C/UVULft Kftj tiwf*wjB '.wSw,.^ ARMY MEDICAL LIBRARY FOUNDED 1836 WASHINGTON, D.C. DUE M LAST DATE DEC I m' m DEC 161964 /• A TREATISE ON THE DISEASES OF INFANTS, FOUNDED ON RECENT CLINICAL OBSERVATIONS AND INVESTIGATIONS IN PATHOLOGICAL ANATOMY, MADE AT THE HOSPICE DE8 ENFANS-TROUVES: WITH A DISSERTATION ON THE VIABILITY OF THE CHILD, BY iS C. M. BILLARD, Docteur en Medecine de la Faculty de Paris, etc., etc. WITH NOTES BY DR. OLLIVIER, OF ANGERS. " Vides, ut amplissima, eademque propemodum intentata pateat via ad recens natorum morbos attenta, dum vivunt obBervatione, accurata autem post mortem dissectione pervestigandos, nisi parcntum inepta charitas obstaret."—(Mohoagni, de sedibus et causis morborum. Ep. 48, p. 582, ed. Tissot.) TRANSLATED FROM THE THIRD FRENCH EDITION, WITH AN APPENDIX EY JAMES STEWART, M. D." NEW YORK: >>$/S~S~& GEORGE ADLARD, 168 BROADWAY; JOHN CHURCHILL, LONDON; and FANNIN & CO., DUBLIN. MDCCCXXXIX. ,^ ## WS ' l?3, in which he proposes to pass a needle, armed with a double ligature, through the base of the tumor and tie it on both sides, thus circumscri- bing the base, which being gradually compressed, produces a shrinking, and finally a complete destruction of the fungous tu- mor. Several cases treated in this manner, are reported by hiin.§ * Traite des Malad. Chirurg, f Surgical Works, vol. 2. t Med. Chir. trans, v. 9. 5 30th vol. of the Medico- Chirurgical transactions. ON THE DISEASES OF INFANTS. 73 None of these methods of removal, however, need be resorted to immediately after birth, for it is possible that the tumor may remain stationary until puberty ; but they ought not to be delayed after the first symptoms of increase, or of disorganization appear; the ulterior progress of the affection may hasten the death of the patient, or may render the operation more difficult or dangerous. Section II. DISEASES OF THE SKIN NOT INFLAMMATORY, DEVELOPED DURING BIRTH, OR OCCURRING SUBSEQUENTLY TO THIS PE- RIOD. I propose to treat under this head of local or general conges- tion, of petechias, and of some alterations of color. § I. Ecchymoses observed upon different parts of the body of a new-born infant, are, as is well known, generally the result of difficult labor. They are particularly to be remarked in those parts which have been strongly compressed in the strails of the pelvis : this is the ordinary cause of the ecchymosis of the scalp. It may be well to observe, however, that this ecchymosis is not always the result of pressure which the head undergoes in passing the pelvis. In the month of May, 1827, I delivered a woman at the " Maison Royale de Sante" of a fcetus about four or five months old; she told me she had experienced much pain for about fifteen days, and for eight days had lost so large a quantity of blood as to give her reason to apprehend an abortion. The membranes of this fcetus were entire ; the clearness of the liquor amnii enabled me to see the fcetus, the head of which was down- ward and the feet elevated. On the summit of the head appeared a large ecchymosis surrounded by a number of small vessels ramifying beautifully over the scalp. This child had no doubt been dead for some days, and from the time of its death, being entirely free in the waters, the fluids had submitted to the laws of gravity ; and this ecchymosis of the skin of the cranium must be regarded, not as the effect of compression, but as the result of the position of this part since the death of the embryo. It is not always so; for in an infant born at the full time, by either of the first positions, it is evident that the cause of the 10' 74 ON THE DISEASES OF INFANTS. ecchymosis is both the position and the compression of the ec- chymosed part. In most cases, the resolution of these tumors is effected spon- taneously. If, however, they should be accompanied by much tumefaction of the integuments, the application of topical dis- cutients, such as a solution of the muriate of soda, acetate of lead, or muriate of ammonia, will hasten their removal. But it is seldom necessary to have recourse to these remedies, for general- ly the ecchymosis and tumefaction disappear of themselves. I have made a number of anatomical examinations upon the condition in which the integuments of the cranium are found when thus ecchymosed, and upon the period at which the ecchymosis usually disappears. The following are the results of these researches. § II. Tumor of the scalp.—The tumor of the scalp, as Ca- puron remarks, may arise from two causes; it is either the result of an oedema, a serous infiltration,or of the accumulation of blood. In the former case the tumor is never well circumscribed; it scarcely rises in the form of a cone, but consists of a general en- gorgement of the integuments of the cranium. It then quickly disappears. In the latter case the blood is infiltrated either in the cellular tissue, or in the ultimate vascular ramifications ; blood flows from all the incisions made in the scalp, which is black or mottled. It is not uncommon to find drops of blood interspersed in the adipose matter ; at other times there exists an effusion of blood between the skin and pericranium, produced by exhalation, or by a rupture of the small blood vessels. The blood is then very black and fluid, and is contained in a sort of sac caused by the separation of the scalp ; ail the surrounding parts are tinctured with a violet red, even the bones partake of this color, resulting evidently from the absorption of this fluid. I once saw in a child, three days old, a sanguineous effusion of this species so extensive as toj produce an entire separation of the skin of the cranium. This child died of pneumonia, and so universal was the effusion of blood on the exterior ofthe cranium, as to produce what may be termed a tegumentary apoplexy. The proper course of treat- ment in these cases, I think, would be to make a longitudinal incision at the summit of these sanguineous tumors, after discu- tient remedies have failed. ON THE DISEASES OF INFANTS. 75 The period of the disappearance of the ecchymosis and tumors of the scalp, is very variable. I have known children to re- tain the traces of them at the age of fifteen or twenty days, whilst, in the greatest number of instances, they usually disappear at the age of eight days. It depends on the extent of the ecchymo- sis and the quantity of blood effused.* We should avoid, as Capuron judiciously remarks, confound- ing these tumors with encephalocele, as the error might be fatal, in mistaking the latter disease for a sanguineous tumor; the distinctive characters of the two affections will be pointed out when treating of cerebral hernia. Other ecchymoses may often be seen on various parts of the bodies of infants recently born. They are always found on parts that have been rubbed or compressed ; they soon disappear like those of the head, undergoing a change in their color, to violet, blackish, or yellow, like ecchymoses in adults. § III. Contusions.—When the use ofthe fillet, forceps, lever, or chrochet, has been found necessary to terminate labor, the child often exhibits contusions in different parts of the body, which demand the attention of the physician, for they may give rise to erysipelatous inflammation, the progress and complica- tions of which, endanger the life of the child. Happily, these * I do not here allude to the sanguineous effusions described in the latter part of the last century, and also quite recently, under the names of abscessus capitis sanguineus neonatorum, Hematoma, Haematoma capitis, caphalcematoma neonatorum, Ecchy- moma capitis, Tumor cranii sanguineus, by Levret, Smellie, J. F. Frank, Pa- letta, Nagele, and other authors. In this kind of tumor, the blood is not simply effused beneath the skin, but rather between the pericranium and the bones ; according to the observation of a number of authors, this effusion results from the rupture of the veins near the junction with the sinuses; according to others, it occurs in the diploe and de- pends on a primary alteration of the bone, which often involves the destruction of its external table. It should be added, that this kind of sanguineous tumor does not arise from long and difficult labors, since all authors agree that it is observed when the pas- sage of the child has been quick and easy. Paletta, Excercitat. pathol. Milan, 1820. Car. Zeller, De cephalcematomate, seu sanguineo cranii tumore recens natorum. Hiedleberg, 1822. Ant. Herr. Hal- ler, De tumore capitis sanguineo neonatorum, dissert. Dorpat, 1824. G. C. L. Brandau, Eccymomata capitis recens natorum. Morbourg, 1824. G. Fr. Hrere De tumore cranii recens natorum sanguineo, et externo, et interno. Berlin 1824. This author admits a species of sanguineous tumor, in which the blood is between the peri- cranium and dura mater. J. D. Strewe, De cephalcematomate, seu sanguineo cranii tu- more externo recens natorum. Giessen, 1828. 76 ON THE DISEASES OF INFANTS. accidents are less to be feared at the present day, when the obste- tric art is reduced almost to the study and direction of the pro- gress of a function, which, however difficult or complicated it may sometimes be, is not less natural than those to which our bodies are daily subjected during the continuance of life. The general congestion ofthe skin ofthe fcetus being ordinarily con- nected with some affection of the respiratory apparatus, I will reserve the consideration of this subject until the diseases of those organs are noticed. § IV. Petechia.—The hemorrhagic spotted disease, which Riviere,* Werlhof.t Bateman, and other authors, have described under different names, and the history of which has been so well exhibited under the title of Hemacelinose, in the work of M. Rayer,t are seen in feeble and badly nourished children, where the capillary circulation is found, from some cause difficult to ascertain, quite deranged, and disordered in such a manner as to give rise to effusions of blood on the surface of the body. The skin then presents a greater or less number of small spots or pe- techias, of a violet color, and almost always of a round shape. This disease is ordinarily apyrectic, particularly in children. It may be simple, that is to say, unaccompanied with any general or particular symptoms during its commencement, development, or termination; or it may be complicated with symptoms of a nature more or less serious, such as hemorrhages from the gums, stomach, intestines, or bladder, or even with inflammation of these organs. I saw this petechial disease in two young infants, who exhi- bited a condition of debility and prostration in a very marked manner ; one of them, eight days old, revived after the disappear- ance of the petechias, which faded, by degrees, assuming succes- sively a kind of black, livid, and finally a yellow color; the other, younger, more feeble, and possessing less vivacity, quick- ly succumbed. The following, is the examination of the case. CASE II.—Delarue, a female child, was deposited at the Found- ling Hospital, on the 27th of March, 1829. A billet fastened to the * Praxis med. Lib. 17. t Opera med. See note 65, chap. iii., De variolis et anthracibus. t Traite thiorique et pratique des maladies de la peau, fonde sur de nouvelles ra- ther ch e d'anatomic et de physiologie pathologique. Paris, 1827. 2 vol. avec planches pnloriees. ON THE DISEASES OF INFANTS. 77 arm, indicated her age to be three days; she was strong, and large ; color slightly jaundiced, respiration but little developed; the cry scarcely heard ; the inferior extremities were cedematous. The face, trunk, arms, and legs, were covered with violet-colored petechiae of various sizes, from that of a point to a lentil. The unequal manner in which they were disseminated, and the intervals of yellow between them, gave to the body the appearance of a tiger's skin. She re- mained in this state for two days, drinking a few drops of milk, crying with difficulty, and respiring but little. She died on the evening of the 29th of March. The examination of the body was made on the succeeding day. Digestive apparatus.—The stomach was filled with a considerable quantity of black, viscid blood ; its internal surface, together with that of the jejunum, was filled with a number of petechiae like those on the exterior of the body. Effusions of blood were found in dif- ferent parts of the interior surface of the intestinal canal, the mucous membrane exhibited at the parts corresponding with these effusions, petechial ecchymoses resembling those of the stomach ; the termi- nation of the ileon contained blood rather more black, and more fluent; the large intestines presented a well-defined follicular erup- tion; and at their termination, theie was a considerable quantity of blood ; the walls were thick and firm. The spleen was very large, and very much engorged with blood; it presented, near the entrance of the small vessels, an oblong su- perficial rupture, on the surface of which, there adhered a little solid clot of blood. In the cavity of the abdomen, was found a large table- spoonful of blood, effused probably b^/ the rupture of the spleen. The heart was very large, and engorged with blood, and the surface covered with petechiae; a yellow serum was contained in the peri- cardium ; the pleura was spread over with petechial spots. The usual foetal openings still continued unclosed; the lungs were en- gorged, the kidneys and the bladder had on them likewise a number of ecchymosed spots. The cerebrum was very highly congested. The cellular tissue of the limbs and the integuments of the abdo- men, presented large ecchymoses, and blood was infiltrated through- out the tissue. The condition of this child was analogous to those which Werlhof has noticed in adults, and of which I also have given examples in another work.* These different sanguineous effu- * De la membr. muq. gastro-intest. Paris, 1825, 78 ON THE DISEASES OF INFANTS. sions are doubtless the effect of the plethoric state in which this child was born, and particularly of the congested condition ofthe circulatory and respiratory apparatus. The coincidence of the sanguineous exhalation on both the external and internal surfa- ces, is worthy of notice. For the treatment of this disease, acidulated and diluent drinks are usually advised. In children who exhibit, like the one whose case has just been described, a well marked sanguineous conges- tion, the best application, without doubt, would be a few leeches to the arms, to diminish the quantity of blood in the seat of the disease. When hemacelinosis is simple, it had better be left to nature. I once saw upon the inferior extremities of a child aged eight months, much emaciated and affected with a chronic inflamma- tion ofthe mesenteric glands, several ecchymosed spots of a violet color, developed spontaneously, analogous to marks of a scorbu- tic character, which appear on the limbs of old people reduced by age and suffering. Of some alterations of the color of the skin.—Alterations of the color of the skin, are usually the effects of age or of disease. They are rarely to be seen on sucking infants; still there may occur at this tender age, the different varieties of lentigo, ephel- ides, etc.; but as these various alterations of color are common to all ages, I must refer to the works of Franck, Lorry, Bateman, Al- ibert, and Rayer. Section III. INFLAMMATIONS OF THE SKIN. Some are developed in the uterus, and the child is born with them; and others do not occur until after birth. Congenital inflammations of the skin.—Physicians have, for a long time, described different eruptions that appear on the body of a new-born child. Almost all are regarded as syphilitic, al- though often they are not so; and it is in works that treat par- ticularly of venereal diseases, that we find examples of congenital cutaneous inflammations: accoucheurs also have mentioned them. Infants have sometimes been born with measles ; Vogel, says Rayer, asserts that he has seen children born with the ON THE DISEASES OF INFANTS. 79 traces of measles upon them. Duges has reported, in his Inau- gural Dissertation, several cases of cutaneous phlegmasia? on the bodies of infants at the Hospice de la Maternite. I have seen in a young infant, an erythema under the form of small irregular patches, disseminated upon different parts of the body, the ap- pearance of which resembled much that of measles. Small-pox has been developed while the child was within the uterus.* Jen- ner has recorded, in the first volume of Medico-Chirurgical Transactions, a case of congenital variola, occurring in an in- fant born on the 11th of June, 1808, whose mother had been vaccinated on the 6th of May. The body of this child was cover- ed with the beginning ofthe eruption. New variolous pustules ap- peared the day after birth, and the child died on the eighth day in convulsions. I saw at London, in the Anatomical Museum of Astley Coop- er, at Guy's Hospital, a fcetus preserved in alcohol, the body of which was covered with well-marked variolous pustules. Dr. Hodgkin, conservator ofthe Museum, communicated to me some very interesting facts in relation to this case, of the authenticity of which I was well assured, as they were duly recorded in the register containing the history of the principal articles contained in this Museum; these details were furnished, together with the preparation, by Dr. Jos. Laird. CASE III.—Hannah Howard, aged 26 years, was attacked with the small-pox, while pregnant with her second child, about the middle of the fifth month. She became sick on the 28th of August, 1805, and the eruption appeared on the 30th. She entered the general dispen- sary, in Aldergate-street, on the 2d of September. The pustules were confluent, and formed, as we may say, but one crust on the face and arms. They were distinct upon the trunk and inferior extremities, where they appeared projecting and surrounded by a red circle. The symptoms were those which usually accompany small-pox. The bowels were maintained in a soluble condition, opiates were adminis- tered, and cold and acidulated drinks freely given. In ten days after the desquamation, she was convalescent; was able to walk about, and felt the movement of the child three or four times ; but since * Moriceau, Watson, and Sydenham have given examples of this; they have seen children covered with variolous eruptions born of healthy mothers. 80 ON THE DISEASES OF INFANTS. that time she experienced no motion, and on the 28th of September, was delivered of a foetus, which, from its size and form, appeared to be about six months old. It had been dead probably for some time, for the skin of the abdomen and hands was raised, and it presented some evidences of putrefaction. On the back and shoulders, and more particularly on the superior part of the thighs, where the in- teguments were in a good state of preservation, there were several very distinct pustules, characterized by their round borders, slight- ly projecting, and their depressed centre; the placenta was not examined. This case appears to me interesting in two respects: it proves, in the first place, the communication of diseases from the mother to the child; and, in the second place, the possibility of the de- velopment of diseases during the intra-uterine life, analogous to those with which adults, or children after birth, are attacked.* I do not intend to enumerate here all the congenital cutaneous diseases noticed by authors, and will conclude by referring to a curious case of pemphigus, observed by M. Lobstein, of Stras- bourg,t and which M. Duges erroneously considered as a syphi- litic affection.t I shall give below the characters of cutaneous diseases ; it will be easy after that to arrange those of infants in the classes, gene- ra, and species in which they belong, and thus to devote more attention to them. Section IV. INFLAMMATIONS DEVELOPED AFTER BIRTH. Authors, in general, have not sufficiently urged the considera- tion of the cutaneous phlegmasia? of new-born and sucking children. Still they are numerous ; and as it is important to be well acquainted with them, that they may not be confounded with congenital syphilis, which often shows itself in this form, I have thought it incumbent on me to trace their history with pe- * Analogous cases are to be found in Bartholin, (Epist. med. cent 2, p. 682,) and in Philos. trans, abridged, v. 3, p. 308. Boerhaave, also, speaks of having seen a similar case. Van Swieten, Variolas. See appendix. t Journal complementaire du Diet, des Sciences med. Tom. 6, p. 3. t Maladies les plus importantes et les moins connues des nouveau nes. Disserta- tion inaugurate. Paris, 1821. ON THE DISEASES OF INFANTS. 81 culiar care. In order to facilitate the diagnosis, I have followed a particular method, of which I shall now proceed to give some idea. Considering the great number of classes, genera, and species, according to which modern authors, more especially Willan and Bateman, have arranged cutaneous phlegmasia?, I have thought that the method proposed by M. Lamark for the examination of the classes, genera, and families of plants, might be advanta- geously applied to the study of the subject before us. It is well known that this celebrated naturalist has placed all the known plants in successive divisions, exposed in such a manner as to leave always a choice between two contrary propositions, so that the observer selects one of the two propositions agreeing best with the subject under examination ; he then finds one for reference, which conducts him to propositions or descriptions successively and constantly opposed, finally arriving at that which gives him the most exact description of the object of his search, and enables him in this manner to assign to it the class, genus, and species, to which it belongs. My object is to follow nearly the same course in the exposition ofthe diseases ofthe skin; and, in order to accomplish it, I will trace in the synoptical tables the opposing characters ofthe classes, genera, and species of inflammations ofthe skin, arranged accord- ing to the classification of Willan and Bateman, modified by the more recent work of MM. Biett and Rayer. The reader finding himself conducted by the signs or numbers, to the successive ta- bles, will gradually arrive at the characters of the class, genus, and species of the disease of which he is in search. With Rayer, I denominate inflammation of the skin all dis- eases characterized, at their commencement, by an accumulation of blood in one part or in the whole of the surface of this mem- brane ; an alteration followed by a complete resolution, desqua- mation, morbid secretion, ulceration, induration, or other changes in the organization of the part affected. n 82 ON THE DISEASES OF INFANTS. TABLE FIRST—CLASSES. INFLAMMATIONS. 1. Redness, more or less viv- id, resulting from a morbid ac- cumulation of blood in the in- teguments, to a greater or less extent, with or without tume- faction ; without pimples, usual- ly disappearing under the pres- sure of the finger, and reappear- ing when the pressure is remov- ed. EXANTHEMATOUS INFLAM- MATIONS. See A. Table 2d. 3. Transparent vesicles form- ing small serous elevations less voluminous than bullae, result- ing from a drop of serum effus- ed between the epidermis and the corpus reticulare ; on being ruptured, the contents flow out, accompanied or followed by su- perficial excoriations of thin and lamellated crusts. VESICULAR INFLAMMATIONS. See C. Table 2d. 5. Elevations small, firm, round, color corresponding with that of the skin, accompanied by itching, more or less severe, 2. Redness, more or less viv- id, of variable extent, preceded or accompanied by small tu- mors, formed by an accumula- tion of serum or of sero-puru- lent matter accumulated be- tween the epedermis and the in- flamed corpus reticulare. BULLOUS INFLAMMATIONS. See B. Table 2d. 4. Elevations from one line lo three lines in diameter, usual- ly circumscribed and not trans- parent, often surrounded by an inflamed areola, and formed by pus deposited between the epi- dermis and the corpus reticu- lare. They terminate by desic- cation, ulceration, and indura- tion. . PUSTULAR INFLAMMATION. See D. Table 2d. 6. Elevations or tumors solid, resisting, circumscribed, indu- rated, lasting, more voluminous than papula?, and almost always ON THE DISEASES OF INFANTS. 83 ordinarily terminating in reso- lution and furfuraceous des- quamation, and sometimes in small ulcerations. PAPULAR INFLAMMATIONS. See E. Table 2d. 7. Elevations and red spots largely prominent, little hard- ness to the touch, continually covered with scales of the alter- ed epidermis, which are con- stantly detached from the sur- face, ofthe skin. SQUAMOUS INFLAMMATIONS. See G. Table 2d. 9. Redness circumscribed, painful to the touch, accompa- nied by a base, and soon by a puffiness of the subcutaneous cellular tissue, usually terminat- ing in suppuration. FURUNCULOUS INFLAMMATIONS. Seel. Table 2d. terminating in suppuration or ulceration. TUBERCULAR INFLAMMATIONS. See F. Table 2d. 8. Redness diffused, ordinari- ly of little intensity, sometimes succeeded by other inflamma- tions, and characterized by spontaneous linear divisions of the skin, in those parts alone where it is developed. LINEAR INFLAMMATIONS. See H. Table 2d. 10. Redness, at first more or less vivid and painful, after- wards suddenly violet, livid, or blackish, with but little or no pain, terminating rapidly in mortification of the skin to a greater or less extent. GANGRENOUS INFLAMMATIONS. See J. Table 2d. 11. Redness and alteration of the tissue more or less analo gous to the general characters of other species of inflammations, and presenting in their phases much more variety of form and aspect. These are usually caused by excess of cold or of heat. INFLAMMATION FROM COMBUS TION OR CONGELATION. See K. Table 2d. 12. Redness variable, altera- tions of the skin, difficult to re- fer to any ordinary forms of in- flammation, having a continual tendency to extend or to reap- pear, observed in children of suspicious parents. SYPHILITIC AFFECTIONS. See L. Table 2d. 84 ON TIIE DISEASES OF INFANTS. TABLE SECOND—GENERA. INFLAMMATIONS. A. EXANTHEMATOUS INFLAMMATIONS. 1. Red spots of a few lines to several inches in diameter, with- out tumefaction of the subcuta- neous cellular tissue, sometimes so numerous as to produce a ge- neral red tint over the skin. This is the first of a great num- ber of phlegmasia? ofthe integu ments. This redness, ordinarily transient, is generally develop ed on those parts habitually in contact with urine, fecal matter, erythema. See p. 95. 3. Small red points, soon re- placed by large scarlet patches, indented at their borders, the exanthema soon becomes con- tinued; the skin is burning, dry, and sensibly reddens to the touch. Color deeper at night; the surface of the body appears 2. Tint of the skin of a deep red, with tumefaction of the subcutaneous cellular tissue. The redness does not consist of small patches, but of a large sheet. Irregularly circumscrib- ed, it uniformly occupies a por- tion ofthe limbs, trunk, or face, to a greater or less extent. It is of- ten accompanied with fever and gastric or cerebral symptoms. The redness always moves from one place to another, and is co- vered with phlycta?na? (phlycte- noid erysip.); the inflammation extends itself in the cellular tissue, producing suppuration (phlegmonous erysip.); eschars form (gangrenous erysip.); limbs are infiltrated (cedematous ery- sip.) erysipelas. See p. 98. 4. Patches prominent, paler than the surrounding skin, ac- companied with itching; the patches appear first on the limb, then upon the trunk; their form, number, and extent, vary much. They resemble the marks produced by nettles. ON THE DISEAS then as if it had been daubed with the juice of strawberries. It has three periods: incubation, development, and desquama- tion; ordinary complication, simple or malignant angina. scarlatina. See p. 104. 1. Large bullae without an areola, preceded by a simple erythematic redness, constantly followed by a denudation of the inflamed corpus reticulare, with suppuration, more or less abund- es of infants. 85 Very rarely followed by des- quamation. urticaria. See p. 106. 2. Tumors solitary, in small numbers, formed by an effusion of sero-purulent fluid between the epedermis, developed in parts that have been violently rubbed, accompanied with redness and 5. First period. During the existence of the symptoms of angina or pneumonia, small red spots are to be observed, distinct, almost circular, resembling flea- bites ; they appear first on the forehead, chin, nose, etc., then spread on the neck and limbs; they are accompanied by fever and itching, and great heat of the skin. Second period : other semicircidar patches mingle with the first; they do not give on touching them with the fin- ger the sensation of a promi nent surface. In the interstices, the skin preserves its natural tint. Third period : at the end of four or five days, when the redness has disappeared, a slight desquamation ensues, accom panied with itching. rubeola. See p. 101. 6. Patches, rose-colored, vari- ously figured, not prominent, much larger and more irregular, separated by a number of spa- ces; sometimes the patches are annular; they are at first of a pretty dark red, soon becoming rose-colored. They are accom- panied with itching, but no irri- tation nor smarting; the inflam- mation is more deeply stamped than in erythema; it is scarcely ever followed by desquamation; it is not contagious. roseola. See p. 103. B. bullous inflammations. 86 ON THE DISEASES OF INFANTS. ant, and sometimes with a mem- brani-form excretion caused by blisters. vesicatoria. See p. 108. 3. One or more voluminous, yellow, and transparent bullae, the eruption of which may be either simultaneous or progres- sive, terminating by an effusion of lymph, which concretes and forms a yellow scab, or gives rise to a superficial ulcer ; these bulla? are usually round, and are preceded by red spots but slightly prominent. The areolae formed by the disks ofthe eryth- matic spots, disappear during the growth ofthe bulla?. The skin is not deeply inflamed, neither has it any tendency to form deep ulcerations. pemphigis (acute or chronic.) See p. 108. 5. Inflamed vesicles and bul- lae, surrounded by a small red circle, appearing particularly on one side of the trunk, disposed in the form of a band, producing a great itching; the vesicles open, ulcerate, and form yellow or black scabs. zona. See p. 102. 1. Globular and transparent vesicles, filled with a colorless, or citron-colored fluid, of the heat; a thick fluid flows out when they are broken. essera. See p. 108. 4. Small bullae, the bases of which are inflamed, few in num- ber, flat, and filled with a fluid, at first serous, but soon thick, sanguinolent, drying in the form of black scab. The skin beneath them has a strong tendency to ulcerate. The ulcers become atonic, and are to be observed in badly nourished, debilitated, scro- fulous individuals. rupia. See p. 111. 2. Small vesicles, very near each other, ordinarily whitish and very evident, accompanied C. vesicular inflammations. ON THE DISEASES OF INFANTS. 87 size of a grain of millet seed, ap- pearing in groups, more or less numerous, in different parts of the body, accompanied with prickling, and separated by in- tervals, where the skin is often the seat of an inflammation, which only occurs in the inter- stices of the vesicles forming the group. These groups are irre- gular, arranged in a circle, or in the form of a crown. Herpes. See p. 112. 3. Contagious vesicles, apy- reclic, slightly elevated above the level of the skin, color but little altered; transparent at their summits, accompanied with an itching tvhich compels the pa- tient to be continually scratch- ing : more particularly devel- oped in the folds of the articu- lations. psora. See p. 116. 1. After a fever of 14 to 48 hours, accompanied with gastro- intestinal irritation, small oblong, flattened, red spots are seen, giv- ing to the touch the sensation of a flattened seed, in the centre of which a prominent vesicle is formed, containing a colorless, or a citron-colored humor. Soon the base of the vesicle inflames, the vesicles break and leave in their place a yellow scab; these vesicles may be conical, globu- by a redness and tension of the skin, terminating by a re-absorp- tion of the fluid contained in them, or by a rupture of the vesicles ; succeeded by serous ex- udation, more or less abundant; the skin covered with very su- perficial scabs, formed by the destruction ofthe epidermis, and the concretion of the excreted fluid. Eczema. See p. 113. 4. Pearl-colored vesicles, about the size of millet seeds, formed in great numbers epidemically, accompanied with fever, gastro- intestinal inflammation, sweat abundant and foetid, and with great irritation ofthe skin. miliary sweat. See p. 117. 2. After symptoms of gastro- pulmonary and intestinal inflam- mation of two or three days' du- ration, small pustules appear, at first pointed, but soon become umbilicated, distinct, and some- times confluent. At the same time that the pustules assume an umbilicated form, and their cen- tre becomes puriform, the skin reddens and tumifies in a very remarkable manner. At the end of eight or ten days, the D. PUSTULAR INFLAMMATIONS. ;es of infants. 88 on the diseas lar, or umbilicated. In general the duration of these pustules is only six or eight days; they have but one form during their various periods; they are al- ways either conical, globular, or umbilicated. varicella. See p. 117. 3. After the insertion in the skin of a fluid taken from pus- tules on the teats of a cow, there appears at the end of eight days an elevated redness, which soon contains a fluid, at first transparent, afterwards thick; the centre of these pustules are depressed, their bases inflame and tumify, and finally the hu- mor they contain is transform- ed into a brown scab, which de- taches itself about the twelfth* day, and afterwards leaves a cicatrix. vaccinia. See p. 120. 5. Large pustules elevated on a hard, cireidar, and very red base, ordinarily separate, and appearing successively in various parts of the body. They * This is evidently an error, the scab scar day.—S. pustules begin to dry, and are covered with yellow or black scabs. After the fall of the scabs, circular spots appear on the skin, of a reddish brown, afterwards cicatrices, more or less regular; sometimes there occurs an abundant ptyalism. In general the duration of these pustules is from twelve to fif- teen days. The pustules at first acuminated, do not become um- bilicated, except during their progress. variola. See p. 117. 4. After the insertion of the vaccine-virus in persons pre- viously vaccinated, or who have had the small-pox, there appear cireidar pustules, the borders of which are flattened and irre- gular, and are not swelled, con- taining in their centre a lim- pid yellow humor. These pus- tules are accompanied with an insupportable itching; from the seventh to the eighth day, scabs form and fall off withont leav- ing a cicatrix. vaccinella. See p. 120. 6. Pustules, slowly forming in the midst of a reddish, and sometimes violet, induration, which are to be seen on the cheeks, in the forehead, and on cely ever becoming detached before the 21st ON THE DISEASJ are soon covered with brown scabs, thick and adherent, be- neath which there forms either a cicatrix or an ulceration. They often leave after them a chronic induration; they are developed more particularly in debilitated subjects. ecthyma. See p. 121. 7. tSinall superficial pustules irregularly disseminated on the scalp, where they exclusively exist; at first they are humid and irregular; to the pustules succeed gray or brown scabs, which are never depressed, the fragments of which are often found disseminated among the hair. When these scabs run together, and dry, they become hard, and are strongly attached to the hair with which they are intermingled. They are rarely communicated by contact. tinea granulata. See p. 127. 9. To a number of small red pimples, scarcely elevated above the level ofthe skin, small yel- low pustules succeed, the sum- mits of which are immediately covered with irregularly circu- lar scabs, strongly adherent, at first yellow, afterwards brown- ish, and always cupped in the centre. These pustules are sometimes separated and some- times agglomerated. They are particularly to be seen on the scalp; yet they may appear on ss of infants. 89 the nose. Sometimes these pus- tules are intermingled with small black points, formed by an alteration of the follicles of the face; these pustules are never covered with scabs, and they almost always dry without ulceration. acne. See p. 122. 8. Small pustules, disposed in irregular groups, developed on the face and on the scalp, fur- nishing a large quantity of hu- mor, adhering closely to the hair, at first white, and but lit- tle projecting; they break, and are surrounded with red in- flammatory patches; a red or greenish fluid issues from them, which is transformed into thin and yellow scabs, which, by an accumulation of a viscid hu- mor, forms sometimes a perfect mask. porrigo larvalis. See p. 127. 10. Circular groups of small yellow jmstules on the scalp, elevated in the middle of red in- flamed spots. The centre of the pustules is sometimes tra- versed by a hair. The contents of these tumors thicken and form scabs, beneath which the skin is red and inflamed. The inflammation is propagated to the tubes of the hairs ; the hair sometimes falls, but is after- wards reproduced; the scabs are never hollowed in the ceiv- 12 90 ON THE DISEASES OF INFANTS. different parts of the body. These scabs emit a disagreea- ble odor on their being raised ; beneath them will be found small red excoriations, superfi- cial and lenticular. They will produce, after a length of time, a general or local baldness. porrigo lupinosa. See p. 121. 11. Pustules acuminated, de- veloping on the chin, detach- ed on a base of a vivid red. The pustules are preceded by a slight smarting; little red points at first show themselves; they become more salient, their summits whiten, rarely exceed- ing the size of a millet seed; when the pustules are ruptured, an oozing takes place, produ- cing a scab but slightly adhe- rent. In this manner occur se- veral successive eruptions; the chin and side of the face are soon covered with them, the pustules form in groups, their bases spread and thicken, the scabs augment, but they are never very thick nor very adhe- rent ; the subcutaneous cellular tissue inflames and becomes the seat of phlegmonous affections always remarkable for their red appearance. mentagra. See p. 122. E. PAPULAR INFLAMMATIONS. 1. A number of small pirn-1 2. Small papulae, sometimes pies, hard to the touch, com- \ scarcely visible, ordinarily acu- tre ; the fluid of the pustules is always contagious, and infects successively various parts ofthe integuments of the cranium, where it is carried by the fin- gers of the patient. TINEA ANNULARIS. See p. 127. 12. Small pustules agglome- rated or distinct, developing on different parts of the body, but more especially on the face; they consist at first of small red spots, in the centre of which are formed yellow pustules not ac- uminated, accompanied with a great itching; they break at the end of five or six days, yielding a yellow fluid, which drying, resembles concrete honey. The oozing beneath the scabs aug- ments their thickness; some- times several eruptions succeed. After the fall of the scabs, the skin beneath is found of a vio- let color, covered with a newly formed epidermis. impetigo. See p. 123. ON THE DISEASES OF INFANTS. 91 pact, red or white, forming at first on the face, afterwards on the limbs, particularly in in- fants at the breast, never termi- nating in pustules, scabs, or ulceration, but leaving some- times in their place a slight ef- florescence, generally accompa- nied by a great itching; they may be scanty, intermingled with patches of erythema, or spread in great numbers over all parts of the body. strophulus. See p. 130. 3. Papulae scarcely visible, causing a great itching; when torn by the nails, a sero-sangui- nolcnt fluid issues, which con- cretes immediately, and forms a small black scab, sometimes ac- companied with fever; they are always the seat of an insupport- able itching. prurigo. See p. 128. minated, and hard to the touch, containing neither pus nor se- rum, accompanied by a disa- greeable sensation, especially in the night; persisting for a long time, spread over the face and upon different parts ofthe body, rarely accompanied with febrile symptoms, appearing dissemina- ted or sometimes grouped at the root of the hairs. When they dry, they give rise to the secretion of a fluid, which con- cretes in small humid scales. They are often complicated with vesicles or pustules. The nature of the disease may al- ways be known by the presence of papulae about the scales. lichen. See p. 132. tubercular inflammation. 1. One or more tubercles, of I 2. Solitary tubercles, remain- a medium size, flat or promi- ing a longtime indolent; they nent, of a livid red, terminating, are the seat of lancinating pain ; after several months or years,'they become violet,'and ulce- in ulceration, secreting ichorous rate. The ulcers present in- pus, the concretion of which I verted, hard, or fungous bor- 92 ON THE DISEASES OF INFANTS. solid, adherent yellow scabs, ders ; a sanious pus flows from The ulceration extends in them, and they diffuse a pecu- depth, the borders remaining unequal and hard; they are continually covered with scabs, which fall of themselves. lupus. See p. 133. 3. Numerous indolent tuber- cles, livid, and sometimes of the same color as the skin, de- veloped principally in the face and the ears, as well as on the limbs. These tubercles some- times ulcerate, and are covered with adherent scabs, beneath which are found cicatrices; the parts on which these tubercles are developed, acquire an in- crease of size. GREEK ELEPHANTIASIS. See p. 133. liar odor. CANCER. See p. 133. G. SQUAMOUS INFLAMMATIONS. 1. Scaly plates, almost al- ways circular, of a whitish co- lor, at fiist but a little project- ing, resembling small spangles ; they enlarge and rise; their bor- ders, surrounded by a red cir- cle, are prominent, ivhilst their centres are depressed , they af- terwards form small red pim- ples, hard, grouped, but never pustular ;—simple and isolated, they enlarge and multiply, pre- serving always their white and scaly appearance, together with their orbicular form ; they cov- er, at the same time, one part or 2. Scaly plates, never circu- lar, of a red color, at first small and projecting; they enlarge and rise, but their borders are never prominent, nor their cen- tres depressed. They form af- terwards, in groups, small red pimples, rarely isolated; they multiply promptly, exhibiting an irregidarly circumscribed surface; they are often con- founded with one another, ap- pearing in several parts of the body, but more particularly on the face, trunk, and head ; the inflammation of the reticular ON THE DISEAS several parts of the body, but appear to be more particularly developed in the projections and articulations. lepra. See p. 133. 3. Small red patches, very- thin, covering superficial scabs, which are continually detached in small fragments, sometimes purulent, and almost always re- placed by new epidermic des- quamations. It is usually seated in the scalp. ptyriasis. See p. 136. 1. After a puncture by an in- sect, or with an instrument with which animals have been killed. an cedematous tumefiction of the skin is developed in a cir- cumscribed point. In the cen- tre of this tumefaction appears a violet colored ecchymosis. sliirbtly prominent, bmeath which a lenticular induration is formed, which is soon replaced by a reddish areola; or a gan- grene, and an extensive disor- ganization of the subcutaneous tissue ensues. The patient, re- ZS OF INFANTS. 93 tissue imparts a deeper tint to the scales, which are sometimes cracked. psoriasis. See p. 133. 2. In those infants where the circulation is slow, and the face and extremities blue, cold, and cedematous, there occurs at first about the toes and hands, and afterwards in other parts of the body, an obscure redness with- out tumefaction; the skin be- comes brown, dries, hardens, and finally presents all the characters of gangrene. Dur- ing the development of this disease, the infant, respirinc with difficulty, and almost in- animate, exhibits all the precur- H. LINEAR INFLAMMATIONS. Linear divisions of little depth, developed usually at the bot- tom of the folds of the skin, or in the neighborhood of the differ- ent natural openings of the body. fissura. See p. 136. I. GANGRENOUS INFLAMMATIONS. 94 CN THE DISEASES OF INFANTS. duced to extreme debility, has sory signs of death from slow frequent faintings, and in the asphyxia. space of a few days or hours, will be brougdit to the last ex- tremity. MALIGNANT PUSTULE. See p. 138. K. INFLAMMATIONS FROM HEAT AND FROM COLD. INFANTILE GANGRENE. Sec p. 137. 1. Erythema, erysipelas, bul- lae, vesicles or gangrene, pro- duced on the skin by caloric or caustic. See p. 138. 2. Erythema, with engorge- ment of the cellular tissue, bul- lae, fissura, gangrene ; produced by cold on parts remote from the centre of circulation. See p. 138. Li. SYPHILITIC AFFECTIONS. Some of the species of diseases above described may assume a syphilitic character, which maybe known by the eruption fol- lowing other venereal symptoms; by their resisting the usual treatment of simple cutaneous diseases ; by their constant tenden- cy to spread and ulcerate ; by their exhibiting a cupreous appear- ance, particularly on the use of mercury, sudorifics, and other remedies used for the treatment of syphilis ; and. finally, by their manifestation under circumstances proper for the development of the venereal disease. It is worth observing, that among all the cutaneous diseases which more often assume a venereal character, are the exanthe- mata, pustulae, papulae, and tubercula. On the other hand, of all the symptoms produced by mercury, cutaneous affections are the most frequent, concurring to render the diagnosis of syphilitic affec- tions and mercurial eruptions both obscure and difficult. Phy- sicians ought, on this account, to exercise great discrimination in examining the cutaneous diseases of young infants ; they should not forget that they have need of all the circumstances connected with the case, the nature and mode of development of the affec- tion they are called to treat, to enable them to make a correct diagnosis, since the anatomical characters are very variable, often ON THE DISEASES OF INFANTS. 95 deceiving, and are not of themselves sufficient to confirm the judgment of the physician. TABLE THIRD.—SPECIES. ERYTHEMA. Erythema intertrigo, caused by the contact of fcecal matters. " co-mbustio, " " the action of fire. " pernio, " " the absence of caloric. " paralrima, " " lying on the part. " a punctnra, " " a puncture. " idiopalhicum., " symptomaticum, " fi'gace, " marginatum, " papulatum, " tubercidatum, " nodosum. All external causes capable of irritating the skin, may produce erythema, in some of the numerous varieties mentioned above. In general it is a very superficial inflammation, disappearing with gre:it facility. It is rarely accompanied with any general de- rangement of the system. Erythema produced by the contact of fcecal matters, is more often seen in new-born children, occupying the breech, upper part ofthe thighs, and scrotum ; suitable care, and simple emol- lient lotions, are sufficient for its removal. If it be very severe, seated around the anus, and if there exist at the same time a diarrhoea, it may be considered as a symptom of enteritis. I will recur to this subject hereafter. During the exfoliation of the epidermis, the skin of the infant is often covered with erythematic plates, or striae, situated in the folds of the joints. The scrotum and the superior parts of the thighs, are more particularly subject to these affections. CASE IV.—Induration of the cellular tissue, erythema of the scrotum, gastro-enteritis.—Marcanel, aged twelve days, a male, en- 96 ON THE DISEASES OF INFANTS. tered the infirmary on the 10th of May. This child was very small, and was affected with a general oedema ; the epidermic exfoliation was in full activity. The scrotum, entirely deprived of its epidermis, was intensely red and tumified ; the superior part of the thigh? pre- sented the same appearance. The child was feeble, his cry com- plete, but scarcely to be heard; respiration tolerably free, and the chest sonorous ; the face, continually drawn up,. expressed great pain ; the alvine dejections were abundant, clear, and foetid ; the pulse was natural. The treatment consisted of diluent drinks and bran baths. He did not rally, and on the 16th of May, perished of marasmus. On examining the body, after death, there were found congestions with sanguineous exhalation in the, small intestines; an intense red- ness, with tumefaction and friability ofthe mucous membrane ofthe ileo-cecal region and commencement of the colon, and finally a pas- sive congestion of the cerebro-spinal apparatus. The organs of respiration were healthy. M. Rayer has given some analogous cases of erythema, in which emollient lotions were successful in treating; it in children at the breast.* It sometimes happens, without any exterior appreciable cause, that erythema spreads over different parts ofthe body, under the form of irregular patches, leaving intervals between them ; with- out doubt these are what Bateman has described under the name of erythema marginatum. According to the English patholo- gists, this variety co-exists ordinarily with an internal affection, and may be accompanied with fever; I have observed one case of this kind, which will be noticed hereafter. The erythema occurring on one of the cheeks at the lime of the appearance of the teeth, about the umbilicus when the cord separates, over the two internal malleoli when the feet of the in- fant are compressed, hardly deserve our attention. I believe I ought to consider as a case of erythema nodosum of Bateman, an affection of the skin which I observed in an in- fant, the subject of the following case. CASE V.—\Muguet, erythema nodosum.—Marie Mosieux, aged thirteen days, of a medium strength, crying but little, respiring well, * Rayer, vol. i., p. 104. t Muguet, a variety of thrush. Seep. 164. ON THE DISEASES OF INFANTS. 97 with several spots of muguet on the buccal mucous membrane, which was slightly tumefied and of a very intense redness, entered the infirmary on the 12th of January, 1826. (Barley, gum syrup, emoll. garg., abstinence from the breast.) On the following day the muguet had made some progress ; and on the 16th, at the inferior and internal part of the legs, there appeared irregular red patches, slightly elevated, and hard to the touch, three or four lines in breadth. They appeared to be painful, for the child cried on their being rubbed with the finger; the limbs were enveloped in compresses, wetted with a decoction of marshmallows. On the 18th they had still in- creased, the skin on one was excoriated; on the 20th, resolution had commenced, but the left limb still remained hard and swelled. From the 20th to the 25th, a great change had taken place in the condition of the child ; the muguet had disappeared, and there only existed a violet redness of the legs, which however was not of much hard- ness, and on the third of February the child was returned to her nurse. This erythema must not be confounded with a hardening of the cellular tissue, the history of which will be given hereafter; it appears to exhibit a great analogy to that which Bateman has observed in the legs of old females. With respect to this, and many others, we meet with striking analogies between the dis- eases of the two extremes of life. For the present, we have only been considering acute erythe- ma ; as to the varieties of papular and tubercular erythema, they appear to relate to those affections which we have just consider- ed. I have not had an opportunity of observing, in sucking children, the chronic erythema of which Rayer has given some examples, and which has been described by Alibert under the name of dartre erythemoide. We shall see in the great number of cutaneous diseases, erythematic inflammation precede, accom- pany, and follow, the development of various species of phleg- masiae. The erythematic redness which is developed in the neighbor- hood of the genitals in new-born children, should be examined with close attention ; and when they exhibit a red coppery color, and resist the continued applications necessary for the treatment of ordinary cutaneous affections, and when the surrounding cel- lular tissue becomes engorged, it will be necessary to obtain a 13 98 ON THE DISEASES OF INFANTS. more exact information as to the health ofthe parents, and to be assured whether or not this erythema be not a syphilitic affection. ERYSIPELAS. Erysipelas simplex, " miliaris, " phlyctenoides, " eraticum, '• phlegmonodes, " aedematodes, " capitis,—thoracis,—membrorum, " umbilici. It is well known that in adults, erysipelas is usually connected with some affection of the digestive organs, the functions of which are disturbed either before or after the development of the cuta- neous disease, and that some authors regard it as a symptom of gastric disorder, or of gastritis. The history of erysipelas in young children is, in this respect, somewhat different. In the first place, it is to be remarked, that of all the cutaneous phleg- masiae, it is the one which attacks the most frequently, because, without doubt, in an infant recently born, the sanguineous con- gestion of the integuments is a predisposing cause of this inflam- mation, and that the irritability of the skin, recently deprived of its epidermis and exposed to the contact of the alvine excretions, renders it more liable to become the seat of erysipelas, which fre- quently succeeds to the erythema of which we have been speaking. During the year 1826, I observed in the Hospice des Enfans Trouves, thirty cases of erysipelas ; sixteen of them were sim- ple ; three cedematous; six. phlyctenoid; four phlegmonous; and only one ofthe miliary form. In two the face was affected ; sixteen, the trunk; and twelve, the limbs. Erysipelas ofthe trunk and limbs then, appears to be of more frequent occurrence than that of the face. The ages of these thirty children varied from one day to a year; but it should be noted, that there were eighteen below the age of six months ; four between six and eight months ; and two from eight months to a year ; but this proportion will not admit ON THE DISEASES OF INFANTS. 99 of extensive application, because children below six months are more numerous at the Hospice des Enfans Trouves than those of more advanced age. Eight of these infants were affected with erysipelas of the su- perior extremities, and of the parietes of the thorax, following vaccination, and during the eruption of the pustule. In the thirty cases just mentioned, sixteen were fatal, either from the simple disease, or from its complication; and among these sixteen, there were six simple, two cedematous, four phlyc- tenoid, three phlegmonous, and one miliary. One case of erysipelas of the face was followed by gangrene of the mouth, terminating in the death of the child, but fifteen days old ; another case of erysipelas of the face did not give rise to any unfavorable symptom. I scarcely remarked any gastric symp- toms in these cases of erysipelas; but there existed symptoms of enteritis more or less violent, acceleration of the pulse, dryness and heat ofthe skin, and rapid emaciation ; the frequency and nature of the cries of the child, together with the expression of the face, usually indicate suffering. Upon examining the bodies of sixteen children that died. I found in two, gastro-enteritis; in ten, enteritis ; in three, pneumo- nia, complicated with enteritis and cerebral congestion; and in one, pleuropneumonia. Ofthe four cases of phlegmonous erysipelas, it was situated in one, around the umbilicus and other parts of the parietes of the abdomen; in another, on the left side of the chest; in a third, on the hip and superior part of the right thigh. The patient died after a very extended disorganization and suppuration of the sub- cutaneous cellular tissue of this region; finally, the fourth was affected on the right leg. In fcur cases of phlyctenoid erysipe- las, the disease appeared on the abdomen ; in the remaining two, on the superior part of the thighs. The miliary erysipelas spread over almost every part of the body. In no instance, in the rapid disappearance of the disorder, was it followed by any serious metastasis, as is observed in adults. Yet I believe this pathological phenomenon may occur in children. Hoffman, and after him, Underwood, MM. Gardien, and Ca- puron, have directed their attention particularly to erysipelas of 100 ON THE DISEASES OF INFANTS. children. Underwood has described, under the same name, gangrenous inflammation of the extremities; this, I believe, is incorrect. I will hereafter recur to this affection, when consider- ing the gangrenous inflammations of the skin. From the preceding considerations and observations, it results that erysipelas, in sucking children, is remarkable for the follow- ing characters: 1st. It is frequent at an early age by reason of the sanguineous congestion of the integuments at this period of life; 2dly. It is of more frequent occurrence on the abdomen, thorax, and limbs, than on the face or head. It may terminate either by resolution, epidermic desquamation, or by suppuration of the subcutaneous cellular tissue. It is less often accompanied by o-astric symptoms than when it occurs in adults, but is usually attended with symptoms of enteritis ; lastly, it almost always produces an acceleration of pulse, heat and dryness of the skin, together with pain and wakefulness. The duration is from six to twelve days. It varies from a simple erythematic redness to that of considerable tumefaction, hard to the touch, of an intense redness, and sometimes of a violet color. The treatment should vary according to the complications. Emollient applications ought to be made to the inflamed integu- ments, particularly when the erysipelas has a tendency to ter- minate in suppuration, and also to prevent the formation of sinus- es under the skin, which follow suppuration of the cellular tis- sue. The enteritic or pneumonic symptoms which supervene, should be met by the administration of mucilaginous drinks, with but little nourishment. The external causes which produce or continue the irritation of the skin, should be removed ; such as the contact of fcecal matter, clothes either too hot, rough, or tight. If the affection be simple and superficial, there will be no occasion for any other than topical applications: an atten- tion to diet and the use of emollient drinks, is all that is necessary; but should it not yield to these means, recourse must be had to slight scarifications and local bleeding at some distance from the limits of the inflammation ; yet we ought to be careful about the extent to which we carry blood-letting in children. We will re- turn however to the consideration of this subject in another place. Local or general bathing ought not to be neglected, and in the ON THE DISEASES OF INFANTS. 101 last place, we should apply blisters on the inflamed part, as M. pupuytren has recommended in adults. It is important to remove the idea foulness of the bowels, or of gastric disorder, for although this complication is not chimerical, it rarely shows itself in infants at the breast affected with erysi- pelas.* RUBEOLA. Rubeola vulgaris, " sine-catarrho, " nigra. Rubeola, or measles, the anatomical characters of which have been already described, is remarkable for the febrile state which accompanies it, and for its complications. The most common of these are inflammation of the trachea, bronchia?, and lungs. The digestive organs are less often affected in the course of this eruption, and the cerebro-spinal apparatus does not become the seat of any derangement, except in certain individuals. At least, this is the result of the examination of the nature and history of this epidemic in different countries by a great number of physi- cians, particularly Sydenham, Mead, Morton, Pinel, and others. Measles appears to be more common after, than before first dentition ; for at the Hospice des Enfans Trouves, those above the age of eight, or nine months, are those more affected with the disease. M. Baron has, for several years, remarked this; and during the year 1826, in six children attacked with it, there were four above the age of eight months. Three of them died; two from acute hydrocephalus, and the third from a severe pneumo- nia. Tn general, M. Baron has remarked, that anginose and cerebral affections, were the most ordinary complication of measles in children at the breast. The symptoms of gastroen- teritis are always of less importance when they exist, and they often do not show themselves until the end of the disease. Other complications of measles, such as petechias, or different kinds of papulae, appear in adults. As to its terminations, we would observe that, in young subjects, the cutaneous eruption is very frequently followed by anasarca or desquamation; the for- *See Appendix. 102 ON THE DISEASES OF INFANTS. mer termination, without doubt, is attributable to the little vital reaction, and to the natural slowness ofthe passage of the blood in patients who have been debilitated ; the latter, to the facility with which the epidermis exfoliates in infants. The treatment of measles must vary according to its complica- tions. It is observed that these have been different in different epidemics ; from this, no doubt, arises the predilections of certain authors for a favorite method of treatment. From this cause it is that some are so partial to emetics. Thus Pinel, who had only seen it prevail at the Salpetriere in a very mild form, has recom- mended the expectant method, whilst Mead has advised bleeding as a remedy of universal application. If the danger of measles is considered as arising from the na- ture of the complication, we should direct our attention to this ac- companying disease. The treatment under these circumstances, will be found in the history of each of the organs which may be- come the seat of these complications. I will, in this place, con- fine myself to the attention which the patient requires with refer- ence to the cutaneous eruption. The drinks which have been recommended as suitable to favor the development of the eruption, ought to be administered with great caution. In case of metastasis, the warm bath appears to me very proper to restore the cutaneous irritation. Of this we must be very careful, should cerebral congestion supervene in the child. Emetics, when there is reason to believe the existence of gastric derangement, and purgatives, when it is necessary to re- lieve the bowels, should be given with much caution in young children in whom the alimentary canal is one of the parts most susceptible of irritation. We should also be careful in the use of remedies for the relief of debility, to which patients with measles are sometimes subject. We shall hereafter see what lesions ordinarily accompany the adynamic condition of young children; and will then understand how dangerous k might be to give cordials and antiseptics in a pathological condition, as va- riable in its causes as in the interpretations which have been given to the term by which it is expressed. Tonics are only useful in a state of extreme debility and ma- rasmus, occurring after measles, and when they are not contra- indicated by any organic lesion. ON THE DISEASES OF INFANTS. 103 ROSEOLA. Roseola aistiva, " autumnalis, " annulata, " infantilis, " variolosa, " vaccina, " miliaris. Roseola is a very superficial inflammation of the skin, never spreading to such an extent as erythema, very often mingled with other symptoms, such as variola, vaccinia, etc., and of frequent occurrence in infants. Its varieties, which refer more to the period of its appearance and to the disposition of the spots, than to the difference in the symptoms, scarcely deserve attention. I have often seen it develop itself on the surface of the body, neck, and limbs of sucking children, as well as of those just born. It appears to produce very great irritation of the skin, for some children cry much when they are attacked with it. Summer is the season in which it more particularly occurs. Its duration is very variable ; and it often consists of nothing more than small patches of a rosy color, irregular and smooth, often appearing and disappearing every moment of the day. In the greatest num- ber of cases there is neither fever nor any disorder in the digestive functions; and were it not for the cries and sleeplessness of the child, attention would be scarcely attracted to this slight eruption. Children are more subject to it at the age of six months to a year, than at an earlier period ; and it more particularly makes its ap- pearance about the time of dentition. When this disease is not preceded by some other cutaneous affection, and no functional derangement accompanies it, it will be sufficient to administer to the child some mild anodyne, such as the syrup of poppies, in a little sweetened water, and to use ablutions at a low temperature. If there exist, at the same time, any cerebral irritation, or any affection of the alimentary canal, or of the respiratory apparatus, the physician should meet these symptoms with suitable means. 104 ON THE DISEASES OF INFANTS. It is particularly important to notice whether roseola be not the first appearance of a disease of more importance, the characters of which will afterwards more fully appear. SCARLATINA. Scarlatina simplex, " anginosa, " maligna. Scarlatina is always accompanied with violent fever, very often with angina or ophthalmia, and sometimes with pneumonia, gas- troenteritis, or encephalitis. Of all the complications, that of the throat is the most frequent and serious. Inflammation of the larynx or tonsils exists in a greater or less degree in almost every case of scarlatina, either at the commencement or in the course of the disease. It would seem that the other complications are only observed in such as are exposed, by a particular predisposition, to inflammations of the encephalon or of the alimentary canal. Scarlatina prevails more particularly during second infancy and in youth, than during the period of sucking. This disease often appears at the Hospice des Enfans-Malade, while it is scarce- ly seen in the course of a year at the Hospice des Enfans Trou- ves ; and in 1826, when scarlet fever existed in this hospital, three children, aged from one year to fifteen months, were attacked with it, while none of a more tender age were affected. M. Baron has, for a long time, made the same remark, the correctness of which is evident when it is considered that all the epidemics of scarlatina prevail among children collected in boarding-schools or hospitals. Be this as it may, 1 admit that scarlatina does not affect children in the first infancy in the same manner as it attacks those of more advanced age. It appears first in a simple form, that is to say, with a slight febrile action, without apparent lesion of any organ ; secondly, with affections of the throat, either sim- ple, croupy, or gangrenous, the most distressing and the most common complications of the disease. Finally, this eruption may assume a fatal character by the simultaneous development of menengitis, of encephalitis, or gastro-enteritis, giving rise to a ON THE DISEASES OF INFANTS. 105 serious train of symptoms, constituting the adynamic fever of authors. The treatment of scarlatina must vary according to the simple or complicated condition in which it exists. When it is simple, it will only be necessary to moderate the febrile action and cutaneous irritation, by attention to diet and the use of emollient drinks at first, afterwards slightly acidulated. The patient ought to be removed, that no communication may exist between him and other children, for this phlegmasia is al- most always contagious. If the redness of the skin, together with the reiterated cries of the child, indicate excessive irritation of the integuments, it should be tranquillized by emollient lotions, slightly narcotized, applied to the body and limbs, such as the decoction of marshmallows and poppy heads; but not by the internal administration of opium, as recommended by Sydenham, except with the greatest caution, under the apprehension of irri- tating the brain, the inflammation of which is often a compli- cation of scarlatina. Dr. Currie, of Liverpool, has spoken in high terms of the ex- ternal application of cold water in the treatment of some acute diseases, and Bateman has recommended it in the treatment of scarlatina, to produce a favorable diaphoresis. This remedy, known from the highest antiquity—since it ap- pears to have been used by Antonius Musa, physician to Augus- tus—ought only to be employed by the most experienced and the most prudent; if the traditions accredited by M. Leclerc are to be believed, Musa himself appears to have suspected that by this means the premature death of the young Marcellus was hastened, the name of whose disease has not come down to us; but the remembrance of this fact, if it be true, should not hinder our using this agent with the precautions mentioned by Bateman. If we are unable to throw cold water over the body of the patient when the skin is dry and hot, for fear of terrifying the mother or nurse, we ought at least to sponge the face, neck, arms, and body, with cold vinegar and water. The practitioner ought to abandon the old routine of envelop- ing the patient in a triple covering of bed clothes ; but direct the air of the bedroom to be renewed, carefully avoiding the expo- sure of the patient to sudden changes of temperature. 106 ON THE DISEASES OF INFANTS. The complications of scarlatina, such as ophthalmia, encephali- tis, pleuro-pneumonia, angina, enteritis, and the symptoms known under the vague title of putrid, demand particular notice, and will be duly considered in the different parts of this work devoted to the history of these diseases. After the disappearance of febrile symptoms, redness of the in- teguments, and the symptoms complicating this disease, the phy- sician will still have to encounter anasarca, a sequela of very common occurrence in scarlatina. M. Viesseux, of Geneva, has recommended that great care be also used in preventing children from being exposed to the cold air for some days, or even weeks, during their convalescence, because he attributes the infiltration of the cellular tissue to the action of this external agent. Sydenham has advised laxatives after the period of desquamation. I think they are useful if there exist no symptoms of gastro-enteritis ; they may be followed by mild tonics, such as a teaspoonful of Malaga wine, or wine of Cinchona, particularly where the circulation is habitually slow. Fi- nally, many physicians recommend dry or aromatic frictions, fumi- gations slightly stimulating, tepid or stimulatingbaths. In addition to these, I would recommend enveloping the child in fine soft flan- nel, applied next to the skin. These means, together with exer- cise and moderate nourishment, should be pursued or suspended, according to the particular indications; and, if properly directed, will serve a much better purpose than stimulants, solvents, de- obstruents, drastics, and other violent remedies, so often praised in the treatment of dropsy.* URTICARIA. Urticaria febrilis, " evanida, " perstans, " conferta, " subcutanea. " tuberosa. All these varieties of urticaria pointed out by Bateman and * See Appendix. ON THE DISEASES OF INFANTS. 107 Frank, depend ordinarily on the varieties of form and complica- tion ofthe eruption. I think it most important to note the three following varieties : First, urticaria arising spontaneously with- out any febrile action, with nothing but an itching sensation in the part of the integuments accompanied by the eruption; se- condly, urticaria arising from indigestion in the stomach of food badly prepared, or composed of principles obnoxious to the sys- tem, such as muscles, under certain circumstances ; lastly, when accompanied by fever, more or less violent, continued intermit- tent, or remittent; the eruption then is moderate or severe, ap- pears and disappears, according to the remissions or intermissions of the fever. I have sometimes observed urticaria without fever in infants at the breast, appear and disappear several times in the day, with- out giving rise to any unfavorable symptom. Yet the crying and restlessness of the child led me to believe that a great itch- ing must have been experienced. Underwood, who has spoken of this mild variety of urticaria, says that it disappears ordinarily in a very short time. Thus, then, urticaria is, in infants generally, a mild disease, and it is commonly in adults that it is accompanied with febrile symptoms, and a greater or less disturbance of the digestive or- gans. If it show itself in young infants with but little intensity, at- tention to diet and the ordinary rules of hygiene, will be all that is necessary. In case of a long continuance of this disease, Un- derwood advises the use of a few grains of the compound pow- der of contrayerva, or of absorbent powder with the addition of a few drops of ammoniated alcohol. But of what utility is this treatment ? Is there any thing more vague than this ad- vice? Would it not be better to seek for some functional or organic lesion, on which the continuance and obstinacy of the disease may depend, and direct the treatment accordingly 1 Should it proceed from indigestion, or from any kind of poi- son, it would then be proper to give a mild emetic to relieve the stomach from the irritating substance which it contains; and if the cutaneous eruption appear on the access of an intermittent fever, the administration of a febrifuge is very naturally indi- cated. 108 ON THE DISEASES OF INFANTS. BLISTERS. It is unnecessary to stop and describe at length, this artificial inflammation of the skin, which, as we shall hereafter see, may either be of great utility, or give rise to the most serious symp- toms in children, according as they may be well or badly employ- ed. The effect of blisters in exhausting the patient by the secre- tion which they produce, should never be lost sight of, as has been remarked long since by Baglivi, Pinel, Corvisart, and Broussais. This remark is particularly applicable to diseases of children. ESSERA. When care is used in clothing infants properly, that is to say without bandaging them in the cruel manner formerly practised, they will rarely have this affection, for it is always the result of mechanical pressure on the part. PEMPHIGUS AND POMPHOLIX. Pemphigus, for the first time described by Sauvage, and united by Bateman to what he calls pompholix, an eruption, the ana- tomical characters of which differ from the former only in a slight degree, has, for a long time, been considered as essentially united to a species of fevers denominated vesicular. But since the publication of the excellent work of Gilibert, Pinel and other pathologists have denominated pemphigus, the cutaneous affec- tion characterized by the development of erythematic patches over different parts of the body, on the surface of which bulla? arise, which soon break, leaving a viscid yellowish fluid. This fluid concretes, and forms on the ulcerated surface a slightly pro- jecting scab, often granulated and yellow, like honey, or rather approaching to a fawn color. This eruption is sometimes accompanied with fever, and is sometimes apyrectic. Its duration may be either for a short or for a long time ; hence the distinction between acute and chronic pemphigus—a very correct distinction, and of great practical utility. Acute, apyrectic pemphigus, is very common among children ON THE DISEASES OF INFANTS. 109 at the breast; the febrile variety is more rare; chronic pemphi- gus is sometimes met with. Willan has noticed in infants, pem- phigus to which he has given the name of infantilis. I have seen the acute form of the disease several times at the Hospice des Enfans Trouves, and the following case appears to present, with great variety, the characters of this affection when occur - ing in sucking infants. CASE VI.—Acute pemphigus, muguet, Enteritis.—Caroline Per- neau, aged four months and a half, had been, from birth, in charge of the nurses at the hospital; on the 12th of January, 1826, was at- tacked with diarrhoea; she became pale ; could not sleep, and took the breast with less eagerness. She entered the infirmary on the 15th of February, and exhibited the following appearance: strength moderate ; face pale and a little shrunk ; but the body and limbs still preserved their firmness and vermillion hue ; she cried but little ; the base of the tongue was covered with muguet; the buccal mucous mem- brane was of an intense red; the pulse beat about ninety; urine abundant; was affected with a diarrhoea of a yellow color ; (gummed rice water, starch injections, abstinence from the breast.) On the following day there appeared on the cheeks a few small, slightly transparent bullae, some of the size of a hemp-seed, others of that of a lentil, and all of them arising in the midst of erythematic spots. The appearance of these bullae did not augment the distress of the child, who neither cried nor manifested any distress, notwithstanding the pulse was accelerated and the skin dry and burning. On the 19th, the bullae on the face had disappeared, or had been torn by the fingers of the child ; in their place, was a yellow superficial scab, surrounded by a red mark or circle, without tumefaction. The di- arrhoea continued ; the muguet had spread over the rest of the buccal membrane; the child became much emaciated; pulse from 110 to 115. On the 20th, other bullae appeared on the neck and upper part ofthe chest; but they were smaller than those on the face, the scabs of which had begun to fall, leaving beneath them a red mark. On the 22d, the bullae on the neck had undergone the same change in the formation of scabs as those on the face, which were, for a se- cond time, covered with very thin yellow concretions. On the 25th the child vomited her drinks ; the paleness and emaciation increas- ed ; the pulse was a little more frequent. From the 25th to the 30th, she gradually sunk, other bulla? showing themselves successively on 110 ON THE DISEASES OF INFANTS. the parietes of the thorax. On examining the body, the brain was found a little injected ; the tongue and velum covered with muguet; oesophagus violet-colored ; stomach covered with red spots; the small intestines healthy ; and on the internal membrane of the colon appeared stria, red patches, and a very evident tumefaction; the liver was healthy ; the lungs gorged with blood—the right congest- ed at the summit; the heart also was filled with blood. This eruption appeared to me to present all the characters of pemphigus, or of pompholix ; and it was here complicated with colitis and muguet. It appears as if this cutaneous inflammation may be developed without this complication, for Willan has described, under the name of pompholis benignus, the successive appearance of trans- parent bulla?, about the size of a pea, and sometimes of a hazel- nut, on the face, neck, and limbs of young children, during den- tition, and of only a few days' duration. When the pemphigus is simple, bathing, together with emol- lient lotions and mild regimen, will be sufficient for its treatment; but if it be complicated with fever or enteritis, it requires close attention on the part of the physician. Lastly, if pemphigus be- come chronic, great difficulty will then be experienced in its treatment; for children affected with chronic pemphigus are usually reduced to marasmus, and present but little chance for the action of remedies suitable for the management of inflamma- tion. Willan and Bateman have, in these cases, recommended tonics and nutritive diet; and cinchona has been used internally, and also externally, in the form of a lotion to the skin, by some physicians; baths, not hot, as Willan advises, but at a low tem- perature, will be found useful remedies ; ablutions with vegeto- mineral water ; frictions with oxygenated pomatum, (unguentum acidi nitrosi E.,) in the parts where the ulcerated derma is con- tinually covered with new scabs ; a change of nurse, of food, and of climate ; daily exposure to the external air, but only for a short time each day ; the selection of good milk when the child is arti- ficially nourished, are the general indications for the treatment of this disease in young infants. Pinel has advised to abstain from all topical applications, and not interfere with the progress of the disease. This is, no doubt, proper in the case of acute pemphigus, accompanied by fever, of which it is, as we may say, ON THE DISEASES OF INFANTS. Ill but a symptom ; but is it wise to remain a tranquil spectator of the progress of the phlyctena? and ulcerations, which in chronic pemphigus undermine, by pain and exhaustion, the constitution, and shorten the days of the little patient 1 I think not. RUPIA. Rupia simplex, " prominens, " escharotica. Rupia is met with in scrofulous children, who are badly nour- ished and debilitated. Certain atonic ulcers of the legs which follow bulla?, the development of which has sometimes escaped the notice of the physicians, are no other than true rupia, recog- nizable particularly by the form and color of the scabs that are continually rising to their surface. Bateman notices three varieties of rupia: small phlyctena?, which are filled with a clear lymph, situated on different parts ofthe body, where, breaking and spreading, they produce small black scabs, constituting that form of the disease denominated rupia simplex. If the scabs are raised, conical, striated, or ru- gose, it then takes the name of prominens; and that of escha- rotica, when the vesicles, which show themselves, in general, on the loins, thighs, and legs, contain a sanious or corrosive fluid, and, terminating by sloughs, produce, on being detached, deep ulcerations. This last variety, according to Bateman, is frequently observed in those infants at the breast previously much reduced by sickness, badly nourished, or badly clothed. I have not had an opportunity of seeing rupia escharotica at the Hospice des Enfans Trouves, where infants are often found in the condition described by the English pathologist; but I have often seen on the legs and thighs of children reduced to maras- mus, phlyctena? or ulcerations afterwards covered with solid black scabs, presenting the characters which Bateman calls rupia simplex. The scabs should be removed by the aid of cataplasms, and the ulcerations beneath dressed with perforated linen spread over with cerate of acetate of lead; the ulcerated surfaces ought also to be washed from time to time with wine and water, or a weak decoction of cinchona or alum-water; powdered alum, or 112 ON THE DISEASES OF INFANTS. cream-of-tartar may be sprinkled over the ulcer; at the same time administering tonics internally, such as a weak decoction of wild cichory, hops, cresses, or saponaria. The strength of the patient should also be promoted by allowing aliments that abound in nutritive principles. In every case, the condition of the ali- mentary canal ought to be closely watched. ZONA, OR ZOSTER. This disease, although common in adults, is rarely observed in infants at the breast; I have seen but one instance of it in eight hundred children that were admitted into the infirmary du- ring the year 1826. This eruption is usually connected with a more or less marked derangement of the functions of digestion; it is almost always preceded or accompanied by some degree of debility, and causes much sickness and pain, particularly when the bullae, or the vesi- cles which are mingled with them, break; they then give rise to superficial ulcerations, which are soon covered with very thin yel- low scabs. The treatment ought to consist of such means as are suitable for the management of disordered digestion. Topical applica- tions to the ulcers should be dispensed with altogether, at least until the excessive pain demands the use of emollient and anodyne cataplasms. HERPES. Herpes phlyctcenodes, " iris, " circinatus, " labialis, " praiputialis, " auricularis. Willan, Bateman, and M. Rayer, have described, under the name of herpes, a disease different from that which bears this name in the works of MM. Lorry and Alibert. Every body has observed these little vesicles, which appear on the lips of those who have recently experienced an attack of fever, at first vesicular, then exhibiting an excoriated surface, covered with a yellowish scab; this is the eruption designated by the English ON THE DISEASES OF INFANTS. 113 pathologists under the name of herpes labialis, and will give an idea of the genus herpes. The general symptoms, usually accompanying herpes, are of little moment; it is not a disease peculiar to infancy; yet some of the varieties may be met with in young infants. 4 The species of herpes are established—1st, According to the form ofthe groups or vesicles : Herpes phlyctcenodcs, globular and trans- parent vesicles, about the size of a millet seed, appearing in dif- ferent parts of the body, generally preceded by red spots, more or less extended, and attended with a violent itching. Herpes iris, vesicles surrounded with concentric rings of various colors. Herpes circinatus, characterized by erythematic spots, sur- rounded by an areola of vesicles. 2dly, Others take their names from the seat of the disease : Herpes labialis, herpes pr&putia- lis; groups of small globular vesicles, accompanied with pru- ritis, developed on the external or internal surface of the lips and prepuce. There are also herpes auricularis, palpebralis, vul- varis. When herpes prceputialis, or vulvaris, is observed in young infants, we should examine whether it be of a venereal nature, and notice particularly the form of the vesicles, the slight circle that surrounds them, the color of the scales which succeed them, and the effect of the remedies used. The treatment of herpes ought to be simple, since there are scarcely ever any complications in this disease. Demulcent or slightly acidulated drinks should be administered, and emollient lotions applied to the part; or when the scabs are constantly form- ing on the surface of the superficial excoriations which succeed the vesicles, the affected part may be washed with a weak solu- tion of alum. ECZEMA. Eczema solare, " impetiginodes, " rubrum, " acutum, " chronicum. This disease has been confounded with psora, and some au- 15 114 ON THE DISEASES OF INFANTS. thorshave described it under the name of "dartre squameuse humide."—(Alibert.) The rounded vesicles, surrounded by small red circles, which characterize eczema, show themselves in a distinct form on the face, limbs, and upper part of the thighs. They disappear promptly either by absorption, or by having discharged the fluid « they contained, and which concretes in the form of thin scabs. In such a case, eczema may be considered as acute ; it scarcely affects the health ofthe patient, and requires nothing more than good nursing, demulcent regimen, and emollient baths. But when it resists these simple means; when, assuming a chronic character, the vesicles are continually renewed, or spread, multiply, and mingle together, producing an abundant secretion, and forming a number of scabs, beneath which numerous vesi- cles arise without cessation ; then emaciation, pain, disorder of the digestive functions, and febrile reaction ensue, seriously af- fecting the health of the patient, the case then demands the especial care and attention ofthe physician. In general, eczema may be either acute or chronic ; and it is more frequently met with in youth and adults, than among old people or infants at the breast. Yet, there is variety of eczema often to be seen among the latter; it occurs in the scalp, and is known by the formation of small bluish vesicles on the head, and upon discharging a fluid which quickly concretes, produces a disease somewhat resembling tinea. I have often noticed on different parts of the trunk and limbs of new-born children, small distinct vesicles, each surrounded by a little red circle ; they appear suddenly, and often end in resolu- tion ; but sometimes breaking, produce small superficial scabs. These vesicles are two, three, or four in number, far removed from each other; and are met with indifferently on the face, trunk, and limbs ; and, except as to their number, they exhibit the strongest marks of eczema. I have no doubt of this being a va- riety of the disease now under consideration. I have met with it in children scarcely a day old, and have thereby been led to believe that the child has brought the affection with it into the world. The sisters of the Hospice des Enfans Trouves, in con- sequence of the dread which even the shadow of a disease, if we ON THE DISEASES OF INFANTS. 115 may so speak, of a venereal nature inspires them, are in the ha- bit of regarding these vesicles as venereal pustules, and adopt, in every instance, an anti-syphilitic treatment. M. Baron does not ordinarily participate in this fear, and I have seen these vesicles disappear of themselves at the end of a few days after the chil- dren have been in the infirmary. Mercurial eczema may, without doubt, be developed in infants nursed by women who have used mercury internally or exter- nally ; but I am not acquainted with any case of this kind. The treatment of chronic eczema is as difficult in its choice and direction, as it is uncertain in its results ; yet the general principles of treatment must be borne in mind. Thus we should consider primarily of what nature are the symptoms of reaction; what the seat of the concomitant alterations of the cutaneous eruption; whether the obstinacy with which the vesicles and scabs are produced, be owing to the peculiar alteration of the fluid, as was formerly taught, and as some physicians at the pre- sent day believe ; or whether the alteration in the cutaneous se- cretion be the result of a change in the tissue, and in the nutri- tive activity of the organ charged with this secretion. The physician should always endeavor to modify the actual state of the constitution ofthe patient, that the disease with which he is affected may be successfully treated. To accomplish this object, several therapeutic means have been advised. As external ap- plications, emollient baths, saturnine lotions, solution of nitrate of silver, diluted muriatic acid, cataplasms of chelidonium minus, sulphurous vapor baths, etc., are recommended. As internal remedies, there have been used the vegetable acids; solutions of the preparations of arsenic ; tonics, such as serpen- taria virginiana, cinchona, tincture of cantharides, bitter sweet, or sulphurous preparations. I have confined myself to the simple mention of these reme- dies, as experience will not allow me to speak confidently in re- lation to their efficacy, and the judicious practitioner will neither reject them altogether, nor use them exclusively; but after hav- ing made trial of simple and rational means ineffectually, will perhaps be obliged to resort to them for the management of a dis- ease which often defies all his efforts, selecting such as will do 116 ON THE DISEASES OF INFANTS. the least injury to the patient; watching closely the digestive or- gans and the peculiar state ofthe constitution. PSORA. Psora simplex, " complex. Psora is a vesicular disease, which some physicians, among whom is Morgagni, attribute to the presence of an insect, (aca- rius scabiei.) M. Gales has even discovered its form ; but MM. Alibert and Biete have in vain searched for it, although aided by microscopic instruments.* Psora may be simple, exhibiting on various parts of the body, but particularly in the folds of the articulations, only the little vesicles which are its characteristics. It may also be complicat- ed ; that is to say, having between the vesicles different kinds of cutaneous inflammation; such as eczema, prurigo, lichen, stro- phulus, ecthyma, etc. In both cases, it is almost always apyrectic and contagions; it is developed in those children who are badly clothed and badly nourished. It is usually communicated by nurses, in which case it apppears on the thighs and breech, because these parts are ap- plied to the arms of those persons who carry, or habitually at- tend them. Psora rarely gives rise to general symptoms of a serious na- ture. Nevertheless, in young infants we ought to exercise a se- vere scrutiny into all the symptoms which may, at the same time, be developed ; and in the event of any important organ be- coming the seat of an inflammation more or less violent, it should be treated with promptness and energy. As to the treatment of the cutaneous disease in particular, those applications, in the case of young infants, ought to be used which are the most simple. Among the number of curative means, ablution with artificial Barege water, alternating with the bath of marshmallows, or of bran, will be found the most convenient for children at the breast. The efficacy of these means has been proved in adults, and in children more advanced in age than those now * See Appendix. ON THE DISEASES OF INFANTS. 117 considered; but I have no doubt, that this remedy will be found equally applicable to very young infants. MILIARY SWEAT. The miliary sweat, the characters of which have been already described, prevails generally as a sporadic disease. It is princi- pally observed in youth and in adults ; but I know not whether it may not also attack infants at the breast. In every instance, these children ought to be isolated, and all those not affected, re- moved from the country where it prevails ; the symptoms of gas- tritis, with which it is almost always complicated, watched with care; neither should the sudorifics, with which the patients are too often gorged, be allowed to be administered ; nor the practice of keeping the patient awake under the fear that the brain may otherwise suffer, be continued. VARIOLA, VARICELLA, AND VARIOLOID. Variola is not a disease peculiar to infancy, but it affects equally individuals of all ages; yet it is of more frequent occur- rence at the period of second infancy than among infants at the breast or among adults. The diversity of ages does not influence this disease so much as the difference of the nature and seat of the complications, for the anatomical character of the eruption remains always the same. The history of this disease comprehends nosological details of the highest interest; and the labors of pathologists, in attempting to discover the origin of variola, and to understand the true na- ture of its varieties, would themselves form the subject of an ex- tended monograph. I will content myself with the exposition of the facts generally admitted in relation to varioloid. This eruption is ordinarily preceded and accompanied by fe- ver, and more or less disorder of the digestive functions, some- times by angina, pneumonia, encephalitis, or menengitis. Variola usually passes through periods distinguished in the following manner,—that of irritation, eruption, suppuration, and desquamation. The pustules exhibit, during these periods, a se- ries of anatomical characters, which have been already described in the table of genera.* * Seep. 88. 