CASE OF 
COLLAPSE OF THE LUNG AND CYANOSIS 
IN A 
YOUNG INFANT, 
PRODUCED BY VIOLENT CRYING, IN WHICH THE SYMPTOMS WERE 
SUCH AS TO CAUSE A SUSPICION OF OPIUM-POISONING ; 
WITH REMARKS ON THE NATURE AND TREAT- 
MENT OF TEMPORARY CYANOSIS FROM POST- 
NATAL COLLAPSE OF THE LUNG. 
BY 
J. FORSYTH MEIGS, M.D. 
lie-printed from the Amebican Journal of Obstetrics and Diseases of 
Women and Children, Vol. XII., No. I., January, 1879. 
NEW YORK: 
WJLLIAM WOOD & CO., 27 GREAT JONES STREET. 
1879. CASE OF 
COLLAPSE OF THE LUNG AND CYANOSIS 
IN A 
YOUNG INFANT, 
PRODUCED BY VIOLENT CRYING, IN WHICH THE SYMPTOMS WERE 
SUCH AS TO CAUSE A SUSPICION OF OPIUM-POISONING ; 
WITH REMARKS ON THE NATURE AND TREAT- 
MENT OF TEMPORARY CYANOSIS FROM POST- 
NATAL COLLAPSE OF THE LUNG. 
BY 
J. FORSYTH MEIGS, M.D. 
Reprinted from the American Journal op Obstetrics and Diseases ®f 
Women and Children, Vol. XII., No. January, 1879. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GEE AT JONES STKEET. 
1879. CASE OF COLLAPSE OF THE LUNG AND CYANOSIS 
IN A YOUNG INFANT, 
PRODUCED BY VIOLENT CRYING, IN WHICH THE SYMPTOMS WERE SUCH AS TO CAUSE 
A SUSPICION OF OPIUM-POISONING ; WITH REMARKS ON THE NATURE 
AND TREATMENT OF TEMPORARY CYANOSIS FROM POST- 
NATAL COLLAPSE OF THE LUNG.1 
BY 
J. FORSYTH MEIOS, M.D. 
On Monday, April 9th, 1877, I was sent for to see a young infant 
said to be alarmingly ill. Arrived at the house at a.m., and found 
an infant four weeks old, quite healthy at birth, and nursed by a 
healthy mother. From birth to the evening of Friday, April 6th, 
the child had been quite well. It had always nursed naturally, and 
had had three or four abundant, smooth, well-concocted yellow 
stools each day, and had seemed healthy in every respect. During 
the night of the 6th, it had been restless and had cried violently. 
It was supposed to be colicky, and no one was alarmed. On Saturday, 
the 7th, it was uneasy, and cried a great deal, and also through the 
following night. On Sunday, it still crie*d very much, but as there 
was no other sign of ill-health, and as the child nursed, and con- 
tinued to have the bowels moved freely and naturally, it was not 
thought to be seriously ill. 
On Sunday, the 8th, as the supposed colic with the frequent crying 
continued, the monthly nurse, without consulting the physician, 
gave at 12 m. 10 drops of Dewees’ carminative. At 9 p.m. of that 
day, no relief being obtained, the nurse gave 15 drops more. This 
second dose was followed by some relief, as the child was easier and 
more quiet up to 11 p.m. It began then to cry again, and continued 
to do so until 6 a.m. of Monday, the 9th. The mother, who was a 
most intelligent person, though without experience, as this was her 
first child, told me that the baby “screamed most violently and 
continuously.” The nurse said that the child “yelled” all night, 
but said afterwards that it would drowse for a little while, and then 
“yell ” most violently for long periods. At 6 a.m. of Monday, there 
having been no rest through the night, the nurse gave 15 drops 
more of the carminative. After this the child slept upon the lap, 
and refused the breast. At about half-past ten o’clock, the baby 
was put into its usual warm bath. It was listless and drowsy through 
all this, and, at the close of the bath, whilst being dressed, was 
observed to be curiously pale and white over the whole body, look- 
ing like a person in a faint. Soon after this she became livid in 
color, had hurried and frequent breathing, and both nurse and 
mother became greatly alarmed, thinking the child might be dying. 
