find it of service to paint the neighborhood of the windpipe every day with the tincture of iodine; a mild, but in the circumstances a very efficacious form of counter-irritation. It still remains for us to inquire into the treatment of cases in which we have not the good fortune to encounter the disease at its outset, but in which we have to combat it when it has already reached the second stage. This subject, however, must be reserved for our next lecture. LECTURE XXIV. Croup continued—Treatment of the more advanced stages of the disease—Tracheotomy—the difference between the result obtained by it in England and in France, and its probable cause—objections to its performance—reasons for not regarding them as conclusive— Inquiry into the object of the operation—indications for its performance—its dangers— and how they are to be obviated. In the last lecture we were occupied with the consideration of the management of those cases of croup in which the patient is seen early, and in which his condition warrants the employment of powerful anti- phlogistic measures. He may, however, be seen too late for such means to be allowable, or they may have been tried in vain. If anti- mony cease to vomit, or if it be rejected immediately, and without effort, the fluid thrown up being unmixed with phlegm or false mem- brane, while the temperature sinks, the lips grow more livid, the pulse becomes more frequent and feeble, .and the paroxysms of dyspnoea are undiminished in severity; or if the respiration though less laborious, be attended with a sibilant instead of a stridulous sound, it is evident that by continuing the medicine we may destroy the patient, but shall fail to cure the disease. A totally different plan of treatment must at once be adopted, though with but slender hope of success. An attempt should be made to arouse the child from the state of collapse into which it is sinking, by placing it for a few minutes in a hot mustard bath, and emetics of the sulphate of copper should at once be administered. The sulphate of copper has been considered by some writers to be possessed of a specific inflence over croup. I cannot, however, take this view of its action. It has seemed to me to be nothing more than an emetic of great power, and therefore espe- cially applicable in cases where considerable depression exists, where the stomach has consequently lost much of its irritability, and where tartar emetic would probably not act at all, or if it did, would be injurious from its depressing action. Alum has been recommended in similar circumstances, aud I dare say would answer equally well, though perhaps there is some advantage in the smaller bulk of sulphate TREATMENT OF SECOND STAGE OF CROUP. 325 of copper.1 I am accustomed to give it dissolved in water in quarter or half-grain doses every quarter of an hour till free vomiting has been produced, but have never trusted to it alone, in the same way as in an earlier stage of the disease I am used to rely on tartar emetic. I employ it with a twofold purpose: first, to obtain the stimulant action of an emetic; second, to prevent, if possible, the accumulation of false membrane in the larynx. Hence, if the child seem again sinking into a state of collapse, or if coma appear coming on, or if the dyspnoea become much aggravated, the sulphate of copper may again be employed to induce vomiting. If, however, in these cases, or in others in which, though some degree of improvement has followed the previous treatment, yet the child has been much reduced by it, emetics should not act, I would advise you to attempt to compel vomiting by irritating the fauces, or by other similar proceedings. On one occasion I saw these endeavors succeeded, not by the vomiting, which they were intended to excite, but by general convulsions, fol- lowed by a comatose condition, in which death took place an hour and a half afterwards. Examination of the body discovered some congestion of the brain, but showed at the same time that the affection of the air-passages had not reached such a degree as to have precluded the possibility of recovery, and that the patient's death had been caused by the disease, but rather by the ill-judged employment of the remedy. In this stage of croup the decoction of senega is a medicine of great value, and may be given in combination with the carbonate of ammo- nia and tincture of squills every two hours.2 The pungency of the ammonia is best concealed by sweetening the medicine with treacle or with coarse sugar, and mixing it with about a third of milk; and in this form children will seldom refuse it. No other remedy or com- bination of remedies has appeared to me to be so useful as a stimulant expectorant in the advauced stages of croup or bronchitis. The pa- tient's strength must be supported by beef-tea, and a generally nutri- tious diet; and even wine may be indicated; though small, indeed, are the hopes that remain when the vital powers have sunk so low as to require its employment. While by these means you try to keep your patient alive, there is still one remedy that you may use, and use actively, though I fear it must be admitted with no great prospect of success. You employ mercury, or you increase the dose in which you have previously prescribed it. A grain of calomel may be given every hour to a child from two to three years old, unless the existence of profuse diarrhoea should contraindicate its use; while, at the same time, a drachm of strong mercurial ointment may be rubbed into the thighs every two hours. If diarrhoea be present, the calomel must be given more sparingly, or must even be altogether omitted. Much difference of opinion prevails among writers of high repute 1 Alum has been used and strenuously recommended in these circumstances by Dr. Meigs, of Philadelphia; and the experience of his son, Dr. J. Meigs, as recorded in his work on Diseases of Children, seems fully to bear out his father's recom- mendation. He gives a teaspoonful in honey or syrup, every 10 or 15 minutes, till free vomiting is produced. * See Formula, No. 12, p. 271. 326 RESULTS OF TRACHEOTOMY IN CROUP. as to the proper time for employing counter-irritation in cases of croup, and still more as to the part to which this counter-irritation should be applied. I believe that when the disease has been checked by anti- phlogistic measures, and the symptoms have lost something of their severity, much good is done by the application of blisters to the upper part of the sternum. But, on the other hand, if croup have reached an advanced stage, unchecked by previous remedies, blisters to the sternum have seemed to me nearly, if not altogether useless; while, from the application of a large blister to the throat, covering the larynx and reaching down nearly to the sternum, I have often ob- served the paroxysms of dyspnoea to be much alleviated, the respira- tion to be rendered far more easy, and expectoration for the first time to accompany the cough. In any case, if very manifest relief were not observed within six hours after the abstraction of blood and the administration of autimony, while further depletion did not appear justifiable, I should apply a blister to the throat.1 It was to be expected that the probable utility of bronchotomy in cases of croup should suggest itself to the earliest observers of the disease. For many years, however, after it was first advocated on theoretical grounds by Dr. Home, the value of the operation was not put to the test; and even for a long time after it had been tried, but one instance was recorded of any other than an unsuccessful result.2 In the year 1825, M. Bretonneau, of Tours, saved the life of a little girl when in the last stage of croup by performing tracheotomy. Eight years afterwards a second operation was performed and a second success obtained by M. Trousseau, and in the subsequent five-and- twenty years the operation was had recourse to in France nearly 500 times, and about a fourth of the patients on whom it was performed recovered.3 This proportion, too, may be taken as representing very nearly the present rate of recoveries after the operation of tracheotomy in early life, when had recourse to either for croup or diphtheria. The results of the operation in this country are, however, far less favorable than those which have been obtained in France, and many attempts, though none to the best of my judgment altogether satisfac- tory, have been made to account for" this difference. I once thought that the difference between the characters of the disease in the two countries might account for the different results of tracheotomy; that 1 This opinion being opposed to that of men such as Dr. Stokes and Mr. Porter, I feel it necessary to appeal in support of it to the authority of Golis, lib. cit., p. 118, and Albers, De Tracheitide Infantum, p. 127 ; and not to rest it solely on the results of my own experience. 1 In this case the operation was performed in the year 1782 by M. AndrS, of London, on a little girl five years old. The particulars are related in a dissertation published at Leyden in 1786, by Mr. T. White, whence they are extracted by Dr. Farre, and appended as a note to a paper of his on Croup, at page 348 of vol. iii. of the Medico- Chirurgical Transactions. 3 The most recent statements with which I am acquainted of the results of tracheo- tomy in France, are those of MM. H. Roger and See, which yield 126 recoveries to 440 operations, or 27 per cent, during the last seven years. Gaz. Hebdom., Nov. 12, 1858, p. 789. The somewhat more recent estimate given by M. Roger, in his paper on Diph- theria already referred to, does but confirm on the whole the accuracy of his previous conclusions. M. Trousseau, in his Clinique de l'Hdtel Dieu, vol. i. p. 414, which was published in 1861, states that down to that time he had performed tracheotomy more than 200 times, and more than a fourth of the cases had had a successful result. RESULTS OF TRACHEOTOMY IN CROUP. 327 the diphtheritic form of croup which prevailed in France might be more amenable to mechanical relief than the sthenic variety, associated with bronchitis or pneumonia almost from the outset, which was more frequent in this country. Recently, however, the character of the disease in the two countries has become more closely assimilated, without influencing the great preponderance of successes on the other side of the channel. My friend, Dr. Jenner,1 suggests that the greater frequency of rickets in this country, and the consequent greater flexi- bility of the chest-walls, as the result of which mechanical power is wanting to draw air beyond the fluid, which from any cause finds its way into the bronchial tubes, has much to do with the different results obtained in the two countries. Something, too, is unquestionably due to the earlier stage of the disease in which the operation is resorted to on the continent2 than in England, so that while in this country a successful tracheotomy represents a child snatched from inevitable death, in not a few of the instances of its performance in France other means might have been tried, and would probably have con- trolled the disease. Still, if these facts detract something from the apparent value of the operation, they at least show that in itself it is not attended by serious dangers; and statistics prove that, in as far at least as the diphtheritic form of croup is concerned,3 there is no sort of connection between an increase of frequency in the perform- ance of tracheotomy and a highter mortality from the disease. Fur- ther, it must be conceded that the, somewhat premature performance of tracheotomy is not without some compensating advantage, by the relief it affords to that spasmodic action of the muscles of the glottis which endangers the patient's life, independently of the extent of filse membrane in the glottis. My own personal experience of the results of tracheotomy is exceptionally unfavorable, inasmuch as I have to record but one recovery out of sixteen operations.4 In most 1 Op. cit., p. 80. s In illustration of this fact two cases may be noticed, recorded in the Journal de la Societe Medicale d'Indre et Loire, extracted and commented on in the Bull. Gen. de The>apeutique, Octobre, 1842. s Roger and Hee, loc. cit. 4 The following Table represents the results of the above mentioned 16 cases. A«e. Date from commence- Date of Interval be- Sex. yr. ni'i. Died. ment of Disease. Death. tween operation and Death. F. 1 2 Primary Croup Operated in 24 hours 36 hours 12 hours M. 2 3 Primary Croup " 26 " 41 " 15 " F 5 0 Primary Diphtheria " 60 " 78 " 18 " F. 5 5 Primary Croup " 3d day 19th day 16 days F. 7 2 Primary Croup " 5th " 8th " 73 hours F. 5 0 Primary Diphtheria 5th " 6th " 19 " F. 3 0 Primary Diphtheria " 5th " 6th " 14 " M. 9 0 Diphtheria after Scarlatina . 5th " 8th " 72 " F. 2 6 Primary Diphtheria 7th " 8th " 27 " M. 5 0 Primary Croup " 7th " 8th " 20 " F. 2 6 Croup, secondary to Measles " . 7th «' 8th " 31 " F. 9 11 Primary Diphtheria " 11th " 13th " 36 " M. 1 9 Croup secondary to Measles " 12th " 13th " 18 " M. 3 0 Primary Diphtheria " 13th " 15th " 44 " F. 3 0 Primary Diphtheria " 16th " 20th " 4 days F. 4 10 Primary Croup " 11th " Survived 328 ARGUMENTS AGAINST AND IN of these cases the disease had already reached an advanced stage when the patients came under my care, and the operation was resorted to as a doubtful remedy, holding out a chance of recovery when other- wise none appeared.1 In spite, however, of their unfavorable issue, I am so far from being opposed to tracheotomy, that the euthanasia which it secures, even when all hope of cure is gone, seems to me cheaply purchased by its per- formance. As a remedial measure, my chief anxiety is to make out the indications that may justify me in having more timely recourse to it in future. The discrepancies of opinion which have prevailed with reference to it are, I think, partly due to an overestimate, on the part both of its advocates and opponents, of the ends which it is proposed to attain by it. In itself, tracheotomy in croup is not a curative pro- ceeding, nor can its performance warrant the discontinuance of those measures previously resorted to, whose object was to overcome the disease of the larynx and trachea. It professes to remove in some cases the danger of immediate death from suffocation, and thus to give time for nature and art to do their best in overcoming the inflammation of their air-passages, or in obviating its results. That it should prove inefficacious to accomplish this in cases where false membrane has extended to the extreme bronchi, is no argument against its performance in the present state of our knowledge, though it furnishes a cogent reason for the endeavor to perfect our diagnosis, so that our failures may be lessened by our less often attempting the impossible, or at least by our performing the operation with the avowed object of mitigating suffering, not of prolonging life. The questions that call for determination in any endeavors to estimate the value of tracheotomy are, first, whether the danger arises from causes which in certain instances tracheotomy, and that alone, can remove; and secondly, whether the dangers attendant or consequent on the operation are themselves of such a kind as to outweigh its advantages. If these inquiries should be answered in favor of the operation, we may then endeavor to determine by what means its danger can be most effectually lessened, and those cases be best dis- criminated in which the benefits of the proceeding are likely to be most signal. It has been objected by no less an authority than Dr. Cheyne, that inasmuch as three-eighths of the aperture of the larynx have been found free in fatal cases of croup, there must have existed during life room enough for the entrance of air; or, that, in other words, the suffocative symptoms of croup do not depend on a cause which tra- cheotomy can remove. The operation, however, is not performed merely on the mechanical principle of removing from the windpipe a quantity of matter which prevents the entrance of air into the lungs; • The thesis of M. Millard, De la Tracheotomie dans le cas de Croup, 4to. Paris 1858 illustrates extremely well the almost invariable fatality of tracheotomy when performed on young children. Of 124 cases in which the operation was performed at the Hopital des Enfans between January, 1857, and July, 1858, 29, or 24 per cent., had a favorable issue. But of 20 children under two years old who were operated on none survived; and of 36 between two and three only 5: the remaining 24 recoveries having been obtained in children between the ages of three and nine. FAVOR OF TRACHEOTOMY. 329 but it is done rather to obviate the dangers of that spasm of the srlottis which the inflammation or the deposit of false membrane occasions, and which will not cease until either the inflammation is subdued, or the spasm relaxes with the approach of death. Even the narrow opening made into the trachea—often much narrower than the aper- ture of the larynx, though diminished by swelling or encroached on false membrane—suffices, for a time at least, to admit all the air which the patient needs, and the dyspnoea is relieved. The larynx is now at rest, while the air entering continuously, and without effort, duly oxygenates the blood, and the child is thus placed in a condition in which all remedial agents would seem much more likely to tell upon it, than when it was in a state of impending suffocation. Tracheotomy, then, in cases of croup, answers a twofold end, and one not by other means attainable.1 It removes in some instances a positive mechanical obstacle to the entrance of air into the lungs, while in all it puts a stop to that spasm of the glottis which interferes with respiration as much as the actual deposit of false membrane, though not as constantly or with equal peril. Now, it may be asked, what evils are there attendant on the opera- tion that counterpoise these indisputable benefits ? To this inquiry it does not seem to me that the opponents of tracheotomy give any sufficient answer. It is admitted on all hands that in itself the opera- tion is not attended by serious hazard; while the uncertainty as to its issue depends, not on any defect in the proceeding, but on an imperfect knowledge of what cases are within the power of art to succor, and what are beyond the help, not of tracheotomy only, but of all other measures likewise. The shock of the operation is seldom serious except in cases where it has been delayed to the very last moment; serious hemorrhage is a very rare accident, and is generally due to the unskilfulness of the operator, while the dysphagia which occa- sionally follows is a troublesome rather than a dangerous occurrence; one, too, which is not encountered until the canula has been worn some days, and which probably is a result of the disease rather than of the operation. The gravest charge against it is that it is apt to induce serious bronchitis, or at any rate to aggravate any previously- existing inflammation of the lungs or air-tubes. I am not altogether 1 I purposely pass with this slight notice the proposition of M. Bouchnt (originally suggested, indeed, by the famous Desault) for the so-called "tubage de la glotte" or in- troduction of a tube within the canal of the larynx, in order to keep a passage per- manently free for the entrance of air, and thus to do away with the necessity for the performance of tracheotomy in croup. M. Trousseau's report on the subject to the Academy of Medicine at Paris, most temperately, but at the same time most conclu- sively, exposes the fallacies of M. Bouchut, and shows the small practical value of the suggestion, as well as its almost complete inapplicability to the treatment of croup. Of seven cases in which this proceeding was resorted to five terminated fatally, and in the only two patients who recovered tracheotomy was performed. The proceeding is very difficult to accomplish, while in some instances the presence of the tube within the glottis could not be tolerated by the patients, and its removal was necessary ; and though M. Trousseau admits its possible utility in cases of oedema of the glottis, and of simple laryngitis, I should doubt whether even in these instances the presence of a foreign body within the opening of the larynx would not be likely to produce a most mischievous irritation of the diseased organ, aud such as would far exceed that which would be excited by a tube in the trachea. 330 TRACHEOTOMY, certain that there is not some ground for this accusation, but on the other hand it must be borne in mind that these very diseases are the ordinary, almost invariable complications of croup, however treated; and further, that they are not ordinary sequelae of tracheotomy when resorted to in other circumstances, as in cases of acute laryngitis, or of oedema of the glottis. But if we come to the conclusion that in cases of croup which have not yielded to ordinary medical treatment, and in which there seems reason to anticipate a speedy death unless the inability to fill the lungs with air can be soon relieved, the operation of tracheotomy does not superadd some peculiar danger of its own more certain and more despe- rate than those by which the patient is already surrounded, it then be- comes our duty to resort to it; and this not at the last moment, but so soon as ever we feel that our remedies are too tardy to overtake the dis- ease. In such circumstances, to gain time is to gain everything, and it is just this which tracheotomy places within our reach. It is not possible to fix absolutely what rate of mortality may be fairly expected to follow an operation performed in circumstances such as those which call for tracheotomy; for that, unlike most surgical proceedings, does not remove the disease for which it is had recourse to; it does but give the constitution another chance of battling with it; and many of the deaths after tracheotomy are, strictly speaking, far from being instances of failure of the operation. The operation may have done all that it could do, but false membrane may have extended far beyond the opening in the trachea, or the bronchitis may have reached the capillary air-tubes, or the pneumonia may have involved the pulmo- nary substance too extensively for recovery to be possible. We may hence deduce a limitation to the performance of tracheotomy which I cannot state better than in the words of its great advocate, M. Trous- seau,1 who " forbids the performance of the operation in any cases where the danger to the child appears to depend on disease of the general system rather than on the affection of the larynx or trachea." But in cases where no such contraindication exists, it is yet evident that the issue of the operation must be in a great measure controlled by the age of the patient, by the fact of the disease being idiopathic or secondary, by the extent of the disease of the respiratory organs generally, and that this influence must be of a kind which no surgical dexterity or medical skill can do much to control or to modify. Some circumstances may, however, be borne in mind as influencing the result of tracheotomy, while at the same time they are not beyond the control of the medical attendant. The^rs^ of these concerns the size of the tracheal tube, a point the importance of which was first insisted on by M. Trousseau. He explains the occasional speedy and apparently causeless disappearance of the amendment that at first succeeds the operation of tracheotomy by the inadequate size of the canula which is frequently employed, and which does not provide for the permanent admission of a sufficient quantity of air. The air admitted through even a small canula is enough to 1 Archives G6n. de Medecine, March, 1855, p. 257. CAUTIONS AS TO ITS PERFORMANCE. 331 afford temporary relief, but not enough for the continued discharge of the functions of the organism ; and the return of hurried breathing, and the reappearance of the livid hue of the surface, betoken the im- perfect depuration of the blood. " Take," says he, in illustration of this fact, "a quill, and, closing your nostrils, endeavor to breathe entirely through it; at first you breathe easily enough, but soon your respi- ration becomes laborious; and at length you are fain to throw away the quill, and with open mouth once more to fill your lungs completely. Now precisely this is what happens when an opening of inadequate size is made into the trachea; air enters readily, and without the interruption which the spasm of the glottis occasioned; but it does not enter in suf- ficient quantity, and hence the return of the symptoms, and the patient's death." Acting on this principle, M. Trousseau makes a larger opening into the trachea, and introduces a larger canula than had previously been customary ; and this practice I believe to be now gaining ground among persons who have omitted to acknowledge their obligation to M. Trousseau for the suggestion. The second of these precautions has reference to the necessity of surrounding the child after the operation with a warm, moist atmos- phere, such as alone it ought to be allowed to respire ; though, unfor- tunately, this is very much neglected, not in hospitals only, but also in private practice. The importance of attention to this point, and also to surrounding the neck with several folds of muslin, so as to cover the orifice of the tube, as well as to keeping the canula free, cannot be overstated; and yet these little things are overlooked or intrusted to unskilful hands, because they seem too trivial for such large issues to be dependent on them. The third caution which I would urge is, that medical treatment must not be suspended, nor necessarily modified, after tracheotomy has been performed. The operation, indeed, seems so heroic a measure, and when it yields relief, the relief is so speedy and so striking as to occasion some risk of its being forgotten that the disease has not been removed by it, that its danger has only been postponed, and that the indications for treatment continue the same after tracheotomy as they were before. A word or two with reference to the after-management of cases of tracheotomy will comprise all that I have to say on this subject. My own patients have rarely lived long enough after the operation for me to become practically familiar with the difficulties which arise some few days after its performance. These, however, apart from such as are the consequences of the supervention or increase of the disease of the respiratory organs, are twofold, and arise from the condition of the wound, and from the occasional supervention of difficulty in swal- lowing. One of the reasons for seeking to remove the canula as early as pos- sible is supplied by the irritation of the edges of the wound which its long-continued presence is apt to produce. I saw the death of a child take place from this cause on the 11th day after the otherwise suc- cessful performance of tracheotomy by my colleague, Mr. Athol John- son; and it was ascertained after death that, in addition to thedestruc- 332 TRACHEOTOMY. tion of several rings of the trachea, an abscess had formed in the ante- rior mediastinum which communicated with the external wound by sinuses that burrowed between the trachea and oesophagus. In fat children the unhealthy state of the edges of the wound is partly pro- duced by the canula remaining deeply sunk in the flesh; an evil which would perhaps be lessened by the use of a long canula with a very- broad shield; or else by the employment of one " a lorgnette," as it has been termed by its inventor, M. Paul Guersant; that is to say, capable of being lengthened by pulling it out, like a telescope or an opera-glass. Besides this, the covering the wound with lint thickly spread with spermaceti ointment, and placing over that a piece of oiled silk so as to defend it as far as may be from irritation, and from the external air, as well as the touching its edges daily with the nitrate of silver, are the most important means of maintaining its healthy con- dition. Another of the dangers of the operation depends on the abrasion of the mucous membrane of the trachea by the end of the canula, and its consequent ulceration. This danger, however, is almost, although perhaps not quite invariably, prevented by M. Liier's modification of the canula, which was introduced to general notice by M. Roger. This modification consists in the canula being movable on the shield, so that its position shifts with the varying attitudes of the child. The difficulty of deglutition is an inconvenience which usually comes on about the fifth or sixth day after the operation: that is to say, at the time when the larynx, though now free from the false mem- brane which before occluded it, has not completely recovered from the effects of the disease, but a state of partial paralysis of its muscles remains, which allows food, and especially liquids, to enter the air- tubes. This accident, which is by no means invariable in its occur- rence, has probably little or no relation to the operation. It is a result of that paralysis of the soft palate and muscles of the pharynx which sometimes succeeds to diphtheria, and which from being a troublesome accident is converted by the previous tracheotomy into a dangerous complication. If the patient is sufficiently intelligent to admit of M. Archambault's suggestion1 being adopted, and will place the finger on the opening of the tube, and endeavor to breathe quietly through the larynx when swallowing, it is very likely that the want of har- mony between respiration and deglutition will be overcome in many instances, though, according to M. Trousseau's experience, by no means in all. In the majority of cases, however, we are compelled, by the tender age of our patients, to confine ourselves to feeding them as far as possible on solid, or at least on pultaceous food; rejecting all drink as far as possible, and giving it when absolutely necessary in small quantities, and either immediately before or a considerable time after food.2 In some instances M. Guersant3 has found the use of the sto- mach-pump, or of a tube introduced through the nares, necessary to ' L'Union Medicale, Juillet, 1854. 2 Archives Gen. de Medecine, Mars, 1855. 3 Notices sur la Chirurgie des Enfants, 8vo. Paris, 1864, pp. 34-48. AFTER-MANAGEMENT OF TRACHEOTOMY. 333 convey food safely into the stomach ; though happily such are excep- tional cases; while generally the larynx recovers itself in three or four days, and deglutition is then no longer attended with difficulty or danger. In M. Guersant's remarks on tracheotomy, he mentions the occa- sional occurrence of cases in which it has been found impossible, after the lapse of the ordinary time, to remove the tube from the trachea, the larynx remaining still partially closed by the adhesion of false membrane to the vocal cords. I have met with a case in which, twelve months after the performance of tracheotomy, it was still impossible to remove the canula, owing to the constriction of the windpipe above the opening; and several such are on record in the annals of medicine. M. Guersant recommends the sweeping out the larynx by a little pledget of lint introduced through the canula, and carried from below upwards, so as to detach from between the vocal cords any false mem- brane remaining there. This means, however, he confesses, has not always been successful, and Dr. Steiner, of Prague,1 found in the case of a little boy who died of acute hydrocephalus nine months after tracheotomy, and who had never been able to dispense with the canula, that the larynx was com- pletely closed by firm cicatrix tissue, the result of previous deep ulcerations of its surface beneath the deposit. In my case, after various unsuccessful measures, my colleague at the Children's Hospital, Mr. Thomas Smith, at length succeeded in permanently dilating the contracted opening with a piece of the sea tan- gle; the child now passes many hours daily without the canula, though she still wears it at night, and I look forward to her becoming able before long to dispense with it altogether. I trust soon to be able to refer to a promised essay by Mr. T. Smith, on the various surgical questions involved in the performance of tra- cheotomy in children, and on their management surgically after the operation. 1 Jahrbuch der Kinderheilkunde, 1863, vol. vi. p. 79. Dr. Steiner was good enough to communicate to me personally the results of the post-mortem examination, the child having died subsequently to the publication of his paper. 334 DIPHTHERIA, OR ANGINA MALIGNA. LECTURE XXV. Diphtheria, or Angina Maligna.—Not a new disease.—Its anatomical characters—mode of extension of the disease.—Its relation to true croup. Symptoms of diphtheria—in its milder form, insidious supervention of croupal symptoms—in its severer forms, frequently associated with albuminuria—peculiar depression which attends it—note showing date and cause of death in 34 cases—evidence of its affinity to the class of blood diseases—paralytic symptoms which follow it.—Relation between it and scarlatina examined—evidence on both sides of the question stated—that in favor of their non-identity considered to preponderate. Treatment—local applications—constitutional measures—necessity for tonics and stimulants. Modified form of the disease—usually a complication of measles—its symptoms and treatment. Laryngitis Stridola, or croup with predominance of spasmodic symptoms—not a distinct disease, but results from constitutional peculiarity.—Illustrative case. Instances of spasmodic cough and affection of larynx, from irritation in lungs—intestines—■ brain.—Note on thymic asthma. Reference was made in the last lecture to a second form of disease, resembling croup in some respects, though differing in others, alike but not the same, and calling therefore for a separate notice. This other disease, Angina Maligna, Diphtheritis, or more correctly Diph- theria, is no new malady,1 but one which, though always prevalent, forces itself occasionally upon general notice by the formidable symp- toms that sometimes attend it, by the rapidity with which it then runs its course, and by its selection of several victims from one town, one village, or one family. At such seasons it wears a character which seems so different from that which it assumes in its milder forms as to render it almost impossible to believe that the slight sore throat which caused only a trivial inconvenience, and hardly required any medical treatment, is one with the malignant disease, whose local symptoms are often cast into the shade by the grave constitutional disorder that attends them. In each case, however, its essential anatomical characteristic is the same, and consists of redness, and swelling involving the tonsils and soft palate, and accompanied within a few hours by the exudation on their surface of a dense white false membrane, appearing in little points or spots which speedily coalesce, and form a uniform investment to the part where swelling and redness were first apparent. The white color of the original deposit is speedily lost as fresh exudation is pro- 1 Starr's unpretending account of the disease at Liskeard, a century ago, details all the most characteristic features of diphtheria: the false membrane on the fauces, its extension to the air-passages, its appearance on blistered surfaces and upon the skin behind the ears, leave scarcely a symptom wanting to prove the identity of the two affections. Those who wish to pursue the question will find all necessary infor- mation in Fuchs' Historische Uutersuchungen iiber Angina Maligna, 8vo. Wiirzbure 1828. 8' ITS CHARACTERISTIC SYMPTOMS. 