118 ON THE DISEASES OF INFANTS. It is again distinguished into simple, discrete, and confluent. Some pathologists, among whom is Adolphus Henke,* have pointed out a great number of varieties of variola, such as serous, siliquoze, verrucous, sanguinolent, or purple, etc. Other species hatfe been denominated catarrhal, malignant, nervous, putrid- distinctions which have been admitted for a long time by the most celebrated nosologists, such as Sydenham, Van Swieten, and others. Without attaching much importance to all these varieties, we should still keep two things in remembrance: sometimes variola only exhibits the symptoms that strictly belong to it, or those which result from its usual complication, gastric or pulmonary affections ; sometimes, on the other hand, inflammation of a vital organ ensues suddenly; the practitioner ought then to direct his attention as well to the plegmasiae thus developed, as to the cuta- neous inflammation, and use for both affections the suitable therapeutic means for their relief. The term varioloid has recently been applied to variolous eruptions appearing on those who have been vaccinated. M. Mo- reau de Jones asserts that varioloid is a disease distinct from common variola in its symptoms, its effects, and in its origin; that neither the ordinary small-pox nor the vaccine disease is a protection against its contagion ; that the vaccine virus, in every instance, modifies its pernicious influence. (Mem. read at the Acad. roy. des Science, Oct., 1827.) An attentive examination, however, has proved that this kind of variolous eruption which occurs in those who have been vaccinated, does not differ, with respect to its anatomical characters, from that which arises in pa- tients who have not been vaccinated; that they even offer the same complications, and, in general, they are neither more mild nor more mortal. Dr. Thompson, of Edinburgh, showed me some very correct paintings of variolous eruptions developed after vacci- nation, the characters of which did not, in any respect, differ from the eruption of small-pox. I particularly noticed among these drawings, that of a young man who had been vaccinated by Jenner. The word varioloid, which Dr. Thompson himself * Handbuch zur Erktnntnisa und heikcng dtr kinderkrankheiten von A. Henke, ON THE DISEASES OF INFANTS. 119 uses, is nothing more than a conventional term applied to vario- la arising after vaccination, and to which there ought not to be attached any peculiar signification, or any idea that will es- tablish or justify any appreciable difference in the anatomical characters of this disease, in its form, its progress, or in the du- ration of its symptoms. The prognosis of variola is unfavorable in proportion to the im- portance of the organ which is the seat of the complication ; thus, in young infants, encephalitis, and particularly meningitis, are fatal complications, and unhappily of too frequent occurrence. The name of varicella is given to an eruption, the form of which differs from that of variola, properly so called. Its pecu- liar characters have been before described. This eruption, quite distinct and very mild, is rarely accompanied by any unfavorable symptoms; it scarcely ever produces fever, and is to be found indifferently in those who have, or have not, been vaccinated. It usually disappears after a few days continuance, and never leaves after it any deep scars. The treatment of variola should be confined to the use of de- mulcent drinks, and to a strictly antiphlogistic regimen, when there are no serious complications added to the eruption; but should there arise an intense gastritis, pneumonia, angina, or meningitis, it will then be necessary to meet the complication by the use of appropriate means, which will be considered when treating of the history of each of these diseases. Care should be taken to avoid the treatment of what is still vaguely denominated a state of ataxia or putridity, by the administration of tonics and stimulants ; such medicines will act much more fatally on young children, because they are more disposed to inflammation of the gastro-intestinal apparatus, at all times much disposed to phleg- masia?. Among all the means recommended to facilitate the pro- gress of the eruption, and to diminish the pain and fever, opium is the most prominent, the success of which is supported by the experience and authority of Sydenham,* Huxham,^ Morton.t * Sydenhamii opera, sect. 3, cap. 2. t Opera phys. med. t De variolis, cap. 7. 120 ON THE DISEASES OF INFANTS. Werlhof,* Van Swieten,t Frank,* Hufeland,§ and A. Henke.H The latter mentions his having used it with great advantage in the small-pox, in 1802, at Brunswick. When the child mani- fests great distress by its cries, wakefulness, and restlessness, a little syrup of poppies may be given in its milk with advantage. Sydenham never gave opium except to patients advanced in age, and with the greatest caution ; he preferred for infants laudanum r or syrup of poppies; but he never used it except compelled by the universal excitement of the patient. This medicine should certainly be given with care; and when convulsions arise, a symptom to which children are very liable in the course of va- riola, it would be better not to have recourse to it until after having endeavored to calm the irritation of the patient by tepid baths or blood-letting, practised according to the rules laid down in speaking ofthe diseases ofthe cerebro-spinal apparatus. VACCINIA. Is there any need of referring here to the origin ofthe discovery of Jenner, when public gratitude has for ever engraved it upon the memory of men ? It is useless any longer to copy that which has for twenty years been repeated in every book published on this subject. We are indebted, moreover, to the researches of G. Pearson, M. Husson, R. Willan, and a number of others, for some highly valuable documents on the history of vaccination. The process of vaccinating is so simple that it has become popular, and its effects are at this time so well known and ap- preciated, that no one can any longer hesitate to protect children by means of this preventive from one of our most fatal diseases. Yet the success of vaccination has lately been brought in ques- tion, because there have been several individuals affected with variola who had been vaccinated. The serious doubts raised as to the efficacy of vaccination as a preventive of small-pox, have been thought worthy of the attention of the Acadsmie royale de Medecine, and a commission was appointed by that body, charged * De variolis et anthracibus. t G. Van Swieten, comm. in Boerrh. t. 5. t Epitome de curandis hominum morbis. § Bamerkungen, uber naturliche und gaimpft Blattern. II Henke, loco cit. ON THE DISEASES OF INFANTS. 121 with the examination of the facts relating to this important point in pathology. In a report, remarkable for its clearness, and for the excellent spirit with which the facts alleged on both sides of the question were examined, M. Paul Dubois, secretary of the commission, has demonstrated that although vaccination has failed under some circumstances, it has not the less modified, in almost every instance, the variolous affections, when it has not entirely preserved individuals from an attack ofthe disease. So that the discovery of Jenner deserves still the confidence which it had acquired by its success in innumerable cases ; and if its infalli- bility is not demonstrated, it is at least impossible to harbor a doubt of its immense utility. M. Moreau de Jones has remarked, that the modifying influence of vaccination is so great, that, in the United States, among individuals vaccinated, that are attacked with variolous disease, scarcely one per cent, are fatal, whilst one half of the non-vaccinated, of those who take the disease, die.* Vaccination may be performed at all ages ; yet I must observe that the congestion of the integuments, during the early days of life, appears to contra-indicate the operation at this period. I have seen, at the Hospice des Enfans Trouves, where infants are vac- cinated very young, a severe erysipelas form on the vaccinated limb. It will probably be thought a proper place to enter upon the de- tails of the history of spurious vaccination, and of the eruptions resembling cow-pox, which are developed on the arm after the insertion of the virus ; but, apart from the great numoer of sub- jects of which I am obliged to treat in this volume, compelling me to speak briefly on each, I feel no disposition to commence the discussion of one still in litigation. ECTHYMA. Ecthyma vulgare, " infantile, " luridum, " cachecticum. Ecthyma, which consists, as we have already seen, of large pustules, elevated upon a hard, red, and inflamed base, and * See Appendix. 16 122 ON THE DISEASES OF INFANTS. covered with greenish yellow scabs, is seen more especially in children that are feeble, badly nourished, and badly clothed. This disease is not contagious; but it often succeeds affections that possess this character, such as variola, rubeola, scarlatina, and psora. In general, ecthyma is connected with a chronic af- fection of the digestive or respiratory apparatus, and is developed often in the emaciated condition to which children affected with these diseases are reduced. The pustules of ecthyma appear more particularly on the neck, shoulders, arms, and breast. Sometimes there is but one eruption developed, which runs its course in a very short time; in other cases the eruption is renewed without ceasing, multiplies, spreads, and becomes confluent. This difference in the course of the dis- ease, has caused a division, by authors, into acute and chronic; in both cases there is always lassitude, rapid emaciation, and other violent symptoms. Bateman, regarding only the state of cachexia which accom- panies ecthyma, has recommended the use of tonics, such as cin- chona, Virginia snake root, sarsaparilla, and the preparations of antimony. But would it not be better at first to remove the child from the external causes capable of keeping up the wasted and debilitated condition, to subject it to a better directed and more suitable diet; to immerse it in mucilaginous and emollient baths, and to consider the condition of the digestive organs before ad- mitting tonics ? As to the external treatment, it should consist of emollient applications. ACNE. Acne simplex, " punctata, " indurata. Acne has not as yet been observed in infants at the breast; it is scarcely ever developed until after puberty; I must therefore refer, for the detailed history of this disease, to works ex jwofesso on cutaneous diseases. MENTAGRA. Mentagra is not an infantile disease ; it appears almost always in adults, and particularly in those persons in whom the chin is covered with a thick strong beard. It should not be confounded ON THE DISEASES OF INFANTS. 123 with porrigo larvalis, which sometimes appears at first on the chin. IMPETIGO. Impetigo figurata, " sparsa, " erysipelalodes, " scabida, " rodens. The varieties of impetigo described by Bateman, are evidently too numerous, and I think it would be much better to have but two, as described by M. Rayer—impetigo figurata and impetigo sparsa. Impetigo figurata ordinarily appears under the form of patches resulting from the agglomeration of several small pustules, which soon excoriating, form thin yellow scabs, slightly prominent, surrounded by an inflammatory circle, and occurring principally on the face and limbs. Impetigo sparsa consists of various collections of pustules, which are developed separately on several parts of the body, but especially on the inferior extremities, fore-arm, wrist, and ankle. It may be either acute or chronic, and may exist with or with- out disturbance ofthe digestive functions. It is a disease of much more frequent occurrence in adults than in children; yet au- thors place among its predisposing causes, the first and second dentition. 1 have never met with it in infants at the breast; they are, however, greatly subject to various kinds of tenia, and there exists so much resemblance between tenia mucosa and im- petigo sparsa, that it is difficult to establish a well-defined line of demarcation. Besides, impetigo, according to Bateman, may follow tenia mucosa, (Porrigo larvalis—Willan;) and according to some au- thors, the shades which are observed between tenia mucosa, and impetigo sparsa, result entirely from the different regions in which the pustules are developed, and from the no less remarka- ble difference of the ages of the individuals affected with the dis- ease.* * Rayer, Traite des Maladies de la peau, 1st voL p. 479. 124 ON THE DISEASES OF INFANTS. Be this as it may, if well marked impetigo is met with in an infant, the plethoric condition should be relieved if it exist, and the gastro-intestinal complications closely watched; the cuta- neous inflammation moderated by the use of tepid baths, of sim- ple water, or bran water, by lotions made with marshmallow roots, to which poppy heads or the extract of opium may be added. Finally, Rayer has advised the use of mild ointment of oxide of zinc and acetate of lead, in order to relieve the inflam- mation. Neither douches nor vapor baths should be used until the inflammatory period is passed. It should not be forgotten that impetigo is developed usually in those children who have been previously much reduced by other chronic cutaneous affec- tions, and that it is often accompanied by a violent itching and great intestinal irritation, arresting their sleep and disturbing their digestive organs, reducing them to marasmus, and exposing them to lymphatic engorgements of the neck and mesentery. It would, no doubt, be proper, under these circumstances, to have recourse to sea-bathing, or baths of Barege water, and to use all other means for the renovation of the general health of the pa- tient. "TEIGNE FAVEUSE"--PORRIGO LUPINOSA.* This disease is much more common in children of the age of seven, eight, or nine years, than in those still at the breast; it is usually seated on the scalp, and is communicated by contact and by the use of the same brushes or combs. It may occupy other parts besides the head. I have twice seen it, at the Hospice des Enfans Trouves, appear on the inferior extremities of very young infants; in one ofthe two particularly, the peculiar char- acters of the disease were very strongly marked; it was develop- ed on the posterior and lateral parts of the thighs. This child was three weeks old when it was exposed, so that the affection might easily have been communicated by contact, during its so- journ with its parents. The inflammation and the scabs disap- peared at the end of fifteen days, after the use of nothing more than bran baths and emollient lotions. There remained in their * This disease has been confounded with Porrigo favosa, but it is evidently Porrigo lupinosa of English authors, as may be seen by comparing the descriptions of them. See Plumbe on the diseases of the skin.—S. ON THE DISEASES OF INFANTS. 125 places violet-red spots, which began to fade in about three weeks after the period when the child was sent into the country. The "teio-ne faveuse" is developed more frequently in the scalp ; to the pustules succeed scabs, which enlarge, mingle to- gether, and form a great number of cup-like hollows, bearing some resemblance to a honey-comb, or to the depressions in a lupin-seed, or to the fructification of certain species of lichen. When the disease has recently appeared, they are either of a yel- low or fawn color, but as they grow old they become white, break and detach themselves from the scalp in the pulverulent form. When the inflammation has continued for some time, the bulbs of the hair become affected, and are altered or destroyed in such a manner as to cause the hair to fall, leaving the skin smooth and white. The surrounding cellular tissue becomes the seat of a chronic abscess, the glands of the neck at the same time swell, and it is not unusual to find the disease complicated with ophthalmia, coryza, and chronic inflammation of the stomach and intestines. When the pustules and scabs are few in number, and of limit- ed extent, all that is necessary is the application of emollient lo- tions to the head, together with revulsives to the skin or bowels. For this purpose, the child may take a little manna, or super tar- trate of potass, dissolved in whey, and a blister may be applied to one of the arms; the head should, at the same time, be washed with a decoction of poppy-heads, or of marshmallows, or with tepid water; cleanliness is of the greatest importance to prevent the multiplication of pediculi, which are generally produced in great numbers beneath the scabs. If the pileous follicles have been disorganized by inflammation, the removal of the hairs becomes indispensable; yet it ought to be deferred as long as possible if the infant be very young or feeble; but when age and strength will allow of this treatment, we should not hesitate about using it early in the disease. The method of treatment adopted by the freres Mahon, is the best that can be used for this purpose; it consists—1st, In cleansing the scalp, and preserving it clean by the use of linseed poultices and saponaceous lotions: 2dly, In cautiously and ten- derly removing the hair. The following, according to M. Rayer, is the treatment of the freres Mahon. The part on which the 126 ON THE DISEASES OF INFANTS. disease is developed, is anointed every other day with a depila- tory cerate composed of four ounces of lard, and of one powder marked No. 1. The application of this must be continued for the space of one month and a half, or two months, according to the obstinacy of the disease. On the intermediate days, the hair should be combed with a fine-toothed comb, by which it is de- tached without pain. After using these dressings for fifteen days, a small quantity of depilatory powder, No. 2, is sprinkled through the hair once a week. The following day, the hair on the dis- eased parts is combed, and the depilatory cerate reapplied ; this is continued for a month or six weeks. Another depilatory ce- rate is then used, consisting of four ounces of lard, and of one powder, No. 3, with which the part is anointed for fifteen days, or more, according to the severity of the disease ; after this it is only applied twice a week, until the redness of the skin has disappeared ; on the days on which the cerate is not used, the patient's hair should be combed once or twice in twenty-four hours, taking the precaution not to press the comb on the skin. This method has been attended with great success, and is of very easy application to children at the breast.* M. Rayer has given a remarkable example, the subject of which was a little girl aged three months, affected with tinea of the scalp, treated, on the 14th February, 1826, according to the method of Mahon, and cured on the 9th of May, of the same year. M. Rayer also treated with success a little girl who had been affected with the disease from earlist infancy, and who, at the time of his attend- ance, had been just weaned. " I shaved the head of this child," says M. Rayer, " and covered it with a flaxseed poultice ; the scabs softened and soon became detached ; the head was washed every day with a decoction of flaxseed; at the end of four or five days it was perfectly clean ; I then applied a blister to each arm, and kept them discharging for three months, and every day washed the head myself with a decoction of flaxseed ; I thus obtained a cure of this case of tinea without depilation ; the blisters were then permited gradually to heal." I think it most rational to attempt the cure of tinea by simple antiphlogistic means, before the adoption of any other course, and not to have recourse to depilation until other measures have * Recherchea sur la siege et la nature des Teignes, par Mahon, jeune, 1829. ON THE DISEASES OF INFANTS. 127 failed. In every instance we should renounce the use of the pitch cap, still in use in some parts of the country. TINEA ANNULARIS. This disease is very rare in sucking children ; it generally ap- pears between the age of two years and piiberty. It is evidently contagious, and is one of the most obstinate inflammations of the scalp. The same method of treatment should be adopted for this as for the preceding diseases. TINEA GRANULATA. Tenia granulata, the distinctive characters of which have al- ready been described, is of less frequent occurrence than " teigne faveuse," and is rarely to be seen in nursing infants. It is ordna- rily accompanied with the same general symptoms, and requires nearly the same treatment as " teigne faveuse." TINEA MUCOSA--PORRIGO LARVALIS. This affection is extremely frequent in infants at the breast; it usually shows itself about the age of three, five, or eight months. It is neither contagious nor dangerous ; and it is very rare to see any ofthe children die with it. Common people, who are easily led to adopt the theory of a corruption of humors, habitually re- gard this affection of the scalp as a salutary depuration. What- ever foundation there is for this opinion, it is proved that, during the course of the disease, children rarely exhibit any gastric or thoracic complications, which so often render cutaneous diseases fatal; and tenia mucosa ordinarily disappears without leaving after it any of those serious affections of the constitution which some in- dividuals experience after certain cutaneous diseases. I have seen a great number of sucking infants affected with tenia mu- cosa, at the Hospice des Enfans Trouves; very few of them perished, but the greater number exhibited, after the disappear- ance of this inflammation, a. state of vigor and embonpoint, which appeared to give some support to the popular opinion just men- tioned. However, I am far from thinking that this general assertion admits of no exceptions ; and I believe it possible that the disease may be complicated with an inflammation of the pri- mae viae, of greater or less intensity. It may exist in an acute or chronic state; may confine its ra- 128 ON THE DISEASES OF INFANTS. vages to the scalp, or extend them to the face and neck; may be with or without fever; and may sometimes form small phleg- monous tumors about the ears and surface of the cranium, from which arise the engorgement of the lymphatic glands of the neck. We see it also complicated with aptha?, angina, ophthal- mia, and existing in connexion with other cutaneous phlegmasia?. Simple emollient lotions to the inflamed parts, together with/1 small doses of calomel, for the purpose of producing a revulsion on the intestinal canal, constitute the treatment ofthe acute form of this disease. But if it assume a chronic form, and resist these simple means; and if, by reason of the abundant excretion, the strength of the child be wasted ; and if it spread to the face, or to the superior parts of the neck, causing chronic engorgements of the lymphatic glands, it then becomes necessary to employ more energetic measures, such as counter irritants to the skin, drinks rendered slightly tonic, a nourishing diet, sulphurous lotions, saturnine cerate, and ointment of zinc, or of nitrate of mercury, to change the nature of the cutaneous irritation. It is rare that recourse to depilation is necessary, the inflammation seldom at- tacking the bulbs of the hair, and seldom leaves cicatrices, so superficial is its situation. The different complications, such as ophthalmia, gastro-enteritis, thrush, etc., should be met by appro- priate treatment.* PRURIGO. Prurigo mitis, " formicans, " senilis, " infantilis. This papular inflammation, characterized by the great itching which it produces, is often complicated with gastro-intestinal in- flammation ; it is observed both in children and old people, it is, * Dr. Jemina has published a number of cases showing the complete efficacy of su- pertartrate of potass in the treatment of tenia mucosa of the face, (Porrigo larvalis—Wil- lan,) in nursing infants. This medicine is administered through the medium of the nurse. The usual dose is from one to two drachms in a pound and a half to two pounds of the decoction of dog-grass, (Triticum repens,) sweetened. This should be given to the nurse during the day, and repeated daily until a cure is effected. It is specially ap- plicable to those cases which have obstinately resisted all the usual means of treatment. V. Observations du Docteur Jemina, in the Archives general de medicine, v. 21,1829. ON THE DISEASES OF INFANTS. 129 however, a little less rare in young infants, and on this account there have been formed two varieties, referring to the age of the individual affected—prurigo senilis, and prurigo infantilis. It is with the latter only, in this work, that I have any interest, and shall commence by presenting an example of the disease. CASE VII. In the month of September, 1826, a little girl, aged about six or seven months, was brought to the Hospice des Enfans Trouves. She was pale, emaciated, and affected with a copious diarrhoea, and a slight ophthalmia. The filthy and ragged condi- tion of the clothes, with the general appearance of wretchedness, de- noted the extreme poverty in which she had lived; she cried almost constantly, seized the breast with the utmost eagerness, and did not enjoy a moment's repose ; upon the face, neck, and fore-arms, there were a great number of small, slightly prominent papula?, torn and bloody, or covered with black crusts formed no doubt by the desic- cation of the blood. The legs and body also presented small pa- pula?, much more evident to the touch than to the sight; but these parts being covered, and the child on this account not being able to scratch them, they were not at all torn. Besides this, there were marks over the .whole body of innumerable flea-bites, so that this little child appeared to have been for a long time a prey to the two- fold pain caused by the violence of the disease, and the bites of the insects by which she was devoured. This child was immersed in a decoction of marshmallows, and the limbs and body anointed with oil of sweet almonds, carefully cover- ing up the hands and arms. Rice water, sweetened with the syrup of marshmallows, was administered internally, and milk and water was given for nourishment. The pain, cries, and wakefulness lasted for some days, but the cutaneous irritation having been at last allayed, the child became more calm, the functions of digestion were soon restored, sleep re- turned, and at the end of fifteen days no other traces of the disease remained, than a few violet spots on the neck and superior extremi- ties. Three weeks after, when the strength had already begun to return, the child was returned to the parents, at whose residence no doubt there still existed the causes which had produced the disease, and to a return of which she was inevitably exposed by their ex- treme wretchedness. Thus poverty and filth may become a cause of prurigo in young infants. It may be local or general, simple, or complica- 130 ON THE DISEASES OF INFANTS. ted with another affection of the skin, but particularly with lichen or psora. In general prurigo, emollient, saponaceous or sulphurous baths, demulcent or slightly acidulated drinks, constitute the treatment. In local prurigo, it will be necessary to apply emollient, sulphu- rous, or alkaline lotions alternately to the diseased parts. Gelati- no-sulphurous douches have been employed with success. The greatest care should be used to accomplish the early removal of the prurigo that is developed around the vulva or anus in chil- dren advanced in age, because the excessive itching of these parts compelling the child to scratch them constantly, they may there- by continue in a state of erythism and irritation, extremely preju- dicial to their health. The works of MM. Alibert, Mouronval, and Rayer, on cuta- neous diseases, may be consulted with advantage for detailed ac- counts of prurigo. STROPHULUS. Strophulus intertinctus, " albidus, " confertus, " volaticus, " candidus. Strophulus is a very common disease in sucking children; it exhibits several varieties, on which I shall offer some remarks. I refer particularly to those which Bateman has described, under the names candidus and albidus. Strophulus candidus, which, according to the English patho- logist, consists of medium-sized pimples, having a smooth and shining surface, and of a lighter color than the surrounding skin, is seen upon the shoulders and arms at the same time that porri- go larvalis affects the face. I have twice seen an eruption of this species; it occurred once in a little girl of five months, and occupied the neck and arms; she was at the same time affected with tenia mucosa and gastro-enteritis. She died, and upon dis- secting the pimple, and examining it carefully, I discovered that it enclosed a small quantity of puriform matter. There were three pimples of this kind on the right arm, and two on the neck; ON THE DISEASES OF INFANTS. 131 each of them presented the same phenomenon. In a little boy, aged fifteen days, two pimples, large, hard, and of a white ap- pearance, were developed on the face without any known cause ; he remained eight days in this condition ; at the end of which time, the pellicle that covered them softened, became broken, and the pimples were replaced by small yellow scales, which soon fell off, leaving the skin they had covered of a violet color. From these considerations, we are led to believe that strophu- lus condidus is not, properly speaking, a papular but a pustular disease, which can be referred to a particular species of pustules existing at the same time on other parts of the body of the child. As to strophulus albidus, it has not been in my power to make the same observations in relation to it; but as it scarcely differs from the former except in the red circle that surrounds the base, the same remarks, I think, are applicable to this disease. With regard to the other varieties, the same remark does not apply, they all preserve the distinctive marks of their species ; they consist of small pimples of a red color, more or less deep, slightly prominent, grouped or scattered over the face, body, and limbs, and are described by authors in various treatises on dis- eases of children, by the vague terms of " boutons," " rongeurs," " elevures," " feux de dents," etc. Strophulus intertinctus is known by the existence of bright red pimples, disseminated over the face, limbs, or hands, with ery- thematic patches between them. Strophulus confertus consists in a large number of pimples, more or less approximated, of variable diameter, imparting to the body, by their re-union and their number, a red tint, more or less deep. Strophulus volaticus is, without contradiction, the most fre- quent in children ; yet it is sometimes seen in adults ;* in the summer, particularly, it prevails among the children nursed at the Hospice des Enfans Trouves. It consists of small circular pimples, grouped on the cheeks and body, which, upon disap- pearing, are replaced by other pimples, themselves in turn un- * I once knew a lady, 32 years of age, affected with a chronic disorder ofthe diges- tive organs, on whose arms and hands a number of pimples of strophulus volaticus appeared every time the symptoms of inflammation became exasperated. 132 ON THE DISEASES OF INFANTS. dergoing the same change. This eruption often continues seve- ral weeks. Bateman, I think, has greatly exaggerated the complications of strophulus : it is true that it is sometimes accompanied with gas- tritis, or gastro-enteritis, but more frequently they either do not exist, or the symptoms are very light; and among the children I have seen with strophulus at the Hospice des Enfans Trouves, there was but a very small number with sufficient disease to allow of their admission to the infirmary. Yet as strophulus often appears at the period of dentition, when a great number of infantile diseases are developed, it is not sur- prising that symptoms of intestinal disorder have been at the same time observed. Strophulus for itself requires no treatment; the complications, however, should be met by means applicable to each of them. LICHEN, Lichen simplex, " pilaris, " circumscripta, " agrius, " lividus, " urticatus, " tropicus. Lichen is a disease of more frequent occurrence in children of the age of eight or nine years, and in adults, than in children at the breast; I have never yet seen any case of it in the latter. In every instance, this affection can be recognized by the characters which it preserves in all its varieties. Lichen simplex consists of small pimples developed on the face and arms, accompanied, on the first appearance, with fever, and often succeeded by exfoliations of a pulverulent kind. Ac- cording to Lorry, it may re-appear anew in the same individual every summer. In lichen pilaris the pimples show themselves at the roots of the hairs of the skin. Patches, or the union of pimples, in a circular form, character- ize lichen circumscripta. Lichen agrius, one of the most serious from its complications, ON THE DISEASES OF INFANTS. 133 and especially from the febrile state with which it is accompanied manifests itself under the form of large red, highly inflamed, and painful pimples ; they soon become excoriated, and are covered with scabs, bearing some resemblance to impetigo. Lichen lividus is known by the livid color of the pimples and the petechia? mixed with them. Lichen urticatus is remarkable for the resemblanee which the pimples bear to the marks left by the pricking of nettles; and Bateman has included under the name of lichen tropicus, the eruptions produced by the influence of a tropical climate. Emollient baths, during the inflammatory stage of lichen, sulphurous baths and saturnine lotions, acidulated drinks, sul- phuric lemonade, towards the termination ofthe disease ; finally, the removal from the atmospheric causes producing lichen, should form the base of the treatment. For further details of treatment, the works of Bateman, Alibert, and Rayer, may be consulted. CANCER--LUPUS—ELEPHANTIASIS. Cancer, lupus, and Greek elephantiasis, are not properly in- fantile diseases : their history will be found in works of general pathology. LEPRA. Lepra vulgaris, " alphoides, " negricans. I do not believe that lepra has been observed in infants at the breast. M. Baron, whose experience ought to be authority, has never seen it at the Hospice des Enfans Trouves; and Rayer says he never met with it in young infants. But this remark is not applicable after the first dentition, for the different varieties have been often seen at the Hospice des Enfans Malade. For the history of this disease, the work of Alibert, and the excellent chapter of Rayer on this subject, may be consulted. PSORIASIS. Psoriasis guttata, " diffusa, " gyrata, " inveterata. 134 ON THE DISEASES OF INFANTS. Psoriasis may attack children at the breast; besides, it is one of those cutaneous diseases which are evidently hereditary. It has often been described under the name of "dartre squameuse," or confounded with lepra; it has also sometimes been mistaken for syphilitic pustules. These mistakes may be avoided by pay- ing attention to the anatomical characters appertaining to this disease, and which we have endeavored to exhibit in the preced- ing tables. Psoriasis guttata consists in small squamous patches covering small solid elevations, red, and of the size of a bin's head, the summits of which are soon covered with little, dry, white scales. The centre of each of these patches is always more elevated than the borders; the intervals which separate them are of various extent, and they are surrounded by an inflammatory circle. When the patches are elongated in a spiral form, they are de- nominated psoriasis gyrata. If the patches increase in number, spread, and mingle, it is then denominated psoriasis diffusa. When the squamous inflammation continues several months or several years, it receives the name of inveterata ; formerly the appellation of agria was given to this variety; and as the skin then assumes an appearance analogous to the bark of trees, cov- ered with lichens, Alibert has described this disease under the name of " dartre squameuse lichenoides Psoriasis may be developed on the scalp, face, about the eyes, (psorophthalmia,) around the lips, on the trunk, scrotum, pre- puce, hands, feet, or other parts of the limbs. Children can be affected with psoriasis from the age of two months to two years, which, according to Bateman, has induced Willan to make a distinct species called psoriasis infantilis. The following case will furnish an instance of this species. CASE VIII.—Joseph, aged three months, was suckled for two months and a half at the Hospice des Enfans Trouves; he was thin, pale, and miserably wretched ; and had been frequently affected with diarrho?a, and sometimes vomited the milk shortly after sucking. He was sent to the infirmary on the 25th of May, 1826, for a cutaneous affection of ten days standing; this affection consisted in a gray scaly patch, irregular in its form, three lines in breadth, and half an inch in length, between the chin and lower lip. This scale was su- perficial, and surrounded by a small red circle, and had begun to ON THE DISEASES OF INFANTS. 135 crack in the centre. There also existed two others, much longer, but not less irregular, on the internal portion of the right fore-arm ; there was a third, about the size of a two franc piece, on the left hip. These scales were slightly salient, and their borders surrounded by a bright red line, resembling the colored lines used to designate the limits of a country on a map. The child was weaned ; milk and water sweetened were given for drink, and every morning he was immersed for half an hour in a bran bath. Sleeplessness, pain, manifested by his cries, his progressive emacia- tion, and the continued diarrhoea, hastened the approach of death. On the eighth day after his entrance into the infirmary, he succumbed ; when the scales detached were no longer reproduced, leaving the skin covered with small slightly projecting pimples, and of a violet color, on the places which had been covered with the scales. A violent inflammation of the colon was discovered on examining the body. All the other organs were in a healthy state. The treatment of psoriasis should be more or less active, in proportion to the recent invasion or long continuance of the dis- ease ; in the former case it will be sufficient to use emollient ap- plications, either by effusion or bathing, until the irritation of the skin is relieved, and the scabs, which form without ceasing on the inflammatory parts, are removed. In the latter case, the chronic inflammation of the integuments should be first attended to; and afterwards, the actual condition of the constitution of the patient. To accomplish the first object, emollient and narcotic baths have been recommended; and for the second, internal remedies have been highly extolled, such as epsom salts, subcarbonate of potass, calomel, resin of jalap, tincture of cantnarides, arsenical preparations continued for several months ; this method appears to us an irrational one, and M. Rayer has offered the following remarks in relation to it. " To submit a patient, affected with obstinate psoriasis, to arsenical treatment, in the faint hope of producing a transient relief, is certainly to expose him to the fa- tal effects of disease in the internal organs, which are much more irritable than the skin." It is much better to attempt some con- stitutional treatment in children with psoriasis ; by changing their nurses, climate, or habitation;' and by attending to cleanli- 136 ON THE DISEASES OF INFANTS. ness, together with the prudent adoption of such measures as will meet the pathological condition of the digestive organs. PITYRIASIS. Pityriasis must not be confounded with dandrif, so often ob- served in young children. It consists of a very slight inflam- mation of the skin, accompanied and followed by a furfuraceous/' exfoliation ofthe epidermis. It may be seen on the head and on different parts of the body. It is, properly speaking, nothing more than a termination of erythematic, erysipelatous, or lichenoid inflammation; and I am surprised that pathologists, and Bate- man in particular, have described, as connected with this species of inflammation, several varieties which are much more closely allied to other diseases than to that now under consideration, and with which they have nothing in common, except the exfoliation of the epidermis. Pityriasis occurs on the head, eyebrows, arms, trunk, and legs. The cutaneous inflammation is so trifling, that it ought rather to be placed among the alterations of the epidermis, than among in- flammations of the skin; and I only place it here in accordance with the order established by authors whose names give authority in science. Cleanliness appears to me all that is necessary in the treatment of pityriasis, at least when it is not caused by some more serious cutaneous affection, such as erysipelas or lichen. FISSURES—CHAFING. This affection is developed in young children in the folds of the articulations, especially in the groin. The part should be sprinkled with powdered lycopodium or starch. Powders of the white oxide of lead should be avoided, because, as Gardien re- marks, children may experience effects analogous to painters' cholic. Plenk and Professor Chaussier, have made similar ob- servations. If the disorder resist the usual method of preserving cleanliness, emollient lotions, and the application of the powder spoken of above, the ointment recommended by Rouen may then be used : 5: Cerati simplicis, gss. Pulveris Lycopodii, Oxidi Zinci, aa, 3j. ON THE DISEASES OV INFANTS. 137 The operation of this ointment may change the chronic and indolent character which this disease sometimes assumes. It should not be confounded with the fissures observed on the body during the exfoliation of the epidermis. GANGRENE OF NEW-BORN CHILDREN. By the term gangrene of new-born children, I understand a variety of gangrenous inflammations, which is particularly ob- served in the earlier period of life, in those infants in whom the respiratory and circulatory functions are imperfectly executed, producing a very evident sanguineous congestion of the extremi- ties, which become purple and cold, and soon shrink, dry, decom- pose, and sphacelate, until an inflammatory circle forming, bounds the ravages of the gangrene, analogous to the gangrene of old people—or until death terminates this disorganization of the in- teguments. The gangrene ordinarily commences in the fingers or toes; and it sometimes shows itself on the arms and legs. The skin around the nails assumes a violet color, and tumefies ; afterwards it shrinks, wrinkles, or is covered with small blisters containing a sanguineous fluid. This fluid soon flows out, and a livid excori- ation appears in the place of the blisters; the integuments become emphysematous and assume a brown appearance, diffusing the well known gangrenous odor. During this time the child is almost without motion, is insensible, and scarcely respires ; the cry is smothered and plaintive, and he gradually sinks; the ab- domen first becoming tympanitic, and the different parts of the body cedematous, while scorbutic petechia? appear upon the body and limbs. Underwood appears to have confounded this gangrenous inflammation with erysipelas. In relation to this latter disease, he observes: "Ina few instances the disease has been attended with some varieties. Infants have not only come into the world with several hard inflammatory patches, and ichorous blisters about the thighs and belly, but with other spots already in a state of mortification. A slough soon spreads to two or three inches in length along the edges of the skin, with smaller ones about other parts of the legs, and on several of the toes and fingers." I believe that there really exists a difference between ordinary 18 138 ON THE DISEASES IN INFANTS. erysipelatous inflammation and the gangrene of the skin, which is now under consideration. In this case it is not by excess of inflammation that gangrene occurs, but it is in consequence of a great disturbance in the capillary circulation, and to the retarded circulation of slightly oxygenated blood in the subcutaneous tis- sue, the inevitable result of which is a shrinking and gangrenous degeneration of the integuments. In all the children exhibiting this livid color of the extremities, this cedematous tumefaction, together with this spontaneous gan- grene of the skin, if we may so sptak, I have found the lungs crepitating but little, but they were always gorged with blood, which also filled the right cavities of the heart, and the whole venous system; and, penetrating and engorging all the organs, produced thereby a disposition to disorganization. The object in the treatment ought to be to diminish the san- guineous congestion by the application of leeches, either to the arms or to the armpits, and to promote the capillary circulation by the use of dry or aromatic frictions to the surface of the body. When the gangrene is formed, lotion of cinchona wine, or Vir- ginia snake-root, ought to be applied to the ulcers or sloughs. But what efficacy can we expect from the internal administration of cordials in young children, the delicacy and irritability of whose organs naturally contra-indicate these remedies, and whose stomachs are very often either actually inflamed, or are in a con- dition to be easily excited to inflammation ? Underwood men- tions that Dr. Wolsmon, having opened the bodies of two children who had died of erysipelas, found the membranes of the stomach possessing so little consistency, that the least effort was sufficient to detach some portion. MALIGNANT PUSTULE--CARBUNCLE. Infants at the breast may, without doubt, be affected with ma- lignant pustule, or with carbuncle; but these diseases are ex- tremely rare at this period of life; should they occur, they ought to be met by the usual energetic means advised in such cases. BURNS—CHILBLAINS. The history of burns and chilblains in new-born and nursing infants, requires no particular consideration, as they do not differ ON THE DISEASES OF INFANTS. 139 from the same affection occurring in adults; I shall, therefore dispense with entering on the examination of this subject, which can be found in all works of general pathology. DISEASES OF THE APPENDAGES OF THE SKIN. I shall here speak only of ichthyosis, of the alterations of the cutaneous follicles, and of the puriform secretion of the skin. Ichthyosis is an affection of the epidermis, appearing under the form of patches separated from each other by irregular lines of little depth. These epidermic patches are generally of a dirty gray; they become detached, and upon separating, leave beneath them the epidermis thickened and a little rough to the touch. This disease is usually congenital. It lasts sometimes for years, and is either partial or general in its extent. Ichthyosis of young infants ought not to be confounded with the epidermic exfoliation of which we have spoken, and which occurs a few days after birth. The thickness of the epidermic lamina?, their continual renewal, the persistence of the disease beyond the ordinary term of epidermic exfoliation, and, finally, the form and appearance of the lamella?, are the diagnostic signs of these two pathological conditions. The treatment of ichthy- osis in young infants, ought to consist of tepid and emollient baths, gentle frictions with oil of sweet almonds or olive oil, aci- dulated drinks, and strict attention to cleanliness. Time will ef- fect more in the cure of this disease than remedies; still, it is well known that it often continues for a very long time, and does not disappear even in advanced age. Cutaneous follicles.—The follicles of the skin in young in- fants are very much developed. Their disposition, situation, and their relation to the other parts of the skin, have been well de- scribed in a memoir by E. H. Weber, inserted in the number of the Journal Complementaire du Dictionaire des Sciences Medi- cales, for December, 1827. These follicles, quite prominent on the face and scrotum, are subject to engorgements and swelling, and form a projection, which is usually black in the centre, de- nominated by some pathologists " crinons."* When these projec- tions are pressed, a small quantity of thickened matter issues, of * Gardien, t. 4, p. 135. 140 ON THE DISEASES OF INFANTS. a black color, which may be taken for worms, but which is the result of the disorganization of the follicle. This disease, gener- ally of little extent, disappears with age, and requires no treat- ment. Yet, if there exists a number of these tumefied follicles, as they often cause a violent itching, it would be well to apply emollient lotions to the skin, and to extract by pressure, or by means of a needle, the dead cellular substance contained in the little follicular tumor. The puriform oozing occurring on various parts of the skin of children, and particularly behind the ears, is an alteration in the secretion of the derma; the surface of which, deprived of its epidermis, continually pours out a fluid, which concretes in the form of yellow scales. This discharge is usually favorable to the health of the child ; for experience has shown, that when it is suddenly suppressed, the most serious effects will often follow, such as encephalitis, ophthalmia, etc. In the treatment, we should confine ourselves to the preservation of cleanliness, and by the application of linen or fine lint, or the leaves of the white beet. DISEASES OF THE CELLULAR TISSUE. The diseases of the cellular tissue are divided into inflamma- tion, and serous infiltration. It may, besides, be the seat of san- guineous effusion, or of infiltration, either at the parts that have been compressed, or at points which have not been exposed to pressure ; in the latter case, the blood is found effused by a true sanguineous exhalation, a phenomenon of very common occur- rence, as we shall see in those cases where respiration and circu- lation are established with difficulty. Art. 1.—Inflammation of the Cellular Tissue. Phlegmon and anthrax are usually seated in the subcutaneous cellular tissue ; the former is of common occurrence in children at the breast. It sometimes produces an extensive destruction of the skin. I once saw an infant, aged two months and a half, in whom the lateral portion of the skin of the right breast was de- stroyed to a great extent, in consequence of phlegmonous inflam- mation causing so abundant a suppuration, that rapid sinking and death were the consequence. ON THE DISEASES OF INFANTS. 141 Indolent abscesses are also very common diseases in young children. They show themselves especially on the limbs ; and when they ulcerate, their hard, violet-colored, and undermined borders, present an appearance so much resembling venereal sores, that they have often been regarded as such. Simple antiphlogistic treatment for acute phlegmonous abscess- es, the use of slightly stimulating topical applications, gentle compression, escharotics, alkaline or aluminous lotions for those that are chronic and indolent, are the proper remedies; they should be used with great precaution, and according to the rules laid down in surgical works on the subject of these affections. It should be particularly noted, whether these abscesses are not symptomatic of some other remote disorder. (Edema or serous inflammation of the cellular tissue in young infants, deserves to be studied with minute attention ; we shall, therefore, devote an extended space to its history. Art. 2.—(Edema, or Induration of the Cellular Tissue of New-born Children. The hard or indurated state in which a child is sometimes found, is manifested by a swelling of the limbs or face, which are more or less colored, and their firm resistance to the touch, analogous to what is experienced on pressing a hard and com- pact body. The sensation, therefore, produced by touching, gave rise at first to the expression, induration of the cellular tis- sue. Anatomical examinations, however, have proved the vague- ness of such expressions, and the denomination, compact oedema, has been proposed in the place of induration. Some physicians have recently observed, that induration of the cellular tissue offers two varieties : 1st, That of the cellular tissue, properly so called; 2dly, That of the adipose tissue, (Duges, Denis.) In the esta- blishment of this variety, there is an evident proof of the progress of our knowledge of this disease. According to Andry and Auvity, from the cells of the indurated cellular tissue a large quantity of serum escapes, when an incision is made and the tumor pressed. But if we fix our attention on the cellular tissue, properly so called, besides the serum with which it is distended, does it exhibit a hardness resembling that 142 ON THE DISEASES OF INFANTS. of sclerotic or schirrous affections, or of callous tumors ? No; on the contrary, it preserves all its elasticity, suppleness and cel- lulosity ; its fibres have not undergone any organic transforma- tion, but still preserve their reticulated condition ; but as they are considerably distended with serum, and as the whole cellular membrane of the body and limbs is filled with fluid, it necessa- rily results that the cellular tissue is hard to the touch ; but this hardness does not really exist in this tissue, which has undergone no other change than that of mechanical distension : in a word this induration has no existence except in our sensations. The same phenomenon occurs when a bladder is filled with water, mercury, or even with air. If it be completely distended with them, it offers to the touch a hardness in which its tissue has no participation ; for, if one third or one half of the substance be re- moved, the bladder then becomes soft and flaccid. The same oc- curs in the induration ofthe cellular tissue of new-born children. It increases in hardness in proportion to the accumulation of se- rum. Thus, then, strictly speaking, there is no induration ofthe cel- lular tissue in the disease designated by this title. Modern au- thors who have retained this name, are certainly to be blamed, and much more those who have proposed that of "sclereme," to which term is very naturally attached the idea of a transforma- tion of the cellular tissue, which does not really exist. I have said that the apparent induration of the limbs of a fe- tus may be seated either in the cellular or adipose tissue. When the hardness of the integuments is owing to a serous infiltration of the cellular tissue, the limbs are swelled, or at least increased, in size. The violet color of the integuments indicates a sangui- neous congestion of those parts; the irregularity of the pulse, and the difficulty of respiration, are evident signs of a superabun- dance of blood in the heart, lungs, and large vessels. Induration of the adipose tissue exists with or without gene- ral infiltration of the subcutaneous cellular tissue: it is usually seated in the cheeks, nates, calves, or back; and occurs both with or without derangement of the circulation or respiration. It usually appears when the child is in articulo mortis; and I have often seen it developed after death on the dead body of children that had suddenly died. If the adipose tissue be then ON THE DISEASES OF INFANTS. 143 examined, it will be found firm and hard, like tallow, and entire- ly congealed; resembling the fat of animals killed in the slaugh- ter-houses. It can be easily conceived that the adipose tissue may also, under some circumstances, congeal in the same man- ner even during life, if from some cause the animal heat should cease to exist. Does the infiltration of the cellular tissue, which in young in- fants produces the apparent induration of their limbs, differ from that which sometimes occurs in adults ? The solution of this question appears to me of much importance. M. Breschet, regarding this oedema as peculiar in its nature, has had recourse, in order to establish the truth, to the assistance of one of our most celebrated chymists, who undertook to ascer- tain the condition of the serous infiltrations in the cellular tissue of children thus affected. M. Chevreul gives the result of his experiments in the following language: " I have already established the fact, that in the icterous affec- tion accompanying the induration of the cellular tissue in new- born children, the blood is diseased ; it has two coloring substan- ces not found in the blood of healthy children, or if they are found, are in very small quantities; besides, there exists also an ingredient which imparts to the serum when separated from the fibrin, the property of spontaneous coagulation. The coloring principles explain the color of the cellular tissue ; and the spon- taneously coagulable matter explains the induration of the cellu- lar tissue, if it were demonstrated that this matter does not exist in the blood of healthy children, or that it is found in very small quantities, and also if it can coagulate in the cellular tissue, as it coagulates in the serum drawn from the bodies of those children who have died from induration."* The reading of this paragraph gave rise to the following re- flections. M. Breschet has considered icterus and induration of the cellular tissue as one and the same disease; he has only pre- sented to M. Chevreul's notice such infants as have at the same time been affected with induration and icterus, and it is to the yellow serum alone that this chymist has particularly directed * Chevreul, considerations general sur I'analyse organique et sur ses applications. Paris, 1834, p. 218. 144 ON THE DISEASES OF INFANTS. his attention. There also exists, in the language of M. Chev- reul, a kind of uncertainty or philosophical doubt, arising from the severity and impartiality of his judgment. He has not laid down the principle, that the induration of the cellular tissue is attributable to the principle of spontaneous coagulation of the serum; but he has well expressed the uncertainty of his infer- ences by observing that such would be the course of the indura- ? tion, if it had been shown that this matter did not exist in the blood of healthy children ; and also that it might coagulate in the cellular tissue, as it coagulates in the serum drawn from the bodies of children who have died from induration. General infiltration ofthe integuments must not be confound- ed with icterus, because one exists without the other ; yet both these phenomena also may exist together. The serosity, there- fore, must be considered as independent of the coloring matter which it sometimes contains. I placed in a vessel, as M. Chevreul had previously done, a small quantity of serosity, drawn from the cellular tissue of a child, cedematous and affected with induration, and observed that it coagulated spontaneously. After having established this fact, I was desirous of ascertaining whether serosity taken from the cellular tissue of a child in good health, would likewise coagu- late ; the same phenomenon occurred. I placed in two differ- ent vessels, serosity taken from the cellular tissue of a child whose integuments were indurated, and from one in whom they had undergone no change. Coagulation was effected in both in near- ly the same time. This double experiment was made with yel- low serum, taken from an icterous subject, and on the same fluid taken from one not so affected; the same result occurred in both. I drew the serosity from the cellular tissue of the feet of a child a year old, who had died of gastro-enteritis, who was reduced to marasmus, and whose legs alone were cedema- tous ; the fluid, after remaining at rest for half an hour, became thickened: and I have also seen the serosity taken from the dead body of an adult, who had died of an affection of the heart, coagulate at the end of six hours. Hence, is not this sponta- neous coagulation an inherent property of the fluid, causing the induration of the cellular tissue 1 Consequently, the first condi ON THE DISEASES OF INFANTS. 145 tion required by M. Chevreul for the explanation of the indurat- ed state of the cellular tissue, according to M. Breschet's theory, has not been fulfilled. Let us see if the second is better, or, in other words, let us see if the matter of the spontaneous coagula- tion of the serum, can coagulate in the cellular tissue. Heat and rest hastened the coagulation of the serosity deposit- ed in one of the vessels. If the liquid already thickened were shaken, it soon returned to its fluid state. Now, we cannot con- ceive of the serosity being in such a state of immobility in the middle of the cellular tissue, as to allow of its coagulation ; on the other hand, the temperature of indurated children is usually quite low; consequently, neither immobility nor heat, both fa- vorable to the coagulation of serum drawn from the cellular tis- sue, exist in the cellular tissue of young infants. There is still another manner of proving that this condensa- tion does not occur in the cellular tissue. If an incision be made in the infiltrated limbs of a child, the slightest pressure will cause abundant drops of liquid serosity to flow out. When it has flow- ed in this manner, the cellular tissue, heretofore engorged, dis- tended, and hardened, returns to its softened condition, and the relieved limbs are no longer hard. I repeated this experiment with success before M. Chevreul, on a fcetus both icterous and indurated, the body of which presented all the characters of those on which this celebrated chymist had made his first researches. Besides, I suspended during one night, by the head, the body of an indurated infant, making a number of incisions in the legs. On the following day these parts were covered with serum, which flowed from the incisions and appeared on the limbs like dew. Now the serosity could in no way have obeyed the laws of gravity, and would not have flowed thus freely, if it had been congealed in the midst of the cellular tissue. It results, from these considerations, and from the preceding facts, that the induration of the cellular tissue of young infants, is nothing more than simple oedema, analogous to that which oc- curs in adults and old people affected with diseases of the lungs, heart, and large vessels. It is known that the infiltrated limbs sometimes possess a hardness equal to that of the limbs of a young infant. The redness ofthe skin in children depends on the constant state of congestion in which it is found 19 146 ON THE DISEASES OF INFANTS. It remains for us to examine what are the causes which pro- duce oedema in young children. Authors have explained them in different ways. It is useless to consider the singular idea of Uzembezins, that the sight of marble statuary might influence mothers during pregnancy, and extend to their offspring. Neither shall we stop to consider the tanning property of the liquor am- nii; but it is of greater importance to consider more natural ex- planations. Andry and Auvity have regarded the action of cold as one of the principal causes of induration of young infants ; this agent interrupts the insensible transpiration, retards the circulation, and condenses the mucous and serous fluids in the tissues. We shall see of what degree of confidence this opinion is worthy. M. Troccon has controverted it, and has asserted that cold usual- ly has the effect of increasing instead of retarding the circulation. Most authors, and Hulme in particular, have insisted on the co- existence of a state of congestion or inflammation of the lungs, with induration of the cellular tissue, and have pointed out in this case the passive congestion of the heart and large vessels. Underwood has vaguely ascribed it to the influence of unhealthy air; whilst Baumes attributes the induration to the rigidity of the muscles, considering an attendant symptom as the end ofthe disease. Palletta ascribes this disease in part to the agency of the liver. Breschet regards it as the result of an accumulation of serum separated from the blood, and as a disease dependent on the imperfect closure of the foramen ovale. Leger appears dis- posed to admit, as one ofthe causes of the induration, the slight development of the intestinal canal, which is about three feet or less in length, in children with this disease. M. Denis, who has attached extraordinary importance to this disease, has gone still farther than his predecessors in search of its cause, for he regards it as true phlegmasia, a sympathetic and consecutive irritation of the gastro-intestinal apparatus, which he calls uphlegmasie en- tero-cellulaireP I cannot assent to this notion, and he has ex- posed himself to the charge of having mr.de a forced application of the principles of the new medical doctrines. Lastly, M. Ba- ron has, for a long time, regarded it as an oedema,—a simple se- rous infiltration of the cellular tissue, and symptomatic of a de- rangement or obstruction either in the heart, lungs, or large vessels. ON THE DISEASES OF INFANTS. 147 Such are the most remarkable opinions which have been en- tertained with reference to the causes of the induration of the cellular tissue. I shall now submit them to the test of experi- ment. I shall report and comment on a number of facts, from the study of which T will draw conclusions which may enable us to decide what are the proper causes, and what the nature and treatment of this affection. It is the only method of clearing up an obscure subject; for in a science of observation, man ought, if I may be allowed the expression, to conceal himself behind the facts which alone give force to his opinions and guaranty their correctness. In the year 1826, there entered the Hospice des Enfans Trou- ves of Paris, 5,392 children; 1404 of this number died either in the surgical or medical infirmary, or. at the " Creche ;"* in the medical infirmary under the care of M. Baron, 111 were received. The number of children affected with cedema, or induration of the cellular tissue, either in the medical infirmary or at the " Creche," was 240. This number will be found divided as fol- lows, according to the different months in the year; the number of patients in the infirmary was always from 30 to 32. January, .......15 February, .......15 March, ........16 April,.........18 May, .........22 June,.........3 July, .........4 August, ........14 September,........10 October, ........16 November,.......29 December, .......15 Indurated children not treated in the infirmary, 63 Total 240 According to this statement, it is evident that cedema does not * This name is given to the apartment where infants are deposited on their arrival. 148 ON THE DISEASES OF INFANTS. affect young infants only during the winter; consequently the explanation given by Auvity of this disease, that it is the result of the condensation of the serous fluid by cold, is invali- dated by the exposition just given. If we compare the entire number of infants affected with induration, or cedema, during the summer months, with the number attacked with it in the winter, it will be seen that the difference does no amount to one half, and that but a single inference can be drawn from this calculation,— that is, that the disease is more frequent in winter than in sum- mer ; thus, during the months of January, February, November, and December, seventy-four indurated or cedematous infants en- tered the infirmary, and forty-three during the months of May, June, July, and August. Let us add to the preceding remarks, that diseases are, in general, more frequent in winter than in sum- mer, and consequently it is not surprising that the induration of the cellular tissue is more often manifested in the one season ra- ther than in the other. Before endeavoring to ascertain what are the organs most often affected during the existence of this disease, or after its cessation, let us study it with reference to its seat, its invasion, and its progress. Almost all the children that are the subjects of these remarks, were of the age of one to eight days; some were just born, and appeared to have brought this disease with them from the womb. This fact has also been mentioned by those physicians who have written on this subject. In almost all, the skin still retained the peculiar red color of new-born children. In nearly all, the epidermic exfoliation had not commenced, or had but just commenced at the time of the development of cedema. The cedematous disease was not present in the same degree in all the subjects ; the induration appeared successively on the feet, hands, limbs, pubic region, back, and face, of some; while every part of the body was affected in others, in a very violent degree. It is extremely common to meet local induration or cedema. I have several times seen this affection develop itself some days after admission to the infirmary. The induration of the adipose tis- sue is sometimes united with cedema of the cellular tissue; most generally the first exists without the second. The progress of the disease is very irregular; it presents no fixed period;—no ON THE DISEASES OF INFANTS. 149 particular phenomenon announces its resolution ; and its degrees of intensity, the only phenomenon worthy of observation, offer in their progress and in their decrease, the greatest, but, at the same time, the least, appreciable variety. In general cedema, the se- rum is not only infiltrated through the cellular tissue, but is also effused in other parts of the body. I have often met with it in the sub-peritoneal cellular tissue, in the cavity of the mediasti- num and in the plexus choroides. Of all the phenomena accompanying cedema of infants, icterus is one of the most common. In seventy-seven infants affected with cedema, I observed thirty with jaundice ; but did not find among them any organic lesion that could account for this difference. I shall not extend my observations to the causes which appear to produce jaundice in young infants, this being an incidental ques- tion deserving more particular consideration ; let it suffice to re- mark, that one of these diseases may exist without the other ; that it is neither the cause nor effect of the other, and consequently they ought not to be placed together in nosological arrangement. It is important to know how far hepatic derangements may in- fluence the production of cedema; the following exhibits the re- sult of my observations on this subject. In ninety indurated children, on a post mortem examination made with great care, the liver exhibited no alteration, except in twenty instances; there were ten with considerable sanguineous congestion of this organ : the blood with which it was filled was found black and fluid; the large abdominal vessels were equally engorged, and the body itself was in a state of general congestion. In fine, the liver was friable and very much engorged ; the bile thick and al- most concrete. In four others, the liver was of a slate color, firm, and resisted the cutting of the scalpel; and in the last ofthe number, there existed peritonitis, a congestion of the liver, and a sero-sanguinolent effusion in the abdomen. It cannot be infer- red from these facts that the sanguineous congestion, the friabili- ty or inflammation ofthe peritoneal coat, or even of the liver it- self, are the ordinary causes of cedema of the cellular tissue; for I have met with a great number of children presenting these al- terations in v/hom induration did not exist, and many others where the cellular tissue was infiltrated with serosity, in whom 150 ON THE DISEASES OF INFANTS. the post mortem examination did not result in the discovery of the alteration I have pointed out. Inflammation or congestion of the lungs has been regarded as a cause of the affection which we are now considering; and wishing to ascertain, by facts, the truth of this assertion, I examin- ed the state of the lungs in the seventy-seven cedematous infants already mentioned while speaking of icterus : in forty-three of these, the lungs were perfectly sound; the remaining thirty-four presented the respiratory apparatus in a pathological condition more or less serious. In twelve of these, there existed a pulmo- nary congestion ; in six, complete hepatization, four of them in the right, and two in the left lung; in three, there was pleuro- pneumonia, and in the others, simple passive congestion at the posterior borders of the lungs, and particularly in the right lung. It is sufficient that there exist examples of induration or cedema of the cellular tissue of young infants, without pneumonia or pulmonary congestion, to be satisfied of the little influence that the latter disease exercises in the production of serous infiltra- tion of the cellular tissue, and to make us call in question the truth of M. Hulme's assertion. I shall now examine the opinion of M. Breschet, who regards the induration: of the cellular tissue as depending upon the con- tinuation of the foramen ovale. In seventy-seven children men- tioned above, forty presented the foramen completely closed; in twenty-eight of these, the ductus arteriosis was considerably narrowed, and the blood could not pass through it. The theory of M. Breschet, therefore, falls before the evidence of these facts. If the foramen ovale be found still open in indurated infants, it is, that inasmuch as induration of the cellular tissue affects parti- cularly very young infants, the changes which take place in the heart and ductus arteriosis of new-born children, after the es- tablishment of the independent circulation, have not had time to occur before the development of cedema. I believe, therefore, that there exists no relation between these two phenomena. I have also measured the intestines, to ascertain the correctness of the fact advanced by M. Theodore Leger, who found them in children affected with this disease much shorter than in others. I have observed nothing that has any resemblance of the fact, ON TOE DISEASES OF INFANTS. 151 either because I may have carelessly conducted my observations, or that chance, which seems to have aided M. Leger, has not led me to the same result. Besides, this point in the history of the induration of the cellular tissue appears to me of little importance, for it is difficult to conceive what relation of cause and effect can exist between these two states of organization. If our opinions are to be supported only by the number of facts, and if we are not to avail ourselves of the advantages af- forded by our judgment and experience, in commenting on these facts, I should be inclined to think, with M. Denis, that one ofthe most common affections that accompany induration ofthe cellu- lar tissue is gastro-enteritis, and to admit the union which he has attempted to establish between these two diseases. But, as Mor- gagni has said, neque enim numerandm sunt, sed perpendendai observationes ; we ought not to stop solely upon ascertaining the number of facts, we ought to weigh them and duly appreciate them, that no forced inferences may be drawn, nor any false principles established. In the seventy-seven cases mentioned as the subjects of examination, there were fifty with inflammation of the alimentary canal to greater or less extent. But it should be recollected that diseases of the organs of digestion are much more frequent in young infants than any other disease; that in the Hospice des Enfans Trouves, most of the children die of those inflammations, and that the induration or cedema of the cel- lular tissue may exist without the concomitance of an inflamma- tion of the digestive passages. It should also be remembered that the induration of the cellular tissue is of more frequent occur- rence in winter than in summer, at which season the phlegma- sia? of the alimentary canal are more rare; but they occur more commonly in summer, when the induration of the cellular tissue is less frequent. These considerations are sufficient to prevent us from attaching to the co-existence of these two kinds of affec- tions, all the importance accorded to them by M. Denis. In the last place, what is of more importance to note, is, that almost all the indurated or cedematous children exhibit a univer- sal sanguineous congestion, that is very remarkable. Venous blood especially, predominates in their tissues; the heart is al- most always gorged with blood, and the large vessels filled, and when the bodies of those who have died of this disease are ex- 152 ON THE DISEASES OF INFANTS. amined, it flows from all parts on the incision of the scalpel. This general congestion is more owing to a superabundance of blood in the system, to a kind of congenital plethora, rather than to any mechanical obstruction in the blood vessels. Again: the skin is remarkable for its extraordinary dryness ; no moisture appears to transpire on its surface; it is arid and tense, bearing the evidences of great disturbance in the capillary circulation,,. and that the cellular tissue, which physiologists tell us is the seat of the very abundant secretion of perspirable matter, is clogged in the exercise of its proper functions. In the first place, the ma- terials for its secretion have come to it in great abundance, since the whole of the tissues are engorged with blood; and in the se- cond place, the state of dryness of the skin, the suspension of cu- taneous transpiration, and perhaps that also of the pulmonary transpiration, prevent the free flow of the secretion, which, re- maining in the same cells which produced it, causes the cedema that has received the name of induration of the cellular tissue. There is one circumstance which goes to support the opinion we have advanced, relative to the effect of the suspension of cuta- neous transpiration on the passive infiltration of the cellular tis- sue ; it is, that irritating frictions of the skin, such as campho- rated oil of chamomile, will cause rapid disappearance ofthe cede- ma ; and when the child is wrapped in warm woollen applied to the skin, it is surprising to find it on the succeeding day bathed in sweat, which sometimes rises in a thick vapor, and to see the disappearance, at the same time, of the induration to a greater or less extent. To conclude: it cannot be admitted, I think, as is asserted by M. Denis, that the disease now under consideration is a phlegmasia? of the cellular tissue, for inflam- mation of this tissue gives rise to a very quick and abundant se- cretion of pus, possessing peculiar properties; and nothing of this kind appears in the limbs of cedematous children, which are not usually the seat of phlegmonous tumors. General conclusion.—In following the analytic method in the study of the phenomena of life, in accordance with the advice of the celebrated Pinel, we believe that the following truths have been established. 1st. The induration of the cellular tissue in young infants, is nothing else than simple oedema, analogous to the cedema of ON THE DISEASES OF INFANTS. 153 adults. It may be either local or general: it should always be distinguished from induration of the adipose tissue. 2dly. This disease is more common in winter than in summer, and more frequent in young infants than in those of more ad- vanced age. The predisposing causes are—1st, The natural feebleness of the child ; 2dly, A state of general and congenital plethora; 3dly, A superabundance of venous blood in the tissues; 4thiy, A dry state of the skin before the exfoliation of the epider- mis. The immediate causes are—1st, An obstruction in the course of the blood, resulting from its quantity in the circulato- ry apparatus; 2dly, Its engorgement in the cellular tissue, to which it furnishes too much materials for secretion; 3dly, and lastly, The action of external agents on the skin, which, without condensing the serous fluid, as has been asserted, are yet capable of suspending the cutaneous transpiration, and thus favor the ac- cumulation of serosity in the cellular tissue. The sanguineous engorgement of the liver, lungs, and heart, the persistence or closure of the foetal openings, are not the exclusive and indispen- sable causes of this affection ; they ought not to be considered as concomitant phenomena, and as accessory circumstances to a disease which may exist without them, and which is often ob- served to be the case in local cedema or induration. 3dly. When cedema is general, and the serous congestion is carried to a high degree, all parts where there exists cellular tis- sue undergo a disturbance in the functions which they dis- charge. Thus, the glottis becoming cedematous at the same time that the lungs are the seat of congestion, the cry of the child is generally painful, acute, and smothered. The slowness of the circulation easily explains the coldness of the limbs, and the state of debility into which the patient falls. In this manner all the symptoms described by authors may be explained. 4thly. The therapeutic indications pointed out by these con- siderations are—1st, To relieve, by suitable evacuations, the gene- ral plethora; 2dly, To excite the skin by irritating frictions, by the use of woollen garments next to the skin, and the adoption of all means proper to establish cutaneous transpiration. Vapor baths, for the administration of which M. Peligot has constructed a very ingenious apparatus at the Hospice des Enfans Trouves, has not, according to the experience of M. Baron, so good an ef- 154 ON THE DISEASES OF INFANTS. feet as frictions, and the application of woollen to the skin. I have often seen the latter succeed perfectly. The respiration of a child during its continuance in the bath is painfully accelerat- ed, and congestion and effusion on the lungs or brain have been seen to follow the use of these baths. Such are the conclusions which naturally flow from the con- sideration of the facts contained in this chapter. I have not, as will be seen, attempted to overthrow altogether any particular theory of those authors who have written on this subject; but have approved or controverted each, as they appeared to me to be either correct or otherwise. It is not by destroying exclusive theories and replacing them with others not less exclusive, that the edifice of science is to be perfected, but rather by establishing the facts by analysis, and gathering the results of the observations of all men and all times. I shall finish my remarks on this subject by mentioning a fact worthy of notice. The great mortality of the Hospice des En- fans Trouves has, for a longtime, been attributed to induration of the cellular tissue. This, I believe, is incorrect. There often exist at the same time affections of the brain, lungs, and intestinal canal, much more serious than cedema, and much more fatal to children. The number of those who really died of cedema or induration of the cellular tissue, that is to say, in that state of ple- thora and general congestion which I have described, without the existence of serious lesions of some of the organs at the same time, amounted in 1826 to fifty." The following is an extract from the register of deaths in the hospital: January, 8 July, . 0 February, 2 August, . . 2 March, . 4 September, . 2 April, . 8 October, . . 3 May, . . 13 November, . 0 June, . 4 December, . 4 It was in the months of May and November that the greatest number affected with induration, were admitted. All these pa- tients, in the latter month particularly, died of affections of some important organ, and more frequently of that of the lungs, rather than of induration of the cellular substance. When cedema is local, or if it be general and yet not severe, it ON THE DISEASES OF INFANTS. 155 is not to be regarded as a fatal disease; nor will it become so un- less complicated with some affection seated on an organ essential to life. CHAPTER II. DISEASES OF THE DIGESTIVE APPARATUS. I have adopted the division of the alimentary canal proposed by Meckel, who considers it as consisting of the cephalic, tho- racic, and abdominal or subdiaphragmatic portions. The cephalic portion comprehends the mouth and its appenda- ges. I shall, in the first place, consider the form and aspect which they present in a state of health, both during intra-uterine life, as well as after birth. The buccal cavity is very small at the first period of foetal ex- istence ; it is not until about two months that it deserves the name of a cavity, and it is then almost entirely filled with the tongue; and the motions of the lower jaw are so limited, that I doubt whether, at this period, there could be any motions exer- cised analogous to those of deglutition. The color of the mem- brane lining the mouth, and that of the tongue, does not present any thing remarkable until about the sixth month; but at this time, and to the seventh, eighth, and ninth month, it deserves some notice. It may be more or less colored, and more or less in- jected, agreeing with the general condition of the fcetus; for in three individuals of this age whom I dissected, it was in one of a violet red, and in the other two pale red. From the seventh to the ninth month, the color of the buccal membrane is generally of a deep rose; the papilla? at the extremity of the tongue are more projecting, but those at its base better delineated and more prominent; the pillars of the velum, and the velum palati itself, present the arrangements of the parts which they afterwards have, and the distance with which they are separated from the exter- nal opening of the mouth, is evidently increased. And again : the lateral parietes of this cavity are separated, and the lower 156 ON THE DISEASES OF INFANTS. jaw has become more moveable, so that at the sixth to the eighth month, the buccal cavity becoming larger, and the lower jaw ad- mitting of more motion, it is possible that the child may execute some movement analogous to mastication or deglutition ; this is indeed what really occurs, if we may judge from analogy and from the observations made on quadrupeds by Haller, and subse- quently by Beclard. At the period of birth, the buccal membrane is usually very red; it is the same with the tongue and gums; all these parts are congested with blood analogous to that of the external inte- guments ; they might be pronounced inflamed on a superficial inspection, but against such an error we should be carefully guarded. They gradually lose this deep color, and soon acquire that ofthe rose, which is, for the most part, the color ofthe skin; for in children whose integuments are very pale, the buccal mem- brane, if it be not inflamed, is itself but faintly colored. The salivary glands are scarcely visible during two-thirds of the foetal life ; it is only towards the seventh month of gestation that they acquire any size. At first they consist of a few granula- tions which are blended with the cellular tissue ; but at seven to nine months they agglomerate, and assume their proper form. Their excretory ducts open into the buccal cavity by a hole al- most imperceptible. The sublingual gland appears to me to be developed the first, then the submaxillary, and lastly the parotid. At birth these glands are scarcely formed ; but they are devel- oped with great activity, and towards the seventh month, that is, when the incisor teeth appear, the sublingual and parotid glands are considerably augmented in size and furnish an abun- dant secretion. It appears as if their development and function- al activity are more perfect in proportion as the mouth, and espe- cially the gums, require to be moistened and softened. Section I. DISEASES OF THE MOUTH. §1. Congenital malformations.—Absence of the month.— The malformations of the mouth and those of the face in ge- neral have been described with great care by M. Larocheof ON THE DISEASES OF INFANTS. 157 Angers, in his excellent inaugural dissertation.* This author correctly distinguishes between the complete absence of the mouth and the obliteration of its anterior orifice. The absence of the buccal cavity is called astomia (a ero^a), and the obliteration of the anterior orifice, atresia of the mouth. The absence of the buccal cavity occurs when the bones of the face have been arrested in their development, and particular- ly when the lower jaw is wanting. This deformity cannot be remedied, and the child affected with it soon dies. Sometimes, M. Laroche observes, in the place of a mouth an irregular open- ing is found, although situated lower, and communicating with the larynx and oesophagus. Borichius has seen instead of the mouth, a hole in the right cheek. In a very young embryo, five or six weeks old, for instance, the mouth is not closed, properly speaking; but the two lips are so closely approximated, and the labial orifice so narrow, that one can hardly be led to believe that an orifice exists. Yet the contrary may be easily ascertained by separating the lips with the point of a needle. The buccal cavity may then be easily distin- guished, entirely filled with the tongue, which extends to the borders of the lips. In the natural state, this opening gradually enlarges, the borders of the lips cease to be contiguous; at about four months, the comissures are found to be on each side, on a line drawn perpendicularly from the middle of the eye- brows. Finally, at six, seven, and nine months, this opening ac- quires a diameter corresponding in size to the other parts of the head. Obliteration of the mouth.—It sometimes happens that the borders of the lips, irritated and inflamed at some period ofthe intra-uterine life, contract and adhere either in a part or in the whole of their extent, and we can conceive, from this, the possibility of an incomplete or complete obliteration of the mouth. There exist but few instances of this malformation; when it is met with, it may be remedied by making, with a suita- ble incision, an artificial buccal opening, or by separating the adhesions which make it incomplete. Congenital division of the lips, or hare-lip.—The upper, and * Essai a?anat. path, sur les monstruosites ou vices de conformation de la face • these presentee et soutenue a la Faculte de Medicine de Paris, le 3 julliet 1823. 158 ON THE DISEASES OF INFANTS. very rarely the under lip, sometimes exhibits solutions of con- tinuity or vertical divisions, either at the middle, or at the lateral part of the raphe, on one or on both sides. This congenital di- vision exists the more often with hydrocephalia, anencepalia, or acephalia. It may consist ofthe commencement of the division, of a complete division, or of the absence of a considerable portion of the upper lip and alveolar arch, whence results a deformity of the buccal opening, known vulgarly by the name of wolf-mouth. Anatomists have explained, in different ways, the cause of this malformation. One of the most probable is that given by J. F. Meckel. He considers hare-lip as the result of an arrest of the development. According to him, the formation of the upper lip commences at three points, one middle and two lateral. If these three points do not unite, but leave between them the intervals which sepa- rated them in the primitive state of embryotic life, the child then has a double hare-lip, that is to say, two vertical clefts of the up- per lip. Each of these clefts is directed obliquely outward, and a red fleshy tubercle exists between them, the appearance and form of which are very variable. If but one of these parts unites whilst the other remains isolated, only one fissure or cleft exists e|her on the right or left of the median line. When the fissure is double, the alas of the nose are drawn outward to a greater or less extent. Lastly, it very often happens, that behind these so- lutions of continuity ofthe upper lip, the alveolar process is also divided either on one side only, or on both sides at once, and the fissure is generally found between the second incisor and the canine tooth, although it is possible to meet with it between the first and second incisors. Division of the palatine arch and velum.—The two lateral parts of the palatine arch, in place of uniting on the median line, as is observed in the normal state, may be arrested in their development, and leave between them a fissure varying in depth and breadth, which establishes a communication between the mouth and the nasal passages. And the velum itself may like- wise have the same imperfection of development, and exhibit al its central part a complete or incomplete cleft, which interferes with deglutition, alters the tone of the cry, and at a later period prevents, to a considerable degree, or greatly impedes articula ON THE DISEASES OF INFANTS. 159 tion. These divisions of the constituent parts of the mouth, may exist separately or together in the same individual. The ex- treme deformity, in times of gross ignorance, induced the belief that it was possible for a child to be born with the face of a hare, a calf, or wolf—most absurd comparisons, which are not deserv- ing mention at this day, except to cite them as examples of the whimsical fancy of the human mind. The curative means so happily conceived by surgeons, and which have been employed with so much success, ought not to be adopted in early infancy. It will be necessary to wait until the child is more advanced in age, before the operation for hare- lip, or that of staphyloraphy, is performed. It remains for us to point out here the particular care which an infant affected with this organic deviation requires. The division of the upper lip prevents sucking, and especially when it is double ; and such Is the difficulty in some children, that it is necessary to bring them up with the spoon. The de- glutition of liquids in those children affected with a division of the palatine arch and velum, is so difficult and dangerous, that the child is sometimes threatened with suffocation when the li- quids taken pass into wrong passages. I cannot refrain from in- troducing here the excellent advice of professor Roux on this subject. " A child born with a bifid velum, and at the same time with the arch ofthe palate and the lips perfectly formed, can, without difficulty, take the breast of its mother or nurse; but as it cannot empty the mouth, it sucks badly, or perhaps cannot suck at all, particularly if kept in a horizontal posture; deglutition also is performed in a defective manner." M. Roux advises the placing of the child in a vertical position when it is about to suck, and to assist the mechanism of suction by gently pressing the breast. If there exist a large communication between the mouth and the nasal fossa?, it will be better to cause the child to drink its milk from a small spoon. A child was one day brought to M. Roux affected with a division of the velum and arch of the palate, that for eight days had not been able to suck. This child was re- duced to a state of marasmus, and appeared about to perish. M. Roux caused the child to be held erect, and in this position gave it a small spoonful of sugared water. In this manner it drank a 160 ON THE DISEASES OF INFANTS. glassful. From this time, it was artificially fed by taking the same precautions, and was soon relieved from the state of lan- guor and wasting in which it had fallen.* The different parts which constitute the buccal cavity, may likewise present some malformation. M. Larochet has pointed out as such—1st, The congenital fissure of the cheeks, of which Nicati has published two cases ; in one, the fissure was double, a and extended from the angle of the lips, terminating at the globe of the eye; in the other, it only existed on the right side. This last fcetus presented besides, a division of the left lip, and a double insertion of the umbilical cord, one at the umbilicus and the other at the head.* These fissures probably depended on the slow union of the different pieces which compose the bone of the upper jaw. 2dly, The uvula may be partially or entirely wanting, (We- del, Eph. nat. cur. dec. 2, obs. 2.) 