They sent at once for the accoucheur, for myself, or for any phy- 
sician they might be able to find. They stopped a physician in the 
1 Read before the Obstetrical Society of Philadelphia, September 6th, 1878. 4 
Meigs: Case of Collapse of the Lung 
street, and when I reached the house, at 11£ a.m., this gentleman 
was there. He told me that he found the child very pale, with 
scarcely any pulse at the wrist, and looking very ill. A mustard 
plaster had been applied to the chest, and, as it had reddened the 
skin considerably, was removed. 
On examination I found it looking pallid, but not blue at all. 
The breathing was short, feeble, and uneven; the pulse was fre- 
quent and weak, but could be felt distinctly; the pupils were con- 
tracted to a very small size, and the eyes motionless. 
At first view of the case, after hearing of the Dewees’ carmina- 
tive, and observing the drowsiness and contracted pupils, I thought 
it was one of overdosing with opium—that either the carminative 
had been stronger than usual, or that more had been given than 
was intended. When I suggested this fear, the nurse broke down in 
great despair, and the mother was deeply distressed. Upon going 
over the history more carefully, however, and reflecting that nine 
hours had elapsed between the first and second doses, and nine 
hours between the second and third doses, and that between the 
second and third doses the child had screamed most furiously and 
continuously, I felt convinced that, if real narcosis were present, it 
must be the result of the last dose alone. The last dose had con- 
sisted of 15 drops only, and 1 began to think it impossible that this 
small quantity could have produced such an effect. The first 
two doses, containing 25 drops, had caused no narcosis. How could 
then one of 15 drops determine it ? 
Dismissing from my mind, therefore, the theory of narcosis, I 
thought at once of collapse of the lung, post-natal atelectasis, of 
which I had seen several examples in children of a few days or a 
few weeks old, with symptoms much like those here present. 
The child was now lying quietly on a sofa. 1 passed a finger 
gently into the mouth. It was not grasped by the tongue as it 
ought to have been, but was merely nibbled at in a feeble way. I 
had the patient lifted carefully and gently upon a pillow and placed 
upon the mother’s lap, and told the mother I wished to see whether 
the child could or would nurse. I selected the left breast in order 
that the child’s heart might have free play in the act of nursing. 
At first no notice was taken of the breast. 1 then had the mouth 
held gently, but with some persistence, at the nipple, and the nipple 
inserted between the lips. The child now tried apparently to make 
an eflect at suction, but, suddenly, the head was thrown back stiffly 
on the neck, and the body was stretched out with a convulsive 
movement. The face was distorted, being drawn towards one side, 
the breathing became labored and irregular, and the body assumed 
a dark livid color all over. In fact, there was a manifest attack of 
cyanosis with convulsive stiffening. I lifted the child as quietly as 
possible from the lap, and, having an inclined plane of about 15° 
formed of pillows, laid the body carefully on the right side upon this 
plane, and gave strict orders that it should not be disturbed in the 
least from this position for several hours. Presently the dark color 
passed away, and the body became pale. The respiration was short 
and feeble, the face dull and passive, and the mouth and eyes were and Cyanosis in a Young Infant. 
5 
closed. There was no sign of coryza, and no nasal nor faucial 
rattle; the pupils continued very much contracted. I added ten 
drops of brandy to two teaspoonfuls of breast-milk, and poured a 
few drops into the mouth. Each time that I did this, the child 
moved, threw back the head, aud the face was drawn upwards and 
outwards in a strong grimace. This was a slight convulsive move- 
ment, and was repeated several times within an hour—indeed, 
whenever the child was at all disturbed. I made a meche of soft 
cambric rag, wetted it with the milk, inserted it between the lips, 
and left it there, telling the nurse to wet it afresh from time to time, 
by dropping a little milk upon it from a teaspoon. 
At p.m., the child was doing well; lying quietly on the side, 
looking pale, and now and then sucking at the wetted rag. At 
p.m. no change ; no spasmodic movements nor blueness. Treatment 
to be continued. 
At 3 p.m., I was sent for to meet the accoucheur who had arrived. 
This was a gentleman of the largest experience, and one whom I 
often met in consultation. He had already examined the patient, 
inquired into the antecedents of the case, and announced his opinion 
that it was one of narcotism from the opium contained in the car- 
minative, so that he was impressed, as I had been, with the strong 
resemblance of the symptoms to those of opium-poisoning. 
Just before this the bowels had been moved. The stool was un- 
like any one the child had had since its birth. It was small in 
quantity, yellowish in color, and consisted of a thin feculent matter, 
intermixed with a large proportion (about halt) of tough, stringy 
mucus, and a good many small rounded, undigested lumps of caseine. 