335 duced; and the membrane becomes gray or blackish as the air acts upon it, or as blood from the congested mucous surface beneath stains it. Speedily too it splits up into shreds, which hangiug down at the back of the fauces, produce that appearance of a sloughing tissue which imposed upon the early observers, and obtained for the disease the name of Angina Gangrasnosa. If detached from its connections, a number of minute bloody points on the subjacent tissue attest the firmness with which the false mem- brane adhered to it; but beyond increase of their vascularity the parts do not in general display any marked alteration. I doubt, however, whether that rigid classification which would refer to a separate cate- gory all those instances in which there exists distinct erosion or ulce- ration of the mucous membrane beneath the exudation is either practically useful or pathologically tenable; for while the surface of the tonsils is not invariably free from ulceration, I believe that in a very large proportion of the instances in which the exudation extends into the air-passages the mucous lining of the larynx is distinctly eroded, and small specks of ulceration are discernible about the edges of the glottis. Coupled with this condition of the fauces there is usually a swelling of the sub-maxillary glands, and of the adjacent cellular tissue, as well as to some extent also of the parotids. This swelling, however, though very rapid in its formation, and equally so in its disappearance, is seldom so considerable as that which often attends upon scarlatina; it has but little tendency to terminate in abscess, and still less to assume the brawny hardness, and the extremely indolent character, which often add so much both to the suffering and the danger of that dis- ease. Although the soft palate and tonsils are the parts on which the deposit is first observable, it often does not remain limited to those situations, but its tendency is to extend by mere continuity of tissue to the mouth, the pharynx and oesophagus; to the larynx and trachea, and also occasionally upwards to the nares. Affection of the mucous membrane of the mouth, and the deposit of exudation on the tongue or on the inside of the cheeks or on the surface of the gums, are ex- ceptional occurrences. I have met with such deposit only on three occasions, and I believe that at all times it is far more frequently absent than present. In two instances, though the mouth was free from false membrane, the oesophagus was lined by it for two-thirds of its length; the subjacent mucous surface showing but very slight increase of vascularity, and the exudation being but very loosely con- nected with it. In one case, although the oesophagus was perfectly normal, the stomach was lined by a thick false membrane, intimately adherent but terminating abruptly both at the cardiac and pyloric orifice. False membrane was in this case deposited also on the tonsils, velum, upper surface of the epiglottis, pharynx, root of tongue, in the nasal fossae, and in the larynx as low as the cricoid cartilage. The disposition of the false membrane to affect the nares seems to vary much in different epidemics. It has very rarely come under my notice in this country in its most characteristic form as a distinct false 336 DIPHTHERIA, OR ANGINA MALIGNA. membrane, though a discharge from the nostrils similar to the scarla- tinal coryza is present in almost all cases of severe diphtheria. M. Bretonneau1 gives a caution with reference to these cases which must not be forgotten, to the effect that in some few instances the disease begins at the nares, and extends thence in a manner so insidious as to escape the notice of all who are not forewarned, and on the lookout for the occurrence. The relation between the amount of deposit on the fauces and the extension of false membrane to the air passages is by no means con- stant. A very slight deposit on the soft palate and tonsils, soon dis- appearing, may yet be succeeded by a very abundant exudation in the larynx and trachea, while, on the other hand, most extensive forma- tions of false membrane at the back of the throat may yet never in- volve the air-passages. The appearances produced by the extension of the diphtheritic deposit to the air-passages are precisely the same as those observed in cynanche trachealis, in which, without any pre- vious affection of the fauces, the inflammation has attacked the larynx and trachea. It has indeed been suggested by M. Isambert,2 in a very valuable paper, that the condition of the subjacent mucous membrane furnishes a ground of distinction between the affections; and that while in diphtheria the surface beneath the exudation is often ulcerated, no such erosion of the mucous membrane is met with in genuine croup. My own observation does not, however, altogether bear out this dif- ference; for ulceration of the mucous membrane has come under my notice in primary croup, though less frequently than in cases of the diphtheritic kind; and its presence or absence seems to me mainly dependent on the rate of progress of the disease towards a fatal termi- nation. When false membrane is deposited very extensively, and when death takes place in consequence most speedily, the mucous surfaces have appeared least altered; when the course of the disease is slower and the false membrane limited almost or altogether to the larynx, ulceration has seemed to me most frequent, and has in some of these cases amounted to an almost complete erosion of the lining of the larynx. In conformity with this I may add that it is in the diphtheritic croup that succeeds to measles, which is usually the least rapid in its course, that we commonly find the alteration of the mucous membrane the most considerable. I have come indeed to the conclusion, which I long hesitated to adopt, that what differences soever exist between croup and diphtheria, they must be sought elsewhere than in the pathological changes observable in the respiratory organs. The mere extent of false mem- brane in the air-passages certainly affords no ground for a distinction between the two affections, though I think it is more common to find the false membrane reaching to the tertiary bronchi in diphtheria than in primary croup. A distinction between the two diseases founded on the greater frequency of bronchitis and pneumonia in primary croup becomes to my mind with every year's added experience less 1 Archives Gen. de Medecine, Jan. and Sept. 1855. * Ibid., March aud April, 1857. SYMPTOMS CF DIPHTHERIA. 337 and less tenable; and when once it has invaded the air-passages, diph- theria seems to produce precisely the same changes, to the same ex- tent, and with at least the same rapidity, as primary croup. But even though this be so, the sameness of the anatomical changes produced by the diseases does not suffice to establish their identity. The practitioner of midwifery knows that simple puerperal metritis and puerperal fever are diseases which differ widely in their symptoms, their course, their danger, and the degree in which they are amenable to remedies, though in both, when they terminate fatally, precisely the same alterations in the womb are discovered. In the same way, if we extend our inquiry beyond the mere changes wrought in the respiratory organs, the differences between croup and diphtheria at once become apparent; and the affinities of the latter disease are seen to be to the class of blood diseases, rather than to that of purely local inflammations to which croup belongs. Diphtheria presents itself in two forms; either as a primary or as a secondary disease. In the former case it is often sporadic, and is then generally mild in character; but occasionally it is epidemic, and then conforms to the general laws of epidemic disease, and manifests on its first attack a degree of severity which passes off as its preva- lence declines. When it occurs as a secondary affection, it is as a sequela to one or other of those diseases (especially measles and scar- latina), which are distinguished by the alterations that they bring about in the circulating fluid. With scarlet fever too its relations seem to be peculiarly intimate, for while there is no evidence that the one furnishes any protection from the other, both not unfrequently prevail together; and it does occasionally happen that even in the same household some individuals will be attacked by diphtheria, and others by well-marked scarlet fever. Until within the past few years, diphtheria had not been observed in London or its vicinity, within the memory of the present genera- tion, except either as a sequela of measles, or else in that sporadic form which derives all its importance from the extension of false membrane to the larynx and trachea, and the consequent production of croupal symptoms. Recently, however, the disease has assumed a more formidable type, and its symptoms have resembled those which it often displays in France, though to the best of my knowledge that disposition to the formation of exudation on abraded surfaces, and at the outlet of all mucous canals, which is by no means unusual there, has occurred much more rarely in this country. In its less severe forms the disease is ushered in by mild febrile symptoms accompanied with slight sore throat—the most remarkable feature of the case being generally that the depression of the patient is out of proportion to the severity of the local ailment. Examina- tion of the throat shows a slight degree of swelling, and redness not usually very vivid, and at first confined to one tonsil. In the course of a few hours white specks are observed on the tonsil, chiefly on its inner surface, and before long the other tonsil becomes similarly allected, while, in some instances, though by no means constantly, a 22 338 SYMPTOMS OF DIPHTHERIA. slight deposit appears on the velum and uvula. One or two applica- tions of caustics or astringents to the part are usually sufficient to clear way the deposit, or it may disappear spontaneously, and not be reproduced, and in two or three days the patient is pretty well again, though strength is in general regained less quickly than might have been expected from the comparative mildness of the attack. In cases so slight it is no easy matter to recognize the features of a highly dangerous disease; for there is no coryza, no swelling of the sub-maxillary glands, no increased secretion of saliva, no offensive odor of the breath, nor any disorder of the respiratory functions. Still, out of forerunners as trivial as these, croupal symptoms may be developed, and as the deposit on the fauces, when slight, is often not persistent, no trace of it may be perceptible when the' signs of the affection of the larynx first attract attention. Whether croup comes on as a primary or as a secondary disease, its signs are always much the same, and I need not therefore occupy your time in repeating the description of them; but it must not be forgotten that its advances are often most insidious when it succeeds to diphtheritic deposit on the fauces. The cough, in these circumstances, may present but little of the loud clangor of ordinary croup, and the respiration may have little of the characteristic stridor; but grave apprehensions may be all at once excited (and this especially in infants and young children) by the breathing suddenly becoming sibilant and interrupted by paroxysms of urgent dyspnoea, the evidence of the already complete formation of false membrane, and the herald of death, which may not delay four and twenty hours from the first sign of serious danger. But, much though it imports us to be on the look-out for this train of symptoms, they are not the expression of the special severity of the disease, but rather of the accidental extension of its consequences to the air-passages. It is true that to this accident much of the danger of diphtheria is due, and true too that in the worst forms of the disease it is more frequent than in its slighter manifestations; but while we must be always on the lookout for croupal symptoms, they do not constitute the disease; they are by no means the only source of its dangers; nor is it in their occurrence that the most characteristic features of diphtheria are to be sought. Even in the more serious cases, the course of the disease, in its early stages, is usually slow and often insidious. For a day or two there is perhaps much febrile disturbance and a heat of skin which raises the suspicion that scarlatina is about to appear, of which the painful swelling of the sub-maxillary glands seems to be a still further indication. No rash, however, makes its appearance; the heat of skin often subsides completely, so that the surface becomes even cooler than natural; while the absence of the red and prominent papillae which beset the tongue in scarlatina, belies the evidence of the sore throat. The fauces are red and swollen, sometimes very much so, but the red- ness is not vivid, and there is not in general that difficulty in opening the mouth which is experienced in scarlet fever when the sore throat is at all severe. The false membrane appears almost simultaneously SYMPTOMS OF DIPHTHERIA. 339 on both tonsils; and soon after on the soft palate and uvula, and the latter is generally much swollen, and contributes a good deal to ob- struct the channel of the fauces. Accompanying this state of the throat, there is often a discharge from the nares, resembling the coryza of scarlet fever, and as has already been mentioned false mem- brane is occasionally deposited there, whence it may travel to the pos- terior nares, and so to the throat and air-passages. When the deposit is considerable the appearance of the tongue is peculiar. It is usually red at the tip, but thickly coated with white fur, which on the dorsum and towards the root of the tongue is almost membraniform. It is not usual for the inside of the mouth to be affected, but now and then the gums are red, soft, and spongy, and covered here and there, as well as the inside of the cheek, with patches of false membrane, beneath which the tissue appears red and shining. When the mouth is thus affected the secretion of saliva is considerably increased; but I have never seen that profuse dribbling of it which takes place in stomatitis, nor have I observed that complication of stomatitis with diphtheria of which M. Bretonneau speaks, and which led him to regard the two diseases as closely related to each other. It is after the false membrane has been formed somewhat abundantly for two or three days that it un- dergoes those changes which impart to the breath its peculiarly offen- sive odor, and give to the fauces that appearance of being the seat of a sloughing ulceration, whence arose the old names of angina maligna, angina gangraenosa. Even when the affection of the throat is most considerable, deglutition can still almost always be performed, not easily indeed, but yet in general without that extreme difficulty which one often observes in the sore throat of scarlet fever, and of common quinsy. The voice is often hoarse and indistinct, independently of actual affection of the larynx, and a short spasmodic, slightly ringing cough, is frequently heard, due to the irritation of the larynx by the mischief in its vicinity. But, though these symptoms do not necessarily imply that the air-passages are actually involved in the disease, they should keep us most anxiously on the watch, since very few tokens indicate this event, and they are often of a kind to escape the notice of the unobservant. In proportion to the severity of the case is usually the shortness of the premonitory fever, which sometimes does not exceed twelve hours in its duration, and at other times scarcely occurs at all, the child being struck down by the disease; false membrane being deposited exten- sively on the fauces in the course of a few hours, and the coryza, which usually does not appear before the third day, showing itself almost from the first. The mode in which such cases tend to a fatal issue is very various. As a general rule it may, I think, be said that the laryngeal affection, which is so grave a source of peril, does not so fre- quently occur in cases where the constitutional symptoms of diph- theria are most severe, as in those in which they wear a milder form. At the same time, however, no guarantee is furnished against its super- vention by the gravity of the disease in other respects, while, when 340 VARIOUS MODES IN WHICH the larynx becomes involved in severe diphtheria, the case must be regarded as at once utterly hopeless.1 ■ The subjoined Tables represent the conditions in which 34.cases ^ d^th^ proved fatal. In 18 cases the affection of the air-passages was the chief if not the onlv cause of death ; in the remaining 16 the larynx was unaffected. Table of cases in which death took place from diphtheria independent of affection of the larynx. Sex. M. F. F. F. F. F. F. F. F. F. M. M. M. F. M. F. Age. yr. mo. Primary or Secondary. 5 0 8 0 0 8 3 2 3 3 3 6 9 0 1 0 3 5 2 10 4 6 2 8 2 0 2 0 2 4 9 0 Primary. Mode of Death. Date of Death. Secondary to Per- tussis. Primary. Secondary to Pleuro pneumonia. Primary. Measles su- pervened. Exhaustion ; paralysis of respi- ratory muscles; urine albu- minous. Sudden syncope ; urine albu- minous. Exhaustion; urine albumin- ous. Respiratory paralysis ; urine not noted. Do. ; urine not noted. Exhaustion ; urine albumin- ous. Exhaustion ; incessant vomit- ing ; urine albuminous. Exhaustion; urine albumin- ous. Convulsions ; urine albumin ous, suppressed for 48 hours Exhaustion; vomiting, ii which blood was brought up; urine not noted ; died on way to hospital; mem- brane in stomach. Exhaustion ; vomiting ; urine albuminous. Exhaustion and Empyema of right side j albumen in urine temporary. Exhaustion; nervous and paralytic symptoms j embo- lism ; urine albuminous. 5th day. 15th " 7th " 18th " 2 months. 18th day. 14th " 7th " 4th " 6th Diabetic patient; came on on the 23d day of Scarlatina. Supervened on Tuber- cular Hydrocepha lus. Primary. Exhaustion ; urine albumin - 12th " 28th day from commence- ment of pleuropneu- monia; 19th of diph- theria. 50th day of diphtheria; 27th of measles ; clot choking both common iliac, right external iliac, femoral and pop- liteal arteries; veins healthy. 48 hours. Exhaustion ; not noted. Exhaustion; not noted. state of urine state of urine 48 4 days. In the following, death was due mainly to the laryngeal affection :— Sex. Age. yr. mo. Primary or Secondary. Croup super-vened. Symptoms lasted. Death took place. M. F. F. 2 9 9 11 3 0 Primary. << 10th day. 9th " 3d " 52 hours. Urine albuminous. 4 days. Urine not albumin-ous ; tracheotomy 36 hours before death. 3 days. Urine albuminous ; tracheotomy 14 hours be-fore death. 13th day. 13th " 6th " DIPHTHERIA PROVES FATAL. 341 Setting aside these cases, we find that the evidence of general con- stitutional disorder becomes more marked day by day, and this even without an invariable aggravation of the local malady. Of these evidences one of the most important is furnished by the presence of albumen in the urine. I believe that albumen is rarely absent in cases of other than the very mildest diphtheria; though the amount is strangely fluctuating, varying even on successive days; and these fluctuations are by no means constantly associated with any corres- ponding modifications in the other symptoms of the disease. When the albumen, however, is very abundant, the urine is invariably scanty,' Age Croup super- Death R(-X. yr. mo. Primary or Secondary. vened. Symptoms lasted. took place. M. 6 0 Secondary to Scarlatina, on 18th day, while con-valescent. 12th day. 2 days. Urine albuminous. 14th day. F. 3 0 Primary. Scarlatina su-pervened. 13th " 8 days. Tracheotomy 4 days before death ; scarlatina 2 days ; died in syncope on being placed in a sitting posture. 21st " F. 5 0 Primary. 5th " 36 hours. Tracheotomy 29 hours before death. Urine very albuminous and scanty; convulsions 7 hours ; death exhausted. 7th " F. 4 9 Secondary to mild Ty- 6 hours. 4 days. Urine very albu- phoid Fever, on 11th day. Secondary to typhoid minous ; much exhaustion. 5th " F. 3 0 1st day. 2 days. Urine not albumin- Fever of moderate se- ous ; much exhaustion. 3d " verity, on 11th day. Convalescent from Diphtheria 3 months before. M. 5 0 Secondary to Scarlatina 3 weeks before ; very slight albuminuria. 7 hours. 44 hours. Urine albumin-ous ; sudden increase of albumen preceded any other symptom. 51 hours. M. 3 0 Primary. From com-mencement. 5 days. 5th day. M. 3 0 8th day. 7 days. Tracheotomy 44 hours before death. 15th " F. 5 0 Secondary to mild Scar-latina 1 month before, and to Erysipelas 5 days before, which had been preceded by fever for 4 days. From com-mencement. 36 hours. Urine albumin-ous ; had become so dur-ing attack of erysipelas. 2d " F. 5 0 Primary. 36 hours. 42 hours. Tracheotomy 18 hours, convulsions 17 hours, before death. 4th " M. 8 0 " 6th day. 12 hours. 6th " M. 9 0 " From com-mencement. 13 days. Tracheotomy 38 hours before death. 13th " F. 1 8 u " 3 days. 3d " F. 6 0 " 2d day. 6 " 6th " M. 6 0 " 8th " 4 " 12th " 1 I am glad to be able, from further experience, to correct an error which I fell into in my former edition ; in which I stated that no relation existed between the amount of albumen in the urine and the scantiness of this secretion. My friend and colleague Dr. Hillier, has pointed out this mistake in his very valuable article on Diphtheria, in the British Medical Journal for September 24, 1864. 342 MODES IN WHICH DIPHTHERIA PROVES FATAL. and there is perhaps no single symptom.of worse omen than the ex- tremely scanty secretion of urine. In cases of average severity the albumen seldom makes its appearance within the first four or five days; and then, according to the subsequent progress, it either goes on increasing, or lessens with the gradual improvement in the patient's condition. The complete suppression of urine is an almost invariably fatal symptom, and I do not know of any instance in which the patient has recovered after the urinary secretion has been suspended for twenty-four hours. In these circumstances, and even in cases where the urinary secretion, though not absolutely suspended, is unusually scanty, uraemic convulsions are likely to occur and suddenly to carry off' the patient. But even where the urinary secretion continues in tolerable quan- tity, and the albumen is not excessive, the symptoms that attend the progress of the disease are invariably those of depression, and of de- pression which, like that attendant on the worst forms of puerperal fever, is by no means constantly proportionate to the apparent local mischief. The child, feeble yesterday, becomes still feebler to day, and often, without any actual increase of deposit, sometimes even in spite of its diminution, and of the absence of any apparent cause for difficult deglutition, the repugnance to take food goes on increasing, until at length he positively refuses all nourishment. This refusal of food, whether in childhood or in adult age, is a very unfavorable occurrence. It is sometimes associated with vomiting, and may then be dependent on the presence of false membrane in the stomach, though this is by no means always the case; but whether it be so or not it tends to reduce the patient's strength very much, and if persistent for any con- siderable time almost invariably occasions fatal depression. It is not always easy to realize the degree of peril, for the intellect is generally clear, and the muscular powers are not inconsiderable, while at the same time the extremities are cold, and the pulse is either extremely frequent or else very feeble or irregular in its beat. For two or three days altogether, this condition may continue, the pulse growing feebler, the signs of failing power more manifest, and this in spite of stimulants being administered lavishly, and taken readily, until at length either the signs of the last stage of croup suddenly appear, showing that the local mischief has been extending silently and unperceived, or else an attack of syncope follows on some sudden and violent action of the bowels, or causeless convulsions come on, and in the subsequent coma the patient dies. This depression too, as already mentioned, is by no means constantly proportionate to the extent of the false membrane, nor is the danger of it passed even when the local mischief, as far at least as the eye can reach, has altogether disappeared; for I have known frequently recurring syncope take place even when no traces of false membrane remained on the fauces; and fatal convulsions come on when the local mischief was so slight that nothing but the previous death of a member of the family from well-marked diph- theria had called attention to the throat, and had led me to watch with painful solicitude a local ailment which owed all its importance to being an evidence of grave constitutional disease. RELATION OF DIPHTHERIA TO BLOOD DISEASES. 343 The simultaneous or successive affection of different and distant parts, is one of the great evidences on which we are wont to rely, in proof that a disease belongs to that great class of blood diseases whose importance, and whose distinctive characters modern pathology has done so much to elucidate. The more closely we study diphtheria, the stronger will its claims appear to be referred to this category. The false membrane, whose most usual seat is on the fauces, whence it extends into the air-passages, is not limited to those situations, but occasionally invades other parts, and is deposited behind the ears, upon the vulva, or on abraded surfaces; while, in the albuminuria which generally accompanies its severer forms, another point of re- semblance exists1 between diphtheria and other maladies which results from purulent infection. In some epidemics of diphtheria the forma- tion of false membrane on diff'erent parts has been a frequent occur- rence. Thus Bard,2 describing the disease as it prevailed nearly a century ago in America, speaks of the formation of ulcers behind the ears, covered in some places with sloughs resembling those on the tonsils; and Starr, in his description of the epidemic at Liskeard,3 notices "a rotten membranous body, or slough, generated on the skin of a patient, on the neck and arm, where blisters had been applied;" and says that the part presented "a white surface which had the aspect of an oversoaked membrane." Such a deposit I saw take place on the neck of a little girl, around whose throat before the diphtheritic deposit had been recognized on the fauces, a stimulating liniment had been applied to relieve her swollen glands. But besides the formation of false membrane on abraded surfaces, the mucous membrane of the vulva seems often to be the seat of a similar deposit; and in some rare cases the prepuce is affected in the same manner, or small super- ficial ulcers break out on different parts of the body, and become speedily covered with false membrane. Once, too, I saw in consulta- tion with Mr. Alford, of Haverstock Hill, twin boys, eight months old, in each of whom a small abrasion formed on the raphe of the perineum, and became covered with false membrane. The membrane extended, though unaccompanied with other local symptoms of diph- theria, to the margin of the anus, and to just within the external sphincter. Both children died within a week from the commencement of their illness, sinking as under some grave constitutional disease, with troublesome diarrhoea and exhaustion which stimulants failed to remove. The identity of the disease in these circumstances with ordi- nary diphtheria is established beyond doubt by facts such as those observed by M. Trousseau4 in a village in the neighborhood of Orleans, where diphtheria prevailed, presenting in some persons its ordinary features; manifesting itself in others by deposits of false membrane on the vulva, on the mamma, on blistered surfaces, or on ulcers, and proving fatal in some cases without the throat being at all involved in the disease. Among the sequelae of diphtheria we shall presently have to notice 1 Bouchut and Empis, Gaz. Hebdom., Nov. 12, 1858. * Loc. cit., p. 392. 3 Loc. cit., p. 440. 4 Dela Diphtherite cutanee, in Arch, de Med., Juillet, 1830, p. 383. 344 DURATION OF DIPHTHERIA. peculiar paralytic symptoms, which sometimes affect the extremities, as the pharynx, soft palate, and other parts that have been more immediately involved in the disease. But besides these, which belong rather to the remote phenomena of diphtheria, we sometimes meet with even a graver form of disordered innervation, occurring in its earliest stage, and leading, by affection of the vital centres, to a speedily and often to a suddenly fatal issue. Disordered innervation of the heart is perhaps the most frequent, and betrays itself by a remarkable diminution, sometimes for two or three days, in the fre- quency of the pulse, which may even sink, as in the case of a little girl, related by Dr. Jenner, to sixteen beats in the minute. This occurrence indeed is by no means constant, and death may take place by sudden failure of the heart without this forewarning. When observed, however, its import is always serious, and you may augur ill of any case in which, be the local symptoms what they may, the heart's pulsations fall much below their natural standard. But there are other cases in which the disordered innervation seems to affect the muscles of respiration rather than the heart itself; the breathing, without any extension of the false membrane to the larynx, and without any notable mischief in the lungs, becoming by degrees more and more labored, and the patient dying at the end of some four and twenty hours from asphyxia, for which a post-mortem examination discovers no adequate cause. It seems then that death may take place in the acute stage of diph- theria, either— 1st. From blood-poisoning, as in cases of malignant fever. 2d. From extension of the local mischief to the larynx. 3d. From progressive exhaustion aggravated by the difficulty in deglutition. 4th. From uraemia and ursemic convulsions. 5th. From various forms of aff'ection of the nervous system, as— a. Sudden syncope. b. Disordered innervation of the heart. c " " . organs of respiration. d. General disorder of innervation, accompanied with affection of the stomach, and uncontrollable vomiting. It is not easy to fix the duration1 of a malady whose course is not hili 1 died on the 2d day in 2 K ii 4th " 2 IC ci 5 th " 1 (( a 6th " 1 II n 7th " 2 It a 12th " 1 it a 14th " 1 it it 15th " 1 It ii 18th " 2 it !< 28th " 1 it (( 50th " 1 it in 2 months 1 In 18 cases in which death took place chiefly from the affection of the larynx, The child died on the 2d day in 1 3d " 3 4th" 1 5th" 2 6th" 3 7th" 1 12th " 1 13th " 3 14th " 1 15th " 1 21st " 1 18 SEQUELAE OF DIPHTHERIA. 345 unfrequently so anomalous, and which, as we shall see hereafter, not seldom leaves sequelae in its train such as are themselves only fresh manifestations of the working of the original morbid poison. Of 34 fatal cases, 19 terminated within the first 7 days; and after the ter- mination of the second week death may be regarded as a decidedly unusual and exceptional occurrence; though it is not easy, perhaps even not possible, to fix any date before convalescence is perfectly established at which some of the remote sequelae of diphtheria may not unexpectedly come on and endanger life. The most rapidly fatal cases are those in which death depends on aff'ection of the larynx, and in them death sometimes takes place in from twenty-four to thirty-six hours from the apparent commencement of the attack; the local symptoms throwing the signs of constitutional disorder completely into the shade, sometimes rendering it almost impossible to deter- mine whether a case should be classed with diphtheria or with simple cynanche trachealis.l Reference has already been made to the occasional death of patients in whom the local aff'ection had throughout been so inconsiderable as to produce but few symptoms, or had even altogether disappeared before the fatal issue took place. But other cases are sometimes observed where long-continued illness remains, or where even death takes place, not from the disease itself nor from any of its immediate effects, but from its remote sequelas, from a sort of accidental conse- quences. These remote results of diphtheria have been noticed both by Bretonneau and Trousseau, and some of them have probably come under the observation of most persons who have had even a very limited experience of the disease. Thus, for instance, I saw a child, between three and four years old, whose infant brother had died of diphtheria, and who herself had had very slight deposit of false mem- brane on her fauces, attacked by causeless convulsions when apparently convalescent, and when more than a week had elapsed since the throat presented any unnatural condition: and these convulsions terminated in fatal coma within less than twenty-four hours. A lady, whose child (aged three years) had died of diphtheria extending to the air-passages, and who herself had suffered from very slight sore throat with a trace of false membrane on the tonsils, was attacked by sudden faintness, almost amounting to syncope, with extreme feebleness of pulse and a sense of impending dissolution, which for more than twenty-four hours were scarcely kept in check by the almost incessant administration of stimulants. Cases of a similar kind might no doubt be multiplied; but besides these earlier sequelas, there is a peculiar form of temporary paralysis, which occurs by no means rarely as a remote consequence of the disease, and which is yet both important in itself, and also as furnishing an additional distinction between diphtheria and any simply inflammatory affection. Both MM. Bretonneau and Trousseau have referred to this peculiar condition; and incidental mention of it is to be found a century ago in the writings of physicians who have noticed the so-called malignant sore-throat, by which name diphtheria was then described.1 It is to 1 M. Maingault's valuable essay De la Paralysie Diphtherique, 8vo. Paris, 1860, contains an interesting historical sketch of the early notices of this affection. 346 DIPHTHERITIC PARALYSIS. Mr. Faure,1 however, that we are indebted for the first complete account of it, derived partly from his own observation, partly from facts detailed by others. He describes it as " a state characterized by a gradually increasing loss of power, showing itself especially in all functions connected with muscular movement. In some instances, several sets of organs are affected, in others only one; while, again, in others, the whole system is evolved in the general debility. But, whatever are the variations in this respect, there is no definite relation between the severity of the primary symptoms of diphtheria and that of the sequelae. The primary symptoms, though very formidable, yet by no means of necessity prove fatal; while, on the other hand, the comparative mildness of the attack will not justify an absolutely favorable prognosis, since death sometimes follows where everything had seemed to warrant the most confident expectation of recovery." Several cases are related by M. Faure, in illustration of the diff'erent phases of this condition, and he then proceeds to sum up the general results as follows: " Some time after an attack of diphtheria, from which the patient has so completely recovered that no trace of false membrane is left behind, the skin grows causelessly more and more colorless, so that at length it assumes an almost livid pallor. Severe pains begin at the same time to be felt in the joints, the patient loses power over his limbs, and soon sinks into a state of indescribable weakness. At the same time, the disorders that appear in different functions show that the various organs which should minister to them are involved, so far as they are dependent upon muscular power. In this respect, however, the phenomena are not constant, for sometimes it is one set of organs, and sometimes another, which suffers most from this weakness. " Yery generally, in consequence of the want of muscular power, or, more strictly speaking, in consequence of its complete abolition, the patient becomes unable to sit upright, or does so with great diffi- culty ; while the legs cannot bear the weight of the body, the arms become nerveless and cease to obey the will, and all the movements grow uncertain, tottering, hesitating, and apparently purposeless. Very remarkable disorders show themselves also within the throat; for the velum is completely paralyzed, and hangs down like a flaccid lifeless curtain, which interferes with speech and deglutition. All the muscles of the jaw, those too of the neck and chest, are partially para- lyzed, in consequence of which mastication is rendered difficult, and the food can neither be easily moved about in the mouth, nor readily swallowed. From the same cause too it is not unfrequently regurgi- tated, and the laborious deglutition often induces spasm of the respi- ratory apparatus. Vision is impaired, one or other pupil often remains widely dilated, even in the strongest light, and squinting is not unu- sual. The sensibility of the skin is much diminished; in the limbs it is sometimes completely lost, though morbid sensations—such, for instance, as formication—are sometimes experienced. (Edema of various parts often occurs, while, though less commonly, parts here 1 L'Union Medicale de Paris, Fevrier, 1857; and J. Kinderkr., Jan. 1858. DIPHTHERITIC PARALYSIS. 347 and there lose their vitality, and become gangrenous. No general reaction occurs, fever is rare. The skin usually has a certain degree of moisture. The features grow duller and more and more expres- sionless, though a foolish smile sometimes crosses them, or now and then a ray of intelligence appears. Some patients have frequent faint- ing-fits. As the condition goes on from bad to worse, the weakness becomes extreme; and death at length either follows some fainting-fit, or takes place when exhaustion has reached its uttermost—life as it were quietly, almost imperceptibly, passing away." This fatal termination is, however, an exceptional occurrence; and, indeed, the symptoms of diphtheritic paralysis are not usually by any means so severe as the above description implies. My own impres- sion too (though I have not statistical data sufficient to warrant a posi- tive statement on the subject) is that diphtheritic paralysis is far rarer in this country than on the Continent, or at least than at Paris. I have not seen in the Children's Hospital any of the graver forms of the affection succeed to diphtheria for which the patient was admitted when in its acute stage; and, further, the number of children received on account of paralytic symptoms at all has been but small, and the cases not severe. Even in private practice, while a large number of diphtheritic patients have come under my observation, the instances of paralysis succeeding have been so few, that I may, I think, feel sure that in London paralysis does not follow diphtheria with anything like the frequency with which it is stated on the best authority to occur in Paris.1 The form in which diptheritic paralysis most frequently shows itself, is that in which the soft palate is affected, producing nasal Voice, and occasional difficulty in deglutition. Next in frequency, I have observed impaired power over the limbs, the lower being affected oftener and to a greater degree than the upper; and with this there was associated, in many instances, indistinct articulation, with strabis- mus, dilated pupils, and imperfect vision. Once I saw a child on whom tracheotomy had been successfully performed on account of diphtheria affecting the larynx, and from whose windpipe the canula had been removed early, attacked some days after the wound had healed completely, by such difficulty in breathing from paralysis of the muscles of the larynx, as to raise in the mind of the medical at- tendant the question whether fresh disease had not come on. I have also seen death occur in two children three years old—in the one ten 1 M. Roger, in his valuable paper on this subject, estimates the frequency of para- lysis at a third of the cases in which life was prolonged sufficiently to allow of its occurrence. See his " Recherches sur la Paralysie Diphtheritique," in Archives de Medecine, 1862, vol. i. p. 1. It can scarcely be necessary to observe that as the characters of the same disease vary at different periods in the same country, so may they also differ in different countries at one time ; and that discrepancies between the statements of observers in France and England do not of necessity imply error on the part of either. It so chances that in the whole course of my practice I have only thrice met with cutaneous diphtheria, once affecting the vulva, once the anus, and once attacking an abraded surface. Judging by the statements of French physicians, my experience would have been widely different if the scene of my observations had beeu on the other side of the Channel instead of in England. 