3dly, The tongue may be very small, but it is never absent except in the case of absence ofthe face. It maybe defective in symmetry, and not exhibit the sulcus in the centre, of which I have seen a very striking example. This organ has been seen deprived of all the muscles of one side; (Cholet, dans la Desser- tation de Laroche.) offering a bifid point; (Dana Mem. de Tu- rin, 1787.) The tongue may be very small and hollowed like a canal, (Haller, Opera minora, p. 9.) As to adhesions of the tongue, they have been explained by saying that the same state is met with in the normal condition of the embryo. I have dis- sected with great care three embryos, of six weeks, of two months, and of nine weeks, and did not find in either, the tongue adher- ing to the subjacent part. It was very much developed, and had no other adhesions except at the base and froenum. The lateral and inferior parts were free. The froenum of the tongue may be too long, and thus may embarrass the movements of this organ and the mechanism of sucking. The froenum should be cut immediately after birth ; this may be done by raising the tongue with a grooved director * Memoire sur la staphyloraphie, ou Suture du voile du palais. Paris, 1825. t Loc. cit. t were there not rather two umbilical cords, and was not this a trace of the inclu- sion of another fetus 1 ON THE DISEASES OF INFANTS. 161 held in the left hand, whilst with a scissors in the right hand, the preternatural membrane which forms the adhesion, is cut to the required extent. If the cutting of the vessels causes a hemor- rhage, which is increased by the suction of the child, it will be ne- cessary to cauterize the veins and arteries with nitrate of silver, or with a red hot needle.* The Vandermonde journal of medicine and pharmacy contains an example of a child born with a monstrous tongue. After the birth of this child, this organ appeared much longer and thicker than usual, and entirely prevented sucking. The surgeon in at- tendance having examined it, found that it adhered to the gums and lower jaw by a spongy tumor of the size of a small filbert. He tried by all the means in his power to separate the tumor from the tongue, but the hemorrhage, which was considerable, intimidated him. The part which he had begun to separate af- terwards united, the tumor increased in size from day to day, and affected the tongue, with which it appeared to unite itself; and after a short time no difference could be perceived between the tumor and the tongue. "During this interval the child lived only on liquid aliments, which were introduced far into the mouth to enable it to swallow, which it accomplished by draw- ing the lower jaw farther back than the upper. In this manner it took the breast; and it was quite a pleasure to observe with what quickness and dexterity this young infant, instructed by its wants, advanced and drew back the lower jaw in drawing at the breast." In proportion as the child increased in age the tongue increased in size; at last it was two inches thick, and projected four fingers breadth from the mouth. The incisors and canine teeth fell out; the lower jaw was bent in the middle, and pre- sented a hollow in which the tongue was lodged. The child could chew and articulate sounds in spite of this infirmity.f * The work of J. L. Petit, entitled Observations anatomiques et pathologiques on the froenum of the tongue, may be advantageously consulted. In a chapter in his Traite des mal. chir., will be found some important observations which deserve the attention of the practitioner. The simple incision of the froenum is not an operation to be done lightly ; and although at this day it is not considered so dangerous as it was for- merly, yet care should be taken to prevent and to remedy accidents which may at- tend it. t Observations published by M. Mauraut, surgeon in Mortigue in Provence Journ. de med., chir. etpharm. 1.15, p. 158. 21 162 ON THE DISEASES OF INFANTS. This child ought to have been relieved by perforating the tongue and passing a double ligature, which, being tightened gradually on each side, would have detached, by degrees, the superfluous appendage without hemorrhage. It is known that Mirault of Angers has performed this operation with success on an adult. 4thly, The lower jaw may be wanting, or be of a remarkably small size. I have seen a child born with all the constituent parts of the mouth reduced to extremely small dimensions. I shall here record this curious case in detail. CASE IX.—On the 25th of June, 1826, a young female infant was brought to the Hospice des Enfans Trouves. The inferior portion of the face was very much narrowed ; and the two cheeks, instead of being round and projecting, were almost concave ; the opening of the mouth was very narrow, the lips round and prominent, the low- er jaw projecting and extremely narrow; the tongue straight and pointed, having altogether the form of a hare's tongue ; the isthmus of the fauces was very narrow. The child could not take the breast, and drank with great difficulty; the imperfect deglutition caused sometimes a dangerous suffocation. The cry was acute and jerking, and both the parts constituting it were distinctly heard. This child soon perished from enteritis, on which account it was placed in the infirmary. On the examination of the dead body, the various parts just enumerated were measured, and were of the following dimen- sions : the anterior orifice of the mouth was six lines in diameter; the tongue, from the base to the point, two inches and two lines, and its diameter near the base, six lines, and at the point, five ; the dis- tance between the two large cornua of the os hyoides, was seven lines ; and the distance between angles of the lower jaw was found to be fifteen lines ; the greatest diameter of the palatine arch was fourteen lines; the ossification of the lower jaw was as much ad- vanced as it usually is at birth, and the tongue possessed all its muscles. Thus, all these parts were of their natural length, but not of their ordinary breadth, so that it may be said that the lateral por- tions of the face had been compressed in a manner to hinder their development in breadth. I acknowledge that I could not find ON THE DISEASES OF INFANTS. 163 the cause of the deformity in this child, who, in other respects, possessed a perfect organization. § II. Passive congestion.—Passive congestions of the buccal membrane are rare during intra-uterine life ; yet I once saw in an infant just born an ecchymosis at the base of the tongue; it was of a violet color, and spread from the base to the middle part of the organ; it penetrated to the depth of three lines. The tissue of the tongue wasvery much softened at this place. There was nothing else in the general condition of this subject worthy of remark. It is very common to meet, at birth, with instances in which the buccal membrane is the seat of a well-marked congestion. This congestion, and the redness arising from it, disappear by degrees after birth; but certain portions may remain, for some weeks, the seat of red patches, which however are gradually effaced. An ecchymosis of greater or less extent, is often seen continuing for a long time in the palatine arch. § III. Inflammations.—Inflammations of the buccal mem- brane are distinguished by the term stomatitis. STOMATITIS. It is impossible to convey, by a general description, a pro- per knowledge of stomatitis, because every part which enters into the composition of the parietes of the mouth, may be- come the special seat of the varieties of inflammation which are developed in this cavity. The disease then takes a peculiar as- pect, and gives rise to symptoms which are proper to it; so true it is, that the different modes of alteration of organs are often the principal and essential cause ofthe difference ofthe symptoms of diseases. I shall therefore describe stomatitis under the following va- rieties : Erythematic, With altered secretion, (muguet,) Follicular, (aphtha?,) Ulcerous, Gangrenous. 164 ON THE DISEASES OF INFANTS. ERYTHEMATIC STOMATITIS. The congested state in which the buccal membrane always exists in new-born children, disposes it to become the seat of erythematic stomatitis, an affection usually characterized by red- ness, heat, and sometimes by dryness of the parietes of the mouth and of the tongue. This is usually the first degree or precursory symptom of the other varieties of stomatitis. It varies in inten- sity, and is either transitory in its duration, or may continue for a length of time. It often accompanies inflammation of the sto- mach or intestinal canal; but it rarely gives rise to any febrile derangement in very young infants; but in children from seven to nine months of age, it is often accompanied by this symptom. The inflammation is confined, in some cases, to one part of the mouth, while in others it occupies the entire cavity, and spread- ing to the lips, they tumefy, excoriate, crack, and frequently be- come the seat of herpes labialis. When this inflammation is of long duration, it may produce an abundant ptyalism, particularly in children from seven to nine months. Simple erythematic stomatitis promptly yields to emollient gargles and to milk diet; and when it is accompanied by a phlegmasia of the stomach or intestines, it disappears in propor- tion to the dissipation of the gastric inflammation accompany- ing it. STOMATITIS WITH ALTERED SECRETION, OR MUGUET. Many pathologists have confounded muguet with aphtha?. In order to avoid the confusion into which they have fallen, we will, in the first place, establish the characteristic differences of these two diseases. It was not until the labors of MM. Breschet and Guersent appeared, that sufficient data were established in rela- tion to this variety of inflammation. M. Veron, in an essay read at the Academie royale de Medicine, and M. Lelut, in a paper placed in Archives general de medicine, (March, 1827,) have contributed much to elucidate the history of the disease in ques- tion. We will endeavor to present its history divested of all dis- cussion, and the vain show of scholastic erudition. It is characterized by a concretion of mucus on the surface of ON THE DISEASES OF INFANTS. 165 inflamed mucous membranes, whether the membrane be an epi- thelium or not. This concretion may be observed in the mouth, oesophagus, stomach, and small or large intestines. This last assertion may appear strange after what some physicians, and particularly M. Veron, have said.on this subject; but I advance it here, as it will presently be supported by unexceptionable proofs. I will con- fine myself to muguet of the mouth. This affection appears under three different forms—1st, under the form of very small white points, dispersed upon the tongue and parietes ofthe mouth ; 2dly, that of variously sized shreds ; 3dly, that of a membrane entirely covering the tongue, or spread over the other parts of the buccal cavity. I do not speak of the yel- low or red color which the pellicle sometimes assumes, because it depends on the contact of bile, or on a sanguineous exhalation on the surface of the mucous membrane, circumstances altogether independent of the disease now under consideration. This excretion, under what form soever it may appear, is usually preceded by an erythematic inflammation of the surface ofthe tongue, or ofthe parietes ofthe mouth. When inflamma- tion has continued one, two, or three days, there are seen at the extremity, or on the sides of the tongue, or on the internal sur- face ofthe lip, small white points which appear to crown the pa- pilla? of the membrane to which they adhere. I have examined the seat of this excretion with great care, and I never saw it un- der the epithelium, on the surface of which it is always seated. It overspreads the membrane like mucus, of which indeed the muguet is but a morbid concretion. This is the first degree of the disease, which, as I have just re- marked, is always preceded by inflammation of the mouth. If the inflammation makes no progress, and if the excretion accom- panying it is suspended, the white points alluded to soon disap- pear, and the disease may be regarded as mild. When the inflammation has made some progress, the white points unite and form small lamina? either on the surface of the tongue or on the internal surface of the lips and cheeks. These lamina?, becoming very thick, exfoliate and detach themselves, leaving in their places an inflamed surface, which soon secretes materials for a new concretion, until at last, the inflammation 166 ON THE DISEASES OF INFANTS. ceasing, the reproduction of morbid matter is no longer to be ob- served. The disease increasing, the inflammation spreads rapidly and deeply over the whole cavity of the mouth; the lamina? of which I have spoken, quickly uniting, form a pellicle of a greater or less extent and thickness, which spreads over the tongue, sides ofthe mouth, and velum. Under these circumstances, as in the pre- ceding, the disease is said to be confluent or malignant. Such is the exhibition of the three principal aspects of this inflammation as it appears in the mouth. These varieties are more remarka- ble with reference to their ordinary seat. The pointed variety usually occupies the extremity and edges of the tongue ; that in laminae appears on the internal surface of the lips and cheeks; the membraniform occurs at the base of the tongue and on the velum. To a certain extent, the reason of this difference of ap- pearance can be explained. The pointed variety, which is no- ticed on the upper part of the tongue, occurs in the numerous papillae, secreting at their extremities small mucous drops which immediately concrete. As the papillae and villosities of the mu- cous membrane are longer and less fine at the palate, base of the tongue, and on the internal surface of the cheeks, the mucus is secreted in the form of a covering, and concretes in the same manner, assuming the membraniform appearance spoken of above. We shall now take several interesting questions into considera- tion, and endeavor to ascertain the nature, causes, symptoms, complications, and treatment of this species of inflammation. It is admitted as a fact, sanctioned by the observations of the present time, that the accumulation of blood, redness, and with- out doubt, pain in the mucous membrane of the mouth, always precede the appearance of the white points. It is also worthy of remark, that the pellicular or curdy production takes the place of the mucus which moistens and lubricates the mouth. Thus, then, this affection follows an accumulation of blood in the in- flamed membrane, and replaces the normal secretion of mucus. It is probable that the blood accumulated by the inflammatory stimulus in the thickness of the mucous tissue, transmits to it the materials of secretion, the product of which concretes on the sur- face ofthe epithelium, in proportion as it is deposited there. ON THE DISEASES OF INFANTS. 167 Does this facility in the mucus to concrete arise from the blood, in children and sometimes in adults who are found in analo- gous cases, having been rendered more plastic and rich in fibrin by the inflammatory condition, thereby supplying the elements of a mucus abounding in fibrin? This is a question the solu- tion of which we will leave to those who, more fortunate than we, have better authority than conjecture. The researches of M. Lelut go to the support of this opinion; for this physician, hav- ing treated the pellicle or false membrane by chymical agents, arrived at results nearly resembling those which have been ob- tained from the examination of mucus by Fourcroy, Schwilgue, Vauquelin, Berzelius, and Hatchett; or of the epidermis by Bi- chat, Vauquelin, and Hatchett; or of the buff of the blood, the false membrane of the serous membranes, of the bladder, or croup by Schwilgue, Double, Guersent, Desrouelles,* and Bre- tonneau.t Such are the few data we possess on the nature of the disease ; let us now examine the causes. This affection shows itself more commonly in early infancy. Sucking infants are more often the subjects of it than those more advanced in age. There exists something peculiar in the consti- tution of one so young which singularly disposes it to this modi- fication of inflammation ; and those children that are crowded together in the same place, are feeble and wretched, and that re- ceive unsuitable nourishment at an age when nutrition plays the principal part in the functions of the economy, are the subjects of stomatitis and muguet of the greatest intensity. There is no part of the year that can be mentioned as peculiarly favorable to the development of this disease. It prevails with almost equal intensity, and at all times, at the Hospice des Enfans Trouves. In the quarter ending in March, 1826, in two hundred and nine- ty patients, there were thirty-four cases of it. In the quarter end- ing in June, in two hundred and thirty-five patients, there were thirty-five ; in the quarter ending in September, in two hundred and thirteen sick, there were one hundred and one cases; and forty-eight cases in the quarter ending in December, among one hundred and eighty-nine patients. M. Baron has seen it prevail among a number of individuals at certain periods, without beino- * Traite theorique et pratique du croup. Paris 1824. t Archives generates de medicine, March, 1827. 168 ON THE DISEASES OF INFANTS. able to assign for its cause any influence from temperature. I am disposed to think that the development of this disease is more connected with the constitution ofthe patients, and to their dispo- sition to inflammation of the mucous membranes, than to any cause of an atmospheric nature. I do not believe it is contagious. M. Baron rejects entirely the idea of contagion, from often having seen children drink from' the cup used by those who have been affected, without contract- ing the disease. This fact I also have observed. From these considerations, it follows that the causes of this disease are : the first period of infancy—bad nutrition—the as- semblage of a great number of children in the same place—de- bility—inflammation of the buccal membrane—and lastly, the disposition which the mucous membranes exhibit in young chil- dren to be covered, when they are inflamed, with thick, curdy, and membraniform concretions. The local symptoms are found traced in the description given of the development and form of the morbid excretion, which shows itself on the surface of the inflamed mouth. As to gene- ral symptoms, they scarcely exist in very young infants ; fever is hardly ever manifested. I counted the pulse and the beatings ofthe heart in forty children, aged from one to twenty days, af- fected with it, and found fifty, sixty, sixty-five, eighty, and in one instance one hundred, pulsations in a minute. With the excep- tion of the last case, the number of pulsations did not differ from the natural state of the pulse, as will be seen on comparing what has been just stated with what has been already said upon the state of the pulse. The skin is usually hot and dry, and the thirst great. The cry does not vary except with reference to its strength and fee- bleness ; yet when the membraniform concretions spread to the glands, and cover the pillars of the velum, the cry then becomes husky. It is sometimes complicated with other phlegmasia?. In fifty cases which were fatal either from the progress of the disease, or from some other affections, I found, as complications, a phlegma- sia of the cerebro-spinal apparatus in two children; of the skin in four; of the respiratory and circulatory apparatus in twelve; and of the digestive apparatus in thirty-two. Whence it results ON THE DISEASES OF INFANTS. 169 that the inflammation of the digestive apparatus is its most usual accompaniment, while the other phlegmasia? are of accidental occurrence. In the thirty-two children presenting the complication of phleg- masia? of the alimentary canal, there were ten where the sto- mach was not inflamed. In six of these, the large intestines, and in four the small intestines, were found more or less in- flamed. As to the remaining twenty-two, they showed an inflam- mation of the stomach, oesophagus, or of some part of the great or small intestines. This disease, therefore, is not always a sign of gastritis, since it can exist without this phlegmasia; but it coexists almost always with an inflammatory state of some part of the intestinal canal. This assertion, already made by several authors, needed still the support of well-established facts, and these are what I had pro- posed to give here. The treatment of muguet flows naturally from the exposition of the facts which have been exhibited, and from the nature of the considerations to which they give rise. When it is simple, and consists of nothing more than a few points disseminated over the surface of the tongue, or on the bor- ders of the lips, all that is required is to wash the mouth of the child several times a day with a piece of lint soaked in a decoc- tion of marshmallows. If it should be more confluent, and compli- cated with a phlegmasia ofthe digestive organs, or of some other important part, in addition to emollient gargles, the accompany- ing disease ought to be met by appropriate treatment; which will be found in the history of each of these diseases. I have seen this treatment, simple as it appears, completely suc- cessful in the hands of M. Baron. M. Guersent advises, besides, the employment of some mucilaginous decoction to which is added a fourth part of the chloride of soda, as a wash for the mouth of the child. This preparation, diluted with muci- lage, observes M. Guersent, appears to me preferable to a solu- tion of subborate of soda, or that of the sulphate of zinc. It is equally preferable, in injections, to lime water, which is irrita- ting to the intestines.* A small quantity of alum may be added to * Guersent, art. Muguet, du Diet, de Med. in 21 vols, 22 170 ON THE DISEASES OF INFANTS. the gargles, after having ineffectually employed emollient lo- tions. The remarks which have been made on confluent muguet, are equally applicable to certain phlegmasia? of the mouth and gums, which produce a concretion more or less abundant, covering with white or yellow pellicles the gums and internal surface of the cheeks. Several authors have described this phlegmasia under the name of aphthae; others have called it pustular, pellicular inflammation, etc. These varieties may be referred to stomatitis with altered secretions, and should be treat- ed with the same therapeutic means. FOLLICULAR STOMATITIS, OR APHTHA. For a long time pathologists were not agreed as to the true nature and seat of aphtha?; in order to be satisfied of this, it is only necessary to cast a glance over the principal works which have been published on this subject. Hippocrates and Aretseus, it is said, described this disease, but it is difficult to find the essential characters of it mentioned in their writings. Hippocrates mentions it without any description. " In atatibus autem talia eveniunt. Parvis quidem, et recens natis pueris aphtha vomitus, tusses, vigilice, pavores, umbilici inflammationes, aurium humiditates."* Aretaeus scarcely enables us to undersand, in the following passage, whether he is speaking of aphthae. " Crustam vero circumveniunt rubor excellens et in- fiammatio et venarum dolor, quemadmodum in carbunculo ; ex- iguai rarceque pustula. quasGraci exanthemata vocant, orientes, hisque aliai supervenientes in usum coalescunt; atque inde la- tum ulcus efficetur."t If Areta?us wished to designate by the ex- pression exiguce rarmquai pustulm, the inflamed follicles of the mouth, it must be allowed that he has lost the proper distinction . of it in the confused description of the various affections of the mouth, each of which merits a place in a perfect and complete nosological arrangement. The commentators of Hippocrates, Galen, Celsus, and Are- taeus have exhausted themselves in vain conjectures to ascertain to * Aphorism 24, Sec. 3. t De tonsillarum ulceribus, cap. 9. ON THE DISEASES OF INFANTS. 171 what alterations of tissue aphtha? are to be referred. Some phy- sicians, such as Boerhaave, Van Swieten, Stohl, Armstrong, and Underwood, have applied this term to ulcers of the mouth, what- ever may have been their primitive form. Others, as Sylvius, Mercurialis, Etmuller, and Pinel, have regarded them as vesi- cular pustules, white in the centre, red at their borders, having a great analogy to the mucous disease of Roederer and Wagler; an opinion to which Gardien appears to incline. Which of these various opinions shall be adopted 1 Bichat, whose genius has discovered all the advantages that may be drawn from the study of the anatomical characters of diseases, in order to establish positively their differences and ana- logies, says, on finishing his chapter on the mucous chorion : " Are aphtha? an affection of the mucous chorion ? do they apper- tain to the papilla? ? are they seated in the glands ? do they arise from the isolated inflammation of these glands, while catarrh is characterized by a general inflammation of the mucous system spread to a great extent 1 All these questions deserve to be exa- mined, and Pinel has felt the defects of pathological anatomy on this point."* Gardien has not been willing to attempt the solution of a question, upon which, says he, Bichat has not ventured to pro- nounce an opinion. He has been contented to describe in detail, and with great care, the history of the opinions advanced upon the nature and progress of aphthae from the remotest antiquity to the present day.t But whatever distrust one may have, as regards his own abilities, ought he always on that account to stop at difficulties which have foiled men of greater talents ? and from the constant progress which is made in pathological anatomy, furnishing incessantly new materials, are we not at this day bet- ter able to solve the problems which in the time of Bichat were considered as not admitting of solution ? I am of this opinion ; and though I might perhaps do better by imitating a modesty so honorable to him, it would be prejudicial to the cause of sci- ence, since it confines our efforts and arrests our discoveries. I will therefore attempt to respond to the questions of Bichat, and * Anat. Gen. Tome 4, p. 437. t Gardien, Traite complet d'accouchmens et des Maladies desfemmes etdcs enfans. Tom. 4, p. 113. 172 ON THE DISEASES OF INFANTS. show that aphthae consist of an inflammation of the muciparous follicles of the mouth. The muciparous follicles of the mucous membrane ofthe mouth are invisible in their ordinary state, and remain hidden in the thickness of the membrane, and compensate by their infinite number for the smallness of their size ; but when they begin to inflame and to tumefy, they appear on the internal surface of the lips and cheeks, on the pillars ofthe velum and the palatine arch, on the inferior surface and the lateral parts of the base of the tongue, under the form of small white points, sometimes exhibit- ing a colored spot in their centre, slightly prominent, and often surrounded by a slight inflammatory circle. These follicles are either isolated and few in number, or multiplied and spread over every part of the mouth. Sometimes they may be felt with the finger, when they are not sufficiently distinct to be seen. They often do not stop at the mouth, but spread to the oesophagus, stomach, and intestinal tube. I shall confine myself here to the consideration of the follicles of the mouth. The inflammation of these follicles is sometimes arrested in the first stage, and will remain for a greater or less time without pro- ducing any symptom, but this inflammation will often make a considerable progress, and insensibly produces the following alterations: The follicular points enlarge, preserving also their circular, primitive form; and from their central aperture there soon issues a white matter, which being squeezed by the epithelium, the ulcer- ation of which soon commences, leaves the white puriform matter of which I have just spoken, freely exuded over the parts. The aphtha? take a new aspect, and then commences the second stage, or period of ulceration. The projecting points of which mention has been made, are neither tubercles, as M. Gardien has said, nor vesicles nor pustules as has been asserted by others; but they are evidently the muciparous follicles, as their central orifice and unvarying form demonstrate. They are analogous, in every respect, to those which are found in the stomach, small intestines, ca?cum, and colon. Now, if this be the case, why then does there exist a doubt, that the ulceration which follows at these follicular points, is the result of their inflamma- tion? wherefore is there still an opposition to the idea that aphtha? ON THE DISEASES OF INFANTS. 173 are inflamed follicles of the buccal cavity, when there is no doubt, at the present day, that the round ulcers throughout the small in- testines are the effects of an inflammation of the glands in those regions, and which possess the greatest analogy to those of the mouth ? But the better to elucidate a question upon which Bichat has hesitated to give an opinion, let us pursue our description. The follicle once broken, consists only of a prominent mark ; it is a superficial ulcer, with circular borders, sometimes slightly cupped, more or less tumefied, and almost always surrounded by a red inflammatory circle. That the borders and the centre of this light ulceration often secrete a white, pultaceous matter, adhe- ring like a small scab, ending by becoming detached and ejected with the saliva of the child. Isolated aphthae generally occupy the internal surface of the lower lip, the froenum of the tongue, the internal surface of the cheeks, and when there are no teeth, the summit of the gums. If the aphthae are in great numbers and very near each other, their borders unite, the curdy matter, which they excrete, spreads from one to the other, forming a bed of greater or less extent and thickness. It is then that aphthae are confounded with muguet, but they may always be distinguished, in considering the deve- lopment of the inflamed follicles, and the solution of continu- ity which does not exist in the latter disease ; besides, the excre- tion which accompanies aphtha? always follows the ulceration, and almost always exists at the internal part of the lips and cheeks, while the white points of the other affection appear at first on the lateral parts, and towards the extremity of the in- flamed tongue, extending afterwards to the surrounding parts. Aphtha? do not always present the same characters in the vari- ous places of their development; sometimes when the follicular points are about to ulcerate, the edges of the ulcers, instead of being covered with a slight curdy excretion, exhale a small quantity of blood, which concretes under the form of a slight brown scab, mistaken by some authors, as in malignant sore throat, for a gangrenous eschar. But Guersent and Bretonneau have clearly demonstrated that what has been taken for gano-re- nous affections of the throat is really nothing but an inflammation of the mucous tissue without loss of substance, an inflammation 174 ON THE DISEASES OF INFANTS. giving rise to the formation of a pellicle which, projected by the exhaled blood on the inflamed surface, gives to a certain extent the aspect of an eschar. Before pronouncing, therefore, these es- chars to be gangrenous, the nature and causes of the brown scabs covering the aphthous ulcerations should be examined with the closest attention. This mistake might produce fatal consequen- ces, for it is probable that the idea may be conceived of treating with stimulants and tonics a disease which it would be more ra- tional to treat with simple antiphlogistic means. Yet I do not deny that the ulcerated follicles of the mouth may sometimes terminate in gangrene. I would only remark, that this termination is much less rare than Van Swieten, Rosen, Un- derwood, and many others appeared to have believed. When the inflammation lessens, or when it yields to the means employ- ed for its relief, the ulcer, on cicatrizing, scarcely ever leaves a sensible trace ; its apparent depth arises also from the thickness of its inflamed and tumefied borders. Thus, then, aphthae of the mouth may present two stages iu their inflammatory development; or they may either consist of small white miliary tumors, or these tumors may ulcerate and become disorganized. Now it results from this, besides being dictated and supported by observation, that aphtha? are neither tu- mors, as some will say, nor ulcers, as is thought by others ; but sometimes one and sometimes the other of these pathological al- terations, according as the degree of inflammation is more or less advanced. If occasionally the ulcer alone is observed, it is because the primitive development of the follicle had escaped the attention of the physician, or of those having charge of the pa- tient. Callisen has well described aphtha?, and has considered them in a manner analogous to that we have adopted. The description which Plenck has given of them, approaches still more to Ours, except that he regards as vesicles, accidentally formed, the small tumors which we consider as a morbid development of muci- parous follicles. " lncipiunt aphtha sub forma vesicularnm mi- liarum albarum qua. in apice foraminulum gerunt, dein colics hunter et aliquantum latescunt?'* * Doctrina de morbia cutaneis. ON THE DISEASES OF INFANTS. 175 The analogy which some have thought exists between the small tumors of the mouth and those which are observed on the skin in some cutaneous phlegmasia?, has caused a comparison to be made between aphthae and miliary eruption.* But this com- parison has no foundation, if it be true that aphthae are owing to a tumefaction of the muciparous follicles. There cannot really be any comparison between them and the vesicles of miliary erup- tion, from which they essentially differ. Finally, the aphthous ulcerations differ still from the other ulcerations ofthe mouth, and which will be hereafter noticed. Since we are now in possession of some of the data upon the nature and development of aphtha?, let us see what are the causes, general symptoms, complications, and treatment of this disease. This is not a disease peculiar to infants, for adults are also lia- ble to them. From this, doubtless, arises the division of Bate- man, Aphtha lactantium, Aphtha adultorum. They are particu- larly to be seen in children who are very feeble, pale, and of a lymphatic temperament. We do not look for the causes of aph- tha? in the retention of the meconium, acidity of the milk, or in the predominance of acidity in the fluids of the child; we at- tach more importance to the consideration of the original pre- dominance of the lymphatic system, or rather to the remarkable predominance which this system acquires under the influence of bad nutrition and vitiated air, which is respired in badly ventilat- ed places, in those who are crowded together with a number of sick children. This is, in truth, the result of the researches and reflections of Raulin, Lapoyrenie, Baudelocque, Auvity, M. Sanponts, and many others. It will appear, then, that the folli- cular apparatus ofthe intestinal tube acquires an increased vital energy with the lymphatic system; hence this disposition of in- fants to inflammation of the follicles, and to the alterations which follow in the different parts of the digestive tube. I have observed in the Hospice des Enfans Trouves, that while muguet prevails almost universally among children re- cently born, aphtha?, on the contrary, are more frequently observ- ed in such as are teething. M. Denis, who denominates these aphthae ulcerated phlyctena?, has also remarked that aphtha? are * Van Swieten, Boerhaave, Sauvage, Arneman, Willan, Bateman, etc. 176 ON THE DISEASES OF INFANTS. not developed as often in very young infants.* Now if we follow the anatomical development of the lymphatic glands and follicu- lar apparatus of the digestive tube of a young infant, it will be seen that these glands, scarcely formed at first, grow rapidly in the first four or five months; so that the development of the lymphatic system, drawing with it, as we may say, all the ap- pended parts, impresses on the constitution of the child a pecu-A liar idiosyncrasy, from which results a predisposition to phleg- masia? of the follicles and muciparous glands. Thus, anatomical and pathological observations are here found to agree, and throughout the whole of this work they will be found to afford a mutual support to the opinions which I shall endeavor to es- tablish. I will recapitulate the first observations by remarking, that the principal cause of aphthae lies in the anatomical development and increased vital energy of the follicular apparatus, while other causes of an external nature excite and promote the development. The general symptoms are often of little moment. For the most part, the child has no febrile action. The skin is hot and dry, but the pulse beats with the greatest tranquillity. In twelve children affected with aphthae, I found but sixty or eighty pulsa- tions, which certainly indicates the absence of any febrile action. This remark has been for a long time made by those physicians who have attended to infantile diseases. Underwood says, "The thrush, in its commencement, is said to be generally attended with fever; but those who have been of this opinion do not seem to have made what is a very necessary distinction ; since I have by no means found this to be the case when the thrush is an original disease, though the mouth is so much heated as to excoriate the nipples of the nurse, and become so tender that the child is often observed to suck with reluctance and caution."! Fever does not show itself in children affected with aphthae, un- til they are a little advanced in age, and even then all may not experience it. This remark, which I make by the way, is wor- thy ofthe attention of physicians, for its application will be found in the history of general pathology. Indeed, was it not from the * Researches oVanatomie et de physiologie pathologiques sur plusieurs maladies des enfans nouveau-nes, Commerce, 1826. t Treatise on the Diseases of Children, by Underwood, p. 35. ON THE DISEASES OF INFANTS. 177 peculiar alteration ofthe mucous membrane of the alimentary ca- nal, that the celebrated Pinel gave the name of mucous fever to one of his essential fevers? But if this alteration can exist with- out fever, as is the case in very young children, the seat and cause of Wie fever must be in some other part than in the altera- tion of which the fever is but a possible and not a necessary nor constant symptom. Yet M. Pinel insists much upon this lesion, and upon the anatomical characters, as one of the principal points among the lesions observed on the dead bodies of those who have died in the different epidemics of mucous fever. The state of the mouth, oesophagus, stomach, and intestines, says he, is particularly worthy of notice in the affection of the mucous mem- brane of these parts. Nothing has been more common than to find aphtha? in the pharynx—that is to say, a detachment, in cer- tain places of the epidermis which covers the mucous membrane.* It is true that there exists, at the same time, in these patients, a similar alteration ofthe follicular apparatus of the intestines; but we can point out cases resembling these in young infants who have not experienced any febrile symptom. We will note this fact now, and examine it more fully hereafter. When the aphtha? are small in number, a few consecutive symptoms present themselves ; but this is not the case when they are confluent. The child is then pale, quickly becomes thin, has a diarrhoea more or less copious, and vomits every thing that is given. These occur when the disease has spread to the oeso- phagus, stomach, and intestines—the most frequent and fatal complications. There are also often seen regurgitations and eructations which diffuse an acid odor, attributed to the milk with which the child is fed, or which it sucks, not beino- digest- ed by the diseased stomach. This acid odor is analogous in re- spect to that of milk changed by heat or vinegar. It appears to me more rational thus to explain the acid odor of the matters vomited or voided by the child, than to seek for causes in the acid or alkaline nature of the fluids, explanations which are not adopted at the present day. Is it to the acidity of the humors that the acid odor of the indigestible substances vomited by one * Nosogr.philos.t. l.p. 130. 23 178 ON THE DISEASES OF INFANTS. who has indulged in too copious a dinner, or who has been jolt- ed in a carriage, or rolled in a ship, is to be attributed? If one may judge from the cries, wakefulness, and restlessness observed in children affected with aphtha?, this disease is not with- out pain. When the inflammation is propagated to the pharynx, and produces a swelling of the glands and an inflammation of the trachea, the cry of the child is sensibly altered, and it is doubtless as Gardien observes, that children manifest their pain sooner by the harsh or hissing cry than by their tears.* I shall hereafter examine the question of the existence of aphtha? in the trachea. Treatment.—The therapeutic means advised by authors, in the treatment of aphthae of the mouth, have varied according to the particular opinion of each upon the nature of the disease. For our part, seeing nothing more in it than an inflammation of the follicular apparatus of the mucous membrane of the mouth, we advise, in the first place, an antiphlogistic course. Yet as there are among the means advised, according to particular views, some medical agents capable of advantageously modifying and overcoming this inflammation, we will but perform our duty in pointing them out. When aphthae exist in a mild form, it will be necessary to wash the mouth with a piece of lint dipped in a decoction of marshmal- lows, barley-water, or milk and water. The vapor from a decoc- tion of marshmallows or simple water, is also a useful remedy. The general condition of the constitution ofthe child, and its causes, unhealthy air and bad diet, should be borne in mind. We often see infants artificially fed, suddenly acquire a good condition upon being placed in the care of a good nurse, and al- ter from a state of weakness and decay to which they had been reduced by insufficient or bad food : it will be necessary then to remove from infants affected with aphtha?, all the causes capable of favoring in them the predominance of the lymphatic system, in having, at all times, a proper regard for the condition of the digestive organs, and not irritating them by the internal adminis- tration of tonics. When the aphtha? remain stationary, or are confluent, and re- * Traite complet d'accouchemens, etc., t. 4. ON THE DISEASES OF INFANTS. 179 sist simple antiphlogistic means, then it would be well to sub- stitute acidulated gargles for emollient drinks. A mixture of barley-water and honey of roses, with a few drops of sulphuric acid, may also be used with benefit. In order to change the mode of irritation, and to dispose the inflamed surfaces to cica- trize, it will be advantageous sometimes to touch the ulcerated part with a piece of alum. Aretaeus long since advised the use of alum as a topical application, in the treatment of chronic in- flammation of the mouth and throat. It should always be used with caution, and employed alternately with demulcent gargles and no irritation produced beyond what we wish to obtain by this therapeutic agent. I will not speak of other stimulating means, such as borax, sulphate of zinc, etc., because alum, which is innocent if cautious- ly used, will accomplish the same end. Gargling with chloride of soda, as advised by Guersent in muguet, should not be neglect- ed in this disease. If the child, by its cries, gives evidence of excessive pain, a little syrup of poppies ought to be added to the gargles, in the pro- portion of one to two drachms to two ounces of mucilage or gum- water. As to tonics, emetics, and purgatives, it appears impossi- ble, by the internal use of them, to obtain any exclusive or gene- ral result. We will return to the consideration of their employ- ment, when the history of the phlegmasia? of the digestive tube becomes the subject of our remarks, when this complication will be examined. If aphthae should become gangrenous, the treatment recommended in the article on gangrenous stomatitis, must then be adopted. If they are complicated with a cutaneous affection, we should endeavor to ascertain and establish its char- acters, in order to treat it according to its nature, progress, and the indications it presents.* ULCEROUS STOMATITIS. Besides the ulcerations which succeed the disorganization of the follicles, there often exist both in new-born infants and in those a little advanced in age, ulcerations in the mouth of a dif- ferent character. These ulcers occupy indifferently every part * See Appendix. 180 ON THE DISEASES OF INFANTS. ofthe buccal cavity. I have seen them on the froenum of the tongue, at its base, and on the internal surface of the cheeics, and on the palatine arch ; they may occur in different ways. As these ulcerations have been, and still are, confounded with aph- tha?, I think it will be well to begin their history by the detail of a few cases. CASE X.—Gastro-enteritis, ulcer at the base of the tongve.— Chabert, a male child, aged eleven days, of strong constitution, but pale, and a little emaciated, entered the infirmary on the tenth of April, 1826. He had a slight coryza, and a diarrhoea of green dis- charges. The abdomen was distended with gas; there was no fe- ver. A tisan of rice, and injections of starch were administered. On the thirteenth, the diarrhoea ceased; the buccal membrane be- came red and dry ; the tongue exhibited at the base a sensible tume- faction ; the cry of the child was painful without any alteration in the tone. (Gummed rice water, emollient gargles.) On the fifteenth the diarrhoea returned with increased violence. The discharges were no longer green, but were liquid, frothy, and white. The child soon became atrophied ; the centre of the tumefaction at the base of the tongue softened, and became yellow. On the sixteenth, emacia- tion had made great progress; the pulse was feeble; the skin dis- cojDred and dry, the inferior extremities were infiltrated, the abdo- men very much distended, the diarrhoea continued, and the base of the tongue exhibited an elliptical ulceiation, the borders of which were depressed, and the centre red and sanguinolent. This ulcera- tion spread more particularly towards the left lateral portion of the base ofthe tongue. (Gummed rice water, starch injections, emol- lient gargles.) The child died during the night. Post mortem examination.—Oesophagus healthy ; stomach con- tracted, with red points and iidges on its surface ; small intestines healthy, but the large presented a general discoloration and soften- ing of their internal membrane. The circulatory and • sensitive ap- paratus were healthy. This ulceration was doubtless caused by acute inflammation of the membrane of the tongue, and differed essentially from the ulcer arising after aphthae. CASE XI.— Ulcer of the arch of the palate.—Derpois, a boy aged nineteen days, entered the infirmary on the 1st of February^ 1826. V ON THE DISEASES OF INFANTS. 181 This child was small, thin, and pale ; his skin hot, and pulse scarcely perceptible ; his tongue very red at the extremity, but was white at the base; there was a slig'it tumefaction of the abdomen, copious diarrhoea, and frequent vomiting. (Gummed rice water, cataplasm to the abdomen.) On the 4th of February, the mucous membrane of the arch of the palate became tumefied, and very red at a circum- scribed point; the general condition of the child was not altered. (Same treatment, emollient gargles.) On the 8th, the diarrhoea in- creased ; the child was excessively pale, slightly agitated, often drowsy, and had rapidly become emaciated ; the mucous membrane of the mouth presented an irregularly rounded ulceration ; its edges were tumefied, hard, and red, and the centre yellow; the centre was about two lines in diameter. On the 12th, same condition ; the ulcer remained indolent; nothing used but a wash of marshmallows. The child vomited almost every thing that was given. On the 16th he died. Post mortem examination.—Complete marasmus, and an exsan- guined state of the integuments. The mouth exhibited, besides the ulceration mentioned, an intense redness of every part ofthe buccal membrane, and a very strongly marked tumefaction existed at the base ofthe tongue and the lateral parts ofthe pharynx. The oeso- phagus was injected ; the internal surface of the stomach, which con- tained coagulated milk, exhibited a rosy hue ; the duodenum was healthy. From the middle of the jejunum to the ileo-coecal valve, the internal membrane of the intestine was of a deep red, tumefied, and friable ; towards the extremity ofthe ileon it was less red, but it was in a pulpy, softened condition. The large intestines were healthy. The other organs presented nothing remarkable. The ulceration in this instance was much more advanced than in the preceding case. It was evidently the result of inflamma- tion of the buccal membrane, which was found very much in- flamed, particularly about the pharynx. In dissecting the body of a child, whose case I had not exam- ined during life, I found upon the internal surface of the lower lip, end on its left side, a large superficial ulceration, the irregu- lar edges of which were tumefied, and upon the sides a curdy excretion, analogous to that sometimes seen in aphthae. I have often seen the froenum ofthe tongue destroyed by similar ulcers cases of which I shall give hereafter. Denis has observed a 182 ON THE DISEASES OF INFANTS. softening of the mucous membrane of the palate, which, accord- ing to this author, almost always occupies the centre of the pa- late, on the median line. Sometimes it is situated on the outside of this line ; the mucous membrane, red, inclining to a fawn co- lor, is changed to a kind of pulp. If it be raised, it will be ob- served that the edges of the ulceration are perpendicular, and that the bottom of the ulcer is formed of the bone apparently in a healthy condition.* M. Baron has told me that he has several times seen this disorganization, an affection which I have not as yet happened to meet. The treatment of these ulcerations differs but little from that of aphtha?; when they resist the use of emollient gargles, and continue to increase, we should then endeavor to arrest their ra- vages by touching them with mild escharotics; and if they ter- minate in gangrene, recourse must be had to the active measures pointed out hereafter. The softening ofthe mucous membrane is a very serious alter- ation, and one which I believe it is impossible to remedy. PUSTULAR STOMATITIS. I give this name to the inflammation which is developed during the course of small-pox, producing pustules analogous to those on the skin. As it presents no particular indication, and as the treatment is comprehended in that of the cutaneous phlegmasia?, T merely mention here this variety of buccal inflammation, the development, progress, and termination of which is connected with the development and progress of variola. I have not been able to establish exactly the seat of this alter- ation, which, from the analogy it bears to the cutaneous inflam- mation accompanying it, I regard as pustular. GANGRENOUS STOMATITIS. Gangrene of the mucous membrane of the mouth, may occur in various ways. It may be the termination of the various kinds of stomatitis already described, but particularly of the follicular variety. It may be developed as an effect of some particular al- teration arising, in the first place, in the soft parts ofthe buccal pa- * Denis, loc. cit. p. 109. ON THE DISEASES OF INFANTS. 183 rietes, the causes and nature of which we will endeavor to state. Gangrene which shows itself on the ulcerated points of the mouth, has been pointed out by a number of authors. This is what is ordinarily designated by the name gangrenous aphthae. I believe also that aphthas have been sometimes regarded as gan- grenous when they were not so, as has already been observed. When aphthae become gangrenous, their edges shrink and as- sume a burned, torn, and flabby aspect; then a brown eschar often forms in the centre, which soon detaches itself, leaving a granulated surface of a vermilion color. In place of an eschar, the centre of the ulcer sometimes gives off a creamy substance of a brown color, and of a very evident gangrenous odor. The surrounding parts tumefy, assume a violet aspect, become softer, and are easily depressed. In the mean time, from the mouth of the child, always half open, there flows a ropy saliva. The face becomes pale; the patient remains drowsy, and sinks without having exhibited any febrile reaction or cerebral excitation. The pulse remains always extremely feeble, and the skin is remarka- ble for its pallidness and insensibility. To these symptoms there are often added vomiting, diarrhoea, and distention of the abdo- men, and sometimes hiccup and frequent eructations. This termination of aphtha? is extremely fatal, for it happens usually at a period when the child, wasted by the previous phlegmasia with which it was affected, affords no opportunity for the administration of therapeutic agents demanded by its situation. As soon as the gangrene is formed, it will be necessary to touch it with gum-water, slightly acidulated. Should this appli- cation effect no alteration in the aspect of the ulcer, sulphuric or muriatic acid must be used. In order to apply them in the easiest manner, a glass capillary tube may be used, immersing one end in the acid, and drawing up one or two drops, which may afterwards be deposited on the surface of the ulcer, with the end ofthe tube. After the application of these acids, and when the eschar is detached, it will be necessary to touch the remain- ing gangrenous parts with a stick of nitrate of silver, sharpened at the point; for by using the acid again, it might touch the parts deprived of the eschar, and which are then in a state of ex- treme irritability. It is much easier to moderate and limit at 184 ON THE DISEASES OF INFANTS. will the action of nitrate of silver, which however does not act very deeply if it be used at first. Our remarks on gangrenous aphtha?, apply to all ulcers of the mouth which assume that character. I shall now consider gangrene ofthe mouth properly so called, that which does not follow any well characterized inflammation, but appears to be brought about by some particular alteration of/ the parietes of the mouth. This disease has, for a long time, attracted the attention of the physicians ; but it is not until quite recently that it has been stu- died with much attention, and it is to the works of MM. Baron, Guersent, Jadelot, and Isnard,* that we are indebted for positive data on this disease. When the commentaries of Van Swieten on the aphorisms of Boerhaave arc examined, it will be seen that this physician has spoken particularly of the destruction of the tissues ofthe gums by gangrene or softening, an alteration which will be examined below, and that he has not described with pre- cision the gangrene of the mouth, as we, at the present day, un- derstand by the disease, and as is described in the works of the authors above mentioned. Van Swieten says, " Si aidem niul- turn tumeat gingiva, simulque adrnodum rubeat, validm, in- flammationis sigttum est quemadmodnm in gangranum satis cito terminatur, precipue si acrior humorum indoles simul adsit.y'i In gangrene of the mouth, which we propose to de- scribe, not only may there be destruction of the gums, but also of the mucous membrane of the parietes ofthe mouth, in every part of this cavity. In studying this affection, we must not confine ourselves sole- ly to the time of the appearance of the eschar or point of disor- ganization, which constitutes the principal characters of this dis- ease. It is necessary to ascend higher, and to examine well the morbid condition which precedes and leads to the gangiene. We have seen, in treating of the diseases of the skin, that in young infants, the feet, hands, and labia pudendi, were subject to indolent swellings, which frequently, in place of disappearing, * Baron, Mem. sur une affection gangreneusc de la bouche. Bulletins de la facul- te. Isnard, Dissertation sur une affection gangreneuse particuliere aux enfans. Paris, 1818. t Van Swieten, in Boerhaave Aphor. com. morbi infantum, t. 4. ON THE DISEASES OF INFANTS. 185 terminate in gangrene. The same phenomenon occurs at the anterior orifice and at the parietes ofthe mouth of some infants. Indeed those children that are born feeble, and in a kind of stu- por which denotes a low degree of vital energy, often exhibit indolent swellings, of which the following case will furnish an example. CASE XII.—Adele Montaban, aged one month, has been nursed at the hospital from birth ; Avas of a very feeble constitution ; color pale, abdomen habitually distended ; and she vomited the milk she had taken. She entered the infirmary on the 4th of February, 1626. Besides the signs already indicated, she presented the fol- lowing symptoms: the drinks vomited shortly after being taken ; edges of the tongue red ; abdomen tympanitic ; diarrhoea of yellow discharges ; redness about the anus. (Gummed rice water, emoU lient fomentations to the abdomen, milk and water.) She continued for eight days in the same condition. On the twelfth, some spots of muguet appeared on the surface of the tongue; emaciation made ra- pid progress ; the child exhibited a chlorotic paleness; and the face was swelled and infiltrated. On the fifteenth, infiltration ofthe face had much increased, and a well-marked tumefaction of the upper lip was also observed, which was thereby half raised, leaving the mouth partly open ; the eyelids also were slightly cedematous. The gene- ral condition of this child was remarkable for nothing except the uni« versal sinking and prostration which it presented ; there existed no febrile action. (Gummed rice water, milk and water.) On the eighteenth, the diarrhoea and vomiting had ceased ; the face and lip in the same condition. On the twentieth, the tumefaction of the up- per lip was much greater, the border of which had become of a vio- let color ; general coldness ; the cry, which before had been feeble, was not now heard ; the pulsations of the heart were very slow, irregular, and trembling; the child died on the night of the twen- tieth. Post mortem examination.—Upon dissecting the upper lip, there was found a citron-colored serum mixed with drops of blood, infil- trated through the subcutaneous cellular tissue ; the membrane on a level with this part was tumefied and very soft; the inferior lip also presented a slight cedematous tumefaction. On the froenum of the tongue there was a superficial ulcer, which had not been observed during life. The glottis was the seat of an cedematous swelling, and the oesophagus that of a sanguineous congestion. The stomach was 186 ON THE DISEASES OF INFANTS. healthy; the duodenum, which contained a viscid fluid of the color of bistre, exhibited a number of red stria?. The remainder of the small intestines were only of a slight rose color ; yet the internal membrane was tumefied and friable. The colon presented some red stria?, and between them, several of a slate color. The liver and the two lungs were gorged with blood. The foramen ovale was still open, but the ductus arteriosus obliterated. The vessels of the peri- phery ofthe brain were engorged, the ventricles containing but little serosity. This case is remarkable, inasmuch as the external condition of this child, the paleness and sinking, appeared to indicate the employment of tonics, which must have been injurious to the di- gestive passages in their inflamed condition. Perhaps this ge- neral sinking might be attributed to a sanguineous congestion of the principal organs of the circulatory apparatus. Be this as it may, we ought to note the cedematous swelling of the upper lip, which, if the death of the child had not occurred, would doubt- less have led to, the disorganization of which the following cases furnish us examples. CASE XIII.—Rose Camusot, aged twelve days, born feeble and wretched, wasted daily while in charge of the nurse to whom she was confided. She was brought to the infirmary on the 9th of July, 1826. She was pale, cried aloud, and was at times drowsy. The temperature of her skin was natural; the pulse beat from seventy to seventy-two ; the pulsations were small and sometimes indistinct. (Milk and water, with barley-water.) In the same condition until the fifteenth. Emaciation then advanced; great paleness; tongue very red and dry, and covered with spots of muguet at the edges. (Gargles of marshmallows, milk and water.) Ojj the fifteenth, the muguet was more widely spread on the surface of the tongue ; all the lower parts of the face were cedematous, and the lower lip became the seat of a considerable tumefaction, in consequence of which it was turned downward ; the skin covering it had an oily appearance. The mucous membrane was, as it were, ecchymosed at the internal part of this lip. (Gargles of a decoction of cinchona, acidulated, milk and water.) On the twentieth, the swelling of the lip had made great progress; a large violet .*pot, analogous to what is known by the name of na?vus, showed itself on the integuments of the lower lip, which was quite hot to the touch. The pulse was ON THE DISEASES OF INFANTS. 187 slow and almost imperceptible. The child, in a state of complete exhaustion, had neither vomiting nor diarrhoea. This state contin- ued until the twenty-second, and in the same night she died. Post mortem examination.—When the lower lip was dissected, an infiltration of bloody serum was found, the accumulation of which gave to the tissue of the lip a thickness of about four lines ; the mu- cous membrane began to detach itself on the internal surface of the maxillary bone. But slight traces of muguet continued on the tongue. The stomach exhibited a violet color ; the internal mem- brane was tumefied and friable ; all the intestinal tube was covered with red stria?, the mesenteric ganglia were redder and more tume- fied than in the natural state. The lungs were healthy ; the ductus arteriosus was obliterated, and the foramen ovale still remained a little open ; the brain was perfectly healthy. We have seen in this latter child, an erosion or an ulceration ofthe mucous membrane ofthe mouth follow the oedematous tu- mefaction of which the walls of this cavity had, for some days, been the seat. We shall see, in the following case, gangrene making wide spread and rapid progress. CASE XIV.—Delosane (Victoire,) aged nine days, entered the in- firmary on the 5th of January, 1826. General oedema was present', color of the integuments of a medium tint; pulse full, irregular, and a little frequent; the cry but little developed, and possessing a slight huskiness ; the chest, on percussion, returned an obscure sound on the right side. (Pectoral infusion, sweetened milk and water.) From the fifth to the eighth, no remarkable change was manifested, except that emaciation had commenced. On the eleventh, the left side of the face was sensibly swelled ; the gums of the same side tu- mefied ; the cry was feeble, and a constant discharge of a mucous san- guinolent fluid took place from the mouth. There was not the slightest febrile action. (Sweetened barley-water, emollient gar- gles.) On the twelfth, the swelling of the face had made frightful progress, and the child was much disfigured; the cry smothered; cedema of the limbs continued ; the mouth, which was almost con- tinually filled with bloody mucus, emitted an odor of rotten eggs. The tumefaction corresponding with the gums, had not made as much progress as that of the face. M. Baron directed my attention to the smooth and oily aspect of the cedematous part of the face; in the middle of this tumefaction appeared a round spot about the size 188 ON THE DISEASES OF INFANTS. of a ten sous piece, of a dull red. In the centre of the cheek was a small part much harder than the other parts. (Acidulated gargle, milk and water.) On the thirteenth, a round eschar, brown in the centre, and yellow at the borders, appeared at the internal surface of the swelled cheek, and extended to the lower part of the gums, near which there existed a deep erosion, the edges of which were brown, and appeared as if burned. It exhaled from the mouth a well-mark- ed gangrenous odor. The red spot on the exterior of the cheek had assumed a violet color. The child was much sunken, quiet, and without fever. On the fourteenth, the eschar was enlarged ; it had invaded the whole of the cheek, on the interna] surface of which it was soft, brown, and surrounded by a circle of a violet red. The erosion of which I have spoken, was replaced by a sinus of some depth, formed by the sloughing of the mucous membrane. From this sinus, there issued a brown, bloody, viscid matter. The child died at night. Post mortem examination.—The face still presented the same cedematous tumefaction which was observed during life; the eschar in the centre ofthe cheek was of the consistence of cream, and se- parated in shreds; the tissue of the cheeks exhibited a lardaceous aspect; the gums were entirely destroyed by gangrene at the cor- responding part ; the inferior maxillary bone was bare; the oesopha- gus was injected ; spots of red were found in the stomach ; general injection of the capillaries of the small intestines ; the large intestines were healthy. I dissected the arteries, veins, and nerves going to the cheeks, without finding any thing worthy of remark in them. There were also solid cellular adhesions between the pleura cos- talis and pleura pulmonaris of the right side ; the lungs of this side crepitated. The right lung was much infiltrated with blood in the inferior lobe, while it crepitated at the superior part. The pericardium was a little distended, and contained nearly two spoonsful of puriform serum ; the internal surface of the pericardium exhibited a slight red; the membranous covering of the heart was very red, and was spread over with a pseudo-membranous exuda- tion about the thickness of letter-paper ; this exudation was of greater thickness at the auricles than at the ventricles ; the tissue of the heart was dense and very pale; the foetal openings were obliter- ated. The brain-exhibited a general congestion. This case presents several interesting points, such as chronic pleurisy and acute pericarditis; but in order to confine our- ON THE DISEASES OF INFANTS. 189 selves to the subject before us, let us fix our attention particularly on the progress ofthe gangrene ofthe mouth, and let us notice— 1st, The cedematous swelling of the check, the skin of which had assumed an oily aspect; 2dly, The indurated spot which showed itself in the centre ofthe engorgement, and which without doubt resulted from the commencement of the disorganization of the cellular or adipose tissue; 3dly, The muco-sanguinolent dis- charge; 4thly, The violet spot replaced by an eschar; othly, and lastly, The extensive disorganization of the cheeks and of the tissue ofthe gums in the spot corresponding with the eschar, which had presented all the characters of gangrene, and which first showed itself at the point of contact ofthe buccal parietes and the inferior maxillary bone. M. Baron, in his excellent memoir on the gangrene of the mouth, inserted in the Bulletins de la Faculte de Medicine de Pa- ris, has also pointed out these various stages of the disease now under consideration, and to which practitioners ought carefully to direct their attention ; for by closely observing their approach, all the evil consequences which follow may be prevented, and this disorganization encountered before its arrival at a stao-e which, for the most part, is incurable and mortal. There may be two well-marked stages in this disease:—1st, An cedematous, circumscribed tumefaction, characterized by an oily aspect of the skin, and by a central body more or less hard, on which there is sometimes an obscure red spot, either oh the internal or external surface of the buccal parietes; this is the first stage, and in young infants is not accompanied with fever or any symptom of reaction ; 2dly, This central part presents an eschar which usually forms from within, the mucous membrane becomes disorganized, the bones are laid bare, all the soft parts, even to the periosteum, mortify and separate in shreds, at the same time that the mucous or bloody matter, mixed with the re- mains of the gums or sides of the mouth, flows out, exhaling an infectious odor ; this is the second stage. Gangrene of the mouth must not be confounded with malio-. nant pustule, for, as has been well observed by Rayer, the o-an- grenous inflammation commences in the interior of the mouth and from thence spreads to the skin. There is nothino- to prove the contagiousness of this disease; it is usually observed in one 190 ON THE DISEASES OF INFANTS. patient at a time, in an hospital, even when surrounded by num- bers of other children. It is difficult to explain the cause of this gangrene; neverthe- less it is a fact which ought to be taken into consideration, that cedema and indolent tumefaction always precede the formation of the eschar. Is it because the blood no longer circulating in the capillary vessels, the lymph and serum engorge and. spread through the cellular tissue, and the parts which the blood should nourish become thereby disorganized? I cannot answer this question positively; but I can at least observe that this gangrene, far from proceeding from inflammatory action, is, on the contra- ry, the result of an indolent engorgement, analogous to that which constitutes anasarca. In the latter case, the parts of the body which are compressed readily become gangrenous; now the internal surface of the mouth, the walls of which are thus tu- mefied and infiltrated, become gangrenous at first at the part where it is exposed to pressure, opposite the horizontal part of the jaw and the dental arch. It appears, then, that gangrene is the effect of cedematous tumefaction, the cause of which we will now endeavor to ascertain. It is well known with what facility the cellular tissue of new- born children is infiltrated, until so great a tumefaction is pro- duced as to have induced several authors to call the oedema by the name of induration of the cellular tissue. This disposition to serous infiltrations, at the same time exposes them to indolent engorgements and to gangrenous phlegmasia? of the skin and extremities. The frequent occurrence of gangrene in the fin- gers, toes, and vulva of very young infants, has already been al- luded to when treating of the diseases of the skin. Now, does not this species of alteration coincide in the frequency of its oc- currence with the predisposition of infants to cedema ?—a predis- position which, without doubt, arises from the actual state ofthe circulatory apparatus, the exercise of which is not as yet perfect- ly regulated ; and probably also from the superabundance of se- rum in the blood of young infants. This would appear to be the cause of cedema, which, in its turn, becomes the predisposing cause of gangrene. If we will now consider the development of gangrene of the mouth in children more advanced in age thau those° whose cases ON THE DISEASES OF INFANTS. 191 have been detailed above, we shall see that this disease shows it- self principally in such children as experience a general infiltra- tion which so frequently follows cutaneous phlegmasia?, as vario- la or rubeola. They are then in a morbid condition analogous to the usual state of new-born infants during the first months of life. Among the children that are the subject of M. Baron's es- say, several had had rubeola and were affected with gangrene of the mouth, at the same time that the face and limbs were cede- matous.* It is not without a proper motive that I have entered into these considerations on the causes and nature ofthe diseases of which we are now treating, for these data may enlighten us in the choice of the proper treatment. Treatment.—The treatment should vary according to the pe- riods of the disease ; when there exists a general infiltration, it will be necessary to meet it by the means pointed out in the chapter on cedema, or induration of the cellular tissue; if this in- filtration should become local, if the face, for example, should continue solely to be its seat, the removal ought to be attempted by aromatic or dry frictions. If the cedema become circumscribed, if it exhibit a nucleus of engorgement harder than the other parts, more energetic measures must be adopted, particularly frictions with ammoniacal liniment: the cheek should be covered with compresses saturated with a weak solution of hydrochlorate of ammonia. I believe it will be imprudent to make use of mer- curial frictions on account of the liability of the buccal mem- brane to ulceration from its use, and it is well known that when this membrane is once ulcerated, gangrene makes extraordinary and rapid progress. Lastly, if at the interior of the mouth a slight erosion, and on the exterior a violet ecchymosis, should appear, it will then be necessary to resort to extreme measures, and cauterize the cen- tral part of the tumefaction, either with the butter of antimony introduced to the bottom of a crucial incision made on the out- * A similar affection may also be developed in the genitals. They have been ob- served under circumstances analogous to those which appear to influence the com- mencement and progress of gangrene of the mouth. We will be contented to point out at present the coincidence. In the article on the diseases ofthe generative organs, we will cite in its support a remarkable example of gangrene ofthe vulva. 192 ON THE DISEASES OF INFANTS. side ofthe cheeks, or, what is still better, with the actual cautery. This latter method of cauterization appears to M. Baron prefera- ble to potential cautery, and he insists on its employment as the sole means of restoring the health of the patient; it will be ne- cessary to have recourse to it as soon as possible, for if we await the progress of the disease before deciding on its employment, it will be necessary to destroy a great part of the cheek, and thus / expose the child to the certainty of having a much larger cica- trix. The mouth should, at the same time, be washed Avith ho- ney-water, or acidulated barley-water. When the eschar is detached, or when it has been destroyed by caustic, it is well to have recourse to emollient cataplasms and lotions, in order to moderate the inflammation. As to general treatment, I attach less importance to it, because the slowness and uncertainty of its action will never compensate for the advantages of caustic applied directly to the seat of a dis- ease the progress of which is of so frightful a nature. The strength of the child should at all times be sustained with a mix- ture of equal parts of milk and broth, or by giving a few spoons- ful of Malaga wine in the course ofthe day. Internal stimulants should be employed with caution, and the practitioner must not lose sight ofthe fact that, in spite of the apparent feebleness of the subject, the digestive tube is sometimes the seat of an irrita- tion and inflammation, which may be much exasperated by the use of stimulants. Yet, if the abdomen be without pain, if there be constipation, it would be well to try the effect of calomel, or of injections composed of a solution of sulphate of soda and olive oil, or castor oil. As the object is to augment the intestinal secre- tion, and to establish a revulsion on a part of the digestive passa- ges opposite to that occupied by the disease, calomel and sul- phate of soda ought to be preferred ; the former taken by the mouth in syrup, the latter given in injections.* § IV. Diseases of the parts contained in the mouth* Glossitis.—Glossitis is an inflammation of the fleshy part of the tongue. I have not observed this disease in infants at the breast. I have already spoken of ecchymoses, which may often * See Appendix. ON THE DISEASES OF INFANTS. 193 be met with at this age in the tissue of this organ, and which must not be confounded with the traces of inflammation ; neither should the hardness ofthe tongue, which is seen almost always in children after death, be regarded as a pathological condi- tion ; this hardness is the result of a sort of cadaveric rigidity, or a kind of spasmodic contraction of the muscles of the organ, which occurs at the approach of death. As to the inflammation of the mucous membrane of the tongue, its history is contained in that of stomatitis; on this account, I abstain from treating the subject separately. Section II. OF THE DEVELOPMENT AND DISEASES OF FIRST DENTITION. Art. 1.—Of the development of the Teeth. In general, there is great importance attached to the pathological phenomena connected with the development of the first dentition. It has been customary to attribute them to the effort that nature ap- pears to make for the protrusion of the teeth : it is in the state of the gums, in the inflammatory action which takes place there, in the pruritis, congestion, and pain, that the causes ofthe various af- fections to which a child is liable at this age are sought. I believe th.it this manner of viewing the subject is too exclusive, and that it is wrong to admit these causes in so general a manner: and I pro- pose to show that there is another reason for all these symptoms, which it is necessary to consider, in order to treat methodically and successfully young infants that are affected with symptoms usually attributed to slow, painful, and difficult dentition. In order to demonstrate the views I entertain, it is necessary to examine what takes place anatomically and physiologically in the development of the germ of the teeth, and of the teeth them- selves, from their first appearance until their protrusion through the gums; considering afterwards the pathological phenomena of dentition. There exists between the development of the dental follicles, and that ofthe maxillary bone, some very remarkable relations.' In the embryo of about three months, the alveolary borders of the two maxillary bones consist in a uniform groove, narrower 194 ON THE DISEASES OF INFANTS. towards the median line than towards the molar portion, enclos- ing a number of follicles which, without being joined together, are yet grouped so closely that they appear to form one many- lobcd mass. From four to five months these lobuli, which are the dental follicles, are more distinct, and in place of being group- ed together, they form a kind of elongated cluster, composed ge- nerally of eight distinct follicles ; they are all contiguous, and may be raised from the groove of the maxillary bone, and if care be taken in the dissection, the artery and nerve may be raised at the same time with them. If the common alveolar cavity be then examined, there will be seen on the two lateral parietes, small vertical projections, corresponding to the slight furrows which separate the follicles, the adhesion of which could not be called in question, since they can be raised together, and cannot be separated without destroying their reciprocal adhesions. In proportion as the fcetus approaches the period of birth, these commencements of the alveolar partitions become more evident; these projections meet together and unite, forming so many seg- ments or transverse partitions, the intermediate spaces between which constitute the alveoli. It has been remarked that all the dental follicles have a globular form ; but from the moment the alveoli are formed, they cease to continue of that shape, the osse ous plate cuts them, if we may say so, into several small separate follicles, which are attached to the bottom of the maxillary groove by a filament of nerve and a branch of an artery; these follicles receive their form and direction from the cell in which they are enclosed. At birth, these are generally found in the lower and upper jaw, and particularly in the lower five well-marked partitions; the first two spread laterally, and are destined to receive the two inci- sors ; the third, narrower andgencrally oblique from below upward, and from behind forward, are squeezed between the first two and the fourth ; it contains the canine teeth ; finally, the fourth, broader and rounder, is the alveolus ofthe first molar. The partition of this alveolus opposite to that which separates it from the canine tooth, is found at theperiod of which we are speaking in the mid- dle of the space comprised between the symphasis of the lower jaw and thecoronoid process; so that the fifth alveolar cavity of a new-born child extends from this intermediate point beyond ON THE DISEASES OF INFANTS. 195 this process--that is to say, almost half the distance comprised be- tween the process and the maxillary symphasis. In the remain- der ofthe dental groove, there is already to be seen the rudiments of a partition which is to separate it into two sections, for the se- cond and third molar teeth. At the bottom of the new alveoli, which are not yet perfectly formed, the dental artery and nerve are to be seen directing their course towards the internal part of the mouth and sending branches to the dental germs. Our remarks as to the formation of the dental alveoli will ap- ply particularly to the lower jaw. The same phenomena occur in the upper jaw, but the dental groove being narrower and shorter, the alveoli form in a manner more irregular and less dis- tinct, although in the main the same process takes place. But let us see what occurs in the germs of the teeth during the process of the ossification of the jaws. Each follicle, we have said, is isolated in its alveolus ; this fol- licle, the structure of which it is somewhat difficult to see, ex- hibits more evidently at this time the elements of its composition. When the groove was single it was lined with an extremely thin membrane, which was at the time joined to the follicular mass. In proportion to the formation of the alveolar sections this membrane is divided, and forms, in remaining united with the internal surface of the alveoli, what is denominated alveolar periosteum. The follicle is composed of two membranes, difficult to see, it is true, but described by J. Hunter, Fox, Black, Bichat, and Meckel. Between these two membranes, says Meckel, is found a fluid more or less abundant in proportion to the age ofthe fcetus. Meckel has well described these two membranes, and I have been able to establish, with the greatest facility, on the dead body, the description he has given. " The external layer is more spoiisy, looser, thicker, and softer than the internal. It is very distinctly continuous with the gum ; whence it is easy, in the fcetus, espe- cially during the early months of pregnancy, to extract the alveoli attached to the gum. "The internal layer is harder, but thinner, than the external. We can demonstrate that it forms a sac entirely distinct from the external and from the gum. Its relations with the teeth are more intimate than those of the external layer, for it is the proper or- 196 ON THE DISEASES OF INFANTS. gan of formation. The vessels of the teeth are distributed there much more evidently, and when injections succeed, it appears entirely red."* This double sac encloses at first nothing more than a red or yellow fluid, but by degrees there is formed in the centre a point of much greater consistency, which, it is said, is itself enveloped in a thin membrane, and which constitutes the germ of the tooth. In proportion as the follicles become more developed, and the al- veolus begins to enclose it, the germ is more distinct; and, ac- commodating itself to the cell which contains it, begins to take the shape ot the tooth by which it is to be succeeded. Lastly, about the end of five months, at the superior part of the germ of the incisor teeth, there appear two or three small red indurated points, almost always situated at the side. These small points soon unite, thus forming a species of bifurcation, of which the incisors sometimes exhibit a trace on their protrusion. After- wards a similar point appears at the summit ofthe follicle ofthe canine teeth, and several others on those of the first molar. Small scales quickly succeed these primitive indurations, soli- tary in the incisors and canine teeth, multiple and distinct in the first molar. These scales already present an osseous consistence; they gradually enclose the pulp, to which they are solidly adhe- rent, as they increase in size. It is evident that they are the pro- duct of a kind of secretion taking place on the surface of the den- tal germ. This ossification soon makes progress from above downward; and when it has taken the form of the crown of the tooth, it then exhibits a depression or circular neck, below which it elongates in the form of a root. Hitherto, we have seen that it was at the external surface ofthe germ that the ossification commenced, proceeding from within outwards, so that, the little osseous crown encloses in its cavity the pulp or germ, and is enveloped by the double membrane which formed the walls of the dental follicle. The internal layer of this double membrane, applied directly to the point of ossifica- tion, secretes, according to the greater number of anatomists, the enamel of the teeth. * J. F. Meckel, Manuel d'anat. general, descript. et pathol. traduit par A. Gourdan et G. Breschet. Paris, 1825.—[V. English translation by A. Sidney Doane, M. D., v. 3, p. 231.—S.] ON THE DISEASES OF INFANTS. 197 Thus the phenomena of the ossification of the jaws, and those ofthe development ofthe teeth, are simultaneously affected dur- ing the continuance of the foetus in the uterus. From this pe- riod, the disposition, form, and progress of the teeth, appear to be governed by the development of the maxillary bones, and the changes which occur in the dental groove. This assertion is supported by the well-known fact that the alveoli are much sooner formed in a distinct manner in the lower than in the upper jaw; and it is in the lower jaw that the teeth are developed first, and appear sooner on the outside of the gums at the time of den- tition. Until this time, the teeth did not require to be separated from each other, and to have, as we may say, a separate existence; but the development ofthe alveoli has placed them in a suitable con- dition for such a change. We shall now see by what mechanism they shoot up from the jaws, pierce the gums, and protrude into the mouth. There have been two different opinions presented on the sub- ject of dentition. M. Serres has advanced the idea of the exist- ence of some force exterior to the tooth—a species of gubernacu- lum - drawing and conducting it to the outside of the gums.* Other authors have found the cause existing only in the evolu- tion ofthe tooth. For my part, I have not seen the gubernacu- Ium spoken of byM. Serres, and am persuaded that this protru- sion of the teeth depends both on their evolution and the con- comitant development of the maxillary bor.es ; it is then a phe- nomenon almost of a mechanical nature, which has been vainly sought to be explained by brilliant theories, but which simple anatomical observations have enabled us to demonstrate. Indeed, at the period of birth, the dental germs exhibit points of ossification which, with the exception of the canine teeth, are all situated on the same line, and do not pass the osseous border ofthe dental groove ; the inferior extremity ofthe germ is not as yet ossified ; it remains at this part soft and transparent, and the osseous cap appears to be held at the upper part of the groove by its adhesion to the alveolar periosteum which lines the inferior border ofthe gum. The gum is of a firm tissue, solid and dry * Mem. sur la dentition, inserted in the Mem. de la Soc. Med. d'emul. t. 8. 193 ON THE DISEASES OF INFANTS. enough to have been compared to cartilage, and at the place des- tined to he supplied with the teeth is sufficiently solid to fulfil, provisionally, their functions. Sometimes this border presents projections and depressions analogous to the teeth and the de- pressions which separate them. 1 have seen in a young infant these projections so evident, and possessing so distinctly the shape of the incisors and molar teeth, that it was said the child had fleshy teeth. The tissue of the gums after birth gradually loses its consis- tence ; it becomes soft, and insensibly spreads in such a manner as to exhibit, in place of a continued border, a slightly depressed surface, which does not swell except when affected by inflamma- tion. The opening in it for the passage of the teeth cannot be distinguished. When the cervix of the tooth has acquired a determinate form, the root grows larger and reaches the bottom of the alveolus. The maxillary bone also making progress in its ossification, rises, as it were, to the root of the tooth, and soon there is noth- ing to be seen between the tooth and the bottom of the cell, ex- cept a small space occupied by the pulp, and in part lodged in the dental cavity. The two alveoli ofthe incisor teeth are found to be on the same plane, when they are examined sometime after birth. At four months this difference is still more evident; the inferior maxillary bone at the median line grows rapidly in height and thickness, and appears to raise with it the first incisor, which, gradually entering in the gum, insensibly separates it, and in which it becomes imbedded. Finally, about the seventh, eighth, and ninth month, the first two lower incisors appear out- side ofthe gum. The second incisor tooth shows itself much later, because the bottom of its alveolus being lower by a line, or half a line, than the upper, in order to reach its level, has to pass over a much greater space. I have now before me the lower jaws of four infants that have died at the usual time of the ap- pearance ofthe first incisors; in neither had the second appear- ed. On measuring the length ofthe four incisor teeth they were all nearly the same, having the same degree of ossification ; but the first appeared soonest, because the ossification ofthe jaw had produced an earlier elevation of the alveolus, so that there exist- ed between them a difference of almost a line at the level of their ON THE DISEASES OF INFANTS. 199 insertion : to make a comparison, the bottom of these two alveoli presented the same difference as two consecutive steps of a stairs. The canine teeth do not appear immediately after, because they are much more deeply implanted, are confined, and situated obliquely in their narrow alveoli, and require some enlargement of the dental arch, and ossification ofthe maxillary bone, in order to obtain at the bottom of their cells a point of support necessary for their progress upward. But the first molars, the ossification of which has commenced early, and which are generally more superficial than the canine teeth, appear much sooner than they ; following the second incisor. Lastly, the canine tooth comes in its turn, completing the number of teeth which furnish the jaw during the first year of an infant's life. Dentition usually com- mences from the seventh month to a year; this, however, varies much. From these considerations, which are based upon the rigor- ous observation of facts, it results—1st, That the teeth are the product of secretion ; 2dly, That their development regularly fol- lows the progress of the ossification of the maxillary bones; 3dly, That their appearance outside ofthe gum results in part from the evolution of the teeth, and in part from the development of the ossification and enlargement of the alveoli and dental arch ; 4thly, That the cause of the successive appearance of the first and of the second incisor, then ofthe first molar, and afterwards of the canine tooth, is altogether mechanical ; that it resides iu the more or less prompt formation of the alveoli proper to each of these teeth, and in the greater or less depth of their implantation in the maxillary bone. From this view of the subject, it is not necessary to admit as a cause the gubernaculum dentium of M. Serres. This ana- tomist, moreover, considers it difficult to establish its existence in reference to the first teeth, but that it is easily discovered in the second dentition. It is not my business to consider the pheno- mena ofthe second dentition, but to confine myself to the appear- ance ofthe first teeth. I will, however, make one remark ; it is this—that the teeth of second dentition are less regularly ranged than those ofthe first. If, therefore, the gubernaculum dentium be not chimerical, it is at least very useless, since the teeth are ranged with less regularity at a period when it is more easy to 200 ON TIIE DISEASES OF INFANTS. recognise the apparatus which directs them, than when the appa- ratus is so small that it cannot be seen. As to the follicles which are situated in the thickness of the gums, and which M. Serres considers as destined to lubricate the parts through which the teeth pass, Meckel regards them as new formations produced by the irritation caused by the teeth, and in no respect differing in their nature from that of abscesses.* These follicles, which consist only of a yellow fluid, sometimes thickened, appear to me to be formed in the following manner: during the time the tooth is undergoing development, it presses on all sides the fluid and soft parts which the alveolus encloses; the fluid, which is still at the root ofthe tooth, and which is but the remainder of that which the dental sac contained before ossification, is crowded back, and lodges either at the lateral part or at the summit ofthe teeth. In the molar teeth, the crowns of which exhibit elevations and depressions, this fluid ordinarily lodges in these depressions in the form of small semi-fluid drops, irregularly round. When the gums are torn in the dead body of a child ofthe age of nine months, or a year, there is often found the small yellow bodies pointed out by M. Serres, and there is frequently discharged from the lateral parts of the alveolus a small quantity of viscous fluid, which appears to have escaped by the rupture which was made in e sac containing the germ of the tooth ; so that it is altogether probable that the small col- lection of follicular appearances spoken of by M. Serres are nei- ther follicles nor abscesses, but are the result of an effusion of superabundant fluid contained in the membranes of the germ. This effused fluid may also lubricate the soft parts which sur- round the tooth, and perform to a certain extent the functions attributed by M. Serres to these pretended follicles. It is by considering the development of the teeth as I have done, in their relation to the progress of ossification of the jaws, and of the formation of the aveoli, that we are able to explain without hypothesis and without recourse to theories more bril- liant than true, all the phenomena belonging to the appearance ofthe teeth. By studying dentition, therefore, in this point of view, M. Leveille, in one of the best works which I think has * Loc. cit. t. 3, p. 347. ON THE DISEASES OF INFANTS. 201 been published on this subject, has explained with great clearness all the circumstances of this physiological phenomenon.* M. Delebarre has also made an approximation to the truth, in attaching the greatest importance to the relation between the development of the teeth and those of the jaws.t Art. 2.