It was much more offensive, too, than usual. It was the first of the 
kind, the mother said, the child had ever had. Previously they had 
always been smooth, yellow, perfectly well concocted, without 
mucus or lumps of caseine, never greenish, never fetid, but having 
the light odor which belongs to the dejections of a healthy infant. 
The character of this stool explains, I think, the violent crying of 
the three days before the cyanosis set in. It showed that the child 
had had a fit of indigestion from some cause. There was a lientery 
of undigested caseine, and as a consequence, catarrh of some part 
of the intestinal mucous membrane with colic and pain. 
The child was still lying quietly on the side, but was nursing gently 
through a small india-rubber tube attached to a shield which fitted over 
the mother’s nipple. We directed that perfect rest in the same posi- 
tion should still be maintained. The baby was to be allowed to nurse 
for two or three minutes at a time, once in an hour, the breast 
having first been partially emptied by a breast-pump. At 9 p.m., 
all going on well, the child composed, and breathing more freely 
and naturally. 
April 10th, 9 a.m.—Doing well; a quiet night without crying or 
disturbance; nursing now well from the breast, but restricted to a 
few minutes once in an hour. Had had in the night another stool, 
of the same kind as the one above described—mucous, offensive, 
with small undigested lumps. 
Evening.—Child seems quite well. Had had one stool since the 6 
Meigs: Case of Collapse of the Lung 
morning. It was bright yellow, smooth, of the consistence of thin 
gruel, considerable in amount, without lumps, and of the natural 
odor. We agreed now that, if there should be any return of the 
crying, the child should have ten drops of brandy in warm water, 
and should that fail to quiet the pain, a teaspoonful of the following 
mixture, every two hours : $ Sodse bicarb., 3 ss.; Tr. opii cam- 
phorat., gtt. xl.; Tr. rhei dulc., gtt. lxxx.; Syrup., 3 ij.; Aq. menth. 
pip., 3 xiv. M. 
From this time forwards the child remained well, and, in August, 
1878, it was a fine, well-grown, healthy infant. 
Remarks.—The case just detailed is an interesting, and even 
an important one. It shows how difficult a thing diagnosis 
may be. For here an infant, four weeks old, supposed to be in 
good health except for a sharp colic, for which the nurse is 
ashamed to send for the physician, became suddenly dangerously 
ill, and developed a series of phenomena so much like those of 
opium-poisoning as to suggest that diagnosis to two experi- 
enced physicians. So strong was the resemblance of the 
condition to that of opium-poisoning that my friend was dis- 
posed to maintain throughout the case that it must have been 
the result of the doses of Dewees’ carminative. For myself, I 
soon became convinced that the amount of opium contained in 
the carminative was quite too small to cause dangerous narco- 
sis, and that, moreover, the symptoms, when carefully analyzed, 
were not those which belong to opium-poisoning. 
It is easy to imagine the terror and distress of the nurse, and 
the horror of the mother, when they were told that the case 
was one of overdosing with opium, and the comfort they felt 
when I was able to assure them that, in my opinion, the dan- 
gerous symptoms were not the result as I had at first feared, of 
the doses given by the nurse, but of a morbid condition of the 
lungs and circulation to which very young infants are occasion- 
ally liable. In the one case, the child, should it die, would 
have been killed by the nurse; in the other, it would have died 
by the hand of God. 
I can very well understand how the first opinion I formed 
was that of opium-poisoning. The child was drowsy and stupid, 
and had been so for several hours; it had refused the breast, 
had had a convulsive seizure, and had taken several doses of a 
carminative containing opium. But, on more careful study of 
the history of the case, I learned that nine hours had elapsed 
between the first and second doses without any sign whatever of and Cyanosis in a Young Infant. 
7 
opium action, and that nine hours had elapsed also between the 
second and third doses, and that during this time the child, so 
far from being stupefied as from opium, had screamed, or, as 
the nurse said, “yelled” for a number of hours. The third 
dose was then given, and it was after this that the infant became 
quiet and drowsy, then, after the bath, very pallid as though in 
a fainting state, and after this, convulsed, blue in color, and 
apparently dying. If, therefore, the condition was one of 
opium-poisoning from the carminative, it must have been the 
last dose which had produced all these dire results. More- 
over, how suppose that, if the first dose of ten drops, and the 
second of fifteen, had caused no sign whatever of opium 
action, the third of fifteen drops could act with such intensity? 