348 DIPHTHERITIC PARALYSIS. and in the other seven weeks after the invasion of diphtheria—and who had both appeared to have completely recovered from the disease. The paralytic symptoms supervened in both these cases on slight catarrh, which, however, was unattended by bronchitis. In both cases the little patients objected to take food; and in one, any attempt at deglutition, especially of fluids, brought on most distressing cough. No rales were heard in the chest, but mucus collected in the windpipe1 which the children made fruitless efforts to expectorate; while the pupils became dilated, the lips livid, and the surface cold and clammy, during the attempt to get rid of the obstacle to the entrance of air. At length the power of coughing ceased, and then the children died— one seven days, the other five days, from the first interruption to their convalescence. These paralytic symptoms vary in the date of their occurrence as well as in their severity. I have already referred to the failure of the power of the heart, and to the paralysis of the respiratory muscles, as sometimes carrying off' patients during the acute stage of diphtheria. The more remote results, however, with the exception of the paralysis of the soft palate, which sometimes persists from the first attack of the disease, do not come on until after a distinct interval of apparent convalescence, marked by nothing but that state of general weakness which might be expected to succeed to the previous illness. They bear no necessary relation to the severity of the previous attack, nor to the quantity of albumen which had been present in the urine; and I remember to have seen them in a very marked form in a little boy, in whom the previous diphtheria was so slight as to have been unrecog- nized, and he was supposed to have suffered only from influenza with a little sore-throat. I do not know after how long a period from the attack paralytic symptoms may come on, and to the best of my belief we are not as yet furnished with data sufficient to form a positive opinion on the subject, though the two cases I have related above prove that a lapse even of several weeks furnishes no positive guaran- tee against their occurrence. It has been alleged, that these paralytic affections have in them nothing of a specific character—that, so far from belonging exclusively to diphtheria, they are occasionally met with, presenting the same essential features, after many acute diseases; or that, in other words, diphtheritic paralyses are but a particular example of a very general rule. Now I do not believe this; for though, as I have already stated, diphtheritic paralysis has appeared to me to be of far less frequent occurrence in this country than on the Continent, I yet have met with paralysis after diphtheria far more frequently than after any other acute affection of early life. In some very rare instances, indeed, T have known paralytic symptoms succeed to measles and typhoid fever; but even in these cases it has assumed a form similar to that of the so called 1 See the most elaborate series of papers by Dr. Gubler, devoted to the support of this paradox, in the Archives de Medecine, 1860. Vol. i. pp. 257, 402, 534, 693- vol. ii. pp. 187, 718; and 1861, vol. i. p. 306. DISTINCTIONS BETWEEN DIPHTHERIA AND SCARLATINA. 349 essential paralysis of childhood, has affected the same parts from the outset, and has presented nothing of that progressive character which one observes in diphtheritic paralysis. In France—where this paralysis, as I have already mentioned, has occurred in as many as a third of all cases of diphtheria in which the patients have survived the urgent dangers of the acute stage of the disease—there is even stronger ground than my own experience would furnish for regarding it as one of the ordinary sequelae of the disease, and for looking on it as having as much of a special character as belongs to that form of dropsy which we look upon as one of the peculiar incidents of the desquamative stage of scarlatina. This disposition to the occurrence of paralysis as its most frequent sequela, is also not without interest as bearing on a question more debated a few years since than it is at the present day—namely, that of the exact relation subsisting between diphtheria and scarlatina. Of late, indeed, the question seems to have been nearly set at rest by the unanimous recognition of the essential differences between the two diseases. It may, however, be worth while to sum up briefly the majority of those differences, which I think justify us in the assertion that diph- theria and scarlatina, however allied in some of their characters, are yet diseases essentially distinct from each other:— 1st. In all epidemics of scarlatina the anomalous cases, in which the characteristic rash is absent, form but a very small minority. In epi- demics of diphtheria, however, the existence of a rash, even though most partial and evanescent, is but rarely noticed, and in the majority of epidemics is not at all observed. 2d. In cases of malignant scarlet fever terminating fatally, and with- out the appearance of any rash, death usually occurs very early, and is preceded by very marked cerebral disturbance, by violent delirium, or by profound insensibility; while, on the other hand, the fatal issue in diphtheria is generally far less speedy in its approach, and the dis- ease, even in its worst forms, is usually remarkable for the perfect clearness of the intellect almost to the very last. 3d. The characters of the tongue in diphtheria differ entirely from those which it presents in scarlatina; and even the rash, on the occa- sional appearance of which so much stress has been laid, is in many respects dissimilar from the scarlatinoid eruption. It is for the most part a uniform blush of erythematous redness, unattended by the pecu- liar punctated appearance which marks the scarlatinoid rash. It appears suddenly in patches, is vivid from the very first, not deep- ening gradually in intensity like the rash of scarlet fever; while its sudden and speedy disappearance is not followed by any change in the other symptoms, nor by any increase in their severity. 1 may add, still further, that the appearance of any rash at all is a purely exceptional occurrence. 4th. The oedema of the surface, which is occasionally present, comes on during the acute stage of diphtheria, not during its decline: it is inconsiderable in degree, is unaccompanied by serous effusion into the cavities of the chest or abdomen, and is by no means of necessity asso- 350 DISTINCTIONS BETWEEN DIPHTHERIA AND SCARLATINA. ciated with albuminuria. The presence of albumen in the urine is not accompanied with any other change in its character such as would be obvious on a cursory examination; for, though lessened in quantity, it still continues pale in color, and acid in its reaction,, and I have not met with any instance in which blood was present in it. The albu- men seems also often to disappear at a very early period of the dis- ease—its disappearance takes place suddenly; and though its presence is almost invariably observed in cases where the disease is severe, yet there does not seem to be any necessary connection between the urine becoming non-albuminous and the disease assuming a milder type. 5th. The whole train of the sequelae of the two affections is entirely diff'erent; and while, on the one hand, the convalescence from diph- theria presents none of the formidable dropsical symptoms which so often succeed to scarlet fever, the peculiar loss of nervous power and the temporary muscular paralysis which often follow diphtheria have no analogy to any of the sequelae of scarlet fever. 6th. Scarlet fever does not protect from diphtheria, nor, on the other hand, does diphtheria defend from scarlet fever. To both of these facts universal experience bears testimony, and it would scarcely be justifiable to assume that every instance, or even the majority of instances, of the succession of diphtheria to scarlet fever, or the oppo- site, are illustrations of a secondary attack of scarlet fever. An exam- ple which puts this in a very strong light was recently communicated to me. In a school in the neighborhood of London diphtheria broke out; many of the lads were affected by it, and one or two died. Several of those who were convalescent from the disease were sent to the seacoast for the more speedy recovery of their strength, and while there some were attacked by scarlet fever; and this also, in one or two cases, proved fatal. Still stronger, however, is the evidence sup- plied by cases in the Children's Hospital, where patients recovering from scarlatina have been attacked by diphtheria; and the reverse, in which children convalescent from diphtheria have been attacked by scarlatina; showing that the one disease exerts no more preservative influence from the other than does measles or typhoid fever, each of which (as the table referred to some short time since proves) may fol- low diphtheria, or be followed by it. Two main points are involved in the treatment of this disease—the one the control of the local mischief, the other the support of the con- stitutional powers. All the various measures which have been em- ployed are directed to one or other of these objects; and there is at the present day a degree of unanimity as to the means to be resorted to, such as is of rare occurrence in questions of therapeutics. Depler tion, antiphlogistics of all kinds, blisters, and all counter-irritants by which the surface may be abraded, though used at one time, under what are believed to have been mistaken views as to the nature of this affection, are now by common consent altogether discontinued; and the only points debated among practitioners regard the compara- tive merit of this or that local application, or of this or that tonic medicine. 1 do not believe that there is any remedy, either local or general, TREATMENT OF DIPHTHERIA. 351 which exercises a specific influence over diphtheria—such, for instance, as the chlorate of potass seems to possess in controlling stomatitis, or as quinine displays in cutting short an attack of ague. There is, how- ever, usually a very marked connection between the early arrest of the deposit, however affected, and the speedy recovery of the patient, although it sometimes happens that the constitutional symptoms of the disease have a fatal issue after all trace of false membrane has dis- appeared from the fauces. In illustration of the connection between the arrest of the deposit and the cutting short of the disease, M. Trous- seau relates the story of the epidemic prevalence of diphtheria in a village, where all the cases treated by the medical men, who confined themselves to the employment of constitutional remedies, proved fatal; while the only cures were wrought by an old woman, who despised the doctors and their remedies, and applied indiscriminately to every- body's throat a rough and rather violent escharotic. The practice, however, which this story seems to inculcate—and which I, in common with many others, was at one time accustomed to adopt—has come of late years to be regarded as of more than doubt- ful expediency. The application of a strong solution of nitrate of sil- ver, as two scruples to an ounce of distilled water, or of equal parts of hydrochloric acid and honey, by means of a soft camel's-hair brush, on the first discovery of the deposit, sometimes seems to arrest its extension. At the same time I am fully satisfied that often-repeated cauterization, in the hope of thereby overtaking the spread of the disease, not merely fails of this result, but often produces an increase of swelling and greater difficulty of deglutition. But, though the repetition of the stronger caustics is injurious, bene- fit may often be derived from some of the milder local applications. T.hus, for instance, a gargle of half an ounce of the solution of chloride of soda to six ounces of water, or a similar application made to the back of the throat with a soft camel's-hair brush, or the syringing the mouth with it every three or four hours, often relieves the local mis- chief, and at the same time promotes the patient's comfort, by freeing the mouth from the ropy mucus and the other secretions which are apt to accumulate in it. The mere gargling with iced water, or the frequent swallowing of small pieces of ice, is also of much service in many instances, when the swelling and the difficulty in deglutition are considerable; but, unfortunately, it is almost impossible to induce children to carry out any of these measures with perseverance. The discharge from the nostrils, which is a very frequent and very troublesome complication, may generally be checked by the injection, twice in the twenty-four hours, of a solution of one or two grains of nitrate of silver to an ounce of water; and the swelling of the sub- maxillary glands may often be diminished by warm fomentations, or by the application of spongio-piline, or a linseed meal poultice to the neck. Something, too, may be done to promote the patient's comfort, and to lessen the danger of aff'ections of the air-passages, by providing (as was suggested when I spoke of croup) for the presence of a warm and moist atmosphere in the room ; and, in the early stage of the affection, 352 TREATMENT OF DIPHTHERIA. by the inhalation, if the child is old enough to employ it, of the steam of warm water, or of warm vinegar and water. While the above local measures are had recourse to, the constitu- tional treatment must be pursued no less diligently. In this it is important to bear in mind that the feverish condition, which is often observed at the outset of diphtheria, must not mislead us into with- holding nourishment, or into resorting to any strenuously antiphlo- gistic treatment. If, indeed, there is much heat of skin at the onset of the attack, if the tongue is coated, and the bowels are constipated, an ipecacuanha emetic may be given, followed by a few grains of gray powder, and a mild saline aperient, as the sulphate of magnesia, or its effervescing citrate. A simple saline, as the citrate of potass, may afterwards be continued every three or four hours, to each dose of which four or five grains of the chlorate of potass should be added. All this time, too, the child should be kept in bed, since it is of the greatest moment to avoid all needless expenditure of the strength; while, though wine may at first be unnecessary, beef-tea must be given from the very first, and stimulants can seldom be long delayed. The softness and feebleness of the pulse, indeed, almost always give, in spite of the temporary heat of surface, plain intimation of the course which we shall have to pursue; and very often a shorter time than twenty-four hours suffices to dissipate entirely the febrile symptoms with which the disease set in, and to show it in its real characters. I have already expressed my disbelief in the existence of any spe- cific remedy for diphtheria, though I have given, and am accustomed to give, the tincture of the sesquichloride of iron in a large proportion of cases. It has seemed to me to be a valuable medicine, but no more; and in my hands it has never vindicated its claims to those special virtues, for which some practitioners give it credit. I gene- rally employ it in combination with the chlorate of potass, giving about four grains of that salt and eight minims of the tincture every four hours, to a child five years old. I have never seen reason for believing that where ordinary doses of a remedy fail, extraordinary doses would succeed; and when one physician talks of giving fifteen minims every quarter of an hour, day and night, for seventy-two hours, I do not know whether to marvel more at the endurance of the patient, or the hardihood of the doctor.1 Iron has seemed to me, in some instances to indispose the patient for taking food, or to incapa- citate the stomach for bearing it; and sometimes on this account, sometimes simply from its failing to produce any good effect, I have discontinued it, and had recourse instead to quinine, with hydrochloric acid and tincture of bark; and this again has succeeded in some in- stances, and not succeeded in others. In the great majority of instances, it must be confessed that the employment of medicine has seemed of importance altogether subor- dinate to the administration of food and stimulants; and children of four years old have taken six ounces of port wine, and one or two 1 Dr. Aubrun, in a communication to the Academie des Sciences, at Paris, Nov. 20 1860: reported in the Journal f. Kinderkrankheiten, Jan. 1861, vol. xxxvi. p. 141. TREATMENT OF DIPHTHERIA. 353 ounces of brandy, for several days together, not only with manifest advantage, but apparently as the only means by which Hie could fee maintained. When deglutition has been very difficult, or when, without any absolute difficulty in swallowing, the patient has refused nourishment, or the stomach has rejected it, I have had recourse to beef-tea enemata with temporary advantage; though in no instance did a patient ultimately recover in whom vomiting, or indisposition to take food was other than a very transitory symptom. Mention has been made of the scanty secretion of urine in some cases of diphtheria, and of the excessive quantity of albumen which it is then found to contain, as one of the gravest symptoms of the dis- ease. Dr. Wade1 of Birmingham—to whom we are indebted for pointing out the structural changes in the kidneys which are found associated with this condition of the urine, and which are in many instances apparent even within the first three or four days from the commencement of diphtheria—insists on the employment of the iodide and chlorate of potass almost from the first, and on the administration of large quantities of fluid, as infallible preventives of this danger, and indeed of every other. There can be no doubt but that the quan- tity of the urinary secretion may be greatly increased by drinking large quantities of water, and that, in many instances, the absolute (not the merely proportionate) quantity of albumen is simultaneously diminished to a very considerable extent. It is, however, a very different thing to induce a child of three years old, suffering from scarlatinal dropsy, to drink a quart of water daily, from what it is to force upon it large quantities of fluid, at a time when every attempt at deglutition produces intense pain, and when it taxes the attendants to the utmost to induce the patient to swallow enough to maintain the flagging powers of life. It is during the early stage of the disease, when deglutition is commonly most difficult, and dangers from other sources are most pressing, that the troubles of the urinary secretion are commonly encountered in their gravest forms. I have given the iodide of potassium in these cases, just as I have given it in combi- nation with other valines in scarlatinal dropsy. I believe the remedy to be a serviceable one: but I must at the same time add, that there seem to me to be few things more injurious to the advancement of medical knowledge, than the aphoristic dogmatism which enunciates a certain mode of treatment as one in which "no instance of a fatal termination" is met with " where it has been carried out." Now and then a single dose of ipecacuanha, in the earlier stages of the disease, has relieved the difficulty of deglutition where that was troublesome; but I have not observed any internal remedy check the advance of croupal symptoms coming on in the course of diphtheria for which tonic and stimulant measures had already been necessary. In those instances in which the disease has announced itself almost from the outset by croupal symptoms, I believe that the presence of false membrane on the fauces should not betray us into any wide devia- 1 In his essay, "Observations on Diphtheria," 8vo. London, 1858 ; and a subsequent paper, "On Diphtheria," priuted at Birmingham in 1863. 26 354 DIPHTHERITIC CROUP COMPLICATING MEASLES. tion from that course of treatment which we should adopt in cases of primary cynanche trachealis; and the administration of emetics (though not of antimonials) and the steady employment of mercurials, though the patient may at the same time stand in need of support and stimu- lants, have seemed to me of great moment. In these cases, however, even more than in those of inflammatory croup, the early performance of tracheotomy has appeared to me to be indicated, so soon as remedies ceased to tell on the symptoms of disordered respiration. I do. not know that there is any specific treatment which we can recommend for the removal of the paralytic symptoms that succeed to diphtheria. First of all, it is to be borne in mind that they have a tendency to spontaneous subsidence with the lapse of time; in the next place, the longer the interval between the acute stage of diphtheria and the supervention of the paralytic symptoms, the less is in general their gravity; and thirdly, so long as the impaired power is limited to the extremities, and to the muscles of deglutition, we are warranted in entertaining a favorable view of the case, which, however, is no longer justified when either the muscles of respiration are involved, or the action of the heart is disturbed. As a general rule, tonic remedies are indicated; and I have been accustomed to employ preparations of iron, in combination with nux vomica, or strychnine. I have fre- quently observed recovery to take place, slowly but steadily, under the use of these means: I do not, however, know of any case in which the improvement was so marked as to justify me in saying, that the remedies, independent of the influence of time and of general hygienic measures, had had an important share in producing it. There is another form of disease, allied to diphtheria by many of its characters, allied to cynanche laryngea by others, which presents itself to us as a most dangerous complication of some other affection, almost always of measles. I was familiar with this, and described1 it, at a time when my acquaintance with genuine idiopathic diphtheria was ^'ery slight and imperfect; and I reproduce my account of it here, because in a few respects—as for instance in the ulcerative stomatitis, with which it was associated—it differed from those forms of diph- theria with which I have since become conversant. This variety of croup seldom begins until the eruption of measles is on the decline, or till the process of desquamation has commenced. Its occurrence is most frequent from the third to the sixth day from the appearance of the eruption, but it oftener occurs at a later than at an earlier period. It is sometimes attended with well-marked symp- toms from the very first; but it often happens that the character of the disease is masked, and its course insidious, and that the degree of suffering during life affords no correct index to the amount of mischie^which may be revealed by a dissection after death. Of itself it is highly dangerous, and its hazard is increased by the frequent coexistence with it of inflammation of the lungs, which serves more- over to throw the symptoms of croup into the shade. When the laryngeal affection comes on three or four days after the appearance of 1 Medical Gazette, Aug. 25, 1843. DIPHTHERIA COMPLICATING MEASLES. 355 measles, its presence is usually betokened by much more obvious symptoms than when it occurs after the lapse of a longer period from the febrile attack. Sometimes, however, it develops itself unnoticed, simultaneously with the measles, and causes a fatal issue when the medical attendant is least prepared to expect it. The child in such cases is evidently more seriously ill than can be accounted for by the mere existence of measles; but he makes no definite complaint, neither are there any obvious indications of the special suffering of any particular organ. There are considerable drowsiness, disinclina- tion to swallow, and reluctance to speak; but the cough may be very slight, and the respiration free from distinct croupy stridor, while the child speaks in so Iowa tone that it is almost impossible to appreciate any alteration of the voice. In such circumstances, the most careful observation is needed to avoid error. The loss of voice should of itself direct attention to the state of the larynx; the cry should be listened to attentively ; pressure should be made on the larynx, to ascertain whether much tenderness exists, and examination of the fauces should never be neglected. But little less obscure, and of much more frequent occurrence, are those instances in which the laryngeal affection attends the process of desquamation. Recovery up to a certain point has probably gone on well, when sometimes with, sometimes without, an increase of the cough and morbillous catarrh, the febrile symptoms become exacer- bated, and the child droops again, apparently without any adequate cause. Sometimes a loud sonorous cough, succeeded or accompanied by alteration of the respiratory sounds, betrays the nature of the disease; but at other times there are no symptoms besides unusual drowsiness, reluctance to speak, or alteration in the tone of the voice, with disinclination to swallow, or difficulty in the act of deglutition. In many instances deglutition is scarcely at all impeded; and I remember only one case in which the difficulty of swallowing was so great that fluids returned by the nose. But even though these symp- toms be but slight, it will usually be observed, on examining the mouth, that the gums have a spongy appearance, or are actually ulcerated, that the tongue is preternaturally red and raw, and that small aphthous ulcers have formed upon its edges and on the lining membrane of the mouth. The soft palate will usually be seen to be red and swollen, and specks of false membrane will be observed on the velum or tonsils. In such a case, if it terminate fatally, the dura- tion of life is very variable; though the disease, for the most part, runs a somewhat chronic course. The child's strength declines daily, and emaciation makes rapid progress ; yet no acute symptoms appear. There is great restlessness, and no posture seems easy to the child; or else it sits constantly upright in bed, distress and dyspnoea fol- lowing any attempt to place it in the recumbent position. The alter- ation of the voice is succeeded by complete aphonia; the frequent hacking cough, which had previously caused much annoyance, ceases altogether; and, although evidently thirsty, the child often refuses drink, or swallows with difficulty. Diarrhoea, or pneumonia, usually supervenes, and hastens death; though in some instances exacerbation 356 LARYNGITIS STRIDULA. of the croupal symptoms, coupled with the increasing weakness of the child, are the only causes of the fatal termination. On examining after death the bodies of children who have died of this aff'ection, not only is the mucous membrane of the mouth found inflamed and ulcerated, but the soft palate, fauces, epiglottis, and the upper part of the pharynx are seen to be more or less intensely con- gested, and coated more or less extensively with false membrane. The epiglottis is often ulcerated on both its surfaces, and partially coated with false membrane ; and the mucous membrane of the larynx is generally eroded by numerous small ulcerations, as well as covered with a similar deposit. I have in no instance observed false membrane extending below the larynx; and although the trachea is usually congested, sometimes intensely so, yet this is by no means of invariable occurrence. Bronchitis and pneumonia, especially the latter, are frequent complications of this aff'ection. The peculiar sound that characterizes the cough of croup, the stridor of the respiration, and the urgent dyspnoea which attend the progress of the disease; result, as I scarcely need remind you, almost entirely from the spasmodic action of the muscles of the larynx, and not from the mechanical obstacle which the presence of false mem- brane offers to the free admission or exit of air. We have seen that these symptoms are, on the whole, less marked in cases where croup appears as a secondary aff'ection, and the larynx becomes involved by the extension to it of disease beginning in the throat, than in those where the air-passages themselves are primarily affected. Still they vary much, both in the period of their occurrence and the degree of their severity, even in those cases that much resemble each other; and they bear no certain relation to the intensity of the inflammation any more than to the amount of the deposit of false membrane. The diversities in this respect depend on constitutional peculiarity rather than on any essential differences in the nature of the disease. This view, indeed, is not taken by all writers, but some observers of deservedly high repute—such, for instance, as M. Guersant1—have conceived that there are differences sufficient to warrant our placing it in a separate category those cases of croup which are marked by the predominance of spasmodic symptoms. They have proposed to desig- nate this form of the disease by the name of laryngitis stridula, to dis- tinguish it from ordinary croup, the laryngitis pseudo-membranacea. It was doubtless the observation of some cases of this kind that led Dr. Millar,2 more than ninety years ago, to describe under the name of the "acute asthma" a disease resembling croup in many respects, but presenting a mixture of spasmodic and inflammatory symptoms— the former predominating at the commencement of the disease, the latter towards its close. Dr. Millar appears, indeed, in some measure to have confounded two very diff'erent aff'ections,—the true spasmodic croup, or laryngismus stridulus, with the inflammatory croup, or 1 In the article " Croup," in vol. ix. of the 2d edition of the Dictionnaire de Mede- cine, &c. Paris, 1835. 2 "Observations on the Asthma and on the Whooping-Cough," 8vo. London, 1769. LARYNGITIS STRIDDLA. 357 cynanche trachealis, under the idea that they constituted the two stages of one disease. But, nevertheless, cases are sometimes observed that bear a very close resemblance to Millar's description, though no advan- tage seems to me likely to arise from constituting a new species of croup out of a modification in its symptoms produced by the idiosyn- crasy of the patient. In some children there is a greater tendency to spasmodic affections than in others: in such the laryngeal nerves will take the alarm at the very outset of the disease, and the paroxysms of dyspnoea will consequently commence at an early stage, and will soon attain great intensity but may become masked by the permanent distress of breath- ing to which the disease in its progress gives rise. In other instances, the symptoms of inflammatory disease, and those of spasmodic distur- bance, may be so commingled, or may so alternate with each other, as to render it hard to tell from which the child suffers most. This was the case with a little boy, ten months old, who some years since came under my care, suffering from what seemed at first to be ordi- nary inflammatory croup. The symptoms, though not very urgent, were plainly marked, and the active employment of antimony soon dissipated them. During the whole course of the disease, however, the child, who seemed highly nervous and excitable, suffered from fits of dyspnoea far more severe than could have been anticipated from the general mildness of the attack, or than would have been supposed to exist by any one who had seen the child only in the intervals of the paroxysm. The cough and respiration had for forty-eight hours entirely lost all croupy character, and nothing but catarrh seemed left behind; when the child was suddenly seized with extreme difficulty of breathing, attended with slight croupy noise, and lay stiff in his nurse's arms with his thumbs drawn into the palms of his bands, aud his great toe separated from the others. Four-and-twenty hours had elapsed from the supervention of these new symptoms before I was able to visit the child. He was then extremely restless; his face was flushed, his thumbs were drawn into the palms of his hands, and his feet were forcibly extended; his breathing was labored, and attended with a hoarse croupy sound, which became still more distinct whenever the child coughed. The bowels had not acted for a couple of days; but an hour after my visit some purgative medicine, of which large doses had been given during the previous six or eight hours, began to act, and produced three very copious evacuations, with perfect relief to all his symptoms. The carpopedal contractions disappeared, the respiration became easy, and the face ceased to be flushed or anxious. The child slept well through the night, was cheerful on the following day, and still hoarseness attending his occasional cough was the only remaining symptom. In a day or two that also disappeared, and the child perfectly recovered. The influence of that spasmodic element which enters so largely into the production of the symptoms of cynanche trachealis, is seen in many cases in the long persistence of a croupy sound with the cough, aud in its subsequent recurrence when a patient who has once 358 SPASMODIC AFFECTIONS OF THE LARYNX. had croup catches cold. In these cases the nerves have doubtless not thoroughly recovered from the effects of the previous inflammation. Before closing this lecture, one or two additional illustrations may be adduced of spasmodic affection of the larynx in connection with dis- ease seated elsewhere;1 though the remarks made at an early period of the course, on spasm of the glottis as a frequent attendant on the convulsive affections of infancy, must have made you thoroughly familiar with its occurrence.2 1 See Lecture xiii. p. 162. 2 There is a form of spasmodic affection of the larynx, which, under the name of Thymic Asthma, has attracted considerable attention among continental writers, though my own experience concerning it is confined to a single case which I observed many years ago. The spasm of the glottis which is the most prominent symptom in this affection is supposed to be due to the pressure of the hypertrophied thymus on the larynx, and the consequent irritation of its nerves. The essay of Haugsted—Thymi in homine, etc.: descriptio anatomica, pathologica et physiologica, 8vo. Hafnise, 1832—may be consulted with advantage by any one desirous of becoming thoroughly acquainted with the subject. I owe to Professor Gairdner, of Glasgow, the obligation of his having directed my attention in a note at p. 263 of his Lectures on Clinical Medicine, by which he has left all members of our profession largely his debtors ; to the memoir by Dr. Hood, of Kilmarnock, on Spasm of the Glottis from enlarged Thymus, published in the Edinburgh Medical Journal for January, 1827. He " who proves, discovers," is an old adage, but a true one ; I am glad that it should find a fresh verification, as in Dr. Hood's case, among our northern countrymen. I will merely relate the case to which I have referred, and do so rather on account of its rarity than of any important practical inferences which I am prepared to deduce from it. The subject of the observation was a little boy, who was brought to me at the age of six months, suffering from symptoms which his mother said had existed, though in a less aggravated degree, almost from the time of his birth ; but which had not much alarmed her until they were followed by an attack of general convulsions a day or two before I saw the child. These symptoms consisted in the occasional occurrence of great difficulty in breathing, attended with considerable livor of the surface, con- tinuing for a very short time, and returning every two or three weeks without any assignable cause. From the sixth month the child seemed very liable to catch cold, and had frequent cough and wheezing; but a little rhonchus was all that was ever perceptible in the lungs; and febrile symptoms were at no time apparent. The attacks of difficult breathing often occurred at night, the child waking from sleep with them, or they were sometimes produced by deglutition, which process always seemed to be attended with slight difficulty whenever the child attempted, as it grew older, to swallow semi-solid substances. It was remarkable that no distinct crowing sound ever attended the inspiration : but that the child having turned extremely livid during the paroxysm of dyspnoea, gradually recovered its breath, and the livor and anxiety of the countenance disappeared by degrees. Profuse perspiration about the head gene- rally followed these seizures; and sometimes the child would pass into a state of general convulsions, in which, however, it did not struggle much, but continued to breathe hurriedly for some time after they had passed off. From about the ninth month, slight cough was almost constantly present, though still unattended by any febrile disturbance : the head was sometimes very hot, and the difficulty of deglutition, the dyspnoea, and the convulsions, increased both in severity and in the frequency of their recurrence. The child now cut the two lower incisors, but without any change taking place in his general condition. Two or three weeks before his death, which happened when just a twelvemonth old, he had an attack of coryza, with abundant puriform discharge, which, by its hardening, blocked up the nostrils, and caused a good deal of distress in breathing though unattended by any really grave symptom. He was recovering from this, when one morning early, a paroxysm of dyspnoea came on, which was followed by a slight fit that left him pale and exhausted. About two hours afterwards, his breathing not having become as quiet and natural as before the first paroxysm, another attack came on, in which he died. On examining the body after death, the lividity of all the depending parts was very remarkable. SPASMODIC AFFECTIONS OF THE LARYNX. 