—Anomalies of t)entition. If all that authors had written on the aberration of the process of dentition should be recorded here, an extended chapter of absurdities would be the result, and on this account I shall merely point out the opinions which appear to be the nearest to the truth, and which anatomy and physiology alone can properly elucidate. The general anatomy of Meckel contains very im- portant details on this subject. The teeth present anomalies in their development ; that is to say, they may appear earlier or later than the period of first den- tition, which is usually from the tenth month to one year. This, however, is of little importance ; neither should there be attached any to the irregularity with which they proceed from the gums. Sometimes children are seen born with teeth ; they are generally the incisors. This anomaly often coexists with a malformation ofthe face, and particularly with hare-lip and congenital division ofthe velum. It is also possible for the mouth not to exhibit the least anomaly, although furnished early with teeth. Such in- stances are found in the case of Louis XIV, and that of Mi- rabeau. These teeth are generally of but short duration, because, being but superficially implanted, they become still less so in propor- tion to the development ofthe maxillary bone, and are on this account quickly shed ; at least, this is what I saw in a child brought in the month of June to the Hospice des Enfans Trouves. It had two teeth, one of which was shed at the end of six weeks, and the other very soon followed. * Mem. sur les rapports qui existent entre les premiers et les secondes dents, etc. Mem. de la Societe med. d'emulation, t. 7 and 9. t Methode Naturelle de diriger la seconde dentition. Paris, 1826. See also the Memoir ot Miel, entitled, Quelque idees sur le rapport des deux dentitions, et sur Vaccroisement des mdchoires dans I'homme. Mem. de la Soc. med. d'emulation, t. 7, 202 ON THE DISEASES OF INFANTS. If these teeth interfere with sucking, they should be removed; for it would be better for the child to be without incisor teeth until the period of second dentition, than to be deprived ofthe means of nourishment, without which its life would be en- dangered. With reference to number, the teeth may present any anoma- lies at the time of first dentition ; and it is not until the appear- ance of the second set that it is possible to find two rows in the same individual, as this results from the continuance of those teeth which, in their natural state, are but temporary. The anomalies of direction and of situation are of more frequent occurrence; even in children in the cradle, they are always the result of malforma- tion in the superior or inferior alveolar arch. It may easily be conceived, that if the alveolus, the shape of which generally di- rects the growth of the tooth, be not readily formed in conse- quence ofthe narrowness of the maxillary bone, the tooth itself will also partake of the same deviation, protruding outside of the line ofthe other teeth, or at some distance from the dental arch. Albinus has recorded the case of an individual in whom there were two teeth of considerable length and thickness, that were hidden in the nasal process ofthe maxillary bone ; their bodies were above, and the roots below.* When the primitive situation of the germ of the teeth is considered, we ought not to be sur- prised at the strangeness of their position, for they neither had the dental groove nor the alveoli to direct them in their develop- ment and progression. He also met with a tooth in the part of the maxillary bone which unites with the palate ; and Sabatier once saw an individual who had two canine teeth in the same situation. It is worthy of remark, that almost all teeth that are thus separated from their natural position, are of this kind. Now, in the development of the germ of the teeth the canine are those which are the last to form; besides, they are often compressed be- tween the other teeth. If the dental arch be not sufficiently spread to allow of a consistent place for the growth ofthe tooth, it may be easily understood how it can be pushed backwards and grow opposite to the place assigned to it by nature. I do not know of any well authenticated cases of molar teeth * Sabatier, Traite complet d'anat. Paris in —12, 3 v. t. p. 80. ON THE DISEASES OF INFANTS. 203 being formed in the place of incisors. I am unable to conceive how this aberration can occur, because the alveolus ofthe incisor tooth is too narrow to enclose a germ of the form proper to the molar tooth ; in every instance this tooth occupying an ununited alveolus, has a singular form, and is nothing more than an abor- tive molar. Teeth may be wanting either in whole or in part. The for- mer case is extremely rare ; yet it appears to have been observed, since Borelli has given the case of a woman aged sixty years. If the primitive teeth are not developed, the permanent may appear much later than the usual time for their protrusion. Certain diseases of the gum and germ, which subject will be considered hereafter, may destroy the germ of the teeth, and thus cause their absence in certain individuals.* If the alveolar partitions, during the development ofthe jaws, be arrested in their formation, and if the dental groove remain free in all its extent, the dental germs are then always grouped and adherent; the teeth which succeed them, are themselves united and form a unique mass, composed of several teeth adher- ing either at their crowns or roots. Soemmering, says Marjolin, has seen an example of this disposition of teeth, which, however, must not be confounded with the union of the teeth by a collec- tion of tartar.t Fox has likewise given cases of the mutual ad- hesion of adjacent teeth by their bodies or roots. I shall here conclude my remarks on the anomalies of the teeth, which are indeed but very rarely met with in children at the breast. Art. 3.—Diseases of Dentition. M. Guersent, in the article on Dentition in the Dictionaire de Medicine, commences with an observation full of truth, and which comes in support of the opinion advanced above. " Most of the diseases of infancy," says this excellent pathologist, " have been attributed to teething. The difficulty of an accurate obser- vation of diseases at this early age, and the little positive know- ledge we possess in this department of pathology, have contribu- * See Appendix. t Marjolin, art. Dent. path, du Diet, de Med. en 21 vol. 204 ON THE DISEASES OF INFANTS. ted greatly to the establishment of this opinion ; and this preju- dice, the result of our ignorance, has at last become popular, like all the other prejudices in medicine."* As I propose, in this work, to elucidate, as far as I can, the diseases of infancy, I shall not treat here of the sympathetic af- fections of dentition, such as fever, convulsions, vomiting, diar- rhoea, etc. I shall consider these symptoms in treating of the his- tory of the various organs, or the systems of the organs, of young infants, and I shall then endeavor to demonstrate how these dis- eases become so common at the period of the protrusion of the teeth, and likewise that they are not the cause of this frequency. I shall also make it appear why convulsions of children at the breast, which, since the days of Hippocrates to the present time, have been attributed to the irritation of the teeth, do not depend directly on this irritation, but are really owing to other causes. I shall then consider the local symptoms of dentition. Dentition being a natural function, may occur without giving rise to the least untoward accident, and, with the exception of an increase of saliva, many children pass this period without any disturbance of their health. Yet there almost always occurs some itching of the gums, which often become a little red and slightly tumefied. This tu- mefaction is generally transient, and the accompanying irritation often imaginary, for nurses suppose that it exists because, in pla- cing their fingers in the child's mouth, it bites with evident gra- tification, thus calming the irritation of the gums. But this con- clusion must be false, for how can we conceive that compression of the inflamed gums on the finger can ease the pain 1 On the contrary, the distress must be thereby augmented, and the eager- ness with which infants bite whatever is put in their mouths, is attributed to the effects of a wish to allay the itching of the gums. Do we not rather see in this the commencement of the proper motion of the jaw, which has just acquired a new degree of development, and is soon to become a part of the digestive ap- paratus ? We have seen that from the period, of birth to eight months or a year, the teeth grow and raise themselves from the bottom of » Diet, de Med. en 21 vol. t. 6. ON THE DISEASES OF INFANTS. 205 the alveoli to the surface of the gums. During this time, an af- flux of blood takes place towards the gums, producing in them and in the jaws a state of congestion and of inflammation; the ulterior progress of which may soften the tissue of the gums, give rise to slight hemorrhages, excoriations, and ulcerations more or less deep, and often end in the destruction of the germs of the teeth. These affections are observed from the most tender age to the time ofthe appearance ofthe first teeth. They must not be con- founded with gangrene of the mouth, already considered; but they have a nearer relation to scorbutic affections of adults. I will endeavor, by some examples, to convey an idea of their character. CASE XV.— Tumefaction ofthe gums, effusion of blood intne alveoli.—Marie Dume, aged six days, of a tolerably strong constitu- tion, having a good color in the face, but exhibiting a slight jaundiced tint on the trunk and limbs, entered the infirmary on the 13th of Oc- tober. She cried a little, but remained tranquil, as if drowsy ; the mucous membrane of the mouth was in a natural state, but the tongue, at its borders and extremity, was Ted. (Gummed rice-wa- ter.) On the fifteenth, the jaundice was less intense, and there ap- peared a copious diarrhoea ; the child became pale, and cried much ; the gums ofthe upper jaw were swelled without being red. (Same treatment.) The same state continued until the 20th of October ; the diarrhoea then increased ; she became pale, but without much emacia- tion ; the upper gum was constantly swelled, and of a livid red. On the twenty-fifth, all the symptoms increased, and the child died in the night. Post mortem examination.—The upper gum of the right side ex- hibited a violet-colored tumefaction, with an evident fluctuation. An effusion of black fluid blood was found in the alveoli of the first three teeth. The incisor teeth and the portion of the germ which was not ossified, were loose in the midst of the effused blood which formed the tumor; the osseous crowns of the teeth were soft, red, and some- what macenated in the fluid. The surrounding soft parts had begun to separate from the alveolar pocess. The rest of the mouth was healthy. At the lower extremity of the oesophagus, there were found some traces of muguet, and traversing the surface of the stomach, several 206 ON THE DISEASES OF INFANTS. striae; the mucous membrane at the end of the duodenum was thick and tumefied. In the neighborhood of the ilco-caecal valve, were six follicular spots, red, and much tumefied ; the liver was gorged with blood; the bile was abundant, ropy, and of a pale green. The lungs, heart, and brain were healthy. This case is remarkable in two respects : it shows us, in the first place, that the affections having their seat in the teeth or their germs, may exist at the earliest periods of life, as at the seventh and ninth month; and in the second place, it enables us to understand how it happens that hemorrhages occur in the dental grooves after this sanguineous congestion, so frequent in these parts in young infants. The following instance gives us a case ofthe same affection in a more advanced stage. CASE. XVI.—Muguet, sanguineous congestion and destruc- tion of the gums, suffocating cough, gastritis.—Anna Gens, aged twenty days, entered the infirmary on the 13th of August. She was vigorous, and generally in good condition ; the tongue was red on , the upper surface, where there appeared several spots of muguet; it was on this account that the nurse ceased to have the care of her. (Gummed barley-water, emollient gargles, milk and water.) On the fourteenth, the muguet had extended over the whole mucous membrane of the tongue even to the velum. (Same treatment.) On the eighteenth, the child vomited the drinks immediately after they were taken ; nothing remarkable occurred until the 1st of Septem- ber, when the respiration became much accelerated ; the skin at night was very hot and dry ; the pulse was full, but did not beat with more frequency than ordinary, (ninety pulsations.) The mouth was co- vered with several patches of muguet. (Dococt. of m.arshmallows, a linctus with half drachm of syrup of poppies, strict diet.) On the eighth, the cough increased, and assumed the characters of hoop- ing cough ; the face was (Edematous; the gums were red, puffed, and bloody. (Same treatment.) On the twelfth, there was a con- siderable increase of all the symptoms, and a general tumefaction of the gums and jaws. On the fourteenth, the upper gum of the right side was more tumefied than at other points. On the fifteenth, the deglutition was more difficult, and the drinks regurgitated through the nose; the child, by the violence of the cough, was every mo- ment threatened with suffocation. (Same treatment.) On the seven- ON THE DISEASES OF INFANTS. 207 tecnth, the deglutition of liquids was almost impossible, whilst the child easily swallowed pap. On the eighteenth, the swelling of the upper lip had made considerable progress ; the face continued cede- matous ; the muguet no longer appeared, and the buccal membrane, in general, was not very red. On the nineteenth, a violet-colored ecchymosis manifested itself on the ala of the nose ; the cough con- tinued frequent, but without suffocation ; the skin was very hot, yet the pulse was in the natural state. The child died at night. The examination of the body was made on the ensuing day. An cedematous swelling, red, and very soft, was observed on the upper right gum ; there existed, on this side only, an cedematous tumefac- tion ofthe parietes ofthe mouth ; but on the outside, the skin did not exhibit the cupreous and oily aspect which characterizes the precur- sory cedema of gangrene ofthe mouth. On opening the tumor of the gums, it was found to consist of grumous and black blood, in the midst of which floated the germs of the teeth, entirely detached, fall- ing out with the blood which flowed from the tumor. There also existed a thick bed of muguet at the base of the tongue. The sto- mach was contracted and wrinkled, and its mucous coat thick and of an intense red. At the lower part of the ileon, there were some follicular patches, pale, and slightly projecting. The liver was gorged with blood, and the entire venous system of the abdomen was in a very remarkable state of congestion. The glottis was the seat of a strongly marked cedema; the tra- chea, bronchia?, and lungs were healthy; the arterial duct and fora men ovale were both closed. The coexistence of the affections of the teeth, the congestion ofthe gums, and the cedematous swelling of the face on the dis- eased side, ought particularly to be noted. This agreement es- tablishes the existence of some connection between the diseases ofthe gums and of the teeth, and gangrene of the mouth. I do not doubt that this latter disease may follow the swelling and the disorganization of the gums. If it should occur in a child in whom the second dentition had commenced, the consequences would be very serious, and might result in the loss of the teeth for the remainder of life. I am led to believe that Van Swieten has alluded to this complication of gangrene ofthe mouth, when he says : Vidi aliquoties in pauperum infantibus, qui omninO neglecti fuerant partem- ossis maxilla cecedisse una cum alve- 208 ON THE DISEASES OF INFANTS. olis et dentibus contentis : unde in hoc loco destructa maxilla tot A vitdfucrmit adentuli* These effusions in the alveoli become less frequent in propor- tion as the child advances in age, and as the tooth, in becoming developed, fills the alveolar cavity. The sanguineous exhala- tion then occurs on the surface of the gums in the buccal cavity, a circumstance which can scarcely be perceived because the child, by sucking, prevents it from flowing to the outside.t The gums of a young child may become much more superfi- cially inflamed ; at the time of the appearance of the first teeth they become partially tumefied, and a slight local inflammation ensues at the place of each tooth. I have seen this affection in a child of eighteen months, in whom all the first teeth had protrud- ed. This inflammation was characterized by a red festooned line following the contour of the gums in the direction corre- sponding with the neck of the teeth. It is possible that this inflammation may be so far advanced as to cause a dryness ofthe mouth, and a general redness ofthe mu- cous membrane lining this cavity—in a word, all the characters of erythematic stomatitis accompanied with fever, restlessness, and constant crying ; but it must be admitted that this is or'rare occurrence. Great attention must be paid to the treatment of this phlegmasia, the propagation of which, by contiguity to other parts ofthe digestive passages, being very rapid. The treatment of local affections of first dentition ought to be simple when they are the only ones which occur. Van Swieten is one ofthe authors who has given, with great plainness, the in- dications which should be followed in such cases ; therefore the method of treatment which I propose to recommend may be con- sidered, in some respects, but kind of translation from this author on the same subject. It is necessary, says Boerhaave, to soften, sooth, and refresh the gums with emollients, mucilages, and antiphlogistics, and to make use of hard, smooth bodies, or to make incisions in them by means of a lancet.—(Aph. 1377.) This aphorism contains the sum of all the means advised by * Coram, in Boerhaave, aphor. de morbi infant. 11 have not seen the inflammation of the germs of the teeth; yet Baglini, Moreau de la Sarthe, and M. Oudet have given examples of it. ON THE DISEASES OF INFANTS. 209 authors to favor the eruption ofthe teeth. But the commentator of this illustrious writer, in developing his precepts, apparently opposes or disapproves them. Thus, he advises the use of emollients and mucilages to calm the irritation, and he recommends, among other preparations, a mixture of cream, the white of egg, and syrup of violets: the mixture may be rendered more liquid by the addition of rose wa- ter. It may be applied to the mouth by means of a piece of lint, and without doubt will be found very useful in the treatment of acute inflammation ofthe gums. The root of marshmallows sa- turated with syrup may be given to the infant to chew with ad- vantage. If there should occur in the head a sanguineous con- gestion giving rise to serious apprehensions as to the result, it will be useful, observes Van Swieten, as Harris remarks, to apply a leech behind the angle of each jaw. The extreme irritability of the mouth ought also to be taken into consideration, and no hot drinks or food be given. It may be necessary to remove the child from the breast, or to give the nurse very mild nourish ment, together with emollient drinks. She should also be re quired to abstain, during the period of dentition in her charge from the use of wine and other stimulating drinks. As to the employment of hard substances between the gums for the purpose of making a passage for the teeth, Van Swieten has not rejected them, and in this he is wrong; and M. Gardien has clearly demonstrated that their use is by no means rational. It has been said that it diverts the pain of the teeth, and that it is seconding the desires of nature, which inspires the child with a constant wish to carry to its mouth every thing given to it. But is the patient who is affected with the itch, and who tears the skin with the violence of scratching to calm the irritation, in obeying the counsel which nature appears to dictate to him for the assuaging of his distress—is he following a rational indica- tion, and is he sooner cured of hio disease? Let us guard then ao-ainst the use of these pretended inspirations of nature a vague term and better suited for the vulgar than for physicians. If, as is of daily observation, the infant sleeps when the nurse gently rubs the end of her finger over the irritated gum, it is because the pressure is extremely gentle, and the pleasurable sensations there- by produced assuage the pain of the gums. But this is far differ- y 27 210 ON THE DISEASES OF INFANTS. ent from the introduction of a coral, crystal, ivory, or amber. Let us reject all these useless means, and leave them in the obli- vion to which the good sense of the present day has condemned the necklaces, bracelets, and amulets. The question upon the necessity of cutting the gums in order to facilitate the eruption of the teeth, a practice which is at this time much followed in England, has been much agitated. Van Swieten a ~*--^'- ON THE DISEASES OF INFANTS. 289 cable to the diseases of the intestinal canal, and we will begin by studying the causes and nature of diarrhoea without enteritis, as we considered vomiting and gastric indigestion without gastritis. Art. 1.—Intestinal Indigestion. There are a great number of sucking children affected with diarrhoea without enteritis; they become pale and sink into a state of marasmus, and upon examining the dead body no trace of inflammation will be found in the intestines. These children really perish from want of food ; they die, it may be said, of hun- ger—the instestinal canal not digesting either the milk that is sucked, or that which is given to drink. Let us; in the first place, examine what are the external signs of this intestinal in- digestion, and afterwards seek for its cause. These signs are—progressive emaciation, paleness of the face, continual hunger of the child, who seizes the breast with extra- ordinary eagerness. The diarrhcea, which consists of white mu- cous matters, is sometimes so fluid as to soak into the clothes and stain them, like the fluid which flows from the vagina in leucor- rhcea. With these mucous matters there are often mixed lumps of coagulated milk, which has passed unaltered through the in- testinal canal. After a certain time, the child perishes in the last stage of marasmus, and if the intestinal tube is opened, the mucous membrane is found without color through its whole ex- tent, and is often softened ; but, in this case, it has undergone an alteration of tissue, the nature of which will be examined in an- other place. Sometimes the digestive tube is inflamed, ulcer- ated, and disorganized, to a greater or less extent; but the white softening is the lesion most frequently met with in children that have died from the disease now under considera- tion. In the year 1826, I examined, after death, fifteen cases of chronic diarrhcea without inflammation, in children from the age of fifteen days to two months. In eight of them, I discover- ed no lesion ; there existed nothing but a general discoloration of the integuments and of the intestinal tube, while all the organs were exsanguined. During life, these children experienced an incessant vomiting and diarrhcea ; in almost every one, the ab- domen appeared to be distended with gas, which was found in 290 ON THE DISEASES OF INFANTS. great abundance, together with white, frothy fluid matters, upon examining the intestinal tube. In two others, the colon con- tained some green floculi, analogous to the meconium in color and consistence. In five others, there were different lesions of the lungs or of the brain, and the intestinal tube exhibited the characters which I have just described. This discoloration of the mucous membrane is almost always the first degree of a species of softening, which must not be confounded with inflammation. I will also remark that the in- testinal tube, in place of being without color through its whole extent, sometimes exhibits at various parts red patches or streaks, which are the last traces of a normal coloring, or of the conges- tion so frequent in this part in a young infant. I shall return to the consideration of this subject when speaking of the soften- ing of this membrane. This alteration of the tissue is, I believe, one of the effects of a defective nutrition, for the consequences which result from this aberration of the digestive functions, are not confined to a simple marasmus, such as have been described, but other lesions happen, and which will be examined in another place. I will content myself, for the present, with referring to those cases where the functions of the intestinal tube are per- verted without any appreciable lesion of an inflammatory nature. Every thing connected with this subject leads to the belief, that this defect of nutrition consists in the nature of the food, or, perhaps, in the mode of suckling to which the infant is sub- jected. In truth, all the children at the Hospice des Enfans Trouves, and who are confided to the care of the wet-nurses, are pale, thin, and in a bad condition. A great number perish in this hospital from imperfect nutrition; in almost all, the symp- toms which they present, even to the time of their death, arise from an evident disturbance of the digestive functions, whether the organs discharging this function are inflamed, or whether they have arrived at the stage of debility, discoloration, and wast- ing, of which I have spoken. In all probability this wasting arises from the suckling of the children by women who have for a long time discharged the office of nurse, and who by changing the child frequently, feel a perfect indifference for the one placed under their care, and establish no regular hours for suckling, nor fix upon the quantity of milk necessary for the child; so ON THE DISEASES OF INFANTS. 291 that, always hungry from receiving but little substantial nourish- ment, it takes too large a quantity at a time of a liquid which, from its superabundance and bad quality, is rendered doubly hurtful. This is the proper occasion to speak of the interesting re- searches of M. Payen, the distinguished chymist, who has made several experiments upon the nourishment of young infants.* M. Payen observes, that during the period of suckling, great disturbances in the digestive organs frequently either proceed, accompany,or follow a forced alteration in the alimentation; and also the milk that appears suitable for one child may be highly deleterious to another of the same age. There has been no more success in substituting the milk of the goat for that of a female. This is what M. Payen has demonstrated in comparing the physical characters of several kinds of milk which had pro- duced different effects on the same infant, or the same effects on different individuals. (Experiment No. 1.) The milk of a goat, which was permit- ted to run at liberty in the fields during the day, and which was fed at the stable with dry food, was found white, opake, without any defined odor, and of a density equal to 3 degrees 75 centiemes (Baume,) having no sensible action on the tincture of turnsole. Fifty grammes of this milk, treated by a chymical process which is too long to be reported here, gave the following results:— Water, with some traces of acetic acid, . 42.75 Fatty matter, (butter,) .... 2.04 Caseum, and traces of insoluble salts, . 2.26 Sugar, soluble salts, and some traces of azotic matter, ..... 2.93 Total, 49.98 This is about equal to 14.5 of solid matter for every 100 parts of milk. (Experiment No. 2.) The milk of a female seven months after her confinement, in a healthy condition and of a good con- stitution, suckling but from one breast. She had submitted, as did also the others which are mentioned below, to the regimen most suitable for nurses, as advised by physicians. * Journal de Chimie Medicate, de Pharmacie et de Toxicologic, recorded by the members ofthe Societe de Chimie Medicate, March, 18-8, p. 118. 292 ON THE DISEASES OF INFANTS. Physical properties.—White, opaque, of the density repre- sented by 3° 5 of Baume's asrometer, very sensibly alkaline upon the application ofthe proper test; which alkaline quality con- tinued during the entire evaporation. Chymical properties.—Fifty grammes of this milk gave the following results:— Water, .... 43.00 Fatty matter, .... 2.58 Caseum, and traces of insoluble salts, . 0.09 Sugar, soluble salts, and traces of azotic matter, . 3.81 Total, 49.48 Equivalent to about 13 parts of solid matter to every lOOof milk. (Experiment No. 3.) Milk of a healthy female eighteen months after her confinement. Physical properties.—Opake, white, alkaline, indicating 3° 6 of Baume's aerometer. Chymical properties.—Fifty grammes were composed of— Water, .... 42.80 Fatty matter, .... 2.60 Caseum, etc. .... 0.125 Sugar, soluble salts, etc. - . 3.965 Total, 49.490 About 13.4 solid matter for every 100 of milk. (Experiment No. 4.) Milk of a female in good health, of a larger size and more corpulent than the preceding, four months after her confinement. This milk indicated 3° 55 of Baume's aerometer, and yielded the same as the others, in the following proportions, in the fifty grammes submitted to the experiment:— Water, .... 42.90 Fatty matter, .... 2.59 Caseum, etc. - . • . 0.12 Sugar, salt, etc. .... 8.93 Total, 54.54 About 13.8 solid matter in 100 parts of milk. ON THE DISEASES OF INFANTS. 293 Several other specimens of milk, taken from females from four to twenty months after confinement, gave the like results as those in experiments Nos. 3, 4, and 5. From this it appears that the milk of the female differs from that of the goat principally in its marked alkaline quality, and in its containing about half the quantity of caseum. As to the milk of the females, under the circumstances just mentioned, it differs in respect to its composition. That in ex- periment No. 2, contained one third less of caseum, and I also observed that this milk always issued in a much larger quantity from the breast. The children under the care of each of those females were in good condition. These data are certainly of the greatest interest, and they be- come still more important, when we apply them to the regimen of sucking infants. Let us therefore examine still further the dissertation of M. Payen, and quote his remarks at length at the end of his paper. " A child aged seven months and a half, healthy at the time of birth, although it had evidently suffered a little from too slender nourishment during the first months, in consequence ofthe acci- dental diminution of the milk of several nurses in whose charge it had been successively placed, was fed for ten days with the spoon, with thin oatmeal water mixed with a tenth part of goat's milk, taken four times during the day and twice at night, rather less than a quart in twenty-four hours containing— Solid substances of milk, . . 14 grammes Dry extract of the oatmeal, . . 16 Total, 30 During this time the infant thrived, but a nurse better than the former was sought for ; and one was at last chosen who appeared to have abundance of milk, and possessed a healthy look. This was the female whose milk was made the subject of the experi- ment No. 2. The child sucked greedily, and the milk flowed abundantly; but, from the third time of nursing, the stomach was overloaded, the mouth remained open, and the child ceased to smile in its usual manner. During the night the sleep was much disturbed. The physician then advised that the child should be kept at the breast but three minutes at a time. 294 ON THE DISEASES OF INFANTS. " The untoward symptoms returned with increasing intensity, repeated vomitings took place, and one of them was followed by syncope. " I determined to make an experiment with this milk ; and in the first place I measured the quantity taken by the child in five or six times in twenty-four hours. I ascertained it to be more than eleven decilitres. Having also discovered the proportion of the solid matter it contained, I found that this measure repre- sented 160grammes, that is to say, five times more than the milk of the goat diluted with oatmeal water. In addition to this, the flow of milk, was so easy, that the child sucked this quantity in less than ten minutes. "I informed the physician of these facts, and of the quantity of butter which I found in the milk of this female ; he immedi- ately decided to stop the suckling, and to substitute milk and water; the unfavorable symptoms disappeared in a few days. sleep and liveliness returned, while the strength of the nourisli- ment was gradually increased to a third of the proportion of milk." 1 have reported this fact in detail, because it suggests to us the precautions necessary to be taken iu managing the suckling of children. When a child appears feeble and pale, and does not digest the milk of its nurse, it is well to attempt the feeding it with the spoon or bottle, to regulate the quantity, and to correct the quality, by diluting it with barley-water. I have often seen at the Hospice des Enfans Trouves, goats' milk diluted with bar- ley-water, perfectly digested by those children who rejected the milk of their nurses, and who had wasted away daily from,de- fect of alimentation. However much we may be gratified with the feeling, so elo- quently expressed by one of our most beautiful writers, that is produced in contemplating as a law of nature, the suckling of the infant by the mother, and which it is believed to be a duty implicitly to obey, we may nevertheless find some exceptions; and where the mother may be obliged to renounce this most no- ble of duties. We should not forget that our social state often removes us far from the state of nature, and that there exist cir- cumstances where it would be absurd to force a mother to nurse a feeble infant, for the sole reason that it is the order of nature ON THE DISEASES OF INFANTS. 295 that an infant should only live on the milk of a woman during the first months of its life. 1 repeat it, that suckling by the mother ought not to be considered so generally and exclusively necessary as to be deemed the only means suitable for nourishing feeble infants. Every mode of alimentation should be tried, and that adopted which is found best for the digestive apparatus of each infant. I would again recommend, in such cases, to use the different varieties of food which have been already men- tioned, when treating of gastric indigestion. Art. 2.—Invagination of the Intestines. Intestinal invagination is of very frequent occurrence in suck- ing infants; it may not show itself by any symptom, for I have often found it, on a post mortem examination, in children who, during life, were affected with nothing more than constipation, and who appeared not to have had any abdominal pains; yet it is very possible that obstinate constipation, considerable tension of the abdomen, excessive pain, and even death itself may follow intestinal invagination, particularly if the mucous membrane of the invaginated portion become inflamed, and then it may be considered as one of the most serious affec:ions of early infancy. Obstinate constipation, progressive tumefaction of the abdomen, vomiting of drinks, and afterwards of intestinal and sterco- raceous matters, in a word, the symptoms which we have pointed out when treating of imperforation of the rectum, show them- selves in intestinal invagination, when complicated with a com- plete interruption of the passage of the contents in the digestive tube. This condition is very difficult to remedy; yet we should attempt to establish the functions of the digestive tube by the use of baths, by abstinence from the breast, laxative enemeta, gentle compression of the abdomen, and lastly, by the administration of a dessert spoonful of olive oil. A complete interruption to the passage of intestinal matters, together with its consequences, may arise from other causes ; the consideration of which we will hereafter make the subject of our inquiries. Is the intestinal tube of young infants susceptible of becoming the seat of nervous colic, such as ileus, miserere, etc. 1 And is 296 ON THE DISEASES OF INFANTS. the excessive pain in the bowels of young infants, which is in- creased on pressure, and known by their restlessness and obsti- nate cries, always simply nervous, and not the effect of inflam- mation of some of the abdominal organs? I do not think so. I believe that the violent colics to which children are exposed, are as often owing to well-marked anatomical lesions, as to a sim- ple morbid exaltation of sensibility ; it is indeed wrhat we shall demonstrate in the course of these researches. Whichever it may be, if a physician be called to a young in- fant suffering from violent abdominal pains ; if they are accom- panied with constipation, vomitings, and even convulsions; if they are remarkable for their alternate remissions and exacerba- tions, and have not been preceded or accompanied by symptoms of enteritis, the existence of a nervous affection of the digestive tube may be then suspected, and antispasmodics, such as a little ether diluted with water, or syrup of poppies mixed with sweet- ened water, may be administered. But we should use these means with great caution, and not forget that nervous affections of the digestive tube are much more rare than inflammations in young infants.* Art. 3.—Inflammations of the Digestive Tube. The intestinal mucous membrane may become, like that ofthe stomach, the seat of different varieties of inflammation. We shall then consider in succession, erythematic, follicular, and gangrenous enteritis. Enteritis with altered secretion, or muguet of the intestines, is very rare ; yet it may occur, and we shall give one example of it. We will commence on the subject of inflammation of the in- testines developed before birth, arriving afterwards at the exami- nation of enteritis occurring in infants after this period. § I. Intestinal inflammation during intra-uterine life.—The state of congestion of the intestines, even before birth, necessarily exposes these organs to inflame during intra-uterine life. The observers of this condition have given us several ex- amples, but their descriptions are sometimes of so dubious a nature, that we can scarcely put any confidence in them; yet we * See Appendix. ON THE DISEASES OF INFANTS. 297 may refer to a very curious case, described by Professor Desor- meaux, in his article Pathologie de Vauf, in the Dictionaire de Medecine, in 21 volumes. I had charge of an infant, says he, some years since, born of a mother who had enjoyed excellent health during her pregnancy. This child, when born, was ex- tremely emaciated ; the surface of the body was of a yellowish white, with an expression of face like that of an old person suf- fering with pain. The abdomen of this little patient was swelled, hard, and painful ; the convolutions ofthe intestines were easily discovered beneath the integuments; all the symptoms announced the existence of enteritis of long standing. It was placed under the care of a good nurse, and notwithstanding its extreme feeble- ness, it was able at first to receive a few drops of milk, and after- wards to suck, and subsequently became a fine and healthy child. As the anatomical examination of this case did not occur for its more complete elucidation, I will add others which I have seen, and where the post mortem examination of the disease re- moves all doubts as to its nature. CASE XLIII.—Enteritis, excrescence or vegetation on the sur- face of the duodenum.—Blanchard, a boy, was brought to the Hos- pice des Enfans Trouves on the 11th of December, 1826. This child was pale, thin, and very small; he remained for six days under the care of the wet-nurses, but instead of increasing in strength, he became rapidly more emaciated, with an incessant diarrhcea, together with vomiting. He entered the infirmary on the seventeenth ; we had hardly an opportunity of examining the case, for he died at night. The post mortem examination was made on the succeeding day. I found the stomach slightly injected, and spotted with red ; some red transverse striae existed in the duodenum ; a red, irregularly shaped excrescence, resembling a strawberry, was found about the middle of the second portion of this intestine. It was about the size of a French bean, and was firmly attached by a pedicle to the surface of the mucous membrane upon which it was developed ; it resembled in every respect the excrescences which are sometimes formed on the surface of this membrane in adults, cases of which I have reported. Its structure was spongy, but not erectile ; it was easily crushed be- tween the fingers, and the blood which it contained was readily squeezed out. Besides this organic alteration, there existed at the termination of the ileon a chronic inflammation, characterized by a 38 298 ON THE DISEASES OF INFANTS. thickening of the mucous membrane, which was of a strongly mark- ed slate-color ; striae of the same color existed in the colon. There was nothing remarkable in any of the other organs. This vegetation of the duodenum can hardly be attributed to chronic inflammation, and it is very difficult to explain the na- ture and cause of these kinds of excrescences, which, without doubt, have some analogy to warts on the skin. But the slate- colored appearance of the ileon, which was at the same lime tumefied, must bo regarded as an incontestable evidence of chronic inflammation ; it is to this phlegmasia, with which the infant was born, that the languor, rapid emaciation, and death must be attributed. CASE XLIV.—Chronic colitis, sclerosis of the colon.—Joseph Camison, aged six days, entered the infirmary on the 22d of Septem- ber. He exhibited a slight icterous tint, was affected with an abun- dant diarrhrjea, and was in a very advanced state of marasmus. Since his birth, emaciation had steadily increased; the face very much altered, continually expressed the presence of great pain ; a number of wrinkles were formed on the forehead, and the commis- sure of the lips was drawn backward; he cried but little, and re- mained immoveable in his cradle. He died the same night that he entered the infirmary. There were found, on a post mortem exami- nation, a passive congestion ofthe oesophagus, and a spotted redness of the stomach; the duodenum and the jejunum presented nothing more than a slight injection ; but towards the extremity ofthe ileon a thickening of the walls of the intestines commenced, which in- creased more and more towards the caecum ; the ileo-caecal opening was much contracted, and its valve more red, hard, and tumefied. This thickening was more particularly in the sub-mucous cellular layer ; the mucous membrane was also a little thickened, very red, and quite tender. The peritoneal membrane was as thin as in the natural state; so that the cellular membrane, considered by itself, formed a membrane of half a line in thickness, very solid, and in color resembling pearl ; its tissue, which retained no longer its cel- lular form, was, on the contrary, homogeneous, and, when cut, left a smooth surface. This lesion presented the anatomical characters assigned by Laennec to sclerosis. It existed in the entire length of the colon. ON THE DISEASES OF INFANTS. 299 The intestinal matters were yellow, liquid, and but slightly adhe- rent to the parietes of the intestines. The liver was black and gorged with blood ; the bile abundant, viscid, and of a deep black. The lungs and brain were healthy. This lesion was without doubt developed during the intra- uterine life, and the child brought with it the chronic colitis of which we have spoken; and to this affection must be referred the state of feebleness, diarrhcea, and the rapid emaciation of the patient immediately after birth. These two cases of congenital enteritis, may throw some light on the state of feebleness in which some infants are born, and where life is scarcely establish- ed, and who are affected with lesions, the premature develop- ment of which produce an important change in the young em- bryo. This should also prove to us the necessity of examining, with the greatest attention, the nature of the causes to which is attributed the feebleness of birth. I could also give several examples of congenital lesions ofthe digestive tube, but the recital of their history would occupy too much space ; I will simply state that I have observed ten cases of congenital enteritis in infants that have died on the first or second day after birth. In three of them there was an evident inflammation of the follicular plexus of the ileo-ceecal region. In others, there existed a number of white follicles, slightly pro- jecting, in the caecum, surrounded by a red circle; ulceration had commenced on the summits of some of these follicles. In five others, the inflammation only consisted in red patches, with tumefaction and friability of the mucous membrane ofthe small intestines. The most remarkable thing in these cases was, that the meconium exhibited no sensible alteration, but possessed its ordinary consistence and aspect; the children, however, were almost all pale and thin. Yet one of them, where the follicular apparatus was inflamed, was strong and vigorous. The symptoms of congenital enteritis are analogous to those of enteritis which is developed after birth. § II. Inflammations of the intestinal tube devel- oped after birth.—Inflammation of the mucous membrane of the intestinal tube ought particularly to be noted with refer- ence to the varieties of its seat; but before studying it in this 300 ON THE diseases of infants. respect, let us examine the general lesions arising from the phleg- masia; of the interior of the digestive tube of young infants. Inflammation of the intestines may exhibit the same anatomi- cal varieties as those of the stomach; we shall therefore make the following divisions of phlegmasia of the bowels. ENTERITIS, Erythematic, With altered secretion; Follicular, With disorganization of tissue. Erythematic enteritis.—There is a very trifling differ- ence between erythematic inflammation of the intestines and the passive injection of which they are often the seat in young infants, and it is very difficult to establish the line of demar- cation between these two lesions. We can, however, say that the one is sometimes the predisposing cause of the other, and that if the intestinal tube is so frequently inflamed in young infants, it is because it is almost always injected. The blood which constitutes this passive injection becomes, by its prolonged retention in the vessels or in the tissue of the membrane, an irritating, foreign body, which may produce lesions and symp- toms peculiar to recent inflammation. When, in place of a simple ramiform capillary injection, the erythematic inflammation exhibits, as its anatomical characters, patches of redness of greater or less extent, indifferently situated either in a dependent or other part of the digestive tube, accom- panied by a tumefaction and friability of the mucous membrane more or less evident—the lesion is then evidently inflammatory, and is often the result of a true passive congestion. To obtain an exact knowledge ofthe existence of erythematic enteritis, I have particularly remarked the symptoms which appeared dur- ing the life of those children that showed the anatomical lesions, the characters of which I have just described. The following is the result of this analytical examination. I have seen a great many cases of erythematic enteritis, but many of them were accompanied with gastritis, pneumonia, etc., ON THE DISEASES OF INFANTS. 301 and if they were accumulated here it would be extremely diffi- cult to separate and group the symptoms belonging exclusively to this disease. When the number of complicated cases was separated from those which existed without complication, the lat- ter is reduced to forty. They were of different ages, from one day to one year. In thirty, there existed a diarrhcea of yellow, liquid matters ; in six, vomiting of drinks ; in twenty-five, dis- tention ofthe abdomen; in four, natural stools; in six, there was no diarrhcea; in five, an erythematic redness about the anus, caused, without doubt, by the contact of intestinal matters; in neither of them was there abundant transpiration ; in almost all, the skin was dry and burning; and in four only did there exist a febrile acceleration of pulse, and those four were aged from five months to one year. In twenty-five, the face possessed the pe- cu iar expression of pain, characterized particularly by vertical wrinkles at the root ofthe nose, and by the drawing outward of the commissure ofthe lips. Erythematic enteritis is often complicated with hemorrhage. In four of these children where there existed a violent inflamma- tion, blood was found exhaled in different parts of the intestinal tube. One of them h;id passed a considerable quantity both by vomiting and stool. We have already seen this symptom exist in cases of passive abdominal congestion; but the hemorrhage now under consideration, is not the result of a superabundance of blood in the intestinal vessels and in the large vascular trunks ofthe abdomen, but is evidently a sanguineous exhalation result- ing from the afflux of blood by the stimulus ofthe inflammation in the mucous membrane. The following is an interesting case of this kind. CASE XLV.—Marie Colin, aged ten days, small, but of good strength, entered the infirmary on the27th of September. Her cry was well sustained and complete : integuments were of a vermilion color. She was then in the ninth day of the vaccine disease, which had passed regularly through its stages. She cried incessantly ; several points of muguet appeared on the borders of the tongue, the mem- brane of which was of a cherry red; she had a copious diarrhcea, but the abdomen was not tense. (Gummed rice-water, emollient gargle, starch injections, milk and water.) On the twenty-eighth, 302 ON THE DISEASES OF INFANTS. the same condition ; the child slept none ; cried night and day ; was in a constant state of restlessness ; the face continually pinched, ex- pressed pain ; diarrhcea abundant, and mixed with a considerable quantity of b ood ; yet she did not become much emaciated. The skin was hot and dry, and the pulse beat about sixty-six in a minute. On the 1st of October, the muguet extended to the internal surface of the lips and cheeks ; the child was very restless, and vomited the drinks for the first time; there were several streaks of blood in the matters vomited. (Sweetened tilia, warm bath, milk and water.) The same general state continued for several days. On the fourth, the expression ofthe face was much altered ; the abdomen became disteaded, and when compression was made, wrinkles were observ- ed in every part of the forehead ; the muguet formed a thick layer on every part of the tongue, and extended to the lateral part of the froenum ; the cry was feeble and exhausted ; alvine dejections green, bloody, and very abundant; abdomen hard and tense to the touch ; thorax resonant in all parts. Death took place at night, and the post mortem examination was made the next day. The body still retained much of its embonpoint; the limbs were in- flexible ; adipose matter was thickened in different parts of the body ; a thick layer of muguet existed above and below the tongue, and the inferior extremity ofthe cesophagus was the seat of a well-character- ized gelatinous softening. On the internal surface of the stomach there was only found a spotted redness ; there existed throughout the whole extent of the digestive tube a large quantity of bloody matter of the consistence of pitch. In different parts of the small in- testines there were several red patches, accompanied with a well- marked tumefaction, and a great friability of the mucous tissue, which was torn with the nail with the greatest ease. There was found besides, some blood which had been recently effused at these inflamed parts. Several follicular patches, red and tumefied, were discovered at the extremity of the ileon. The caecum was studded with a number of separate follicles slightly inflamed, and there existed in the colon a number of red patches, mixed with slate-colored streaks. The liver was not much more colored than natural; the gall blad- der contained liquid bile of a deep green. The lungs were healthy; the right lung only was found a little engorged with blood at its base; the ductus arteriosus was still open, and the foramen ovale closed. The brain was firm, and much injected. The disease of which this child died, was evidently concen- ON THE DISEASES OF INFANTS. 303 trated in the intestinal tube, and the symptoms produced by it are remarkable for their severe and positive character ; a copious green-colored diarrhcea, painful expression of the face, continual- ly increasing tension of the abdomen, ceaseless motion, caused, without doubt, by pain, and in the midst of all this excitement, without any febrile action, are the symptoms which are at first presented to our notice. Soon after, vomiting supervened, and the examination of the body leads to the belief that this was owing to a softening of the oesophagus, which took place to- wards the termination of the disease. Finally, the appearance of blood in the vomitings and injections, are sufficient evidence of the existence of intestinal hemorrhage. The traces of it were found upon examining the body; and in analyzing the symptoms exhibited by this child, we are able to appreciate their value, and can thus decide on the existence of enteritis, complicated with hemorrhage. Erythematic enteritis, wherever its seat may be, may precede different varieties of inflammation, of which iudeed it is the first stage, and assume various aspects while it continues. The in- tense redness which is peculiar to this inflammation, is followed by a brown or slate color, diffused in patches, striaB, or points, in various parts of the digestive tube ; so that it is very common to find in infants dying after a prolonged diarrhcea, and by which they are reduced to a state of complete marasmus, several slate- colored stria?, either in the small intestines or in the colon ; and this alteration of color in the mucous membrane ought to be re- garded as an indication of chronic phlegmasia. I must add, that enteritis does not always show itself in a man- ner so strongly marked as in the case just mentioned ; but the dis- ease may be recognised, although the symptoms be not quite so clear, by comparison with those in the case which 1 have chosen as a type. This disease is often complicated with gastritis. Gastro-enter- itis is really a disease of common occurrence in sucking infants. The symptoms of this complication do not differ much from those belonging to simple enteritis ; vomiting of greater or less obstinacy exists, but it is very common to see children vomit who are only affected with enteritis ; the presence of this symptom, therefore, will not enlighten us as to the union of gastritis with 304 ON THE DISEASES OF INFANTS. enteritis. One of the most probable signs of the existence of these two diseases simultaneously, is pain in the epigastric re- gion, indicated by a painful expression of the face, and by the cries of the child when compression is made on this region. But may not this be a very vague indication ? and may not the in- flamed colon, which is near the place of pressure, actually be the seat of the pain which is referred to the stomach 1 Thus, then, if pathological anatomy demonstrate to us that enteritis is often accompanied by gastritis, clinical observation on the diseases of young infants, is not sufficient to enable us to distinguish gastro- enteritis from enteritis alone. What I have observed with re- spect to the inflammation now under consideration, may be ap- plied to other phlegmasia?. In all cases, however, the impossibi- lity of making this distinction is of little consequence in a thera- peutic point of view, since the treatment of enteritis is perfectly applicable to gastro-enteritis. Enteritis, with altered secretion, or muguet of the intestines.— The alteration of the secretion which constitutes muguet, may be met with on the surface of the muctms membrane of the in- testines during its inflammation. I have met with one instance of this altered secretion on the surface of the ileon : but as I did not record the symptoms which appeared during the life ofthe child, I will not report the anatomical investigation. I will here give the history of a case of muguet of the colon. CASE XLVI.—Partial softening of the stomach, muguet of the colon.—Louis Simonet, aged three days, entered the infirmary on the 21st of April, for a severe diarrhcea, with which he had been affected about two days. He exhibited besides, a slight icterous tint over the whole body. (Sweetened rice-water, milk and water.) On the twenty-fifth, the icterous disappeared, and the child vomited the drinks ; the diarrhcea continued abundant, and produced a rapid emaciation. Death occurred on the twenty-seventh. On opening, the body, the buccal membrane was found healthy; there was a complete disorganization of all the coats ofthe stomach, the mucous membrane of which exhibited a gelatinous softening, particularly about the great tuberosity. The inferior third of the ileon, the cae- cum, and the colon, were red, tumefied, and rough, and exhibited on their surfaces a great number of flakes, floating in the midst of fcecal ON THE DISEASES OF INFANTS. 305 matter, ofthe consistence of cream, liquid, and of a green color; but the greatest number were firmly adherent to the membrane, and could not be separated without scratching them with the scalpel. This appearance did not exist in the sigmoid flexure of the colon ; but it was found in the rectum, in which were several deep red, longitudinal striae. The remainder of the body exhibited nothing remarkable. It is impossible not to admit that this altered secretion bears a resemblance to that which, in the mouth and stomach, has been called muguet. If this altered secretion be analogous to the false membranes which are developed on the surface of mucous mem- branes generally, we must not be surprised to see it developed in the colon, since inflammation of this membrane sometimes pro- duces membranous pellicles, spread to a greater or less extent over different parts of its surface, as is seen in dysentery and other intestinal phlegmasia?. There exists no symptom peculiar to muguet, by which a correct diagnosis can be made of it in the intestines. The case reported presented nothing more than the symptoms of enteritis, and it has been recorded as an instance of the variety of inflammation which we have designated as enteri- tis with altered secretion. Perhaps we might find false mem- branes in the colon of infants ; but I have never seen them. Follicular enteritis.—The follicular apparatus of the intestinal tube may become, like that of the stomach, the seat of various al- terations. It consists, as is well known, of small isolated glands in the upper two thirds ofthe small intestines, grouped in oblong plexuses, almost always occupying the free borders of the intes- tines, and varying greatly in number. They again appear, iso- lated, in the caecum and colon, and occur even in the rectum. In their natural state they are more or less apparent; many children do not show them at all, and their development varies according to the individual. The changes in the muciparous follicles ofthe intestinal tube are not all of an inflammatory character. They experience, for example, at the period of dentition, an increase of vital energy, which augments their secretion considerably, and renders their size larger, and their number greater, but which still does not produce any redness, tumefaction, or ulceration, as is observed in 39 306 ON THE DISEASES OF INFANTS. ordinary inflammation. It is important for us to stop and consi- der this species of organic and functional excitability which oc- curs in the follicular apparatus of infants at the breast. I have seen isolated follicles and follicular plexuses of the in- testinal tube, in considerable numbers, and developed without being inflamed, in twelve infants. There were three, aged from eight days to three weeks ; two aged two months ; the remaining seven, were from nine months to one year. The follicles appeared at the commencement of dentition. Ten of these children were affected with diarrhcea of liquid, white mucous matters. This is really the serous diarrhcea of authors ; and every symptom leads to the belief that there is a direct relation between the develop- ment of these follicles and the augmentation of their secretion. Most of these children had arrived at the period of dentition, so that there appeared a remarkable coincidence between the period ofthe appearance of the teeth and that of the organic develop- ment of the follicular apparatus of the intestines. A physiologi- cal explanation may be given of this coincidence. In fact, the fol- licular apparatus appears destined to second the action ofthe in- testines in digestion, by furnishing the surface of these organs with a fluid, which, in all probability, assists in the elaboration of aliments. Dogs, and other carnivorous animals, where the di- gestive power, if I may use the expression, is truly remarkable, possess this apparatus in a high degree of development. We ought not to be surprised to find the follicles, or the muciparous plexuses, augment in volume and activity at the period of den- tition in man, since the organs of digestion then receive a modifi- cation which renders them fit to fulfil their functions. It appears then, that nature has fixed the same period for the development of all parts of the digestive apparatus, for at the same time the salivary glands acquire a much larger size, and secrete saliva in greater abundance. This coincidence in the normal development of the teeth, and in the increase of size and activity of the follicles, explains the relation that exists between dentition and the frequency of the serous discharges from the bowels, at this period, in infants; in this mariner, then, can be explained the sympathy pointed out by authors between the appearance of the first teeth and affec- tions ofthe bowels, without having recourse to those hypotheses ON THE DISEASES OF INFANTS. 307 too often referred to in researches on the phenomena of life. There is here a remarkable coincidence—or if the expression be thought better, a morbid functional sympathy, because there is a coincidence of development. Although children do not exhibit the development of the muci- parous follicles before dentition so often as after this period, it must not, on this account, be thought that these follicles do not exist at birth. They have been very often found in considera- ble numbers from the first moment of life; but generally speak- ing, they are not very numerously developed in the intestinal ca- nal, except at the period above mentioned, and sometimes even not until a more advanced age. I do not consider this morbid development of the muciparous follicles, as a true inflammation. Nevertheless, this state of ex- citability which causes the augmentation of their secretion, is, as it were, an intermediate stage between the normal state and the state of inflammation ; and it would be proper to keep the child affected with this diarrhcea, to a strict regimen. We may satis- fy ourselves whether it is owing to the morbid state I have de- scribed, by examining the nature of the discharges. The child ought then to be fed on milk and water or barley-water. The diarrhcea which supervenes in such cases is so abundant and so debilitating, that in a few days the child is reduced to complete marasmus. The follicular development may not be confined solely to the intestines; but it may also occur in the whole length of the digestive tube, as will be seen by the following case. CASE XLVII.—Charles Marand, aged six months, entered the infir- mary on the 8th of March. He had, for some days, been affected with a diarrhcea, at first of yellow matters, afterwards white and frothy ; he was pale, thin, and extremely feeble ; a great number of small project- ing points were seen in the mouth ; the tongue was dry, without be- ing red ; the limbs were cold ; there was nothing remarkable in the pulse. (Sweetened rice-water, milk and water.) On the ninth, the diarrhcea continued ; the abdomen was slightly tumefied; the child cried but little ; yet the face was pinched, and presented the appear- ance of facies hippocratica. A tumefaction was observed on the lower gum, produced by the first incisors, which were ready to ap- pear ; an abundant saliva flowed from the mouth, and every thing 308 ON THE DISEASES OF INFANTS. seemed to indicate that the child was suffering from dentition. He died on the night of the eighth. Post mortem examination.—The body exhibited a great degree of emaciation ; the mouth, oesophagus, and stomach presented a great number of small, Avbite, slightly projecting follicles. The mucous membrane of the small intestines was pale and studded with numerous follicles, and fourteen well-marked uninflamed follicular plexuses were discovered in the lower two thirds of the ileon. There were but few in the caecum ; the colon was pale, like the small intes- tines ; the lungs and brain were healthy. Although the follicular apparatus was very much developed, it certainly was not inflamed in the subject of this case. The diarrhcea and the marasmus which were observed, were owing to an abun- dant secretion from the intestinal tube. This disease is the more serious in proportion as it is compli- cated with encephalitis, or aphthous or follicular stomatitis, as is often observed in dentition. Children perish then in a very short time, and the abundant discharges ought to be arrested; and the affection not being accompanied with inflammation, as we have just seen, may be advantageously treated by using slightly astringent drinks. I am not able to designate precisely the mode of treatment which it is necessary to pursue, because experience has not enabled me either to test any, or to observe that of others. The follicular apparatus may become, in some instances, the seat of evident inflammation, such as is met with in adults. M. Denis was one of the first to describe this affection in young in- fants : and having myself often had opportunities of studying the disease at the Hospice des Enfans Trouves, I am satisfied with the correctness of M. Denis's description. When the isolated follicles or the follicular plexuses of the in- testinal tube become inflamed, they may exhibit two species of alteration. They are either simply red and tumefied, or disor- ganized, forming ulcers remarkable both for their form and ap- pearance. I will not stop to follow them in their various pe- riods of development, tumefaction, and ulceration, but will re- fer to another work, in which I have given the details in full, ON THE DISEASES OF INFANTS. 309 and confine myself here to the examination of the difference be- tween the disease as it appears in children and in adults. It is well known that inflammation of the follicular apparatus in adults, gives rise to symptoms analogous to those which are assigned to putrid and adynamic fevers. This has been de- monstrated by the researches of MM. Petit and Serres, and in the more recent work of M. Bretonneau. What I have published on the same subject, goes equally to the support of this opinion. But it is not in every respect the same in young infants, for in twenty cases of inflammation of the follicular apparatus of the intestines in young infants aged from a few days to two months, I saw no other symptoms than those of enteritis. No cerebral complication, nor any of the symptoms which have been attri- buted to putridity, appeared in these cases, which, however, ex- hibited, on a post mortem examination, the same anatomical le- sions as appeared in adults. This, however, was not the case in infants more advanced in age. The affection then presented a great analogy to that of adults. I will endeavor, in two exam- ples, to convey some idea of this difference ; the description of these two cases will enable us to obtain a knowledge of the ana- tomical lesions which appertain to this disease. CASE XLVIII.—Meillenet, a girl, aged twenty-four days, enter- ed the infirmary on the 2(ith of January. She was pale, and a little emaciated ; she had been affected with a copious diarrhcea of green matters for two days previous ; the abdomen was tense and painful to the touch ; the tongue was red at the point, and very dry at the base; the skin very hot; the pulse natural. (Gummed rice-water, cataplasm, to the abdomen, strict diet.) On the twenty-seventh, the child vomited the drinks; continued in the same general condition, but became progressively emaciated. On the 1st of February, there was not quite so much vomiting, but the diarrhcea, tension of the ab- domen, and emaciation continued ; a number of wrinkles appeared at the root of the nose, and the face, which until then was without expression, indicated the existence of pain. On the eighth, the same general condition continued ; marasmus very much advanced • diarrhcea continued; the discharges yellow, and sometimes green. (Gummed rice-water, bath.) From the eighth to the sixteenth there was a rapid increase of symptoms ; excessive weakness ; hol- lowness of the cheeks, and a projection of the cheek bones resem- 310 ON THE DISEASES OF INFANTS. bling those of an old man; numerous wrinkles on the forehead ; skin of an ash-color; cry extremely feeble. Death occurred on the nineteenth. On examining the body on the following day, there appeared a general paleness and emaciation. The mouth and oesophagus were healthy ; stomach of a rosy hue ; some red transverse striae existed about the valvulae conniventes of the small intestines, where were also found a number of red projecting pimples ; some of them had already commenced to ulcerate. Eight follicular plexuses, very red and much tumefied, existed at the extremity of the ileon ; that which terminated this intestine was also a little excoriated and bloody, and the surface was covered with a thick and tenacious mucus. The caecum was healthy. There existed at the end of the colon a large number of red striae, and a quantity of purulent mucus adhering to the surface of the internal membrane. The liver was dark-colored, and filled with black blood ; the gall- bladder contained a quantity of liquid bloody bile. The right lung was engorged with blood at the posterior border. The brain was very much injected; its substance was of a bright rose-color; its ventricles contained a quantity of serum. This child presented no other symptoms than those ordinarily attending enteritis; but such was not the case with the follow- ing patient. CASE XLIX.—Francois Tessont, aged thirteen months, entered the infirmary on the 12th of September. For several days he had been very restless, and had scarcely slept; the pupils were dilated ; the tongue red and dry ; the skin very hot; the pulse very frequent. There was neither vomiting nor diarrhoea. (Gummed barley-wa- ter, sinapised pedeluvium, cataplasm to the abdomen, three leeches to the epigastrium.) On the thirteenth, a very abundant diarrhcea of green liquid matters ; abdomen less tender; child cried less and appeared enfeebled. From the eighteenth to the twentieth, there was no change. On the twenty-first, diarrhoea less abundant, and vomiting supervened. On the twenty-third, respiration was painful, and the child exhibited a state of general prostration difficult to de- scribe ; the face was pinched, and the forehead particularly exhibit- ed a number of wrinkles which continued even after the cries had ceased; two livid circles appeared about the alae of the nose ; the pulse beat from ninety to a hundred. On the twenty-fourth, the ON THE DISEASES OF INFANTS. 311 same general state ; the fceces were extremely foetid ; great prostra- tion ; extreme marasmus ; and the pulse became evidently enfeebled, although the skin presented much of its heat. On the twenty-fifth, prostration complete ; facies hippocratlca, convulsive motion of the globe of the eye ; the bites of the leeches had become violet; they ulcerated, and a purulent sanies flowed from them. The child died on the night ofthe twenty-sixth. The examination ofthe body was made on the twenty-seventh. General paleness and marasmus ; an eschar ofthe size of a two- franc piece was found on the sacrum; mouth and oesophagus healthy ; slight redness of the stomach. In the duodenum and ileon there were found a large number of glands, red and tumefied ; some of them were open, and exhibited in their centres superficial ulcera- tions. Twelve follicular plexuses, very red and tumefied, existed at the end of the ileon. In the colon and caecum there were a great number of isolated follicles about the size of a hemp-seed, and which, instead of being red like, those in the ileon, were, on the con- trary, surrounded with a blue circle. The circulatory and respira- tory apparatuses presented nothing worthy of remark. The brain was injected, and contained in its ventricles a quantity of slightly turbid serosity. The spinal marrow was healthy. I have selected these two cases from a number in my posses- sion, because they exhibit a remarkable antithesis with respect to their symptoms, while there can be nothing more remarkable than the resemblance in their pathology. The difference of age between these two children can explain, without doubt, the dif- ference of symptoms. Indeed, we almost always see that reac- tion is very trifling in young infants, although their lesions may be very serious; but in proportion as they advance in ao-e, we are able to observe all the general symptoms depending on the sympathetic relations which exist between the different organs of the system. This observation will be more fully developed when we consider the history of the diseases of the cerebro- spinal apparatus. From the preceding facts and considerations, it results that follicular enteritis is not to be distinguished by its symptoms from ordinary enteritis, except in children already advanced in ao-e- that in very young infants, inflammation of the muciparous glands of the intestinal tube, although of frequent occurrence 312 ON THE DISEASES OF INFANTS. does not give rise to any remarkable symptoms either in their progress, their peculiar characters, or their complications; it is not until about the seventh, eighth, or tenth month that this in- flammation produces any particular symptoms, the assemblage of which constitutes the disease described under the name of entero-mesenteric fever by MM. Serres and Petit, and dothin- enteritis by M. Bretonneau. / Chronic inflammation of the follicular apparatus is met with sometimes, but rarely in infants at the breast. This inflamma- tion is seen principally when there exists tubercles in the lungs, or when the mesenteric glands inflame, become engorged and disorganized. Enteritis with disorganization of tissue.—Under this subdi- vision I arrange the inflammatory softening and gangrene of the intestines. The inflammatory softening must not be confounded with the white softening of the intestinal mucous membrane. It is the former only that we are now to consider. When the mucous membrane has been a long time the seat of a phlegmasia, the stimulus of which has continually maintained the blood in its tissue, it acquires at first a great degree of friabili- ty ; it is easily torn with the nail, and when this friable condition is kept up by a continued afflux of blood, it persists for some time, and the membrane becomes disorganized so as to exhibit but few traces of its membranous structure ; and when we en- deavor to separate it from the other membranes, it is found to be a soft and reddish mass. This disorganization ought to be con- sidered as of a very serious nature, particularly when it occupies a general extent of the intestinal surface. All the children which have exhibited the disease, have experienced during life the most serious symptoms of enteritis ; but showing no external evidence by which the existence of this alteration could be known. I shall, on this account, give no examples of it here ; for we would but see the collection of symptoms of enteritis al- ready exhibited, of which this softening is one of the fatal termi- nations. Gangrene of the mucous membrane of the intestines equally deserves our attention ; it appears under different aspects. Thus we see certain ulcerations of the ileo-ca?cal region, exhibiting ON THE DISEASES OF INFANTS. 313 their edges black like soot, and like that which is observed on ulcerated aphtha? ofthe mouth. Some circumscribed points of the mucous membrane may ulcerate and become gangrenous, without inflammation having preceded this ulceration, and which always commences in the following manner, as described by Cloquet; a black line appears, about which the mucous mem- brane changes to a gray pulp. The eschars which then form, soon separate, and are followed by an ulcer with a projecting edge, the bottom of which is destroyed so as to produce a com- plete perforation. This occurrence is of a very serious nature, for it may give rise to the escape ofthe contents of the intestines into the abdomen. Adhesions are often very promptly formed be- tween the intestines, which sometimes prevents this effusion.* I have not had an opportunity of seeing this species of gangre- nous ulcerations in infants at the breast; yet Cloquet has met with it in children of a very tender age. As to gangrene produced by excess of inflammation, and which occupies a greater or less extent of the intestines, it is some- times to be seen in young infants. I shall give a very remarka- ble example which occurred in a young infant, and where, dur- ing life, all the symptoms of dysentery existed. CASE L.—Enteritis, gangrene of the colon.—Caroline Jossey, aged nine days, small and feeble, entered the infirmary on the 7th of November. She exhibited a general redness of the integuments, and an cedematous swelling of the limbs ; the heat of the skin was natural; the cry exhibited no alteration ; the pulse was regular, beating ninety-two in a minute. This child was attacked with a copious green diarrhoea. An intense redness was observed about the anus : the abdo- men was distended. On the twelfth there appeared several streaks of blood in the green discharges from the bowels, which occasionally consisted of black pitchy matters; the general condition was the same. (Sweetened rice-water, starch injections, milk and water.) On the thirteenth, the limbs were not so much swelled, the face was pale, the commissure of the lips was drawn backwards, the forehead very much wrinkled, particularly at the nose; the pulse was extremely small and feeble ; the bloody diarrhoea continued, and froth issued at the mouth. On the fourteenth, a large quantity of blood passed from * Nouveau journal de med by Beclard, Cloquet, etc. torn. 1, January, 1818. 40 314 ON THE DISEASES OF INFANTS. the bowels ; the face became thin and livid ; the drinks were vomit- ed with a quantity of filamentous mucus. The limbs were coJd and livid ; the abdomen contracted ; the pulsations of the heart extremely slow. She died at night, while passing a large quantity of liquid black blood. On examining the body the following day, a number of sugilla- tions were found on the back and nates. There was a thick layer of yellow mucus on the tongue, a very great congestion of the oeso- phagus, and a spotted redness of the stomach. The duodenum was healthy ; at the extremity of the ileon there existed an intense red- ness, with tumefaction and friability of the mucous tissue, and san- guineous exhalation on its surface. The mucous membrane of the caecum and colon was remarkable for its thickness and its intense redness ; it was covered with blood throughout its whole extent. When this was removed, the membrane appeared rugous and bloody ; its surface was furrowed with a number of wrinkles, between which there appeared several excoriated and black lines, as if they had been burned with nitric acid. Besides these furrows, there were, at dif- ferent parts of the colon, a large number of ecchymosed spots of the same appearance. The mucous membrane was so soft about these points, that it easily separated with the nail. This condition was particularly remarkable about the rectum, where was found a large quantity of blood mixed with membranous shreds of a black color. This intestine diffused an evident gangrenous odor. The liver was gorged with blood ; the lungs were healthy; the foetal openings obliterated ; the brain much injected. Entero-colitis could hardly have been more violent than in this case. The gangrene of the large intestines was doubtless the result of inflammation, and of the great afflux of blood which took place to the part; the general prostration and intestinal hemorrhage were here the only peculiar characteristics of this enteritis, which exhibited, besides, the ordinary symptoms of in- flammation of the intestines. All the varieties of intestinal inflammation have now passed in review. We have pointed out, as far as possible, the peculiar symptoms of each of these varieties ; and it now remains to study the phlegmasia? of the mucous membrane with reference to their seat. From the most remote antiquity, the diseases of the small were ON THE DISEASES OF INFANTS. 315 distinguished from those of the large intestines. Celsus has ob- served that this distinction was long before made known by Dio- des. " Diodes Carystius tenuioris intestini morbum, xoeSx^ov, plenioris, tlxtiv nominavit. A plerisque video nunc ilium prio- re.n uc^)>v, hunc x«A«*a« nominari." In dividing then, at the present day, the diseases of the intestinal tube into two sections, we follow a method supported by the experience and authority of the most ancient authors. But an important question here arises ; is it easy to distinguish in very young infants, during life, inflammation of the small in- testines from those of the large? We will answer by facts. I will, in the first place, observe that it has always been im- possible for me to establish a well-marked distinction between in- flammation of the duodenum, and that of the rest of the small intestines, in nursing children, and I will on this account use the more general term enteritis or ileitis, to distinguish the inflam- matory affection of the small intestines ; and will denominate that of the large, colitis. In eighty cases of inflammation of the intestines that I ex- amined with great care, there were thirty of entero-colitis, thirty- six of enteritis, and fourteen of colitis. In the thirty cases of entero-colitis, there were twenty with diarrhcea of yellow or green matters ; in the other ten, the diar- rhoea was not noted. In all, there was a distension of the abdo- men, which was more or less painful on pressure. In twelve of these children there was vomiting of yellow matters, although there existed no gastritis. In all, there was an erythematic red- ness about the anus, of greater or less intensity; caused, doubt- less, by the abundance and contact of the alvine dejections. The tongue was very often red and dry ; the skin very hot and arid ; but the pulse was rarely raised to the degree that generally indicates fever ; in several of the cases the pulsations were feeble and slow. In the thirty-six cases where the small intestines alone were affected, there were twenty instances of vomiting, either of drinks or of intestinal matters; and among twenty cases of vomiting, the inflammation was seated in the ileo-caecal region, and even at the valve, in fifteen instances; it is possible, therefore, that the obstruction resulted from the tumefaction of this valve, and this 316 ON THE DISEASES OF INFANTS. consequently produced an interruption in the course ofthe intes- tinal matters, followed by vomiting. In every instance the abdo- men was tumefied, if not at the commencement ofthe disease, at least during its course. There were twenty-five instances of di- arrhoea, consisting of yellow, and often of green matters, analo- gous to the meconium; the tongue was almost always red ; the skin hot; the pulse but little disturbed, except in two infants, considerably advanced in age, one of whom had a very severe inflammation of the muciparous follicles. I also noticed a red- ness about the anus of all. Lastly, there existed a diarrhcea in fourteen affected with coli- tis ; the tympanitic state of the abdomen was in general less ; in six cases only, was there vomiting, and I often observed a very remarkable dryness of the integuments, which in general were cold and livid. The pulse was not quicker than in the preceding case. The eighty children forming the subjects of this analysis, were, for the most part, aged from one day to six months; some were from the age of six months to a year. From this calculation, it is evidently very difficult to make a correct diagnosis of inflammation of the intestinal tube in suck- ing infants, yet it would seem as if the proper signs of enteritis or ileitis were the rapid tympanitis of the abdomen, the diarrhcea accompanied with vomiting; while in colitis, diarrhcea alone, with- out tympanitis, is the most frequent. The complication of gastritis with enteritis, or gastro-enteritis, is extremely common in young infants ; the predominance of the symptoms peculiar to gastritis, and which have already been de- scribed, will alone enable us to suspect the existence of this com- plication. In the impossibility of tracing with exactness the series of symptoms peculiar to inflammation of each of the parts of the digestive tube, we shall only present an analysis of the causes, symptoms, and ordinary progress of inflammation of the mu- cous membrane of the intestines in general. Causes.—The injection of the intestinal tube at birth, the fa- cility with which this apparatus becomes injected, producing very considerable congestion upon the slightest disturbance oc- curring in the course of the blood in the thoracic and abdomi- ON THE DISEASES OF INFANTS. , 317 nal vessels, the ingestion of aliments too stimulant, too nutijtious, or too difficult to digest; and lastly, the functional activity of the digestive apparatus from birth, are the numerous caries of inflammation of the digestive passages of young infants. The activity of these various morbid causes, easily explains tie fre- quency of diseases of the digestive organs of young chjdren. Of all the affections to which they are liable, these are tlf most numerous and most fatal ; we should, on this account, exft the utmost care in directing and superintending the mode of iimen- tation to which nursing children are subjected. The diseases of the digestive tube do not always prelnt, at the commencement, a well-marked inflammatory characr; at first, they frequently are only simple passive congestions ; u. the continuance of the blood in the tissue of the mucous menWne, really excites inflammation, as is observed in old people! r in those individuals affected with diseases of the heart and rge vessels. Symptoms.—The symptoms of diseases ofthe digestive [sa- ges iu young infants are almost always local; they do notive rise to symptoms of reaction such as is observed in adultex- cept as the children advance in age. We ought, thereforear- ticularly to direct our attention to the disturbance of the res- tive functions, when we wish to make a correct diagnosis cthe diseases of the intestines. Vomiting is very frequent in enteritis, but it generally prents this peculiarity, that the matters vomited are yellow and fhy, and that it does not occur immediately after the ingesti' of drinks. Diarrhcea almost invariably exists ; the discbarg are green and yellow, and are rarely serous. In the latter cast is generally owing to an increase of secretion, caused by funonal activity and a morbid development in the follicular apparas of the intestines. The tympanitis and tension of the abdom<, its pain on pressure, are also remarkable, and almost constantigns of enteritis. Unite to these symptoms, those of rednesand dryness of the tongue, heat of the integuments, but whii, to- wards the end of the disease, become cold and icy—lastly, cy the- ma of the anus and surrounding skin, and then we have thmost common symptoms of gastro-enteritis, and of entero-coliti While these symptoms successively succeed each oth<, and 318 ON THE DISEASES OF INFANTS. the diease which causes them is making its progress, the child falls iito a complete marasmus, the integuments assume an ashy aspect the osseous projections become more evident than is usual at thi age, the fat of the cheeks disappears, and they become hollored ; the orbits are sunken like those of old people; the face cquires the same old appearance which is observed in adult arising doubtless from the absence of the teeth, which, in the iiant, as well as in the old man, gives the physiognomy an expresion altogether different from that of adults who still re- tain te two dental arches. Lastly, several lineaments are seen uponhe face, which we will endeavor to compare with those whic M. Jadelot has pointed out in children of a more ad- vand age. MTadelot describes the nasal lineament as appearing on the insicof the ala? of the nose, and embracing the whole of the or- bicuris oris muscle; and the genial lineament, that which ex- tendfrom the commissure of the lips, and loses itself near the lowpart of the face : he regards both these as a symptom of abddnal affections. In very young infants, although these sign.re not observable with great distinctness, yet they are still to been in some degree. The commissure of the lips, for in- stant as I have often indicated in the cases mentioned, is drawn outvtd, thus causing a fold of skin more or less prominent on the cside of the orbicularis oris muscle; there is also formed anotr fold, very analogous to the genial lineament, which is di- recWfrom the inferior lip towards the chin; this, however, is less iquently seen than the preceding. Other folds of the skin whicare constantly to be observed in abdominal affections, and whic are also noticed under all circumstances where the child expemces violent pains, are remarked at the root of the nose and ithe forehead. The skin at this part presents a wrinkled aspe(!and a well-marked indication of distress which ought not to beieglected. I have always been struck with the coinci- dencof these irregular wrinkles on the skin of the forehead, wiih \e existence of an inflammation of the digestive passages Altogher these traits give to the physiognomy of the child an exprdlon known ordinarily by the name of "face grippee ;'- this epression is always an index of a violent gastro-intestinal phlegmasia. ON THE DISEASES OF INFANTS. 319 Treatment.—The treatment of enteritis and of gastro-enteri- tis ought to be grounded on the doctrines we have advanced in this article. We have seen that a sanguineous congestion of the abdomen is often the primary cause of phlegmasia of the in- testinal tube ; when we are called, therefore, to prescribe for en- teritis at its commencement, the application of one or two leeches to the anus ought not to be neglected, particularly if there be any signs of sanguineous plethora present. Abstinence from the breast is very necessary, and the use of mucilaginous and de- mulcent drinks, such as a sweetened decoction of marshmallows, milk diluted with barley-water, etc., ought to be substituted. If the child appear to suffer much, and if the diarrhoea be very abundant, enemeta of starch, with from four to eight drops of laudanum, ought to be administered. Preparations of opium ought to be given to young children with great caution, for their action is much greater on them than on adults ; it would even appear as if the absorbent function of the rectum is in a greater degree of activity. 1 have often seen infants, from the age of eight to twelve days, almost completely narcotized by six drops of laudanum introduced into the rectum by an enema. Three to four ounces of fluid is sufficient as an enema for very young children. A larger quantity distends the intestines, and forces them to return the fluid before it has had time to produce any effect. On no account should the application of cataplasms to the abdomen be omitted. The greatest benefit will arise from the use of emollient baths, and nothing so soon arrests their cries and their pain; for they often become so tranquillized as to fall asleep as soon as they are immersed in the bath. The hours of feeding, and the quantity of aliment, ought particularly to be regulated. Before concluding my remarks on phlegmasia? of the gastro- intestinal mucous membrane, there still remains a question for me to examine. Do the violent pains of the bowels experienced by an infant, for a greater or less time after birth, arise from an inflammation of the digestive passages ? I believe that these colic pains may arise from several different causes. These are—1st, The difficulty of the first al vine evacua- tions. The retention of the meconium, for instance, may cause violent pains in infants, analogous to those which are experienced 320 ON THE DISEASES OF INFANTS. after a long and obstinate constipation. This is what we have seen in children affected with an imperforate anus. In these cases, the alvine evacuations ought to be excited by means of in jections with olive oil, or castor oil. Two drachms is sufficient, in two ounces of tepid water. A suppository of soap might also be introduced into the rectum. It would be proper, like- wise, to give the child one or two tea-spoonfuls of syrup of rhubarb or chicory. 2dly, I have examined, after death, the bodies of a number of infants that have been affected with colic, or sharp pains, after their birth, where I have almost always found, either a congestion, or more often an inflammation of the intestinal tube; it would appear, therefore, that abdominal pains, the restlessness and cries which they produce, are probably the result of phlegmasia of the intestines. 3dly, The pains may be caused by ileus or peritonitis; whence it follows that it is impossible to establish, in a general manner, a treatment for colic of young infants, because the causes which produce it may vary almost to an infinite degree. It would appear, nevertheless, that infants are liable to certain spasms of the intestines, of which authors have vaguely spoken in their works. It is to be regretted that, for the most part, they have not accompanied their descriptions with an account of the pest mortem appearances ; we shall endeavor, however, to ob- tain a knowledge of what is meant by this term. Art. 3.—Spasm of the Intestines. The intestines, after birth, sometimes become extremely irrita- ble, and are affected with spasms, in consequence of which the digestive functions are completely disturbed ; sometimes also ge- neral convulsions or spasmodic movements of the face and limbs occur. It is often impossible to understand the cause of these convulsions, which frequently cease and reappear with greater intensity at a period more or less remote from the appearance of the first symptoms. These symptoms are as follows : the abdo- men swells, the child cries acutely, the face is contracted, the limbs are stiffened, the bowels arc very tender to the touch, the alvine evacuations are suspended, and vomiting sometimes super- venes. I have seen infants seized with these nervous colics ON THE DISEASES OF INFANTS. 