There could have been no cumulative action of the two first 
doses, as nine hours had passed between the first and second, 
and nine hours after the second, without a sign of narcotic influ- 
ence. To make it at all probable that the third dose was 
the cause of the symptoms, I should have been obliged to sup- 
pose that the nurse either deceived me as to the quantity she 
had dropped, or had been herself deceived, and given a much 
larger dose than she thought. 
I found, moreover, on careful calculation, that the amount 
of laudanum in Dewees’ carminative was not more than three- 
eighths of a drop in ten drops of the carminative, and five-eighths 
in fifteen drops, so that the child could not have taken more 
than a drop and a half of laudanum in the whole thirty-five 
drops of the carminative administered, and that the whole 
amount had been distributed over a period of nearly twenty- 
four hours. 
But, not only were the doses of opium insufficient in quan- 
tity, and given too far apart to produce dangerous narcotism ;— 
other conditions were present opposed to the theory of opium- 
poisoning. The respiration and circulation were both frequent 
and feeble—they are usually slow in opium-poisoning. Move- 
ment and agitation of the body, instead of being beneficial, as 
in opium coma, developed new and dangerous symptoms, to 
wit, cyanosis and convulsive phenomena. Previous to my 
first visit, what first alarmed the mother and nurse was the 
effect of the disturbance necessary in bathing the child at half- 
past ten o’clock. Before the bath, the child was heavy and 8 
Meigs: Case of Collapse of the Lung 
lethargic, and it would not nurse. During the bath, it was 
listless and dull, and, at the close, became very pale, as though 
in a fainting state, and then grew livid. It was this condition 
which gave rise to the fear that it was dying. An hour later, 
when 1 arrived, it was lying quietly on a sofa, without the 
appearance, at first glance, of dangerous illness. The face was 
still, the respiration rapid and high, the pulse frequent and 
very small (indeed the physician who was present stated that 
it "was nearly extinct when he first felt it), and the pupils con- 
tracted. When the child was moved, at my request, gently, 
to the mother’s lap, to try whether it would nurse, the result 
was a sudden development of cyanosis, grimaces, gasping, and 
stiffening of the body—the very effects of movement which I 
had seen several times before in cases of cyanosis from collapse 
of the lung, and certainly not those one should expect to see 
in opium-poisoning. The contraction of the pupils, which was 
one of the striking symptoms, and one of the most frequent and 
marked in opium coma, occurs in other forms of disease of the 
nerve-centres besides poisoning by opium, and may be explained 
in this case on other principles, as I shall attempt to show fur- 
ther on in the discussion of the case. 
Dismissing then, on these various grounds, the theory of 
opium-poisoning as the cause of the symptoms in the case, how 
are we to explain the cause and nature of this alarming and 
sudden illness—an illness which had nearly proved fatal to the 
child, and which had so much the appearance of opium-poisoning 
as to suggest that explanation to two competent physicians ? 
I believe that the symptoms were the result of the violent 
crying which had been continued, off and on, for two days and 
three nights, and which had for its cause colic pain, induced by 
a fit of indigestion. This crying had, in my opinion, induced 
finally such exhaustion of the respiratory muscles as to cause 
collapse of a portion of the lungs, and collapse of an amount 
sufficient to determine obstruction of the pulmonary artery, 
overloaded right heart, empty arteries, and such diminished 
supply of arterial blood to the nerve-centres as to establish 
anemia of those centres, and so coma, convulsion, contracted 
pupils, and the various phenomena which looked so much like 
opium-poisoning. 
If this opinion be a correct one, it is certainly an important and Cyanosis in a Young Infant 
9 
fact for the medical practitioner, since he might otherwise, in 
such a case, assert opium-poisoning and so injure the reputation 
of an innocent nurse, or cause a cruel and unnecessary wound to 
some family. But as all this is, so far, only my own explanation 
of such cases, I desire to call the attention of the Society to some 
of the reasons on which 1 base this opinion, and to explain, in 
some detail, what I conceive to be the mode in which violent cry- 
ing may produce this result. [ will lirst quote the history of 
two cases which I had seen prior to the one described this 
evening. In one of these, the cyanotic attacks followed so 
directly upon violent crying that I think no one can doubt the 
relation ot cause and effect between the two conditions. In 
the other, though the crying was not so violent, I could, at the 
time the case occurred, discover no other cause. 