359 MM. Rilliet and Barthez have described a spasmodic cough that returns in paroxysms, is loud, attended with an imperfect hoop, and may be easily taken for hooping-cough by the inattentive observer. It is, however, a symptom of bronchial phthisis, due to the extension to the larynx of irritation seated in a distant part of the respiratory organs. Intestinal irritation is a frequent cause of nervous cough in child- hood. It is sometimes a loud, solitary, ringing cough—the tussis ovilla, tussis ferina of medical writers; at other times it is a short dry cough, attended with no particular inconvenience, but teasing from its frequency. Both of these forms appear to result in many instances from the presence of worms, and speedily cease under the judicious employment of purgative medicines. Lastly, I may once more remind you of the cough which is oc- casionally heard in the early stage of inflammatory affections of the brain. It is a very short, hoarse cough, which sometimes continues for a few minutes almost incessantly, then ceases for a time, and then, after a pause, returns again. The disturbance of the brain is sympa- thized with by the larynx, and the depletion which relieves the former organ, removes the irritation of the latter. The pericranium stripped off very easily from the bones of the skull, which were exceedingly vascular. There was considerable vascularity of the dura mater, the sinuses of which, aud the cerebral veins generally, were gorged with fluid blood. There was no injection of the pia mater; sections of the brain presented a rather greater number of bloody points than natural, but its substance was firm, and the lateral ventricles contained but little fluid. The first object seen on opening the chest was the thymus gland, which occupied the whole of the anterior mediastinum, and nearly concealed the heart. Its structure was apparently natural; its length was 3| inches, and it weighed 328£ grains. The heart was extremely large, as large as the heart of a child three years old. Its auricles and the veins, both the cavae and the pulmonary veins, were full of fluid blood. The organ was not well contracted; its structure was perfectly healthy, and the footal openings were closed. There was a good deal of thick mucus in the trachea and bronchi, but they were perfectly healthy ; and the rest of the body presented no remarkable appearance, except that a considerable extent of both lungs was in a state of carnification. Now, notwithstanding some points of difference between this case and those in which spasm of the glottis has been induced by a different cause, yet we recognize in it the grand symptoms of that affection, and those the same as make up the spasmodic element in cases of inflammatory croup. The enlargement of the thymus appears to have induced permanent irritation about the windpipe, which betrayed itself by the frequent cough and the constant wheezing. To the same cause, too, must be referred the difficult deglutition, while the convulsions were probably much favored by the enlarged gland pressing upon the superior cava and right auricle, and thus impeding the return of blood from the head: nor must we forget, among the probable causes of the child's sudden death, the remarkable degree of cardiac hypertrophy. The fatal event, however, might possibly not have occurred but for the attack of coryza, and the consequent impairment of the respiratory function, which naturally tended to increase the congestion of the brain. 360 HOOPING COUGH. LECTUEE XXVI. Hooping-Cough.—Course of the disease in its simplest form—subject to great variations in its mode of onset and degree of severity.—Signification of the hoop.—Course of the dis- ease when declining—Its danger depends on its complications—Complication with bron- chitis—at its outset, or when it has continued for some time—Complication with disorder of the nervous system—sometimes exists from the first, and causes death even before characters of disease are fully developed—but may come on at any period—various forms assumed by disorder of nervous system—great danger when paroxysms of cough termi- nate in convulsions—caution as to nervous character of dyspnoea in many cases, and as to danger of over-treating it.—True hydrocephalus rare as a complication. We pass to-day to the study of one of the most common disorders of childhood. Few persons attain to adult age without having ex- perienced an attack of hooping-cough, and still fewer of those who escape it when children suffer from it in after-life. Hooping-cough, then, claims our notice as being essentially a disease of early life; but as it is one which almost every old woman professes to cure, we might fairly expect not to be detained long with its study. We find, however, that in this metropolis it ranks forth among the causes of death under five years of age; inflammation of the lungs, convulsions, and hydrocephalus, being the only more fatal ailments. A cursory inquiry will not suffice to make us thoroughly acquainted with all points of importance in the history of a disease that has so many victims. The aff'ection in its simplest form consists of a cough of spasmodic character, that usually succeeds to catarrhal symptoms, and having recurred at intervals for a few weeks, ceases without having occasioned any serious disturbance of the general health, or having required any active medical treatment. In its graver forms it is one of the most fearful diseases that we ever have to encounter, often keeping the life of the patient for days or weeks together in almost constant jeopardy, liable to be exaggerated by the most trivial cause, or rendered fatal by the slightest error in treatment; while the highest effort of our art is limited to mitigating the severity and warding off' the urgent danger of symptoms which we are unable wholly to subdue, and which we must trust to time and nature thoroughly to cure. Such great differences in the course of the disease in different cases have given rise to many ingenious theories as to its nature and seat, framed with the view of explaining that which cannot but strike all observers as so enigmatical in its character. None of these specula- tions, however, have led to any useful practical result, and we shall be better employed than in their study, if we confine ourselves to the simple observation of the phenomena of the disease. In doino1 this, we will begin with those cases in which it is most simple and least perilous COURSE OF THE DISEASE IN ITS SIMPLEST FORM. 361 and will then examine in succession the different modes in which its course becomes complicated and dangerous. An attack of hooping-cough usually begins with catarrh, and pre- sents at first little or nothing to distinguish it from a common cold, except that sometimes the cough is attended almost from the outset with a peculiar ringing sound. By degrees the catarrhal symptoms abate, and the slight disturbance of the child's health altogether ceases, but nevertheless the cough continues; it grows louder and lasts longer than before, and assumes something of a suffocative character, in all of which respects a tendency to exacerbation towards night becomes early apparent. As the cough grows severer, its peculiarities become more and more manifest; during each paroxysm the child turns red in the face, and its whole frame is shaken with the violence of the cough. Each fit of coughing is now made up of a number of short, hurried expirations, so forcible, and succeeding each other with such rapidity, that the lungs are emptied, to a great degree, of air, and the child is brought by their continuance into a condition of impending suffocation. At length the child draws breath with a long, loud, sono- rous inspiration, the hoop from which the disease derives its name, and the attack sometimes terminates. More often, however, the hoop is followed by but a momentary pause, and the hurried expiratory efforts begin again, and are again arrested by the loud inspiration, perhaps only to recommence; until, after the abundant expectoration of glairy mucus, or retching, or actual vomiting, free inspiration takes place, and quiet breathing by degrees returns. If you listen to the chest during a fit of hooping-cough, you will hear no sound whatever in the lungs; but when the hoop occurs, you will once more perceive air entering, though not penetrating into the minuter bronchi. It is not till the fit is over, and respiration once more goes on quietly, that the air reaches the pulmonary cells again; but then you will hear vesi- cular murmur as clear as if nothing ailed the child, or at most inter- rupted only by a little rhonchus, or by slight mucous rale. If the cough is severe, quiet breathing does not return, nor the vesicular murmur become audible, till some time after the paroxysm is over; and occasionally, short and laborious respiration ushers in each fit of coughing. The child then seems to have a presentiment of the coming seizure; its face grows anxious, it looks up at its mother, and clings more closely to her; or, if old enough to run about, you may observe it, even before its breathing has become manifestly affected, throw down its playthings, and hasten to seize hold of a chair, or of some article of furniture, for support during the approaching fit of coughing If the case is uncomplicated, even though the attack be severe, the child's health continues good, and little or nothing ails it during the intervals of the cough. Its appetite is not impaired, but after throwing up the contents of the stomach in a fit of coughing, it asks for food almost immediately. It sleeps soundly, except when roused by the cough; the bowels act regularly, or are perhaps a little constipated, and slight complaint of headache or languor, with loss of the usual cheerfulness, are often all the permanent ill effects to be discerned between the seizures. 362 DURATION OF CATARRHAL STAGE OF HOOPING-COUGH. After the hoop has been heard, the disease goes on for about a week to increase in severity, the cough becoming more frequent, its parox- ysms severer and more suffocating, and attended with more frequent hoop. After remaining stationary for ten days or a fortnight, it begins to decline; and one of the first indications of this is usually afforded by a diminution in the severity of the nocturnal exacerbations. We next find, either that the fits of coughing are less frequent, or, though they should occur as often as before, yet they are less severe, and some- times cease without the occurrence of a hoop. When 'on the decline, however, exposure to the cold, neglect of the state of the bowels, or mental excitement, will suffice in many cases to bring back the hoop, and to increase the previously diminished severity of the attack. For the most part, the cough loses its spasmodic character for many days before it ceases altogether; and you may even find a child, otherwise in good health, who, some six weeks after an attack of hooping cough, still has occasional returns of cough, which a slight cause would once more convert into an ailment with all the characters of fully developed pertussis. Such is the ordinary course of the disease in those cases in which it is unattended by any complication, and does not give rise to any formidable symptom, but issues in the complete recovery of the patient. But even in favorable cases its course is often variously modified, while these modifications derive additional importance from frequently betokening or accompanying some of those serious complications to which the danger of the disease is almost exclusively due. The average duration of the catarrhal stage of hooping-cough as deduced from a comparison of fifty-five cases, in which the date of the occurrence of the first distinct hoop was ascertained, was 12.7 days. In nineteen of these cases the first hoop was heard within seven days from the commencement of the catarrhal symptoms, and in nineteen more cases during the succeeding seven days; but the extreme limits of the duration of the premonitory stage are very wide apart, since on one occasion it lasted only two days, and on another thirty-five days. But there are many other respects in which the mode of onset of hooping-cough varies, as is clearly shown by the following facts:— In fifty-five cases the average duration of the catarrhal stage was 12.7 days; the extremes being 2 and 35 days. In eighteen cases the catarrhal stage lasted on the average only 8.3 days, when the cough assumed a distinctly paroxysmal character; but no hoop occurred till the fifteenth day. In four cases, after the catarrhal stage had lasted on the average 11.5 days, the cough became paroxysmal, but no hoop occurred during the whole course of the aff'ection. In one case the cough had a distinctly paroxysmal character from the first, but no hoop occurred during the whole course of the affection. In six cases the cough was paroxysmal from the outset, and continued so on the average 9.3 days, at the end of which time distinct hoop accompanied it. In three cases a distinct hoop attended the cough from the very commencement. Some of these may be merely accidental differences, but I believe that most of them are by no means unimportant, and that they depend VARIATIONS IN MODE OF ONSET OF HOOPING-COUGH. 363 on causes with which a little observation will make you acquainted. My excuse, indeed, for bringing before you such dry detail with refe- rence to hooping-cough, is, that there is scarcely any other disease of early life concerning which we are so much in want of definite facts. Its general features are so obvious, that persons have not observed with equal care those less striking characters which yet are of much moment, as affording sure grounds for prognosis, and trustworthy indications for the guidance of treatment. Unusual protraction of the catarrhal stage of hooping-cough is, I believe, usually met with either at the commencement of an epidemic of the disease, or towards its close. Epidemic hooping-cough very frequently succeeds to epidemic catarrh; the former disease becoming gradually developed out of the latter, and the persistence of cough in Beveral cases long after the decline of all other indications of catarrh is often one of the first signs of the commencement of an epidemic of hooping-cough. The characters of hooping-cough, like those of other epidemic diseases, often become less marked towards the decline of its prevalence, and we then meet with cases in which catarrhal symptoms continue long, while the paroxysms of cough are slight, and the hoop occurs very seldom and not severely. It may be laid down as a gene- ral rule, that those cases in which the catarrhal stage is of long con- tinuance seldom become severe during their subsequent progress, and the same holds good with reference to the majority of those cases in which the hoop does not come on until after the cough has for some time assumed a paroxysmal character. There are, however, some instances, which we shall hereafter have to notice, where the long duration of the paroxysmal and suffocative character of the cough, unattended by any hoop, is a sign of the peculiar intensity of the dis- ease, rather than of its mildness: on the other hand, the preternatural shortness of the catarrhal stage, or its total absence, is not of itself any proof that the disease will be more than usually severe. It is usually observed in very young children, who, as I have already told you, are but little liable to catarrhal affections, and who are not so often attacked by hooping-cough as those who are older. Sometimes, how- ever, when other children in the same family are suff'ering from it, they contract the disease apparently by contagion, and in that case it frequently happens that no purely catarrhal symptoms precede it, but that the cough from the first presents a paroxysmal character, and soon becomes attended with a distinct hoop. Instead of coming on with catarrh of moderate intensity, hooping- cough sometimes sets in with great fever, dyspnoea, and many symp- toms of severe bronchitis; though the results of auscultation do not indicate such serious disease as, judging from the amount of constitu- tional disturbance, we should expect to discover. In such cases, it is only on the subsidence of the acute symptoms, which usually give way speedily under treatment, that the real nature of the disease becomes apparent. We then observe, however, that while the child in all other respects improves, the cough continues unabated, that it soon grows more severe, returning in paroxysms, and being attended before long by the characteristic hoop. Besides these cases, there are 361 PROGRESS OF AN ATTACK. others, though much less common, in which, though the catarrhal symptoms are not unusually severe, the child yet has paroxysms of dyspnoea, which generally come on at night, and may excite much apprehension on the part of the parents. The attacks do not appear to be induced by any previous fit of coughing, and after lasting from half an hour to an hour they pass off of their own accord, leaving the child free for many hours together, and probably not returning until the following night. While the child continues subject to them, auscultation discovers no sign of serious mischief in the lungs ; but in proportion as the paroxysms of the cough increase in distinctness, and the hoop becomes established, the fits of dyspnoea diminish, and in the course of a few days entirely disappear. Some days usually elapse after the general characters of the disease have become well marked, before it reaches its acme, and during this time its nocturnal paroxysms generally increase in a greater ratio, both as to frequency and severity, than those which occur by day. Such, at least, was the course of the disease in thirty-eight out of forty-seven cases in which this point was especially noticed. The nocturnal ex- acerbation is sometimes so marked, that the fits of coughing are not only severer, but are actually more numerous by night-time than by day. In very mild cases of hooping-cough there is but little differ- ence between the frequency and severity of the paroxysms at night- time and by day; and in other instances, while the child rests quietly through the greater part of the nightn there is yet a marked aggrava- tion of the cough on first lying down at night, and on first waking in the morning. When the exacerbations occur at these two periods, the evening exacerbation is often induced by the child being removed to a bed-room less warm than the apartment in which it spends the day, while the morning attack results from the accumulation of mucus in the bronchi during the hours of sleep. Neither of these causes, however, is the sole occasion of the in- creased severity of the disease at night, nor is the occurrence peculiar to hooping-cough, but is observed also in asthma, and in many other affections of the respiratory organs in adults. The severity of the nocturnal paroxysms is often a very good criterion of the general se- verity of the disease; and any exacerbation of the disease is usually attended with special exacerbation of the nocturnal paroxysms, and not merely by more frequent coughing and hooping, but likewise by a marked increase of dyspnoea. On the other hand, a diminution of the nocturnal exacerbations is one of the most frequent indications that the disease has begun to lose something of its previous severity, and the cough often ceases entirely at night for some time before it disappears completely during the daytime. Cough, preceded by catarrhal symptoms, aggravated in paroxysms, assuming a suffocative character, and attended with a peculiar sonor- ous inspiration called a hoop, were said to be the characteristics of this disease. The last two of these phenomena are the special results of the nervous element which goes to make up the very compound character of hooping-cough. Hence, in those cases which are very mild, there is so little spasm of the glottis, that air enters freely when CAUSE OF HOOP WHICH ATTENDS FITS OF COUGHING. 365 the child draws breath after a fit of coughing, and the hoop is occa- sional and faint, while it is still more seldom that the cough displays that suffocative character which, when severe, constitutes one of its most formidable peculiarities. None of the phenomena of this disease call forth such close obser- vation as the hoop from which it derives its name. Its occurrence in- dicates on the one hand the existence of spasm of the glottis; and hence in those cases which are very slight it takes place but seldom, while it hardly ever comes on until the disease has lasted a certain time, and acquired a certain degree of intensity. It shows, however, on the other hand, that air does enter when the child endeavors to in- spire, and, therefore, in cases of severe hooping-cough, a loud, long- drawn, sonorous hoop, instead of adding to our apprehension, tends rather to quiet it, for it assures us that the spasm does not amount to actual closure of the glottis, and that, for this time at least, the child will not choke in the fit of coughing. I have already mentioned to you that the nocturnal dyspnoea which excites anxiety in some cases while hooping-cough is coming on, or may disappear altogether when the disease has assumed its regular type, and the hoop has become loud and distinct. Just in the same way, the violent suffocative cha- racter of the paroxysm often abates, the fits of coughing become fewer, and the dyspnoea grows less urgent, after the hoop has become developed. But, if the disease should increase in severity, cough comes on more frequently, and the paroxysms are of longer continuance, so that the face grows quite livid before they pass away. The pauses in the fit are now no longer marked by the sonorous hoop, but after a momen- tary cessation, the cough recommences; and though when at length the attack passes off'a hoop is heard, it is more stridulous than it used to be, though not so loud. Each paroxysm of cough is now preceded and followed by marked dyspnoea, and the child has scarcely recov- ered from one attack before another comes on. The hoop now some- times disappears altogether, or is very occasional, very short, and suppressed ; and then the cough itself loses its former character; the child dreads its approach much, and tries to suppress it, but in vain ; the whole frame labors with the convulsive efforts, but no sound is produced : the larynx is now completely closed ; violent, but fruitless, expiratory efforts are made, as in some of the worst cases of spasmodic croup, till general convulsions come on ; or at length the spasmodic constriction yields, and the attempt at expiration is successful. The spasm over, the child once more draws breath, but it seems quite ex- hausted by the violence of the struggle; while sometimes, before it has recovered from this seizure, another, and then another, succeeds, till one at length proves fatal. When the disease has approached to this degree of intensity, we should rejoice to hear the loud, long hoop again, which would be a sure token of some diminution in the suffocative character of the cough. We should next find that as the hoop regained its former character, those more numerous but less distinct efforts, which the child had made before, would be merged in the single prolonged 366 COMPLICATIONS OF HOOPING-COUGH. inspiration. The dyspnoea would next diminish, and then the severity of each paroxysm would grow less; and then they would not recur so often, and the hoop would be less loud, and the night attacks less frequent. If amendment were to continue, the attacks would become more brief, and they would sometimes pass off without any hoop, while the mucous expectoration would become more copious; next the hoop would altogether cease, but the cough would continue to recur in paroxysms, and to present something of its old suffocative character; and then this too would cease, though cough might still continue for a time longer. The variations in the course of hooping-cough which I have now described, depend for the most part either on the greater or less in- tensity of the disease, or on some idiosyncrasy of the patient, or on some peculiarity in the epidemic constitution of the year. There are, however, other, and some of them much more important changes in its symptoms and its course, which resultfrom hooping-cough becoming complicated with another disease. Of these complications, by far the most frequent and most perilous are those which it presents with bronchitis and pneumonia on the one hand; and with convulsions, congestion of the brain, or hydrocephalus, on the other. Their import- ance, too, is greatly increased by there being no period of the disease to which we can look as bringing with it any immunity from either; but, from the commencement of the cough to its complete disappear- ance, we are at any moment exposed to the risk of disease, either of the lungs or of the brain, converting a trivial into a most formidable affection.1 The circumstances in which hooping-cough becomes associated with other affections of the respiratory organs are very various. Sometimes, as I have already mentioned, rather severe bronchitic symptoms, fre- quent short cough, and considerable dyspnoea, precede the full development of the disease. This occurrence is oftenest met with at the commencement of epidemics of hooping-cough, or in children the mucous membrane of whose air-tubes may be supposed to have acquired a peculiar susceptibility from many previous bronchitic 1 Of 35 children who died of hooping-cough under my care, 17 perished in conse- quence of the supervention of bronchitis or pneumonia ; 18 from congestion of the brain, from convulsions coming on in a fit of coughing, or from hydrocephalus. Reckoning the commencement of the disease from the first distinct hoop, or first appearance of a well-marked paroxysmal character of the cough, it appears that of 31 cases in which this point was noted— Dying through the lungs. 0 2 2 0 1 2 3 1 4 15 Dying through the brain. 1 4 3 2 1 0 3 1 1 16 Total. 1 6 5 2 2 2 6 2 5 31 Dying \rithin 7 days. 14 " 21 " 28 " 5 weeks. 6 " 7 " 8 " from 8 weeks to 3 months. COMPLICATIONS OF HOOPING-COUGH. 367 seizures. On the whole, however, these are not the cases which need excite our greatest solicitude, for the constitutional symptoms, which are generally out of all proportion to the amount of the local mischief, usually subside in the course of a few days, just as we often .observe to be the case with epidemic influenza in the adult: and as the char- acteristic cough and hoop come on, all cause for anxiety disappears. Those cases are in general much more serious in which the symp- toms of bronchitis or pneumonia come on after the cough has assumed the characters of hooping-cough. This complication sometimes occurs very early in the course of the disease, and then the bronchitis and hooping-cough appear to be developed almost simultaneously. -For a day or two, perhaps, a hoop has been heard accompanying the cough at intervals, and nothing has appeared to indicate that the attack will be unusually severe, when all the symptoms suddenly become very much aggravated; the skin grows hot; the respiration and pulse become very much hurried, and this increase in their fre- quency is permanent, though much greater at one time than at another. The cough at the same time becomes more frequent and more severe, and the hoop is more violent; but the cough is almost entirely unattended with expectoration, or if a little mucus be spit up it is almost always streaked with blood. Though very violent, the fits of coughing are not very long, and they seldom or never end with vomiting. The ear detects mucous rale through nearly the whole of both lungs: on a deep inspiration, still smaller sounds are heard, for inflammation has attacked the minuter air-tubes; and the case is one of hooping-cough complicated with capillary bronchitis. Supposing the disease to continue, the cough will often in a day or two lose its characteristic hoop, an occurrence which you will likewise observe in the course of many other intercurrent febrile or inflam- matory affections that may supervene during an attack of hooping- cough. The cough, too, may become less frequent, or may lose its paroxysmal character, though it will still appear to cause much suf- fering. The respiration will increase in frequency, the child constantly laboring for breath, and being distressed by the slightest movement, since that adds to its dyspnoea. In one little child two years old, the inspirations two days before her death were 130 in the minute, and then on the following day they sank to 80: but her feet were now cold, her face was livid, and her pulse very feeble. It was she of whose lungs I showed the drawing some days since, illustrative of vesicular bronchitis; and her case might be taken as a type of those in v\ hich acute bronchitis comes on at an early stage of hooping-cough. Death takes place more speedily in cases of this kind than under any other form of affection of the lungs which comes on in the course of hooping-cough. I have seen a child on the sixth day from the first appearance of any indication that the disease was other than a very mild attack of hooping-cough. It will not surprise you that the fatal event should take place so speedily, if you bear in mind that after death we discover either intense injection, even of the smaller bronchi, with copious effusion of pus into their cavities, or very extensive vesi- cular bronchitis, or both conditions together. 368 COMPLICATIONS OF HOOPING-COUGH. But it is not only at the outset of an attack of hooping-cough that we encounter the danger of becoming complicated with other disease of the lungs. Exposure to cold, or damp, may at almost any period induce an exacerbation of the cough, or a distinct attack of bronchitis. If, however, the disease have already lasted for some ten days or a fortnight, without having presented any grave features, such inter- current bronchitic seizures are usually very tractable. As a general rule, those cases have appeared to me to be far more serious in which bronchitic symptoms become developed of their own accord out of severe hooping-cough. In such cases there has usually been a gradual increase in the child's sufferings; the cough growing more frequent, and, though not more violent, yet evidently occasioning the child greater suff'ering: while the hoop is unchanged in its charac- ter. At the same time the child seems overwhelmed by the disease; its face is anxious and puffed, the eyes are much suffused, the skin usually dry and hot; dyspnoea is no longer confined to the periods just before and just after a fit of coughing, but the respiration is habi- tually wheezing, hurried, and rather irregular. The ear, at the same time, detects mucous or subcrepitant rale through the whole of both lungs. Such cases are seldom very rapid in their course. The symp- toms, after exciting our solicitude for a week, ten days, or a fortnight, may gradually abate in severity, and the disease may run the remainder of its course slowly, but safely. If the case should have an unfavorable issue, this sometimes takes place speedily, owing to the supervention of cerebral symptoms; and the child then dies during a paroxysm of coughing. Or the minute bronchi may become involved in the inflam- matory mischief; the case may assume the characters of pneumonia, and bronchial breathing and dulness on percussion may reveal during the patient's lifetime the nature of the mischief which will be disclosed on an examination after death. In a still more numerous class of cases, the disease retains its chronic character to the last, and presents little or no variation from day to day. The violence of the cough, and the frequency of its return, some- times continue unabated, though often they undergo a marked dimi- nution. The respiration grows more hurried than before, the fever becomes exacerbated, and the emaciation extreme; while the child's strength is still more enfeebled by the supervention of a troublesome diarrhoea, which no remedies are adequate to restrain. Death at length takes place, sometimes from pure exhaustion ; and the transition from sleep to death is so gentle as to be almost imperceptible. At other times an increase of the symptoms of bronchitis or pneumonia becomes apparent for two or three days previously: or in other cases the child dies exhausted in a fit of coughing, or convulsions take place a few hours before death, and the patient dies convulsed or comatose. The complication of hooping cough with serious disorder of the nervous system, is almost as frequent as its association with grave mischief in the lungs and air-tubes, and even more dangerous and perplexing Hazard from this source attends alike the onset of the disease, its acme, and decline; and the mode in which the danger presents itself is no less variable than are the seasons of its occurrence. The ner- CEREBRAL CONGESTION. 369 vous system sometimes suff'ers so severely from the very first, that death takes place almost before the disease has had time to assume its usual characters. At other times hooping-cough comes on naturally ; its two elements, the bronchitic and the nervous (if I may be allowed the expression), increase daily in intensity, till all at once the symp- toms of the former recede, and are almost lost in those of the latter, which in a day or two bring on the fatal termination of the case. Or, lastly, no symptoms referable to the nervous system call for our solici- tude until after the hooping-cough has continued many weeks; but then the long continuance of the disease seems to excite mischief in the brain, and death overtakes the patient when we had already begun to hope that nothing more than time was needed to perfect his cure. Danger from this cause sometimes assumes the form of simple con- gestion of the brain ; drowsiness is followed by convulsions, and these are succeeded by fatal coma. In other instances the spinal system of nerves becomes excited to more tumultuous reaction; and carpopedal contractions, and attacks of spasm of the glottis, are superadded to frequently recurring general convulsions; while in some cases the long continuance of hooping-cough gives rise to the development of acute hydrocephalus. The time will not be lost which we may spend in the examination of each of these various modes in which hoopiug- cough becomes complicated with disorder of the nervous system. In very young children, and in those in whom the process of den- tition is still going on at the time of their becoming affected with hooping-cough, the symptoms of disturbance of the nervous system are sometimes formidable even from the outset. In such cases the preliminary catarrh is usually of short duration, and the cough, though not very frequent, yet assumes a paroxysmal character almost from the first. Each fit of coughing is extremely violent and suffocative ; it lasts for several minutes, is not attended by any distinct hoop, nor followed by vomiting, but ceases apparently from the child being too exhausted to make any further effort. In the intervals of the cough the face is flushed, the eyes are suffused, and the child is very drowsy, and averse to being disturbed—a condition which is manifestly in- creased by each paroxysm of coughing. When the cough comes on, the flush of the face deepens to a livid hue, the pupils become dilated, convulsions seem impending and at length come on, and though but of short continuance, yet they often leave the child in a state of pro- found stupor. This condition seldom lasts long; sometimes the effort at coughing brings on a fatal convulsive seizure, at other times the cough does not return, but convulsions recur independently of it, and in twenty-four or thirty-six hours from their first occurrence, the child dies. No cases of hooping-cough run so surely or so speedily as these to a fatal termination, which even the most judicious treatment will often fail to prevent. I have seen death take place in less than a week from the commencement of the cough, and have known several instances of its occurrence long before the lapse of a fortnight. The circumstance of the cough having run its course naturally up to a certain point, affords, however, no guarantee against the superven- 24 370 DANGER WHEN CONVULSIONS RETURN FREQUENTLY. tion of a danger similar to that which we have just been contemplat- ing. It is, indeed, but seldom that any case which for the first ten days or fortnight has been mild in character, afterwards presents these alarming symptoms of cerebral disturbance ; for in most instances the cough will have been severe from the commencement, the paroxysms frequent and of long continuance, the hoop loud, each attack terminat- ing with vomiting, aud the return of each being much dreaded by the child. In all this, however, there is nothing to direct special at- tention to the head, and the approach of the new danger is not always very obvious. Sometimes the first indication that the head suff'ers is afforded by the increased irritability of the stomach, which becomes almost unable to retain food or drink. And here let me urge upon you the importance of duly estimating the signification of this symp- tom. Vomiting, independent of the fits of coughing, if it persist for above twenty-four hours, and be not referable to the remedies you are employing, nor connected with obvious gastric disorder, should always excite your solicitude, and direct your attention most anxiously to the head. At other times, either in connection with this irritability of the stomach, or even independently of it, the child is observed to become daily more heavy and drowsy, and averse to movement; complaining of headache if able to talk, and appearing overwhelmed by the disease to a greater degree than can be accounted for either by the severity of the paroxysms or by the frequency of their recurrence. This con- dition is generally succeeded by aggravation of the dyspnoea both before and after each fit of coughing, the respiration sometimes not regaining its proper frequency during the interval between their re- turn, though auscultation fails to detect any adequate cause for this hurried breathing. In some instances the hoop still continues as loud as before; but if that be the case, the cough grows harder, and hardly any mucus is expectorated; while streaks of blood are seen in the matters rejected by vomiting. It happens more frequently, however, that these symptoms are associated with a more or less complete sup- pression of the hoop; the cough losing something of its distinctly paroxysmal character, but becoming more suffocative; the child, on each occasion of its return, vainly striving to suppress it. A convul- sive seizure now, in some cases, supervenes on an effort to cough, and in this the child expires; or the fatal convulsion may come on to all appearance causelessly; or, more frequently, the first convulsion does not occasion death, but it leaves the child in a comatose condition, which is interrupted by the frequent return of convulsions, one of which at length proves fatal. , It happens sometimes that children who are laboring under severe hooping cough are suddenly seized, during a paroxysm of coughing, with a fit of convulsions; and they may die in this fit, even though they had not previously seemed to suffer from any serious disorder of the nervous system. Death in such cases takes place as the result of spasmodic closure of the larynx, and consequent congestion of the brain:: you watch for a few moments the fruitless expiratory efforts of the child, and then all is over, just as in many fatal cases of spas- COMPLICATIONS OF HOOPING-COUGH. 