321 while sucking; they quitted the breast abruptly, cried suddenly and violently ; the abdomen swelled immediately, and their agi- tation did not cease until a quantity of gas had escaped by the anus. Dr. Joseph Parrish, one of the physicians of the Pennsylvania Hospital at Philadelphia, has published in the North American Medical and Surgical Journal a very interesting article on this subject .* It is probable, he observes, that this spasmodic affec- tion has its seat in the intestines, and particularly in the muscu- lar fibres. Children experience a very great relief upon the ex- pulsion of gas, which is contained in the intestinal tube in such quantities as to give rise to a true tympanitis. In one case that I saw in 1821, says Dr. Parrish, death enabled me to verify my views on the cause of this affection by dissection. " The subject of this attack was an infant about five months old. The convulsions came on instantaneously, without the least warning, and immediately after they had passed, the patient was quite sensible and even playful. At first, several days inter- vened between the fits; and, contrary to the general rule, they came on at one stated time, about, or a Itttle after, daybreak. They afterwards became more frequent and distressing, and to- wards the close of the case, several spasms or partial convulsions occurred at intervals, the child screaming out, and appearing to be much in pain. The treatment was principally directed to the bowels; but leeches were twice applied to the head, and blisters were placed behind the ears. Though relief was occasionally obtained, yet no permanent impression was produced upon the disease, and notwithstanding all my efforts, the little sufferer ex- pired. Upon dissection, the bowels exhibited strong evidence of having been under the influence of severe spasm. More than half of the small intestines were irregularly contracted. In some places, for more than an inch in extent, the bowel was reduced to the size of a goosequill; in others, it appeared as if tied by a thread, its calibre being almost obliterated. The omentum was closely folded up in the form of a thick twine or small rope, and lay on the arch of the colon. In the gall-bladder was a * On infantile convulsions arising from spasm ofthe intestines. N. A. Med. & Surg. Journal, January, 1827. 322 ON THE DISEASES OF INFANTS. light-colored and glairy fluid. No other sign of disease was visi- ble in the cavity of the abdomen and thorax. The condition of the brain I did not examine." It is evident there had been spasmodic contraction of the in- testinal tube; but it is unfortunate that the brain was not open- ed, because there perhaps the cause of the spasmodic disease might have been found, which perhaps was but a secondary af- fection. The formation of gas in the intestines often gives rise to symp- toms nearly resembling those which we have just pointed out; they cease as soon as the gas is expelled, thus proving that this is the true cause. In the treatment of this disease, two things ought to be con- sidered : the nervous excitement, which produces it, and the dis- turbance of the digestive organs which follows. The spasm of the intestines is evidently owing to an irritation of the cerebro- spinal apparatus, which must first be attended to in the treat- ment ; two or four leeches should therefore be applied to the mas- toidean region, or blood be taken from the arm or foot. The ap- plication of leeches is preferable to general blood-letting, if the cerebral irritation be owing to an accumulation of blood about the head, and if the extreme feebleness of the patient appear to counter indicate general bleeding. At the same time warm baths should be used, for they are excellent antispasmodics. Among the antispasmodics, asafcetida has been recommended to be given in injections ; this might be assisted by adding a lit- tle laudanum; two to five grains of asafcetida with two or three drops of laudanum, will be sufficient for an injection. Dr. Par- rish recommends the rubbing of the spinal region, at the same time, with a liniment composed of a tea-spoonful of oil of amber and laudanum in a table-spoonful of olive oil and alcohol. He considers the irritation ofthe gums produced by dentition, as one of the causes of this spasmodic affection, and therefore recom- mends us to examine the condition of the gums, to cut them, and thus to allay the irritation in the mouth. But if dentition, and the consequent irritation of the gums, be the predisposing cause of the intestinal spasm, it is not excited however until after hav- ing sympathetically irritated the brain, and the nervous system ought therefore to be attended to first. ON THE DISEASES OF INFANTS. 323 The removal of the constipation ought not to be forgotten, by which also the expulsion of gas is effected. Gentle laxatives, the introduction of a suppository of soap into the rectum, will accom- plish this object. Dr. Parrish has removed the gas by introdu- cing an empty syringe into the rectum, and then pumping out the air. A gum elastic tube might be passed into the intestines, by which the air could escape while compression is gently made on the abdomen. I have not considered this affection at length, because it appeared to me to belong more particularly to the dis- eases of the nervous system, of which we shall hereafter treat. Art. 4.—White Softening of the Gastro-intestinal Mucous Membrane. I did not speak of this alteration of the mucous membrane im- mediately after inflammation, because I have not seen it as the result of inflammation. We have already seen that, in consequence of bad or imperfect nutrition, children often become pale, sink into a state of maras- mus, and die. Upon opening the bodies of these children, the mucous membrane is found pale and colorless, like the external integuments. Now this state of the internal membrane of the di- gestive tube is the first stage of softening of the intestines, a soft- ening which must not be confounded with that which is pro- duced by an afflux of blood in the mucous membrane in conse- quence of the inflammation developed in it. The softening appears then in two stages, that in which the membrane is only discolored ; here the mucous tissue does not present its proper consistence ; it is raised with the greatest ease when scratched, but the shreds are still membranous. Notwith- standing this, it may be destroyed with facility. In this case, the mucous membrane presents still here and there a mottled red, which are the last traces of its normal color, or ofthe accidental redness of which it is the seat, as was the case in the following subject. CASE LI.—Fanny Bombardy, aged ten days, entered the infir- mary on the 16th of November. She was robust, skin of a vermil- ion color, and she exhibited an induration of the cellular tissue of the superior and inferior extremities. From the sixteenth to the twentieth, the oedema of the limbs disappeared, but vomitino- and co- 324 ON THE DISEASES OF INFANTS. pious diarrhoea supervened. Some points of muguet appeared on the edges of the tongue. On the twenty-fifth, the muguet disappear- ed ; the diarrhcea continued, and the child constantly passed a quan- tity of yellow frothy matters. She became pale and emaciated. On the thirtieth, there was a rapid progress of emaciation ; a universal discoloration of the integuments, which were of a very remarkable chlorotic paleness. The child was without fever ; cry feeble ; the skin cold, particularly on the limbs. From the 1st to the 6th of De- cember, all these symptoms continued with great intensity ; the di- arrhoea continued to be abundant; vomiting still existed ; at last the child, pale, feeble, and excessively wasted, succumbed on the eighth, after vomiting a large quantity of green and yellow matters. Post mortem examination.—There was a general discoloration of the integuments, and some violet-colored sugillations appeared on the back and nates. The base of the tongue exhibited a violet ec- chymosis about the size of ten-sous piece ; the oesophagus was pale throughout its whole length; the stomach exhibited the same ap- pearance ; but besides this, four superficial excoriations, three lines in length, and pale like the rest of the membrane, were found near the pylorus. The mucous membrane of the small intestines presented, throughout its whole extent, a marked discoloration; it was at the same time so friable, that on scraping it very slightly, it was raised in small shreds which were easily reduced to a soft mass. In the ileo- caecal region there existed several follicular patches, which partook ofthe paleness ofthe rest of the intestines, and besides this, there were in the same region a mottled redness, pale at the edges, and which appeared to be the traces of the color of the intestinal tube before it changed. The liver was large, and filled with blood; the gall-bladder very much distended by a large quantity of green porraceous bile ; the lungs were gorged with blood; the foetal openings obliterated; the brain very much injected. It is remarkable that the large abdominal veins in this child had retained much of the blood, while the mucous membrane was entirely colorless. Softening ofthe digestive mucous mem- brane supervened here in a child who was doubtless affected prematurely with gastro-enteritis; and this gastro-enteritis hav- ing suspended the digestive functions, produced marasmus, paleness, and afterwards a softening of the digestive tube from a defect of alimentation. If this softening were the necessary re- ON THE DISEASES OF INFANTS. 325 suit of inflammation, there never would occur softening without inflammation ; yet we have seen the contrary of this. The sub- ject ofthe following case was in a condition analogous in every respect to that usually occurring in the marasmus and wasting of a child badly nourished, and of which we have already spoken when treating of intestinal indigestion. CASE LH.—Louise Massan, aged one month, had been suckled at the Hospice des Enfans Trouves since birth. She was pale and thin, as all are that are under the care of the hospital nurses. She vomited often, and was affected with a diarrhcea of green matters, which ceased spontaneously after two or three days. This child en- tered the infirmary on the 26th of February. She was thin, pale, and very quiet; the skin was so white as to be almost transparent, and the small blue veins could be distinctly seen on various parts of the body. She was not affected with fever, respired well, and cried but little. (Sweetened rice-water, milk and water.) This child remained in the infirmary until the 1st of April, without presenting any other symptom than those just described; during this time she became affected with marasmus, and the skin assumed the appearance of wax. She died on the 1st of April. On opening the body, the abdomen was found excessively distended with gas, and the intestines wrere so thin and transparent, that their contents could easily be seen through their walls. The stomach, small and great intestines, exhibited, through their whole extent, a chlorotic pale- ness, and the mucous membrane was so soft, that the mere touch re- duced it to a soft mass, resembling mucus more than a membranous substance. The liver, spleen, lungs, heart, and brain were healthy, and all these organs were exsanguineous. This infant was doubtless reduced to this state of marasmus and extreme feebleness by the insufficient and improper alimen- tation to which she was subjected, the effects of which were ma- terially aided by her prolonged continuance in the infirmary, where a great number of sick children were assembled, render- ing the air insalubrious. The softening in this case was not pre- ceded by inflammation, but had been for a long time comino- on from an opposite cause. Sometimes this softening, instead of be- ing general, is only found in. a few isolated points ofthe intesti- 326 . ON THE DISEASES OF INFANTS. nal tube. It is met with not only after birth, but likewise in children who die during birth, as I have often had occasion to observe. It appears always to follow an absence of the blood in the mucous tissue ; it is this which has led M. Denis to consider it as a sort of retiring of the blood, retrait du sang, as he has termed it. But here the absence of the sanguineous fluid is not the immediate cause of the softening; it is itself, like the pale- ness and softening, the effect of a default of alimentation; be- sides, there is not, properly speaking, a retiring of blood; for whence would it retire ? When an infant dies in the condition we have just described, all its organs are found exsanguineous, particularly the external integuments ; and it is rather to be at- tributed to a diminution, alteration, and suspension of sanguifica- tion, the disturbance of which function being caused either by the indigestible drinks taken, or by the unhealthy air respired ; so that the very spring of life is insensibly dried up, and the child perishes from debility and hunger. The white softening now under consideration, is, therefore, to be regarded as an advanced stage of the discoloration of the intestines pointed out in the his- tory of intestinal indigestion, the cause of which has its origin in the insufficient and improper alimentation to which an infant is exposed in hospitals. This softening has apparently some ana- logy to that which is both generally and locally developed in the intestinal tube of persons affected with phthisis, upon the nature of which MM. Louis and Andral have made some interesting re- searches. Among the symptoms indicating this sort of softening, we will particularly point out the general discoloration of the integu- ments, and the blanched appearance of the children affected with it, the skin having a close resemblance to that of a chlorotic girl. Other symptoms, such as diarrhcea, tympanitis, etc., being com- mon to other intestinal affections, cannot be considered as of any importance in the diagnosis of this disease. Softening of the intestines must be regarded as an affection al- together incurable ; an entire regeneration of the mucous mem- brane would be necessary, which is an impossibility. The treat- ment ought then to be previously directed to an attempt to reme- dy the first effects ofthe want of alimentation, and in having re- course to every means that can restore the impaired condition of ON THE DISEASES OF INFANTS. 327 the digestive functions, before the disorganization of the mucous membrane has occurred. Art. 5.—An examination of the principal Symptoms of the Diseases of the Digestive Canal. All the lesions to which the digestive apparatus is liable, have been considered; and I will now endeavor to give an account of the symptoms proper to each, and such as may be recognised during life. Authors, generally, who have written on the dis- eases of children, have been more systematic, and have taken the symptoms, or the groups of symptoms, as a foundation of their divisions, without regard to the anatomical lesions. In a rapid examination, I propose to estimate the value of these symptoms, together with their relation to the anatomical lesions of which they are the effect. Vomitifig.—Vomiting may occur from several causes ; such as gastric or intestinal indigestion, produced probably by the bad qualities of the milk, oesophagitis, gastritis, enteritis, particularly when seated in the ileo-ca?cal region, interruption of the course of fcecal matters from invagination or spasm of the intestines, and lastly, from softening ofthe mucous membrane. In considering this symptom, the cause producing it should always be taken into ac- count, and the facts properly studied. It is impossible to draw any practical inference from this symptom taken separately; but to give its clinical history it will be necessary to examine all the affections of the digestive tube, for vomiting, as we have seen is common to all of them. This manner of considering and esti- mating the vomiting of infants at the breast, appears to me much more philosophical than to imagine and establish, a priori, the causes of this morbid phenomenon, as has been done by a num- ber of authors. Diarrhoea.—Diarrhcea is not a constant sign of enteritis; it may be produced by intestinal indigestion, by a state of irritation, or an increase of the secretion of the follicular apparatus, by co- litis, or enteritis. The discharges vary in color and consistence ; a yellow, frothy, and fluid diarrhcea is very often accompanied with inflammation ; a white and mucous diarrhcea is often pro- duced by an augmentation ofthe secretion ofthe muciparous fol- 323 ON THE DISEASES OF INFANTS. licles; when mixed with green flakes, it often exists without in- flammation. Redness surrounding the anus.—This exists in almost every case of diarrhoea, whether with or without inflammation. Tension ofthe abdomen.—This affection is usually observed in enteritis, and is then accompanied with abdominal pain. The distension ofthe intestines by gas, when it arises from spasm of the intestines, produces the same phenomenon ; but it is inter- mittent, and the pain ceases when the gas escapes, while it con- tinues without intermission when arising from inflammation. Tension ofthe abdomen, when there is softening ofthe mucous membrane, generally exists without pain, and is accompanied with a state of general wasting and paleness. Colic.—Colic may be spasmodic, or the result of inflamma- tion, invagination, imperforation ofthe anus, distension from gas during inflammation, or when this pathological condition does not exist, it may arise from indigested aliments remaining for some time in the intestines. This is what authors have de- scribed under the name of flatulence.* Cholera.—Cholera is not generally noticed in our climate ; it is a disease peculiar to infants in the United States; and as I have not observed any thing analogous to this affection, I must be indebted to Dr. Dewees for the principal details of the symp- toms.f This disease begins with vomiting, copious diarrhcea, great cerebral affection, and an intense thirst. The pulse is small, quick, and corded. The evacuations from the bowels vary con- siderably ; they are sometimes yellow, brown, and watery; at other times, more thick and tenacious; they are sometimes mix- ed with blood, and almost always yield an odor exceedingly of- fensive. The irritability of the alimentary canal is sometimes so great that the ingesta rapidly pass off as in lientery. The skin of the forehead is tight; the eyes are sunk; the nose is sharp, and the lips are shrivelled; the belly is tumefied ; the feet are cedematous, and aphtha? appear. This condition may con- tinue for five or six weeks, but as death approaches, a gradual * See Appendix. t A Treatise on the physical and medical treatment of children, by W. P. Dtwees, M. D., 2d edition. Philadelphia, 1826, p. 395. ON THE DISEASES OF INFANTS. 329 aggravation of symptoms take place. Sometimes there are seen on the chest an immensity of watery vesicles. Children are sometimes seen thrusting their fingers into the back part of the mouth, as if desirous of removing something. The popular opinion is, that there is a worm irritating the back part of the throat. Dissections show the following anatomical lesions : the brain is generally in a state of congestion ; the thoracic viscera are rarely affected; but it is on the contents of the abdomen that it mainly expends its force : the stomach and small intestines ex- hibit dark livid spots dispersed over the mucous membrane, par- ticularly near the pylorus. In many parts there is an alteration ofthe structure, by the thickening of their coats ; so much so, that the calibre of the tube is reduced considerably. The large intestines are seldom or never involved in the mischief, excepting where the disease assumes a dysenteric form. The liver is of a large size, and filled with blood, and the gall-bladder is filled with a dark green bile. The other viscera of the abdomen are usually healthy. It is evident that all these symptoms described by Dr. Dewees, are those of a violent gastro-enteritis, complicated with hemorr- hage, of which affection we have given several examples, (v. cases xli. and l.,) and although cholera infantum is rare in our country, yet there sometimes exist instances of it, particularly in our hospitals, where children are brought that are born in the midst of the most frightful misery, scarcely protected by a few rags from the inclemency of the atmosphere. Dr. Dewees has detailed the treatment of this disease at length; and in truth, nothing, in our opinion, can be more irritating than his method ; he attaches too much importance to the treatment of the prostra- tion and the symptoms of putridity. He also advises the treat- ment to be commenced with vomiting, and afterwards a tea- spoonful of strong coffee, without sugar or milk, every fifteen minutes, to be given especially to very young children. We have, says he, since we first tried it, seen it act like a charm. He adds, "If the stomach has not been tranquillized by the cof- fee, we immediately commence with minute doses of calomel, but never combined with opium. The following is the form and average dose we use: 42 330 ON THE DISEASES OF INFANTS. fy Calom. ppf. gr. iij. Sacch. all. gr. -vi. M divid. in pulv. xij. This should be given until the stools become less abundant, and less green." When the evacuations of the bowels are moderated, injections with laudanum, proportionate to the age of the child, should be administered ; to this is added the use of rhubarb and absorbent powders, the application of blisters to the limbs, and dry frictions with flannel, etc. Such tonic treatment might per- haps succeed in a climate different from ours ; but when the na- ture of the anatomical lesions which produce the symptoms con- stituting cholera infantum, are considered, we ought certainly to hesitate about employing it; and it must be acknowledged that it has not been very successful in America, since the disease still continues to make frightful ravages in that country. Indeed, Dr. Parrish commences an essay, which he published in 1826, with these remarkable words: " The great mortality of cholera infantum renders it one of the most interesting diseases which comes under the notice ofthe physician. Its ravages among the infant population of our large cities, are well known and too strongly felt to require any comment. No disease contributes so large to swell our bills of mortality during its prevalence ; and were it not restricted to the summer season, it would prove a greater scourge to the community than consumption itself."* Considering the nature of this disease, if the American physi- cians were to adopt a system of treatment less inflammatory, they might perhaps have less reason tr- lament the ravages of this species of gastro-enteritis. Dr. Dewees advises the removal of the child from the infected atmosphere to the country as a preventive, and to this precau- tion Dr. Rush recommends nourishing the child with milk, to cover the skin with flannel, and to avoid the use of fruits, being careful, at the same time, to give as aliment nothing but farina- ceous substances, as rice, arrowroot, biscuit, etc., and some time after the appearance of the teeth, to give a little animal food to strengthen the digestive organs. * Remarks on the prophylactic treatment of cholera infantum. North American Medical and Surgical Journal, July, 1826, ON THE DISEASES OF INFANTS. 331 Dr. Parrish, in the memoir cited, also insists much on the ne- cessity of a tonic and stimulant diet, as a prophylactic of cholera. In this manner he was enabled to raise the child of a lady who had previously lost eight children from this disease. This child, from its earliest infancy, was accustomed to the most stimulating food, and several spoonfuls of ginger tea were daily given to it, followed afterwards by the juice of meat. During the summer, the nurse used the most nourishing aliment, taking the precau- tion not to eat either fruit or vegetables. The second year, va- rious preparations of animal food, beef tea, port wine, etc., were adopted as diet for the child, until it had passed the period of dentition, without experiencing any symptom of disease, the very idea of which was extremely distressing to the mother. I know of no practitioner in France that would be tempted under similar circumstances to adopt the same method of ali- mentation for infants, or to approve of its use.* Symptoms of reaction of intestinal diseases.—A very remark- able fact, and one to which we have frequently alluded in the view we have taken of the diseases of the digestive apparatus, is, that generally in young infants there do not exist so well-marked symptoms of reaction as in adults. The heat of the skin alone is augmented, and we have seen a great number sink under the most serious lesions, without exhibiting any fever, the feebleness of the pulse being rather a symptom of reaction than the accele- ration of the circulation. Thus then, age exerts an important modification on the affections of the digestive tube. I shall finish this long chapter with an observation worthy of the attention of all pathological physiologists ; it is, that the di- gestive apparatus, possessing at the period of birth an advanced state of formation and development, and fulfilling functions of great activity, becomes at the same time the seat of a great num- ber of diseases in young infants ; it is indeed by derangement of the digestive tube that great numbers of them perish, and it is by means of this, that their general health becomes affected, and the proper development of their constitution is prevented. I have not spoken of intestinal worms ; children at the breast being seldom or never affected with them. * See Appendix. 332 ON THE DISEASES OF INFANTS. CHAPTER III. DISEASES OF THE APPENDAGES OF THE INTESTINAL CANAL. Section I. DEVELOPMENT AND CONGENITAL MALFORMATIONS OF THE LIVER. The liver begins to be developed at a very early period; Walter has proved that in the embryo of three weeks, its weight is half that of the rest of the body; and in the fcetus at the full term, with reference to the body, it is as one to eighteen or twen- ty.* In the infant at birth, it fills almost the third of the abdo- minal cavity, for it descends even to the crest of the ilium. During the intra-uterine life, therefore, the liver exhibits very early a development sufficient to allow of its being considered as one of the most important abdominal organs; it exercises indeed some essential functions with respect to the foetal circulation ; and perhaps also with respect to nutrition, for its secretion may in some sort concur in the alimentation of the fcetus. I shall not stop to examine this idea, which may as yet be regarded only as a conjecture. Congenital malformations.—The liver is only completely absent in cases of complete acephalia; it does not always occupy in the infant at birth the place which nature generally assigns to it; and it may be found on the outside of the abdomen, in cases of an imperfection of the walls of the abdomen, and even in the thoracic cavity, when a portion of the diaphragm is wanting. It also exhibits deep divisions, and sometimes alterations of form of little importance. Absence of the gall bladder, when the ducts exist, is possible, without being productive of any accident; but I do not know that children are ever born with a complete absence of the biliary ducts. * Meckel, General Anatomy. ON THE DISEASES OF INFANTS. 333 In a word, children at birth are rarely affected with malforma- tion of the liver, which, like the greater number of those hereto- fore considered, alter the health or compromise the life of a new- born child. Section II. DISEASES OF THE LIVER. English physicians attach the greatest importance to diseases of the liver in children, as they do also in adults. Most of the disorders of digestion are attributed by them to a derangement of the functions of this organ ; they attribute many diseases to the qualities of the bile that the liver pours into the intestines. In order to obtain fixed data upon this subject, I have examined the liver in a number of infants with great care, and considered especially the physical qualities of the bile, and the symptoms which they had presented during life, and I have never seen any thing in these lesions and symptoms which could explain the ideas ofthe English pathologists in reference to the influence which affections of the liver might exercise upon the health of the child. Before exhibiting the general results of these re- searches, I will say a few words on the diseases of the liver de- veloped before birth. Congenital diseases of the liver.—This organ is often the seat of sanguineous congestion during intra-uterine life. It is fre- quently of a dark red color. In two instances I found its tissue considerably softened, and diffusing an odor of sulphuretted hydrogen : in both these cases, the children had arrived at the full term, possessed a good constitution, and externally exhibited no evidence of wasting. I once found in the liver of a newly born child, a number of small tuberculous granulations; they also existed in the spleen and lungs. They will be considered when we come to treat of pulmonary tubercles. As to the quan- tity and physical qualities of the bile in infants, nothing is more variable, and I am unable to furnish with regard to it any gene- ral and fixed doctrine. In short, passive congestions of the liver are the most frequent lesions of this organ in young infants • a condition easily understood since the hepatic circulation is under 334 ON THE DISEASES OF INFANTS. the direct dependence ofthe general circulation, and would con- sequently experience promptly the disorders which supervene in the functions of the circulating apparatus. Diseases developed after birth.—In order properly to appre- ciate the changes which take place in the liver, we must first make known its various aspects in a state of health. In nearly all newly born children, the liver is of a deep reddish brown, and is almost always gorged with blood, which issues in nume- rous drops whenever the organ is cut, and is generally black and fluid ; the gall-bladder long, and of little volume, is filled with viscid bile of a porraceous green. In proportion as the child advances in age, the sanguineous engorgement becomes less, and the bile somewhat more abundant, and the gall-bladder more distended. The consistence of the tissue of the liver is such, that it can always be cut smoothly, and does not tear except upon the appli- cation of considerable force. Congestion.—The slightest impediment to the circulation gives rise to passive congestions of the liver. These congestions are very common in infants at birth, and vary considerably with respect to the quantity of blood accumulated in the tissue of the organ. It is sometimes also found there in so great quantity as to produce a sort of sanguineous exudation on the surface ofthe liver, particularly on the convex portion, which is in this case covered with a layer of blood over its whole extent. I have also seen in several infants, an effusion of blood in the abdomen, the result of this turgescence. The symptoms presented by children affected with hepatic congestion, are so obscure as to make it difficult to detect the existence the disease; they are the same as those of pulmonary congestion. In asphyxia of new-born children, for instance, there is nothing more common than to find the liver considerably gorged with fluid black blood; the large abdominal vessels and the whole of the circulatory appara- tus are in the same condition. Hepatic congestion then arises from a kind of reflux of the sanguineous fluid towards the abdo- minal organs, among which the liver, by reason of its great vas- cularity, is peculiarly disposed to injection and engorgement. The congestions of the liver would appear sometimes to change the nature of its secretion: in some infants, where the liver ON THE DISEASES OF INFANTS. 335 was very much injected, I have found the gall-bladder distended and filled with thick bile, of a black green, and even bloody. I once saw in a young infant in the place of bile, black ropy blood. It might be supposed that in this child, the liver, changed in its texture, could not produce in the blood which it receives for the biliary secretion, the vital or physiological modification, which this fluid must undergo to form bile. The treatment of hepatic congestions ought to be the same as that of intestinal or thoracic congestions, since this condition oc- curs in all three of them at the same time, all apparently being closely connected by the various branches of the same circulatory trunk. Inflammations.—I know of no organ the inflammation of which is so difficult to prove, as that of the liver ; its alterations of color and texture are so numerous and so variable, that it is extremely difficult to know to what cause to refer these changes; and, without alluding here to the innumerable changes of color in the liver of an adult, I might mention a great variety of color which the liver in a young infant presents. Possessing no posi- tive facts in reference to the anatomical characters and the symp- toms of hepatitis in infants at the breast, I shall refrain from being a barren copyist of authors; and, in the absence of data necessary to give a correct history of inflammation of the liver, I shall only record the general results of my researches upon the various aspects of the liver, considered in its relation to the quan- tity and quality of the bile, and the symptoms which the diges- tive apparatus presents. Examination of the different states of the liver, considered in their relation to the qualities of the bile.—These researches were made upon fifty children, of both sexes, aged from one day to six and eight months. In twelve of these, where the liver exhibited all the apparent characters of a state of health, without being injected or infiltra- ted with more blood than ordinary, I found the bile discolored and slightly viscid in two ; abundant, without color, and clear like serum in three ; of a beautiful green, and in small quantity, in one ; black and very abundant in two; small in quantity and of a clear yellow in two; of a yellowish green and very viscid in two. 336 ON THE DISEASES OF INFANTS. From this it is already seen that, however healthy the liver may appear to be, the color and consistence of the bile are extremely variable. But let us pursue our analysis. The liver was very much gorged with blood in twenty-eight children; the bile was of a deep green and of the usual quanti- ty iu ten of these ; in eight others it was of a very pale green ; in two it was mixed with blood ; it was yellow, thick, and con- crete in three ; in small quantity and of an ochery color in four; and in one, it was replaced by a white ropy fluid, like mucus. Thus it appears that the sanguineous congestion of the liver does not produce any alteration ofthe secretion always identical, at least, in appearance ; since we have here seen that the quan- tity and quality of the bile varies greatly in infants where the liver is found in the same pathological state. There remain ten infants to examine : in these the liver exhibited several shades of color, and the character of the bile was not less variable. In three, the organ was exsanguineous and very pale ; the bile was very pale in one, of a very deep color in the second; of a black- ish green, mixed with blood, in the third. Here, and this is very remarkable, we find the bile of a deep green in an infant where the liver was exsauguined, -whilst in those where the liver was gorged with Llood, the bile, on the contrary, was clear and color- less. In the fourth of the ten children now under consideration, the liver was friable, and had a granulated appearance when torn, and its substance, which appeared infiltrated with a yellow sero- sity, was of the color of ochre. The bile, which was very abun- dant, was green and slightly viscid. In the fifth, the liver was of a rose color; the bile was yellow and scanty. In the sixth and seventh, the liver was very large and pale; the bile in one was colorless, and in the other of a yellowish green. In the eighth, the liver was grayish externally ; this color only existed at the surface ; for, upon cutting into the substance, it was found of a deep brownish red ; it was also very friable, and could be torn with the greatest ease. The bile was green and ropy; the gall-bladder was covered on the interior surface with very thick mucus. In the ninth, the liver, externally, was of a slate color, and green internally ; it was firm, and left a smooth surface on cutting it; the bile was in its natural condition. And in the ON THE DISEASES OF INFANTS. 337 tenth, the liver was reduced to a soft reddish mass, and diffused, when crushed, an odor of sulphuretted hydrogen. The bile was very abundant and of a deep green ; it contained a great quan- tity of blood, which, instead of being mixed with the bile, was separated into distinct clots and filaments. From these researches it results, that the appearances of the liver are very variable, and of the bile not the less so; and that it is really impossible to establish between the state of the bile still retained in the reservoirs, and the normal and pathological state of the liver, any connection that may lead to general conclu- sions. The qualities of the bile may vary, from a number of modifications occurring in the secretory process of our organs : modifications which we cannot understand while the veil which conceals the manner of the process from our senses still remains. Thus, then, in ascending to the causes and nature of the dis- eases of the liver in young infants, I am obliged to acknowledge my ignorance and incapacity ; however, I here find an opportu- nity of pointing out a vacuum to be supplied, and this is a re- compense for my trouble, for it is still serving the cause of sci- ence to exhibit error, and to learn how to shun it when disco- vered. I have not limited these preliminary researches to the consider- ation of the nature and causes of diseases of the liver, but have undertaken other analytical observations ; to ascertain how far authors are correct in attributing to affections of the liver, diar- rhoea, consisting either of green or yellow evacuations, with which infants are so often affected. Examinations of the conditions of the liver and qualities of the bile, with reference to intestinal discharges.—Of forty-eio-ht children that died of enteritis, or gastro-enteritis, twenty had di- arrha;a of very abundant yellow faeces, and twenty-six diarrhcea equally abundant of very green faeces. The following exhibits the condition of the liver and bile in these infants: in fifteen, the liver was scarcely injected; and in these fifteen cases, the bile was small in quantity, and very clear in four individuals ; it was of a deep green, of the consistence of pitch, and very abundant, in three ; and in the remainder presented nothing remarkable. In twenty-five, the liver was gorged with blood, as is often observed to be the case at this period of life ; the bile in each of them ex- 43 338 ON THE DISEASES OF INFANTS. hibiting different characters; it varied from a pale yellow to a deep green: in one of them, there existed a large quantity of black blood in the gall-bladder, instead of bile. With respect to the eight children completing the number of those on whom my researches were directed, the liver exhibited shades of yellow, green, brown, and slate color; the bile was fluid and clear in some, while it was thick and green in others. Tims it appears that in the forty-eight children to whom I di- rected my attention, affected with diarrhcea of yellow or green matters, the liver exhibited very different appearances; some- times it was healthy, often injected, and again it presented certain anatomical characters which the state of our knowledge does not permit us to refer to any class of well-ascertained diseases. What inference is to be drawn from these facts ? and what theo- ry is to be established on so uncertain a foundation ? Ought we, after the example of most of the English pathologists, to attri- bute gratuitously to the liver the derangements of the digestive functions? Ought these yellow and green, evacuations to be regarded as an alteration of the biliary secretion? I leave it to other authors to answer these questions, when ulterior researches shall throw more light on this subject; as for myself, I will re- nounce my opinions only when convinced of their error,—still believing that the yellow and green dejections, whatever may be the cause of their color, are more probably a symptom of enteri- tis, an affection which must be removed before the diarrhcea, which is only its effect, can be cured. Such, however, is not the opinion of Dr. Dewees, when he says, in his work under the article Diarrhcea, " In bilious diar- rhoea, the foeces are loose, copious, and of a bright yellow or green; and the bowels are stimulated to inordinate action, by an overcharge of bile, either vitiated or not. This complaint is very frequent among our children during the heat of our sum- mers, or as the fall approaches. The influence of the hot sun upon the actions of the liver, is well known to every body; it is familiar to common observation, that after a spell of very warm weather, even the healthy evacuations of an adult give evidence of its rapid formation, and sometimes of its abundant absorption. Thus the faeces are observed to be loaded with bile; and the urine to be deeply tinged with it; and when the complaint of ON THE DISEASES OF INFANTS. 339 which we are treating seizes upon children, it is called the < sum- mer complaint.'" Dr. Dewees observes, that no period of infancy is free from attacks of this kind, and he has even seen extensive bilious eva- cuations from children of ten days old. The American physicians, therefore, regarding the yellow diarrhcea that affects children during the summer as an indica- tion of an afflux of irritating bile into the intestines, advise, in the first place, to evacuate the bowels, using the remedy for that purpose which exerts a special action over the functions of the liver; such as calomel, given in small and repeated doses. Dr. Dewees has recourse to laudanum to tranquillize the intestinal irritation during the night: he gives half a drop for a child under ten days ; a drop for one from that period to the end of the month ; a drop and a half or two drops for one from that period to three months; three drops from this time to nine months; four drops from nine months to eighteen. If fever attend the diarrhcea, he advises the use of the warm bath, and tartrite of antimony, which he administers in doses from the tenth to the twentieth or twenty-fourth part of a grain. Mr. Barnes advises besides this, nourishing the infant with beef tea, arrowroot, and white wine whey.* Thus then while the examinations of the bodies of those who die of yellow or green diarrhoea demonstrate, in almost every instance, the existence of enteritis, the American physicians, without taking this state of the alimentary canal into considera- tion, advise emetics, purgatives, and stimulants. Perhaps the great ravages of inflammatory diseases, in general, in those cli- mates, may in part be attributed to the method of treatment. Why not endeavor to ascertain whether there really exists an afflux of bile in the intestines in this disease ? And why not attempt to show by anatomical researches, that the liver, under the influence of heat, is irritated, and ceases to discharge its normal functions; instead of advancing, without motive and without evident facts, the opinion that the bile neutralizes the acids formed in the stomach, and that when these acids are very abundant, and mix with the bile in such a manner as not to be neutralized, a green color is thereby imparted to the alvine eva- * Dewees, loc. cit. p. 364. 340 ON THE DISEASES OF INFANTS. cuations ? A great number of effects are attributed to this acid, which is considered a sort of poison that ought to be speedily removed from the alimentary canal.* These ideas, transmitted from period to period, with a respect for which it is difficult to account, except by referring it to the blindness with which men sometimes love to retain their preju- dices, cannot be sustained by the analytical examination of ana- tomical facts, and will, with other medical errors, fall into obli- vion. If,.in overthrowing them, we are unable to place in their stead other theories, it is of little importance, for doubt and un- certainty are still better than error ; for instead of satisfying us with easy explanations, they will be continually harassing us with the truth we need, and thus force us to have recourse to new attempts to discover it. We conclude by remarking that nothing is more difficult than to make a diagnosis of inflammation ofthe liver, and to prove its existence in infants, by post mortem examinations ;t that yellow and green evacuations exist almost always in inflammation ofthe intestines ; that it is not proved to be the result of disease of the liver; that it is much better, when in doubt, to consider these symptoms as those of enteritis, and to treat the child accordingly, rather than to imagine the diarrhoea to be the result of an afflux of irritating bile into the intestinal canal, which it is necessary to expel by purging. Several authors have spoken of abscesses in the liver in young infants affected with icterus.t But as M. Denis has observed, autopsical examinations have not proved the existence of this lesion. There is still another fact pointed out by authors, it is the co-existence of the diseases of the duodenum, and liver. M. Cruveilhier has observed that in infants affected with a softening of the duodenum, there existed at the same time a morbid paleness of the liver. M. Denis also entertains this opinion, but it is necessary here to obtain a correct idea of this softening. I will observe here first, that I found the liver in a very variable condition in children affected with duo- denitis. Some of these, who form the objects of the cases * Dewees, p. 367. See Appendix." t This distinction is not much easier in adults, v. Andral. clinic, medie. t. 4. t Baumes, Mere des enfans de naissance. Paris, 1806. ON THE DISEASES OF INFANTS. 341 enumerated above were affected, as I have already said, with phlegmasia of the duodenum; but we ought to call to mind the great variety of appearance which the liver presented. As to the softening, I am not of the opinion of MM. Cruveilhier and Denis, if they allude to inflammatory softening, that which follows greater or less intense inflammation of the mucous mem- brane of the intestines ; but if they refer to the white softening, it is quite another thing; all the organs, and every part, are blanched and exsanguineous, and it is not surprising to find the liver also in the same condition. I do not speak here of icterus of young infants, because I do not consider it as a symptom of an affection of the liver. I shall examine this subject hereafter. The gall-bladder appears to me to be seldom diseased ; I have not often had occasion to observe its congenital malformation; M. Denis mentions his having met with its absence in three instances. It is sometimes very slightly developed and reduced to a small globular pouch ; generally its walls are colored green by the bile, and its internal surface covered with a thick layer of mucosity; its walls are in this case thin and transparent; and vascular ramifications more or less numerous are seen on its sur- face. I once found in the dead body of a child whose case I had not particularly noted, the gall-bladder evidently inflamed; its internal surface presented a bright redness, and the thickness of its walls was considerably increased. It is very common to find in it a very minute spotted redness, which can scarcely be seen except after removing the bile which generally covers the sur- face of this viscus. Alterations ofthe biliary ducts, such as stricture, obliteration, and inflammation, occur much more frequently in adults and old men than in young infants. Diseases of the spleen and pancreas, which are also appen- dages to the intestinal tube, have not furnished me with any thing worthy of notice: congestions of the former are the disor- ders most usually observed. I have cited an instance of its rup- ture in consequence of this pathological state. In infants at the period of birth, the pancreas exhibits a devel- opment considerably advanced; I do not doubt that it concurs in the performance of the digestive functions, and pours its secre- 342 ON THE DISEASES OF INFANTS. tion into the intestinal canal; but I have been unable to prove whether the absence or superabundance of this secretion in any way disturbs the functions ofthe intestinal tube. It would be a curious fact to prove in serous or mucous diarrhcea of infants, that the secretion ofthe pancreas united with that ofthe follicu- lar apparatus of the intestines, to form the abundant and liquid nature of the stools. CHAPTER IV. DISEASES OF THE URINARY APPARATUS. Art. 1.—Development. This apparatus comprises the renal capsules, kidneys, ureters, bladder, urachus and urethra. At two months the venal capsules begin to be distinct in the embryo ; they are even larger and heavier than the kidneys; but their size gradually diminishes, and the kidneys, on the con- trary, become more voluminous, so that at birth the kidneys are three times the bulk of the capsules. They contain, at first, a viscid fluid, which almost entirely fills them ; but this fluid being, by degrees, reabsorbed, leaves nothing but a thick brown layer spread over the internal surface of the capsule; when, therefore, the renal capsules of a young infant are examined, there is al- ways found in them the soft brown substance just alluded to, and which presents great variety in appearance. Sometimes it is of the color of chocolate ; sometimes, on the contrary, it re- sembles cerebral substance mixed with blood. It is often found so white and soft as to be liable to be mistaken for pus. The substance does not melt by heat, nor will it grease silk paper, and appears to be rather of a fibrous nature, analogous to that of the blood, rather than a serous, mucous, or adipose fluid. We must be careful not to consider it as the result of a morbid secretion, or of a disorganization of tissue. The external appearance of these organs is of a reddish yellow or light brown; they are usually rugous or wrinkled ; they are so tender as to be easily ON THE DISEASES OF INFANTS. 343 torn. This consistence, therefore, ought not to be taken for a morbid softening. With Meckel, I am of opinion that they have no cavity; at least it is hardly a cavity which contains the semi- fluid matter throughout the interior of these capsules. The kidneys, which do not appear until after the renal cap- sules—that is to say, between the second and third month—are at first composed of a number of hollow lobules communicating freely among themselves, and which are connected by a tissue very easily separated. The lobules, approaching afterwards more closely, are confounded, as it were, one with the other, and become less numerous ; the openings between them are smaller, presenting very shortly a small hole which opens into the com- mon reservoir, the pelvis. During the formation of this union of the lobules of the kidney, the cortical substance forms gradu- ally ; it is very evident at six months. It is to be remarked that these lobules secrete interiorly, and at an early period, a white serous fluid which distends them, but which is forced out in pro- portion as the cortical substance forms, the thickness of the walls of the lobules increases, and their cavities diminish ; it is proba- ble that this fluid flows into the pelvis of the kidney, and thence into ureters and bladder. The bladder exists at a very early day ; it appears at first un- der the form of a small distinct pouch, when the kidneys are scarcely formed. At this time it is a kind of continuation ofthe urachus, which, from the very first formation of the embryo, is large and distinct towards the umbilical cord, and afterwards di- minishes progressively, and becomes obliterated to sueh a degree that anatomists, who, without 'doubt, observed it only at the pe- riod of birth, have denied its existence as a canal. The ureters and urethra, which are appendages to the differ- ent hollow organs just examined, are found as soon as these or- gans and these canals enlarge, which enlargement occurs in pro- portion to the growth ofthe infant. Malformations.—Malformations of the urinary apparatus fre- quently appear in infants. As this system is composed of several parts closely united together both by their anatomical relations and their functions, malformation of one of these parts is often connected with a deformity of some of the others. Thus it is that the kidneys are often the seat of organic deviations which 344 ON THE DISEASES OF INFANTS. result from congenital malformations of the ureters, bladder, or urethra. We shall hereafter give one example of this. The primitive arrangement of the constituent parts of the organ suf- ficiently explains the congenital malformations. I have already remarked that the kidneys were composed pri- mitively of several lobules, on the internal surface of which is secreted a fluid which flows through the ureters into the bladder; but if the ureter presents an interruption or an obliteration of its canal, this fluid then remains in the lobule, distends, and it be- comes vesicular, opposes the free development of the cortical sub- stance, and in place of a kidney, on opening the dead body, a mass of transparent vesicles is found, irregularly agglomerated with each other, communicating more or less directly with the pelvis ofthe kidney, constituting a true congenital encysted dropsy, as will be seen in the following case. CASE LIII.—Congenital malformation of the kidney, oblitera- tion of the ureter.—Jules Martin, aged four days, entered the infir- mary. He was strong; the integuments highly colored; at the lumbar region there existed a round tumor, soft to the touch, exhib- iting at the centre a red excoriation, and at the circumference a hard, red, and irregular ring. This child remained at the infirmary for one month ; during this time he became thin, and insensibly wasted away; there also existed at first vomiting and diarrhoea ; the cry was feeble, and the circulation very slow; he died on the 1st of March. On the post mortem examination, there was found a con- siderable effusion of serosity in the lateral ventricles, through the extent of the spine, and in the tumor which existed in the lumbar region at the spinous processes of the last lumbar and first sacral ver- tebrae. There was nothing remarkable in the digestive apparatus, but the urinary system presented the following arrangement. The left kidney consisted of a mass of the size of a goose's egg, of semitransparent lobules, irregularly agglomerated, forming seve- ral small cysts filled with a white inodorous fluid. These cysts com- municated freely with one another; those nearest to the pelvis opened into this reservoir, which itself was filled with a fluid re- sembling that in the cysts. The kidneys retained no trace of their natural texture ; yet towards the fissure their existed a layer of cel- lular tissue of a tolerable thickness, and as if condensed. It was in this tissue that the renal artery and vein terminated, and were obli- terated. I searched in vain for the connection of the ureter with the ON THE DISEASES OF INFANTS. 345 pelvis ; the latter formed a true cul-de-sac. The ureters were well developed near the bladder, in which they opened as usual; but in ascending towards the kidneys they were observed to degenerate into two small thin cords, bifurcated and without any perforation, and near the pelvis these filaments became quite numerous, and were applied to the kidneys in the form of a goose's foot. The right kidney was more developed than usual; the bladder slightly dilated, contained a little turbid urine, in which was found a large quantity of gravel as fine as sand ; the lungs were slightly gorged with blood ; the foetal openings were obliterated. This encysted dropsy of the kidneys was remarkable by reason of its coexistence with an imperforation and obliteration of the ureter. This case furnishes an instance of double malformation of the urinary apparatus, but the one appears to be the result of the other, and I am of opinion that renal dropsy is the effect of a retention of the fluid that has not found an outlet neither by the pelvis or ureters. We ought also to note the presence of gravel in the urine in this case. When the urine is obstructed in its course at any other part of the urinary passages, it is easily conceived that the parts above the obliteration will present a dilatation analogous to that we have just been considering. The following observation is in point. CASE LIV.—In dissecting the body of a male infant, born dead, which M. Delpech, physician at Paris, sent to M. Baron on the 10th of June, 1826, I made the following observations. The head was small in size ; the limbs very thin; the integuments flabby and slightly purple; the abdomen excessively distended, formed a round projecting tumor, presenting the appearance of a kind of circular cone, the umbilicus forming the apex. The insertion ofthe umbili- cal cord was very large. A very evident fluctuation was felt in this tumor. In every other respect the body exhibited all the characters of a child born at the full term. On opening the body, a vast pouch was seen filling all the abdomi- nal cavity, and the intestines were crowded by it backward and up- ward. On the anterior lateral part of this pouch, the vesiculae se- minales were found attached, and at the inferior lateral part of this cyst, the vassa defferentia appeared, together with the testicles. Lastly, near the summit of this cyst, and directly between the two 346 ON THE DISEASES OF INFANTS. vesiculae seminales, was seen the rectum, very large, and distended by a large quantity of meconium, adhering solidly to the walls of this voluminous pouch, and obliterated; which was discovered to be the bladder, and was also enormously distended by a white fluid, which did not alter the color of litmus paper; this fluid contained some white ropy mucosity, and the internal surface of the bladder was covered with a layer of adherent mucus. The interior orifice of the urethra did not exist; on examining the canal, I was only able to pass the stylet of a female catheter about half an inch, and I disco- vered, on dissection, that the passage became gradually narrowed from the extremity of the penis, and finally became obliterated, ter- minating in a filament, lost, as it were, in the cellular tissue of the perinaeum. I was unable to discover the prostrate gland ; at least I could not consider a sort of reddish tissue, adherent to the bladder behind the insertion ofthe rectum, as this organ. The openings of the ureters into the bladder were perfect; their diameter was large and insensibly increasing to the kidney, and on each side was nearly as large as a hen's egg, exhibiting the same lobular structure as the preceding case. Yet the lobules were smaller, less transparent, and were in part covered with the cortical substance, but the infundibuli and pelvis were much larger and more distended than natural. A white inodorous fluid filled the vesicular lobules, which had a free communication with each other, and opened into the pelvis; the urachus existed only as a small obliterated conduit. There was no anus, and the rectum, examined interiorly, present- ed a complete cul-de-sac, closely adherent to the bladder. There was nothing remarkable in the other organs. In this child it appears that the obliteration of the urethra caused the dropsy of the bladder, and the latter, the hydropic af- fection of the kidneys, the normal development of which was hindered or even suspended. The bladder, in distending and in acquiring the size which it exhibited, appeared to have moved from its situation forward and upward; so that the base was found elevated, and drawing with it every part that was adherent inferiorly; they were in this way drawn out of their natural situation; hence the situation of the vesicula? seminales and the rectum at the superior part, and the opening of the ureters at the lateral and anterior part. Thus several disorders resulted from an original malformation—involving not only the portions of ON THE DISEASES OF INFANTS. 347 the same apparatus, but likewise organs which had only the re- lation of contiguity with these parts. This case, as well as the preceding, will serve to prove that the excretions of the fcetus, at least those of the urinary organs, are, in the normal condition, rejected from the body, and proba- bly are mixed with the waters of the amnios, since it appears that when any obstacle occurs to the passage of this fluid, it re- flows into the reservoirs, and distends them excessively, in the same manner as is observed in adults who are affected with a stricture of the urethra, or paralysis of the bladder. This re- mark ought to have a place in the history of embryology. The urinary passages may also present other congenital mal- formations, for, as M. Meckel observes, the urinary apparatus is one of those which presents the greatest anomalies. The kid- neys are sometimes absent, or if there is but one, it is generally found on the median line, and close to the vertebral column. They are more or less voluminous; their lobules are sometimes widely separated : their situation, likewise varies, the effect of different causes ; thus, for instance, they are drawn below or crowded towards the diaphragm, in consequence of adhesion which they may contract with the surrounding parts. Absence, imperfection, occlusion, or plurality of the ureters, have been pointed out in the preceding observations. In addition to the distension and displacement of the bladder, this organ sometimes exhibits a congenital malformation, of which Chaussier, Duncan, and other authors have given instan- ces. I allude to extrusion of the bladder. The anterior portion is absent; at the same time there exists a division of the abdomi- nal parietes, or a separation of the pubis opposite the bladder, so that this organ exhibits, on the outside of the abdomen, the inter- nal surface of its posterior wall, which is red and studded with mamillary protuberances, and the orifice of the ureters are often seen, from which the urine continually issues. This malforma- tion is met with not only in males, as Duncan asserts,* but is also found to exist in females. Meckel observes that the bladder has been seen bifurcated or * Med. and Surg. Journal, 1805, Edinburgh. 348 ON THE DISEASES OF INFANTS. formed into several sacs.* These malformations are so much the more dangerous in young infants, as they offer a greater ob- stacle to the course of the urine. The urethra may be either more or less completely obliterated, or may present only a stricture of its canal. The orifice may be met with in any portion of the inferior part of the penis in- stead of the glans. This malformation has received the name of hypospadias. In such a case, the glans is almost always de- formed ; it is, as it were, curved downward, so that the urine generally falls between the legs, instead of being thrown for- wards. When a child is born with an imperforate urethra, it will be necessary to form an artificial opening, either at the extremity of the penis, if the passage runs as far, or at any other part of the penis ; for it is much better to establish a hypospadias, than to abandon the child to death, which must certainly ensue from a suspension of the course of the urine. The existence and length of the canal may be ascertained by the feeling of fluctua- tion which is experienced on moving the fingers along the under part of the penis. If the abdomen is distended by the develop- ment of the bladder, and should it appear impossible to open the urethra, the puncture of the bladder ought to be attempted, either above the pubis or through the rectum. The latter method is perhaps the best; it will succeed in prolonging the days of the child, particularly if the opening between the bladder and rec- tum is maintained, because the urine may thereby have a con- stant outlet by this organ. In every instance these curative measures can have but a temporary efficacy, and will not pre- vent the child from sinking, sooner or later, under this serious imperfection. DISEASES OF THE URINARY APPARATUS. It is probable that, during the intra-uterine life, both the kid- neys and bladder may become inflamed, but it is very difficult, particularly with respect to the kidneys, to prove the existence of this inflammation in young infants ; indeed the kidneys may be more or less colored, in proportion to the abundance or ab- * S. A. Ehrlich, Chirurgische Beobachtungen, v. 2, p. 123. ON THE DISEASES OF INFANTS. 349 sence of blood in their tissue. I have often observed, on the sur- face of the kidneys of newly born children, ecchymoses of great- er or less extent, attributable to the effusion of blood beneath their proper covering; often, also, there are seen red spots on the papillae, frequently of so great a size as to be regarded as true petechia?. There is a very remarkable alteration of color, which is seen in infants affected with icterus; shining yellow stria? are ob- served to spread in rays from the summit to the base of the pa- pilla?, which, without doubt, are owing to the coloring of the serosity between the fibres of the papillary substance. These colored stria? are uniformly in one direction ; they must not be regarded as the result of any particular alteration in the tissue of the kidneys, but as the effect of a remote cause which produ- ces jaundice. I once saw the cortical separated from the papil- lary substance by a yellow line, analogous to that of which I have just spoken : the papilla? appeared as if enveloped by a,fes- tooned line. I have several times found the kidneys in young infants so soft that they were torn upon the least effort. It would seem as if calculous nephritis might be developed even during intra-uterine life ; such was in truth the fact with the child mentioned in case liii., in whose bladder a quan- tity of gravel was found. M. Denis has often found gravel in the urinary passages and in the urine of young infants. I have also frequently found them, but never saw calculi, properly so called ; still I think it not impossible for them to exist. The bladder in new-born children is usually small and con- tracted ; it is scarcely elevated above the superior strait of the pelvis; its internal surface is remarkable for its white, satin-like appearance, entirely different from that of other abdominal or- gans, which are almost always more or less injected at the period of birth. Once only I found petechia?; but they existed also in other parts of the body at the same time. After birth, the kidneys and bladder sometimes become in- flamed, but phlegmasia? of these organs are much more rare in the infant at the breast than those of other organs. The symptoms which Willan and Underwood have attributed to ischuria renales in children appear to me to be those of a true 350 ON THE DISEASES OF INFANTS. nephritis, at feast we must so infer from the symptoms described, and the success of the treatment employed. If infants have died, as Underwood says, without any evidence of pain or any particular uneasiness, it shows that the most serious inflamma- tions may arise without giving evidence of any well-marked re- action. When the suspension of urine arises from an affection of the kidneys, in consequence of which their functions are suspended, although no urine passes, yet the bladder does not become dis- tended, so that the fluid is not really secreted in so great a quantity as in the natural state. I have not traced with great accuracy the symptoms of cystitis in infants at the breast, as I have not been able to observe them with sufficient care, either because they have not been very evi- dent in the young subjects submitted to my notice, or have been concealed by other symptoms ; but I have often found the blad- der inflamed in opening the bodies of children at a different age. This inflammation was characterized by an intense redness, a well- marked tumefaction of the internal membrane, which was torn and separated in shreds with the greatest facility. I observed particularly in three infants aged, one fifteen days, another two months, and the third four months, where the bladder was dis- tended by a large quantity of urine, a very high inflammation of the neck of the bladder, which was red and very much swelled, which led me to believe that these children had been affected with cystitis, and following it a retention of urine to which they succumbed. The greatest care must therefore be observed in studying the causes of retention of urine in infants, in order to render the necessary assistance for its removal. We should endeavor to distinguish retention produced by cystisis, from that which has its cause in the paralysis of the bladder arising from the existence of an acute or chronic affection of the cerebro-spinal apparatus. It would appear from the remarks and observations of Morton, that infants may be affected with diabetes mellitis, a disease cha- racterized, he says, by a rapid emaciation, an abundant diarrhcea, an urgent thirst, and a great discharge of urine, which, as in adults, possesses a saccharine quality. Catarrh of the bladder is very rare in infants at the breast; ON THE DISEASES OF INFANTS. 351 it is more frequent in children more advanced in age, whether it be idiopathic, or whether it be caused by the presence of a cal- culus in the bladder. The treatment of these various affections is very easy : thus, acute cystitis which may be recognised by a painful tension of the hypogastrium, and suspension of urine, will be advanta- geously treated by the application of one or two leeches to the perinaeum, and the use of warm baths and emollient cataplasms to the abdomen. When there exists a paralysis of the bladder, recourse must be had to the catheter, together with such measures as will be necessary to meet the cerebral affection of which the paralysis is the effect; and lastly, if diabetes as described by Morton be recognised, the treatment recommended by that cele- brated practitioner should be adopted. The method of treating a child that he cured, consisted of a diet of milk, to which the patient was strictly kept from the commencement of the disease, and the only drink that was allowed to quench the thirst with which it was incessantly tormented, was a mixture of honey and the ferruginous water of Islington. New-born children are sometimes affected with retention of urine, arising neither* from inflammation nor paralysis of the bladder ; they are often two or more days without passing any urine. In a case of this kind, when we are satisfied that the natural passage exists, it will be necessary to place the child in a warm bath, and to apply a poultice to the abdomen, or, as is advised by Underwood, a bladder partially filled with warm water.* When infants are affected with gravel or urinary calculi, it will be difficult to adopt the course of treatment necessary for such disorders; how, indeed, can young children, whose sole nourishment is milk, be submitted to a watery vegetable diet, as recommended by M. Magendie ? This disease is doubtless very dangerous at this early age, and we cannot expect to re- move the cause, but in proportion as the advance of age enables us to vary, modify, and select their food. Nevertheless, the nurse should be kept from the use of fat meats, and such as abound in azote, and use exclusively vegetable diet. * See Appendix. 352 ON THE DISEASES OF INFANTS. CHAPTER V. PERITONITIS. Inflammation of the peritoneum is more common than is generally believed ; and, not only is it developed after birth un- der the influence of the exciting causes to which the child is subjected, but it may likewise exist during the intra-uterine life, as will be seen in the following instances. Congenital peritonitis.—I have seen in the dead body of two children, that died, the one eighteen hours, and the other twenty- four hours after birth, old and very firm adhesions between the different convolutions of the intestines, and in one of them the convex surface of the liver adhered firmly to the interior walls of the abdomen. These accidental adhesions must be considered as the result of peritonitis developed during intra-uterine life, and which had passed through its different stages before birth. One of these children was thin, small, and very pale; but the other exhibited the usual appearance of infants at birth. Acute peritonitis in children has to appearance often been brought with them from birth. M. Duges, in his essay on the diseases of children, where will be found a very interesting chap- ter devoted to the history of peritonitis of new-born children, has reported the case of a child born on the 9th of February, 1821, at the Maternite, between the seventh and eighth month, well- formed, about sixteen inches in length, weighing three pounds and a half. It was affected with a general cedema; the abdomen was tense; and although the child had respired, cried, and lived for three hours, it had passed no meconium ; yet it had received and passed a tepid enema. The post mortem examination was made on the ensuing day, in the presence of professor Chaussier. " All the abdominal viscera," says M. Duges, " were agglutinated/' by yellow concrete albumen. False membranes were found attached to the liver, spleen, bladder, &c. The epiphora was adherent to the intestines; the latter were joined together in a bundle, and were yellow, hard, and thick ; their tissue appeared to be mixed with concrete albumen; and they contained a yellow frothy mucus, etc." ON THE DISEASES OF INFANTS. 353 This infant was a first child; the mother twenty-two years of age, and in good health, having been subject only to chil- blains, and sometimes to pimples on the hands.* I have seen peritonitis to the same extent in three infants that died a short time after birth, and who were all quite vigorous; the post mortem examination alone revealed the cause of their death. In one of them, sero-purulent effusion was very abun- dant ; the intestines were very red exteriorly, and had already begun to contract adhesions. We can easily believe that the recent adhesions of the perito- neum in the case cited by M. Duges, and in the last instances which I have given, were indications of the existence of acute phlegmasia, developed either in the latter period of pregnancy or during birth: it is not the same, however, with chronic peri- tonitis accompanied by old and firm adhesions, of which I have spoken, and which has passed through its several stages in the uterus. But what can be the exciting cause of this inflamma- tion ? It must be transmitted from the mother to the child; if otherwise, in what way can it be accounted for ? Peritonitis developed after birth.—From the time children are subjected to the stimulating causes which surround us, their in- fluence may to a greater or less extent produce irritation and in- flammation in their organs, which are not less sensible than our own; we ought not, therefore, to be surprised at the existence of peritonitis in young infants. It appears either in an acute or chronic state, of which I will give instances. CASE LV.—Acute peritonitis.—Alexis Sonnecourt entered the infirmary on the 13th of February, aged fourteen days. This child possessed some strength ; but in the last two days he became pale, vomited all the drinks, was affected with an infiltration of the lower limbs, and the expression of the face indicated great distress. He was continually restless ; his abdomen was tympanitic, and formed a point towards the navel; it was hard, and very painful to the touch, for immediately upon pressing it the child cried, became red in the face, and respired with the greatest difficulty. The thorax * Recherches sur les maladies les plus importantes et les moins connues des enfans nouveau-nes. Paris, 182L 45 354 ON THE DISEASES OF INFANTS. resounded throughout its whole extent; the skin was dry and burn- ing ; the pulse could not be distinguished at the wrist, and the beat- ing of the heart was very obscure through the stethoscope ; the cry was small, feeble, acute, and scarcely to be heard ; there were no alvine evacuations. (Diet, sweetened water, cataplasm to the abdo- men,bath.) He died on the night of the thirteenth. On examining the body on the following day, the mouth, oesophagus, and stomach were found healthy. The intestines were distended by a great quantity of gas ; the peritoneum presented no redness in the different parts of its surface ; but there existed recent and firm adhesions between the convolutions of the intestines, a thick pseudo-membranous layer on the mesentery, and nearly two ounces of a sero-purulent liquid effused in the cavity of the abdomen. The brain and circulatory ap- paratus were healthy. Among the symptoms of this peritonitis, we have particularly remarked the painful distension of the abdomen, the absence of diarrhcea, the extreme smallness of the pulse, and the painful ex- pression ofthe physiognomy. The anatomical lesions were here of a nature too evident to admit of a doubt as to the existence of peritonitis. CASE LVI.—Chronic peritonitis.—Josephine Perrine, aged ten months, of a good size, but thin and pale; had already cut the two incisor teeth of the lower jaw ; was suddenly seized with dyspnoea. This child, usually lively, had become morose and fretful. She entered the infirmary on the 22d of January, 1826. The abdomen was tympanitic; the respiration a little difficult, and was indistinctly heard at the upper part of the right side of the chest; the tongue was dry, pulse small, skin burning ; she was affected with diarrhoea con- sisting of green and mucous foeces. (Syrup of gum, cataplasm to the abdomen, milk and water.) On the twenty-third, the diarrhcea became more light-colored ; on the twenty-fourth, the same general symptoms, but without fever; tension of the abdomen, facies hippo- cratica, forehead wrinkled. On the twenty-sixth, deglutition diffi- cult ; retching whenever drinks were given ; cry feeble. The isthmus of the fauces appeared of a bright red. Death took place on the morning of the twenty-seventh. Post mortem examination.—Body considerably emaciated; ge- neral paleness of the integuments ; nearly two ounces of yellow se- rosity was found in the abdomen. Numerous and firm adhesions ex ON THE DISEASES OF INFANTS. 355 isted between the transverse portion of the colon and the great cur- vature ofthe stomach. Some ofthe convolutions ofthe small intes- tines were likewise adherent, but in a less solid manner. The mu- cous membrane of the stomach was of a pale rose-color; that of the small intestines was covered with red stria?, and a number of slate- colored spots existed in the whole length of the colon. The supe- rior and inferior maxillary bones were so soft and spongy, that they could be cut as easily as cartilage ; the gums were not inflamed ; the brain contained a quantity of citron-colored serosity in the lateral ventricles ; the substance of the brain was very much injected ; the right lung was engorged. It appears to me to be very difficult to have made a correct diagnosis of this peritonitis, which, in consequence of its chronic state, presented but slightly marked characters, and was besides concealed by the intestinal inflammation with which it was com- plicated. The dyspnoea was perhaps the result of the effusion, which, in the abdomen, would impede the movements of the diaphragm, particularly when the abdominal cavity was com- pressed with the hand or the child's clothes, for the lungs exhib- ited no serious lesion that could explain the disordered respira- tion with which the child had been distressed. M. Duges considers constipation as one of the causes of peri- tonitis in young infants. In support of this opinion, he cites some very striking facts; but besides the fact that constipation is more often the effect than the cause of peritoneal inflamma- tion, since it does not supervene until after the commencement of this phlegmasia,—how does it happen that the child can be affected with this disease in the womb, when constipation is, without doubt, as it appears after birth, the result of a distur- bance of the digestive functions ? Obliteration of the rectum and internal strangulation ofthe intestines, may produce this disease, of which M. Legouais and M. Duges have seen examples; but these accidents may also arise without inflaming the peritoneum, as we have seen in the cases already reported. It is very difficult, therefore, to explain the causes of peritoni- tis in infants at the breast. There is one circumstance very re- markable in this disease, and observed by M. Duges ; it is, that children affected with it were not born of mothers suffering from puerperal peritonitis. 356 ON THE DISEASES OF INFANTS. The symptoms peculiar to peritonitis are, tension of the abdo- men, which rises in a point towards the umbilicus, restlessness, pain, indicated by a pinched face and the increasing cries of the child, vomiting, eructation, constipation, and lastly, a gen- eral sinking and smallness of the pulse. Such are the symp- toms that characterize peritonitis, and which require the closest attention and tact on the part of the physician to distinguish it from phlegmasia of the intestinal tube, with which it may be complicated and confounded. Peritonitis may be distinguished from pleurisy by the full sound of the thorax. Dyspnoea, as we have seen in case lv, does not always indicate an affection of the lungs ; it may arise from a tympanitic state of the abdomen and the labored move- ment of the diaphragm; and the abdominal pains being con- stant, differ from those caused by a spasm of the bowels, and their distension with gas, for in the latter case these colic pains are almost always remittent, and cease with the evacuation of gas. The prognosis of peritonitis in infants is always unfavo- rable. Treatment.—The treatment should be commenced by a sus- pension of sucking; one or two leeches should then be applied on the abdomen, not far from the umbilicus, and the child placed in a warm marshmallows bath, and poultices of flaxseed applied to the belly ; it may also be covered with a little oil of almonds, and oil of chamomile, as recommended by M. Chaussier.* From two to three grains of calomel ought then to be given, and a few spoonfuls of the syrup of succory, or an injection of castor oil, or honey of mercury, to procure some fcecal discharge, and there- by establish a point of revulsion on the intestines; but before having recourse to these means, we ought to be well assured that we have, in some degree, overcome the acute inflammatory symptoms, and that there exists no enteritis. When the patient is convalescent, we should return gradually to the use of a tonic regimen suited to the age of the child, who ought not to be returned to the breast until after having been nourished for some time with cows' or goats' milk, diluted with a decoction of oatmeal. The feet must be kept warm, and the * Duges, loc. cit., p. 42. ON THE DISEASES OF INFANTS. 357 body covered with flannel applied next to the skin; this kind of permanent irritation is very necessary in convalescence from abdominal phlegmasia?. CHAPTER VI. ASCITES. It is not uncommon to find in the abdomen of a child that has perished slowly from chronic phlegmasia, a greater or less quan- tity of citron-colored serosity, and which is unaccompanied by any lesion or morbid production capable of revealing the exist- ence of an actual inflammation of the peritoneum. The quan- tity of this effusion varies from one to three and four ounces. Where this is found, the children are generally pale, thin, and ex- tremely feeble ; the inferior extremities are almost always cede- matous, and the digestive passages, although sometimes inflamed, are usually colorless or softened. This affection is more frequent after the first year, but is sometimes observed in very young in- fants. Infants at birth have been affected with true dropsy. An instance of this is found in the journal of medicine, pharmacy, and surgery of Professor Roux. A woman of Charleville, aged thirty years, having fallen and injured herself on the abdomen during her pregnancy, experi- enced, on rising, a general movement about the lumbar and hy- pogastric regions ; she was soon affected with strangury. About a month afterwards, labor pains began to be felt, but the labor was very difficult on account of the great size of the bladder, which it became necessary to puncture. About six pints of fluid were discharged by the canula, and four by the natural passage: she was delivered of a dead child. Upon opening the body, nearly a pint of water was found in the abdomen, thorax, and other parts ; and the cellular tissue was the seat of a general in- filtration. Every part of the child was well-formed, and there did not appear any disposition to mortification.* ^Journal de Medicine, Chirurg. et Pharm., par A. Roux, t. 17. p, 180. 358 ON THE DISEASES OF INFANTS. This case is interesting, inasmuch as it presents an instance of congenital dropsy, and also with reference to the intimate con- nection which existed between the strangury, the retention of a large quantity of urine in the bladder of the mother, and the hydropic affection of the child.* In order to adopt a rational course of treatment in cases of as cites of newly born children, we ought to refer directly to the causes which produce it, and which appear to continue its ex- istence. CHAPTER VII. HERNIAS OF THE ABDOMEN. Congenital hernias of the abdomen may occur at any of the natural openings in the abdominal parietes, or they may be the result of an imperfection, by which spaces of greater or less * Dr. Ollivier (of Angers) has reported a case of a species of congenital dropsy, of which there does not exist, at this time, another instance. The serosity was con- tained in the cavity of the gastro-colic epiploon. The following are the details of this case, which are recorded in the Archiv. gen. de med., t. 8, p. 383. " A woman whose health had been invariably good, was confined at the eighth month with a dead child ; it was well-formed, possessing all the characters of a foetus whose development had proceeded with regularity. I was struck with the great size ofthe abdomen, the walls of which were so thin as to allow of the transparent fluid with which it was filled to be perceived. On making an incision through the integu- ments, several spoonfuls of transparent yellow serosity flowed out; the peritoneum was white and without any trace of injection. The cavity of the abdomen was entirely filled with a transparent tumor, formed by the great omentum, the laminae of which were widely separated by a yellow, limpid, serous fluid contained in their folds, in the middle of which floated two large albuminous flakes. The surface of the tumor was of an irregular form, caused by the vessels which crossed the lamina of the epiploon, and forming several irregular ridges. In the posterior fold of the epiploon there ex- isted a slight opacity; the rest of this membrane was of usual transparency. The hiatus of Winslow was open, and the small quantity of fluid enclosed in the cavity of the peritoneum, had probably flowed out by that opening. None of the other abdomi- nal organs exhibited any alteration." Do not the preceding details tend to prove that this dropsy was the result of epip- loitis, without any participation of the rest of the peritoneum in this circumscribed in- flammation 1 ON THE DISEASES OF INFANTS. 359 extent are left, through which the organs enclosed in the abdo- men escape. Umbilical hernia.—We have seen that, in the beginning of the fostal existence, the intestinal tube is almost entirely situated at the base of the umbilical cord, which, by growing in breadth, forms the anterior part of the parietes of the abdomen ; in pro- portion as the child advances in age, the base of the cord retires, the intestinal convolutions enter the cavity which is henceforth to contain them, and an aponeurotic ring surrounds and contracts the base of the cord, which contains at birth nothing more than the urachus and the umbilical vessels. But if this part of the cord remains large, and continues to lodge some of the convolu- tions of the intestines, there is formed a sort of round or conical pouch or sac, the summit of which corresponds with the implan- tation of the cord; the base, to the circumference of the aponeuro- tic ring already, spoken of, and which is then much larger than it usually is, when in a natural state; the skin and cellular tissue more or less condensed, together with the peritoneum, form a triple coat to this hernial sac, where are usually lodged one or more convolutions of the small intestines. When a child pre- sents this infirmity at birth, care must be taken, in tying the cord, not to include the protruding intestine in the ligature; but it most often happens that it is not until the end of some days that the hernia is first perceived, because the intestines are pushed to- wards the umbilicus, escape through the opening and project from the umbilicus, when they are distended with aliment, and are crowded downward by the contractions of the diaphragm during respiration and the act of crying. Thus, although her- nia may not have been very apparent at birth, still it is not the less congenital, because the disposition of parts which constitute it existed at that period. At other times, hernia shows itself fully formed as soon as the child is born. In either case it will be necessary to attempt the removal of the affection. Two methods of doing this are recommended by authors—ligature and compression. The ligature formerly in use, and described by Celsus, has been revived by Desault. This celebrated surgeon tied the base of the tumor, which, being thus compressed and narrowed, be- came the seat of adhesive inflammation, and in this manner the 360 ON THE DISEASES OF INFANTS. umbilical opening was closed, and an adhesion of the sides of the peritoneal sac effected.* This method, most successful in appearance at the time of the operation than in its results, has been disapproved of by most modern surgeons, who have abandoned it from having found that a great number of children operated on by Desault, had ex- perienced a relapse; what, therefore, this celebrated surgeon regarded as a radical cure, was but a temporary relief.t Compression, then, is the method most generally adopted at the present day, and if its success be slower, it is more perma- nent. It is applied by fixing an appropriate bandage over the umbilicus; or we may find it only necessary in young infants, where the cord has fallen off, to use a graduated compress, kept in its place by a bandage around the body; or, in order to main- tain compression, an elastic belt might be found useful. In propor- tion as the child advances in age, the umbilical opening contracts, as the intestines acquire too great a volume to pass beyond it. Congenital inguinal hernia.—The testicles, in passing out of the abdomen of the foetus through the abdominal ring, carry with them the peritoneum as a kind of envelope, at first partial but afterwards more general, and which subsequently closes up over the organ so as to form a sac, without any communication with the abdomen. But if, instead of closing, the sac remains freely open, a doubling of the intestine or a portion of the omen- tum may descend, producing congenital inguinal hernia, in which the intestine is in contact with the testicle, and even sometimes adheres to it. This species of hernia does not always exist at the period of birth ; often it does not manifest itself until some time after, fol- lowing the efforts that attend painful respiration or crying; but it is necessary to its existence that the child be born with the peculiar disposition of parts wdiich we have just described be- tween the testicle, tunica vaginalis, and the communication^ more or less free between it and the abdomen. This communi- cation may exist without causing hernia, an instance of which is given by Hesslebach.J * Bichat, CEuvres' chirurgicales de Desault, t. 2, p. 315. t Richerand, Nosographie chirurgicale, t. 2, p. 453. t Med. chir., Zeitung, 1819, p. 110. ON THE DISEASES OF INFANTS. 361 It often happens that the testicle, at the period of birth, has not descended into the scrotum: it may be at the ring, either on the point of passing, or may have just passed, forming a round tumor of some hardness, which must not be mistaken for a her- nia. There can be no certainty that inguinal hernia exists in young infants, until the testicle has descended into the scrotum. Again, we must be cautious against mistaking the fold of intes- tine for the testicle, and vice versa. This error appears to be possible, since Pott has seen, in very young children, a portion of the intestine or omentum descend to the bottom of the sac, whilst the testicle was still at the ring, or even in the abdomen.* All hernias occurring in young infants are not congenital, for Mr. Lawrence has seen an ordinary inguinal hernia which be- came strangulated in a child of fourteen months.t I shall not enter into all the anatomical details appertaining to the history of congenital inguinal hernias ; but will refer to those works especially devoted to this subject for further information. When a child is born with inguinal hernia, or when it appears some time after birth, it will be necessary, in the first place, to reduce it, and to apply a temporary bandage, but slightly com- pressive, often changing it to prevent the irritation of the skin at a point which perhaps may be continually soiled with alvine evacuations, using a permanent bandage so soon as the age of the child will allow of its use. In every instance we ought to be positively assured that the testicle is in the scrotum, before using compression at the ring, and that the fluid which the sac some- times contains is returned to the abdomen. If the hernia become inflamed, of which we may satisfy our- selves by the tumefaction and pain, it will be necessary to apply a few leeches, and a poultice, using a warm bath at the same time. From what has been said in relation to the formation of ingui- nal hernia, evidently caused by the descent of the testicle into the scrotum, we might conclude that congenital hernia is only to be found in boys ; yet I once saw it in a little girl. Before explain- ing how this hernia is caused, I will relate the case. CASE LVII.—Congenital inguinal hernia, formed by the ovari- um.—Josephine Romer, aged seventeen days, entered the infirmary * Cooper's Surgical Diet, t Lawrence on ruptures, p. 65. 