In the first case1 a female infant, which had been perfectly well 
at birth, and up to the moment of the attack about to be described, 
was put suddenly into a bath by the nurse, on the eighth day after 
birth, directly after it had waked from sleep. The child, not yet 
properly awake, was greatly terrified, and began to scream violently. 
Instead of removing the infant from the bath, the nurse persisted 
in holding it immersed in the water for some minutes. It became 
deeply blue and convulsed, it frothed at the mouth and nose, 
seemed to be suffocating, and appeared to be dying. These symp- 
toms continued for three-quarters of an hour, when they gradually 
passed away, and it fell into a heavy sleep. When I saw the child, 
soon after this, the only signs of disorder that remained were 
unusual paleness, drowsiness, and an expression of feebleness. 
Some three hours later, it waked, nursed, and from that time con- 
tinued well. The only directions given were, no more bathing for 
some time, and slow, careful handling. 
The second case is as follows :2 
In the spring of the present year, I attended a lady in her con- 
finement, who gave birth at full term to a healthy boy, weighing 
between nine and ten pounds. The child was perfectly well in 
every respect when born, and gave no disquietude up to the 
sixth day after his birth. On that day he cried a good deal in the 
morning. At one o’clock in the day, he began to moan, and seemed 
distressed, so that the mother asked whether he was not ailing. 
Just before 2 p.m., whilst in the nurse’s lap, he ceased moaning, 
became bluish, and seemed to lose his breath, so that the nurse 
thought he was dying. She immediately placed him in a warm 
bath, and sent for me." The bath restored his respiration, the blue- 
ness passed away, and he looked much better, though he continued 
1 Meigs and Pepper, Dis. of Children, 6th ed., p. 135. 
2 American Journ. of Med. Science, January, 1852, p. 94. 10 
Meigs: Case of Collapse of the Lung 
to breathe irregularly and unevenly. A short time after this, he 
again became blue, and breathed slowly and irregularly, but had 
no spasm. A neighboring physician was called in, and ordered a 
repetition of the bath and a bottle of medicine of some kind. 
Shortly before 4 o’clock p.m. 1 arrived, and found the child lying 
upon the lap of the nurse, and just beginning to have another one 
of the paroxysms which had caused so much alarm. The whole of 
the exposed surface, the head and neck, and the arms, hands, and 
feet, were bluish. As I looked at the patient, the color of the skin, 
especially that of the head and neck, became more and more blue, 
and at last almost black, so that the child looked more like the 
child of a black than of a white woman. At the same time, the 
head was drawn backwards and to one side by a tonic muscular 
spasm ; the ai ms and legs were extended and rigid, and the lingers 
were flexed in the palms of the hands. The respiration was slow 
and imperfect, and the child seemed as though about to die in the 
convulsion. This condition lasted for some moments, after which 
the convulsive state subsided, but the child remained bluish and 
in a state of stupefaction. 
There was nothing in the history of this case that allowed me to 
refer the symptoms to any other cause than obstruction to the pul- 
monary circulation from collapse of the lung, and perhaps a 
reopening of the foramen ovale from the congestion of the right 
side of the heart, brought about by the partial arrest of the current 
through the branches of the pulmonary artery. There was no 
derangement of the digestive function, nor was there any sign, 
even the least, of a catarrhal condition to explain the symptoms. I 
concluded, therefore, that the case was one of sudden collapse of 
some portions of the lungs, with consequent congestion of the 
right side of the heart, and, perhaps, reopening of the foramen 
ovale and admixture of the two kinds of blood. I told the mother 
that there was no indication for any medicine ; that all we could 
do was to place the infant on its right side, on an inclined plane of 
pillows, in order to let the heart have full play, and to give every 
half hour live drops of brandy in a teaspoonful of breast-milk. He 
was not to be disturbed from this position for several hours for 
any object whatever. 
My directions were accurately complied with. In a very short 
time the color of the skin began to improve, and, though there 
were two slight paroxysms of convulsive stiffening with increased 
depth of the cyanosed tint, between this time and the evening, I 
found the child much better in all respects at my evening visit. 
There was still, however, some blueness, with irregular, short respi- 
ration, and with a continuation of the dulness and inattention. 
During the early part of the night the breathing was short and 
uneven, and attended with some moaning; but about 4 a.m. these 
symptoms disappeared, the child fell into a natural, easy sleep, 
lasting until 7 a.m., when it waked, nursed without any difficulty, 
and seemed quite well. 