371 modic croup. The relation between hooping-cough and spasmodic croup, indeed, "is sometimes very apparent; and you may observe, after some unusually violent fit of coughing, the thumbs drawn into the palms, the hand flexed upon the wrist, or the great toe drawn apart from the others. At first, probably, the symptoms will be slight, and will soon pass away ; but their import is most serious. You will ex- pect soon to see other and graver indications of the disturbance of the nervous system—if, indeed, they be not already present. It is especi- ally in cases of this sort that you will observe a degree of dyspnoea which you cannot explain ; and that the child will seem to make the most violent efforts to suppress the cough—efforts which are really involuntary, and are the result of the spasmodic closure of the glottis, which is sure, if complete and long continued, to be followed by an attack of convulsions. If treatment fail, the carpopedal contractions will become permanent, the eyes will close but partially, the breath- ing will grow extremely unequal and irregular, as well as hurried, the hoop will no longer be heard, and the cough itself will yield only a kind of smothered sound. The surface will grow quite livid, in consequence of the extremely imperfect performance of the respi- ratory function ; the child will sink into a state of stupor, in which it will lie with dilated pupils and constant twitching of the muscles of its face, till a great effort to cough comes on, and passes almost at once into a convulsive paroxysm. The fits at length occur independent of any attempt at coughing, and once I saw a considerable degree of stiffness of the whole spinal column precede for twelve hours the death of a little boy, who fell a victim to hooping-cough thus sadly com- plicated with disorder of the nervous system. It would be only by the recital of cases that I could bring before your notice each minute variation in the characters of these formida- ble complications of hooping-cough ; and for such details there remains no time to-day. There are two points, however, bearing on this sub- ject, which I am most anxious to impress on your memory. One is, that the supervention of dyspnoea, or the sudden aggravation of diffi- culty of breathing which had existed previously, is often one of the earliest indications of serious affection of the nervous system. The other point, on which I shall have to dwell at our next lecture, is, that if, mistaking the import of this nervous dyspnoea, you direct your treatment to some imagined mischief in the chest, and make free use of antimony and other depressing medicines, you will aggravate, instead of relieving, the difficulty of breathing; and—the irritability of the nervous system increasing in proportion as the respiration becomes impaired—j^ou will hasten the occurrence of convulsions and of that formidable train of symptoms which we have just been contemplating. I mentioned that true tubercular hydrocephalus is now and then met with as a complication of hooping-cough. Fortunately it is not of fre- quent occurrence, though the danger of its supervention should never be forgotten in the case of weakly children who have long suffered from severe hooping-cough. Two instances of it have come under my observation; but in one of these cases the cerebral disease was asso- 872 COMPLICATIONS OF HOOPING-COUGH. ciated with such a large amount of mischief in the chest as would of itself have sufficed to destroy the child. The other case was of much importance, as showing the insidious manner in which fatal disease may steal on, presenting little to excite serious apprehension till long after the possibility of doing good has passed away. The patient, a boy five years old, of a phthisical family on his mother's side, was attacked by hooping-cough, from which he suffered severely. The disease was attended with great dyspnoea, with general cedema and great lividity of the surface. No auscultatory signs of serious mischief in the lungs existed at any time; but the oppression of breathing was so considerable, and the child seemed so completely overwhelmed by the disorder, that I feared he would not recover. After he had suf- fered from the cough for about five weeks, and three weeks before his death, matters seemed to take a more favorable turn; his cough dimin- ished greatly both in frequency and severity, and his strength returned under a tonic plan of treatment. He still, however, continued low- spirited, and very much disposed to sleep; and this condition of depression progressively increased, until, about a week before his death, he sank into a state of complete stupor; but no convulsions occurred either as precursors of the stupor or during its continuance. He lay on his back, either sleeping, or in a state of stupor, from which, how- ever, he could be partially roused, when his pupils, before contracted, would become suddenly dilated to the full, and he would stare wildly about for a few moments: the pupils would then oscillate for a short time between dilatation and contraction, but soon revert to their for- mer contracted condition. The bowels were not constipated at any time, neither did vomiting occur, and the pulse continued frequent till within a day or two of his death. Strabismus came on a day or two before he died, and two days before his death deglutition became dif- ficult, and he began to make slight automatic movements with his hands and arms. Paroxysms of cough continued to recur to the very last: they were suffocative in character, but unattended by hoop. At the end of the eighth week from the commencement of his cough, the child, who was extremely emaciated, died quietly. After death, the membranes of the brain were found much congested; there was a large quantity of fluid in the ventricles; the central parts of the brain were diffluent, and its lower parts were likewise con- siderably softened. The membranes at the base of the brain presented an opalescent appearance, and were bestudded with numerous minute granules, while about the optic nerves they were greatly thickened and infiltrated with that hyaline matter to which I have often called your attention. There was much congestion of the bronchi and pulmonary substance. The lungs contained a good deal of tubercle, mostly in the state of gray granulations, and a small cavity occupied the lower part of the left upper lobe. Many points of importance connected with the history of hooping- cough remain for our examination before we can proceed to consider its treatment; but all of these must be reserved till our next meeting. COMPLICATIONS OF HOOPING-COUGH. 373 LECTURE XXVII. HoopiNG-Couon continued.—Complications with diarrhoea and intestinal disorder—with great irritability of the stomach—with measles and varicella.—Duration of the disease.— Relapses.—Influence of age, sex, season, &c, in its production.—Post-mortem appear- ances. Treatment.—No real specific for hooping-cough.—Treatment of first and second stages— utility of hydrocyanic acid — of counter-irritation—of attention to temperature— danger of overtreating the bronchitis of hooping-cough.—Treatment of third stage of disease. It is a peculiarity of the affection which we are now studying, that much of the suffering, and almost all the danger that attend it, are the result, not of the disorder itself, but of some complication that super- venes during its course. We have already examined the two most frequent and most formidable sources of danger to patients laboring under hooping-cough, but others remain, against which it behooves us to be no less sedulously on our guard. Some days ago I mentioned to you that a state of extreme irrita- bility of the lining of the air-tubes is one of the characteristics of early childhood. To this are due the attacks of catarrh which chil- dren often experience while teething, and the cough which, wholly independent of exposure to cold, comes on as the result of sympathy with irritation in some distant viscus. This high degree of suscep- tibility, however, is not confined to the bronchi, but is possessed in the young subject by the whole tract of mucous membranes: diar- rhoea often accompanies catarrh, or alternates with it, and in the course of inflammation of the lungs, the patient's life is sometimes jeopardied, or his death hastened, by the supervention of intractable looseness of the bowels. Diarrhaa, though comparatively seldom fatal, is frequently a very troublesome complication of hooping-cough, and if it continue, it greatly reduces the strength of a child, and interferes with the em- ployment of some of those means to which otherwise we might have recourse. It sometimes sets in with the preliminary catarrh, and abates as that subsides, but in other cases it harasses the patient at intervals during the whole course of the affection. It is, however, when it supervenes in the course of an attack of hooping-cough which has already attained considerable severity, that it should excite our chief solicitude. It does not, indeed, in the majority of instances, betoken the supervention of disease in the intestines, but it is one of the forms of constitutional disturbance that attend upon a congested state of the brain, or it indicates the advance of serious mischief in the lungs. I have, indeed, seen diarrhoea become the most prominent symptom in a case of severe hooping-cough, the bowels being for days so irritable, that their action was excited by the slightest article of 374 COMPLICATIONS OF HOOPING-COUGH. food and drink, while the abdomen was exquisitely tender; and yet, when death at length took place, unusual redness and prominence of the Peyerian glands were the only morbid appearances in the intes- tines, while the signs of intense bronchitis and inflammation, which in some parts had advanced to suppuration, were discovered in the lungs. An irritable state of the stomach, with occasional vomiting, are symp- toms almost constantly observed at some period or other in the course of hooping-cough. In cases of a mild character, they usually occur only when the cough has reached its acme, and vomiting succeeds to none but the severest fits of coughing, while it is one of the earliest symptoms to cease as the severity of the disease declines. Sometimes, however, very distressing nausea harasses the patient, and efforts to vomit not only follow the paroxysms of coughing, but are excited by food or by the blandest fluid. I have already warned you of the serious import of this symptom in many instances, and have called your attention to it as being frequently one of the earliest indications of cerebral mischief. In some few instances I have observed it come on very early in the disease, and subside by degrees as the cough assumed a distinctly paroxysmal character; just as is the case some- times with that nervous dyspnoea of which I spoke in my last lecture. Sometimes it continues to be a troublesome though almost a solitary symptom of disturbance of the nervous system, the cough not being severe, nor the child's health at all seriously impaired; and in two instances that I met with it appeared to be the result of a state of extreme irritability about the fauces, so that the cough, which hardly ever occurred at other times, was immediately excited by any attempt at deglutition, and the effort to cough terminated almost directly in vomiting. Nausea and vomiting are sometimes associated with general intestinal disorder, and diarrhoea; at other times there is equal evidence of disorder of the digestive organs in a constipated state of the bowels, a red tongue, with perhaps numerous small aphthous ulcers about the mouth, or in the large quantity of frothy mucus rejected by the stomach at each effort to vomit. Before leaving the subject of the complications of hooping-cough, I must notice the relation that appears to exist between it and two of the eruptive fevers, namely, measles and chicken-pox. It has been thought, indeed, by some writers, that there is no connection between these dis- eases other than that of their accidental association ; but my own expe- rience would lead me to incline to an opposite opinion, which is like- wise entertained by several high authorities. I am not, indeed, able to adduce a number of observations bearing on this point sufficient to establish the fact beyond doubt; but my belief is, that the occurrence of any one of these diseases during the epidemic prevalence of another, increases the liability of the child to become affected by that which is epidemic, and that an exacerbation of the fever of hooping-cough, and the appearance of more serious illness than the local symptoms account for, is very likely to be due to the approach either of measles or of varicella. Like other intercurrent febrile and inflammatory aff'ections, both measles and chicken-pox often produce some temporary abate- DURATION OF HOOPING-COUGH. 375 ment of the paroxysms of hooping-cough, and sometimes cure the dis- ease altogether. In this, however, there is nothing constant, for hooping-cough often appears not to be in the least modified in its character by the supervention of the other malady; while in some cases the complication adds to the mischief in the chest, and increases the patient's suffering and danger. Although there are many important points of analogy between hooping-cough and some of the exanthemata, yet in nothing is the difference between these affections more apparent than in the uncer- tain duration of the former, in the exacerbations which take place during its course, either causelessly or from very slight occasions, and in the actual relapses that sometimes occur after apparent cure. It is a matter of considerable difficulty, in the case of a disease so protracted in its course as hooping-cough, to make even an approximation to a correct estimate of its duration. In twenty-five cases, however, I had the opportunity of watching the patients from the time when the cough first assumed a paroxysmal character, or the hoop first became audible, until the final cessation of all cough. From this small number of observations I should be disposed to estimate the average duration of hooping-cough at ten weeks; of which period nearly two weeks1 would be occupied by the preliminary catarrh, for four weeks the cough would present the characteristic hoop, and the cough would continue for about the same period to occur occasionally, gradually losing its paroxysmal character; though exposure to cold, or any trivial cause, would suffice to bring back the hoop, and to restore to the paroxysms of the cough all their former intensity. So long as any cough con- tinues, even though very occasional in its occurrence, and though the hoop have entirely ceased for many weeks, the patient cannot be re- garded as well; while the neglect of proper hygienic precautions may protract the duration of the cough for between three and four months— an occurrence by no means unusual among the poor. I have on several occasions treated children for hooping-cough during the spring, in whom the hoop has disappeared, and the cough almost ceased, in the warm months of summer; but on the approach of autumnhas returned with nearly its former intensity. In other cases, hooping-cough con- tracted in the early part of autumn has returned during the prevalence of cold March winds; or a casual catarrhal seizure has been followed by a recurrence of all the signs of the disease in a severe form. These relapses of hooping-cough frequently set in with considerable severity, the paroxysms of cough being very frequent, and the hoop loud and often repeated; but, if treated judiciously, they are much more ame- nable to remedies than is the first attack of the disease. A true recurrence of hooping-cough, after the disease has been per- fectly cured, is at least as unusual as the occurrence of measles or smallpox twice in the same subject. Only one instance of hooping- 1 The estimate of the duration of the catarrhal stage is deduced from the observa- tions of 55 cases, and the exact period of its continuance was 12.7 days. Of the 25 in which the total duration of the cough from the occurrence of the first hoop was noted, 11, or nearly half, showed a duration of eight weeks ; and the duration in the remaining 14 cases varied from four to twelve weeks. 376 CERTAIN CAUSES WHICH PRODUCE HOOPING-COUGH. cough affecting the same patient more than once has come under my notice. In that case the patient was a girl aged seven years, who, when three years old, had very severe hooping cough, which lasted for several weeks, the paroxysms of cough being frequent, and the hoop loud and often repeated. In March, 1815, hooping-cough being then epidemic, she experienced a return of the disease in a very severe form, and continued to suffer from it until the end of June. But little more remains to complete the history of the disease, except that we notice briefly the circumstances in which it comes on. It is essentially an affection of childhood, few children escaping from it, while more than half of the cases of it occur before the completion of the third year. After the age of five years its frequency rapidly dimi- nishes, and after ten it becomes so extremely rare, that out of 1,367 cases in which I noticed the patient's age, I find but eleven in which it exceeded ten years.1 The occurrence of the disease appears to be influenced to a considerable degree by sex as well as age; and, as is the case with a large number of the non-inflammatory disorders of the nervous system, females suffer from it in a considerably larger pro- portion than males. Of 100 cases of hooping-cough, at the Children's Infirmary, 55.3 per cent, occurred in females, only 44.7 per cent, in males; although the total number of female children to the total num- ber of males among my patients at that institution was only as 50.2 to 49.8. Age and sex exert an evident influence on the mortality of the disease as well as on its prevalence, both being greatest in early cnild- hood, though hooping-cough does not seem to be so formidable before the commencement of dentition as it is while that process is going on. Female children are not only more liable to the aff'ection, but it proves more fatal to them than to boys in the proportion of about 3 to 2.2 1 Of the above 1,367 cases— 41.2 per cent, occurred during the first 2 years of life. 56.7 " " " " 3 " 82.9 " " » " 5 " 98.4 " " " " 10 " The subjoined table shows the proportion borne by these hooping-cough cases to 14,440 cases of all diseases at the same ages, which occurred during the same period at the Children's Infirmary. Cases of hooping-cough constituted— 8.4 per cent, of all cases occurring under the age of 6 months. 10.4 " " 10.3 " " 9.3 " " 12.2 " " 14.6 " " 13.2 " " 11.2 " " 7.2 " " .8 " " 2 The subjoined table shows the age at which death took place in 35 fatal cases of hooping-cough:— from 6 months to 12 " 12 18 " 18 2 " 2 years to 3 3 4 4 " 5 mder 5 from 10 " 10 " 15 years. 0 under 6 months. 5 between 6 months and one year. 6 " 1 year and 2 years. 8 " 2 " 3 " 4 " 3 " 4 " 6 between 4 years and 5 years. 1 " 5 " 6 " 3 " 6 " 7 " 1 " 7 " 8 " 1 " 10 " 11 « MORBID APPEARANCES IN HOOPING-COUGH. 377 Hooping-cough is a disease of all climates, and though more fre- quent in the cold than in the warm months of the year, yet its epi- demics break out at almost all seasons. The epidemic of 1811-2 reached its acme in the months of December and January ; while in 1815, cases of hooping-cough were by far more numerous in the months of June and July than during any other part of the year. Though little influenced by the season of the year, the outbreak of an epidemic of hooping-cough seldom, if ever, takes place suddenly, and altogether without warning. Sometimes, as already mentioned, it succeeds to an epidemic of measles, but still more frequently it fol- lows an unusual prevalence of catarrh, which gradually assumes a paroxysmal character, and puts on the characters of hooping-cough. In a similar way, epidemic hooping-cough sometimes resolves itself into simple catarrh; the signs of disturbance of the nervous system by degrees disappearing, and the cases presenting the indications of mere bronchial irritation. The question whether hooping-cough is a contagious disease, has long since been set at rest by a general answer in the affirmative. How long it retains this character is an inquiry to which it is not pos- sible to return any very precise reply; but so long as a child who has suffered from hooping-cough continues to cough at all, even though only once or twice a day, I should be unwilling to restore him to the society of children who have not already had the disease. All children are not equally susceptible of the contagion, and infants under six months old appear to be especially indisposed to receive it, either by association with other children, or as the result of atmos- pheric influence. If carefully kept from contact with other children, infants of tender age will very often escape during the general preva- lence of hooping-cough, and in nearly half of the cases of hooping- cough that I have met with in infants under six months old, other children in the family had suffered from it for a week-or ten days be- fore the infants showed any symptom of it. You may expect, perhaps, that before I pass to the consideration of the treatment of hooping-cough, I should say something about the morbid appearances to which it gives rise, and about the essential na- ture of the aff'ection. I know, however, of no morbid appearances peculiar to this disease, nor do I think that much would be gained by a disquisition on its seat, or on the occult cause of its symptoms. It is through the medium of the lungs, or of the brain, that death takes place in nearly every instance of fatal hooping-cough ; and almost all the structural lesions of importance are found in one or other of those This result tallies very closely with that afforded by the Fifth Report of the Re- gistrar-General, from which it appears that the deaths from hooping-cough in London were to the deaths from all causes in the proportion of— 5.6 per cent, under one vear old. 5.0 per cent, between 5 and 10 years. 10.6 " between 1 and 3 years. .8 " " 10 " 15 " 10.2 " " 3 " 5 " Of the 35 cases that came under my notice, 21 occurred in female, and only 14 in male children ; and the mortality under ten years of age from hooping-cough is to the total mortality at that age in London in the proportion of 8.9 percent, among female, and 6.1 per cent, among male children. 378 STATE OF THE LUNGS IN HOOPING-COUGH. organs. The vessels of the brain and its membranes are often found over-filled with blood, though even in cases where death has taken place in convulsions, or has been preceded by a comatose condition, these appearances are sometimes much less marked than might have been expected, and occasionally are altogether absent. Softening of the cerebral substance, or other indications of inflammatory action, are very seldom met with; increased vascularity of the organ, with perhaps a small quantity of fluid in the ventricles, being almost the only morbid appearances in the encephalon. It is but seldom that the lungs are found free from disease, though they present no structural changes that can be regarded as character- istic of hooping-cough. The mucous membrane of the bronchi is generally injected; sometimes it is intensely red, while an abundant secretion of thick mucus occupies the cavities of the air-tubes, and their calibre is much increased. This dilatation of the bronchi, which sometimes is very remarkable, arises from inflammation of the air- tubes, just as it does in ordinary bronchitis, and is not due, as has been erroneously supposed, to the violence of the child's inspiratory efforts. The emphysematous condition of the lung, which is likewise observed in many cases of fatal hooping-cough, has also been referred to the same forcible attempts at inspiration. MM. Eilliet and Barthez,1 however, have observed that the supposed violence of the inspiratory efforts during hooping-cough is altogether a mistaken assumption; for the efforts made during a paroxysm of coughing are expiratory, the lungs during a severe seizure being almost emptied of air; while in the inspiratory efforts that succeed, the air at first does not pene- trate beyond the larger bronchi, and is long before it again freely permeates the pulmonary vesicles. The objection raised by these gentlemen to the inspiratory theory, as explaining the production of emphysema in cases of uncomplicated hooping-cough, is, I believe, quite unanswerable. The fact, however, still remains that the condi- tion is met with, and sometimes in an extreme degree, in the lungs of children who have died of hooping-cough unassociated with other diseases of the respiratory organs. To such cases the expiratory theory2 applies pre-eminently; for, during the violent expiratory efforts with a closed glottis which characterize a paroxysm of the cough, the air is driven forcibly towards the upper part, and the circumference of the lungs; in other words, towards just those parts which are the least compressed, and which observation shows to be the favorite seats of emphysema. In those other cases of hooping-cough, in which exten- sive collapse of the lungs takes place, the emphysema is produced by iust the opposite means; on which, indeed, I need not dwell now, since I explained them fully in a former lecture.3 I may, however, just observe, that the forcible expiratory efforts which are so charac- teristic of hooping-cough, as they tend in one way to the production of emphysema, so in another they exercise a powerful influence in ' Lib. cit., vol. ii., 2d ed., p. 631. 2 See Dr. Jemier's exposition of it in vol. xl. of the Medico-Chirurgical Transactions. * Lecture xx. p. 262. CONDITION OF THE PNEUMOGASTRIC NERVES. 379 occasioning collapse of the lung; and few cases of hooping-cough ter- minate fatally in which you will not find after death a more or less considerable portion of lung in this condition. It may be simply collapsed, resuming its natural appearance readily when inflated; or the bronchial tubes may have been the seat of inflammation, and be more or less filled with puriform mucus, when the characters of vesi- cular bronchitis will be superadded to those of mere collapse or carni- fication, and air will permeate the organ very imperfectly or not at all. It cannot be necessary to describe again those other changes which may take place in carnified lung, and which end in the infil- tration of pus into its tissue, or in the formation of vomicae, since I treated fully of this subject a few days ago.1 I do not dwell on other appearances in the chest, such as pleurisy and lobar pneumonia, which are much less often met with, and which have none other than a perfectly casual connection with hooping- cough ; but I must notice one morbid condition alleged to have been frequently observed, and which is of the more importance, since it has served as the foundation of a theory of the disease. The pneu- mogastric nerves have been discovered by various observers redder than natural, and in some cases swollen and softened—appearances which have been regarded as indicating that they had been the seat of inflammation. Even those observers, however, who have noticed this condition, appear to have met with it but seldom, while others have sought for it in vain in a large number of cases. Professor Albers, of Bonn,2 states that, having examined the bodies of 47 children who died of hooping-cough, he found the nervi vagi perfectly healthy in 43. In 3 the vagus of the right side, and in 1 that of the left side, was slightly reddened; but this redness corresponded to the side towards which the body had been inclined, and in no respect differed from what is observed in the bodies of plethoric persons, and of 1 It would be unjust to leave this subject without calling the reader's attention to the excellent account of collapse or carnification of the lung contained in Dr. Alderson's paper on the Pathology of Hooping-cough, published in the year ls30, in vol. xvi. of the Medico-Chirurgical Transactions. In this paper, he not only describes very cor- rectly the anatomical characters of this condition, which had merely been indicated by previous observers, and speaks of it as a state different from pneumonia, which MM. Rufz and Gerhard did four years later, but he also suggests an explanation of its occurrence, which the recent researches of MM. Bailly and Legendre prove not to have been far from the truth. It may be well to quote two passages from this paper: "In many other [cases] I have invariably found the same appearances, uncomplicated with any evidence of pleuritic inflammation. In the lower and posterior portions of the lungs, the structure was rendered very firm and dense ; the portions which were the subjects of this change were exactly defined by the septa ; of a dull red color, devoid of air, sinking instantly in water, and thin slices undergoing no change by ablution. The individual lobules were more dense than in hepatized lungs ; and the cellular membrane between them retaining its natural structure, conveyed to the touch' the same sensation that is felt on touching the pancreas.....I apprehend that the appearances detailed differ from those found in peripneumony. In hooping-cough, the lung is always dense and contracted, as if the air had been expelled, and from the throwing out of adhesive matter, the sides of the air-cells had been agglutinated together ; while in hepatization the lung is less dense than in hooping-cough, and is rendered more voluminous than in its natural state." (pp. 90-91.) 2 Quoted by Abei le, De Tussi Convulsiva, 8vo. p. 45. Vindobonae, 1843. 380 TREATMENT OF FIRST STAGE OF HOOPING-COUGH. patients who have died of typhus fever. Out of 24 examinations of the bodies of children who have died of hooping-cough, it has only once happened to me to observe any alteration in the appearance of the vagus, though my attention has been directed to it on every oc- casion. In that instance both nerves seemed to be of a decidedly redder color than natural, although they were not otherwise altered. We are, I think, warranted in concluding that an appearance so fre- quently absent, cannot be one of much moment, that it is probably a post-mortem alteration, and that certainly it is not a phenomenon which can be adduced in support of any particular hypothesis as to the nature of the disease. I have endeavored to describe to you the symptoms of this affection, to make you acquainted with the circumstances in which it occurs, with the course that it usually follows, and with the chief dangers that threaten a child while suffering from it. It now remains to examine the treatment which may be best calculated to mitigate its severity, and to ward off or overcome the dangers that attend it. There are few diseases for the cure of which specifics have been more eagerly sought after, or more earnestly recommended, than for that of hooping-cough; neither is there anything unreasonable in the expectation that a remedy may some day or other be discovered which shall cut short its course with as much certainty as quinine arrests an intermittent fever, or which shall render the constitution insusceptible to its poison as infallibly as vaccination preserves from variola. At present, however, no such remedy has been discovered; and, though the severity of an attack of hooping-cough, or its duration, varies greatly in different individuals, during different epidemics, or at dif- ferent seasons of the year, yet we are unable by any medicinal agents to produce effects such as in these cases flow from causes quite beyond our control. For the present, then, the treatment of hooping-cough must be con- ducted in accordance with the ordinary principles of therapeutics, and we shall study their application best by examining in succession the course which, in each stage of the disease, it will be our duty to pursue. The first stage of hooping-cough is distinguished, as you know, by catarrhal symptoms, with some degree of febrile disturbance, and a cough which gradually assumes more and more of a paroxysmal character, until at length it returns in well-marked fits, and is attended by a distinct hoop. In the majority of cases the treatment of this first stage of hooping-cough must be just that of an ordinary catarrh. The child must remain in the house, and it is desirable that it should be confined to its own apartments, both of which should be maintained at a temperature of 60°, so that when it leaves the day for the night nursery, it may not, as is too commonly the case, enter a colder atmos- phere, and thus have the irritability of the bronchi increased, and the severity of the cough aggravated. If these precautions are carefully observed, and the diet is light and unstimulating, there is but little need of medicine beyond what may be required to keep the bowels regularly open. If the cough is at all troublesome, a mixture may be given, containing small doses of the ipecacuanha and antimonial TREATMENT OF SECOND STAGE OF HOOPING-COUGH. 381 wines, with a few drops of laudanum or of the compound tincture of camphor1—medicines that I should advise you always to use in pre- ference to the syrup of poppies, the strength of which is variable, and its action uncertain. If, as is sometimes the case, the child should wheeze a good deal, this symptom will be much relieved by the administration of an emetic of ipecacuanha every evening, or more frequently if necessary. It is not always, indeed, that either much care or much medicine is needed; and if hooping-cough comes on in a perfectly healthy child, in whom the process of dentition is com- pleted, and during the warm months of summer, strict confinement to the house may not be necessary. Usually, however, care in this stage is very important, and will do much towards mitigating the severity of the subsequent course of the disease, while no precautionary measure is of so much moment as the preservation of the child from fluctua- tions of temperature, and from damp as well as cold. When the first stage of hooping-cough has passed into the second, in which the disease assumes its characteristic features, the condition of the patient must still determine whether any remedies are to be employed, and must likewise influence their selection. It sometimes happens that the cough and hoop are very slight, and the paroxysms but few in the course of the day; and, in such circumstances, medi- cine can well be dispensed with. If the paroxysmal character of the cough be well marked, and the fits of frequent occurrence, but the child in other respects ails little, much benefit will accrue from the use of the hydrocyanic acid. I usually begin with a dose of half a minim of the acid of the London Pharmacopoeia every four hours for a child nine months old; and so in proportion for older children. The specific influence of the remedy is, I think, both more safely and also more efficiently exerted by increasing the frequency of its admin- istration, than by adding to the dose, and I should therefore prefer to give half a dose every two hours rather than to double the dose with- out increasing the frequency of its repetition.2 This remedy sometimes exerts an almost magical influence on the cough, diminishing the frequency and severity of its paroxysms almost immediately; while in other cases it seems perfectly inert; and again, in others, without at all diminishing the severity of the cough, it manifests its peculiar poisonous action on the system, so as to render its discontinuance advisable. I have never but once, however, seen really alarming symptoms follow its use, though I have employed it in many hundreds of cases. In that instance I gave one minim of dilute hydrocyanic acid every four hours to a little boy two years and a half old. He had hooped for four days before he came under my care, and was then suff'ering from rather severe cough, and considerable dyspnoea. ' See Formula No. 9, p. 303. ' (No. 15.) (No. 16.) R.—Acid. Hydrocy. dil. ni^iv. R.