46 362 ON THE DISEASES OF INFANTS. on the 12th of September. She was strong, and appeared to possess a good constitution ; the abdomen was a little tense ; there existed at the left inguinal region a round tumor about the size of a filbert, somewhat hard to the touch, and could neither be returned to the ab- domen nor diminished by pressure, nor did its size augment on the crying of the child. It was directed obliquely towards the labium of the same side, but did not quite reach it. When the situation of the tumor was considered, the conviction could hardly be resisted that it was a congenital inguinal hernia, yet the sex of the child for- bid this supposition. Our judgment was therefore suspended until, at the end of twenty-six days, the death of the child from pneumo- nia enabled us to ascertain, by dissection, the nature of this tumor. The body was much reduced by marasmus ; there existed an evi- dent injection of the intestinal tube ; a slight inflammation of the fol- licles of the large intestines, and a well-marked hepatization of the right lung at its inferior lobe and posterior border. The hernial tumor was formed by the left ovarium, which had de- scended through the inguinal canal and ring, which was much larger than is usual to find it in girls. The uterus, drawn by the round ligament, and by the ovarium which formed the hernia, had deviated from its natural position, and was inclined towards the left side of the bladder. The left kidney, instead of being found on the level with the other, was drawn downwards by the cellular tissue, with which it was enveloped, and also by a fold of the peritoneum, which was intimately connected with the orifice of the sac; the renal artery and vein had also yielded to this traction, and were elongated and narrowed at the same time ; and lastly, the ovarium and the fimbriat- ed extremity of the Fallopian tube, a little reddened and tumefied, were lodged at the bottom of the sac formed by a prolongation of the peritoneum, with which cavity it communicated. There were no convolutions of the intestines adhering to the surrounding parts, and the ovarium of the opposite side was in its usual situation. Upon carefully examining the round ligament of the uterus on the side on which the hernia existed, I found it much shorter than that of the opposite side, and that it terminated in the labium by an apo- neurotic expansion, in place of losing itself in loose filaments, as is usually observed to be the case ; from which it would seem that the ligament, shorter and more firmly fixed to the labium, had, in the first place, caused the deviation of the uterus, and afterwards drew with it the ovarium through the inguinal ring. It followed from this abnormal adhesion, that all the moveable parts on the left side ofthe ON THE DISEASES OF INFANTS. 363 abdomen which had connection of continuity or of contiguity with the hernia, were drawn to the side of the hernia, for they were not separated from each other, nor did they follow the abdomen in its enlargement during the development of the fcetus in the uterus. I will return to this subject when considering the diseases of the genital organs. I have said that other abdominal hernias may result from a default in the development ofthe walls of this cavity. It is near the umbilicus and on the median line that it is more often ob- served. The skin at the umbilicus is sometimes wanting, and the base of the cord alone forms the exterior of the sac, enclosing the intestines that had passed through an opening at the umbili- cus. Sometimes it happens that the covering is so thin, that the intestine forming the hernia can be seen through the tissue. Mr. Hey, in a similar case, had recourse to the following means to cure this infirmity: having reduced the intestines, he confided to an assistant the compressing of the cord close to the abdomen to prevent the return of the intestines into the hernial sac. "I procured," says he, " some plaster spread on leather cut in circu- lar pieces, and laid upon one another in a conical form. This compress I placed upon the navel, after I had brought the skin on each side ofthe aperture into contact, and laid one of the lips a little over the other. I then put round the child's abdomen a linen belt, and placed upon the navel a thick circular quilted pad. This bandage kept the intestine securely within the abdo- men, and was renewed occasionally. The funis was separated about a week after birth ; and at the expiration of a fortnight from that time, the aperture at the navel was so far contracted that the crying ofthe child did not cause the least protrusion."* A much greater imperforation in the parietes of the abdomen may occasion considerable displacement of the viscera contained in this cavity. Mellet has reported a case in the Vandermonde Journal, of a woman who was delivered of a child where the in- testines and the whole of the mesentery had escaped from the abdomen through a round opening, about an inch and a half in diameter, situated in the umbilical region, about two lines from the navel. * Dictionary of Practical Surgery, by Samuel Cooper. 364 ON THE DISEASES OF INFANTS. The smallness of this opening, the great volume which the parts presented in consequence of the swelling of the intestines and stomach, and the extreme feebleness of the child, would not allow of any measures being used to effect a reduction. The child was sustained by sweetened wine and water ; and although the intestines appeared to be strangulated by this small opening, the fluids given it were observed to pass even to the rectum, since some hours after passing the meconium, the child vomited by stool other liquid matters, which possessed something of the co- lor of wine. The child died in about two hours, and on the fol- lowing day the disposition of the parts were examined, and the portion which escaped from the opening described, was found to reach even to the thighs. The whole of the stomach, the small intestines, colon,—the extremity of which, where it joins the rec- tum, re-entered the abdomen through the opening,—the mesen- tery, the left kidney, the supra-renal capsules of the same side, and the spleen, were found outside ofthe abdomen, without any membranous envelope; the peritoneum and the omentum were entirely wanting. There was nothing in the interior but the liver, which was prodigiously enlarged, and the right kidney, which occupied its natural place; the left ureter was much larger than the right; there was no pancreas.* In such a case, I am of opinion that the stricture should be relieved, and the viscera gradually and cautiously returned. The application of a bandage, armed with a pad slightly com- pressive, would probably assist in obliterating the opening. This is the proper place for speaking of those accidental tu- mors enclosing the fragments of another fcetus, and which have been sometimes seen developed in different points ofthe abdomi- nal cavity ; but the consideration of this subject would lead me into details which do not comport with the limits which I have prescribed to this work.t * Case of a child born with all the contents of the abdomen outside of the cavity, by M. Mellet, surgeon and accoucheur at Chalons, sur. mer. journal de med. chirurg. etpharm. May, 1756. t Consult Dupuytren, Rapport fait a la Societe de la Faculte. Reports of this Society No. 1, p 4. Ad. Lachaise, de la duplicite monstrueuse par inclusion. Paris, 1823. C. P. Ollivier, Memoire sur la monstruosite par inclusion, Archives ge- neral de medecine. t. 15 and 17.—Isid. GefTroy St. Hilaire, Hist, des ar.omalies de ON THE DISEASES OF INFANTS. 365 PROLOPSUS OF THE RECTUM. Prolopsus ofthe rectum consists in an unlining, as it were, of the internal membrane of this intestine. As this membrane is soft, and only adheres to the other membranes by loose cellular tissue, it projects externally, and forms at the anus a thick red ring, which is sometimes bloody whenever it is pushed down- wards by any cause whatever—such as constipation, or the con- tinual crying of an enfeebled child, or when a large quantity of foeces is passed after an obstinate constipation. It may also be produced by large stools following the administration of a pur- gative. I do not know on what reasons Underwood has founded his opinion that this 'accident is a symptomatic affection of the pre- sence of worms or other irritating matter in the intestines. There really exists no relation between these affections. Immediately on the protrusion of the rectum, it will be neces- sary to attempt the return of the ring formed by the mucous membrane ; this may be accomplished by pushing the protruded part upwards with the fingers, anointed with cerate or oil, taking the precaution to cause the ring to enter first. The tu- mor thus reduced may be kept in its position by means of com- presses wetted with cold water, and which may be retained in their place with a T bandage. If this disorder should continue, it will be necessary, as the child advances in age, to prevent the prolopsus by supporting the circumference ofthe anus during the efforts at defecation. Aromatic powders, or astringent lotions, add but little to the mechanical means to which i,t is necessary to resort in order to support the rectum. torganisation chez Vhommes et les animaux, 1832, in 8vo. fig.— Serres, Rescher- ches d'anatomie transcendante et pathologique; theorie des formations organiques appliquee a I'anatomie de la duplicite monstrueuse. Paris, 1832. 366 ON THE DISEASES OF INFANTS. CHAPTER VII. DISEASES OF THE RESPIRATORY APPARATUS. In the respiratory apparatus is comprehended the nasal fossa?, larynx, trachea, and lungs. Section I. DISEASES OF THE NOSE AND NASAL FOSSAE. It may create some surprise to see the nasal fossa? classed with the organs of the respiratory apparatus. In man, the nose and the nasal fossa? are but an accessary part, and one not immedi- ately dependent on the respiratory system; they are especially destined to olfaction. In some animals, and particularly among fishes, the nasal fossa? are altogether separated from the respira- tory passages; but this is not the case with an infant at birth; it respires very little by the mouth, which is almost always shut, and while sucking, it is essentially necessary that the air pene- trate the lungs through the nasal fossa?, since the buccal cavity, applied to the nipple, is continually filled with milk. Besides, without this it would be impossible to prolong the act of sucking for any length of time. The importance of the functions which the nasal fossa? fulfil, as an organ subsidiary to the respiratory apparatus, is also de- monstrated by the seriousness of the diseases which are developed in them. Thus, it appears of more importance to consider the nasal fossa? rather as an organ of respiration than an organ of olfaction in an infant, who cannot enjoy the sense of smell. These considerations will suffice without doubt for our motive in placing the diseases of the nose and nasal fossa? among those of the respiratory organs. Development and congenital malformations.—During the first period of intra-uterine life, the nose does not exist; the nasal fossa?, which at first communicate with the mouth, separate from it gradually by the approximation and union of the two lateral ON THE DISEASES OF INFANTS. 367 parts of the palatine arch. At six weeks or two months, two small holes situated by the side of each other appear above the mouth ; these are the commencement of the opening of the nos- trils ; very soon two slight projections arise above these openings; they are the first rudiments of the ala? of the nose, which arise by degrees, but are very incomplete; for during the whole of the intra-uterine life, it continues quite small and obtuse. Whilst the progress of the formation of the nose is in operation, the nasal fossa? enlarge, particularly in height; they are also a little spread at the bottom, but continue very narrow at the superior part. ' The sinuses and cornua are formed without leaving any thing but a very narrow space between them; the mucous membrane with which they are covered is very red and thick in the latter period of foetal life, and it exhibits the same characters at birth. The frontal and maxillary sinuses do not as yet exist; they are not formed until a more advanced period. We have seen that the holes of the nose do not exist at first; their development may be impeded or suspended, and the child be born with an entire absence of the nose, or with a considerable flatness of this organ, which preserves through life the traces of this primitive formation; but its complete absence usually de- pends on the absence of the ethmoid bone; the two eyes, united together, are lodged in a cavity commonly situated at the place of the nose. M. de Larue has given in the Vandermonde Journal, the case of a monster, of the cyclops order, which presented the following appearance: the size of the head, he observes, was proportioned to that of the body; the forehead was very large, and occupied three fourths of the face ; not the slightest trace of a nose could be found ; there appeared to be nothing more than an oval opening, situated horizontally at the place where the point of the nose should have been, six lines above the superior alveolar process. Neither the cerebrum nor cerebellum exhibited any thing extraordinary; there was no olfactory nerve, and al- though the bed of these nerves existed, there was no ethmoid bone nor cribriform plate.* Sometimes there is found in place of a nose a kind of prolon- * Observation sur un monstre cyclope, by M. de Larue, surgeon and demonstrator of anatomy at Rennes, Journal de med. chir. and pharm., t. 7, p. 278. 368 ON THE DISEASES OF INFANTS. gation, produced without doubt by the remains ofthe skin which ought to cover the nasal eminence. The nose may be prolonged in such a manner as to form a real proboscis descending below the mouth. I have seen an instance of this deformity preserved by Dr. Garnier of Angers. Without being thus prolonged, the nasal eminence instead of being short and depressed, as is the case in infants at birth, already possessed the full form of an adult's nose, and bore a close resemblance to it: this premature development ought to be regarded as a species of deformity. I have also seen an infant at birth, where the nose possessed the shape known by the name of aquiline. Lastly, there have been examples of bifid noses,*—or without being completely double, showing in a very marked manner, the medium line which sepa- rates the two lateral parts of this organ-t Diseases developed after birth.—In an infant at birth, the pituitary membrane is always very red, and very much engorged, and it possesses besides great irritability ; for we often see chil- dren sneeze at birth, immediately on the air coming in contact with this part. The membrane also secretes an abundant mucus * The complete separation of the two portions of the nose may also be produced by the formation of tumors in the nasal fossa, which date their existence from the earliest period of the formation of the embryo. Dr. Rosata Dimidry has given a very remark- able instance of this. On the 7th of September, 1830, a young woman, of the com- mune de Vaglie, canton of Brindisi, in the province of Lecce, was delivered of a girl, who exhibited a large-sized fleshy prolongation, extending from the nose over and below the mouth. An attentive examination satisfied Dr. Dimidry, that the nose of this child was bifid, being divided at the base so that the two portions were separated, and between them projected a tumor ofthe size of a goose's egg, closely adhering to the entire circumference of the nasal opening and the upper lip, before which it descended; afterwards becoming free, it was extended even to the lower Up, thus almost com- pletely closing the opening of the mouth. At the upper part of this abnormal produc- tion appeared a nipple-like protuberance, and one of similar shape and appearance at the inferior part contiguous to the lower lip. Dr. Dimidry ascertained that this tumor interfered with respiration, by the complete closure of the nostrils, and the almost entire closure of the buccal opening; and not doubting but a complete asphyxia would ensue, which would be quickly mortal, he decided to remove the tumor by one stroke ofthe knife. The dissection of this tumor proved it to be enveloped by a prolongation of skin, and that its tissue had the granu- lated appearance of a glandular body. Notwithstanding all the means employed to sustain this child, it could not be accom- plished, and it died four hours after the operation. (Anali di med. et chir. di Napoli, Septem. 1830.) t Victor Laroche, Dissert, inaug., p. 50. ON THE DISEASES OF INFANTS. 369 at a very early period, and it flows constantly from the nose in some children. Thus, the sanguineous congestion, redness, irri- tability, and the abundant secretion of the pituitary membrane in young infants, demonstrate the great disposition in this mem- brane to inflame, and explain the frequency of coryza in new- born children. This disease has attracted the attention of pa- thologists ; and I will endeavor to give an account of the affec- tion. It may be simple or complicated, with a more or less rapid formation of a membranous concretion throughout the whole extent of the nasal fossa?. Simple Coryza.—The action of cold, humid air, the chilliness of the extremities, when wetted with the urine, in those infants where there is a great negligence in changing their clothes, ex- posure to a strong fire, and particularly to the light and heat of the solar rays, are the usual causes of this affection in young infants. When children are taken out for the benefit of the air on the return of spring, it is almost always observed that they sneeze and experience a discharge from the nose, and the promptitude with which insolation acts on the pituitary mem- brane is greater at this season, because during the winter they are less accustomed to the impression of the sun. This is per- haps the reason why people regard the sun in the month of May as unhealthy. From whatever cause it may arise, whenever the pituitary membrane of infants is inflamed, it presents the follow- ing symptoms. j Frequent sneezing is the first sign of this affection. Soon after, mucosity flows from the nostrils, at first ropy and clear, afterwards yellow, and lastly, purulent. The child, who almost always sleeps with its mouth closed, cannot now sleep without keeping it open : the respiration is noisy, and instead of the usual rale, a whistling sound occurs in the nasal fossa?. This sound becomes greater, and the difficulty of respiration increases in proportion as the nasal mucosities become thicker and more abundant. This discharge dries at the orifice of the nostrils, which are more or less closed, and thereby prevents the entrance of air : the restlessness, cries, and the physiognomy of the child express the distress it suffers. If at this time it is placed at the breast, its anxiety and the suffocation increase, it leaves the nip- 370 ON THE DISEASES OF INFANTS, pie because unable to exercise suction, as it can only respire by the mouth, which is filled with the nipple and the milk that flows from it; and being thus in a continual state of agitation from the sense of hunger, and the impossibility of satisfying it, soon becomes exhausted by fatigue, pain, and inanition, and quickly perishes, even before arriving at an advanced stage of marasmus. The progress of symptoms is sometimes very rapid, and a young infant may die in three or four days, from this dis- ease ; and on this account it is justly regarded as of a most serious character in infants. On the other hand, it is not to be always looked upon as so serious ; for the danger of the disease is always proportionate to the degree of tumefaction of the pitui- tary membrane, and to the abundance, and especially the consis- tence of the mucosities secreted by the inflamed membrane. When therefore the inflammation is slight, the nasal mucosities are only a little more abundant, clear, and ropy than in the na- tural state, and the inconvenience of respiration is but slight. In general, coryza is not a dangerous disease when the infant can suck; the danger begins with the difficulty of respiration, and the inability to suck ; and all other things being equal, it is more serious in proportion to the tender age of the child. Coryza with pellicular concretions.—Inflammation ofthe pitu- itary membrane sometimes gives rise to the formation of pseudo- membranous concretions which cover the surface of the nasal fossa?. In forty children affected with coryza of greater or less intensity, that were treated at the infirmary of the Institution of the Enfans Trouves, there were five with the false membranes covering the sinus and the cornua, and adhering more or less closely to the pituitary membrane, which was of a vivid red, thick, and very friable. The formation of these false membranes had been preceded by all the symptoms peculiar to coryza, they were covered with thick mucosities, in the midst of which ap- peared either the remains, or the pseudo-membranous rudiments. These children had sunk very quickly under the disease, and in only one of them was it possible to make a diagnosis of the pre- sence of the membranous concretion in the nasal fossa?, for the others presented nothing more than the usual signs of a very intense inflammation of these parts. The following is the history of this remarkable case. ON THE DISEASES OF INFANTS. 371 CASE LVIII.—Coryza, with pseudo-membranous concretion.— Marie Eseril, aged six days, entered the infirmary on the 18th of May. She was small, the integuments were vermilion, pulse natu- ral, abdomen a little tender; the dejections were green and very abundant. (Gum syrup, rice, emollient cataplasm to the abdomen, milk and water.) Same condition to the twenty-first, when it was perceived that the child sneezed frequently, and that she swallowed with difficulty the milk that was given her with a spoon ; the face was pale, the limbs were not more oedematus ; and there supervened a slight ophthalmia, and frequent vomitings of undigested milk. To- wards night there occurred an abundant flow of ropy mucosity from the nostrils. On the twenty-second and twenty-third, same condi- tion. On the twenty-fourth, the respiration was much more difficult, and the child slept with her mouth open ; the forehead was wrinkled, the alae of the nose drawn outward, the restlessness, anxiety, and frequent cries, which the feebleness of the child, however, would not allow of their being prolonged, all led to the belief that there exist- ed an obstacle to the free passage of the air in some point of the air passages. (Same treatment.) On the twenty-fifth, infiltration and paleness of the face, continuation of the diarrhoea and vomiting, nasal respiration very noisy, accompanied, when the child cried, with a sudden snorting, which terminated the respiratory move- ment. M. Baron was of opinion that the coryza, which, until then, had produced an abundant secretion of mucosity, had become com- plicated with the formation of a membranous concretion. This state continued until the twenty-ninth ; the child fell into a state of com- plete marasmus, the nasal respiration was conducted with less noise, but the mucosities, puriformand green, flowed from the nose in great quantities. On the thirty-first, the nasal sound returned; vomiting of mucus matters occurred every moment, and the child, almost un- able to respire, and reduced to a state of great feebleness, expired at night. Upon opening the body, the mouth was found healthy, and the stomach without any mark of disease; two thirds of the small in- testines healthy; but there existed in the ileo-caecal region a very large red patch, with tumefaction and friability of the mucous tissue; the ileo-caecal valve was so tumefied as only to admit the stylet of a female catheter; the large intestines were perfectly healthy; the liver was pale. In the nasal fossae was found a white pseudo-mem- branous concretion, a little projecting by the blood exhaled on its surface. It commenced at the superior part of the glottis, and in- 372 ON THE DISEASES OF INFANTS. stead of extending to the trachea, spread towards the sinus and cor- nua of the nose, which it covered closely and solidly. The mucous membrane beneath it was much tumefied and of a vivid red, and was even bloody in certain places. The right lung was gorged with blood at its posterior border ; the brain was healthy. It is evident that this child died from a coryza, which, at first, simple, and attended only with an increase of a very abundant secretion, was finally complicated with the formation of a pel- licular concretion, and that this pellicle, by obstructing the pas- sage of air, gave rise to all the symptoms which had been ob- served. It is probable that the abundant vomiting was owing to an obstruction at the ileo-ca?cal valve, since there was neither oesophagitis nor gastritis. Coryza may assume a chronic character, and cause the death of the patient by the disorganization which ensues. This was the case in the following instance : CASE LIX.—Chronic coryza, inflammatory softening of the pituitary membrane.—Paul Galon, aged 17 months, had been wean- ed for some time, entered the infirmary on the 21st of August; he was pale, although he possessed considerable strength ; the skin was hot, the pulse natural, the nasal respiration was extremely difficult, the conjunctivae were slightly injected. (Gummed marshmallows, pedeluvium, milk and water.) During the month of March he pre- sented no other symptom than that of an abundant mucous discharge from the nose, a very difficult respiration, and a great tendency to drowsiness ; the pulse in general was small and slow, yet it became more frequent towards night. (Four leeches to the mastoidean re- gion and a blister to the neck.) This treatment produced ameliora- tion of symptoms, and the respiration became better. On the 3d of April the drowsiness returned ; the pulse was frequent and small; paleness universal; skin dry; abdomen tense ; respiration difficult, with an abundant flow of mucus from the nostrils, and vomiting. (Four leeches to the epigastrium, cataplasm to the abdomen, diet.) On the 4th of April the skin was cooler, the mouth continued dry ; there was no vomiting, and the pulse less frequent. On the 6th of April there was a complete disappearance of the gastric symptoms; there existed an abundant flow of nasal mucosity, and the passage of air through the nasal fossae appeared to be difficult; the upper lip was cedematous. From this time to the fifteenth, the same state con- ON THE DISEASES OF INFANTS. 373 tinued; the child did not waste away ; the nose and upper lip were continually moistened with mucosity, Avhich was always white and ropy, like the white of an egg. During the month of May the child remained much in the same state ; but on the 2d of June a nettle- rash made its appearance, accompanied with a little fever, which, however, disappeared at the end of two days. (Gummed barley- water, milk and water, diet.) There was a slight melioration of symptoms, but the coryza continued, and it was for this affection alone that the child remained in the infirmary. The remainder of this month and the commencement of July passed without any thing remarkable occurring; but in the night of the fifteenth, the respira- tion became difficult, fever arose, and a large quantity of mucosity flowed from the nose and mouth. (Sweetened decoction of marsh- mallows, diet.) The debilitated condition of this child would not allow of farther depletion. On the 20th of July the same state continued, general paleness, hectic fever, characterized by the small- ness and frequency of the pulse, and a burning heat of the skin ; the exacerbation occurring every evening; marasmus made rapid pro- gress ; still there was no diarrhoea nor vomiting ; the nasal mucosity was very thick and abundant. (A linctus with a grain of Kermes mineral, blister between the shoulders.) But slight improvement of symptoms ensued ; the child sunk and wasted from day to day; the respiration was noisy, yet the thorax, which, during the course of the disease, was frequently percussed, did not yield a dull sound. On the 10th of August, great oppression supervened, and continually increased, until a considerable flow of mucosity occurred from the nose, the discharge of which was accelerated by sneezing. On the fifteenth, this discharge of mucus from the nose ceased, and the child rallied a little ; he was extremely emaciated, yet was not affect- ed with any disorder of the bowels. Emollient drinks, mucilages, and milk and water, formed the treatment at this time, care being taken not to prescribe any nourishment but that of the lightest kind ; but the nurse having charge of the ward thinking that a different diet would restore strength to the child, secretly gave him fat soups and broths. On the twenty-fifth of August, during a violent fit of crying, one of the servants, believing it to be an expression of hunger, took the child up and fed him; he immediately showed symptoms of suffocation and died in her arms. On opening the body the next day, the mouth was found healthy, the oesophagus pale, the stomach very much distended and filled with panado; the mucous membrane of this organ was very soft and red ; 374 ON THE DISEASES OF INFANTS^ the mesenteric ganglia were tumefied and red, and the mucous mem- brane of the duodenum covered with red striae ; the small intestines were healthy, but were very much distended with gas; the lungs were healthy, but there existed cellular adhesions between the two pleurae. The two lateral ventricles of the brain contained an abun- dant serosity; the mucous membrane of the nasal fossae was very red, tumefied, and soft; the larynx and bronchiae were healthy. I have been, in the disease of this child, very minute, because it appeared to me interesting to report all the circumstances of the progress of chronic coryza; at the termination of which, the pituitary membrane had experienced the disorganization which a long continued inflammation usually produces on mucous membranes. We ought also to remark the cerebral and gastro- intestinal complications, the state of marasmus to which the pa- tient was reduced, and the fatal effect of an abuse of regimen, administered by those who had the care of this child, and who were imbued with those prejudices which induce people to give to the sick, and particularly to children, a large quantity of food to strengthen them. The most common complications of coryza in young infants, are cerebral affections. From the proximity of the inflamma- tion to the brain, an irritation is transmitted to that organ, from which results acute hydrocephalus, as we have seen was the case in the preceding instance, or accidents not less fatal ; it is there- fore not unusual to find children experience, in the course of this disease, a drowsiness and prostration, and even sometimes con- vulsions, which are evident signs of cerebral irritation. The treatment to be adopted in this disease must vary accord- ing to the age ofthe child; in young infants that are sucking, it will be necessary to suspend alimentation by the breast, on ac- count of the great pain they experience while sucking, and the difficulty of respiration which attends the action, thereby increas- ing the danger of the symptoms attending inflammation of the nasal fossa?. Besides, children in this case suck so badly that the quantity of milk they take is almost insufficient to nourish them, and they are exposed to the hazard of perishing of languor or hunger. Drinks ought to be given with great caution, and they ought to be fed with a spoon with cows' or goats' milk, di ON THE DISEASES OF INFANTS. 375 luted with groat water. If deglutition appear to be very diffi- cult, we must have recourse to nutritive injections. There is no advantage in directing the vapor of a decoction of emollients to- wards the nasal fossa? of young infants, for the air passages are so narrow that the momentary swelling which it occasions, will only increase the difficulty of respiration. The principal means to be employed in the treatment of coryza in young infants, are the removal from the causes which may produce it, laxative drinks, such as a decoction of prunes, or even the administration of a saline purgative, or calomel in a dose of two or four grains, in order to establish a revulsion on the intestinal tube, and by the application of a blister -either to the neck or to one of the arms. If any cerebral complication should arise, it must be met with appropriate means. If, after having combatted the inflammation in the usual manner, there should be formed any pellicular con- cretions in the nasal fossa?, it would be proper to have recourse to some of the extraordinary measures which are recommended in croup. We might, for example, blow gently some fine calo- mel, or a mixture of sugar and alum finely powdered, into the nostrils. The introduction of this powder into the nose will be less dangerous than into the trachea. We ought, above all, so soon as there is perceived any difficulty in sucking, to remove the child from the breast, because this difficulty may become, by frequently recurring, at last the cause of the most distressing ef- fects, either with regard to the nutrition of the child, or by the production of pulmonary or cerebral congestions. Section II. DISEASES OF THE LARYNX AND TRACHEA. Development and congenital malformations.—During foetal life the pharynx and trachea exhibit no series of progressive phe- nomena that can be observed or followed in such a manner as to trace with exactness the various periods of their formation. Their existence and perfection are not of so great importance during intra-uterine life as that of the intestinal tube, kidneys, bladder, etc.; they do not exhibit, like these organs, appreciable stages of formation; and from their first appearance, which 376 ON THE DISEASES OF INFANTS. occurs about the second or third month of conception, there is already distinguished a canal, enlarged at its superior part, and divided inferiorly in a mariner which enables us to recognise evidently the traces of the larynx and trachea ; and at the third month transverse lines may be seen indicating the cartilaginous rings of the trachea. At six and seven months it is easy to dis- tinguish the projections and depressions which form the ventri- cles and cords of the glottis. The mucous membrane which covers these parts is usually of a deep rose-color; this color is less vivid in the trachea where the internal membrane often ap- pears in longitudinal folds, which disposition of the part permits an enlargement of the canal whenever it is distended with air. It is likewise common to find very clear and ropy mucosities co- vering and lubricating the walls of the trachea. At the period of birth, the cartilages, bones, and muscles of the larynx are per- fectly developed, although small and very flexible; and the car- tilages of the trachea perfectly distinct from each other, are soft, and filled with blood ; and there are often found transverse red stria?, corresponding, in infants at birth, to the cartilages of the trachea, and which ought not to be taken for marks of inflam- mation. The congenital malformations of the larynx and trachea are of much less common occurrence than those of many other or- gans ; the complete absence of these parts occurs in cases of ace- phalia. The larynx may be of extreme smallness or only very narrow, of which I have given an instance in the article on mal- formations of the tongue; the absence or imperforation of the epiglottis, and of some one of the cartilages of the larynx, have been also observed. I have seen in an infant at birth, a strongly marked defect of symmetry between the two lateral portions of the larynx. All these malformations are of little importance at a pe- riod when the functions of this organ with respect to phonation, are, as it were, a nullity; but they may afterwards injure speech or singing. The divisions of the trachea may differ greatly in size and extent, and in this respect correspond to a similar diffe- rence in the size of the lungs. Diseases of the larynx and trachea, developed before or du- ring birth.—I have not seen any evident trace of inflammation during intra-uterine life, but I have often met with a very con- ON THE DISEASES OF INFANTS. 377 siderable sanguineous congestion in premature children; several times this congestion, known by a deep redness of the laryngo- tracheal mucous membrane, was accompanied by a sanguineous exhalation, which extended even to the bronchia?, so that it ap- peared probable that it was the result of an afflux of blood to- wards these parts, either during the latter period of intra-uterine life or during birth. There is a condition of the larynx and trachea which, with- out having reference to any lesion whatever of the mucous membrane, does not the less merit the notice of physicians, and especially of accoucheurs. I allude to the abundant mucosity which in some infants obstructs the larynx and trachea, to that degree as materially to hinder the establishment of respiration. This affection is usually accompanied with a peculiar altera- tion of the cry, which is husky and almost always incom- plete. The reprise is not heard but momentarily, and when heard is hoarse and jerking. It is probable that this mucosity was accumulated in the larynx and trachea before birth. The trifling effects of this accumulation are but of short duration ; a few efforts of inspiration and expiration are sufficient to render the cry free and perfect. The accoucheur may assist the dis- charge of this mucosity with the fingers or a feather introduced into the entrance of the larynx, where it usually adheres. I have sometimes seen on the internal surface ofthe trachea of a dead fcetus, small violet-colored patechia?, but know not to what cause to attribute them. Diseases developed after birth.—There are three kinds of dis- eases affecting the larynx of sucking children—congestions, in- flammation, and cedema. Congestions.—The larynx is almost always injected in in- fants at birth ; this injection, after continuing for some time, will gradually cease, and finally disappear altogether. In infants of two to four months, the mucous membrane of the larynx is of a pale rose, and its color differs less from that of the trachea than it originally did. During life the larynx is easily injected, and it is always found more less red in almost every case of death from asphyxia. I have frequently noticed ecchymosis in the cellular tissue surrounding the larynx, as if external violence had been used to effect strangulation. In these cases of laryngeal 378 ON THE DISEASES OF INFANTS. congestions, blood has likewise sometimes been found exhaled to a greater or less extent on the surface of the larynx and trachea ; this blood has also been expectorated by the infant at the period of death in considerably quantities. This is particularly observ- ed in those infants in whom the cellular tissue is cedematous or hard, and who, at the same time, exhibit an evident universal plethora. Inflammation.—Laryngitis is of common occurrence among infants at the breast, but it is to be remarked that it is much less frequently seen than at a more advanced age. It may be simply an erythematic inflammation, or it may be complicated with the formation of pellicular concretions. The erythematic variety may vary much with respect to its intensity ; it may be of a rose-color without any alteration of tex- ture ; it is sometimes accompanied with tumefaction, or with softenino; or ulceration ofthe mucous tissue. The causes of laryngitis are sometimes difficult to ascertain; it may, however, arise from the impression of cold moist air, the action of cold wind, or wet feet, but above all, from prolonged cries ; it may also be produced by a previous phlegmasia occu- pying some other point of the mucous membrane of the respira- tory passages. This inflammation, even in its mildest form, is accompanied with an abundant secretion of mucosity, which is at first clear,but soon becomes thick and yellow. The respiration ofthe child is labored, and the cry sensibly altered. This alteration consists more in its tone than in its form ; both parts constituting the cry exist, but they are husky. When inflammation of the larynx is violent, the alteration in the cry is more evident; it is often then so faint as scarcely to be heard, whilst the reprise is, on the con- trary, acute and predominant. This particular modification of the cry of a child, as I have already remarked at the commence- ment of this work, is a positive sign that inflammation exists about the upper portion of the air passages, while the complete absence ofthe reprise indicates a lesion in the bronchial ramifi- cations or the pulmonary tissue. It is important to remember this rule. Laryngitis rarely exists alone; it very often follows coryza, and is sometimes soon accompanied by inflammation of the tra- ON THE DISEASES OF INFANTS. 379 chea and bronchia?; it is also not uncommon to see inflamma- tion of the larynx occur only after that of the nasal fossa?. The progress of the symptoms of this affection is usually rapid, and sometimes very obscure at its first appearance; but so soon as the inflammation becomes less intense, the alteration in the tone and form ofthe cry will enable the practitioner to recognise the disease without any difficulty ; besides, it may be in our power, at times, to satisfy ourselves by inspecting the velum and sur- rounding parts, for the inflammation will extend even to them ; and an erythematic redness extending to the larynx may be seen upon opening the mouth and pressing down the tongue. This inflammation is seldom accompanied with vomiting, like that of the pharynx or Oesophagus; yet the child sucks badly, and if too large a quantity of milk be taken into the stomach, it will often happen, at the moment of deglutition, that the pain caused by the movement of the pharynx will cause him to leave the nipple and give a sudden cry, causing the fluid introduced into the oesophagus to reflow towards the mouth ; and some of it also penetrating the larynx, produces a sudden suffocating cough to the great danger of the child. This regurgitating movement, with the cough and suffocation following it, deserves our attention. In three children, who, when sucking, almost al- ways experienced this suffocating cough on swallowing, I found a pulmonary congestion and an intense anginose affection, which were probably its cause. A quantity of mucosity accumulated in the larynx may pro- duce similar symptoms ; this occurs when the child is sleeping, who awakes with a sudden start, and coughs, making an effort at crying, which however is only accomplished when, with the most painful exertion, the mucosity obstructing the passage to the glottis is removed. I will here make a general remark in relation to inflammations of the larynx in young infants ; when the passage is very narrow, the least tumefaction resulting from inflammation may produce suffocation, followed by spasm and distress, during the existence of which the physiognomy fully expresses the suffering of the patient. The face becomes purple, especially around the ala? of the nose and about the mouth ; the nostrils dilate, the mouth remains wide open, and at each move- ment of inspiration, there occurs a kind of spasmodic contraction 380 ON THE DISEASES OF INFANTS. of all parts of the body, accompanied with a dilatation of the walls of the thorax: this spasmodic state is observed in the youngest infants. It is without doubt this assemblage of symp- toms, to which authors have given the name of angina suffoca- toria. It is frequently noticed in infants, and I have almost always observed in those that have died of this disease, a large quantity of thick mucosity, which being collected in the cavity of the larynx, and having caused an obstruction, produced as- phyxia. The following case presents something analogous to what I have stated. CASE LX.—Auguste Borlet, aged thirteen days, entered the infirmary on the 22d of May. This child was strong but pale. There had for two days existed considerable vomiting; the tongue was red at the point: the pulse exhibited nothing worthy of remark. (Sweetened rice-water, emollient injection, milk and water.) From the twenty-second to the twenty-sixth, no remarkable symptom ex- isted ; but at this period, there occurred a coryza, accompanied with an abundant secretion of nasal mucosity, and a slight swelling of the nose; the eyelids were also a little tumefied. The coryza soon dis- appeared, and the child appeared tolerably well until the 10th of June. The respiration then became painful, the face purple for a moment, and when the child awoke, the cry was for a short time husky, and did not become clear until after several efforts at respiration; and although both parts could be heard, yet there always existed some- thing obscure or husky, which was not natural. (Pectoral ptisan, sinapised cataplasm to the feet, linctus, diet.) On the fifteenth, the child grew pale and thin, and suffered occasionally a severe suffoca- tion, but the efforts at coughing and vomiting caused the ejection of a quantity of thick mucosity; the hands were often purple ; there neither existed diarrhoea nor vomiting—pulse from fifty-eight to sixty. On the eighteenth, the cry was still husky, the respiratory movements were quick and short, the thorax gave a dull sound at its posterior part, and an imminent suffocation occurred whenever drink was given. On the twentieth, he was so feeble and sunken, that no symptom eould be observed; he gradually wasted away and died on the twenty-third. Post mortem examination.—Injection of the base of the tongue, an intense redness, tumefaction, and softening of the mucous mem- brane of the larynx, the walls of which were covered with thick and almost membranous mucosity. The trachea and bronchia? were of a ON THE DISEASES OF INFANTS. 381 violet red; the lungs very much engorged at their posterior border. In the ileon, there were fourteen inflamed follicular patches; the colon was covered with a number of brown striae, the brain was perfectly healthy. We have seen in this child the ordinary accompaniments of inflammation of the larynx continued for a length of time, and it cannot be questioned that the imminent suffocation which oc- curred from time to time was owing to the presence of thick mu- cosity accumulated in the larynx, and to its narrowness from the tumefaction of its walls. We should also remember that it fol- lowed the coryza, which, as has been already observed, is of very frequent occurrence in young infants. Laryngitis does not always exist alone; it often arises in the course of some other disease, as scarlatina or variola. The ana- tomical characters of the inflammation are not then confined to the erythematic redness, but they are sometimes analogous to the cutaneous phlegmasia? of which this disease is a concomitant symptom. Pustules, similar to those of the variolous eruption, are frequently seen developed in the trachea and pharynx; in this case the symptoms are the same as those just described, at least when the phlegmasia is not complicated with the formation of a pellicular concretion, and then the symptoms are those which characterize croup. This affection may terminate in resolution at/the end of a few days, pass into a chronic state, as we have seen, in the subject of the preceding case, or soon end fatally from asphyxia. The disease should, therefore, be watched with great care from the commencement, that it may be effectually combated before it has made much progress. After the disappearance of the inflammatory symptoms, the cry continues sometimes husky, arising from the altered state of the tissue from the inflammatory action, affecting the integrity of the sound produced by the air in the larynx. I have often observed in adults who have had the small pox in their earliest infancy, a peculiar huskiness of voice, produced without doubt by the extension of the phlegmasia to the larynx, the texture of which had been either modified or altered. Treatment.—When symptoms of an anginose affection are 382 ON THE DISEASES OF INFANTS. perceived in an infant at the breast, we ought in the first place to endeavor to prevent its taking too much milk at one time, and particularly its sucking with eagerness; hence it should be put to the breast frequently and for a short time. If the inflamma- tion be intense and deglutition painful, it will be necessary to suspend sucking altogether, to keep the neck warm by means of a double woollen cravat, or a poultice, to apply two, three, or four leeches, according to the age and strength of the child, above the clavicle, some distance from the seat of the disease. The clothes should not be too tight; for the difficulty of respiration is already very great from the tumefaction ofthe larynx, without our adding more by the distress which may result from com- pressing the thorax. Hot cataplasms to the feet are sufficient oftentimes to produce in them a slight rubefaction ; the applica- tion of mustard in young infants will often cause great irritation and inflammation, terminating in ulcers very difficult to cure. If the intestinal tube be healthy, and if there exist any constipa- tion of the bowels, two or three grains of calomel followed by a half an ounce of manna dissolved in two ounces of milk, or by an injection of half an ounce of castor oil, incorporated with warm water by means of half of a yelk of an egg. Should any cerebral complication arise, it will be necessary to apply one or two leeches behind each ear ; revulsives may also be employed at the same time. Should the disease become chronic, after having used the means just enumerated, recourse must be had to a blister applied to the neck, or ammoniated liniment, or tartaremetic ointment may be applied by friction to the lateral parts of the neck. After the disappearance of the disease, it would be well to keep the neck ofthe child for some time enveloped in some fine fur, or swans- down, or even a piece of flannel, to guard against a relapse, which would be more serious than the first attack. Inflammation with altered secretion, or croup.—Croup con- sists of an inflammation of the larynx and trachea, complicated with the rapid formation of a pellicular concretion spread over the walls of the larynx, and is propagated, in some cases, even to the trachea and bronchiae. The remote causes appear to be the same as those of laryngitis or bronchial catarrh j but it is difficult to explain in a satisfac- ON THE DISEASES OF INFANTS. 383 tory manner the immediate cause of the formation of the false membrane which occurs in this affection. It is almost always during the prevalence of epidemic catarrh, or hooping cough, that the croup is most rife; it precedes or accompanies one or the other of these phlegmasia?, and is sometimes even a compli- cation of them. M. Bretonneau has in vain attempted to sepa- rate the connection existing between the catarrhal affections and croup, and to controvert the opinions that have been held for half a century by Home, Rosen, Michaelis, and supported by Jurine, M. Double, Vieusseux, Royer-Collard, MM. Blaud, Valentin, Bricheteau, and Desruelles.* The physicians who, with M. Bretonneau, have maintained opinions opposite to those of the authors just mentioned, have endeavored to prove that there is something specific in the nature of croup ; but without admitting that there is any thing specific in it, the formation of the false membrane which characterizes it, may be explained to a certain extent. I have already considered this subject in detail, in an essay inserted in the "Archives generates de mede- cine" for the month of December, 1826. The following is the recapitulation of the reasons for believing it in our power to explain in what consists the peculiar nature of croup. 1st. There exists, as it were, but a degree between the thick, tenacious, filamentous mucosity with which inflamed mucous membranes cover themselves, and the membranous exudation of croup. 2dly. The membrane of croup presents nearly the same chemical elements as this mucosity where fibrin predomi- nates. We have already seen the same analogy between the pellicular excretion of muguet and the mucosity of catarrhal affections; so that the puriform mucosity of catarrh, the false membrane of croup, and the excretion of muguet appear to be but alterations of the same secretion, and vary only with respect to their form, and the parts they occupy. 3dly. Before this membrane appears, the mucous membrane is always much in- flamed, red, and gorged with blood: the subjacent tissue also participates in this injection, and when the inflamed membrane is at the same time the seat of sanguineous exhalation, this exha- lation is seen to be accompanied or followed by pellicular concre- tions, from which it is to be inferred that croup is a catarrhal * Traitc theorique et pratique du croup. Paris, 1824. 384 ON THE DISEASES OF INFANTS. phlegmasia, but that the blood destined to the secretion of muco- sity is, in the case under consideration, concentrated in greater abundance, or rendered plastic by inflammation, and imparts to the mucosity that portion of its composition which concretes the quickest, that is, the fibrin ; whence arise the stria?, pellicles, and white patches with which the mucous membranes affected with muguet or croup are covered. Children at the breast are much less subject to croup than those of a more advanced age. It is between the ages of two years to eight or ten that this disease is the most prevalent. Young infants, however, are liable to pellicular inflammations of other mucous membranes, such as those of the mouth, oesopha- gus, and nasal fossa?, whilst the opposite condition exists in chil- dren of more mature age. Age, therefore, and the.organic modi- fications which appertain to it, and which can more easily be understood from their effects than by their physical appearances, seem to produce a difference which ought to be noted, although we are unable to explain it. But on the other hand, the readiness with which symptoms of suffocation arise when the slightest inflammation is manifested in the air passages of young infants, render the ordinary tracheal and laryngeal affections almost as dangerous as croup: we should on this account watch with the greatest care the development and progress of the symptoms of laryngo-tracheal inflammation in infants. From what I have said of the greater frequency of croup at an age more advanced than that of the children whose diseases form the object of this work, I will not enter into a detailed his- tory of this disease, on which a number of monographs have been published ;* but will, therefore, only give succinctly the progress of the symptoms and the treatment of the disease. Symjrtoms.—When the pellicular formation occurs on the in- flamed surface of the larynx, the cry is altered ; the reprise only is heard; it is acute and sudden, like the crowing of a young * Consult, Home, Inquiry into the nature and cure of croup. Edinburgh, 1778. Michaelis, De angina poliposa seu membranacea. Arigentorati, 1778. Royer-Col- lard, Rapp. sur les Memoires Vieusseux, Jurine, Albersde Bremen, Caillau, Double. Desruelles, Traite du croup. Bland, Nouvellcs reserches sur laryngo-tracheite. Bretonneau, De la Diphtherite. Bricheteau, Precis analytique du croup. Also the excellent work of M. Valentin. ON THE DISEASES OF INFANTS. 385 cock; sometimes also it is even very much smothered. The cry proper is no longer heard except momentarily, or if renewed, is much altered. The cough which occurs in paroxysms, produ- ces in the child the greatest anxiety; the most painful efforts at inspiration are made, and it is then that the interval of the cry exhibits the characters of which I have spoken. The painful- ness of respiration is almost constant, but it is, besides, subject to very evident exacerbations and intermissions. To these symp- toms, the commencement and return of which are almost always sudden, is to be added pain in the larynx, of which infants at the breast are unable to indicate the existence in any other way than by continually carrying the hand towards that part, as if to re- move something—a distress which is always augmented when- ever there is an exacerbation of the cough; nasal hemorrhages, which are very rare in young infants, and consist rather of a sanguineous expansion than of true hemorrhage;-and lastly, drowsiness, which is a frequent and severe concomitant symp- tom of croup, indicating a cerebral congestion, or even the exist- ence of acute hydrocephalus, a lesion of very common occur- rence in infants that have died of croup. A greater or less quan- tity of the pellicle is rejected by vomiting and expectoration, when great relief is experienced, until a renewal of it again ob- structs the air passages, causing a return of strangulation, to which the child is every instant exposed. Death almost always suddenly terminates this frightful disease, against which the re- sources of art are too often powerless. Treatment.—Two distinct conditions present themselves in croup ; inflammation, which is the primary cause of all the other symptoms, and the suffocation, either mechanical or spasmodic, produced by the membrane which forms in the trachea and la- rynx. All the means which have been pointed out for the treatment of ordinary laryngotracheal inflammation—such as sanguineous evacuations, general, local, and cupping emollient drinks, topical emollients to the throat, revulsives to the skin and intestinal tube—should be actively employed from the commencement of this disease. Symptoms of suffocation arise not only from the mechanical embarrassment caused by the membranous formation, but like- 49 386 ON THE DISEASES OF INFANTS. wise from a kind of spasm of the larynx, as has been remarked by all authors. Therefore, while we attempt the removal of the membrane by emetics, it will, at the same time, be necessary to administer some antispasmodic, as an injection containing eight or ten grains of assafcetida, or a few drops of tincture of castor, or frictions on the throat, with a liniment composed of camphorated oil of chamomile, or what is still better, with a mixture of ether and water. There is still another remedy which must not be neglected, and the use of which M. Guersent strongly recom- mends.* It is a bath at the temperature of twenty-five degrees, (88° Fahr.) or more. Nothing calms the restlessness of the child more than this, who should be kept in it as long as possi- ble, taking the precaution to cover the bath so that the vapor which arises may not determine an afflux of blood to the head, which would be very injurious. It is almost ahvays necessary also to apply two or three leeches about the mastoidean region, to meet the symptoms of meningitis or hydrocephalus, which are sometimes observed in infants affected with croup. In addition to these means it will be well to apply a blister to the legs or thighs, or to rub the lower parts of the throat with ammoniacal liniment, or tartar emetic ointment. I saved a child of the age of fifteen months, affected with croup, by using for three days the various means which I have advised: after employing local bleeding and baths, and purged with calomel, I had recourse to syrup of ipecacuanha, which was quickly followed by an abun- dant expectoration and vomiting, discharging thereby a quantity of the membranous formations. This treatment was pursued for three days without intermission, when the symptoms of croup disappeared; the cry, however, continued hoarse. Subsequent observations have satisfied me of the advantages arising from the use of calomel administered in repeated doses from the commencement of the disease. It appears to act by augmenting and modifying the secretion of the mucous mem- branes, which are in this manner relieved of the membranous formation on their surface. There is still another circumstance upon which a great part ofthe utility of calomel rests in young infants who do not expectorate, but swallow all that accumulates * Article Croup in the Diet, de m6d., in 21 vols. ON THE DISEASES OF INFANTS. 387 in the back part of the mouth—calomel acting not only in de- taching the membrane, but also causes its expulsion by stool. It often happens that membranous formation is not passed in a tubular form with the foeces ; the fragments only appear, re- sulting from the division of these false membranes by the action ofthe mercurial salt, or from a kind of trituration which it ex- periences in passing through the organs of digestion. I have never employed calomel except in doses of eighteen or twenty grains in twenty-four hours, and have found it sufficient to produce the results intended. At the same time, I am parti- cular in directing purgative injections during the mercurial treatment, for if constipation should exist there is a great risk of salivation. Mercury usually produces abundant liquid and green stools ; it produces but little pain, and no augmentation of the general symptoms which accompany croup. M. Guersent often incorporates it with honey ; but I have remarked that the consistence of honey renders the deglutition tedious, especially in a young infant where the larynx and pharynx are obstructed by an abundant mucus. The retention of this thick substance in the vicinity of the air passages contributes also to render the re- spiration more suffocating. The following is the mixture in which I administer it. R Gum. Tragacanth. gr. x. Aquae destil. 5ij- Hydr. proto-chlor. gr. x. Syrup simp. " Ipecac, aa gr. x. Aquas Auran. 3j. This mixture is to be shaken every time it is to be given, and a teaspoonful of it administered every half hour. Yet I never have recourse to this therapeutic agent except in connection with direct antiphlogistic means, such as the applica- tion of leeches to the nei hborhood of the larynx and trachea, and the use of emollient drinks and topical applications. To recapitulate ; I have come to the conclusion—1st, That it is not hazardous to employ the proto-chloride of mercury in doses of eighteen or twenty grains in twenty-four hours in chil- dren affected with croup; 2dly, That this medicine powerfully seconds the effects of sanguineous evacuations; and while the lat- 389 ON THE DISEASES OF INFANTS. ter relieves the inflammation, the mercury expels the product of it from the system ; 3dly, That supposing it dangerous to admin- ister this medicine, it is better to risk this danger, than to aban- don the child to the greater danger of the disease with which it is affected. In all cases there is much less risk incurred in using the proto-chloride of mercury obtained by sublimation with aqueous vapor.* Is it necessary, as M. Bretonneau advises, to open the trachea and introduce a quantity of calomel or alum, to destroy and re- move the membranous pellicle ? My experience has not as yet sufficiently confirmed me in this measure, and I should not feel authorized in using it until after having made use of other and well-tried means, where only extraordinary measures are al- lowable, and, as Hippocrates says, where circumstances become desperate. I shall never forget the case of a young girl to whom I was called on the third day of croup. At first I had recourse to the most energetic antiphlogistic measures ; my efforts being without avail, and the child rapidly approaching her dissolution, her father, who was not ignorant of medicine, forced me, as it were, in his despair, to use the new means which had been re- cently advised in the treatment of croup. I curved a piece of whalebone and armed it with a pledget soaked with a concen- trated solution of alum, and introduced it into the larynx and trachea; but immediately the child, who was tolerably calm at the time, was seized with violent convulsions, and perished in my arms in less than five minutes. Although it was evident that this child would die, this distressing accident made so great an impression on my mind, that I resolved never again to intro- duce any medicinal substance into the irritated and inflamed tra- chea of an infant. Frictions, with mercurial ointment on the sides of the neck, or calomel given until an abundant salivation is produced, have likewise been employed with success. These means have ef- fected the removal of the false membrane, or entirely prevented its reproduction. As croup usually prevails epidemically, it will be necessary to * See my Mcmoire sur Vemploi du calomelas dans le trautment du croup et des an- gines pelliculcuses, (Arch. gen. demcd. t. xx., 1821).) See Appendix ON THE DISEASES OF INFANTS. 389 remove those children that are not affected with it, to places where it has not extended its ravages. (Edematous affection of the throat.—There is often found, on examining the bodies of children who have died with symptoms of an anginose affection, in place of a well-marked inflammation, a greater or less cedematous tumefaction of the laryngeal pa- rietes. The external signs of this affection are not easily recog- nised ; there is, as in inflammation of these parts, an alteration in the cry, but the other symptoms are less evident, as this cede- ma occurs in general among very feeble children, and who con- sequently do not exhibit a sufficient development of their func- tions to allow of their disorders to be appreciable. I have, how- ever, observed that children affected with cedema of the glottis, had, at the same time, an cedema ofthe cellular tissue in various parts of the body, and that the cry, very irregular, was almost al- ways husky and incomplete, and was also trembling, like the bleating of a goat. It is to this modification that I have given the name of " Chevrotant." I have seen this peculiar phenome- non produced in three infants affected with cedema of the glottis. I will give an instance of one of these. CASE LXI.—Francois Delau, aged two days, a very robust child, but with the integuments livid, and the legs and feet cedematous, en- tered the infirmary on the 13th of October; his cry was painful, smo thered, and trembling; it resembled that produced by the action of scraping the bow over the string of a violin. His limbs were cold ; pulse slow, small, and difficult to be felt. On the fourteenth, a general icterus appeared over the body. (Sweetened water, milk and xoater.) The extreme difficulty of respiration and the state of general conges- tion of this child induced M. Baron to apply a leech to each axilla. The congestion of the integuments diminished, but the face continued of a deep red ; the character of the cry continued the same. On the sixteenth, a violet-colored ecchymosis appeared suddenly on the right cheek, and extended even to the upper lip, which became the seat of a considerable cedematous swelling. The cry of this child con- tinued husky ; the pulsations weie slow, and so obscure that it was impossible to count them. Some thick, frothy, sanguineous muco- sity was passed by the mouth and nose. He died at night. Post mortem examination.—The mouth was healthy, but the glottis presented a considerable (edematous swelling; the lateral 390 ON THE DISEASES OF INFANTS. walls of the larynx were thick, white, and so tumefied, that they almost touched. On pricking them with the point of a scalpel, no water issued; the serosity was, as it were, a kind of jelly in the sub- mucous cellular tissue. There was a very marked congestion at the posterior border of each lung. The other organs ofthe body did not present any thing remarkable ; the liver was very much gorged with blood, and the bile abundant and black. There was in this case a remarkable coincidence between the cedema ofthe limbs, face, and glottis ; a relation not less intimate existed also between the circulation, and the serous infiltration of which we have spoken ; so that taking into consideration these different phenomena and the peculiar alteration of the cry in an infant whose external parts were cedematous, one might be led to suspect the existence of the disease we have described. It is only by grouping together the different physiological phenomena presented by a child, that it is possible to draw in like cases, if not a positive, at least a probable conclusion, for it is impossible to arrive at a degree of certainty from any isolated symptom. 1 have seen this affection in children of more advanced age, and who after having been reduced to a state of marasmus, pre- sented an infiltration in different parts of the body at the same time. In some of them the cry was husky, feeble, and incom- plete, but it never presented, in its tone, the peculiar modification which was observed in the preceding case. It would seem as if the "chevrotant" cry was either more rare or more difficult to observe in proportion as children advance in age. The treatment of this disease need not be directed exclusively to the part affected; we have seen that the cedematous angina in the child whose case is repeated above, was accompanied with a pulmonary congestion and extreme lentor of the circulation. Both these conditions must be met by appropriate treatment, which will be pointed out below. The effect will cease when the cause shall have been directly met. It is much more diffi- cult to treat and cure cedema of the glottis, which arises in in- fants emaciated and worn out by some chronic disease, because then the cedema is not always caused by an evident embarrass- ment of the circulation, or by the congestion of the blood in the respiratory organs. It will be necessary in such a case to attempt ON THE DISEASES OF INFANTS. 391 the resolution of the disease by the aid of dry or aromatic fric- tions, seconding the effect of these means by diet and regimen suitable to the condition of the child. I cannot advise the use of certain aromatic vapors introduced into the air passages, for the narrowness of the larynx and tra- chea, and the great disposition of young infants to spasm of these organs, naturally contra-indicate the employment of these means, which, as in adults, produce very uncertain, or perhaps very little effect. I will not stop to give a particular detail of the diseases of the trachea; the history of their symptoms is comprised in those of the larynx or bronchia?; besides, it is very difficult in young infants to make an accurate diagnosis between the diseases of the trachea and larynx. Section III. CASES OF THE THORACIC PORTION OF THE RESPIRATORY APPARATUS. I shall consider in this section diseases of the lungs, bronchia?, and pleura?. Development and congenital malformations.—I cannot dis- pense with the consideration of the development of the pectoral cavity, for if it perform an active part in the functions of respira- tion from its mobility, and as its alternate dilatation and contrac- tion very materially assist the dilatation of the lungs, its mal- formations must have great influence on the act of respiration. Hence I shall consider together the development of the thorax and lungs. The thorax at first is but a very narrow cavity, the walls are very thin, consisting of nothing more than a flexible pellicle, in the centre of which appear some semicircular white lines, which afterwards form the ribs. In proportion as the child advances in age, and the lungs are developed, the thorax becomes more spacious, its cavity is developed, more especially at the lower part, for at first the abdomen forms almost the whole ofthe trunk of the embryo; and upon its superior and lateral walls are seen two small, round, and slightly projecting eminences constituting 392 ON THE DISEASES OF INFANTS. the rudiments of the arms. The two sides of the thorax do not approach each other, to complete the thoracic cavity, for the thorax is always closed unless there exist some malformation. At the period of birth, the chest has acquired considerable di- mensions ; yet with respect to the abdomen, it is much less capacious than at a more advanced age, and especially than in the adult. During the time the pectoral cavity is acquiring an increase in iis dimensions, the lungs themselves have also passed through their different stages of development. About the sixteenth week, the lungs first appear; they are much lower than the heart, and it is said that in general they are less voluminous. I have been able to discern them in an embryo of six weeks, which I dissected with M. A. Danyau. The heart was of a globular form and about the size of a millet seed; and the lungs, instead of being smaller, were united at their lateral parts, under the form of two transparent vesicles, flabby and much larger than the heart, and hollow interiorly, as was proved by a magnifying glass. These two organs, closely pressed together, were supported by a very thin membrane which separated the chest from the abdomen, and which was evidently the diaphragm. When the lungs first appear, they have a smooth white surface; but in proportion as the child advances in age, grooves appear indicating the separation of the lobes, and then lines which mark the division ofthe lobes appear on the external surface of the lungs; next they are solid: the veins, arteries, and bronchial ramifications begin to grow; and their size in- creases at the same time that the pectoral cavity enlarges, they assume a rose color, and at the period of birth exhibit the ana- tomical characters which we shall now consider. From the seventh to the ninth month, the lungs possess nearly the form which they afterwards have ; but their color is different; and it varies in different children, for they are more or less pale or colored, according to the exsanguineous or plethoric condition ofthe subject. Some lungs exhibit red lichenoid spots on their surface, which would probably become slate-colored, as is ob- served on the surface of the lungs of an adult; others, on the other hand, are white, or of a faint rose-color; their color has a close resemblance to those of an ox or a calf. I have twice seen in ON THE DISEASES OF INFANTS. 393 adults this extreme paleness ofthe lungs. Is this kind of leuco- pathy ofthe lungs an effect of an alteration ofthe primitive con- genial color of the pulmonary tissue? I am much disposed to believe that this is the case. During intra-uterine life, the lungs fill the entire pectoral cavity, against the sides of which they press to such a degree as to receive the impress of the ribs, which are always more pro- jecting on the interior of the thorax in a child than in an adult. I mention here these depressions on the lungs in some infants, that it may not be considered an effect of a pathological condi- tion. I have noticed the same thing in the case of adults, and it is possible that these furrows were formed during intra-uterine life, and continued to an advanced age. If this be so, it ought not to be considered either in adults or infants as the effect of an accidental tumefaction ofthe oro-an ; and if the projection of the ribs in adults is not sufficiently evident to account for these de- pressions cr notches at the posterior border of the lungs, it is not difficult to account for this phenomenon, by referring it to a period of life when the ribs are more prominent, and that it has maintained the same appearance notwithstanding the progress of age. I have heard doubts raised by Professor Laennec, on the possibility of these pulmonary depressions by the ribs, because, he observes, the latter are not sufficiently projecting to cause these furrows: but the explanation which I have given ought to dissipate every doubt on this subject, and suffice to account for these furrows, which the author of mediate auscultation has regarded as chimerical. When the thorax of a child that has not respired is opened, one is struck with the analogy between the thymus gland and the two lungs; it would seem as if this body was a third lung, in which no bronchial ramifications appear. I note this resem- blance, because after birth the thymus gland, preserving still the same aspect, may serve as a point of comparison, and guide us in the examination which we propose to make of the tissue of the lungs when modified by respiration or not. The pulmonary tissue m which the air has not penetrated, is flabby and reddish like the tissue of the spleen; for notwithstanding the existence of the ductus arteriosus, which allows the blood sent from the heart to pass directly into the aorta, yet a certain quantity pene- 394 ON THE DISEASES OF INFANTS. trates the lungs, either by mechanical reflux, or that because this blood is necessary for the purpose of nutrition of the organ, so that the pulmonary arteries and veins are very frequently filled with blood at some distance from the pulmonary tissue. The bronchia?, usually of a pale rose, are sometimes colored by a slight sanguineous exudation. After birth the tissue of the lungs that have been penetrated by the air respired by the child, becomes lighter and crepitating, and always possesses more blood, all other things being equal, than the lungs of adults. 1 will here mention a phenomenon which it is important to note. In almost all young infants, there is found a very evident sanguineous congestion at the posterior border of the lungs, and especially on the right side.* But it is evident that this congestion is a true mechanical phenomenon, and I am'disposed to believe that the congestion occurring on the right side among the children of the Hospice des Enfans Trouves, arises from the common prejudice of the nurses in be- ing careful to lay the child in bed on the right side. Notwith- standing this congestion of the pulmonary tissue, the bronchia? are not always red, but are usually distinguished by their white appearance, contrasting strongly with the redness of the paren- chyma of the lungs. Having thus rapidly treated of the develop- ment and principal characters ofthe lungs in health, let us make a remark on the malformation of these organs and of the thorax. Both lungs, or one of them, together with one or both of the bronchia?, may be entirely or partially deficient in acephalous children. Otto, as quoted by Meckel, has observed the occlusion of the trachea with an absence of the cranium. An extreme smallness of one or both of the lungs, or a narrowness of the pectoral cavity, may occur ; or the abdominal viscera may be found in the thorax in consequence of malformation of the dia- phragm. The lungs, which present on one side two lobes, and on the other three, separated by deep fissures, may exhibit a unique mass without division, or divisions inverse to those which exist in a normal state, or, lastly, fissures more or less numerous. The inversion of the right lung to the left side, and vice versa, is usually found with an inversion ofthe heart. Finally, they may Professoi Chaussier has a long time since remarked this phenomenon. ON THE DISEASES OF INFANTS. 395 not be contained in the thoracic cavity when the walls of this cavity are incomplete in consequence of an original malforma- tion. Haller says that this malformation of the pectoral parietes is more rare than that of the abdomen ; yet he adds, " Sunt ta- men etiam exempla in quibus sternum costcequc imperfecta, cor emiserunt, ut nudum apparcret, quale in pullo est, qui primos dies incubationis experitur?* This illustrious writer quotes, in support of hiso pinion, cases reported by Baron, Bianchi, Fra- cassini, etc. Among these malformations, those of the pectoral cavity which may oppose a free expansion of the lungs in the act of respira- tion, will cause, in new-born children, symptoms of a nature more or less serious. It can be easily conceived that when a congeni- tal diaphragmatic hernia exists, and the stomach, omentum, or intestines are introduced into the thoracic cavity, a considerable obstacle will exist to the proper dilatation of the lungs, and give rise to a variety of symptoms. It is not necessary that there should be so great a malformation in that cavity to produce an evident disturbance in the functions of the respiratory appara- tus; the simplest malformation will sometimes give rise to symptoms that would almost lead to the belief that they were the result of a lesion of the bronchia?, pleura, or lungs. These symptoms may perhaps be little apparent at the period of birth, but in proportion as the child advances in age, and the functions of respiration become developed, and the necessity of a greater expansion of the parietes of the thorax arises, when they are too narrow, or too much depressed, they oppose the dilatation of the lungs, producing symptoms which might be attributed to some lesion of the lungs or bronchia?, if post mortem examinations did not prove their integrity. CASE LXII.—Malformation of the thorax, dyspncea.—Andre Alpin, aged ten months, entered he infirmary on the 14th of Au- gust. This child was pale and thin; the chest exhibited at the sides a considerable depression ; the limbs were long, and the arti- culations were very large ; there existed the commencement of a gib- bosity at the dorsal region ofthe vertebral column ; the abdomen was constantly swelled. This child had been affected for three months * Opera minora—De monstris, chap. v. 396 ON THE DISEASES OF INFANTS. with a continual cough and dyspnoea, which increased whenever he was laid down upon the back, or moved about. His sleep was often interrupted by a sudden choking, which ceased almost im- mediately upon raising him. The heat of the skin was very great and burning; the pulse was small, thready, and frequent; per- cussion gave only a dull sound. (Linctus, gummed marshmal- low water, milk and water.) On the sixteenth, the same general state continued ; cry painful and short. On the seventeenth, rest- lessness ; violet tint of the face, cry plaintive, face painful, pulse quick, heat burning. (Four leeches to the base of the thorax, sinapism to the feet, gummed marshmallows, diet.) After this, the child presented nearly the same appearance ; he did not ap- pear to have experienced much relief from the application of the leeches ; he became pale, was less restless, respired with difficulty, and died on the 23d of August. Post mortem examination.—The oesophagus was healthy; the mucous membrane of the stomach was of a brown color, and con- tracted in wrinkles ; an abundant mucosity existed in the small in- testines, the internal membrane of which was thick, soft, and color- less ; a tumefied follicular plexus of a slightly red color existed in the inferior third of the ileon, and a follicular eruption in the colon. The lungs and bronchia? were perfectly healthy; but they were closely compressed by the walls of the thorax, the transverse diameter of which was very small. The fcetal openings were obliterated ; the cerebral substance was healthy; yet there existed a large quantity of serosity in the lateral ventricles. The dyspnoea, and the cough which accompanied it in this child, therefore were the effect of the little development of the thoracic cavity, for there was neither bronchial catarrh, nor pneumonia, although the existence of these diseases was sus- pected and the patient treated accordingly. M. Dupuytren has published an interesting essay on this sub- ject, in the fifth volume of the Repertoire general d'Anatomie. He has frequently observed a swelling of the tonsils in these children which he has even been obliged to cut out. § I. DISEASES OF THE PLEURA, LUNGS, AND BRONCHIA BEFORE BIRTH. Diseases of the pleura, lungs, and bronchize may be separated ON THE DISEASES OF INFANTS. 397 into those which arise during intra-uterine life, and such as manifest themselves afterwards. Congenital pneumonia and pleurisy.—Inflammation of the pleura and lungs may occur before birth. Some accoucheurs, and among others Mauriceau, have given instances of its occur- rence. I also have often had opportunities of proving this fact. In three children that died on the day after birth, I found an alteration sufficiently advanced to satisfy me that the disease had commenced while the child was in the uterus. In two particu- larly, the left lung was strongly hepatized at the. base; and if this alteration in the tissue did not exist during intra-uterine life, it probably was developed during birth or immediately after. This affection always interferes with the establishment of respi- ration, and consequently causes the death of the child. The following case is an interesting one in reference to this subject. CASE LXIII.—Congenital pneumonia.—Larche, born during the night, was placed, on the 2?th of January, 1823, in the "Creche" of the Hospice des Enfans Trouves. He was sent immediately to the in- firmary, in consequence of his extreme feebleness ; he was small, pale, and thin ; the face became purple every moment; respiration was slow and difficult, and the pulsations of the heart very obscure ; the chest on percussion gave a dull sound. He continued in the same condition for three days, and died on the thirtieth. On a post mortem, examination the digestive apparatus was found healthy ; the large intestines filled with meconium ; the left lung was crepitant and slightly engorged with blood ; the right lung was he- patized in almost all its extent; there existed at its base, a spot about the size of a large nut, where the pulmonary tissue was reduced to a red pultaceous mass ; the bronchia? were red and thickened, and contained a quantity of thick puriform mucosity, mixed with streaks of blood. The heart was gorged with blood ; the ductus arteriosus was open, and the foramen ovale had begun to close ; the cranium was not examined. It is evident that this advanced disorganization of the lungs was an effect of pneumonia existing at the time of the birth of the child. The state of marasmus, extreme feebleness, and dif- ficulty of respiration, were the result of this congenital pneumo- 398 ON THE DISEASES OF INFANTS. nia, the increasing progress of which arrested the first phenomena of life. A simple pulmonary congestion may occur in an infant during its sojourn in the uterus, and give rise, at birth, to an impediment to the introduction of air into the lungs, and consequently pre- vent the establishment of respiration. Pleurisy may also be developed before birth, as may be seen by the following example: CASE LXIV.—Congenital pleurisy.—Henriette Sauvace, aged two days, entered the infirmary on the 4th of October. She was pale and thin, and respired with great difficulty; the pulse was of a remarkable irregularity; the expression of face was every moment very much altered; the chest gave a dull sound on the left side, and the air could scarcely be heard with the stethoscope to penetrate the lungs at the superior part of the thorax. (Gummed barley-water, abstinence from the breast.) On the fifth, the child was in the same state, and on the sixth she died. On opening the body, both the costal and pulmonary pleurae were found spotted, of an obscure red. This membrane, particularly at the part where it lines the ribs, ex- hibited considerable thickness, and there existed between it and that of the lungs, cellular adhesions, as solidly organized as they are often found to be in adults eight or ten years after the existence of pleurisy. The pleura also presented a number of small granulations, and there were also adhesions much more recent than the preceding, for they were still of an albuminous consistence. The pulmonary tissue of this side was much engorged; the festal openings still existed ; the brain presented nothing remarkable ; in the ileo-ca?cal region there were found fifteen very projecting dark-colored follicular plexuses. This child, then, was born with chronic pleurisy, which was doubtless the cause of the extreme feebleness, for which, per- haps, it might have been thought necessary to administer tonics, whilst in truth the first thing required would be to attempt to combat the phlegmasia which so quickly terminated her life. The facts which I have stated prove the possibility of an in- fant being born with congenital pneumonia or pleurisy, and they ought to direct our attention to searching for the causes of fee- bleness of birth, in order to render the proper attention to young infants. ON THE DISEASES OF INFANTS. 399 § II. DISEASES OF THE LUNGS AND PLEURA DEVELOPED DU- RING OR AFTER BIRTH. If a disturbance of the functions of an organ constitutes a dis- ease, the difficulty or impossibility of the establishment of these functions ought also to be regarded in the same light. It is not only when an anatomical lesion or a physical cause, appreciable by our senses, suspends the physiological exercise of an organ, that art should be resorted to.; it is sufficient that any obstacle to the development of life should exist in the different parts of our bodies, for us to require assistance from the different means which science places at our disposal, for the removal of immediate or remote causes which oppose the free development of our func- tions. The lungs of a new-born child, which, during intra-uterine life, are only organized in a manner suitable for the reception into their cells of the air and blood which are to pass into them at the beginning of independent life, present to our notice, at the period of birth, phenomena worthy of attention. For the most part, they at once and without embarrassment fulfil their new functions ; at other times, respiration is not established, and the air does not reach the pulmonary cells. M. Capuron has re- marked, with much reason, that very different states of the Cir- culatory and respiratory apparatus which prevent the establish- ment of life, have been vaguely denominated asphyxia.* I will designate then the condition of new-born children now under consideration, by the title of imperfect establishment of respira- tion. The experiments of Haller, and those more recently made by Beclard,t have demonstrated that the child, during its sojourn in the uterus, exercises in the midst of the waters of the amnios movements of inspiration and expiration ; of course no air can enter during this first act of the respiratory apparatus. It is also possible that these movements continue after birth with too little energy for the air to enter the lungs, either because the cells of this organ do not dilate, or that the bronchia? are closed with mu- * Capuron, Traitc des maladies des enfans, p. 14. t Dissertation inaugurate. 400 ON THE DISEASES OF INFANTS. cosity, more or less thick, adherent to their sides. Yet the child may live in this condition some hours, or even days ; and if the lungs be examined after death, not the least trace of air will be found in them. I have had the opportunity of examining six infants who had lived without air having penetrated their lungs in sufficient quantity to prolong their lives. They were all remarkable for extreme feebleness, the slowness of their movements, the peculiar alteration of their cry, which consisted only of an acute hiccup. CASE LXV.—Three children born at one birth, were brought to the Hospice des Enfans Trouves on the 21st of October, 1826; the smallest, who was a female, attracted my attention by the slowness of her movements, her sinking condition, and the peculiar nature of the cry, which consisted only of an interrupted sound of the re- prise. The chest did not rise or fall regularly, and gave, on per- cussion, a dull sound in all its parts ; the stethoscope did not detect the sound of respiration. The heartbeat fifty times in a minute. A few spoonfuls of sweetened water were given ; she was kept warm, and dry frictions were applied to the chest; the child, however, died eight hours after birth. The post mortem examination was made the next day. The um- bilical cord was found still soft; the trachea having been tied at the larynx, the heart and lungs were immersed in water; they at once sunk to the bottom of the vessel; yet their tissue was not engorged ; the right lung only at its posterior border presented a slight conges- tion. Each lobe was then separated and placed in water, and sunk to the bottom with equal quickness. The heart was filled with blood ; the foetal openings were still free. Respiration, therefore, was not established in this child, or at least the air had only penetrated to the commencement of the bronchia?. Death ensued not from asphyxia, but from defect in the establishment of respiration. It is not usual to meet with so complete an absence of air in the lungs of infants, who, like the one just mentioned, live for some time, as it were, the embryo life, either becaus? the blood preserves its vivifying principle which it received from the mo- ther, or that the oxygen of the air absorbed by the skin or mu- cous membranes penetrated into the circulation, or that this es- ON THE DISEASES OF INFANTS. 401 sential element of life is not at this time of so great importance as it is afterwards. A great portion of the lungs is found destitute of air in those infants who, far from exhibiting a general conges- tion, as is the case in true asphyxia, present, on the contrary, an excessive paleness and debility. This is the condition that really merits the name of feebleness of birth, and which it is necessary carefully to avoid treating by bleeding. The child ought to be placed in such a position as to leave the mouth and nose uncovered, and in a situation to receive a cur- rent of fresh air. Dry or aromatic frictions should be used on the thorax, and care must be taken to prevent the clothes from being tight around the thorax or abdomen. The child must be fed with a spoon instead of the breast, for sucking will be ex- tremely difficult when respiration is not completely established. Asphyxia, properly so called, ahvays coexists with a greater or less congestion of the heart and large vessels; the air some- times passes freely into the lungs at the period of birth, but the sanguineous congestion which occurs immediately, expels it or hinders it from penetrating in sufficient quantity to effect a com- plete establishment of life. There exists, as is well known, be- tween the circulation and respiration, an intimate and reciprocal relation, which is evident during life, but more particularly so at the time of birth. Some children are born in so great a state of plethora, that all their organs, especially the heart, liver, and lungs, are affected with congestion to a considerable degree, and this congestion increased in the lungs by the restlessness and cries of the child, and perhaps by the respiration of heated air in a small room, warmed by a stove, the suspension of respiration and a true asphyxia may follow. The face under these circum- stances is usually purple, the pulse scarcely perceptible, and the cry smothered. Many children born in this condition, make at first some movements of inspiration and expiration, utter some sound, and remain in a state of asphyxia. Others are born in- animate, do not respire, and the air does not penetrate the lungs because the air cells are tilled with blood. This state of turges- ence occurs most often in cases of difficult and protracted labor, and the best means to relieve it is to allow the blood to flow from the umbilical cord as much as possible. The utility of this pre- caution is so apparent, and so naturally occurs to the mind, that 51 402 ON THE DISEASES OF INFANTS. it has become a daily practice, and on this account hardly needs to be recommended here. The custom of endeavoring to excite the cries of the child in order to effect a movement of the thora- cic parietes and of the lungs, ought to be condemned : for possi- bly during the act of crying the movements of the heart are quicker, and the blood may flow in great abundance towards the lungs. It would be better, I think, if this state continue, to apply one or two leeches to each axilla, and to use cautiously dry or aromatic frictions to the thorax. If tonic bathing is necessary, it would be more useful in the preceding case than in true as- phyxia ; let us, therefore, endeavor to distinguish from each other the various causes which oppose the establishment of re- spiration in new-born children, and only use with discernment the means proper for the treatment of those effects which re- sult from them. We must not neglect to satisfy ourselves that there is not an accumulation of serosity in me larynx and bronchia?, which will -become an obstacle to the establishment of respiration, and if it be found to exist, it must be removed with the fingers or a feather, to effect a free passage to the air cells. Such, in general, are the symptoms which appear on the part of the lungs during birth ; we shall now investigate the diseases with which the lungs, bronchia?, and pleura, may be attacked af- ter birth. Art. 1.