The child recovered perfectly, and is now (October 29th, 1851) 
in fine health. and Cyanosis in a Young Infant. 
11 
It seems to me quite plain that, in the first of these cases at 
least, the violent crying and subsequent collapse of the lung 
and asphyxia must have been cause and effect. In the second 
case, the crying was not so marked, but it had recurred, and 
if it were not the cause of the subsequent collapse, I know not 
to what other cause to ascribe the illness. 
For myself, I find no difficulty in understanding the mode 
in which violent crying may produce, in very young infants, the 
results witnessed in these three cases. Why one infant shall 
suffer so seriously from this cause, whilst a large majority 
escape, I do not attempt to comprehend. 
In seeking, then, an explanation of this accident to the 
child, I recollect, first, that the young infant has but just 
issued from its intrauterine life, during which life the forces 
by which the act of breathing is to be established had been, 
so to speak, sleeping. At birth these forces enter at once into 
activity. This new activity is dependent, in all its wonderful 
arrangements for the pulmonic circulation and the aeration of 
the blood, upon the respiratory muscles. Unless these muscles 
enter upon their due and healthy contraction, life is impossible. 
Their play renders possible the new route for the circulation, 
and calls into active use myriads of blood-channels and air- 
cells which had before been closed. 
It is not unreasonable to suppose that the new organisms, 
thus suddenly called into action, may retain, for a time, some 
memory of their previous condition, that their working may 
be feeble and imperfect, and that so they may tend to return the 
more readily, during the first weeks of life, to their fetal state. 
The muscular apparatus in particular must be feeble at first and 
more prone than afterwards to exhaustion. Violent crying can 
be effected only by an amount of muscular work far beyond what 
the ordinary vital work of respiration demands. Such crying 
may wear out and exhaust the muscles of breathing just as the 
locomotor muscles of the hunted hare or over-driven horse are 
worn out. When this occurs, the thorax is no longer expanded 
as in healthy breathing; portions of lung, not receiving the 
due amount of air, collapse, and in the collapsed portion the 
blood-vessels must be more or less obstructed. Should the 
respiratory muscles enter suddenly into inertia—faint, so to 
speak—the child might die suddenly, or in a very short time. 12 
Meigs : Case of Collapse of the L ang 
But so far as my experience goes, this does not happen, and 
yet such a sudden fatality was not far off, perhaps, in the 
first case quoted in this paper. 
How does collapse of the lung induce cyanosis and the vari- 
ous concomitant dangerous phenomena present in the cases 
described ? Evidently by establishing what Hr. Moreton 
Stille, in his admirable thesis on cyanosis, published in 1844,1 
demonstrated to be the chief factor in the morbid condition, 
to wit, a condition of which contraction of the pulmonary 
artery may be taken as a type. Hr. J. Lewis Smith, of Hew 
York,2 generalizes the same condition in the following words : 
“ Cyanosis is due to vices or defects in the organism, usually 
congenital, which prevent the free and regular flow of blood 
to, through, or from the lungs.” 
It is not necessary for me to go into a study of the various 
theories of cyanosis. These concern rather those cases in 
which there is malformation of the heart or great vessels at 
birth, congenital defects which are absolutely incurable. I 
have to deal only with a condition developed in children 
healthy at birth, and of perfect formation, as shown by their 
perfect recovery at the time from the symptoms, and by the fact 
that they do not afterwards develop any sign of malformation. 
It is clear that the blue color seen in my patients is the result 
of congestion of the venous system determined by an impedi- 
ment to the circulation through the lung. But what is the cause 
of the convulsive movements, the drowsiness or coma, and the 
contracted pupils ? The key to all this was explained by my 
father, Hr. Charles H. Meigs, in 1850.3 The cause is to be 
found in the loss to the cerebro-spinal axis of the oxygen 
which is supplied to it by the arterial blood. Hr. Meigs says 
(page 104) : “ I shall proceed to show that the cerebro-spinal 
axis in man is inert and powerless, nay lifeless, inanimate as of 
itself; and that it depends upon the influence of oxygen for 
its power to manifest itself in its life-phenomena.” 