—Acid. Hydrocy. dil. TT\iv. Syrupi simplicis 3J. Mist. Amygdalae Jj. M. A tea- Aquse destill. gvij. M. A teaspoon- spoonful to be taken every ful to be taken every six hours. six hours. For a child 9 months old. 382 TREATMENT OF SECOND STAGE OF HOOPING-COUGH. He took the acid for four days without any effect being produced either on his system generally or on the cough ; but at the end of that time, after taking each dose, he uttered a cry, became quite faint, and would have fallen if not supported. This result having followed three or four times, the child's mother discontinued the medicine, and, of course, I did not resume its employment. Similar though less severe symptoms were produced by the same medicine in the sister of this child, a little girl of five years of age; but in neither instance was the severity of the cough in the least mitigated by it. Though no other instances of the kind have come under my notice, I always give a caution to the parents to diminish the dose of the medicine, or even entirely to discontinue it, if the child appears faint or dizzy, or bewildered, after its administration; and I never persevere with the use of the acid unless it gives a very decided earnest of good within three or four days after its first exhibition. In many instances, although the severity of the cough may be greatly relieved by the hydrocyanic acid, it yet does not enable us entirely to dispense with other remedies. If there be much wheezing at the chest, an emetic of ipecacuanha should be given once or twice a day, in order to free the air-passages from the mucus which collects in them, often in very considerable quantity, and thus tends, by the obstruction it offers to the free admission of air, to favor the occur- rence of collapse of the lung. The degree to which the child suff'ers from the accumulation of phlegm in the bronchi must determine whether the emetic be given once or oftener during the day. If it be given but once, the evening should be the time selected for its administration ; and, after the air-tubes have been thus relieved, the child will often rest well, instead of passing, as it otherwise would do, a restless night, disturbed by dyspnoea and frequent fits of coughing. In other instances the cough is unattended by much secretion, the child scarcely wheezes at all, and, even after a severe paroxysm, rarely vomits, and never rejects more than a small quantity of phlegm; but when night comes on, the cough grows very distressing by its fre- quent return, even more than by the severity of the paroxysms. When this is the case, a small dose of Dover's powder, or of Dover's powder and the extract of hemlock,1 often soothes this irritability of the air-tubes, and diminishes the frequency of the cough. If there is a good deal of febrile disturbance, if the cough is hard as well as violent, if it seems to occasion pain, and is unattended by expectora- tion, while, in the intervals of the paroxysms, a frequent, short, hacking cough distresses the child, and generally diffused rhonchus is heard throughout the lungs, the hydrocyanic acid may be advanta- geously combined with small doses of tartar emetic or of the vinum ipecacuanhse. In other cases, if the existence of drowsiness, with a 1 (No. 17.) R.—Pulv. Ipecac, co. gr. ss. Pulv. Extracti Conii, gr. j. Pulv. Cinnamomi, gr. ij. Sacchari albi, gr. iv. M. The powder to be taken at bedtime. For a child of two years old. USE OF CHLOROFORM—CAUTERIZATION OF LARYNX. 383 flushed face, becoming livid during the fit of coughing, and the sup- pression of the previously distinct hoop, betoken the presence of cerebral congestion, the application of a few leeches to the head will not only greatly relieve these symptoms, but will also diminish both the frequency and severity of the cough, and prepare the way for the more effective employment of the hydrocyanic acid. There are two proceedings which demand a special notice, as having of late years been recommended almost as specifics in hooping-cough. One of them consists in the inhalation of chloroform on the approach of each paroxysm, as a means of cutting it short, or even of entirely preventing its occurrence. There can be no doubt but that just as chloroform sometimes controls convulsions or relieves spasm of the glottis, so it is equally capable of diminishing, or even of arresting, the violence of fits of hooping-cough. I have found it of great service in some of those cases of the disease in which the return of each paroxysm of coughing was the signal for the occurrence of general con- vulsions; but it scarcely need be added that its efficient employment in these circumstances requires the constant presence in the house of some one conversant with its administration. In those almost desperate cases, too, there is the drawback from its use arising from the fact that inas- much as death may take place during any of these convulsive seizures, so its occurrence at the time when the chloroform was being adminis- tered would almost certainly leave the impression on the mind of the friends that death was due to its employment. If, however, warning is given beforehand of the possibility of this accident, the chloroform may be resorted to as a most valuable resource in desperate cases, though, as in other instances where it is employed at short intervals, tolerance of it is soon established, and it will cease in the course of twenty-four or forty-eight hours to produce any effect whatever. In mild cases of the disease, the results which one commonly attains are not remarkable; for the sense of suffocation which precedes and accompanies a fit of coughing, renders young children intolerant of anything being held near their mouth ; while the sense of nausea which the inhalation of chloroform produces, so disgusts those who are older, that in spite of the relief which it may yield, I have on several occa- sions seen older children, who at first had had ready recourse to the chloroform, after a few trials discontinue it, preferring even the unmitigated cough to the nauseating effects of the remedy. Still its trial is free from any objection, and in the course of a chronic ailment there is often an advantage in being provided with means which, though they may be of slight service to the patient, at any rate con- vince the friends that we are not indifferent to his sufferings, nor in- disposed to try all means for their alleviation. The other measure consists in the local application to the back of the fauces, or directly to the larynx itself, of a solution of nitrate of silver, of a strength varying from gr. xv to 9ij of the salt to an ounce of distilled water, by means of a probang, such as that employed by Dr. Horace Green for the introduction of medicated solutions into the interior of the glottis. This proceeding was first advocated by Dr. 381 USE OF CHLOROFORM — CAUTERIZATION OF LARYNX. Ebenezer Watson, in a paper published in the year 1849,1 and after- wards dwelt on by him more fully in a book which appeared five years afterwards, and in which he complains of his suggestions having been passed over without notice.2 Before the appearance of his book I have made a few trials of his plan, and have subsequently resorted to it sufficiently often to be able to form a fair opinion of its value. I have no doubt but that in very many instances the sponge of the probang is actually passed within the glottis; and also that by this manipulation, whether completely successful or not, the violence of the paroxysms of the cough is sometimes lessened, and their frequency diminished. This result, however, was by no means constant; the milder cases were those in which the benefits of the proceeding were most apparent; while, as perhaps might not unnaturally be expected, in those in which there was abiding dyspnoea, or in which any bron- chitic complication existed, little if any good was obtained. The great practical difficulty, however, and one which I am con- vinced will prevent any frequent resort to the proceeding in the case of children, arises from their extreme repugnance to it, and their dread of its repetition. Sometimes by coaxing and promises I succeeded in it daily for three or four days ; but no persuasion enabled me to carry its employment further, while on several occasions I saw paroxysms of cough brought on by the mere fear that the solution was about to be applied. There are very few proceedings, indeed, which are so surely and largely beneficial as to repay us for adopting them at the cost of a passion of tears, or an agony of terror, and this is certainly not one of them. Counter-irritation to the chest and spine is a popular remedy for hooping-cough, in which many non-professional persons place great confidence, while they employ it through all the stages of the disease. I do not think that you will in general gain much by the employment of counter-irritation until the disease has begun to decline, though it is then often of much service. There are, however, some circum- stances in which counter-irritation may be advantageously resorted to, even before the affection has attained its greatest degree of severity. The attacks of dyspnoea which sometimes occur during the increase of the disease, are often much relieved by a mustard-poultice to the chest: and if, as occasionally' happens, these attacks return, though with varying severity, almost every night for several nights together, the application of a mustard-poultice to the chest, and the immersion of the lower part of the body in a hot bath, on three or four succes- sive evenings, may be of service. In cases of this kind, too, the daily friction of the chest and spine with an embrocation of soap liniment and the tinctura lyttae, so as to keep up a slight degree of redness of the surface, is often beneficial; or that popular remedy, Roche's em- brocation, may be used, if the parents of the child fancy, as they often do, that it is possessed of some specific virtue. As a general rule, blisters to the chest are not desirable remedies in 1 Edinburgh Monthly Journal, Dec. 1849. 2 Ou the Topical Medication of the Larynx, etc. 8vo. London, 1854. See p. 123. DANGER OF OVER-TREATING HOOPING-COUGH. 385 young children ; but if the cough should be frequent, hard, and pain- ful, or if, in connection with the evidences of congestion of the brain, the cough is suffocative, and the hoop suppressed, much good often results from their application. They must not, however, be allowed to remain above four hours upon the skin; neither is it desirable to attempt to keep them discharging, on account of the very troublesome sores which they sometimes produce. For the same reason, too, I do not advise you to employ inunction of the tartar-emetic ointment, although this proceeding was once highly recommended, and very generally adopted, as a remedy for hooping-cough. Attention to maintain a warm and equable temperature around the child, to prevent the stomach becoming disordered by unsuitable food, and to avoid constipation, will in many instances suffice to conduct a child in safety through the second stage of hooping-cough. If the seve- rity of the cough, or the condition of the child in other respects, seems to call for more decided interference, your motto in the selection and employment of remedies must be, "ne quid nimis:" and especially must this be your rule in the management of those complications which often render hooping-cough so dangerous a disease. In no case is it of more importance to bear in mind this caution as to the danger of over-treating a patient who suffers from hooping- cough, than when, at the commencement of the second stage of the disease, a sudden increase of fever, and the supervention of a state of permanent dj'spnoea, seem to announce to you that active inflamma- tion has attacked the lungs or air-tubes. It is quite possible that such may be the import of the symptoms, but it is at least as likely that they result from disturbance of the nervous system. In such a case, then, I would advise you to allow nothing but the positive evidence of auscultation to lead you to resort to free depletion and the use of large doses of tartar emetic;—remedies to which you might feel dis- posed at once to have recourse. If you feel in doubt, remain for some time with the child, watch it carefully, auscultate it more than once during your visit, and repeat your visit every two or three hours,1 rather than resort at once to measures which, powerful either for evil or for good, may, if unwisely employed, destroy the life they were in- tended to save. Example teaches louder than precept, and you may learn a useful practical lesson from the following history :— A little 003', about two years old, had had slight catarrh for a fort- night, and towards the end of this time it was thought he had hooped once or twice, though very slightly. He ailed but little, and had had none other than domestic remedies during this period; but one night, without any apparent cause, he became very feverish, his cough grew 1 I cannot refrain from directing the attention of junior practitioners to the anecdote which Dr. Cheyne relates (at page xvii. of the Introduction to his work on Hydroce- phalus), of the very different results that followed the practice of two Army surgeons, one of whom visited his patients, during the prevalence of an epidemic disease twice, the other four or five times daily. The moral which Dr. Cheyne drew from the tale, though obvious enough, is not sufficiently borne in mind by many who undertake the treatment of children's diseases. 25 386 CASE ILLUSTRATIVE OF DANGER OF OVER TREATMENT. worse, and his respiration very hurried. On this account he was de- pleted very freely by leeches, and calomel and antimony were given in large doses for two days, though without any considerable diminu- tion of the dyspnoea. When this treatment was adopted, it was thought that air entered one lung but scantily; but on the evening of the second day both lungs admitted air equally well, although a good deal of mucous rale attended the respiration. On the morning of the third day, the child's face was flushed, and he looked much oppressed; his lips were rather livid, his respiration was extremely hurried and irregular ; he coughed little, but his cough had a suffoca- tive character, and was not attended by a distinct hoop. The hurried respiration was supposed to indicate the continuance of graver mis- chief in the lungs than was apparent on auscultation, aud antimony was accordingly given in emetic doses. It did not produce much sickness, and the respiration diminished but little in frequency during its employment. On the fourth day the child still breathed very hur- riedly, and his inspirations varied from 40 to 60 in a minute, without there being any obvious cause for these great changes in their fre- quency. On the fifth day the breathing increased in rapidity, while the pulse began to lose power; and not only had the antimony ceased to exert any emetic action, but squills and ipecacuanha failed to induce vomiting. Active measures were suspended towards the evening of this day, and a grain of Dover's powder, given every six hours, some- what diminished the hurry of the breathing; but it was discontinued after the third dose, on account of the gradually deepening drowsiness of the child. The child, however, still continued heavy and oppressed, the cough became more frequent and more suffocative, the breathing more rapid and more irregular. Ou the morning of the seventh day, a fit of coughing terminated in convulsions; and from that time until the morning of the eighth day, when the child died, they were ex- tremely violent, frequent in their return, followed by carpopedal con- tractions, which did not subside in the intervals between them ; while after each convulsion the respiration became most distressingly hur- ried and irregular. After a time the breathing grew constantly labored, the face became of a deep livid color, the hands were clenched and the wrists bent upon the forearm; the spine was drawn slightly backwards, and sensation was quite abolished. At length a slight convulsive movement passed across the face, and the limbs relaxed in death. Permission was not obtained to make a post-mortem examina- tion. Other cases have come under my notice, in some of which I fell into the error against which I have just tried to warn you; in some I saw the patient too late to rectify the mistake which others had committed, while in some the right course of treatment adopted from the first was followed by success. In a case such as I have related, the want of correspondence between the general symptoms and the auscultatory signs should have deterred from the copious depletion and the free use of calomel and antimony in the first instance, while it still further contraindicated the employment of antimony in emetic doses subsequently. Two or three leeches to the head, when the TREATMENT OF THIRD STAGE OF HOOPING-COUGH. 387 serious symptoms first came on, would probably have relieved the congested brain; the tepid bath would have soothed the irritability and diminished the fever; and hydrocyanic acid would, most likely, have been of service in quieting the hurried breathing. If much febrile disturbance had still continued, small doses of ipecacuanha, antimony, and hyoscyamus, might have been tried, the antimonial not being given in such doses as to exert any very considerable depressing influence on the system. A stimulating liniment to the chest and spine should have been used several times in the course of the day, and any sudden access of hurried breathing should have been met by the application of a mustard poultice to the ch^st. The difficulties of diagnosis are sometimes rendered smaller, and the right course of treatment more obvious, by the occurrence of occa- sional carpopedal contractions, or of momentary strabismus from the very commencement of this nervous dyspnoea; or in other cases by the absence of any auscultatory signs of mischief in the chest, such as could for a moment lead you to refer the hurried breathing to disease going on in the lungs. Even when acute bronchitis really exists, you must not forget the peculiar impress which hooping-cough stamps upon it. You must bear in mind the impediment to the due aeration of the blood which each fit of coughing occasions, and the influence on the nervous sys- tem generally of the imperfect decarbonization of the circulating fluid; how it heightens the irritability of the spinal system, thus ex- citing the hurried and irregular breathing, and rendering the child peculiarly liable to convulsive seizures. If active interference, there- fore, be necessary, you would abstract blood very cautiously, while you would employ nitre, ipecacuanha, and James's powder in small doses, as febrifuges and expectorants, rather than to attempt to bring the child rapidly under the influence of antimony. At the same time, the peculiar tendency to obstruction of the air-tubes, and consequent collapse of the lungs, which characterizes hooping-cough, would lead you to endeavor to keep the bronchi free, by the administration once or twice a day of an emetic of ipecacuanha. You would employ lini- ments, mustard-poultices, or blisters to the chest, to combat any ex- acerbation of dyspnoea; and if the paroxysms of cough were severe, you would combine hydrocyanic acid with your other remedies. If the powers appeared to be on the decline, and the child neither ex- pectorated with the cough, nor rejected much phlegm by vomiting although the bronchi were loaded with mucus, you would at once dis- continue antiphlogistic measures, and have recourse to the decoction of senega, with ammonia aud squills,1 while you endeavored by a nutritious diet to support your patient's strength. The time allotted to this lecture will not enable me to do more than just indicate the main points to which your attention should be di- rected ; aud I must now pass on to notice briefly your conduct in the third stage of the disease. It is now that the cough diminishes in frequency and severity, that the hoop grows less loud and less constant, 1 See Formula No. 12, p. 271. 388 TREATMENT OF THIRD STAGE OF HOOPING-COUGH. and that any signs of constitutional disturbance that had existed before by degrees disappear. When the disorder runs this favorable course no medicine is needed, and but few restrictions, beyond such as the avoidance of damp and cold requires. Change of air generally ex- pedites the cure; and if the opportunity offers, and the season of the year is favorable, it should never be neglected. There are many instances, however, in which medical treatment in the decline of hoop- ing-cough is of very considerable service. It sometimes happens that the bronchi continue loaded with secretion, which is either expecto- rated, or rejected by vomiting in very considerable quantities after each fit of coughing, while the skin is cold, the tongue moist, and the pulse soft and rather deficient in power. In this condition, alum,1 long a popular remedy in hooping-cough, is often of much service, diminishing the secretion, arresting the sickness, and rendering the cough much less frequent. It may be given in doses of three or four grains every four or six hours to a child of a year and a half to two years old. This remedy, indeed, may sometimes be used with advan- tage, even before the disorder has begun to decline, if the condition be such as I have just referred to, namely, fever being absent, and the bronchial secretion very abundant, even though the cough is violent. In other cases, in which the cough continues violent after the other symptoms have abated, and in which, though there is no superabun- dance of secretion in the air-tubes, yet the attacks of cough often end with the rejection of a considerable quantity of mucus from the stomach, the loss of appetite and general dyspeptic symptoms are present, the hydrochloric acid is often of much service. It has been recommended as a specific against hooping-cough, in doses of from two to six drachms daily ;2 but I have never employed it in other than moderate doses, such as one would prescribe in other circumstances.3 Another mode of treatment, which has been vaunted as almost a specific, consists4 in the administration of the sulphate of zinc and the extract of belladonna, in doses gradually increased until the quantity given is at last far larger than could have been employed at first with- out the production of poisonous effects. I believe that, when on the 1 (No. 18.) R.—Alum. Sulphat. gr. xxiv. Acid. Sulph. dil. rr^xij. Syr. Rhceados, sjiv. Aquae purae, §ijss. M. A dessert-spoonful every six hours. 2 I have made a few trials of the nitric acid in large doses, as recommended by Dr. Arnoldi, and by Dr. Gibbs in his Treatise on Hooping-Cough. Post 8vo. London, 1854, p. 341; but cannot at all subscribe to Dr. Gibbs's statement that " it shortens the dis- ease almost as effectually as quinine does intermittent fever." The nitric acid has, within the past six years, fallen into comparative oblivion, and the last new specific, vaunted as loudly as if its advocates had not extolled other remedies before as equally infallible, is the bromide of ammonium. It has been employed among the out-patients of the Children's Hospital on a scale large enough to demonstrate its worthlessness. 3 (No. 19.) ty.—Acid. Hydrochlor. dil. TTLxxxij. Tinct. Opii, Tr^iv. Syr. Mori, t^iv. Aquae purae, gijss. M. A dessert-spoonful three times a day. • Dr. Fuller, on Diseases of the Chest. 8vo London, 1862, p. 336. TREATMENT OF THIRD STAGE OF HOOPING-COUGH. 389 subsidence of the bronchitic symptoms which attend the first stage of hooping-cough, the nervous element still persists, giving rise to fre* quent, violent, spasmodic fits of coughing, a combination of zinc and belladonna is often of much service. I believe that these remedies are useful just as other tonics and antispasmodics are useful, but my own experience would not lead me to think that two scruples of sul- phate of zinc, and six grains of belladonna, could be given to children of eight years of age, with advantage, or even with safety. If the cough continues frequent, and the hoop loud, while the only signs of constitutional disturbance are those of mere weakness, iron will generally put a stop to it sooner than any other remedy.1 If, however, there be a degree of feverishness, or of gastrointestinal disorder, which for the present contraindicates the use of iron, Battley's liquor cinchonae may be given with great advantage, in com- bination with small doses of hydrocyanic acid;* while every attention must of course be paid, by mild alteratives and other appropriate means, to improve the condition of the digestive organs. It is probably unnecessary to enter into further details, to specify minutely the diet that a convalescent requires, or to refer to the utility of liniments to the chest, or the occasional benefit of anodynes at night. There still remain numerous remedies that have a more or less well-merited reputation in cases of hooping-cough. I must content myself with having pointed out to you the kind of weapons that, in different circumstances, must be employed ; and must leave to you the selection of the one whose form and size may, on different occasions, seem to you most fitting. The armory is large enough to yield you an ample choice. 1 (No. 20.) R.—Mist. Ferri co. ^iv. Tinct. Scillae, rt\, xvj. Tinct. Conii, TT^ xl. Mist. Amygdala?, ^ij. 3iij- M. A dessert-spoonful three times a day. J (No. 21.) R.—Acid. Hydrocy. dil. ITl^viij. Liq. Cinchonae, 3jss. Syr. Auranti, gjss. Aqure Flor. Aurant. sjiij. Aqure destil. $vj. M. 3'j- two teaspoonfuls three times a day. All the above are suited for children of two years old. 390 ' PULMONARY PHTHISIS. LECTURE XXVIII. Pulmonary Phthisis—differences exist between the tuberculous cachexia in the child and in the adult.—Statistical table illustrating its peculiarities in early life.—Anatomical characteristics of pulmonary phthisis in the child—frequency of miliary tubercle and of gray granulations in the lung, independent of each other, and of other forms of tubercle—frequency of tubercular infiltration—rarity of cavities—frequent affection of bronchial glands—description of each of these peculiarities—changes in tuberculous bronchial glands—perforation of bronchi, and elimination of tubercular matter. Symptoms of phthisis—their differences from those of the disease in the adult—danger of overlooking its early stages, or of mistaking it for remittent fever, &c.—peculiarities of its subsequent course. Bronchial phthisis—its characteristics—remarkable fluctuations in its course—occasional unexpected recovery—case of its occurrence attended with expectoration of tubercular matter—its fatal termination usually preceded by merging of its symptoms in those of general pulmonary phthisis—occasional fatal haemoptysis, but this accident not limited to cases of bronchial phthisis. Phthisis in very eafly infancy—pulmonary symptoms often obscured by signs of generally defective nutrition. We enter to day on the examination of one of the most painfully interesting diseases with which we have to do. It is a disease that we not only often see in hospitals, or in the dwellings of the poor, but which has brought grief into the habitations of many among us, and has robbed us of those whom we most dearly loved; while the very mention of its name gives rise to a feeling of utter hopelessness as to its issue. I need hardly say that I propose to-day to call your attention to Pulmonary Consumption, or Phthisis—a malady that attacks persons of all ages, of both sexes, and of every rank, and which, under every variety of condition, medicine seems to be equally unable to cure. It may, however, occur to some of you that, important though this affection is, yet in speaking of it I am transgressing the bounds that I set myself, when I proposed to treat only of those maladies which are either limited in their occurrence to the period of childhood, or on which the early years of the patient impress some well-marked peculiarity. It is true, indeed, that at whatever age phthisis comes on, it presents the same grand features, it works the same kind of changes, and tends to the same fatal result. But yet the disease in the young subject displays differences from its character in the old sufficient to attract the notice of the observant; nor are these differ- ences merely curious, but they influence' our prognosis and modify our treatment—and hence it is fitting that we devote some time to their examination. "That great constitutional malady, of which pulmonary consump- tion is only a fragment, plays its part," in childhood as well as in adult age, "most conspicuously in the lungs." In the adult, however the DIFFERENCES BETWEEN PHTHISIS IN CHILD AND ADULT. 391 lungs are so almost invariably the seat of tubercular deposit that out of 123 cases, M. Louis found but one exception to the rule that if tubercle exists in any viscus, it will be discovered also in the lungs. In the child, though the lungs are still the most frequent seat of tubercle, yet M. Louis' law no longer holds good, for MM. Rillet and Barthez found 47 exceptions to it out of 312 instances in which tu- bercle was discovered in some one or more organs of the body. The first great difference, then, between the tubercular cachexia in child- hood and in adult age, consists in the same organs not being equally liable to it at the two periods of life. The following table will place this difference clearly before you. It shows the proportion per cent, in which diff'erent viscera were the seat of tubercle in children and in adults. The figures in the first column are deduced from 312 cases which form the basis of MM. Rilliet and Barthez's essay on the tuberculous cachexia; those in the second, from the 123 cases on which M. Louis' work on phthisis is founded; and the third contains the results arrived at by Lombard on an examination of 100 adults. Of 100 instances in which tubercle ivas deposited in some of the viscera, it was present in— Children from 1 to Adults from 20 years and 15 years. According to Rilliet upwards. According to According to and Barthez. Louis. Lombard. In tut lungs ..... 84 100 100 K bronchial glands 79 28 9 u mesenteric "... 46 33 19 ii small intestines 42 33 0 l< spleen ..... 40 13 6 11 pleura ..... 34 2 1 (1 peritoneum .... 27 0 0 II liver ..... 22 0 1 l< large intestines 19 10 0 II membranes of the brain 1(3 0 2 II kidneys . . . . 15 2 1 II brain ..... 11 0.8 2 II stomach .... 6 0 0 II heart and pericardium . 3 0 0 This table shows not only that the liability of certain organs to become the seat of tubercle is diff'erent in childhood from what it is in the adult, but also that tubercle is simultaneously deposited in a greater number of organs in the young than in the old. This greater intensity of the tuberculous cachexia in early life is a fact of much importance. It explains how it happens that, death sometimes takes place in the child, before tubercle has anywhere undergone those changes which seem almost always to precede the fatal event in the adult1 1 I have thrown together into the following note some details with reference to Phthisis in early life, which, though far too few to warrant the deduction of any posi- 302 ANATOMICAL PECULIARITIES OF PHTHISIS IN CHILD. These, however, are not the only peculiarities of the disease in early life, but the anatomical characters of tubercle in the lungs (and of this I am now more particularly speaking) differ in some respects in the child from those which are observed in the grown person. tive conclusions, may not be without value as furnishing materials for comparison with the results obtained by other observers. Table of 338 Cases, showing influence of Sex and Age in predisposing to Pulmonary Phthisis. Total Examinations . Tubercle present in chest, in Ditto, not present in chest, in Under 1 year. From 1-2. From 2-3. From 3-5. From 5-10. M. F. ■ M. F. M. F. M. F.M. F. 29 17 26 28 34 26.35 36 50 38 8 8 7 10 13 8|15 19 22 22 21 9!l9 18 21 18 20 17^8 16 I 1 I From 10-15. M. F. 9 10 4 5 5 5 Total. M. F. TOTAL. 183 155 338 69 72 141 114 83 197 In two other instances, though the chest was free from tubercle, tubercular deposit existed in the abdomen; in one boy aged 3| years being limited to slight affection of the mesenteric glands ; in another aged two years the tubercular deposit in the abdo- men was very extensive. The degree of the tubercular deposit in the lungs was not the same in all cases ; but is stated to have been slight in 43, moderate in 34, considerable in 64, proportions which were thus distributed :— Under 1 year. From 1-2 From -'-3 From 3-5 From 5-10. From 10-15. Total. Slight..... Moderate .... Considerable .... M. F. 1 2 7 6 M. F. 2 0 1 5 4 5 M. F. 3 1 4 2 6 4 M. F. 6 9 3 4 6 8 M. F. 9 9 3 8 9 5 M. F. 3 1 — 1 2 2 M. 23 12 34 F. TOTAL. 20 43 22 34 30 64 69 72 141 In 132 of the above cases, the forms assumed by the tubercular deposit were as follows :— / 5 3 o p low ercle ■ned. ellow ercle in taceous state. £ ° 3 S 3 ® ® J ^3 ■3-2(2 •°3 3 a E fa CO o > J OH oJxO EHM Gray granulations ..... 63 40 7 1 12 5 4 44 Yellow tubercle 40 74 10 - 21 11 4 71 " " softened . 7 11 13 - 31 8 _ 13 " " in cretaceous state 2 — — 7 _ _ _ 1 Tubercular infiltration 12 21 3 — 30 8 8 30 5 11 8 — 8 18 4 19 4 4 1 — 8 3 12 6 Tubercle of bronchial glands . 44 65 13 1 30 18 11 119 In 21 of the 119 cases in which the bronchial glands were the seat of tubercle the pulmonary tissue was unaffected ; and this although thrice the deposit in the glands was universal, aud in one of the thr^e cases had gone on to softening. The tubercle of the glands was incipient in . . . . . .25 " " " general in . . . . .54 " " " had reached the stage of softening in . 21 " " " was in a firm, friable, cheesy state in . 9 " " was undergoing cretaceous change in . 10 FREQUENCY OF TUBERCULAR INFILTRATION. S93 The first of these peculiarities consists in the frequency with which gray granulations and crude miliary tubercles exist in the lungs inde- pendent of each other, and of any other form of tubercular deposit. In the adult M. Louis1 discovered miliary tubercles alone only in 2 out of 123 cases of phthisis; and gray granulations alone only in 5 more. In the child, MM. Rillet and Barthez2 found miliary tubercles alone in 107, and gray granulations alone in 36 out of 265 cases; and my own observations, which are based on 132 cases, yield 34 instances . of the presence of miliary tubercles alone, and 23 of the presence of gray granulations alone in the tissue of the lungs. The great rapidity with which the deposit and development of tubercle often take place in early life, is doubtless one chief cause of this peculiarity. If we examine the lungs of an adult affected with the tuberculous cachexia, we shall often observe their lower lobes containing gray semitransparent granulations; as we advance higher, we shall probably find that the granulations have lost much of their transparency, and that they present a yellowish spot in their centre, while near to the apex of the lung the deposit exists in no other form than that of bodies presenting the whitish-yellow color and friable texture characteristic of crude tubercle. These appearances seem to betoken that the deposit of tubercle has taken place slowly and at successive periods, so that those tubercles which occupy the apex of the lung are already approaching maturity at a time when the disease is just beginning to invade the lower lobes. In the child, however, it not seldom happens that all the lobes of both lungs present a nearly equal amount of tuberculous deposit, and that this is seen to be nearly equally advanced in all. Thus we may find the gray granulations diffused in about the same abundance through all parts of the lungs, and all equally transparent; or we may observe each granulation presenting a yellow spot in its centre; or the change may be complete, and crude yellow tubercle may be everywhere present. This same fact, of the acute course of tuberculization of the lungs in children, receives a further illustration from the second anatomical peculiarity of the disease; namely, the great frequency wrth which yellow infiltration of tubercle is observed in early life; MM. Rilliet and Barthez having met with it in 88 out of 265 children, or in 33 per cent.; and I, in 30 out of 132, or in 22.7 per cent. It is a form of degeneration of the lung which seldom exists alone, but is almost invariably associated with gray granulations or yellow tubercle, and usually coexists with a state of very far advanced tuberculization of the bronchial glands. It is often limited to one lobe, generally the upper; or sometimes the middle lobe in those cases in which the right lung is the seat of the disease. Those portions of the lung which are affected by it become converted into a firm solid mass, having much both of the color and consistence of cheese, presenting a smooth surface when cut, and by its solidity compressing the bronchial tubes which traverse it, so as considerably to reduce their calibre. If the patient's^ 1 Recherches sur la Phthisie, p. 3. 2 Op. cit., vol. iii. pp. 221, 227. 391 COMPARATIVE RARITY OF CAVITIES IN THE LUNGS. life be prolonged, a process of softening generally takes place; the tissue breaks down, and a cavity is the result, the parietes of which are formed by solid tubercle. At other times, especially if the disease runs its course with great rapidity, the lung thus infiltrated seems to undergo a different kind of softening, which does not lead to the for- mation of a central cavity, but pervades its tissue throughout, which then presents a reddish-yellow, or rose-colored tint, and breaks down easily into a kind of putrilage, as if the changes produced were the result of a mixture of true pneumonic hepatization, and of tubercular degeneration. Oases of this sort go far toward substantiating the cor- rectness of M. Rokitansky's theory, with reference to the nature of this tubercular infiltration, as compared with the ordinary form of tubercular deposit. He conceives that the deposit of tubercle in the form of gray or yellow granulations takes place in the interstitial cel- lular tissue of the lung; while in the case of tubercular infiltration the matter poured out into the interior of the pulmonary vesicles during an attack of pneumonia becomes converted into tubercle under the influence of the tubercular cachexia. A third peculiarity of phthisis in the child, as contrasted with the same disease in the adult, consists in the greater rarity of cavities in the lungs during early life. Of 123 cases which form the basis of M. Louis' work on phthisis, cavities were present in by far the majo- rity of instances; and though the numbers are not exactly stated, the exceptions would seem to have been but very few. Out of 265 cases, however, that came under the notice of MM. Rilliet and Barthez, only 76, or 28.6 per cent., presented cavities in the lungs; and they existed in only 22.7 per cent, or in 30 of the 132 cases which came under my own observation. These cavities sometimes resemble those which we usually meet with in the adult; and this is especially the case with children above six years of age, in whom, indeed, the general cha- racters of phthisis approximate closely to those of the same disease in the grown person. In other instances, they are not so much caverns, as very small excavations {vacuoles, as the French call them), produced by the softening of small tubercular deposits. Such excavations communicate with the bronchi and with each other, and are sometimes exceedingly numerous, but do not occasion such a destruction of the pulmonary tissue as to produce anywhere a cavity of considerable dimensions. Besides these two forms of cavity, there is a third, to which I have already referred, namely, that produced by softening of the yellow tubercular infiltration, which is more commonly met with in very early life than subsequently. Cavities of this kind sometimes form with great rapidity, and attain a considerable size. The whole of one lobe of the lung may even become converted into a sac, which is often almost quite empty, while its parietes are formed by little besides the pleura and the fibrous capsule of the lung, with a very thin lining of dense tubercular matter. It is far from unusual to meet with cavities of this kind in the bodies of infants only a few months old, who have never thriven, but have presented few signs of phthisis, with the exception of progressive loss of flesh and strength, and some- what hurried respiration. ANATOMICAL CHARACTERS OF BRONCHIAL PHTHISIS. 