—Congestions and Pulmonary Apoplexy. The lungs may, after birth, often become the seat of considera- ble congestions, producing the most serious consequences. The anatomical characters of those congestions vary from a simple sanguineous infiltration to a complete pulmonary engorgement. It is difficult sometimes to draw the line between the effect of a congestion, and that produced by an inflammation in the pulmo- nary tissue. Yet the following are some ofthe anatomical char- acters of congestion, or pulmonary engorgement, in young in- fants. That the pulmonary tissue which the air has not penetrated may not be confounded with that which is engorged or hepatized, it will be necessary to remember the observation already made of the striking resemblance between the thymus gland and the ON THE DISEASES OF INFANTS. 403 lungs of an infant that has not respired. This comparison ought to be made in order to assure ourselves of the state of the luno-s in a post mortem examination, when it is supposed that the child has not breathed. Engorgement is more frequent at the posterior part of the lungs, and at the Hospice des Enfans Trouves it is found more often in the right than in the left lung. The tissue of the organ preserves its texture and solidity; it is only infiltrated with a large quantity of blood, and is easily deprived of its color when immersed in water; sometimes it happens, but not always, that the bronchia?, in the midst of this engorged tissue, are red and covered with a sanguineous exudation. Pulmonary engorge- ment is almost always accompanied with a sanguineous conges- tion ofthe heart and large vessels, a circumstance which it is ne- cessary to remember when we wish to distinguish engorgement from hepatization of the lungs. The causes of engorgement almost always arise from some disturbance to the course of the blood through the heart and large vessels. It sometimes continues for a long time after birth, and appears to be the remote result of a stagnation and super- abundance of blood in the heart and lungs during birth. The symptoms of pulmonary engorgement in an infant are, in general, very obscure, and consequently difficult of observation ; yet we may point out the following: The respiration is labored ; the thoracic parietes are not perfectly developed ; the face is pur- ple ; the general color indicates a sanguineous plethora in all the organs; the cries are obscure, painful, and short; percussion yields a dull sound, especially if, instead of striking the anterior part ofthe chest, the child is exposed, and, as it were, suspended, by the anterior part ofthe chest being applied to the hand, while small blows are struck on the back and lateral parts of the tho- rax with the index or middle finger of the other hand. M. Ba- ron uses this kind of percussion with great skilfulness ; the faci- lity he has acquired of distinguishing the different sounds in the chest, enables him often to make very accurate diagnosis on the diseases of the thorax in very young infants. The importance of this species of examination cannot be too much impressed on the minds of practitioners, for in infancy it is much more useful 404 ON THE DISEASES OF INFANTS. than mediate auscultation, especially when there exists a sim- ple pulmonary engorgement. The treatment of this affection being the same as that of pneu- monia, of which it is often the first stage, we must refer to the history of that disease for the necessary details of the manage- ment. Pulmonary congestion or engorgement may be the cause of se- veral affections or lesions in the tissue of the lungs, but more especially of pulmonary apoplexy. Pulmonary apoplexy.—This is of more common occurrence in new-born children than in adults or old people; the frequen- cy of congestion of the lungs at this period of life, satisfactorily explains this fact. It consists of an effusion of blood circum- scribed in the middle of the tissue of the lungs; it may occur suddenly or slowly, according to the abundance of blood flowing towards the organ and the intensity of the cause which deter- mines this afflux. This disease, first pointed out by Laennec, has since been described by M. Gendrin and M. Bouillaud, who have published some interesting observations on the subject.* I have often met with it in young infants, and M. Denis has also mentioned it in his work. I will here give some cases of it. CASE LXVI.—Francoise Redon, aged three days, entered the in- firmary on the 20th of April, for a diarrhoea accompanied with icte- rus diffused over the whole body. On the twenty-sixth, the child became very feeble, and passed an abundance of green matters from the bowels. On the twenty-eighth, he vomited the drinks; the cry was smothered, and the chest was sonorous only on its right side. On the 3d of May, the same general state continued, but the face was puffed, and the icterus had disappeared; death occurred at night. The internal membrane of the glottis was found intensely red, with a slight pellicular exudation. The right lung was crepitant; the left was so at its circumference ; but in the centre of its tissue there were found three small circumscribed sanguineous effusions; the pulmo- nary tissue was hard, and, as it were, hepatized at its circumference. CASE LXVII.—Auguste Bonnet, aged two days, had not ceased * Observations pour scrvir a Vhistoire de Vapoplexie pulmonaire, by J. Bouillaud, Archives generates de med., 1826. ON THE DISEASES OF INFANTS. 405 crying since his birth ; he was feeble and small, and affected with icterus ; the temperature of the body was very low ; at every mo- ment he was seized with suffocation, which threatened his death ; the face became purple and puffed; the cry was almost entirely stifled ; the pulsations ofthe heart were tumultuous and irregular ; respiration could not be heard except at the upper part of the thorax, and it gave, on percussion, a dull sound in almost every part; the same state continued until the 3d of October, when the child died while vomiting frothy and bloody matters. Post mortem examination.— Extensive congestion of the base of the tongue and thyroid gland ; the same condition of the oesophagus ; a well-marked injection of the intestinal tube, which was covered in- teriorly with thick mucosity ; the liver was gorged with blood ; the bile was clear and not very abundant; the left lung was crepitant, although infiltrated with a quantity of blood ; the right lung appear- ed black externally ; when immersed in water it soon sunk to the bottom of the vessel, ^and when cut a large quantity of blood was found effused in clots, and separated by intervals where the tissue of the lungs did not crepitate, and consequently appeared not to have been penetrated by air ; the foramen ovale was obliterated, and the ductus arteriosus was still open ; the bronchiae were full of bloody mucosity, which even extended to the.trachea and larynx; there was but little serosity in the ventricles of the brain, the substance of which was yellow and a little softened. It is evident that, in these two cases, the suffocation, the gene- ral condition of the children, the alteration of the cry, the swell- ing and purple color of the face, and finally death, were caused by the sanguineous effusion in the pulmonary tissue, which the air had with difficulty penetrated. In a third child exhibiting the same symptoms, aged ten days, I found a much greater lesion in the pulmonary tissue, for in the right lung there appeared two large spots of black liquid blood, around which the pulmonary tissue had begun to soften ; the foetal openings were still free, and the right cavities of the heart were more dilated than the left • the brain was much engorged with blood. We may therefore conclude from the preceding facts, that pul- monary appoplexy may succeed congestion ofthe lungs, or may accompany this condition ; that the most prominent symptom is a suffocating cry; that percussion indicates the absence of air in 406 ON THE DISEASES OF INFANTS. the affected lung, and that there is sometimes an expulsion of bloody mucosity. The first indication to be fulfilled is the abstraction of blood, which can best be done by the application of one or two leeches under each axilla; the subcutaneous venous plexuses in this region communicate directly with the vessels of the thoracic ca- vity, and are thus convenient for the sudden evacuation of blood from the affected part. It is of the greatest importance to avoid clothing too tightly a child that presents these symptoms, either at birth or at a more advadced age, for by impeding the dilata- tion ofthe thorax, there is danger of augmenting the congestion. As to other and subsequent treatment, they will be found under the head of pneumonia. Art. 2.—Pneumonia. Pneumonia of infants exhibits peculiar characters, in which it differs from the same affection in adults. Instead of being an idiopathic affection, arising from irritation developed in the pul- monary tissue under the influence of atmospheric causes, which often excite this disease, the pneumonia of young infants is evi- dently the result of a stagnation of blood in their lungs. Under these circumstances, this blood may be regarded as a kind of for- eign body, and it concurs in producing an alteration in the pul- monary tissue with which it combines, and is identified with it so as to form what is called a hepatization of the lungs. In proof of this, it is known that pneumonia almost always follows con- gestion or engorgement of the lungs, and as this engorgement is more frequent in the right lung than in the left, and at the poste- rior border of the lungs than in any other part of the organ, pneumonia appears much more frequently in the right than left lung; at least it is so with respect to the children which I have examined at the Hospice des Enfans Trouves, who are always placed at rest on the right side. It would therefore appear that inflammation ofthe lungs which produces hepatization, arises, in infants in general, from some mechanical or physical cause, whilst this is not the case in adults; besides, the inflammation of the lungs is ordinarily very circumscribed, and is found almost ahvays confined to a point primarily engorged, and the pleura, ON THE DISEASES OF INFANTS. 407 which, in the greatest number of instances, is inflamed at the same time with the lungs, at a more advanced age, is not affect- ed in young infants. The inflammation, once developed, may give rise to various alterations of tissue, the shades and different degrees of which vary from simple hepatization to a great disorganization of parts. We will commence by detailing cases. CASE LXVIII.—Emilie Tavenne, aged five days, entered the in- firmary on the 20th of September; she was small and feeble; the integuments were very red; had a diarrhoea of yellow and green matters ; the cry was feeble, and at times could scarcely be heard. (Gummed rice water, starch injection, milk and water.) On the twenty-second, the face became livid, and expressive of pain ; the ala? of the nose were drawn outward, and they were surrounded with a violet-colored circle ; the cry was painful, and almost always husky; the thorax gave a dull sound on the right side, where respi- ration could not be heard. (Gummed decoction of marshmallows, sinapised pedeluvium.) On the twenty-third, there appeared to be no febrile reaction ; the limbs were cold and cedematous ; the pulsa- tions of the heart were so obscure that it was impossible to count them. The child died on the twenty-fourth. On opening the body, red streaks were found in the stomach and at the commencement of the small intestine, and fifteen follicular plexuses, red and tume- fied, at the inferior portion of the ileon. The commencement of he- patization appeared in the left lung at its superior lobe; the right lung was hepatized throughout its whole extent; its pieces, when cut, did not present a true cellular texture, and sunk rapidly to the bottom of the water; the pleura was perfectly healthy; the foetal openings were obliterated; the bronchia? were red and filled with blood ; the brain and meninges were very much injected. It will be observed that there was no symptom of reaction in this child, but the local symptoms were very well defined, and not severe. It is then to the latter, that the physician ought to direct his attention in order to make a correct diagnosis of the disease. The subject of the following case was more advanced in age, and the symptoms present a new character, which are to be attributed to the modifications which age produces in the organization. 408 ON THE DISEASES OF INFANTS. CASE LXIX.—Josephine Oudon, aged seven months, entered the infirmary on the 13th of June, for a gastro-intestinal inflammation developed five days after having been vaccinated, which however yielded to the application of three leeches to the epigastrium, bath- ing, and demulcent drinks. While convalescent from this disease, she was on the twenty-second of June, suddenly attacked with a frequent dry cough, accompanied with great restlessness. There occurred at the same time an intense redness on the left cheek ; the skin was burning ; the pulse very frequent; respiration laborious, without any rale ; the cry which was constantly husky, became stifled whenever the child had cried much; the face changed color, became pinched, and appeared also to swell and to become purple whenever the child began to cry. (Three leeches to the upper and lateral parts of the thorax, gummed barley-water.) The leech-bites bled copiously, and produced syncope. On the twenty-eighth, blood oozed from the left eye. In the evening of the 1st of July, there supervened fever and restlessness, accompanied with a slight cough, without expectoration ; there exjsted no rale ; the thorax was dull on the left side. From this time to the 10th of July, the same symptoms continued ; the child gradually sunk ; the pulse became threadlike and yery fre- quent ; and the face was covered with petechial spots which con- tinued several days. The same state continued until the period of death, which took place on the eighteenth. Post mortem examination.—There was great emaciation and uni- versal paleness; the stomach was colorless, but without being soft- ened ; six follicular plexuses, of a very intense red, were found at the extremity of the ileon, which was also very much injected to the extent of eight inches; the right lung was hepatized at the posterior border, and the whole of the inferior lobe of the left lung was in the same state. It presented a smooth surface when cut, and the pieces which were not cellular, and which could be pressed between the fingers without yielding any blood, fell like a stone to the bottom of the water. The bronchial ramifications were filled with slightly red and frothy mucus ; the trachea was healthy ; the heart and brain presented nothing remarkable. We have seen in this child not only the local symptoms of pneumonia, but also those which ordinarily produce febrile re- . action occasioned by phlegmsia? ofthe principal viscera. Cough, which was absent in the former case, was in this added to the ON THE DISEASES OF INFANTS. 409 other symptoms; but, as in the other instance, there was no ex- pectoration, which indeed is impossible, or at least very difficult in young children ; they vomit much sooner than they expecto- rate, a phenomenon produced almost always by the sudden action of the diaphragm on the stomach, on coughing. The ex- amination of the organs also enables us to discover nothing more than simple pneumonia, without the complication of pleurisy, which, I repeat, is very common in young infants. Abscesses in the lungs caused by pneumonia is very rare in adults, where suppuration is not usually observed to exist, in a circumscribed spot or focus, but disseminated and infiltrated in the tissue of that organ ; pulmonary abscess is equally rare in infants ; yet they may occur, as may be seen by the following case. CASE LXX.—Theophile Champion, aged three months, had been twice in the hospital since birth: the first time for an cedema of the limbs; the second for enteritis with green diarrhoea, compli- cated with a cough. These symptoms, however, yielded to simple means, and the child was confided to the care of the ordinary nurses; but on the 2d of March, he entered the infirmary for the third time. He was pale and very thin. There was no diarrhoea; the abdomen was tympanitic, but without pain. He was affected with constant cough, and the respiration was loud; the thorax re- sounded badly throughout, although it did not give a positive dull sound in any part. (Sweetened barley-water, milk and water.) On the 10th of March, he appeared to be much better, or at least the re- spiration was more free ; the cough however continued, although he had no fever; on this apparent improvement, the nurse took charge of him; but the cough returned the same night, accompanied with suffocation, and the cries of the child, which could be heard only for a moment, expressed the greatness of the suffering. He re-entered the infirmary at eleven in the morning ; the cough was frequent and dry, the face purple, the ala? of the nose drawn outward, and were surrounded by a blue circle, which was also observed at the root of the nose ; the cry was plaintive and distressing; the left side of the thorax gave a dull sound, and the respiration could not be heard; the limbs Avere cold and the pulse small and irregular. (Milk and water, sinapism to the feet.) On the thirteenth, the eyes became hollow; the respiration was hurried, and the other symptoms con- 410 ON THE DISEASES OF INFANTS. tinued the same. The same condition continued umil the sixteenth, when death occurred towards evening. Post mortem examination.—The stomach showed a white soften- ing in its whole extent, and near the cardia exhibited several super- ficial erosions. The same state existed throughout the whole ex- tent of the intestinal tube, which was covered with yellow porraceous matters. The liver was healthy, but the gall-bladder was filled with black viscid bile. At the base of the left lung, there was a collection of pus about the size of a filbert, white and thick, but without odor ; the internal surface of the cavity containing this pus, was even and red, but did not appear like a cyst. The right lung was healthy; the foetal open- ings were obliterated; the brain was healthy, but the meninges were injected. We have reason to think that this child had been affected with pneumonia for a long time, with symptoms obscure, it is true, but which were sufficient to fix the attention of the physician ; the nurses who only observed in this infant the paleness and de- bility, withdrew him from the care and attention of the physician, when they discovered what they believed to be a melioration of the symptoms, which could only deceive persons unaccustomed, as they were, to the art of observing the sick. The inflamma- tion had made a slow but steady progress until suppuration oc- curred in the affected organ. This case proves how necessary it is to be constantly on our guard in cases of obscure phlegma- sia?, which in infants, much more often than in adults, may produce the most serious lesions without a suspicion of such an event on the part of the physician. I have seen in the dead body of an infant, aged twenty days, that died without exhibiting any evident symptoms of pneumonia, the right lung hepatized in almost its whole ex- tent, together with three white, soft, and elastic projections on the base of this lung and on its middle lobe, which on being opened discharged a quantity of air, and immediately collapsed. They were formed by a very thin cyst, which contained white, inodorous, thick, and stringy pus. The internal surface of these cysts was red and granulated ; it was confounded posteri- orly with the tissue of the lungs. The bronchia? did not open into them: they were inflamed, and small drops of pus, like that ON THE DISEASES OF INFANTS. 411 just described, oozed out on pressure. The other organs pre- sented nothing remarkable. It is evident that this suppuration of the bronchia?, and the abscess of the lung, were the result of a latent phlegmasia, the symptoms of which had escaped my observation, not having bestowed sufficient attention for that purpose. Inflammation of the lungs may not only produce hepatization and suppuration, but also its softening or disorganization, which is noticed also to arise under the influence of inflammation in other organs. CASE LXXI.—Rony was exposed immediately after birth, on the 7th of February, at the Hospice des Enfans Trouves. He was im- mediately placed under the care of a nurse, and took the breast with eagerness ; he soon stopped sucking, beeause he appeared to become smothered every instant; the face became purple; he attempted to cry, without being able to do so. He was fed with a spoon. This condition continued the same, but in addition to the other symptoms, he vomited almost continually; had a smothered cry ; the stools were natural. Death occurred on the eleventh. As this child was not sent to the infirmary, I was unable to observe him very closely, but it was from the relation of the nurse that I obtained the foregoing account. On examining the body after death, I noticed the com- mencement of the discoloration of the mucous membrane of the in- testines ; the heart, liver, and large vessels were filled with blood; the left lung was considerably filled with blood at its posterior bor- der, which was found in a state approximating to hepatization, while the remainder was reduced to a reddish, diffluent, soft mass. This mass yielded no odor of sulphuretted hydrogen, and when diluted with water exhibited grayish pulpy clots, which appeared to be the effect of the disorganization of the lungs. The bronchia? were a little more red in their remote branches ; they were healthy and white where they first diverge. The right lung was simply en- gorged. This disorganization of tissue appeared to me to be the result of pneumonia, which, perhaps, had succeeded a passive conges- tion, as is often observed in new-born children. Whatever may he the cause, it should convince us of the necessity and impor- tance of observing the symptoms of pneumonia in young infants, 412 ON THE DISEASES OF INFANTS. since this disease may, even at this age, be followed with fatal effects. Before exhibiting the general assemblage of symptoms of pneumonia, let us study the disease as complicated with pleurisy. Pleuro-pneumonia.—I have already remarked that this was much more rare in infants than in adults. It is principally in children that are somewhat advanced in age, that it is to be found ; the disease is then, not the effect of pulmonary conges- tion, as in simple pneumonia of new-born children, but is the result of the direct or remote action of the atmosphere, or of other external causes. CASE LXXII.—Pleuro-pneumonia.—Honore Lucet, aged five months, entered the infirmary on the 5th of May. He had already a month previous been admitted for enteritis, which had been cured. He nevertheless continued pale and thin. He was now affected with considerable tension of the abdomen, and vomited all his drinks: the respiration was labored ; but the cry exhibited no alteration, but had become weakened by its frequency. On the. sixth, the face as- sumed a painful expression, and from being habitually pale, became livid ; the vomiting did not cease. On the seventh, there was great restlessness ; the limbs became stiff, and remained in a state of spasm; the cries could scarcely be heard ; the chest gave a dull sound on the right side, but resounded well on the left; the pulse was slow in the morning, but in the evening it rose to one hundred and forty beats in a minute ; a general sweat supervened, and the limbs, which during the day had remained contracted, again became flexible. (Milk and water, four leeches to the leftside ofthe chest.) On the eighth and ninth, there was a slight melioration of symptoms, for the cries and xestlessness of the child were less violent; but on the tenth, all the symptoms returned, and the face bore the expression of extreme suffering. On the eleventh, a layer of muguet appeared on the buc- cal parietes, and on the twelfth, the child expired. Post mortem examination.—There was a white softening of the whole of the intestinal mucous membrane, redness of the glottis, a healthy state of the trachea, and a hepatization of the right lung in its entire extent. Between the two pleura? of this side, there were adhesions which already possessed some degree of firmness; there was but a small quantity of sero-purulent fluid effused in the cavity ON THE DISEASES OF INFANTS. 413 ofthe thorax; a part ofthe right lung was of a gray slate-color; in the centre there appeared a reddish softening, and the bronchiae of this lobe alone contained puriform mucosity ; the brain was healthy, and when cut, exhibited a smooth, firm surface; neither the spinal marrow nor the meninges exhibited any appreciable alteration. This child, with the exception of the excessive pain which he had experienced, and of which the contraction of the limbs was perhaps the secondary effect, exhibited no other symptom than those of pneumonia; so that it seems to me very difficult to distinguish pneumonia from pleuro-pneumonia in very youno- infants. This distinction, however, is not of much utility, since the treatment ofthe one is perfectly applicable to the other. We are now able to recapitulate the symptoms of pneumonia and pleuro-pneumonia in children at the breast. Respiration is laborious, short, painful, and cannot be heard by auscultation in the portion of the lung, or in the luno- that is hepatized; the chest gives a dull sound on percussion ; breathing is sometimes suffocating, and the rale is not always heard. The cry is incomplete, and almost always smothered; be- coming clear for a moment, and returning afterwards to the alteration in the tone which we have mentioned. The reprise usually exists, and it is more particularly the cry which is want- ing, or which is not heard as in the natural state. Cough is sometimes present, but this is not always the case, and demands but a secondary attention. Expectoration does not exist, and cannot here, as in adults enlighten us as to the nature, seat, and stage of pulmonary phleg- masia ; the same may be observed with regard to pain in the side. Bloody vomiting is rare. The peculiar expression of the face in diseases of the chest consists in a drawing of the ala? of the nose outward, and which the child appears to dilate with great effort, and more especially in a blue circle around the lower part ofthe nose and commissure of the mouth, and which is doubtless the result of a great dis- turbance in the general or capillary circulation. Those wrin- kles on the forehead which are to be observed in abdominal affections, less frequently exist. Yet the nasal and the genal lineaments are frequently observed; the face sometimes becomes 414 ON THE DISEASES OF INFANTS. cedematous, particularly at the termination of the disease. Fe- brile re-action scarcely, if ever, occurs in very young infants, but appears in proportion as the child advances in age; the pulse is often small and obscure, the skin cold and livid, and the limbs are cedematous. As pneumonia is developed very often after pulmonary con- gestion, and as the latter occurs in strong children, that are plethoric, the patient affected with pneumonia has often a high color, and is swelled or cedematous. If the disease continues for some time, a state of marasmus ensues, which is common to chronic phlegmasia? in general. Such are the most common symptoms of pneumonia in chil- dren at the breast. It can easily be conceived, however, that they may offer several modifications in different infants, and especially at different ages, and which can only be learned by close observation of the sick. Treatment.—Children affected with pulmonary congestion or pneumonia ought, in the first place, to have all tight clothing removed. Immediately upon the appearance of symptoms of pulmonary congestion, two, four, or six leeches, according to the strength of the child, ought to be applied to the base of the chest, or under each axilla. The child should not be placed in a warm bath, because the heat and pressure of the fluid will augment the afflux of blood towards the thorax, and increase the labor of respiration. The child must be kept from the breast for twenty- four or twenty-eight hours, giving in. its place some milk and water, or milk of almonds. If the inflammation continue after sanguineous evacuations, recourse must be had to dry cupping on the thorax, or to irritation or blistering either to the chest or arms. Revulsives to the extremities or to the intestinal tube may be employed to diminish the difficulty of breathing. If the pain be excessive, producing continual restlessness and crying, it will be advantageous to give a small quantity of syrup of pop- pies in two ounces of linctus. Anatomical researches have proved that pneumonia in young infants is always the result of sanguineous congestion; that it is purely local, and that often the bronchia? do not participate in the inflammation. Conse- quently there can be but little benefit derived from the use of syrup of ipecacuanha, kermes mineral, or even of squills, usually ON THE DISEASES OF INFANTS. 415 given in these affections, in order to produce an expulsion of mucosity. Besides, it is well known that in new-born children there is no expectoration. Under the supposition, then, that these medicines excite the bronchia?, the child may by their use be teased with desires which it cannot gratify. But at a more advanced age, and when there exist symptoms of bronchitis, there may be given with advantage, particularly in the latter period ofthe disease, half a grain of kermes mineral in two or three ounces of water, by the tea-spoonful. M. Duges, who has given some excellent precepts on the treatment of pneumonia, advises the use of a mixture, made with two drachms of oxymel of squills, and an ounce of gum syrup and orange-flower water. We should be careful not to administer syrup of ipecacuanha in every instance in which a child coughs, without ascertaining the nature ofthe cough, together with the local or general symptoms which exist at the same time. In the use of medicines in gene- ral, we must not lose sight of the importance, while meeting the symptoms, of considering the nature, seat, and modifications of the various lesions which produce them. If the child continue debilitated, after an attack of pneumonia, if for a long time it experience a disordered state of the system, which appears to arise from the remnant of irritation in the thoracic organs, it will be necessary to use the most assiduous care to prevent a return, by covering the skin with flannel, by removing it from all the causes capable of exciting afresh the respiratory apparatus, such as too frequent cries, the exposure ofthe child to cold air or violent wind; by walks, or by a resi- dence in humid places, as valleys, or the bank of a river, etc. We should remember that this is a period of life at which the different organs are susceptible in their progress of development, of acquiring certain modifications which dispose them to idiosyn- cracies, the influence of which may remain during life. How often do we see children born with all the appearances of flour- ishing health, almost always become feeble and sickly from dis- eases which attacking them in their early infancy, leave after them vital or organic modifications which time can scarcely remove, and which in some individuals never disappear! Far be it from me to yield to ridiculous prejudices; but without admitting the remains of measles, hooping-cough, or thoracic effusions, 416 ON THE DISEASES OF INFANTS. to which a thousand distressing symptoms are vulgarly attri- buted, cannot it be easily conceived that it may be possible that a hepatized lung, or bronchia? that have suppurated, will for a long time, if not always, preserve the traces of the pathological modifications supervening in their tissue, and thereby become less suitable to fulfil their functions 7 It is perhaps to pneumo- nia developed during intra-uterine life, or after birth, that short breathing, husky voices, asthmas, or idiopathic coughs, with which some individuals are affected, are to be attributed. This supposition will appear less strange, if the numerous lesions to which our organs are exposed from the first moment of their formation are considered. Art. 3.—Bronchitis, or Bronchial Catarrh. Inflammation of the bronchia? may exist in new-born infants without producing any well-marked symptoms. I have, in four instances, seen the remote ramifications of the bronchia? very red and filled with thick mucosities, in the body of a child who had died eight or ten days after birth, and where there had nei- ther been any rale nor cough during life. In two of these children there was pneumonia with pulmonary engorgement; in two others the lungs were healthy, and death occurred from intesti- nal phlegmasia. But bronchitis is not always so obscure; for the most part it is easily recognised, and the diagnosis of the symptoms is much more easily made as the child advances in ao-e. The following is an instance of an infant of fifteen days, with symptoms of acute bronchitis, with its peculiar characters strongly marked. CASE LXXIII.—Acute Bronchitis.—Michel Colot, aged fifteen days, of a strong constitution, not having been sick from the time of birth, was, on the 22d of November, taken with a violent cough, ac- companied with a rale which could be heard without recourse to auscultation. Respiration was frequent, the chest was sonorous throughout; the skin was burning; the pulse small and frequent; an erythema appeared on the posterior part of the thighs. (Gummed decoction of marshmallows, pectoral electuary, milk and water.) On the twenty-sixth, same condition ; face pale and cedematous ; the child slept but little and cried much. There was an incessant cough ON THE DISEASES OF INFANTS. 417 accompanied with danger of suffocation, which continued for some minutes. On the twenty-eighth, respiration could be heard better on the right than on the left side, where percussion produced a slightly dull sound. The same treatment was continued. On the twentv- ninth, the integuments of the face and trunk became livid ; the mu- cous rale was very distinct; the cough was very frequent, and ac- companied with imminent danger of suffocation ; the child became very restless ; a copious diarrhcea occurred ; the abdomen was soft; the skin burning hot; the pulse small but of extreme quickness ; finally, death occurred on the night of the twenty-ninth. On a post mortem examination the mouth and oesophagus were found pale ; the stomach contracted, wrinkled, and streaked with red ; the left lung infiltrated with blood ; all the bronchial ramifica- tions were very red and tumefied, and were found filled with thick reddish, filamentous mucosity ; the right lung was likewise engorg- ed ; the bronchiae, like those of the left lung, were red, and filled with thick, yellow, ropy mucosity ; the heart was healthy ; the foetal openings still free ; the brain firm ; all the tissues were in general gorged with fluid and dark-colored blood. When bronchitis supervenes on pneumonia, the smaller divi- sions of the bronchia? are the parts that are inflamed. It even happens that the first ramifications near the trachea do not par- ticipate in the inflammation. Wherever the seat of the inflam- mation is, it is sometimes accompanied with very serious symp- toms, which arise from the difficulty with which the air pene- trates the lungs. I have seen, in several children, bronchial catarrh give rise to all the symptoms which authors have re- ferred to suffocating catarrh, and which M. Gardien observes is the result of an infiltration of serosity in the pulmonary tissue.* The suffocation with which the child is threatened appears to me to be the effect of several modifications of the phlegmasia of the air passages; its cause is not always the same ; it is sufficient for its occurrence that the phlegmasia has produced some obstacle to the passage of the air. We have already seen this morbid phe- nomenon arise in several instances, and it can, without doubt, be pointed out on several other occasions. Bronchial catarrh may pass to a chronic state, and cause, for a long time, a secretion of mucosities from the trachea and bron- * Gardien, Traite des Maladies des Enfans, t. 4, p. 302. 53 418 ON THE DISEASES OF INFANTS. chia?. It is often, in children, symptomatic of phlegmasia ofthe pulmonary tissue. Sometimes, indeed, it is accompanied with tubercles situated in the lungs or root of the bronchia?; in every instance it gives rise to a series of peculiar symptoms, and which enable us to recognise it. Such, for instance, in infants that have attained the age of ten months or a year, as constant cough, oppression, quick noisy respiration, very evident mu- cous rale, fever, continual heat of the skin, paleness and tume- faction of the face. To these symptoms there is often added an inflammation, more or less intense, of the digestive tube, the mu- cous membrane of which is disorganized, without color, and is even sometimes softened. I have found the mucous membrane of the trachea and bronchia;, in several infants that have died of chronic catarrh, covered with red streaks, whilst the bronchial ramifications presented a uniform and intense redness, and were at the same time filled with thick and adherent mucosity. Acute bronchial catarrh in new-born children may be of very short duration; it sometimes arises without any appreciable cause, and disappears spontaneously at the end of a few days. There is very often no other symptom than tho mucous rale, or short, noisy, and frequent respiration, without any well charac- terized rale. In older, children it is in general more obstinate, and always produces cough ; some children will even retain it for a very long time, and will pass through the period of suckling without being freed from it, and without experiencing any serious injury to their health ; in general, chronic bronchitis need not be regarded as a serious affection when they do not become ema- ciated, when they preserve the appetite, and the usual, gaiety and vivacity of their age. The usual termination of bronchial phlegmasia is resolution ; I have found but once, on examining the dend body of a child, that I had not seen during its life, a well-marked cedema of the bronchia?; in another an abundant sanguineous exhalation : the ages of both were but five days. The treatment pointed out for pneumonia will also be applica- ble to bronchitis, which is frequently accompanied by inflamma- tion of the lungs. Yet it would perhaps be necessary in this case to make use of blisters more freely between the shoulders, or on the arms, particularly when the disease becomes chronic. When this is the case, we might also resort to the balsam of co- ON THE DISEASES OF INFANTS. 419 paiba, in doses of a few grains each day, increasing the dose ac- cording to the age of the child. Dr. La Roche, a physician of Philadelphia, has met with great success in the use of this medi- cine. He has published an essay on the subject, which, while it con- tains a number of interesting facts, still leaves it evident that fur- ther experience is needed to confirm the efficacy of this medicine.* Mr. Thorn has made a resinous extract of copaiba, which is de- prived of its essential oil, where the unpleasant taste and smell of this medicine reside, without removing its properties. Mr. Tyr- rell has used this extract with great success in gonorrhoea in St. Thomas' hospital. It would probably be well to use it in the place of the balsam af copaiba when it is desired to administer it to children affected with chronic bronchitis, when the ordinary means have not succeeded in curing the disease. Art. 4.—Pleurisy. Pleurisy is more common among young infants than is gene- rally believed; it often appears without the lungs participatino- in the inflammation. I have seen several infants die immediately after birth from this affection. CASE LXXIV.—Acute pleurisy.—Averan, aged two days, was exposed at the Hospice des Enfans Trouves, on the 14th of Novem- ber. He was strong, and the integuments highly colored; the cry full and complete ; he was constantly restless, and cried without ceasing; the face became purple and pinched; the child obtained no sleep at night, and appeared to suffer more when placed in the bed. On the morning of the fifteenth, the same state continued ; the chest, when percussed, gave a dull sound in every part; at night the child became exhausted from fatigue, appeared to faint, and died. On opening the body.the following day, the digestive tube was found healthy; the two cavities of the thorax contained a quantity of yel- low serosity, in the middle of which were a number of albuminous flakes ; there were no adhesions between the pleura ; the two lungs floated on water, the left only was slightly engorged at its posterior border; the foetal openings were free ; the meninges of the brain were healthy. * La Roche, On copaibabalsam in chronic bronchitis. (North American Medical and Surgical Journal, No. VI, p- 34) 420 ON THE DISEASES OF INFANTS. The great restlessness of this child was, without doubt, owing to the development of pleurisy, and the pain, which the lying on the back made so much more distressing, proceeded from the ef- fusion of serosity in the pectoral cavity. The signs of pleurisy were not well marked, and I have only given this example to show that restlessness, cries, sleeplessness, and death of new-born children may sometimes be owing to acute pleurisy. We will, however, observe that one of the signs of this disease is a dull sound of the chest, although the cry may not be altered. This would lead to the belief that if the disease exists in the thorax, the lungs are probably not its seat, since the air penetrates suffi- ciently in their tissue to preserve the cry in its normal state. We shall see, in the following instance, pleurisy appearing in a manner more evident than in the foregoing case : CASE LXXV.—Pleurisy.—Victoire Redan, aged ten days, strong and of a good color, and presenting all the appearances of health, entered the infirmary on the night of the 30th of October. This child had been vaccinated on the second day after birth; the pustule was not well developed, and there existed no inflammatory circle around it. She was attacked with an abundant diarrhoea of a yellow color. The face, which, until the time of admission, had been of a vermilion, was pale and wrinkled, particularly at the external angles of the eyes, and on the forehead ; she cried but little, but the cry was plaintive. The pulse was very small, but exhibited nothing remarkable with regard to its frequency. On the 1st of November there was the same expression of face, the extremities were cold, trunk intensely hot; a marked dulness on percussion on the right side of the chest; the cry was expressive of fatigue, but without being husky; when the child was unclothed and examined, during respiration, the thorax was observed to dilate with difficulty, and that the movements of the diaphragm and parietes of the abdo- men were very evident. (Gummed electuary.) On the 4th of No- vember, there was an abundant vomiting, cry painful, limbs cold, face pale, and the alee of the nose, which appeared to dilate with difficulty, were livid ; the mouth remained open, or opened and closed alternately during the movements of respiration. Respira- tion could not be heard through the stethoscope at any point of the thorax, yet the dulness was not very evident on percussion, espe- cially at the upper part of the thorax. (Two leeches to the lateral ON THE DISEASES OF INFANTS. 421 parts of the thorax, linctus.) On the fifth, general sinking, ex- treme paleness, and death at night. On examining the body, there was found a passive congestion at the base of the tongue and oesophagus, where were also found some spots of muguet, and softening of the mucous membrane of the small intestines. The lungs were slightly red, and injected with a considerable quantity of frothy serosity, which flowed from every part when cut. The right lung exhibited the first stage of hepatization at its poste- rior border; a very fine spotted redness existed on the pleura of both sides; there was about two spoonfuls of serosity effused in each thoracic cavity, and the base of the lungs adhered to the dia- phragm by tender albuminous filaments of a very slight consistence, of a citron color, like the effused fluid. The brain was healthy, but the venrticles were filled with serosity. m We must again remark the restlessness and painful expression ofthe physiognomy ofthe child, the difficulty of respiration, the constantly increasing dulness of the thorax, although the cry did not become altered in proportion as the disease advanced ; the coldness and lividness of the extremities, while the body was at a very high temperature. I will not speak of the pulse, which, in this disease, as in almost all others of new-born children, is very uncertain, and of little use in diagnosis. Notwithstanding all the care I have taken to ascertain correctly the symptoms, I am not able to offer any thing of sufficient precision to enable us to make a correct diagnosis of pleurisy ; but the symptoms mentioned are at least enough to satisfy us that there exists a great probability of the presence of the disease now under consideration, and this is all we can obtain at the bedside, when we wish to ascertain the seat and nature ofthe diseases. Chronic pleurisy.—Pleurisy may pass into a chronic state even in very young children, and give rise to changes in the tissue similar to those observed in adults. A little girl, aged three months, who had been feeble, pale, and sickly from birth, and who had been several times in the infirmary with the most uncertain symptoms, died at last on the 18th of April, 1820. She had insensibly arrived at the last stage of marasmus, and had not been affected with diarrhcea except in the latter period of life; she had never been affected with fever, and although the respira- 422 ON THE DISEASES OF INFANTS. tion was short, the tone of the cry did not exhibit any alteration, and the nurse remarked that the child died from languor. Upon opening the body, I found the small intestines red, tumefied, and filled with a large quantity of black blood in clots ; the large in- testines were healthy. There also existed a very violent pleu- risy on the left side. Both the costal and pulmonary pleura? were covered with a layer of plastic lymph, at least a line and a half in thickness. When this lymph was removed, the pleura beneath was found rugous and very much injected, while the lungs under its coating were found crepitant and perfectly healthy. When the lungs were cut transversely, a well-marked red line could be seen at the circumference of this organ, indi- cating the separation between the inflamed pleura and the healthy pulmonary tissue. The heart and large vessels were exsanguined; the fcetal openings obliterated ; the brain, although healthy, contained a small quantity of serum in the ventricles. From what has been related, we have seen that the emacia- tion and languor of this child were caused by an obscure pleurisy, the progress of which insensibly led to the death of the patient. In every instance, therefore, in which we see a child languish- ing, and becoming thin and feeble, we ought carefully to search for the cause of this condition, and endeavor to ascertain whether it does not arise from some obscure organic lesion ; we ought not to remain in a security which would leave us tranquil spectators of a disease which perhaps might not have terminated fatally if we had examined with scrupulous attention into its cause, seat, and nature. As a general rule, it is not easy to make a diagnosis of pleurisy in young infants ; still its existence may be suspected when we observe much anxiety, restlessness, difficulty of breathing, pain- ful dilatation ofthe thorax, quick and more marked contractions of the diaphragm and abdominal muscles; and in the midst of these symptoms, if the cry should preserve its integrity, and present no other alteration than that which arises from fatigue and exhaustion. Percussion and auscultation give but very un- certain signs in this disease ; yet if the respiration be not heard at any part ofthe thorax while the cry is complete and free, and when there would appear as if there existed effusion without he- patization, the infant, in all probability, is affected with pleurisy; ON THE DISEASES OF INFANTS. 423 this conclusion will, however, be still uncertain. I must, on this account, consider the diagnosis of pleurisy in sucking children as very difficult, and that it is very easy to confound it with pneu- monia. Happily this mistake cannot be very prejudicial to the pa- tient, because the treatment of the one will be the best that can be adopted for the other. The treatment of pleurisy will differ very little from that of pneumonia ; four, six, or eight leeches ought to be applied to the thorax, and the whole of the chest covered with a cataplasm, while a revulsion is made to the arms or legs by means of flying blisters or sinapisms. After sanguineous depletion, dry cups or blisters may be used to the thorax ; and if the disease become chronic, it would be useful to clothe the infant, however young it may be, with a flannel waistcoat applied directly to the skin. (Edema of the lungs.—This disease consists of a serous in- filtration more or less abundant in the pulmonary tissue; it is rarely a primary affection, but is more often a sequel of chronic pneumonia or pleurisy; it sometimes is a fatal termination of these diseases. I have several times found the lungs cedematous in the case of cedema or induration of the cellular tissue ; they are in a state analogous to that of all other parts of the body. Whatever be the cause of cedema ofthe lungs, it gives rise to the most serious symptoms, and especially to a very laborious respiration ; yet I have found very often a considerable quantity of serosity in the lungs of infants who have not exhibited any particular symptom of disorder in the chest; it is very probable that this cedema occurs at the moment of dissolution, and must be regarded perhaps as a phenomenon of death. However, it would appear as if this disease may occur without being caused by any antecedent lesion, and give rise to a series of symptoms which have been described with great care by M. Gardien, among which he mentions, particularly, cough, extreme difficulty of respiration, and the imminent danger from suffocation. When the children that I have observed exhibited symptoms analogous to those pointed out by M. Gardien as the effect of oedema, I have several times found the lungs infiltrated with serosity, but there was, at the same time, pneumonia, pleurisy, or bronchitis, so that I could not attribute these symptoms solely to the presence of se- rosity. 424 ON THE DISEASES OF INFANTS. However this may be, I think that if it were possible to distin- guish cedema of the lungs from pneumonia or pleurisy in young infants, the application of a blister to the limbs or thorax would answer a better end than sanguineous evacuations. Purgatives, and the oxymel of squills, appear to me to be also indicated. Art. 5.— Hooping-cough. I will here record, as concisely as possible, the result of the researches made of the opinions published respecting hooping- cough since its first appearance in Europe. I will endeavor to estimate these opinions according to their just value, and to as- certain what is positive, and draw such practical inferences as will naturally arise in the description of the subject. This disease is characterized by a suffocating cough, returning in paroxysms, accompanied by an excretion of a very abundant mucus, and always accompanied with a vomiting of mucus, caused doubtless by the irritation of the stomach, the internal membrane of which appears to participate in the catarrhal dis- ease of the bronchia?. During a fit of coughing, the child ex- periences all the symptoms naturally arising from immediate suf- focation—such as congestion of the face, injection of the con- junctiva, shedding of tears, and a general spasmodic condition excited by the difficulty of respiration. The cough has some- thing hoarse and resounding peculiar to it. I shall not stop to consider the appropriateness of the terms by which the French, Germans, and English designate this disease. They are all in- dications of the symptoms, rather than the nature ofthe disease.* The causes of this catarrhal inflammation, like those of all other epidemics, are difficult to ascertain. The only positive thing that can be said about it is, that it is not really contagious, but an epidemic disease, a distinction which M. Gardien has in- sisted on with great reason. It prevails often at the same time with ordinary catarrh, sometimes taking its place, or complica- ting and modifying it, and imparting to it some of its peculiar characters. It has sometimes occurred before an epidemic of * The word coqueluche is, it is said, derived from an old custom of covering the head of the patient with a hood or capuchon. The German words keichhusttn and stick- husten, and English expression hooping-cough, signify a convulsive cough. ON THE DISEASES OF INFANTS. 425 croup, or the latter disease may be developed in the middle of hooping-cough prevailing epidemically; so that the usual causes giving rise to simple catarrh, croup, or hooping-cough, appear to be connected by relations and analogies, the characters of which escape us, it is true, but which allow us to see their simultaneous or consecutive effects. During the time I was at the Hospice des Enfans Trouves, I saw at the house of a nurse who lived near the " barriere d'Enfer," three children, aged from ten to eighteen months, who were affected in the space of three months with measles, accompanied by a slight anginose affection, simple bronchial catarrh, which soon assumed the characters of hooping- cough, and lastly with croup ; all these occurred successively in three children, and cut them off in eight days. It is difficult for us positively to ascertain the nature of hoop- ing-cough, but we may still obtain some knowledge of its prin- cipal characters. Thus it is evident that it is a bronchial ca- tarrh, which can be discovered by the most superficial examina- tion of the symptoms ofthe patient. This catarrh, however, has something peculiar; the cough which it produces is always suf- focating, convulsive, and only occurs in paroxysms. This ner- vous complication is to be noted, for here its specific character commences, and we can see it, but are unable to explain it with- out hazarding the danger of wandering into futile hypotheses; yet I will make one remark in relation to this nervous complica- tion ; it is, that in adults, as well as in children, affections of the trachea, larynx, and also of the bronchia, often give rise to a sud- den local or general spasmodic irritation, characterized by spasm of the affected organ, or by general convulsions. Tonsilitis, sim- ple angina, croup, foreign bodies in the trachea, or tumors com- pressing the trachea or bronchia?, produce a cough more or less suffocating, very remarkable for its remissions, and which, in some cases, has a striking resemblance to that of hooping-cough. Admitting, therefore, the specific nature of catarrh in this dis- ease, and that it consists especially in a nervous complication, we are disposed to the opinion that, in many other instances, the diseases ofthe same organ may exhibit very evidently a ner- vous complication; whence it will follow, that if in a similar complication consists the specific nature of hooping-cough, the seat of the disease and the physiological lesion which exists be- 54 426 ON THE DISEASES OF INFANTS. tween it and the nervous system, may concur in a manner that will produce the specific quality ofthe disease in question. The same disease, in different parts of the system, often presents va> rious characters; different diseases having the same seat, some- times exhibit analogous characters; the seat ofthe affection then has something that imparts a specific quality to diseases in gene- ral, and ought to be considered when treating them. There is also another circumstance which ought to be consi- dered as peculiar to hooping-cough—that is, the coexistence of mucous vomitings, effected by the cough. This coexistence is easily explained by the relation existing between the mucous membrane of the bronchia? and that ofthe stomach,, and the fre- quency of the cough very naturally accounts for the frequency of vomiting. I do not pretend that I have, by the preceding- explanation, satisfactorily accounted for the specific nature of hooping-cough, but have only endeavored to exhibit one of the possible causes of it; and there remains sufficient to call forth all our efforts to unveil the nature of this disease. Some ofthe most enlightened observers have exercised their talents in the investigation of this subject; such as Rosen, Cullen, Schcefer, Hufeland, MathaT, John, Authenrieth, Baumes. All have discovered, on examining the bodies of those who have died of this disease, the existence of bronchial catarrh, without any particular lesion of the bron- chia?. This opinion is sustained particularly by Dr. Watt, of Glasgow,* Albers of Bremen, Marcus,t Desruelles,t and Ad. Hencke, who in his learned work appears to adopt the same opinion.§ Hufeland thinks that the eighth pair of nerves may have some agency in the production of this disease, and is probably the cause ofthe double irritation ofthe bronchiae and stomach which sometimes appears.II This opinion, revised by M. Breschet, who * Treatise on the nature and treatment of chin cough, including a variety of eases and dissections, by Robert Watt, M. D., Glasgow, 1815. t Trait'e de la coqueluche, ou bronchite epidemique, son diagnostic, sa nature, tt son traitment, translated from the German by E. L. Jacques. Paris, 1821. t Traite de la coqueluche. Prize essay. Paris, 1827. § Handbuch. der Kinderkrankeiten. Frankfort, 1821. H System der praktische hielkunde. Jena, 1818—1828, ON THE DISEASES OF INFANTS. 427 found in two individuals that died of catarrh accompanied with a suffocating cough, the pneumo-gastric nerves red externally and yellow internally, has not been confirmed by the indefatiga- ble researches of M. Guersent; and I have, in every instance of death from hooping-cough, dissected the pneumo-gastric nerve, without ever being able to discover any lesion; so that this idea must be considered as not yet demonstrated. Lastly, Authenrieth, from the success which followed his me- thod of treatment, is of opinion that hooping-cough is owing to an accumulation of lymph towards the bronchia?, and that this cause can be removed by causing exteriorly the formation of pustules which contain lymph.* The examination of bodies has not exhibited any thing uni- form in this disease, except bronchial catarrh in various stages of advancement, almost always accompanied with a considerable quantity of mucosity accumulated in the bronchia?, which are sometimes sensibly dilated, and exhibit a vivid red color. Among the concomitant lesions of the catarrh, there are very often found inflammation ofthe lymphatic ganglia in the vicinity of the bron- chia?, and a dilatation ofthe termination ofthe bronchia?, pointed out for the first time by Laennec. I once saw this in a child of fifteen months, and who presented at the extremities of the bron- chia? a species of small vesicles filled with a creamy, inodorous pus. The unequal dilatation of the bronchia? has also been met with in some infants; it is the same in emphysema; lastly, this dis- ease is found complicated with pneumonia, pleurisy, pulmonary tubercles, chronic enteritis, mesenteritis, menengitis, hydrocepha- lus ; but in considering the variety and number of these compli- cations, do we not see also that some are the ordinary result of pulmonary affections of long duration, and other accidental effects of peculiar idiosyncracy 1 Wherefore, then, seek among all the complications of hooping-cough for lesions, which will give us a proper idea of the seat and nature ofthe disease, whilst there exists one princpial lesion always constant, always identi- cal, to which it is more natural to refer the prerogative of being one of the principal causes of hooping-cough? I am sensible how much the nature of the discussion upon which we have * Versuchefur die praktische heilkunde. Tubingue, 1808. 428 ON THE DISEASES OF INFANTS. entered is calculated to lead us into vain speculations; I will hasten then to trace the progress of the symptoms and the treat- ment of this disease. All authors since the time of Rosen have recognised different periods in the disease, and M. Guersent, in his excellent article Coqueluche, in the Dictionnaire de medicine, has traced them with great care. The development of this disease doubtless ex- hibits several stages, but notwithstanding the attention I have bestowed on the subject, I have found them so variable with re- spect to their duration, and even their characters, that I believe it to be impossible to assign to them any constant symptoms or limits. Hooping-cough always commences with simple bronchial catarrh; and even during its prevalence as an epidemic, many children have nothing more than a catarrh, which terminates at the end of a few days or weeks without ever exhibiting the cha- racters of hooping-cough, whilst other children living under the same atmospheric influence have the disease with all its pecu- liar traits. Is it that some have a false and others a true hoop- ing-cough ? It would be scarcely in place to repeat what has been said of croup with regard to this question. It is much more reasonable to believe that the disease has existed in these children in different degrees, and that it varies in them from a slight to a severe affection. When the cough increases, with the irritation of the bronchia?, the face becomes puffed, the eyes injected, the respiration accelerated; the expectoration is at first thin, limpid, and serous ; the cry and voice become peculiar in their tone, easily recognised by experienced practitioners. I have often seen children with the disease confined to simple bronchial catarrh, and continue for a long time only affected with it in this simple form. I remember particularly a little girl at the infirmary of the Hospice des Enfans Trouves, who had a peculiar cough, accompanied with symptoms of suffocation and an abundant expectoration, which lasted about forty-eight hours. It was thought that the hooping-cough was about to be devel- oped, to continue for a greater or less time ; nothing of this kind, however, occurred, and the symptoms disappeared rapidly with- out any active treatment; and although this child remained ON THE DISEASES OF INFANTS. 429 some time in the infirmary, there existed no more symptoms of suffocating catarrh. When hooping-cough becomes severe, the chest, particularly about the sternum, is the seat of considerable pain ; the cough returns in paroxysms, with shorter intervals between them, in- creasing more at night, and is almost always preceded by a mu- cous rale, which is more evident as the paroxysms approach each other. In a fit of coughing, the suffocation, pain, and strangling produce the greatest distress in the patient, who seizes every thing within its reach with a spasmodic effort, with violent at- tempts at inspiration, accompanied with acute cries and smothered and incomplete wheezings; in the meanwhile, the face becomes purple and tumefied, the jugular veins are filled with blood, the neck dilates with a painful effort, and the limbs are stiffened with spasm; the child, alarmed at its own distress, sometimes loses its consciousness, and appears, from the momentary suspension of breathing, to be dying. Very frequently there is no rale heard during the paroxysms of coughing, and it is remarkable that the more dry the cough the more painful and suffocating it is; it becomes much less when the mucosities are abundant in the trachea. All these violent efforts usually terminate in vomiting, by which the child not only throws up what it had eaten, but likewise an abundance of mucosity. When the cough ceases, the child recovers from its distress by degrees, remains exhausted for some minutes, and complains, if old enough, of pain in the forehead and sternum; its cry and voice are feeble; but this state of fatigue is of short duration, for its gaiety soon returns, and it enjoys the sports of its age until prostrated by a new pa- roxysm of coughing. Hooping-cough continues for a greater or less time in the acute state, such as I have just described; it is often accompanied with fever, especially in the commencement, but by degrees this symptom of reaction becomes less intense, or does not appear at all. This is not the case, however, when it is complicated with pneumonia, pleurisy, or hydrocephalus. When hooping-cough occurs in scrofulous children, it may hasten the disorganization which tubercles effect, and thus terminate in phthisis of the larynx or lungs. At the end of a few weeks or months, the symptoms diminish 4:30 ON THE DISEASES OF INFANTS. in intensity, the expectoration is more abundant, and the muco- sity thicker; the cough becomes less fatiguing, is less intense and less frequent, and finally disappears with the whole assem- blage of other symptoms. The prognosis of hooping-cough is unfavorable in proportion to the dangerous nature of its complications and the early age of the child. M. Guersent has correctly observed that in infants at the breast it is often complicated with cerebral congestions, and from the first development of this disease in them, this complica- tion is quickly fatal. We can easily conceive the danger arising from pneumonia, pleurisy, softening of tubercles, pneumo-thorax, and other complications of hooping-cough. Treatment.—Two principal indications present themselves in the treatment of this disease—to combat the inflammation of the bronchia?, and to moderate or remove the nervous complication. It will be necessary, in the beginning of the disease, to have re- course to sanguineous evacuations, both general and local, to de- mulcent drinks, and revulsives to the intestinal tube ; in a word, it must be treated by a purely antiphlogistic method, rigorously pursued during its inflammatory stage : as bronchial irritations will quickly produce in young infants pulmonary or cerebral congestions, it will be useful to apply a few leeches to the neck or lateral parts of the thorax, upon the slightest symptoms being perceived of irritation in these organs. This was the practice, observes Dr. Dewees, of Willis, and appears to have been the general practice of the age, and particularly of Sydenham, As- true, Home, and others. The success of these celebrated practi- tioners ought to induce us to imitate their practice. I cannot be- lieve it to be a natural practice to administer emetics at the same time, in order to relieve the stomach from the mucosity with which it is filled. If antimony and squills are to be given, it ought rather to be as expectorants than in vomiting doses ; as half a grain of kermes, (sulphuret of antimony,) in a two-ounce mixture, for a child of eight months to a year old, is sufficient to produce an abundant expectoration. We should remember that very young infants do not expectorate, and that it will but fa- tigue them in vain to persevere in giving medicine of this kind. The English physicians assert that calomel, given in doses of a few grains every two or three days, renders the progress of hooping- ON THE DISEASES OF INFANTS. 431 cough more irregular and shorter. I can conceive, indeed, without partaking of their predilection for this medicine, that it will accom- plish a good purpose in keeping the bowels open, and thus advan- tageously counteract the catarrhal inflammation of the bronchia?. When we are satisfied that the first symptoms of inflammation are moderated, and that the nervous irritation ofthe bronchia? is the cause of the existing symptoms, we should endeavor to re- move it, and not remain inactive, which may be fatal to the pa- tient, under the belief that the hooping-cough must run through its course; for it is not more dangerous to arrest the progress of this disease than to stop an intermittent fever, the progress of the one requiring as much attention as that of the other. We ought, therefore, to avail ourselves of narcotic and anti- spasmodic remedies at the period of the disease—as a demulcent mixture, with a quarter or half a grain of the extract of opium, or, what is still better, one or two drachms of syrup of poppies. As- safcetida, given in injection, has succeeded in the hands of some practitioners, but its efficacy is not as yet sufficiently demonstra- ted. Cullen, observing the periodical return of the cough, em- ployed cinchona, but his example has not been followed by others. Some advantage might be obtained from the use of sul- phate of quinine in small doses ; yet it must be observed that the remission is very irregular, and consequently we cannot foresee its return, and might give it even at the moment the cough com- mences, which, without doubt, would interfere with the efficacy of the remedy. Hyoscyanus, belladonna, and cicuta have not been forgotten among the narcotics used for the treatment of hooping- cough. The powder of belladonna, or its gummy extract, in doses of a quarter to half a grain in any vehicle, will produce good effects, but its operations are very uncertain. The sedative used by M. Guersent with great advantage, is a mixture of equal parts of oxyde of zinc, belladonna, and cicuta, commencing with a quarter of a grain of these substances, given three times a day, and increasing it according to the effect experienced from its use. He has also used the oxyde of zinc with success in the dose of a grain every hour in an infant of six weeks, where he had in vain attempted to arrest the paroxysms of coughing.* * Guersent, article Coqueluche, in the Diet, de m6d., t. vi. p. 20. 432 ON THE DISEASES OF INFANTS. We should also use counter irritants to the skin, when the dis- ease exhibits no more sign of active inflammation. Blisters be- tween the shoulders, camphorated and ammoniated frictions on the arms or lateral parts of the chest, may perhaps be of some utility. Without endeavoring to accomplish the end for which Authenrieth has advised frictions with his ointment, we may nevertheless use it as a simple revulsive; the epigastrium or tho- rax may be rubbed with an ointment composed of one part and a half of tartar emetic to eight parts of the lard; care must be taken not to rub the pustules already formed, for ulcers may arise and cause fever. Dr. Dewees uses an ointment composed of the same, with the addition of fifteen drops of ol. lavend. or lemon. The state of feebleness in which the child Temains for a long time after the hooping-cough has disappeared, requires the greatest attention from the physician. Before using tonics, such as the syrup or wine of cinchona, it will be necessary to habitu- ate it gradually to nourishment of increased strength, as chicken water, veal or beef tea, animal jellies, feculent vegetables, and only habituate it progressively to the use of medicinal or other wines. Goats' milk, pure or diluted, a good nurse, a residence in the country, particularly in the spring and summer, will ma- terially conduce to the recovery of infants at the breast. This is perhaps the proper place to speak of nervous respira- tion—such as hiccup, spasm of the glottis, etc.; but as we are in possession of no other than very uncertain data upon these af- fections, I do not think it necessary to devote a chapter to the consideration of a subject on which I have nothing more to say than has already been advanced a number of times. It is, be sides, to be remarked, that spasm of the glottis is often but a symptom of different inflammatory diseases of which 1 have al- ready spoken. I will end this account ofthe history of diseases of the thorax by observing that the application of the stethoscope and percus- sion are neither so useless in infantile diseases or so injurious to them as M. Denis has asserted in his work, (page 336,) or as is expressed by M. Guersent in the article Enfant in the Diet, de mod. We have seen in this chapter that these means may be used as a proper method of investigation in the thoracic diseases of children. ON THE DISEASES OF INFANTS. 433 CHAPTER IX. DISEASES OF THE CIRCULATORY APPARATUS. Development and congenital malformation.—The heart does not appear until some large vessels are already formed, and the vena porta usually exists before it. At the commencement it appears to be but a swelling of this vein ; this swelling soon be- comes curved in a semicircle, presenting three dilatations and two contractions ; these dilatations are the auricles, left ventricle, and the commencement of the aorta; they gradually disappear by the approximation of the cavities. Such, at least, are the first appearances of the heart and vessels observed in the chick by Haller, and in the heart of the human foetus by other experiment- ers. In proportion as the heart is developed, the various parts composing it assume, by degrees, the form and dimensions which they naturally have. Sabatier and Wolff have seen, however, the septum which separates the two auricles form, by degrees, but having at the period of birth an opening by which the blood passes from the right to the left cavities ; and it appears that the septum which divides the two ventricles is formed by a kind of prolongation which rises from the base of the left ventricle, and is continued towards the summit. M. Meckel has made some very interesting observations on the respective dimensions of the cavities of the heart during its formation. At first the left ven- tricle is the largest; afterwards the same size as the right; and then the latter, in its turn, becomes the most voluminous. The auricles surpass the ventricles in size when the embryo is quite young, but at the time of birth it is reversed. The aorta exists singly at the seventh week; but it soon ex- hibits two divisions, the one of which is the pulmonary artery. The latter, at the fourth and fifth month, has branches which go to the lungs, and which are not so voluminous as the arterial duct. All these parts of the circulatory apparatus' are developed 434 ON THE DISEASES OF INFANTS. successively, and acquire the dimensions, divisions, and relations which each of these vessels have during the remainder of life.* While the heart is thus passing through its various stages of formation, it may undergo some arrest of its development, which will produce, at the period of birth, and for a long time after, the most serious symptoms. I will not stop to describe all the mal- formations which the heart can undergo, for they are of infinite number. The most of them, besides, are only developed in pro- portion as the child advances in age, or are the persistence of the particular disposition ofthe heart in new-born children ; so that they give rise to no symptom during first infancy, and only man- ifest their existence by external signs at a more advanced period of life, and do not constitute one of the diseases of infancy. I will, therefore, confine myself to pointing out some of the princi- pal malformations of the heart. An entire absence of the heart is only found in acephalous children. It is a rare thing to see a single heart: that is to say, destitute of one of its lateral portions, and consequently present- ing only one ventricle and one cavity. I will here record an in- stance of this kind, the more interesting as the description of this monstrosity is accompanied with an account of the symp- toms presented by the child during life. This case was commu- nicated to the Journal of Medical Sciences, of Philadelphia, by Dr. Mauran, a physician residing at Providence. CASE LXXVL—On the 19th of March, 1827, I was requested, through the parent, Mr. A. B., to examine, post mortem, the case of his child, who had died under peculiar and inexplicable circumstan- ces, the history of which was as follows : The labor was natural; the child, though small, appeared well and healthy ; the respiratory apparatus responded readily to its natural stimulus, and thus contin- ued while the child remained in a quiescent state, but from the change of position in washing, dressing, etc., it was noticed to be particularly affected. The child experienced the greatest difficulty on crying and respiring. These symptoms occurred occasionally on motion, but were counteracted by restoring the child to a quiescent state. Ten days after birth I was called to revisit the patient, who was laboring under a supposed inflammation of the lungs, attended with a difficult and apparently painful respiration; there was a light fever and slight * Ph. Beclard, Embryologie, p. 84. ON THE DISEASES OF INFANTS. 435 cough. I learned from the nurse that the paroxysms would recur at irregular intervals, commencing with a convulsive or spasmodic ac- tion of the whole chest. Respiration was interrupted, and would continue for many minutes, when the patient would apparently cease to breathe, the whole surface to the extremities putting on the above described livid or purple hue—in fact, exhibiting the perfect " puer coeruleus." By inclining the child forward on the nurse's lap, thereby afford- ing a pressure upon the chest and abdomen, a slow return of the functions of respiration was noticed ; the livid hue at the same time yielding to the improved circulation, its ordinary healthy aspect was gradually restored to the surface. The prima? viae were directed to be moderately evacuated, slight pectorals, with antispasmodics, pre- scribed, and perfect rest enjoined. Notwithstanding these means, it died in one of the paroxysms we have mentioned. The dissection, fifteen hours after death, discovered the following interesting appearances. The child was small, and exceedingly emaciated ; surface yet livid ; abdominal viscera perfect. On intro- ducing a blow-pipe into the vena cava ascendens, we could inflate the whole viscus (auricle, ventricle, and coronary arteries). The heart being divided through the ventricle, vertically from its apex to the origin of the aorta, the following unique appearances were dis- covered. It was in fact a single heart! having but one auricle and one ventricle, communicating by a large free foramen, the borders of which gave origin to a tricuspid valve. The pulmonary artery exhibited the most interesting feature of the general malformation • arising almost in immediate connection with the aorta on its left side, from one common ventricle, it passed backwards, giving out its accustomed branches, and thence becoming ductus arteriosus, was found pervious and opening into aorta descendens. From the fact of the previous state of this duct at its aortal termination, a more minute investigation was instituted, which exhibited it perfectly im- pervious at its origin, from the ventricle between which and the bi- furcation was a perfect cul-de-sac. The auricle was next observed attached to the ventricles extensively and on its left side; its size, when dilated, being more than two thirds that of the ventricle, and exhibiting, anteriorly, two auricular appendages. A vertical section of the ventricle exhibited the parietes unusually thick and strong, being largely studded with the columna? carnea?.* * Account of a malformation of the human heart: by J. Mauran, M. D., of Pro- vidence, R. I. (Philad. Journ. Med. Sciences, No. 10.) 436 ON THE DISEASES OF INFANTS. It is evident that in this child the blood could not become oxygenated in sufficient quantity to preserve life; yet nature appears to have made the following provisions to supply the ab- sence of one of the cavities of the heart, as Dr. Mauran remarks: the blood having arrived at the ventricle, was propelled towards the aorta, but, instead of coming to the lungs through the pul- monary artery, which was obliterated near the heart, the lesser circulation was affected indirectly by a retrograde current through the ductus arteriosus, thence into the pulmonary branches, to be returned to the ventricle, the common receptacle of this and of the black blood of the cavas. Instead of meeting with so complete an absence of one of the lateral parts of the heart, there is sometimes only a deep depres- sion between the two ventricles, one of which, much smaller than the other, appears to have been arrested in its development. The plurality of the heart, according to Meckel, is extremely rare in cases where there is not a duplicate fcetus. The develop- ment of the auricles is considerable in some infants. I once saw, in a little girl that died some days after birth, a pointed prolon- gation of the right auricle, of about an inch long; it hung loose in the pericardium in front of the heart. The excessive size of the heart may perhaps be owing to a malformation. Narrowness of the auriculo-ventricular or vascular orifices, is scarcely observed at the period of birth ; but in proportion as the child advances in age, if the size of the orifices do not follow the progress of the cardiac development, there is then a greater or less disturbance in the functions of the circulatory apparatus; producing several disorders, designated by authors under the general term of asthma. Lastly, we must mention, also, among the congenital malformations of the heart, the irregular insertion of the large vessels, the transposition of the organ to the right side of the chest, a deviation of more frequent occurrence than is generally believed, and of which M. Baron has presented seve- ral instances to the Academie Royale de Medecine. Besides these, there are several organic aberrations of the principal organs of circulation in an infant at birth—too many for enumeration here. The symptoms of the greater part of these organic devia- tions which have been mentioned occurring at birth, are, defect of haematosis, suffocation, irregular pulsations of the heart, ON THE DISEASES OF INFANTS. 437 cerebral and pulmonary congestions, and, very frequently, death. Soon after birth, the circulatory apparatus undergoes altera- tions of the greatest importance, not only in its organization, but also in its functions ; and it is to these changes that the many affections peculiar to infants are to be attributed ; but in order to understand precisely the modifications of the circulatory appa- ratus may be a cause of the many morbid symptoms in young infants, it appears to me necessary to follow with care the pro- gress of the organic and functional changes, in order to appre- ciate properly the influence they may exert upon the health of the child. I will therefore divide this chapter into two articles : the one treating of the establishment of the circulation, the other of the diseases of the circulatory apparatus. Art. I.—Of the establishment of independent circulation. I have studied with the greatest care the changes which occur in the heart, ductus arteriosus, ductus venosus, and umbilical ar- teries, during the first days of extra-uterine life, and shall exhibit here the results of these researches. I shall consider successively—1st, The period at which the foetal openings are obliterated ; 2dly, Their mode of obliteration ; 3dly, I will exhibit the physiological and pathological conse- quences which naturally flow from these researches. & I. Period of the obliteration of the fcetal open- ings.—Infants of the age of one day.—In nineteen children aged one day, there were fourteen in whom the foramen ovale was completely open ; in two of them it had begun to be oblitera- ted; and in two it was entirely closed. Consequently no blood passed through it. In the same children, the ductus arteriosus was free and filled with blood in thirteen ; its obliteration had commenced in four; and in the remainder it was completely obliterated. 1 also no- ticed that in one of the last mentioned children there was a com- plete occlusion of the foramen ovale. In the other children in the same state, the ductus arteriosus was still open. With respect to the umbilical arteries, they were still open near their junction with the iliac arteries, but their calibre was nar- rowed in consequence of a very remarkable thickening in their 438 ON the diseases of infants. walls. In all these children, the umbilical vein and ductus veno- sus were free, and the latter was most generally gorged with blood. From this examination it appears that the foramen ovale and ductus arteriosus are still open on the first day of birth in most instances, although they may be obliterated at this period. Infants of the age of two days.—In twenty-two children, aged two days, there were fifteen where the foramen ovale was perfectly open ; in three of them it was almost obliterated ; and in four entirely closed. In thirteen of these children I found the ductus arteriosus still open ; in six the obliteration had commen- ced ; and in three was entirely obliterated. In all, the umbilical arteries were obliterated to a greater or less extent, but the umbilical vein and ductus venosus, although empty and flatten- ed, would not allow of the passage of a moderate sized stylet. These facts are sufficient to demonstrate that, in most instances, the foramen ovale and ductus arteriosus are not obliterated on the second day after birth, although the child may enjoy inde- pendent life ; as to the umbilical arteries, having now become useless, they undergo the changes resulting from their default of action. Infants of the age of three days.—I also subjected the bodies of twenty-two children aged three days to the same examination. In fourteen of these the foramen ovale was still open; in five, the obliteration had already commenced, and was complete in the remaining three. The ductus arteriosus was also open in fifteen ; the obliteration had commenced in five, and was complete in two. Both of these subjects also presented the closure of the foramen ovale. The umbilical vessels and the ductus venosus were empty and obli- terated in all these subjects. Now it is evident that these ves- sels are obliterated before the foramen ovale and ductus arterio- sus have undergone any complete occlusion, and it can therefore be asserted, that at the third day the ductus arteriosus and fora- men ovale are not generally closed. Infants of the age of four days.—I found in twenty-seven children, aged four days, the foramen ovale open in seventeen. In these seventeen cases, there were six where this opening was very large, and distended with a considerable quantity of blood; and in the remaining number it was slightly open. In the ON THE DISEASES OF INFANTS. 439 twenty-seven cases now under consideration, the closure of this opening had commenced in eight, and it was completely closed in two. The ductus arteriosus was still open in seventeen children; its obliteration had begun, and it exhibited nothing more than a small hole in seven of these, and its closure was complete in three; the umbilical arteries in almost all were obliterated near the umbilicus, but still susceptible of dilatation near the junction with the iliac arteries. The umbilical vein and the venous canal were completely empty, and considerably contracted. Infants ofthe age of five days.—Twenty-nine children, aged five days, were subjected to the same examination as in the preceding instance; thirteen exhibited the foramen ovale still open; but this opening did not exist in the same degree in all. It was largely dilated in four individuals, and in ten others its diameter was much smaller. This passage was almost completely obliterated in ten individ- uals, and in six others sufficiently so, as to leave no communi- cation between the auricles. I found, in these twenty-nine cases, the ductus arteriosus open in fifteen; in these fifteen there were ten where the duct was very large. The obliteration had made considerable progress in the remaining five; and was almost complete, or at least the calibre ofthe duct consisted of nothing more than a narrow hole, in seven ; and in seven others the obliteration was complete. As to the umbilical vessels, their obliteration was complete in all. We have seen, thus far, that the fcetal openings remained free in a number of children five days after their birth. None of the children exhibited any peculiar symptoms which appeared to have their seat in the circulatory apparatus. We shall find the number diminish in subjects of more advanced age than those which have already been the object of our researches. Infants of the age of eight days.—I have not observed any well-marked difference between children of six or seven days, and those which we have just described. This remark, how- ever, is not applicable to those of eight days. Indeed, I have found but five where the foramen ovale was still open in twenty cases that I examined. It was partially closed in four individu- als, and its occlusion was complete in eleven. 440 ON THE DISEASES OF INFANTS. In these twenty children there were but three in whom the ductus arteriosus was not yet obliterated; one of them presented an aneurism of the duct, of the size of a hazelnut; interiorly it was covered with a thick layer of a yellow color and fibrinous consistence, analogous in every respect to those fibrous layers which cover the interior of an aneurisinal pouch. In these twenty individuals, I found in six the ductus arterio- sus almost entirely obliterated, and its obliteration was complete in eleven. The umbilical vessels were perfectly closed in almost all; I say in almost all, because I observed neither the umbilical arteries nor vein in five of them. From the last examination, it appears that the foetal openings are usually obliterated on the eighth day, but they may yet be found open even at that period ; I will also add that even on the twelfth and fifteenth day, and in the third week, the foramen ovale or ductus arteriosus may still be open without the child experiencing any particular symptom ; for I will again observe that I have chosen for these researches children who for the most part died from affections in which the respiratory apparatus did not participate. From this exposition, it is evident that the foetal openings are not obliterated immediately after birth ; that the period at which this occurs is extremely variable, yet the foramen ovale and ductus arteriosus are usually closed on the eighth or tenth day. It results also from the examination which we have made, that the modifications which follow the cessation of foetal life, in the circulatory organs of a new-born child, occur in the following order: the umbilical arteries are first obliterated, then the vein, next the ductus arteriosus, and lastly the foramen ovale. The pre-existence then of the foetal openings for some days after birth ought not to be considered as a disease, since it is not un- common to meet with it without having given rise to any par- ticular symptom. This irregularity or tardiness is attributable, as will be presently seen, to the mode of obliteration. § II. Mode of obliteration of the fcetal openings.— When the arrangement which gradually occurs in the foramen ovale from the earliest months of conception until the period of birth is examined, it will be perceived that the form of this open- ing and the disposition of the surrounding parts, and particu- ON THE DISEASES OF INFANTS. 441 larly that of the Eustachian valve, are such that the blood, which at first flows without any obstacle from one auricle to the other, by degrees experiences some difficulty in its passage. Sa- batier especially has remarked this. Thus the first modification in the organization of the heart forces the blood to change its course; this fluid, in itself inert, is under the immediate depend- ance of the moving power which projects and directs it through the proper passage. If this be so, it must also follow that in those parts which the blood leaves, an anatomical modification occurs, which changes the form and modifies the action of these organs, and produces, in the blood which flows through them, a change of direction. Now if the umbilical arteries and the ar- terial duct are examined, in proportion as they become oblite- rated, it will be seen that their walls gradually become thickened. The thickening of the umbilical arteries is more remarkable at the point of insertion at the umbilicus, at which part they ex- hibit a kind of swelling which very materially affects the calibre ofthe artery, and this swelling appears to be the result of a spe- cies of hypertrophy ofthe yellow elastic fibrous tissue ; whence it follows that the artery exercises at this part a contractile force superior to the dilating power of the blood propelled by the iliac arteries. It is very easy to prove the thickness of the walls of the artery by cutting it in sections at this part; the thickness, it will be also perceived, diminishes in proportion as we approach the iliac arteries, and it is precisely in this direction that the pro- gress of the obliteration is observed to occur after birth. Two conditions, therefore, cause the blood after birth to leave the course it had while in the uterus : 1st, the establishment of res- piration and the pulmonary circulation ; 2dly, the modification of texture occuring in the umbilical arteries. The following phenomenon proves also that the contractility of the umbilical vessels is susceptible of suspending the course of the blood in them ; if the umbilical cord be cut at some dis- tance from the umbilicus at the time of birth in a plethoric child, the blood will at first be seen to issue in a jet with considerable force, then becoming slower, and afterwards stoppino- altogether • if another portion ofthe cord be cut another jet of blood occurs and soon stops. This hemorrhage may be renewed at each sec- tion of the cord. M. P. Dubois has informed me that he has 442 ON THE DISEASES OF INFANTS. seen this frequently occur. Now the course of the blood is in some degree arrested, because the umbilical arteries contract on it and force it to retrogade ; if there exist near the umbilicus and within the abdomen a portion of the umbilical arteries more contractile from the existence of a greater quantity of elastic fibrous tissue, it can easily be conceived that the course of the blood in the child becoming less quick when the calm which occurs after birth begins to be established, these arteries may have power to resist from the first the progress of the blood ; in proportion as the child advances in age, the artery becomes more obliterated, and undergoing a kind of traction from the progressive widening of the abdominal parietes, it loses altogether its vascular form, and is transformed into a true ligament. What is observed in these arteries occurs also in the ductus arteriosus. In the embryo it is as flexible as the other arteries, and is, therefore, as easily dilated by the column of blood which flows through it, which penetrates without any obstacle into the aorta; but at birth, and after this period, the walls of this duct become gradually thicker, and a sort of concentric hypertrophy is developed in them, which, without diminishing in appearance the size of the vessels, nevertheless produces a contraction of its calibre, by which the blood driven from this duct passes through the pulmonary arteries. When the ductus arteriosus has under- gone this hypertrophy and obliteration, I cannot describe it bet- ter than by comparing it to a tube, the circumference of which is very thick, and that presents in its centre nothing more than a small hole.