The phenomena present in these cases are, then, the results 
of diminished supply of arterialized or oxygenated blood to 
the brain and spinal marrow. Whether we suppose, as some 
1 American Jour, of Med. Sciences, July, 1844, p. 25. 
2 See Diseases of Children. 
3 See Observations on Certain of the Diseases of Young Children, Phila., 1850. and Cyanosis in a Young Infant. 
13 
do, that in asphyxia caused by obstruction to the pulmonic 
circulation, the capillaries between the pulmonary artery and 
pulmonary veins, or the smallest terminal branches of the pul- 
monary artery, contract upon an unchanged venous blood, and 
refuse it a passage in the left side of the heart; or suppose, 
as other writers do, that the venous blood does pass, in asphy- 
xia, through the lung and reaches the left side of the heart, the 
result is the same. The nerve-centres no longer receive arte- 
rial blood or receive but scant supplies. A child in this condi- 
tion is in a state like that of the animal whose carotid and 
vertebral arteries have been ligated by the experimentor. 
This experiment, which has so often been performed, always 
induces instantly, insensibility, coma, and convulsion. 
Even contraction of the pupils is noticed at first in these 
experiments. Kussmaul and Tenner1 state that when the 
supply of blood to the brain is cut off by ligating the inno- 
minate artery and the left subclavian beyond the left carotid 
artery, “ immediately after the stoppage of the blood, the 
various sphincter muscles of the face contract, especially, and 
in a very striking manner, those of the iris and eyelids.” 
This is the first effect upon the iris. After a time, however, 
when the violent convulsions, which always result from this 
experiment appear, the pupils became uncommonly enlarged. 
Contraction of the pupils, which was so strongly marked in 
the case related in this paper, and which was the symptom 
which most strongly aroused the suspicion of opium-poisoning, 
may occur in any condition of disease which paralyzes the cilio- 
spinal centre in the upper part of the cervical spinal marrow. 
Erb2 says that irritation of the nerve-fibres from the cilio- 
spinal centre causes dilatation of the pupil, while paralysis of 
those fibres causes contraction. Dr. Samuel Wilks, in his recent 
work,3 does not write as decisively on this point as Erb does, 
but, at page 243, in speaking of the “heat-centre of the so-called 
cilio-spinal region,” he says that this part has some influence 
over the eye through the sympathetic, and mentions a case of 
“fracture through the seventh cervical vertebra where the 
pupils were minutely contracted.” Again, at page 435, in 
1 On Epileptiform Convulsions from Hemorrhage. Sydenham Soo. Ed., 
p. 14. 
2 Ziemssen Cyclop., New York, 1878, vol. xiii., page 142. 
3 Lectures on Dis. of the Nervous System, Philadelphia ed., 1878. 14 
Meigs: Case of Collapse of the Lung 
some remarks on local paralyses, under the head of the pupils, 
he states that the radiating fibres of the pupil are supplied with 
motor filaments which run into the cervical sympathetic, and 
that pressure on this nerve, as in cases of tumors of the neck, 
will cause contraction of the pupil. He states also that “ in 
those fatal cases where blood has burst into the ventricles or 
diffused itself over the brain, the pupils are often minutely 
contracted, just as they are in cases of effusion into the pons.” 
I may state in this connection that, in this very month (Sept., 
1878), I had a patient, an adult man, who had been brought to 
the Pennsylvania Hospital by a policeman, having been found 
insensible in the streets. The man was quite insensible at first, 
lying almost motionless, in coma, with both pupils very much 
contracted. I found that he had chronic Bright’s disease, and 
from the low specific gravity of the urine, the presence of large 
hyaline and partially granular tube-casts, and of cystic collec- 
tions, crystals of urate of soda at the elbow and about the 
finger-joints, I concluded that he had the gouty contracted 
kidney. On the third day, the patient could be made to bear a 
loud voice, he gave his Christian name, and had distinct right 
hemiplegia, fully developed. The pupils remained contracted 
until atropia was placed on the eye-ball, and even then they 
did not dilate as they ought to have done. He died on the 
fourth day, and at the post-mortem examination, advanced 
cirrhosis of the kidneys was found, with a large effusion in 
the left lateral ventricle of the brain, partly liquid, and partly 
coagulated. This had broken up the structure of the corpus 
striatum to a great extent, and had injured a portion of the 
thalamus. 
So it would seem that conditions which paralyze the functions 
of the upper part of the spinal marrow, and the region about 
the fourth ventricle, give rise to contraction of the pupils. Cer- 
tainly we may look upon the more or less completely paralyzing 
action of asphyxia from temporary collapse of the lungs, which 
cuts off the supply of arterial blood to the nerve-centres, as suffi- 
cient to explain the contraction of the pupils in the case before us. 