395 The last anatomical peculiarity of phthisis in infancy and childhood to which I shall direct your attention, consists in the abundant deposit of tubercle in the bronchial glands, and the changes to which that deposit gives rise. Even in the adult, tubercle is deposited in the bronchial glands in about a fourth of all cases of phthisis; but the deposit there is subsidiary to its deposit in the lungs. In the child, however, this is far from being always the case; but the disease in the glands is often as important as that in the lungs, sometimes much more con- siderable. The tubercular deposit does not appear to begin simultaneously in all the glands, nor to advance in all with the same rapidity; but those about the bifurcation of the trachea, and close to the primary bronchi, are usually the first affected ; and the disease in them attains a more advanced stage than elsewhere. The state in which the glands are most frequently met with is one of tubercular infiltration, the whole of their substance being converted into a firm, resistant matter, re- sembling a portion of lung which has been the seat of tubercular infiltration; and this, even although the number of affected glands be but small, and though the lungs be but little or not at all involved in the disease. Sometimes, however, we may meet with the affection in an incipient state, and it is then usual to find the glands which it has attacked somewhat enlarged and injected, and their tissue infiltrated with fluid, and less firm than natural. The tubercular deposit does not proceed invariably from the centre to the circumference, but fre- quently two or three small deposits may be discerned at different parts of the same gland; or the tubercular matter may be accumulated entirely at one end of the gland, while its other extremity is merely softened and injected. Even when the disease starts from several points, it is not often that the deposit assumes the distinctly circum- scribed form of miliary tubercle, and still less often that of gray gran- ulation ; but it generally presents the character of tubercular infiltration which had taken place at the same time in two or three different situ- ations. Sometimes it is impossible to distinguish any one spot as that from which the disease commenced, but the whole tissue of the gland has a whitish hue, which appears due to the general infiltration of tuberculous matter. Whatever may have been the mode in which the deposit of tubercle began, the tendency of the advance of the dis- ease is to convert the entire substance of the gland into firm tuberculous matter, in which no trace of the original tissue can be detected. The metamorphosis of the gland is attended with considerable increase of its size; the enlargement, however, being much greater in the case of those glands which are situated externally to the lungs, than of those which are imbedded in the pulmonary substance. The enlargement of the glands is not attended, as might have been anticipated before- hand, with a thinning of their originally delicate cellular envelope, but it increases in density and firmness, and at the same time acquires a very considerable thickness. Most of the glands which have become converted into tubercle are inclosed within a cyst a line or more in thickness, aud extremely resistant; its inner surface being smooth, of 396 PERFORATION OF THE BRONCHIAL TUBES. a bright rose tint, and sometimes presenting a considerable degree of vascularity. In a large proportion of cases in which tubercle is found in the bronchial glands, it has not passed beyond the crude stage; but if life be not cut short by the advance of phthisis in the lungs, a process of softening next commences; and the softening usually, though not invariably, begins at the centre of the glands, and extends towards their circumference. The softening is seldom found equally advanced in all the glands ; but in some, a small central cavity containing liquid tubercle is surrounded by a thick wall of solid matter; while in others the whole substance has been softened, and the gland is no longer anything else than a cyst containing a quantity of puriform fluid. When tubercle deposited in the lung has undergone the process of softening, an effort is made by nature to get rid of the morbid matter, which is expectorated; and the cavity, thus emptied of its contents, now and then cicatrizes, and the patient is cured. The cases of cure, indeed, bear but a very small proportion to those in which death takes place, for, in general, fresh deposits of tubercle successively undergo this softening, until but a comparatively small portion of the lung remains unaffected by the disease; or the abundant secretion from the bronchial tubes exhausts the patient, or death ensues from the degree to which other organs are implicated in the tuberculous cachexia. When the bronchial glands are the seat of the disease, a similar effort is made to eliminate the morbid matter from the system; and many circumstances concur to render this a more hopeful task than it is when the pulmonary substance itself is the seat of the disease. The means by which this is effected deserve to be examined. When tuberculization of the bronchial glands has attained an advanced stage, we generally observe a process of thickening and infiltration to have commenced in the cellular tissue around each gland, by no means unlike that which takes place in the pia mater at the base of the brain in cases of tubercular hydrocephalus. This cellular tissue often assumes a grayish semi-transparent aspect, and presents a number of minute granules of tubercle diffused through it. By a process of com- bined inflammation and tuberculization, the connection between the gland and the adjacent bronchial tube becomes extremely intimate. The cellular tissue in the intervals between the bronchial rings becomes next infiltrated with tubercle, and is then the first part of the wall of the bronchial tube which disappears during a process of absorption that advances from without inwards. The cellular tissue sometimes becomes quite removed before the cartilages of the bronchi are much affected; but in process of time they too become absorbed, and the perforation of the tube is then complete; the tuberculated gland, how- ever, blocking up the aperture in its walls, and projecting into its cavity. The next step consists in the thinning of the envelope of the gland, and the next is the discharge of its contents into the tube; and the cyst then in all probability collapses, and becomes applied to the outside of the bronchus, so as to form a part of its parietes. But we are still in want of some exact observations as to this last sta»-e in the cure of bronchial phthisis. SYMPTOMS OF PHTHISIS. 397 This process does not take place with equal frequency in all the bronchial glands; for those which are situated around the trachea, and wholly external to the lung, meeting with no obstacle to their increase in size, often attain a great magnitude without at all compro- mising the integrity of the trachea. Those, however, which are in contact with the secondary and tertiary bronchi, and are imbedded in the pulmonary substance (which prevents their attaining any con- siderable size) not unfrequently perforate the tube in the manner above described, and this not only after they have become softened, but even while the tubercle they contain is still in the crude state. Although the progress of the tubercular degeneration is most obvious in those glands which are situated near to the larger air-tubes, yet it is by no means limited to them, but is in many instances observed also in the pulmonary glands that are imbedded in different parts of the substance of the lungs. They do not, however, become inclosed within a cyst as dense and resisting as that which surrounds the tuber- culous bronchial glands; while in a great number of instances the pulmonary substance for a short distance around them presents a far more abundant tubercular deposit than is apparent in any other part of the lungs. If a tuberculous gland, thus imbedded in the tissue of the lung, should become softened, the excavation thereby produced may easily be mistaken for a cavity in the lung itself. A pulmonary cavity of such small dimensions, however, is hardly ever solitary, unless it proceeds from the softening of tubercular infiltration; but the deposit of tubercle which takes place in the neighborhood of a diseased pulmonary gland is always in the form of distinct deposits — not of tubercular infiltration. Tuberculization of the glands does not occasion perforation merely of the bronchial tubes, but in some rare instances the oesophagus, trachea, and pulmonary artery have been perforated by the same pro- cess as is usually limited to the air-tubes. In some cases in which tuberculization has never advanced far, it comes to a stand still, and the tubercle itself undergoes the cretaceous change. This, however, is a rare occurrence, for it has come under my notice only in 10 out of 119 cases; though, on the other hand, it is more frequent than in the lung, in which it has come under my notice in the child only in 7 out of 132 instances. In 9 other in- stances, the contents of the bronchial glands, though not actually cretaceous, were very dry and friable, as if the more fluid constituents of the tubercle had been removed, and the cretaceous change were about to commence. This change has never come under my notice as having taken place in any gland which had attained considerable size in consequence of the deposit of tubercle in it, nor have I ever seen it when the tuberculization of the glands was general, or when the lungs showed evidence of general, or of advanced phthisical dis- ease. The symptoms of phthisis in early life resemble in many respects those which characterize the disease in adult age, while the points of difference become fewer and fewer in proportion as the child grows older, until they cease altogether at the period of puberty. During 393 SYMPTOMS OF PHTHISIS. childhood, however, even those cases which run a course most similar to that of ordinary phthisis in the adult are in general distinguished by the absence of hasmoptysis at any stage of the aff'ection—the absence of expectoration, or its very rare occurrence—the compara- tive slightness of the cough, and the rarity of those colliquative sweats which so much exhaust the grown person. In many instances the child droops, loses its appetite and flesh, and strength, and complains of vague pain in the chest and abdomen for many weeks before the occurrence of cough excites any apprehension that the lungs are the seat of disease. When the cough does come on, it is slight, short, and dry, and attracts attention by its frequency, rather than by the dis- comfort which it occasions the child. Its usual amusements cease to occupy the child, who sits about, listless and fretful in the daytime, while the skin often grows hot and dry, and the lips become parched as night approaches; but there is so little that is definite in these symptoms, that they are not unfrequently supposed to indicate the existence of remittent fever, or to be due to the presence of worms in the intestines. It is important to bear in mind, that strumous dyspepsia, as it has been called by many writers, is of more frequent occurrence in child- hood than in adult age, and that its symptoms may be all that marks the advance of phthisis in the lungs until within a month or two of the patient's death. A definite commencement can almost always be as- signed to an attack of remittent fever; and the great heat of skin, the very rapid pulse, the thirst, and the delirium at night, which attend it even in its less severe forms, are symptoms which, if borne in mind, would prevent our mistaking for it those slighter and more vague ail- ments that are experienced during the first stage of phthisis, in all ex- cept those rare instances in which the disease runs a very acute course. The referring the symptoms of incipient consumption to the presence of worms in the intestinal canal, is a mistake even less excusable; the natural temperature of the skin, and natural frequency of the respi- ration—the appetite at one time as ravenous as it is deficient at another—the tongue either clean and moist, or else thickly coated— the condition of the bowels, which is generally one of constipation— and the marked relief that almost always follows the action of purga- tives, are indications of the presence of worms sufficiently character- istic to guard the attentive observer from error. Fluctuations take place in the child's condition, and a casual attack of bronchitis often seems to be the exciting cause of that aggravation of the pulmonary symptoms which is observed before long. The respiration now becomes habitually quicker than natural, instead of merely being easily accelerated, and is often accompanied with con- siderable wheezing: the cough grows more frequent and lasts longer, but is still in most instances unattended by expectoration, owing to the circumstance that the child almost always swallows those matters which the adult would spit up. The loss of flesh, and the decay of strength, advance even more rapidly than the signs of pulmonary disease. Well-marked hectic, however, is infrequent; and if night sweats occur, they are often limited to the head and face. Towards SYMPTOMS OF BRONCHIAL PHTHISIS. 399 the close of the disease the mouth often becomes aphthous, especially , in infants; but though diarrhoea sometimes occurs, it does not often seem to contribute so much to the exhaustion of the child as to that of the adult, and that alternation of diarrhoea and hectic sweats, which is so frequent in the grown person, is seldom or never observed in the child. When death at length takes place, it either occurs from ex- haustion, or succeeds to some intercurrent attack of bronchitis or pneumonia. In those cases in which tubercle has been deposited in great abun- dance, in the bronchial glands, constituting what is called bronchial phi/iisis, the symptoms deviate still more from those which are usually observed in the adult. Bronchial phthisis occurs in its best marked form between the ages of two and six years, although as it is scarcely necessary to observe, tuberculization of the glands is by no means limited to that age. Its symptoms in many instances first become dis- tinctly evident after some severe bronchitic seizure, which either accompanied measles or came on without any apparent exciting cause. In other cases, although the commencement of the affection is not clearly traceable to a single attack of severe bronchitis, yet the patients in whom it occurs had in all probability been subject to frequent re- turns of catarrh or bronchitis, which, though not alarming in their symptoms, yet left behind them a cough that never entirely subsided. By degrees this cough becomes severer: it returns in paroxysms not unlike those of pertussis: it sometimes induces efforts to vomit, and can scarcely be distinguished from the cough of the earlier stages' of hooping cough. The respiration grows habitually oppressed aud wheezing, the face becomes puffed and swollen, the veins of the neck distended just as in patients with heart disease, and the superficial vessels of the thorax become enlarged, just as those of the abdomen do in cases of ascites, or of mesenteric disease. The great fluctuations which take place in the condition of the patient constitute one of the most striking characteristics of this form of phthisis. Attacks of bronchitis sometimes come on, during which the respiration becomes painfully accelerated and oppressed, and the paroxysmal cough is merged for a time in a constant hacking, or in suppressed attempts at coughing. These bronchitic symptoms, which often seem to threaten life, and which sometimes actually destroy it, clear up by degrees in the majority of cases, but leave the child with a severer cough and a more hurried respiration than before, while it loses flesh rapidly, and not unfrequently sweats a good deal about the head and upper part of the trunk. Accommodation of posture, too, in many instances becomes necessary to the comfort of the little patient, who perhaps can breathe only when supported in its mother's lap, or when much propped up in bed. It is seldom, when the disease has reached this degree of severity, that there is not also so large a measure of tuberculous affection of the lungs and other viscera as to render recovery quite hopeless, and the characteristic signs of bronchial phthisis become lost by degrees in those of ordinary consumption. Sometimes, however, a long pause takes place in the progress of the disease, even though thus far advanced : the cough, which had acquired 400 PHTHISIS IN VERY EARLY INFANCY. fresh intensity, gradually abates—the respiration is no longer habitu- ally wheezing—the patient can repose in any attitude—the flesh lost is regained—and, were it not that cough still continues, though less frequent and less severe, that the breathing is more hurried than natu- ral, and that auscultation contributes still further to undeceive us—we might fancy that all ground for anxiety was passing away, and that the child was on the high road towards recovery. In some cases, too, in which symptoms such as have been described are observed, recovery does eventually take place. It is seldom possible to say in any case by what means this recovery is brought about; sometimes, no doubt, the tubercular matter makes its way into the air-tubes, and is got rid of by expectoration. Once I observed the disappearance of most well- marked general signs of consumption, in the case of a girl eight years old, during the copious expectoration of a tenacious mucus, in which were small quantities of a substance like broken-down cheese, or grains of boiled rice, and which alternated with an expectoration of thick, puriform matter, more or less tinged with blood. In the case of this child an attack of measles, while in her seventh year, had been suc- ceeded by cough, the formation of abscesses in her neck, and a fre- quent, puriform, and sanguineous discharge from her nose. The abscesses had not been long healed when her mother's alarm was ex- cited by her expectorating blood mixed with the phlegm which she brought up when coughing. Though not much emaciated, the child looked unhealthy; her pulse was very feeble, and there were many small petechias on her extremities. The lungs, however, were tolerably free from disease ; for nothing more was heard during auscultation than a good deal of rhonchus mixed with some moist sounds, which were most evident at the upper part of the chest. Expectoration such as I have described continued for nearly three months, in the course of which time the child by degrees lost her cough, and gained strength under the use of steel and other tonics. Two years afterwards no ausculta- tory signs of disease were perceptible, except a little creaking under both clavicles; and at the end of five years even this had disappeared. The fatal termination of bronchial phthisis usually takes place in consequence of the lungs becoming seriously involved in the tuber- cular disease, though life is sometimes suddenly cut oft' by haemoptysis, owing to the perforation of one of the larger vessels of the thorax by a tuberculated bronchial gland. It must not, however, be supposed that this is the only means by which fatal hemorrhage is produced, for it takes place in other instances in precisely the same circumstances as in the adult. Six cases of fatal hasmoptysis have come under my notice in children ; but in four no examination was made after death. In the fifth case, which was that of a boy between five and six years old, who died at the end of nine months' illness, blood pouring in abundance from his nose and mouth, the amount of disease, both of the lungs and bronchial glands, was very considerable; but no large vessel had been perforated, and it was not possible satisfactorily to determine the source of the hemorrhage. In the sixth case, that of a little boy five years old, in whom symptoms of pneumonia had supervened upon previous signs of phthisis, the source of the bleeding AUSCULTATORY SIGNS OF PHTHISIS IN EARLY .LIFE. 401 in the single and fatal attack of haemoptysis which took place at a time when he seemed recovering, likewise eluded the most careful anatomical investigation. A very considerble degree of tuberculization of the bronchial glands is by no means uncommon even in very early infancy; but it then generally forms only a part of such extensive tubercular disease, that its special symptoms are lost in those of the general malady. In such cases, too, it frequently occurs that the signs of thoracic disease are almost entirely merged in those of generally defective nutrition. The existence even of a large cavity in the lung may be announced in early infancy, by nothing more serious than some acceleration of the breathing, and an occasional short cough; while the frequent vomiting <—the irregular, often relaxed, condition of the bowels—the unhealthy evacuations—the red tongue, and the aphthous state of the mouth— may direct the attention almost exclusively to the condition of the digestive organs. Many points still remain for our investigation, but we must post- pone their consideration, and the study of the auscultatory phenomena of the disease, to the next lecture. LECTURE XXIX. Phthisis, continued.—Peculiarities of its auscultatory signs in early life—some of less value than in the adult—influence of tuberculous bronchial glands in exaggerating the signs of disease of the lung—difficulty in appreciating some signs which are well marked in the adult—sign peculiar to early life. Different forms of phthisis—acute phthisis ; illustrative case—tuberculous pneumonia—bron- chitis grafted on phthisis may lead to an over-estimate of the tuberculous disease. Duration of phthisis ; its course sometimes very acute, at others extremely chronic—cases in illustration.—Modes of death in phthisis—head symptoms sometimes precede death independent of cerebral disease. Prophylaxis, and treatment of phthisis. It would be little better than a waste of your time to enter into a minute description of all the modifications of the respiratory sounds to which the presence of tubercle in the lungs of children may give occasion ; our time will be better spent than in such detail, if we direct our attention to those respects in which the auscultatory signs of phthisis in childhood differ from those which betoken its existence in the adult, or in which the same auscultatory phenomena require a different inter- pretation at the one period of life, from that which is justly applied to them at the other. The grand difference, indeed, is to be sought in the latter rather than in the former of these respects. Tubercle, at whatever age it is developed in the lungs, gives rise to much the same auscultatory phe- nomena; but many of those modifications of the respiratory sound which would warrant us in pronouncing positively that phthisis ex- 26 402 AUSCULTATORY SIGNS OF PHTHISIS IN EARLY LIFE. isted in the adult, cannot be relied on with the same certainty in the child; still less can they be regarded as proving the existence of so large an amount of disease in the latter case in the former. It may be stated, then, that 1st. Many of the auscultatory signs of phthisis deserve less reliance, or have a less grave import, in the child than in the adult. One of the earliest signs of tubercular deposit in the lungs of the grown person is furnished by that peculiar modification of the respi- ratory sound to which the name of coarse breathing has been applied; and this acquires still greater importance, when associated, as it often is, with dry rhonchus and creaking sounds. Much of the value of this sign depends on its being limited to the infra-clavicular regions, or, at least, on its being heard there with much greater distinctness than elsewhere. Since, however, the deposit of tubercle in the lungs of children is more uniform, and more generally diffused than in the adult, the additional value which the localization of these signs fur- nishes is lost; and it becomes impossible to determine whether the bronchial irritation that they betoken is induced by the presence of tubercle in the lungs, or by some other cause. Prolongation of the expiratory sound beneath the clavicle, and interrupted respiration—the respiration succadee of French authors— which are two of the earliest and most important indications of phthisis in the grown person, are, on the whole, of less value in the child. Their occurrence, indeed, should always excite suspicion as to the existence of phthisis, but they are not unfrequently very well marked in cases where but slight disorder of the respiratory organs is present; and where the perfect recovery of the child, and its sub- sequent sound health, prove that tubercular disease either was altogether absent, or at any rate was extremely slight. The exaggeration of these two signs is probably, in some measure, due to a cause which adds greatly to the intensity of some other of those auscultatory phenomena that usually betoken far advanced phthisis. MM. Rilliet and Barthez were, I believe, the first who pointed out the fact that the bronchial glands, when enlarged by the deposit of tubercle, and thus brought into contact with the walls of the chest, which they do not touch in the healthy state, conduct to the ear of the auscultator sounds that in other circumstances are imperceptible. The air passing through the larger bronchi is now beard, on applying the stethoscope to the walls of the chest, in the supra-scapular, and less often in the infra-clavicular region, and can scarcely be distinguished from bronchial breathing produced by solidification of the pulmonary tissue itself. The sounds which are caused by the presence of mucus in the larger air-tubes are in the same way conducted to the ear in other situations than those—such as the root of the lung, where alone they would be heard if the glands were not enlarged. The auscultator may thus be betrayed into the error of supposing that hopeless phthisis exists in cases where yet the amount of the disease in the lung is but small, and where life may be PECULIARITIES IN AUSCULTATORY SIGNS OF PHTHISIS. 403 prolonged for many years. Morbid sounds, too, produced in one lung, may thus be conducted to the walls of the chest on the opposite side, and the extent of disease may, in consequence, be overrated; or the sounds which, when perceived in the front of the chest, may arise from real disease in that situation, being transmitted to the back through the medium of the glands, may thus give rise to the conclu- sion that far more serious mischief exists than is really the case. The means of avoiding error from this cause consist in the careful com- parison of the results of auscultation with those of percussion, and of those of auscultation on one day with those which it yields a few day afterwards. If the sounds proceed from solidification of the lung, or from cavities in its substance, the results of auscultation will be as invariable as those of percussion ; but if they be merely sounds trans- mitted from the larger air-tubes, they will be found to vary much on diff'erent occasions ; while the dulness on percussion in certain parts will continue unchanged, inasmuch as it proceeds from the presence of the enlarged glands. This variability in the results of auscultation is one of the most important indications of bronchical phthisis. It depends not merely on the accidental variations in the sounds produced in the larger air-tubes, but also on the changes which the varying degree of compression of the bronchi, produced by the increase or diminution in the size of the glands, may occasion, and on the variations in the irritation of the air-tubes which this pressure produces. The risk in cases of bronchial phthisis is not so much that of forming an altogether erroneous diagnosis, as of expressing a prognosis far more unfavorable than the nature of the case actually justifies. In cases where a con- siderable measure of bronchitis is'associated with tuberculization of the glands, we are especially likely to fall into this error, and can avoid it only by much caution, and by frequently repeated ausculta- tion. There are differences of another kind, however, between the results of auscultation in cases of phthisis in the young and old, and which depend— 2c?. On the absence or different appreciation, of some auscultatory phe- nomenarin the child, to which much value is attached in the case of the adult. To this head belong the differences resulting from the loss in the child of almost all that information which, in older persons, is afforded by the different modifications of the vocal resonance. The shrill voice of the child, the small power of modulating it that is possessed in early life, and the consequent difficulty of inducing the patient to utter a few sentences, or even a few words, in the same key, even when fear does not reduce the voice to a mere whisper, take away almost all value from the modifications of the voice-sound in young subjects. The extreme excitability of children tends, as it does also in the female subject, to reduce very low the value of mere inequality of breathing between the two lungs; for it is by no means a rare occur- 404 CHARACTERISTICS OF PHTHISIS IN CHILDHOOD. rence for the lung which on one day seemed to admit but little air, to yield the sounds of well-marked puerile respiration on the next day, and for the feeble respiration to have changed sides. Before, there- fore, any conclusion can be drawn from the feebleness of the respira- tion in either lung, its situation, degree, and extent must be confirmed by repeated observation. The finer variations in the sonoriety of the chest are not so easily distinguished in childhood as in more advanced age. The main cause of this appears to be furnished by the extreme resonance of the chest in early childhood, which will admit of very considerable reduction before percussion elicits a sound that the ear would recognize as at all dull. Extremely gentle percussion is much more likely to bring out the more delicate variations of sound, than those smart taps on the chest, which, in the grown person, will often answer the purpose suffi- ciently well. A last source of difference may be mentioned as arising— 3d. From the occurrence of some physical signs peculiar to the form which phthisis assumes in early life. The only sign that comes with propriety into this category, is that dulness between the scapulae which is not unfrequently produced by the presence of tuberculous glands, and which when it coexists with tolerable resonance over the upper part of the lungs, and moderately good respiration in those situations, may be regarded as pathognomonic of bronchial phthisis. The absence of dulness in this situation, how- ever, does not of itself warrant the inference that the glands are free from disease, but merely that they have not yet attained any very considerable degree of enlargement. It may perhaps be useful, before we proceed to the study of some other peculiarities of phthisis in childhood, briefly to recapitulate the general characteristics of the disease in early life. The chief of these are:— 1st. The frequent latency of the thoracic symptoms during its early stages. 2d. The almost invariable absence of haemoptysis at the commence- ment of the disease, and its comparatively rare occurrence during its subsequent progress. 3d. The partial or complete absence of expectoration. 4th. The rarity of profuse general sweats; and the ill-marked char- acter of.the hectic symptoms. 5th. The frequency with which death takes place from intercurrent bronchitis or pneumonia. Bronchial phthisis is characterized by— 1st. The frequent development of its symptoms out of one or more attacks of bronchitis. 2d. The peculiar paroxysmal cough which attends it, resembles that of incipient pertussis. 3d. The great and frequent fluctuations in the patient's condition, COURSE OF PHTHISIS SOMETIMES VERY RAPID. 405 and the occasional apparently causeless aggravation, both of the cough and dyspnoea. In very early infancy, phthisis is remarkable for the very frequent latency of the chest symptoms, which, through its entire course, are often entirely merged in the signs of impaired nutrition. The most important peculiarities in the auscultatory phenomena of consumption in the child are— 1st. The smaller value of coarse respiration, prolonged expiration, and interrupted breathing, owing to their general diffusion over the chest, and to their occcasional existence independent of phthisis. 2d. The apparent, and to some extent the real, exaggeration of the signs both of early and far-advanced disease of the lungs, in some cases of bronchial phthisis. 3d. The loss of that information which the phenomena of the voice furnish in the case of the adult. 4th. The small value of inequality of breathing in the two lungs. 5th. The difficulty of detecting minute variations in the sonoriety of the chest; and 6th. The existence of dulness in the interscapular region, together with moderate resonance of the upper part of the chest, and tolerably good respiration there, which are characteristic of the presence of en- larged bronchial glands. Hitherto we have been occupied with the study of the more com- mon forms of phthisis in childhood; but deviations are occasionally met with from the ordinary course of the disease, with which it behooves us to make ourselves acquainted. Phthisis occasionally runs a course so extremely rapid that many of its most characteristic symptoms have not time to manifest themselves. In such cases we are exposed to considerable risk of error, for the history of the patient's indispositidh goes back only to a few weeks or days; the evidence of impaired nutrition is almost or altogether wanting, and the symptoms appear to be those of an acute malady coming on suddenly, rather than those of a slow and wasting disease. A remarkable instance of this came under my notice some years ago, in the case of a little boy, nine months old, who was fat and ruddy, and had always had perfectly good health until the 10th of April. On that day he was taken with symptoms which his mother supposed to be those of a bad cold. On account of this he was kept in the house, and various domestic remedies were employed, though without any improvement, and on April 24th he came under my notice. There did not then appear to be any urgent symptom, though the child seemed much oppressed at the chest. The case appeared to be one of rather severe catarrh, occurring during the period of dentition. The gums were lanced, and a mixture containing the vinum ipeca- cuanhae was ordered, to which, finding the symptoms did not abate, small doses of antimonial wine were added on the 27th. On the 30th I was informed that the child was much worse, that his dyspnoea was greatly increased, and that his hands and feet had been swollen for the last forty-eight hours. I found the little boy breathing fifty times in 406 CASE OF TUBERCULOUS PNEUMONIA. 4 the minute, with great oppression at the chest, the face much flushed, the skin dry, the trunk hot, the limbs cool, and the hands and feet much swollen. Auscultation detected generally diffused small crepi- tation through both lungs, with indistinct bronchial breathing at the upper and back part of the left side. Three hours after this visit, the child died without a struggle, on being lifted out of bed for his mother to apply some leeches to his chest. On examining the body after death, a very thick layer of fat was found everywhere beneath the integuments. The lungs presented an extreme degree of tubercular degeneration, and many of the bronchial glands were enlarged by the morbid deposit to the size of a pigeon's egg. None of the tubercle in the lungs was softened, but it existed both in the form of yellow miliary tubercle, of tubercular infiltration, and of masses of crude tubercle formed by the agglomeration of many separate deposits. The pulmonary substance in the intervals between the tubercular deposits was of a bright red color, in the first stage of pneumonia, and in many parts bordering on the second stage, and there was very considerable injection of the bronchial tubes. The various abdominal viscera contained tubercle, but it was not far advanced in the mesenteric glands. The case represents a class in which there is much hazard of forming an erroneous diagnosis. It shows the possibility of tubercular depo- sit taking place to a very great extent without at all interfering with the general nutrition of the body, and without giving rise to any symp- tom so serious as to attract the notice of a very careful and affectionate mother. It illustrates also the mode in which the fatal termination of many cases of phthisis in children is brought about, and suggests the inquiry whether there be any means of distinguishing between tuber- culous pneumonia, and pneumonia which occurs uncomplicated with phthisical disease of the lungs. Pneumonia often complicates phthisis in early life, in circumstances where no diagnostic difficulty occurs; but it is of much importance to detect the consumptive element in cases which to the superficial observer present no other symptoms than those of acute inflammation of the lungs. The existence of a considerable amount of tubercular deposit in the lungs may be suspected in those cases in which the degree of oppression of the chest has, from the very commencement of the illness, been altogether out of proportion to the severity of the catarrhal or bronchitic symptoms with which the disease set in. A further evidence of its nature is afforded, if the skin, though very dry, present a less considerable or a less pungent heat than attends simple pneumonia, while the pulse from the very outset is less developed. Suspicion would be strengthened if the frequency of respiration very greatly exceeded the amount of mischief disclosed by auscultation, and especially if the rapidity of the breathing, though so great that it would excite the most serious alarm if the case were one of pneumo- nia, should yet continue the same for days together without marked deterioration in the patient's condition. Auscultation also would throw much light on the nature of the case, for the sounds detected in the chest would be the subcrepitantand mucous rale, rather than the small SIMPLE AND TUBERCULOUS PNEUMONIA. 407 crepitation of pneumonia; while, though the smaller sounds would be discovered at the lower part of the chest, the greatest dulness on per- cussion would generally be detected at the upper part, and bronchial breathing would very likely be perceived more or less distinctly in the same situation. The importance of distinguishing those cases in which inflammation supervenes in a lung already the seat of tubercular deposit, from others in which the organ had been previously healthy, is by no means confined to cases of the severest kind, in which life is immediately threatened. In every instance of pneumonia in early life, both your prognosis and your treatment would be greatly modified if there were good ground for believing that tubercular disease had for some time previously affected the lungs. Hence follows the necessity for that very minute inquiry as to the previous health of the patient, and of the other members of the family, on which so much stress was laid at the commencement of this course of lectures. If you learned that several children in the family had already died of phthisis or of some other aff'ection—such as acute hydrocephalus—which you knew to be most intimately associated with the tuberculous diathesis, the possi- bility of the same complication existing in the patient under your care would at once occur to you. This complication would be rendered highly probable, if you were to ascertain that the child had been par- ticularly liable to catch cold, or had for some months been seldom free from cough for many days together, or had suffered from cough every winter, for two or three years, and had already experienced two or three attacks, similar to that you are called on to treat, and which, though severe, had yet subsided by degrees, without the employment of very active measures. The probability would be raised almost to certainty if there existed that want of correspondence between the general symptoms and physical signs, or between the results of auscul- tation and percussion, to which reference has already been made; or if the history of the present illness went back to a period anterior to that which you would be disposed to assign to it, if the affection had been simple pneumonia. The case of tuberculous pneumonia you would subject to less rigor- ous antiphlogistic measures, than that of simple inflammation of the lungs. Bearing in mind the influence of enlarged bronchial glands in rendering parts of the chest dull on percussion, and in exaggerating in some respects the morbid sounds, you would not over-estimate the degree or extent of the inflammatory mischief. At the same time you would not allow even a considerable measure of improvement to lead you to speak too decidedly of the ultimate recovery of your patient; since you would not forget that, if inflammation do not originate tuber- culous disease, it may yet communicate increased activity to its pro- gress. The overlooking the more serious malady, owing to its symptoms being thrown into Jhe shade by those of the other more curable aff'ec- tion, is not the only error to which you are exposed in cases of infan- tile phthisis. The degree of irritation of the bronchi that exists in different instances, varies exceedingly; sometimes it is so considerable 408 BRONCHITIS EXAGGERATES THE SYMPTOMS. that when the child is placed under your care its respiration is wheez- ing, difficult, and very hurried, its cough violent and exhausting; while such is the general anxiety of the countenance, and so great is the depression of the vital powers, that the struggle seems as if it could not be long protracted. Percussion detects dulness at the upper part of the chest; the bronchi are so laden with phlegm that air scarcely penetrates beyond the larger tubes, and mucous rale is heard throughout the whole of the lungs, while at the upper part it is so large as to amount almost to gurgling. You regard the case as one of far advanced phthisis, and suppose that softened tubercle is diffused through the whole of both lungs, and that cavities exist at their apex. You form the most gloomy prognosis, and entertain, very probably express, the conviction that a few weeks at furthest will be the period of your patient's life. By degrees, however, the most urgent symp- toms subside, and some signs of returning health appear; the respi- ration grows slower and more tranquil, the cough abates, perhaps almost ceases. The signs of a cavity grow less and less distinct, in proportion as the secretion in the bronchi diminishes; and after some months, while the patient's general condition deviates but little from a state of health, a little dulness at the upper and back part of the chest, unequal breathing, prolonged expiration, or morbid sounds equally slight, are the only auscultatory evidence that the most careful examination can discover of pulmonary disease. Non-professional persons are apt to imagine the mistake in cases of this kind to have been greater than it really was. The error is one as to the degree of the malady rather than as to its kind. In cases that present these symptoms, phthisis has in reality existed, but the chief tubercular deposit has probably been seated in the bronchial glands, and their enlargement gave rise to much of the dulness on per- cussion, and exaggerated the morbid sounds at the upper part of the chest. From some accidental cause, such as cold or damp, or from the mucous membrane of the bronchi sympathizing with disorder of the digestive organs, or from inappropriate treatment, which aggravated the evil it should have relieved, or even without any cause that we can assign, it had come to pass that the air tubes were in a state of great irritation. The due regulation of temperature, general appropriate treatment, and nature's own healing power, improved the general health and diminished the irritability of the bronchi; while very probably the diseased glands emptied themselves, at least in part, into the air-tubes, and the tubercle was thus eliminated from the system. You should, therefore, always express your opinion very guardedly with reference to the condition of a child suffering from phthisis, until you have confirmed the results of auscultation by its frequent repe- tition, and till you have had the opportunity of determining how large a portion of the physical signs is due to the morbid deposit, and how much to that irritation of the bronchi which you may fairly hope to mitigate, if not to remove. The average duration of phthisis in childhood is estimated by MM. Rilliet and Barthez at from three to seven months, though, as they justly observe, its extreme limits vary from two months in unusually ACUTE PHTHISIS. 409 rapid cases, to two years and upwards in other instances, in which the course of the disease is very protracted. It is my impression, indeed, that the ordinary duration of phthisis in childhood is less brief than the observations of these gentlemen, made among the children in the Hopital des Enfans at Paris, have led them to believe, though the number of observations on which this impression rests is too limited to warrant my asserting it as a positive fact. Some cases, however, have come under my notice, in which the course of phthisis has been extremely rapid, and others in which the disease has con- tinued for two, three, four, and nearly five years, before it terminated fatally. That form of acute phthisis in which the patient dies as the result of the constitutional malady rather than of local mischief going on in some one organ, is much oftener met with as a sequela of some other disease, such as measles, hooping-cough, or typhoid fever, than as an idiopathic affection. It follows sometimes on the decline of one or other of those disorders, and develops itself out of the convalescence from it, the fever not entirely subsiding, the appetite not returning, the strength not being regained, but the amendment which yesterday seemed to promise, being belied by the deterioration of to-day; and in such circumstances, a month or five weeks will sometimes bring the child to the grave, all its functions suff'ering so equally that we feel at a loss as to the one to which we should endeavor chiefly to minister. But though less frequent, the cases are of greater moment, because they are more likely to be misinterpreted, in which this acute tuber- culosis develops itself out of a condition of previous health, though that health is oftener valetudinarism than vigor. Causelessly, the child loses flesh and strength, and appetite and cheerfulness; it frets about everything, but says it has no pain, that it ails nothing; nor is anything observable save that the pulse is habitually quicker, and the skin habit- ually hotter than natural. The nights are restless, though the child often wants to lie down in the daytime, and sometimes delirium comes on towards bedtime; while when awake there is a remarkable degree of nervousness, the manner is frightened, almost hysterical. Often this condition gradually passes away as symptoms of hydrocephalus come on, and the case loses its peculiarities as its hopeless nature becomes apparent; though not unfrequently, if we examine the body after death, we may be surprised at finding the evidence of cerebral disease slighter than we had expected, and a little fluid in the ventricles, a little opacity of the arachnoid, and a few granulations at the base of the brain, may be all the alterations discoverable. In other instances, the symptoms put on more and more the character of fever; the delirium becomes more frequent and at last constant; the prostration extreme, the tongue dry and tremulous, the teeth covered with sordes, and the abdomen full, tender, tympanitic, so that the distinction between the case and one of typhoid fever is almost impossible; and, indeed, the previous history of the patient, and the longer duration of the ailment, consti- tute almost the only means by which we can discriminate between them. This course of phthisis, too, is not limited to any age, but may 410 CHRONIC PHTHISIS. even be observed in infants at the breast; and the extreme rarity of typhoid fever at so early an age would in them still further raise the presumption that the symptoms were due to the rapid development of tubercle. So little notice has been taken of the chronic form of phthisis in children, that it may be well to relate a few examples of it. In March 1842,1 saw a little girl, six years old, whose father had died of phthi- sis, and who had had a cough ever since she suffered from measles two and a half years before. Her mother's anxiety had been excited by the increase of this cough, and by the child's losing flesh during the few weeks previous to her coming to me. Auscultation at this time discovered that air entered the lung in the left infra-clavicular region more scantily than in the right, and that the respiration was coarse, and attended with much creaking at the upper part of both lungs. In May, the general symptoms were much improved, and the creaking sounds were no longer heard. For many months the child continued to appear tolerably well, though her cough never ceased entirely; but in the early part of the winter of 1844 her health com- pletely failed. Examination of the chest in the beginning of December elicited great deficiency of resonance at the upper part of the left lung, both in front and behind. Bronchial breathing intermixed with large mucous rale, was heard in the left supra-scapular region, and abundant moist sounds pervaded the lung posteriorly. In the left infra-clavicu- lar and mammary regions the respiration was very deficient, and accompanied with distant moist sounds. Extreme coarseness of the respiration was the only morbid sound heard at the upper part of the right lung, and the breathing on that side was puerile in other parts. In January, 1845, the child had slight hasmoptysis, which recurred occasionally at intervals of a few weeks or months until her death, but was not profuse at any time. In September, 1845, resonance was slightly impaired under the right clavicle; and also in a greater degree posteriorly, as far as the angle of the scapula. There was absolute dulness of the left side, as far as the nipple in front, and the angle of the scapula behind. There was no natural breathing in the left lung, but the respiration was bronchial, and accompanied with large mucous r&le as low as the nipple; the rale being smaller, and the admission of air scanty below that point. About the left scapula there were cavernous sounds and distinct gurgling; smaller moist sounds lower down. In the right lung the respiration was puerile in front, except quite at the upper part, where the breathing was coarse, and attended with mucous rale; and posteriorly the same characters were still more marked. It cannot be necessary to detail the results of the subsequent exa- minations of the chest, which showed that disease advanced slowly in the right lung, though there was at no time proof of the existence of a cavity there. The child's condition fluctuated; sometimes she seemed almost dying under an aggravation of all the symptoms, and then again she rallied, and was able to walk about, and seemed toler- ably comfortable. Life was prolonged until June 1st, 1847: and she had seemed almost as well as usual until a very few days before her CASES OF CHRONIC PHTHISIS. 411 death. Unfortunately, permission to examine the body could not be obtained; but the stethoscopic signs enable us to trace back the phthisical disease for more than five years, while the evidence of a large cavity in the left lung was distinct twenty-one months before death took place. Nor is this a solitary case. In January, 1846, I saw a little boy, three years old, who had had cough ever since an attack of typhoid fever in the previous July; and for six weeks before he came under my notice his cough had grown more severe. There was then very marked flattening of the left side of the chest, which yielded a dull sound on percussion in the infra-clavicular and mammary regions; and air entered there very scantily. The same dulness existed on the left side posteriorly; and the scanty breathing was attended with a crumpling sound. In April, moist sounds were evi- dent there; and in May they were becoming larger about the left scapula; and signs of incipient disease were now perceptible in the right lung. In September, there was absolute dulness in the left infra- clavicular region, slightly diminishing towards the nipple, and absolute dulness in the left scapular region. Large gurgling was heard in this situation, most marked behind, and rendered very striking during a fit of coughing, which was followed by expectoration of about a tea- spoonful of pus. From this time to June, 1819, when I last saw him, he continued nearly stationary. The child became considerably stouter than he was when he first came under my notice; but the cough and purulent expectoration continued. I auscultated his chest on Septem- ber 26th, 1847, and, at that time, loud blowing respiration was heard over the whole of the left scapula, accompanied with gurgling; while lower down there were loud moist sounds, though not amounting to actual gurgling. From that time until August, 1848, the child's health continued tolerably good; he coughed but little, but suffered from occasional attacks of diarrhoea. The left side of the chest was much shrunken, and yielded a dull sound everywhere except just under the clavicle. Air entered but scantily; moist sounds attended it, but the evidences of a large cavity were growing less and less distinct. When I saw him for the last time, the amount of air entering the left lung was not increased, but the moist sound had almost completely disap- peared. How long the disease may continue, or what may be ihe ultimate issue of the case, it would be useless to speculate on; though it is by no means unlikely that the child may live, with but little deterioration in his condition, until measles or hooping-cough imparts a fresh stimulus to the consumptive disease, or excites some fatal attack of bronchitis or pneumonia. I used to see occasionally a little boy, who was aged only three years when he first came under my notice, and whom I had the opportunity of watching till he was eleven years old. When first brought to me he had been suffering from cough ever since an attack of what his mother called inflammation of the lungs, when he was sixteen months old; his cervical glands had recently suppu- rated; he had unusually well-marked hectic fever, and profuse night sweats; and a month before I saw him had spit blood once. His right 412 MODES OF DEATH IN PHTHISIS. side yielded throughout a dull sound on percussion ; breathing in that lung was scanty, and attended by large moist sounds. The child went into Devonshire to pass the winter, and, as I expected, to die there of phthisis; but he returned in better health; he grew tall, and played about like other children, though he seldom passed more than a few months without attacks of a pleuritic character, the pain of which he used to refer to his right side, and which usually subsided in the course of a few days, without any treatment more severe than a mus- tard poultice, and some diaphoretic medicine. His cough never left him entirely; but both that and the quantity and character of his ex- pectoration varied, and sometimes he spat a little blood. In October 1844, the auscultatory signs were as follows: The left lung yielded, as it had constantly done, the sounds of puerile breathing in front; posteriorly, the breathing in the lung was also good, except that there were some moist sounds in the infra-scapular region, and that the breathing had a coarse and almost tubular character about the upper angle of the scapula. In the right lung, in front, the respiration was puerile, with now and then a little distant crepitus as low down as the lower edge of the second rib, at which point the moist sounds became larger. Posteriorly there were large moist sounds intermixed with puerile breathing in the supra-scapular region; gurgling, cavernous breathing, and bronchial voice about the scapula; and lower down there was very little respiration, and that of a bronchial character, becoming quite inaudible in the lateral region. In the axillarv region the respiration was coarse, accompanied with large mucous r&les. In March, 1849,1 saw him for the last time. He had then continued for more than eighteen months free from any serious pleuritic attack, and from haemoptysis. His respiration was still hurried, but he had gained flesh, and sometimes had walked five or six miles in a day without inconvenience. Auscultation showed, too, that his disease had been stationary for the previous five years—if, indeed, it had not actually improved. The moist sounds about the left scapula were smaller and heard over a smaller surface. The indications of a cavity in the back part of the right lung continued unchanged, but not increased; while in other respects auscultation gave exactly the same results as before. Other cases of a similar kind have come under my observation, in which the history of phthisis went back for several years, and in which the signs of caverns in the lungs were unmistakable; the children , continuing to lead a sort of valetudinarian existence, improving in health, and gaining flesh and strength in the summer, but losino- gro°und again with the return of winter. ° In the present condition of our knowledge, it is not possible to state with certainty either the anatomical characters of phthisical cavities of long standing, or the signs which, during the patient's lifetime, would warrant the expectation that the disease will run a tardy course ■ but it is well to bear in mind, that such cases are by no means very rare; that the powers of repair are far greater in the child than in the adult. We must now, therefore, pass on to notice briefly the treat- ment of the disease, after glancing for a moment at the different modes in which it brings about a fatal issue. MODES OF DEATH IH PHTHISIS. 413 In a very large proportion of cases of phthisis, the functions of all the organs of the body become at length so much disturbed, and nutri- tion generally so impaired, that the patient dies, because the whole machine is worn out. But though this is the case in many instances, yet it often happens, even when the powers have long seemed nearly exhausted, and when the body is wasted almost to a skeleton, that death is far from tranquil, but is preceded by hours of severe agony, for which it is not easy to account. In mauy cases, and especially in those where the disease runs a rapid course, the fatal termination is due to an attack of intercurrent bronchitis or pneumonia, which is sometimes supposed to have been the patient's only disease, until a post-mortem examination reveals the tubercular degeneration of the lungs, to which the inflammatory affection was secondary. Death from haemoptysis is rare, and still rarer is the perforation of the lung by the walls of the cavity giving way at some point, and thus pro- ducing pneumothorax. The abdominal symptoms sometimes mask the thoracic, and the patient, who, had life been prolonged, would have sunk eventually under pulmonary phthisis, dies of tubercular peritonitis. Many children, in whom the signs of incipient phthisis have appeared, die of acute hydrocephalus, excited by the membranes of the brain having become the seat of tubercular deposit; and some, in whom the disease has attained a more advanced stage, are suddenly carried off' by head symptoms, the cause of which is explained by the discovery of large masses of tubercle in the cerebral substance. Con- vulsions, however, sometimes precede death for several hours, or head symptoms of greater or less intensity constitute the most striking feature in the patient's history for some days before death takes place ; and yet an examination of the body throws no light upon the cause of their occurrence. Sometimes, too, the symptoms that precede death are those of fever of a typhoid character, rather than of serious mis- chief in the chest. They were so in the case of a little boy, nearly seven years old at death, who had shown the symptoms of phthisis for more than two years, and the right side of whose chest had during that time presented the indications of gradually increasing tubercular deposit. The disease had advanced slowly, and with long inter- missions, though, on the whole, very obviously increasing. On No- vember 8th there was a manifest aggravation of his chest symptoms, attended with much fever. On the night of the 12th his mind wan- dered, and, when sensible, he complained of his head. On the 14th he became delirious likewise during the day; and until his death, which did not take place before December 1st, his mind wandered during many hours of every day, while at night he was quite light- headed, extremely restless, and tried to get out of bed, or at other times shrieked loudly, as if in violent pain. In the early part of his illness he had a frequent, short cough, which subsided as the febrile symptoms increased in intensity; but his respiration throughout con- tinued at about fifty in the minute; and this hurried breathing, coupled with the auscultatory signs, afforded the only evidence of the mischief that was going on within the chest. After death the only morbid appearance of any importance was discovered in the upper lobe of the 414 TREATMENT OF PHTHISIS. right lung. Its anterior fourth was perfectly solid and non-crepitant, of a yellowish-red color, owing to the infiltration of tubercle into it. Its posterior three-fourths were of a reddish color, and of a much softer texture; while the slightest pressure with the finger reduced their substance to a putrilage, from which there flowed a dirty reddish liquid, which seemed like a mixture of blood, and pus, and serum. Inflammatory softening of this lobe seemed to have been the cause of death, though manifesting itself less by local symptoms than by the signs of most serious constitutional disturbance. Though the study of phthisis, in its effects and its symptoms, has occupied us during almost the whole of two lectures, yet there need be but little said with reference to its treatment. The main principles by which we are to be guided in its treatment are the same at every age; nor do the differences in the patient's years bring with them many or important modifications in the means by which these prin- ciples are to be carried into action. Among the prophylactic measures adapted to early life, none is of more importance than the keeping the infant at the breast for the first twelve or eighteen months of its existence, by which time it will have passed through some at least of the dangers incidental to the period of teething. The task of thus nursing the infant, however, ought not to be undertaken by a mother who has shown any tendency to con- sumption, or in whose family consumptive disease has been prevalent, but ought at once to be intrusted to a healthy wet-nurse. This rule does not rest on mere theoretical grounds; but actual observation has shown that under some morbid states of the system the milk undergoes great changes, and loses much of its nutritive properties. In the case of the cow, these changes have been ascertained by Dr. Klencke of Leipzic to be very remarkable; and analogical reasoning would war- rant the belief that the scrofulous taint in the human subject may give rise to alterations of a similar kind. Dr. Klencke1 confirmed the observation of Sir Robert Carswell and others, that stall-fed cows are very liable to become tuberculous; and found, moreover, that in these circumstances their milk loses much or the whole of its sugar; that the butter and casein diminish, while albumen is found sometimes in as high a proportion as 15 percent., and elain in the proportion of 1.4 per cent., and that in some cases lactic acid is likewise present. Even if we set aside the assumption of scrofulous disease being actually transmitted through the medium of the milk, of which there is per- haps no clear evidence, it is yet apparent that a very slight degree of such an alteration in its constituents as has just been mentioned, must render it very unfit for the nutriment of a delicate infant. It is needless to dwell here on the general rules for feeding and clothing children as they grow older, or to insist on the necessity for the bed-rooms being airy and well ventilated. When the damp and cold weather of winter approaches, removal to a warm climate, in which exercise in the open air may still be continued, is much to be 1 Ueber die Ansteckung und Verbreitung der Scrofelkrankeit bei Menschen durch den Genuss der Kuhmilch, 16mo. Leipzig, 1840. See especially chapter iii., pp. 21-tjl. TREATMENT OF PHTHISIS. 415 preferred to keeping the child for weeks together a prisoner to the house; and as a general rule more is gained by change of climate in early life than in adult age. In children who are old enough to be taught to wear it, I have sometimes seen the respirator of much ser- vice, in enabling them to continue to take exercise in the open air at a season when, in previous years, exposure to the external air had always induced or greatly aggravated the signs of bronchial irritation. Whenever catarrhal symptoms appear, no care can be too great to bestow on the attempt speedily to remove them. In doing so, how- ever, and in the management of all ailments that come on in children who have shown a disposition to consumptive disease, much caution must be used, in order to avoid over-treating them. On this account it is of extreme importance to encounter them at their very commence- ment, when mild measures will suffice for their cure ; and, for the same reason, the child should be defended with the most punctilious care from the contagion of hooping-cough and of the eruptive fevers—dis- eases in the course of which serious thoracic complications are so apt to supervene, and to require for their cure most active treatment. Iu carrying out this plan of unwearied watchfulness, and of attention to minute detail continued for months and years, you will have brighter hopes with children for your patients, than if you were called on to exercise similar precautions in the case of persons more advanced in life. Without raising baseless expectations, too, you may communicate something of hope to the parents, and thus lighten for them their anxious task; nor will the appearance even of decided physical signs of tubercular deposit, nor the evidence that in some parts that tubercle is softened, warrant an absolutely hopeless prognosis. Cases such as have been related show how long life may be prolonged in circum- stances the most inauspicious; and, where speedy death has been expected, an unlimited reprieve seems almost a pardon. It may suffice to have said thus much about the management of phthisis in childhood; for when the disease is actually developed, we have the same indications as in the adult, and these must be met by similar means. Iron, quinine, and the mineral acids are the most important of our tonic remedies; and for these the extract of bark and the extract of logwood may be substituted, if much tendency exist to a relaxed state of the bowels. In cases where the glands of the neck are affected, and where there seems to be reason for supposing that the disease approximates to bronchial phthisis, the syrup of the iodide of iron may be employed with advantage. Such cases, too, have seemed to me to profit most by the cod-liver oil; though I must confess that my own experience of it does not altogether bear out the high encomiums which have been bestowed upon it by some practi- tioners. Sometimes I have known it excite diarrhoea; at other times it completely spoils the appetite; while, as a general rule, I think it is not borne well in cases where dyspeptic symptoms are, as is so often the case, at all a prominent feature in the disease. Sometimes, too, the child's repugnance to the remedy is unconquerable; though this does not often occur. If given in a little orange wine, or orange juice, sweetened with syrup of orange-peel if necessary, its taste is in 416 TREATMENT OF PHTHISIS. general perfectly disguised; while sometimes, nauseous though the oil is, children become really fond of its flavor. The sickness and the paroxysmal cough are best relieved by the hydrocyanic acid, with which the liquor cinchonae of Mr. Battley may be combined,1 in cases where we are afraid to venture on any but the mildest tonics. Among local measures, the use of stimulating liniments to the chest is even more valuable in early life than in the adult; and sometimes the application of a blister about the size of a shilling, under one or other clavicle, and its frequent repetition, are followed by a very great amendment in the patient's condition, and by a marked improvement in the physical signs furnished by the subjacent lung. I have very rarely employed local depletion, except in the treat- ment of the pneumonia which so often attacks the phthisical patient; but it has then seemed sometimes to be of great service; and it will probably be safer to trust to a moderate abstraction of blood by leeches, followed by small doses of antimonials, than to administer mercury, or to give antimony in larger doses without previous deple- tion. The habitual cough of phthisis requires small doses of ipecacu- anha wine, combined or not with antimony, and laudanum or com- pound tincture of camphor in small doses—remedies which, on account of their strength being definite, are always to be preferred, in the management of the affections of childhood, to a preparation so varia- ble as the syrup of poppies. Opiates in various forms, and for various purposes, may be needed to check diarrhoea, or to relieve suff'ering; and you must not allow any preconceived notion of the danger of employing opium in infantile diseases to prevent your having recourse to so valuable a medicine. We must here leave this subject, so full of painful interest, and proceed at our next lecture to the study of diseases of the heart in early life. 1 See Formula No. 21, p. 389. / Another very useful formula in these eases, and one which has the further advan- tage of forming a very agreeable vehicle for the cod-liver oil, is the following:— (No. 22.) 1£.—Acid. Nitr. dil. Tt^xvj. ----Hydrochlor. dil. n\xxiv. ----Hydrocy. dil. TT\,viij. iEtheris Chlorici, T^xl. Trae. Aurantii, 3iss- Syrupi simplicis, %^ij. Aquae destillatae ad 31 v. M. A tablespoonful every six hours. For a child four years old. DISEASES OF THE HEART. 417 LECTURE XXX. Diseases op the Heart—rarer in childhood than in the adult, and why—but rarity probably exaggerated.—Causes of disease of the heart in childhood, rheumatism the most frequent—heart sometimes affected when rheumatic symptoms are very slight—both endocarditis and pericarditis may come on independently of rheumatism—as sequelae of scarlatina or other fevers—as consequences of congenital defects—as complications of pleurisy—or as purely idiopathic affections—cases illustrative of pericarditis in different circumstances. Endocarditis—symptoms not always well marked—advance of valvular disease sometimes very gradual.—Doubt as to whether valvular disease is not sometimes independent of previous inflammation. Prognosis in valvular disease—less unfavorable in child than in adult—power of growing heart to adapt itself to effects of disease and to repair its evils—such favorable cases still exceptional—importance of presence or absence of dilatation in determining issue of case.—Illustrative cases of dilatation without valvular disease.—Anaemic bruits much rarer in early life, but disordered action of heart occurs at all ages.—Summary of con- clusions. Among the many causes of suffering and death to which persons in adult age or advancing years are exposed, diseases of the heart and great vessels occupy a very prominent place. The frequency of these affections is, indeed, but very imperfectly shown by our tables of mortality, which represent them as occasioning less than one and a half per cent, of the total deaths at all ages in the metropolis; but we know that in a large proportion of cases of rheumatism, asthma, bronchitis, and the dropsy, the real cause of the fatal event is to be found in the cardiac mischief with which those maladies are so often associated. In childhood, however, many of the most influential causes of heart disease are of comparatively rare occurrence; rheumatism is popularly regarded as an aff'ection almost confined to youth and early manhood, as granular degeneration of the kidney is to adult and declining age; while all those forms of atheromatous deposit in the coats of arteries, or in the substance of the valves of the heart, which are a fertile source of suffering, and in their consequences a frequent cause of death, belong essentially to the processes of decay which accompany the decline of life. But though heart disease is confessedly less frequent in the child than in the youth or in the adult, yet its rarity is not so great as, judging from the silence concerning it of many writers on the diseases of childhood, you might naturally infer. The advance of knowledge, too, brings with it every year some fresh illustration of the occurrence of heart disease in early life, in circum- stances where it once would not have been expected. Rheumatism, if less frequent than in the adult, is yet associated with affection of the 27 418 DISEASES OF THE HEART. heart in a greater proportionate number of instances in the child.1 The state of the circulating fluid which attends and follows scarlatina seems to predispose to inflammation of the lining or investing mem- brane of the heart in childhood, in the same manner, though not to the same extent, as does the state which accompanies Bright's disease in the adult. In themselves, too, and in their complications, congenital malformations constitute a large class of affections of the heart peculiar to early life; while the microscope has already taught us that fatty degeneration of the heart may occur in the infant of some months old, as well as in the man of sixty years. Not many years since it would have been necessary to adduce statistical evidence in support of the assertion that disease of the heart was far from being of unfrequent occurrence in early life. This, however, is no longer requisite, for the fact is universally admitted; and I may add that the