I desire to call the attention of the Society to the curious effects 
produced in these cases, so long as the cyanotic state lasts, by any 
irritation or disturbance which calls the muscular system into ac- 
tion. The child behaves somewhat like a patient suffering from and Cyanosis in a Young Infant. 
15 
tetanus or hydrophobia. In some of the cases I have seen, and 
very notably in the one described in this paper, the least move- 
ment—lifting the child, changing its position, putting it, even 
in the gentlest possible manner, to the breast, the touching of 
the lips at first with a spoon—brings on irregular contractions 
of muscles, stiffenings, and when the movement is at all sudden 
or considerable, will develop a fit of cyanosis. 
Treatment.—The only treatment that I have ever seen do 
any good in these cases, or indeed, in any of the forms of 
cyanosis of new-born or very young infants, is one which, so 
far as I know, was devised by my father, Professor Chas. D. 
Meigs, about the year 1840, and which was first published by 
him in the second edition of the “ Philadelphia Practice of 
Midwifery” in 1842. 
This treatment is simply one of rest in a certain position. 
The child is to be placed, whenever it presents the signs of 
cyanosis on the right side, on an inclined plane of from 15 to 
30 degrees, the head and shoulders being directed towards the 
higher part of the plane. Another rule, quite as strict as the 
position, and one as important, is this: that the child is not to 
be removed from this position for several hours, or for two or 
three days, or not until the livid color, the stupor, and the ten- 
dency to convulsive movement have disappeared, if happily the 
case be found to be one in which these conditions can disap- 
pear. My own rule is, to order the child not to be moved, 
not to be touched even, except in the gentlest manner, for twelve, 
twenty-four, or forty eight hours. 
That t! is treatment is sometimes successful I feel it quite 
right to assure the Society. It has succeeded in some five or 
six cases in my own experience, and Dr. Chas. D. Meigs gives 
quite a number of cases in his own practice, and in that of 
others, in his works on Obstetrics and in one on Certain of the 
Diseases of Young Children. The very simplicity of the treat- 
ment may be one reason why it has been so little noticed by 
writers on diseases of children. 
Dr. Chas. D. Meigs based the treatment on the idea that the 
chief cause of cyanosis was a patulous state of the foramen 
ovale at birth, or a re-opening of that orifice in the first weeks 
of life. He supposed that, when the child was placed in the 
position described, the auricular septum becomes horizontal, 16 
Meigs: Case of Collapse of the Lung. 
whereby two conditions were obtained which tended to prevent 
the passage of the venous blood of the right heart into the left 
anricle. One is that the blood, in this position of the body, has 
to be projected against gravity; the other, that the valve on 
the left side of the foramen ovale is pressed downwards against 
the orifice by any blood that may be contained on the left 
anricle. Whether the explanation be right or wrong it mat- 
ters not, if it be true that the position is followed by beneficial 
results. That the treatment can do any permanent good in 
cyanosis depending on malformations of the heart, such as cause 
the incurable forms of cyanosis, is manifestly impossible, but 
that it is useful in the form of cyanosis described in this paper 
I have myself no doubt. 
My own opinion is that the good derived from this procedure 
is the result of very simple causes. In the first place, the posi- 
tion on the right side gives the feeble and over-burdened heart 
the freest possible space for its play. Second, the elevated 
position of the body is one which all patients, or nearly all 
patients, with dyspnea, instinctively assume; and third and last, 
the perfect rest enjoined stops all the coddling, and dandling, 
and cooing, which frightened mothers and nurses are so apt 
to use in all dangerously ill babies. 
The strange tendency to renewal of the gasping and con- 
vulsive movements, which form so essential a part of the cases 
described in this paper, is lessened, and, as these cases show, 
sometimes successfully removed. It can do no harm in any case 
to place a feeble and gasping child on the right side, and order 
it not to be moved for one, two, or three days. If it be neces- 
sary to disturb it to change the napkins, this should be done in 
the gentlest and the slowest way. 
The child should be fed, in the mean time, from a teaspoon, 
or allowed to suck a rag moistened witli breast-milk, or to try, 
as in the case described above, a flexible tube attached to the 
mother’s breast. A little brandy, five or ten drops, ought to be 
given every two or three hours whilst the exhaustion continues.