* The obliteration of the vein and duct does not occur in the same manner. These vessels do not exhibit, as do the others, any re- markable thickening of their walls ; the moment the umbilical cord is cut, the vein is no longer susceptible of receiving blood in its calibre, at least except by regurgitation from the vena cava. The sides collapse and approach each other ; they thus come in * These observations are confirmed by those made previously by Dr. Berndt, of Vi- enna, professor of legal medicine, relative to the changes which the ductus arteriosus undergoes after birth,—changes on which the German professor has founded his most conclusive proofs ofthe persistance of life after the birth ofthe child. The history of the closure of the fetal vessels has been also considered by Careano, Trew, etc. V. the article of Dr. Robert Arrowsmith on this subject, in the Journ. Hebdom. de med., t. iii., 1829. ON THE DISEASES OF INFANTS. 443 contact, and the passage is at last obliterated, as is seen in all tubes of every character as soon as they no longer give pas- sage to the fluid usually passing through them. Yet they still preserve for a long time a free passage, for they may easily be distended by introducing into them an ordinary sized sty- let, while this is not the case with the arteries. In the arte- ries there is, if I may be allowed the expression, an active oblite- ration ; the blood has been forced to abandon them by a succes- sion of organic modifications occurring in the texture of their walls, while in regard to the umbilical vein and venous duct, there is a passive obliteration—that is to say, it follows the ab- sence of the blood; it is the result and not the cause of the retro- pulsion of the sanguineous fluid. This difference doubtless de- pends on the difference of organization between the arterial and venous system. If it be necessary that the foramen ovale and ductus arteriosus should undergo organic changes for their oblit- eration, it will be easily understood that nature, so fertile in anomalies, may prepare these modifications either prematurely or tardily; hence the cause of the obliteration ofthe fcetal open- ings from the first in some children, and the persistance of the foramen ovale and ductus arteriosus in others, to a period far re- moved from birth. Hence also the necessity of a greater or less time in most cases for the completion of this obliteration. In this manner can be explained the irregularities of the period of the complete establishment of the independent circulation, without the necessity of considering them as the cause or effect of certain diseases ofthe heart or lungs. The accomplishment of these phenomena of transition must doubtless be attended with an incomplete oxygenation of blood, since all this fluid which the heart propels to the different parts ofthe body has not passed through the lungs. But after all, is it necessary that the blood of an infant just born should be oxyge- nated, equally with that which passes through the arteries of an adult? Would it not rather appear that the tender frame of a new-born child ought not to receive blood possessing too much stimulating properties, that the materials of nutrition should not be too suddenly charged with exciting principles, the action of which on the organs of an infant may be injurious to its health, and to the progressive establishment of independent life ? I am 444 ON THE DISEASES OF INFANTS. of this opinion, and do not think its correctness can be denied, flowing as it does from the anatomical examination of the circu- latory organs of a young child. This assertion is supported by another remark,—the lungs would be exposed to fatal congestions ifthe pulmonary arteries should suddenly throw into them all the blood which flows into the heart. The ductus arteriosus, by permitting the blood to pass through it, comes, as it were, to the aid of the respiratory organs, the congested state of which will not permit the air to arrive freely in the cells; the establishment of independent life is, therefore, actually promoted by the contin- uance of fcetal life. Thus, then, there is a connection between the organization and disposition of parts, and the exercise of their functions, and they follow in a regular order, and by tran- sitions prepared by nature, to the end that no sudden and unex- pected change may interrupt the order and harmony of the phe- nomena of life. If these openings continue beyond the period we have indicated, they may be followed by diseases which we shall consider in the following article. Art. 2. § I. Diseases of the heart and large vessels. Diseases of the heart in young infants, as in adults, consist for the most part in organic lesions, existing at birth, but the effects of which are not manifested until a more advanced age. The history of diseases of the heart does not then belong exclusively to the pathology of children at the breast. I shall therefore con- fine myself to the consideration of those affections of the centre of circulation which are the most frequently met with in young infants. The persistance of the inter-auricular orifice and ductus arte- riosus does not produce, as we have just seen, any particular symptoms during the first days of life, provided it does not op- pose the perfect oxygenation of the blood. But if. at the same time, there exist a considerable sanguineous plethora, this mal- formation, joined to the impossibility or extreme difficulty of the establishment of respiration, hinders the oxygenation of the blood, producing the disease known by the name of cyanosis. Cyanosis—cyanopathia, as M. Marc proposes to denominate ON THE DISEASES OF INFANTS. 445 it,—is a disease which may be observed at all ages, and upon the nature of which Corvisart, M. Gintrac, and M. Marc have pub- lished some interesting reflections, is not the constant result of the persistance of the foramen ovale, nor of the passage of venous blood into the arterial system, since there are a number of exam- ples of malformation of the circulatory apparatus existing which might have produced this phenomenon without its ever having appeared. But this blue coloring of the integuments is probably owing to the mixture ofthe two kinds of blood, or to a defect in the oxygenation of the arterial blood, either on account of the ex- istence of a communication between the two lateral cavities, or of its incomplete oxygenation in the lungs. Thus it is not sur- prising to find in an infant born in a state of threatened as- phyxia, and in whose lungs the air has not penetrated, a sort of transient cyanopathia, which disappears immediately upon the complete establishment of respiration. Corvisart has very hap- pily described the resemblance between the coloring of a new- born child with incomplete respiration, and that of an adult whose heart exhibits malformations or organic lesions, which embarrass or suspend the normal course of the blood. " In com- paring," says this illustrious physician, " the effects produced by the communication established between the right and left cavities of the heart with those immediately resulting from various species of asphyxia, do they not exhibit a striking analogy 1 Is there not something equally remarkable between this state and that which is seen in some children after birth, especially after a more or less tedious labor ? The face has more or less a blue- violet color, and even the body presents the same tint sometimes to a high degree; in all, the body is cold to the touch." In considering the apparently contradictory facts published on the subject of cyanosis, by Duret, Corvisart, M. Marc, M. Bres- chet, M. Fouquier, etc., I think it in our power to draw a conclu- sion of a middle character between that opinion which regards the affection as the result of a malformation of the heart and the opposite ; it is, that cyanosis being to all appearance the effect of a want of oxygenation of the venous blood, it may exist with or without a malformation of the heart, provided the blood, in pass- ing through the lungs, does not undergo the vital and chemical modifications which naturally occurs in them. If, notwithstand- 446 ON THE DISEASES OF INFANTS. ing the communication between the auricles, cyanosis does not take place, it is because the blood passing through the lungs is in sufficient quantity, and sufficiently oxygenated to impart its oxygenation to the venous blood with which it is mixed. On the other hand, if the cavities of the heart are in a normal state, but the peculiar disposition of the lungs does not permit the oxygen of the air to transform the venous into arterial blood, cyanosis will be the result. Whence it follows that this disease is always an indication of a defect in the oxygenation of the blood, whether there exist a malformation of the heart or not. Do we not see in infants in whom the pulmonary circulation is intercepted by an engorgement or an inflammation of the lungs, the alas of the nose, the lips, the face, and even the extremities become bluish— the first degree of cyanosis? And while children affected with pneumonia are in articulo mortis, is it not very common to see every part of the body become livid and blue ? The cause of cyanosis may, therefore, consist in a malformation of the heart, complicated with congestion or inflammation ofthe lungs, or in an affection of the lungs without organic lesion of the heart; and in every instance where it exists, if the functions of the lungs are performed freely, cyanosis, it is evident, cannot occur, because the venous blood receives, by its mixture with the arte- rial, a portion of its chemical and vital properties, which it needed. This explanation is applicable to a great number of cases, but it is necessarily liable to many exceptions; it cannot, for instance, explain the remarkable fact pointed out by M. Breschet, who saw, in a child about a month old, the left subclavian artery arise from the pulmonary artery, without causing the slightest change of color in the left arm, which received no other than venous blood.* Local or general cyanosis, however, in most instances, in new- born children, is the effect of a sanguineous congestion about the heart or lungs, and the best method of relieving it is that recom- mended by Corvisart, to hold the child near the fire, and to rub gently the head and body with hot cloths. This should be per- severingly continued, and is much better than all the aspersions * Ferrus, art. Cyanose, Diet, de med., in 21 vol. ON THE DISEASES OF INFANTS. 447 recommended by accoucheurs.* When it is the effect of pneu- monia, the proper means for treating this inflammation must be adopted, of which it is only a symptom. It is rare to see in children at the breast the different kinds of aneurism which are so frequently met with in more advanced age. In general, the right cavities of the heart exhibit at birth the difference of capacity which they have with reference to the left cavities during life ; this at least is true with respect to most of the infants which I have dissected. Yet I have often seen two ventricles of the same width and same thickness of the walls; but this is much more rare than the preceding. I have seen but one case of passive dilatation of the cavities of the heart in an infant at the breast. This case appeared to me the more interesting, as the child exhibited symptoms analogous to those which are observed in adults similarly affected. CASE LXXVII.—Passive aneurism of the heart.—Marie Lhe- ritier, aged two days, of a good constitution, entered the infirmary on the 1st of September. It was observed that this child was fre- quently attacked with syncope, prolonged to so great a length of time as to produce a belief sometimes that she was dead. The pul- sations of the heart were usually obscure, slow, and irregular; the cry was strong and complete, the percussion of the thorax very so- norous, and respiration could be heard in every part. As there was no other symptom present, she was placed under the care of the or- dinary nurses, in whose charge she remained until the end of Octo- ber. The symptoms of which I have spoken became more fre- quent, and she re-entered the infirmary, presenting a considerable emaciation; respiration was extremely difficult, labored, and occa- sionally suffocating; there was a bluish coloring about the alae ofthe nose and lips, and the syncope occurred two or three times a day. The pulse was small and irregular ; extremities cold and cedema- tous ; cry distressing, and as if dying. Death occurred on the 2d of November, while vomiting brown and bloody matters. On opening the body, there was found a general discoloration of the mucous membrane of the intestines, on the surface of which there was exhaled some black fluid blood. Some tumefied follicular plexuses existed in the ileo-caecal region. The posterior border and the inferior lobe of the right lung were * Corvisart, loc. cit. 448 ON THE DISEASES OF INFANTS. hepatized; the ductus arteriosus was obliterated; the heart was about the size of a hen's egg ; the ventricle and the auricle of the right side formed, as it were, the volume of the organ. Their cavi- ties were very much dilated, and their walls almost as thin as a sheet of paper, whilst the opposite cavities were very much contracted, and their walls hypertrophied; the inter-auricular orifice was almost entirely obliterated ; the orifices and valves of the heart were free; the brain was very firm and much injected. It is probable that the dilatation of the right cavities of the heart of this child resulted from the hypertrophy and contrac- tion of the left, which did not receive the blood, that was obliged to reflow into the opposite ventricle and auricle, and thus inordinately distend them. There occurred in this case that which is observed in adults who exhibit contractions or calcare- ous productions at the valves or orifices of the ventricles or auricles. I have not seen an aneurism of the large vessels at this early age. Once, however, I saw in a child of eight months, who had a protuberance at the dorsal region of the vertebral column, the arch ofthe aorta and the commencement ofthe descending aorta much more dilated than in an ordinary state. This appeared to me to arise from the difficulty with which the blood passed through the vessel, for the artery itself followed the inflexion of the vertebral column. I once met with an aneurism of the ductus arteriosus in an infant at birth ; the following is an account of this case: CASE LXXVIII.—Aneurism of the ductus arteriosus.—On the 25th of October, 1826, there was brought to the Hospice des Enfans Trouves a male infant, aged two days, who, on the following day, was placed in the infirmary. He was of a medium size and constitu- tion ; the respiration was laborious; face livid; cry smothered ; tem- perature of the body natural; pulse small, frequent, and easily com- pressed. This child remained two days in the same state, and died on the third, without having presented any other symptom than those just indicated. On examining the body, the mouth and oesophagus were found healthy ; the intestinal tube the seat of a very great san- guineous congestion ; the liver was gorged with blood, as were also the two lungs. The heart was larger than is usual for an infant at birth; the two ON THE DISEASES OF INFANTS. 449 lateral cavities were nearly equally dilated, and were filled with black clotted blood; the ductus arteriosus existed in the form of a large cherry-pit; its transverse diameter was about three lines and a half, and its circumference nine ; from an external examination it appear- ed to open widely into the aorta; this size, however, existed only exteriorly, for the interior of the tumor was filled with fibrous clots, organized and disposed in layers, as is seen in aneurismal tumors of adults, leaving in the centre a very small hole. The other organs of the body exhibited nothing peculiar. I do not believe that the symptoms observed in this child were the effect of this aneurism of the ductus arteriosus ; it can be more easily accounted for by the state of the lungs, and I do not think that any external sign could reveal the existence of this dis- ease. I have only recorded it as a case of rare occurrence. M. Baron informs that he has also met with a similar case of aneurism in an infant, where the symptoms also presented nothing peculiar. Inflammation of the heart and large vessels in infants at the breast is very rare, and doubtless very difficult to ascertain. I am not in possession of any positive data on this pathological point; I shall confine myself here to some observations on the color of these organs. The external surface of the heart is usually of a deep red in young infants, and its extreme paleness ought to be regarded as an abnormal state. The internal surface is also of a red color, more or less deep, and sometimes there is a marked difference be- tween the two ventricles ; the right cavities are of a violet, and they have been seen of the color of Campeachy wood, while the left cavities preserve their ordinary red aspect. In these cases the venous blood predominates; the larger vessels are gorged with it, as well as all the tissues ; putrefaction, even when much advanced, does not produce the same effect; and it does not show itself more in all subjects where there exists a consider- able venous congestion. This difference of color, which I have also observed in adults, arises from some cause with which I am unacquainted: I shall therefore confine myself to pointing out the effects of it. The vascular system of a young child is remarkable for its habitual sanguineous turgescence ; it is also very common, in young infants, to meet with engorgements, ecchymoses, and san- 0 450 ON THE DISEASES OF INFANTS. guineous effusions indifferent parts, but paiticularly in the most dependant, and in those where there is much cellular tissue. The vessels, notwithstanding their fulness, are not always colored with the blood contained in them; and when their branches are followed into organs, the tissue of which is impregnated with a large quantity of blood, they are often seen almost white, or of a slight rose color, in the midst of the tissue. I have been led to this remark by the anatomical researches which I made to satisfy myself whether these vessels in young infants partook of the coloring of the organs to which they passed, as M. Trousseau has observed was the case in a number of animals he examined. § II. Pericarditis. If inflammation of the proper tissue of the heart is rare or dif- ficult to prove in young infants, inflammation of the pericardium is more common. Perhaps it is even more frequent at the first period of life than at any other; in nearly seven hundred post mortem examinations which I made at the Hospice des Enfans Trouves, I have seen seven well-marked cases of pericarditis. The causes of this disease are difficult to explain, particularly if we compare them with those which produce it in adults. It is well known that Pinel has pointed out among the causes the immoderate exercise of the mental powers, and in support of this assertion has cited the history and death of Mirabeau, whose youthful hilarity and great moral activity appear to have, for a long time, disposed him to the pericarditis, which caused his death ;* but nothing of this kind is to be observed in the vegeta- tive life of new-born children, who, however, die of this disease. It is sufficient, then, that the functional activity of the heart is increased, and the irritability of the organ redoubled, for its serous envelop to become inflamed and give rise to the most serious ac- cidents. This is undoubtedly the cause of the frequency of this disease in those affected with aneurism, and in nervous females who are subject to palpitations. The symptoms of pericarditis in young infants are not easily recognised, because they may be confounded with those of pleu- risy, meningitis, or gelatinous softening of the brain. * Nosographie philos., t. ii., p. 44. % ON THE DISEASES OF INFANTS. 451 In general, children affected with this disease appear to expe- rience violent pain; theircry is painful; respiration labored and sometimes suffocating ; the face is pinchpd ; the muscles of the face appear to be constantly contracting. 1 have, in two instan- ces, seen spasmodic movements of the limbs. Pericarditis is usually very rapid in its progress, and children die without ex- hibiting symptoms more strongly marked than those just described. It is, then, almost impossible to make a diagnosis of this disease; yet we may make a remark with regard to the subject before us : it is, that when there exists a state of general restlessness, dis- tress, and suffering, in young infants, there is almost always a gelatinous softening of the stomach, pericarditis, or acute pleuri- * sy; and our judgment must be directed to a decision between these three different diseases, when we see these symptoms in a young infant. The pulse does not exhibit any thing worthy of remark ; it is the same with regard to percussion and ausculta- tion ; and therefore in every case of pericarditis which I have seen, it has not been possible to establish, by evident signs, a diagnosis of the disease ; the post mortem examination alone has demonstrated its existence. I once saw, in an infant two days old, firm adhesions between the layers of the pericardium, producing the belief that they were the product of a former pericarditis, developed during the evolution of the fcetus. In six other cases there was a sero-albu- minous effusion in the pericardium, white flakes adhering to the surface of the heart, and very slight bands between the two larger layers of the cardiac envelop. The pericardium and the external surface of the heart very often present, in young infants, violet-colored petechia ; a sero- sanguineous effusion, or even an effusion of pure blood, ordina- rily accompanied this petechial eruption. I do not think that this lesion ought to be attributed to inflammation ; it appears rather to be the effect of passive congestion. In general there is almost always found a certain quantity of serosity in the pericar- dium of young infants. If it be possible to detect the existence of pericarditis, the treatment of it should be the same as that of pleurisy. The thymus gland is susceptible of being affected with certain diseases during the short space of its transient existence. I have 452 ON THE DISEASES OF INFANTS. never been able to observe any peculiar symptoms belonging to these affections; but on opening the bodies of children, I have seen it in two instances much tumefied, very red, and extremely friable. I considered it as the result of an inflammation which perhaps might have led to its suppuration or disorganization. M. Veron reported, in a memoir read by him to the Academie Royale de Medecine, at its sitting on the 26th of April, 1S26, an instance of an inflammation of this gland, with the formation of pus in the interior of this organ. I shall here finish my remarks on the inflammatory diseases of the respiratory and circulatory apparatus in sucking children. I ought perhaps to treat of emphysema of the lungs, asthma, and nervous affections of the respiratory organs generally; but em- physema of the lungs, although common in young infants, does not produce any peculiar symptom ; and further, nervous affec- tions of the circulatory apparatus do not belong exclusively to the diseases of infants ; the history, therefore, of these affections should be referred more especially to works of general pathology, or to treatises particularly devoted to the diseases of the thoracic organs. CHAPTER X. DISEASES OF THE CEREBRO-SPINAL APPARATUS. If there be one point in the pathology of new-bom children which can demonstrate the utility of considering together the science of organization, and the clinical observation of diseases, it is the history of the diseases of the encephalon. We shall see, indeed, what important modification of the organic condition of the brain of young infants is caused by the progress and nature of their cerebro-spinal diseases. Let us commence by taking a rapid view ofthe development ofthe spinal marrow and brain. A great number of authors, from the time of Galen, have con- sidered the medulla spinalis as an appendage to the encephalon; but Gall has revived the contrary opinion, which had been sup- ported by Plato. Praxagoras, and Philotenus; and the immortal ON THE DISEASES OF INFANTS. 453 works of Tiedemann confirm this idea of Dr. Gall. It is now demonstrated that the medulla spinalis is developed before the cerebrum, which is the expansion of the spinal marrow, and which originally is very small compared with the spinal prolon- gation. About the third or fourth week, there is perceived in the cavi- ties of the head and spine a grayish fluid; from the fourth to the fifth week, the medulla oblongata is distinctly seen, bending forward at the place of the union of the head with the spine ; at this time, the spinal marrow is formed of two white threads, which gradually inclining backward form a kind of longitudinal groove, so that at seven weeks the medulla spinalis appears cleft in its whole extent; the rudiments of the cerebellum are then for the first time to be seen, and the cervical swelling coinciding with the appearance of the superior extremities. At the begin- ning of the third month, the medulla spinalis is still open at its upper half, and exhibits nothing more in the remainder of its extent than a longitudinal raphe, which is the mark of reunion ofthe two primitive cords ; the tubercular quadrigemina are large, the thalimi nervorum opticorum perfect, and the enlargement of the medulla very evident; at the twelfth week, the spinal marrow extends only halfway down the sacrum, the tubercula quadrige- mina are united, and the medullary eminences are easily distin- guished, together with the corpora striata. There exists an inter- nal canal produced by the turning over of the borders of the medulla, which communicates with the fourth ventricle. This canal is obliterated by the formation of the cineritious substance, which is secreted in the interior, so that at the sixth month it is no longer found in well-formed embryos. At the fifth month, the corpora pyramidalia, pons variolii, and corpora striata, are very large, and the human embryo exhibits a caudal prolongation; it quickly diminishes as the development and elongation of the vertebral column, according to Tiedemann, rapidly takes place, whilst the medulla spinalis continues fixed in its place. At the eighth month, the spinal cord extends only to the fourth lumbar vertebra; it terminates in small nervous filaments, constituting the cauda equina. Finally, at birth the medulla spinalis and medulla oblongata, which is an appendage to it, exhibit their constituent parts very distinctly formed. 454 ON THE DISEASES OF INFANTS. In fact, the corpora striata are observed forming a well-marked lateral projection, the cords of which penetrate into the thalami optici from the crura cerebri; and the pons variolii is found composed of fibres from the lateral parts of the cerebellum, and of those coming from the opposite hemisphere, and which are disposed in layers alternating with fibres directed obliquely from the corpora pyrimadalia to the thalami nervorum opticorum. While the medulla spinalis is undergoing these different evo- lutions, the cerebrum and cerebellum gradually acquire their proper form and organization. The cerebellum, which at first consists only of two lamina? turned towards each other, is pro- duced by the enlargement of these two laminae, which arise and are united above the fourth ventricle, and by degrees are ar- ranged in branches and twigs, which are seen in the substance of this organ. From the corpora pyramedalia arise the thalami nervorum opticorum and the corpora striata, which terminate on the outside by a lamina, which is observed to be reflected from before backward, and from without inward, to form the cerebral hemispheres. These membranous hemispheres are so short at the second month, that they scarcely cover the corpora striata; but in pro- portion as they increase in size they successively cover the tha- lami nervorum opticorum, the tubercula quadrigemina, and lastly the cerebellum. It is their inflexion on themselves which gives rise to the lateral ventricles. From this short view of the formation of the medulla spinalis and encephalon, we see that the cerebral mass is produced by the spinal marrow, of which, as Reil has observed, it is an efflorescence.* If this be true, the medulla spinalis and medulla oblongata would at the period of birth exhibit an almost perfect develop- ment, and in the fulfilment of their important functions, whilst the cerebral lobes, less useful at this period of life, would be less advanced in organization; this is indeed what really exists. M. Tiedemann has remarked, with much reason, that in infants of the age of six, seven, eight, and nine months, the brain ex- * For further details on the formation of the encephalon, consult Tiedemann, Ana- tomic du cevreau contenant Vhistoire de son developement dans le fatus; translated by A. G. L. Jourdan. Paris, 1823—Ollivier, Traite de la moelle epiniere et de ses maladies. Second edition. Paris, 1827.—Serres, Anatomic comparce du cerveau. ON THE DISEASES OF INFANTS. 455 hibits a homogeneous substance of a light red, in which it is diffi- cult to distinguish the cineritious from the medullary substance. From numerous dissections, 1 am satisfied of the correctness of the assertion of M. Tiedemann. The following are the results of my researches on this subject :* In a child just born, the medulla spinalis is white, its cineri- tious centre is not altogether of the same color as in the adult, but is more of a rosy hue, and softer. It is easy to unrol the two lateral cords of which it is formed. Its consistence is suffi- ciently firm to. allow of its being cut smoothly. The brain of a new-born child only resembles that of an adult in its general form ; it differs entirely in its consistence and as- pect. Its consistence is like that of paste, and will allow of being cut tolerably smooth ; but it soon softens when in contact with air; its color is white, and there exists as yet no well-marked line of demarcation between the cineritious and medullary substance, so that in cutting the hemisphere horizontally, the centrum ovale does not appear as in adults. Yet the seat of the cortical substance may be discovered by the presence of a line less colored than the central substance, and which winds over the superficies of the brain throughout its circumvolutions. The white substance of the brain is generally very much injected, or has a large number of vessels passing through it. " In every part where we have found the gray substance accumulated in considerable masses in the adult," observes M. Tiedemann,t " as in the cerebral peduncles, corpora striata, thalami nervorum op- ticorum, &c, I have observed only that the vessels were larger and more numerous than in those which are composed of me- dullary substance, after the period of birth. The parts which correspond to the corpora striata in the brain of a foetus are com- posed of a white homogeneous substance, with a reddish tint, and penetrated by a number of large vessels. The cerebellum also does not present between these two substances as marked a difference as at a more advanced age; but yet they are more easily distinguished, and appear much sooner than in the brain." * These details are inserted by Professor Orfila, in the 1st vol. of his Lecons de medicine legale. Paris, 1828. t Anatomie du cerveau contenant Vhistoire de son developement dans le foetus, etc.; translated by A. G. L. Jourdan. Paris, 1824, p. 120. 400 ON THE DISEASES OF INFANTS. As the child advances in age, the various constituent parts of the brain assume an aspect, form, and anatomical organization which they are to have during the remainder of life. From the ninth month to one year, the gray substance acquires a degree of vital energy, which doubtless results from the modification occurring in its texture ; it first appears of a rose-color, then red, brown, and lastly, of a reddish gray. It is to be observed that the parts of the cerebral mass which are the nearest to the medulla oblongata are also more advanced in their organization than those more remote—a natural consequence ofthe mode of organization ofthe cerebro-spinal apparatus, the development of which passes progressively from the medulla spinalis towards the encephalon. It appears, therefore, that, from birth to the age of one year, the brain of a child is in a true state of transition, and that this organ, scarcely perceptible in the beginning, reaches its proper organization about the ninth or twelfth month. Is it not owing to this modification occurring in the brain of a child that the frequency of cerebral affections at this age is to be ascribed ? h happens also that at this period the teeth first make their ap- pearance, and it has long been believed that convulsions and other cerebral diseases are to be attributed to this cause. This opinion, found in the writings of Hippocrates, doubtless derives its principal support from the respect and authority which the name of the father of medicine usually inspires. But whatever Hippocrates may have said on this subject, it is evident that the true cause of the frequency of cerebral affections in infants at the period of dentition, is in the brain. Dentition can be only one of the accidental causes of cerebral diseases ; the predisposing cause exists in the organic modifications supervening in the en- cephalon, and it is to this part that we ought to direct our treat- ment. Not only has the brain undergone, during the first year, the organic modifications just pointed out, but the exercise of its functions has also increased; it has gradually acquired its con- trol over the other organs, and it has become fit to receive from them the sympathetic indications with which it was before unaf- fected ; it is the centre and regulator of the sensations, and this influence is felt even in disease; we frequently see, during the first periods of life, great alterations in the organs, unaccompa- nied by any febrile reaction, any general symptom, or any mor- ON THE DISEASES OF INFANTS. 457 bid sympathy; but at the age of which we are now speaking, every thing assumes a new aspect; feyer, which is scarcely ever seen in new-born children, here makes its appearance on the slightest cause; hence the restlessness, cries, spasms, nervous mobility, so common, so easily excited, and at the same time so transient, in children who have passed the period of infancy. These considerations will prove to us the difficulty of studying the diseases of early infancy; the cause is evidently in the or- ganic imperfection of the encephalon, which cannot reveal to us the signs and external symptoms of these diseases. Whilst the medulla spinalis is undergoing its organization, the vertebral column has also passed through its periods of forma- tion in nearly the same manner. The spine, according to Meckel, is, in the beginning, in the form of a groove, continuing open posteriorly for some time, and which closes by the union of the lamina of the spinous processes. The cranium is, at first, entirely membranous ; its ossification commences early about the foramen magnum ; the different bones composing it exhibit in the centre a primitive point of ossification, extending by radia- tion towards the circumference of the bone, the borders and an- gles of which are still separated at the period of birth, by cartila- ginous or membranous intervals, which permit the different parts of the cranial cavity to move over each other with great facility. The membranes of the spinal marrow and brain are formed very early, and present their peculiar disposition and form, so that at birth they possess all their vital and organic properties; their diseases, therefore, are similar to those of the meninges in adults, giving rise to nearly the same symptoms. The arrangement of the vascular system of the brain and spi- nal marrow deserves the attention of physicians, for the disturb- ances which supervene in the cerebro-spinal circulation may arise from the disposition of these vessels. There are the large meningo-spinal veins which pass up through the lateral parts of the spine, and also a network of veins, described by M. Breschet, between the dura mater and the posterior surface of the vertebras. Besides these, there are veins of which M. Dupuytren has given an account under the name of Medulli spinales, and M.. Chaus- sier under that of Medianes rachidiennes, particularly destined 58 458 ON THE DISEASES OF INFANTS. to the spinal marrow. There is also behind the dura mater a thick layer of cellular tissue, which, in young infants, is infil- trated with a yellow serosity, the consistence of which is some- times gelatinous, and must not then be considered as a morbid production. The network of spinal veins is almost always en- gorged with blood, arising, without doubt, from the lentor with which the venous circulation of the spine is affected at this pe- riod of life; the arteries present nothing peculiar. M. Magendie has recently observed that there exists between the pia mater and the tunica arachnoidea, which is reflected on itself, a space of greater or less size, which, as M. Ollivier remark- ed, is interrupted at intervals by small thin ligaments, and where there is constantly during life a serous fluid, communicating, as M. Magendie observes, with the fluids of the cerebral ventricles ;* the pia mater, which is essentially vascular, while the tunica arachnoidea is without vessels, is less adherent to the surface of the brain in children than in adults; it has likewise been re- marked that the pia mater of the medulla is more cellular and solid than that of the brain, and Bichat has observed that this membrane becomes thicker at its inferior part; in order, there- fore, to satisfy ourselves ofthe state of softness or firmness ofthe medulla spinalis, we must always remove from it the pia mater, which can easily be done. The brain and spinal marrow are, during life, in a state of continual movement, elevation, and depression ; the motion of the spinal marrow was a long time unknown ; the demonstra- tion of it is due to M. Ollivier, and who has, I think, very satis- factorily explained its mechanism. There are, says he, three very evident causes which produce the motion observed through- out the whole length of the spine; first, the shock of the part from the action of respiration on this organ, next the dilatation ofthe vessels when there is an afflux of blood, and lastly, the motion ofthe spinal fluid by each respiration.! The primary anatomical and physiological data being estab- lished, let us pass to the study of the congenital malformations of the cerebro-spinal apparatus. My object is not to give a com- * Journal de Physiologic Exper. et Path., tome v. t Olliv. loc. cit., page 43. ON THE DISEASES OF INFANTS. 459 plete history of them, but to consider them in their relation to the symptoms ofthe diseases of infants. Congenital malformations.—The complete absence of the medulla is called amyelia; it would appear that its absence is always coincident with that of the brain. Morgagni has given several instances of the simultaneous absence of the brain and spinal marrow. M. Ollivier has reported, in the scientific jour- nals, nearly all the facts upon this subject, and it has been re- marked that, in nearly all the individuals affected with this de- formity, spina bifida was found more or less complete. Yet it must not be concluded from this that the absence of the parts contained will always produce that of the containing parts, as MM. Serres and Geoffroy Saint-Hilaire have thought. Still the coincidence is not uncommon. Every thing leads to the belief that the absence of the medulla is the result of disease rather than the effect of an arrest of development. I shall not consider the reasons with which Beclard, MM. Meckel,* Ollivier, Duges, and a number of others, have adduced in support of this opinion. I will only observe that there are many cases in confirmation of it. The medulla spinalis may exhibit a deformity at its upper ex- tremity ; in the case of anencephalia, the pons varolii exists, or may present nothing more than the rudiments; sometimes the spinal cord exhibits a trace, more or less deep, of its division into two lateral portions, or it is suddenly obliterated near the fourth ventricle. Children affected with this deformity do not die im- mediately after birth, for the heart and lungs, which receive their nervous influence from the upper portion of the medulla, may perform their functions for some time in a manner that will preserve life for many days. Indeed such children have been seen to respire, cry, suck, and swallow. The division of the medulla spinalis into two lateral cords, to a greater or less extent, which Zacchias, Manget, and Hall have pointed out, and which I also have given an instance in the work of M. Ollivier;! may exist with complete spina-bifida, although the skin may be perfect at the place of the separation of the ver- tebra ; this malformation will not allow of the establishment of * Manual of General, Descriptive, and Pathological Anatomy. Philadelphia, 1832. t Loc. cit., t. i., p. 167. 460 ON THE DISEASES OF INFANTS. independent life, and children thus affected die immediately after birth, or give no sign of life ; another malformation consists in the doubling of the medullary portion, and is particularly met with in foetuses that are double. Lastly, in the centre of the medulla spinalis may be a canal, the effect of a mechanical dis- tension which this organ may experience from the serosity accu- mulating in the centre of the cerebral cavities, in cases of hydro- cephalus or hydrorachis. Hydrorachis consists in one or more tumors situated in the vertebral column, over an opening between the spinous process- es, resulting from an accumulation of serosity contained in a sac formed by the skin and the meninges. In hydrorachis, the tumor may be situated at the superior, middle, or inferior part ofthe vertebral column ; its form may be of that of a chestnut (marronee), oblong, irregularly round, or multi-lobed ; its consistence that of a cyst, enclosing a fluid which disappears more or less on slight pressure, flowing, no doubt, to- wards the brain. This pressure is generally painful. Where- ever it may be seated, it exhibits three stages or varieties of as- pect, of which the distinction is really of practical utility. 1st, The skin covering it is healthy, like that of the other parts of the body ; the seat of the disease, the fluctuation, and the sensa- tion of an opening between the vertebras, are the only signs by which the existence of hydrorachis can then be ascertained. This variety evidently demonstrates that the skin concurs in the formation of the walls of the tumor. This form of the disease is less dangerous than the others, and may continue a long time without any serious consequences. 2dly, The skin is sometimes very thin and transparent, and crossed by purple lines ; in some cases there oozes out a sero-purulent or sanguineous fluid, which indicates the approaching rupture of the tumor. 3dly, The tumor may be open, presenting, at the bottom, a very fine perfo- rated membrane, and allowing of the escape of a quantity of va- riable fluid. There is a red rugous ring surrounding this rup- ture, formed by the skin and subcutaneous tissue. This ring is harder where it is near the edges of the vertebral bifurcation. The two last varieties are much more common than the first; and as infants are almost always born with spina-bifida in a state of ulceration, some authors have thought that the skin formed no ON THE DISEASES OF INFANTS. 461 part of the walls of fhe sac. In seven cases of spina-bifida, ob- served in the wards of the hospital, in 1826,1 saw two where the tumor was covered by perfect skin ; one of these children lived two months, and died from pneumonia. In the other, the tumor was ulcerated, and by degrees assumed the apearance which it usually has. The opening of the tumor accompanying hydrorachis, is al- ways a most unfortunate circumstance, for inflammation of the meninges quickly follows, and all its train of bad consequences, even death itself. If a child, therefore, be born with an ulcera- ted tumor, but incompletely perforated, it ought not to be opened in order to effect a discharge of the fluid. Morgagni has reported a fatal instance from this operation, which an ignorant physician performed, in opposition to his advice; scarcely was the tumor opened when the child became prostrated, and on the third day died. " Non vixit autem ad totum terlium ab inciso tumore diem. Ex quo enim hie incisus est, nunquam flere et clamare destitit, qui anted hilaris csset ac ridibundus et mamman fere arevsari cujus semper appetens fuisset."* In seven children affected with hydrorachis and spina-bifida, who died, there were five who exhibited spinal meningitis. Those in whom the tumor was not perforated, remained for some time without exhibiting the slightest symptom ; but immediately after the destruction of the walls of the cyst, the fluid flowed out and convulsions followed, which continued until death ; where there has existed a perforation ofthe tumor, the convulsions have com- menced at birth, and continued until the death of the child; it is evident, then, that death in this case was caused by spinal meningitis, which soon extended even to the brain. In dissecting the vertebral column and the tumor of the chil- dren affected with spina-bifida, I found in five of them an abun- dant effusion of serosity in the scull and spine, so that it is pro- bable that the separation of the vertebrae, and the tumor follow- ing it, are the ordinary results of this accumulation of serosity, or of this encephalo-spinal dropsy. In two children in whom the tumor, which was small in size, was situated in the sacral region, and which was covered with unbroken skin, the brain was per- fectly healthy, the ventricles had not been distended, and there * De sed. et caus. morborum, lib. 1, epist. xcii., p. 193. 462 OX THE DISEASES OF INFANTS. existed no serosity except in the spine. The medulla spinalis was perfectly healthy. Does not this integrity of the brain, which coexisted with the slightly advanced stage of the tumor, prove that the disease commences sometimes in the spine? 1 have investigated with great care the seat of this serosity, and it appeared to me to exist in the cavity of the tunica arachnoidea. In one instance, it was between the tunica arachnoidea and the pia mater. The seat of this dropsy will therefore be different from that of the cerebro-spinal fluid of M. Magendie ; and would not this circumstance lead to the belief that there exists a serous fluid, not only between the arachnoid membrane and the pia mater, but also in the arachnoid cavity itself? I did not find this fluid thick, turbid and floculent, except in the five cases where symptoms of meningitis existed. It was limpid and without floculi in two others, where death occurred from another cause. I have not always found a perfect communication between the spinal and cranial fluid. The following case exhibits, in this respect, a very peculiar disposition. CASE LXXIX.—Alexandrine Depuis, aged two days, entered the infirmary on the 7th of May; she was small and very feeble. She had, at the lower part of the back, an elongated tumor, an inch and a half long and an inch wide, the walls of which, without being open, were purple and very thin ; she was not affected with convul- sions ; the limbs were cedematous ; and the cry, at first strong, be- came by degrees husky and stifled. This child died on the 8th of May. On a post mortem examination, the oesophagus was found ecchymosed ; the stomach and intestinal tube slightly injected ; the liver healthy ; the gall-bladder empty ; the left lung engorged ; and at the commencement of hepatization, the heart gorged with blood; the ductus arteriosus widely open. Around the spinal tumor there existed some blood effused in the cellular tissue. The separation of the vertebra? existed at the lumbar region ; the fluid contained in the tumor was bloody ; it was easily made to flow through the whole length of the spinal marrow, and it evidently flowed between the tunica arachnoidea and pia mater. The lateral ventricles contained fluid which, instead of being red, was, on the contrary, of a trans- parent citron color. This fluid penetrated into the middle ventri- cle, and the aqueduct of Sylvius, a little dilated, permitted it to de- scend into the fourth ventricle, beneath which was a small red pouch, ON THE DISEASES OF INFANTS. 463 thin and flexible, about the size of a small hazelnut. It formed a cul-de-sac, which interrupted all communication between the brain and spine ; when it was pierced, the fluid flowed out, and it im- mediately collapsed. This case exhibits to us a double peculiarity; the seat of the effused fluid, which was found at the place of that described by M. Magendie, and the evident interception between the brain and the spine. I found, in another child who died of hydrorachis. the fluid effused throughout the spine of a yellow color, and having left a deposit of the same color on the surface of the meninges, whilst the serosity of the brain was as clear as it usu- ally is. Although these facts appear to be contradictory, yet we can as- certain from them one consequence, that the fluid of cephalo-spinal dropsy is sometimes effused between the tunica arachnoidea and the pia mater, and sometimes between the two folds of the tunica arachnoidea ; it is even probable that the source of the secretion is in the canal described by M. Magendie, and that it is intro- duced either by ruptures of the arachnoid membrane, or by exuda- tion on the outside of the canal, which had become too narrow to contain it. Such, also, is the opinion of M. Ollivier. The com- munication of this canal with the brain appears contradicted by the fact which I have just stated ; yet, as it is the only one, so far as I know, which has yet been published, I regard it as a simple exception. Besides, it may be observed that the large and free communication existing in the case of spina-bifida, be- tween the brain and spine, is always the effect of the progress and of the abundance of cerebro-spinal effusion. The medulla spinalis usually remains healthy in the midst of this effused fluid; sometimes, however, it is found soft, like the walls ofthe cerebral ventricles in hydrocephalus. It may at the same time present some of the malformations which we have pointed out. There are generally no symptoms, when the tumor has no communication with the air, and when the fluid does not com- press the brain or spinal marrow so as to interfere with the ex- ercise of their functions. Individuals with this disease have lived to quite an advanced age without experiencing any unto- 464 ON THE DISEASES OF INFANTS. ward consequences; but when the tumor is open, spinal menin- gitis, which soon supervenes, gives rise to all the symptoms which it usually produces. Gentle and gradual compression of the tumor is the only treatment that can be adopted; for experience has not as yet justified either the practice of opening the tumor at several in- tervals with a fine needle, nor the method of passing a seton through it: for inflammation of the meninges almost always soon follows such a practice. Among the congenital diseases of the medulla spinalis, may be mentioned an icterous affection of this part, and which M. Lobstein has described recently under the name of kyrronosis, and of which he has seen two instances in embryos of five months.* This author is of opinion that it is a disease peculiar to the first period of intra-uterine life; but I shall give several instances of a yellow coloring of the brain and spinal marrow, when speaking of icterus, which appear to me to have a great analogy to the kyrronosis of M. Lobstein. The disease may, therefore, be observed at other periods than those indicated by the learned anatomist of Strasburg. Cono-enital malformations of the brain and cranium are of frequent occurrence. I do not intend here to give their history, causes, mode of formation, and nomenclature, but only to con- sider them hastily in their relation to the study of the symptoms belonging to the diseases of young infants. Acephalia, which consists in the absence ofthe brain and even of the medulla oblongata, is seen only when the head, face, and upper part of the neck are wanting at the same time ; in such a case life cannot be established, and the fcetus had only existed by its communication with the circulatory apparatus of its mo- ther, dies as soon as this communication is broken off. The respiratory and circulatory apparatus are at the same time want- ing, or are incomplete. Anencephalia also deserves our attention. It consists in the absence of one part of the brain, with or without the absence of the cranial cavity. It is so common to meet with a deformity ofthe cranium, with a deformed brain, that the most celebrated anato- * Repertoire oVanatomie general, 1st vol. Paris, 1826. ON THE DISEASES OF INFANTS. 465 mists, and among them M. Geoffroy St.-Hilaire, have established it as a general law that when the containing part is deformed or wanting, all the contained parts are at the same time but little developed, or are badly formed. But several contradictory facts have already disturbed this principle, and I could myself give a very remarkable instance. Anencephalia presents different degrees. It exists from a spe- cies of atrophy of the cerebral hemispheres, which is seen in ideots, to the complete absence of the cerebral mass. I have seen it in several degrees. Thus, I once saw a child where the forehead and summit of the head were considerably flattened. From this disposition of parts, M. Baron made a diagnosis of the existence of anencephalia, having in others observed the same with an absence of brain ; and upon a post mortem examination we found only the cerebellum, thalami nervorum opticorum, the third and fourth ventricles: the fornix was separated at its middle. The posterior part of the hemispheres was sufficiently developed, but they were deficient anteriorly, leaving exposed the anterior part of the lateral ventricles. This child lived forty days, cried, respired, and sucked without difficulty; this case has been reported at length in my thesis.* I have also seen a child who came into the world with the cranium very irregu- larly developed ; there was no doubt of this being a case of anen- cephalia. It died in three days, and on opening the cavity of the cranium, instead of finding the brain regularly formed, there was only a sac formed of the meninges, on the surface of which the vessels appeared as usual; this sac contained a bright yellow fluid, liquid and inodorous, like serosity. When it had flowed out, the cerebellum could be seen at the bottom of the cranium, covered by the tentorium, the rudiments of the falx cerebri, the medulla oblongata, the thalami nervorum opticorum, and the corpora striata; on the outside of these floated some pulpous fragments, which appeared to be the rudiments of the cerebral hemispheres. The pia mater, which formed the internal tunic of this cerebral cyst, was covered here and there with a great * See the dissertation on viability at the end of this work. d9 466 ON THE DISEASES OF INFANTS. number of pulpous and cerebiform flakes, which it was said had been secreted by it.* In this case, notwithstanding the integrity ofthe bones of the cranium and the considerable number of vessels of this organ, the brain only existed in a very imperfect state, and exhibited the deformity peculiar to anencephalia. Anencephalia had not in this instance been caused by any exterior mechanical influ- ence, nor by default of development of the vascular system, which, according to the doctrine of M. Serres, exists before the formation ofthe organs; and every thing leads to the belief that a dropsical or some other disease of the brain had suspended its development, or had caused its disorganization, at a period more or less remote from its formation. But what is more important for us to note is the entire absence of all symptoms which would enable us to recognise the existence of this disorganization, and the continuance of life for so long a time, with the absence of so great a portion of this important organ. The most usual degree of anencephalia is that where the cra- nium and the brain are both wanting, the upper part of the cra- nium being open; the ossa frontis are wanting, or are much mutilated, and there is scarcely a trace of the ossa parietalia. A shapeless cerebral mass, covered by red and bloody membranes, is situated at the base of the cranium, which is usually found nearer the shoulders than in a natural state ; the projection of the orbitar arches and of the eyes, the face which presents some analogy to that of the head of certain of the lower animals, to which the vulgar will sometimes compare these children ; such are the ordinary traits of an anencephalous infant, in whom is often found nothing more than the medulla oblongata, and some- times the cerebellum, and the remains of the thalami nervorum opticorum and corpora striata. The causes of this organic devi- ation have been very learnedly discussed by Haller, Sandifort, Soemmering, Klein, Otto, Meckel, Tiedemann, Beclard, Breschet, Geoffroy, St.-Hilaire, Serres, and Andral. The analytical ex- amination of the facts which they have made known, and the consequences which they have deduced from them, would re- * M. Breschet has given some analogous facts in the article Hydrocephalic, in the Diet, de med., in 21 vols. ON THE DISEASES OF INFANTS. 467 quire along dissertation, and lead us too far from the main object of this work. 1 will therefore draw but one conclusion, which is, that most anencephalous children, even though born before the full time, and being otherwise well constituted, have for the most part lived one day, and even for a longer time; and have thereby proved that it is sufficient for the medulla oblongata and medulla spinalis, whence arise the nerves essential to organic life, to be in a certain state of integrity, to preserve life during the foetal evolution and for some time after birth. Congenital hydrocephalus is in all probability the result of an inflammation ofthe meninges during intra-uterine life, or of some malformation difficult to ascertain, bearing some resemblance to a nutritive hyperthophy of the encephalon. This idea is favored by the development of the cerebral mass and the bones of the cranium in hydrocephalic foetuses. These bones acquire a breadth and thickness, not only resulting from inflammation of the meninges, (this circumstance alone cannot explain the phe- nomenon,) but it evidently shows an increase of nutrition, which may be regarded as one of the causes of hydrocephalus. It is worthy of remark, that after birth, children, where the brain and cranium are very much developed, are also much exposed to hydrocephalus. The vital activity, or the power of nutrition developed with more energy than in a natural state, ought doubt- less to be taken into consideration, as one of the possible causes of congenital hydrocephalus. There are, however, different varieties of hydrocephalus: that where the cranial cavity takes no part in the dropsy of the brain, the substance of which is found to be more or less destroyed, and this was the case in the instance of anencephalia which has just been mentioned; that where hydrocephalus supervenes at a more advanced stage of fcetal formation, and the cranium and brain are destroyed or deformed; and lastly, the most common form of the disease, that where there is with it a considerable develop- ment of the bones of the cranium; this last variety appears to me evidently owing to a kind of cerebral and cranial hypertrophy, not observed in other cases. This nutritive hypertrophy, by in- creasing the power of formation in the encephalic mass, will augment the activity of the secretion from its membranes; hence 468 ON THE DISEASES OF INFANTS, the abundance of fluid at the same time that the organ augments in volume. The causes of the normal development of the viscera are con- nected by insensible degrees with the causes of their anomalies, and it is easily conceived how it happens that this species of ve- getative life with which our organs are endowed at the period of their formation, on receiving an increase of energy may, in some way, pass the limits of their regular state, and thus cause con- genital malformation, which ought not always to be attributed to diseases similar to those developed after birth. If we can as- certain that monstrosities supervene when the development is ar- rested, why may we not attribute certain others to an over- growth of the same development ? Be this as it may, congenital hydrocephalus consists in a very abundant effusion of serosity in the distended ventricles of the brain, the size of which is increased one third and a half, and the substance of which, more or less firm at the circumference, is al- ways so where it is in contact with the fluid. The latter does not always remain enclosed in the ventricles; it is sometimes found effused in the arachnoid cavity; hence the distinction, which is very slight, between hydrocephalus internus and hydro- cephalus externus. Thisdisease often coexists with hydrorachis; children then have one or more tumors along the vertebral column, and an enlarged head. It is very difficult to tell which of these two diseases ex- ists primarily ; perhaps they are both simultaneously developed under the influence of the same cause. Well-marked inflamma- tion ofthe meninges does not always accompany congenital hydro- cephalus. Like hydrorachis, it is observed to arise and produce its peculiar symptoms when an external cause, like the introduc- tion of air from an opening, in spina-bifida, causes an irritation of these membranes, which is generally rapid in its progress. Hydro- cephalus may exist in an infant at birth without giving rise to any morbid symptom. Itis in some even accompanied with a very remarkable degree of intellectual activity, and this is an addi- tional proof of the truth ofthe assertion just made relative to the causes of this anomaly. .Indeed if we follow for a greater or less time the causes and progress of this disease, we shall see that it at first consists of an increase of organic energy, which gives to the ON THE DISEASES OF INFANTS. 469 brain and cranium a size and form which in its study affords so much pleasure to physiologists, because it is the presage of a high intellect—a presage which appears to be Well founded, as the child soon astonishes by its instinct, the justness of its judg- ment, or brilliancy of its wit. But if the cause of such organic and functional energy continues to act, it reduces both the organ and its functions to a state of destruction and annihilation, soon to be succeeded by death itself. Hydrocephalus may remain stationary, and Continue to an ad- vanced period of life. It would seem, from the observations of Camper, that children in whom the bones of the cranium are not separated, live a much longer time than those in whom there exist large fontanelles and a considerable separation of the su- tures of the bones. It often coexists with a congenital malforma- tion ofthe vertebral column, or ofthe limbs ; rendering the indi- viduals who are affected with it either idiots, if the cerebral sub- stance be much changed, or remarkable for their genius, if it continues in a slight degree, and if the cerebral activity does not exceed the limits, to us unknown, beyond which intellect is per- verted. It is useless to describe the form of the cranium, and the expression which the accumulation of water in the ventricles imparts to the physiognomy; the fades of those affected with hydrocephalus is well known. I believe that it is difficult to establish a proper treatment in this disease. How, indeed, can the nutritive activity be suspend- ed in the affected organ, and cause the absorption of the effused fluid ? Yet authors have advised various means for effecting this, among which is friction with mercurial ointment : it was for the first time employed by Armstrong; and Lefebvre de Ville- brune has recorded, in his translation of Underwood, several cases by Armstrong and Hunter, where the efficacy of this method is made very evident. But it is to be remarked that the subjects of these cases were of an advanced age, and that their symptoms were more proper- ly those of acute or chronic meningitis, than of a simple effusion of serosity in the cerebral ventricles. I think, therefore, that it is useless to attempt any therapeutic means when hydrocephalus causes no special symptoms ; but we ought to confine ourselves to the directions of hygiene, the object of which will be to re- 470 ON THE DISEASES OF INFANTS. move every thing that would increase cerebral excitement. If meningitis should supervene, we must have recourse to the measures already advised for this disease.* In order to finish the history of congenital diseases ofthe cere- bro-spinal apparatus, it remains for me to speak of fractures and malformations ofthe vertebral column and bones ofthe cranium. I have already mentioned the default in the union of the spi- nous processes of the vertebra?, and shall now say a word on their gibbosity. This is of rare occurrence in infants at birth ; but it is usually developed after that period. Yet when the ver- tebral column of a young infant is examined, a peculiar dis- position is found in some, and which might be the predisposing cause of the malformation of which I am speaking. This dispo- sition consists in a sort of backward displacement of one or seve- ral of the dorsal vertebras, which, instead of being in a parallel line with the others, exhibit a slight depression. I have only re- marked this in two infants at birth, and this disposition was per- haps the commencement of gibbosity. The bones of the cranium present, in infants at birth, either malformations or solutions of continuity. The former are the result of an arrest of development. I have collected three cases of remarkable ossification of the cranium; the osseous fibres, in- stead of passing from the centre to the circumference of the bone, were interrupted and disposed in small isolated masses, between which was found a cartilaginous substance. When these bones were felt through the integuments, they appeared as if fractured or ground. In another instance, I found in a new-born child a considerable depression at the anterior inferior part of the right parietal bone, which appeared to have been produced by some mechanical compressive cause applied to the cranium during the process of ossification. Lastly, the bones of the cranium are subject to present frac- tures in different parts, when the head has undergone much difii- * To the alterations of the brain, which we have just studied, we may subjoin, as an instance of congenital hypertrophy of the dependant parts ofthe brain, the two facts reported by Chaussier. In an infant stillborn, the head of which was well formed, he found the pineal gland compact, elongated, and as large as the extremity of the little finger of an adult. In another it was larger than in adults. Proces verbal dela dis- tribution des prix aux elives sages-femmes de la Maternit':, 1812. (See Appendix.) ON THE DISEASES OF INFANTS. 471 culty in passing through the straits of the pelvis, or when we have been compelled to terminate the labor by the use of forceps. Professor Chaussier and M. Duges long since published in- stances of this kind of lesion. These fractures are almost al- ways accompanied with cerebral congestion or apoplexy; this complication ought to fix the attention of the practitioner more than the fracture. The bones of the cranium sometimes leave between them large spaces, either because they are not sufficiently developed by reason of the great size of the brain, as is observed in hydroce- phalus, or because the development has been arrested. The fon- tanelles are, in consequence of this, very much spread, allowing a greater or less quantity of the brain to project, forming a real hernia. This disease is a very serious one ; it almost always co- exists with hydrocephalus, the progress of which soon causes the death of the child. The nature of this hernia is easily ascertain- ed, particularly from its situation, for it always occupies a point corresponding with one of the fontanelles, and principally to the superior and anterior one. We must be careful neither to com- press nor pierce this tumor ; it ought to be loosely covered, that the friction of the clothes or of external bodies may not pro- duce excoriation and inflammation. There is another species of hernia, which is much more rare, and I have met with but one instance of it, and 1 am not aware of any thing similar in the works of authors. CASE LXXX.—Congenital malformation, hernia of the brain, —Marianne Masse, aged one day, entered the infirmary on the 22d of June; she was of medium strength; the integuments were very red ; she had no other symptom than diarrhoea ; the cry was strong, and the respiration free. She had on the lateral part of the left side of the face, before the ear, a tumor half an inch in diameter, very round, more projecting inferiorly than superiorly, where it was confounded with the skin of the cranium, whilst inferiorly it pre- sented a circumscribed prominent border. The integuments cover- ing it were healthy, and of a vermilion color, like the rest of the face. It was painful and slightly soft to the touch; the forehead, very much depressed above, formed a considerable prominence in front; the eyelids were sunk in the orbits, and their approximation 472 ON THE DISEASES OF INFANTS. prevented the globe ofthe eye from being distinguished ; an oblong vermilion cicatrix, with slightly prominent edges, and apparently but recently consolidated, existed at the left lateral part of the cranium. This child remained in the infirmary until the 20th of July, when she died. On opening the body, there was found an acute inflammation of the digestive tube ; the respiratory apparatus was healthy. The left hemisphere of the brain was about one third less than the right. Neither the longitudinal sinus nor the falx of the brain were found upon the median line of the cranium, but they were directed obliquely from the centre of the forehead to the lateral left part of the occipital fossa ; all the left portion of the hemisphere, which is usually lodged in the middle lateral fossa ofthe base ofthe cranium, was thrown backward in a species of sac, formed ofthe tunica arach- noidea, the dura mater, and the skin. This portion of the brain formed the tumor of which I have spoken ; it issued from the cra- nial cavity by a tolerably large opening, which resulted from the ab- sence of the squamous portion of the temporal bone. This portion consisted of nothing but an edge of not more than two lines in ex- tent, and which was curled below like the shell of a snail ; the an- gle of the parietal bone existed, and formed the upper part of the opening. The meninges and the cerebral substance were very much injected. This hernia was evidently the result of compression which the cranium and brain had experienced during intra-uterine life ; the defect in the development of the squamous portion of the tem- poral bone was doubtless caused by the compression which the corresponding part of the brain had exercised on it. I have al- ready considered some of the possible causes of this hernia, when speaking of the congenital diseases of the skin. Art. 2.—Diseases of the cerebro-spinal apparatus, developed after birth. § I. Congestions.—Passive congestions of the cerebro-spinal apparatus are very common in infants at birth. This arises from the abundance of vessels, the slowness of the circulation, and the influence of respiration on the spinal and cerebral circulation. The length of the labor, the necessary tractions in certain ma- noeuvres, the difficulty with which respiration is established, the changes which the circulation undergoes, explain how this ap- ON THE DISEASES OF INFANTS. 473 paratus is so often the seat of sanguineous congestions, varying from simple injection of the meninges to true apoplexy. By the general term apoplexy in new-born children, is meant several degrees of cerebral congestion ; and for the most part, children dying in an apoplectic state do not, on a post mortem examination, exhibit the effusion of blood, or the circumscribed cerebral hemorrhage which constitutes the disease described under the same name in adults. Let us, therefore, consider the various lesions which belong to this disease. Injection of the meninges, of the medulla, and of the brain, is so common in infants at birth, that it has appeared to me more proper to consider it as a natural rather than as a pathological state. It is found in most dead bodies ; vascular injection, and even effusion of blood at the inferior and posterior extremity of the spine, are very frequent. I have often seen it without its having given rise, during life, to any appreciable symptom. If the injection is continued too long, it will soon produce an exudation on the surface of the meninges ; and the blood which is the product of this exhalation, is ordinarily coagulated in a greater or less quantity, compressing the brain and spinal mar- row, and causing the state of stupor to. follow which is character- istic of apoplexy. This hemorrhage, exterior to the cerebral mass, is almost always met with in infants who have died of apoplexy. This is what M. Serres calls meningeal apoplexy, and which he attributes to the rupture of some one of the vascular branches which wind over the surface of the brain. Injection of the cerebral pulp is equally common ; it exists under the form of a spotted redness, sometimes coloring deeply the substance of the brain ; it usually exists on the lateral parts of the corpora striata and thalami nervorum opticorum. It is in this part that the cerebral vessels exist in the greatest abundance, and which is more generally affected with hemorrhage and in- flammation at every period of life ; the works of Morgagni, and the recent researches of MM. Lallemand* and Bouillaud,! have rendered this fact incontestible. Lastly, it is possible, but it is very rare, to find cerebral hemor- * Recherches anatomico-pathologiques sur Vencephale et ses dependances,Paris, 1820, 1829. Letters 1 to 6. t Traite de Vencephalitc ou inflammation du cerveau et de ses suites. Paris, 1815. 474 ON THE DISEASES OF INFANTS. rhage very circumscribed ; I have met with but one case of it. This child died on the third day after birth, with symptoms of apoplexy. On a post mortem examination, there was found a sanguineous effusion in the left hemisphere, on the lateral parts of the corpora striata. There was no apparent cyst; the cere- bral substance was a little softened in points which surrounded the effusion, the extent of which was one inch in length by half an inch in breadth.* § II. Non-inflammatory softening.—This is a lesion pe- culiar to the ehcephalon of new-born children, and is the result of congestion of this organ. This is a species of softening either general or local, which, far from presenting the characters of in- flammation, on the contrary presents all the signs indicating de- composition, and we might almost say putrefaction, of this organ. I will here give an instance of this affection. CASE LXXXI.—Alexis Louart, aged three days, entered the in- firmary on the 18th of May. He was affected with a general indura- tion of the cellular tissue ; the integuments were of a violet red in all parts of the body ; the cry was smothered, painful, and, at times, very acute. The chest sounded obscurely. He was, besides, affected with a very abundant diarrhcea. The pulsations of the heart were quick, but of extreme smallness. There was no change in his condition on the succeeding day, and he died on the twenty-first. On a post mor- tem examination, the digestive apparatus was found injected in al- most its entire extent. The liver was gorged with black and fluid blood ; its tissue was hard and of a brown slate color; the lungs were floccid, blackish, slightly dilated with air, and gorged with blood at their posterior edge. The foetal openings still existed ; the meninges were very much injected ; the cerebral pulp was red, and reduced to a soft mass, which flowed freely on making an incision into the arachnoid membrane, diffusing a very evident odor of sul- phuretted hydrogen. This softening extended even to the lateral ventricles, where was found a quantity of effused blood; the rest of * A fact observed by M. Berard, junior, proves that cerebral hemorrhage may occur during intra-uterine life; so that apoplexy ought to be mentioned among the number of diseases by which an infant may perish before birth, and bring on labor before the time. The fcetus in which M. Berard has observed this remarkable alteration, was aged eight months and a half; the clot, about the size of a nut, was lodged in the sub- stance of the brain. Societe anatomique, 1828. 56 OX THE DISEASES OF INFANTS. 475 tne brain was softened, and of a violet color, but was far from being soft, like that part of the hemispheres above the ventricles. Here it is evident that this general disorganization of the cere- bral pulp was the result of its contact and mixture with the blood effused in the ventricles, and infiltrated in the proper sub- stance of the brain ; for there almost always exists cerebral hem- orrhage at the same time; but this hemorrhage, when recent, may exist alone, without any softening of the brain; there is only observed, at the superior part of the hemisphere, or at the corpora striata, the points ofthe encephalon, where the softening commences, and which already diffuses the odor peculiar to this disorganization. On the other hand, I am disposed to believe that the cerebral softening may precede the hemorrhage, and may even produce it, for I have several times found it without san- guineous effusion. The softening of which I speak sometimes exists only in one lobe, at other times in both ; very often the whole of the cerebral mass is so destroyed, that nothing more is found on opening the cranium but a soft floculent black mass, mixed with a great num- ber of clots of blood and pulpy flakes. It is a remarkable fact that the meninges are not involved in this disorganization, and that notwithstanding this destruction of the encephalon, children will still live some days, not possessing simply, as is vulgarly thought, a mere breath of life, but actually respiring, crying, and suckinp-: this occurs when the disorganization is arrested at the medulla oblongata, which remains unaffected, and which, with the medulla spinalis, controls the phenomena of life, even pre- serving it for some time. I have often found this softening in new-born children that died immediately after birth, leading to the belief that it had its existence during the sojourn of the child within the womb. When the medulla oblongata and medulla spinalis are thus softened, the child exhibits much less vital activity; the limbs are completely flaccid and immoveable ; the cry is altogether annihi- lated ; the pulsations of the heart scarcely perceptible; the limbs. are cold, and deglutition almost impossible. The child soon sinks under this state of feebleness, and the post mor- tem examination reveals the disorganization of the entire ner- 476 ON THE DISEASES OF INFANTS. vous centre, and thus explains the symptoms and death of the child. This softening is more frequent on the lateral parts of the hemispheres and near the corpora striata, than at any other part of the brain. These symptoms are serious in proportion to their extent, and to their approximation to the medulla oblongata; the prognosis is a very unfavorable one, for death appears to me to be inevitable. Such are the assemblage of the lesions, which the different stages and varieties of cerebral congestion in new-born children may present. The symptoms are usually characterized by a state of sinking, prostration, and sanguineous congestion of the limbs, body, and face, and especially by the proper signs of pul- monary congestion, which almost always accompanies that of the brain. It is difficult in young infants to ascertain the pecu- liar effects of apoplexy of the right or left hemisphere on the opposite side of the body ; for, as I have observed when speaking of the development of the brain, this organ at the time of birth can hardly be said to be formed; it neither enjoys as yet the organic form nor the vital properties which it acquires in the progress of its development. The treatment of cerebral congestions ought to be confined to sanguineous evacuations, produced by causing the blood to flow by the umbilical cord in infants, at the period of birth, or by the application of two, three, or four leeches to the base of the cra- nium. Every thing that can excite and accelerate the move- ments of the circulation ought to be removed. Art. 3.—Inflammation ofthe Cerebro-spinal Apparatus. It is without doubt a great advantage that the brain in chil- dren is one of the last of the viscera that becomes organized; for if at the period of birth it possessed all the organic and vital properties which is observed in the digestive or respiratory appa- ratus, it would be exposed to frequent inflammations. But its pulpous, and, we might almost say, inorganic state, renders it but little disposed to phlegmasia, which might be developed after the congestions of which it is always the seat at the time of birth. I can therefore affirm that well-marked inflammation of the cere- ON THE DISEASES OF INFANTS. 477 bral substance is rare in new-born children. That of the me- ninges is more common ; let us, then, commence with the study of meningitis. § I. S pinal meningitis—Inflammations of the spinal meninges are always more frequent than those of the medulla; they give rise to convulsions of the limbs, and sometimes of the face, par- ticularly if the inflammation be situated near the base of the brain. In thirty cases of convulsions in new-born children, I have found in twenty cases a well-marked inflammation of the meninges of the spine, and in these twenty cases there were six with inflammation ofthe meninges ofthe brain and ofthe spinal marrow; so that itis probable that convulsions of infants are almost always the result of an irritation or inflammation of the rachidian meninges. The following case exhibits the develop- ment and the progress of the symptoms of meningitis. CASE LXXXII.—Louis Russel, aged three days, entered the in- firmary on the 3d of September. During the preceding night he had been attacked with convulsions, which continued until morning. His limbs were rigid and violently bent; the muscles of the face were in a continual state of contraction; the pulse was full, strong, and frequent. (Two leeches to the mastoidean region, sweetened decoction of linden, sinapisms to the feet.) The convulsions dimin- ished, without ceasing altogether, immediately after the application of the leeches. The child was very feeble, and respired with diffi- culty, and discharged a quantity of frothy saliva from the mouth. (Sweetened barley-water, cataplasm to the feet.) On the morning of the fourth, the convulsions returned with increased intensity ; the pulse was quickened, the integuments very hot. The feeble condi- tion ofthe child forbade the application of leeches, and the treatment was confined to the application of cold to the head. The convulsions continued during the whole day; the body remained rigid, and the vertebral column, which the weight of the trunk will cause to bend with the greatest ease in a young infant, remained straight and im- moveable whenever the child was raised. The cry was very acute; the muscles of the face contracted with the same force as before, and they appeared a little more drawn to the left side. In the evening, the child sunk, became cold, with a small, intermittent pulse, and died during the night. Post mortem examination.—General paleness of the teguments, 478 ON THE DISEASES OF INFANTS. spotted redness of the stomach, discoloration of the mucous mem- brane of the small intestines, tumefied and red follicles in the large intestines. A large quantity of effused blood appeared on the sur- face of the right hemisphere of the brain, and a sanguineous serosity in the lateral ventricles at the base of the cranium. The meninges ofthe brain were pale, those ofthe spine very much injected, and on the surface of the tunica arachnoidea appeared a very thick, pelli- cular exudation; this coating was very easily raised, leaving the membrane beneath covered with red points, without any alteration of tissue. Such are the symptoms and lesions usually presented by spinal meningitis. Yet it is possible that there may exist simple irrita- tion without exhibiting, on opening the body, any apparent in- flammatory lesions. It is not unusual to find after convulsions in children nothing more, as in adults, than simple injection of the meninges; but ought we doubt that this is the seat of the disease ; and do we not see that there is in this case only a dif- ference in degree from the slightest irritation to the highest stage of inflammation, the progress of which generally leads to lesions, which afford incontestible proof of the nature ofthe disease? The spinal meninges may participate in the inflammation of all the serous membranes. I once found, in a child that died three days after birth, peritonitis, pleuritis, and rachidian me- ningitis. Inflammation ofthe meninges almost always gives rise, even in very young infants, to an elevation and frequency of the pulse ; febrile reaction is more evident in these affections than in phleg- masia? of the thorax or abdomen ; yet I have sometimes found the pulse slow and depressed; but when this is the case, the physiognomy of the child always expresses great pain and anx- iety. There also exists at times a very laborious respiration, as is shown by lividity ofthe face and limbs, and by the slow dila- tation of the thoracic parietes. § II. Cerebral meningitis.—-The symptoms of arachnitis of the brain differ but little from those of inflammation ofthe rachidian meninges. It is much more common at the base than at the upper part of this organ, and the only alteration which is found in children that die from this phlegmasia often consists of no- ON THE DISEASES OF INFANTS. 479 thing more than a pellicular exudation, more or less thick, ap- plied in irregular layers on the surface of the arachnoid mem- brane, corresponding with the base of the cranium. These concretions are almost always found beneath the tunica arach- noidea and pia mater. One of the most immediate effects of cerebral meningitis is the effusion of serosity in the ventricles. This effusion, desio-- nated by authors under the name of hydrocephalus acutus, often takes place before the formation of pellicular concretions, and even when the inflammation ofthe membrane exists, still under the form of a simple injection ; so that many authors, attaching more importance to the symptom than to the cause producing it, have confined themselves to describing, under the title of hy- drocephalus acutus, this form or variety of rachidian phleo-ma- sia; but the interesting works of MM. Bricheteau, Guersnet, Senn, Goelis, and others, have demonstrated very clearly the per- fect coincidence existing between arachnitis and hydrocephalus; and on this account it appears to me proper to consider the dis- ease in this place, instead of making it the subject of another chapter. The effusion of serosity in the ventricles of the brain occurs very quickly in infants. The slightest meningeal or cerebral irritation will effect it, and as the sudden presence of this water in the ventricles produces, either by its contact or by the pres- sure and distension which it creates, a greater degree of pain and a new train of symptoms, meningitis, or encephalitis com- plicated with hydrocephalus, then assumes its peculiar character. Indeed, to the restlessness and convulsions which appear at the commencement of this disease, follows suddenly the greatest excitement; the child by its acute cries expresses the violence of its pain, which for a moment ceases, to be renewed with in- creased intensity. This remission in the symptoms is very re- markable ; it sometimes observes a periodical return, and it is this, without doubt, that has induced some authors to describe the hydrocephalic fever as intermittent. But this remission is common to all excessively painful diseases, and especially to such as produce some lesions of the nervous system; this is a fact worthy of observation, and which deserves consideration in the history of every periodical irritation. When the effusion is 480 ON THE DISEASES OF INFANTS. considerable, the convulsions are less ; the limbs, which were very remarkable for their spasmodic rigidity, become completely flexible ; the face assumes a peculiar expression, arising from the permanent dilatation ofthe pupils, and the fixed dull stare ofthe child ; the pulse, which was remarkable for its frequency and quickness, becomes very slow, and is scarcely perceptible. Yet the child will sometimes of a sudden come out of this state of , prostration, and a new state of excitement shows itself; the limbs are convulsed anew, the globe of the eye becomes the seat of spasmodic movements; but this exacerbation is of short dura- tion, and is soon replaced by a state of coma, which usually continues until death. Children a little older than those whose pathology I am considering, exhibit other symptoms deserving the attention of the physician ; such especially is the pain in the head, which gives to the child the sensation of something sepa- rating the bones of the cranium, an expression which I have heard a child of six years of age use, and in order to convey some idea of the suffering, compared it to that which might be produced by driving a wedge violently in the head, to separate it in different directions. The secondary symptoms, or those which do not depend di- rectly on acute hydrocephalus in young infauts, are vomiting, difficulty of respiration, and angina, with alteration of the tone of the cry. This last affection doubtless arises from the violence and frequency of the cries. There often exists, also, an obsti- nate constipation. Sometimes hydrocephalus becomes chronic, after having pre- sented the usual symptoms of the acute form of the disease. The patient then falls into a state of stupor and idiocy, which continues during the remainder of life. The anatomical lesions which appear on examining the body are numerous and variable. In a few of the cases, nothing is found but a simple vascular injection of the meninges, together with more or less clear serosity in the ventricles. Ought this to be considered as hydrocephalus without meningitis ? I think it ought not; inflammation does not always cause the pathological alterations which characterize it from the first period of its ex- istence ; we can see every day meningitis and encephalitis char- acterized, during life, by the most marked symptoms, without of- ON THE DISEASES OF INFANTS. 4g| fering any appreciable lesion on an anatomical examination after death. I have already observed above, that the only conclusion that can be drawn from this apparently negative fact is, that the inflammation had not had time to produce all the anatomical al- terations which is usual; one only of these results exists, that of the effusion of serosity. This effusion varies with respect to its quantity and its seat. Its quantity cannot be appreciated, and it cannot be told to what degree it begins to cause distention or painful compression ofthe brain ; its seat is usually in the cerebral ventricles or in the great arachnoid cavity ; it has, however, been found often infiltrated under the pia mater, or even between this membrane and the tunica arachnoidea. Its color varies from a clear to a turbid yellow; it is sometimes mixed with albuminous flakes, sometimes of a gelatinous form, between the circumvolutions of the brain, and is very often sanguinolent at the time of birth. When hy- drocephalus has been considerable, the parietes of the lateral ven- tricles are soft, and are sometimes reduced to a pulp ; an altera- tion which is doubtless the mechanical effect of the distention and compression caused by the fluid, to which, on this account, irritating properties were formerly attributed ; but chemical analysis has proved this opinion to be incorrect, and demon- strated that the fluid of hydrocephalus contains nothing that will corrode the substance of the brain. The latter is often very much injected and of a very firm consistence, and I have found, in one instance, small bloody effusions throughout the two hemispheres. Sometimes it is, on the contrary, pale and in a state approxima- ting to softening, or completely softened. The pia mater is al- ways strongly injected, and on its surface, as well on that of the tunica arachnoidea, there is found a layer of albuminous concre- tions. The plexus choroides, which are almost always of a dark red, are, in some instances, enveloped in a thick coating of albu- miniform concretions. Lastly, meningitis may cause, besides an effusion of serosity in the ventricles, a true suppuration on the surface of the brain. The following case, in illustration of this, is taken from Abercrombie, and is one of considerable interest. CASE LXXXIII.—A child, aged five months, who had previously enjoyed perfect health, was taken with ponvulsions on the morning 482 ON THE DISEASES OF INFANTS. of the 21st of November, 1817. The attack, which was of short duration, was attributed to dentition ; the gums were cut at the place where the teeth appeared to produce the irritation, and the usual remedies in such cases were employed. The child continued better during the night; but on the morning of the twenty-second he ap- peared oppressed with frequent respiration. In the evening he became comatose, without any return of the convulsions. This state continued for some hours, and yielded to local bleeding, active purges, and refrigerating applications to the head. On the twenty-third he was evidently better, with a natural expression of the face. On the twenty-fourth, the same remission of symptoms; but in the evening there was a return of the convulsions, which continued all night; death took place in the morning. Between the tunica arachnoidea and pia mater there was found a pseudo-membranous production, which spread over almost the en- tire surface of the brain. The ventricles contained a purulent matter, and the cerebral substance was softened in the neighborhood of their parietes ; there was found no serous effusion; there existed a gelati- nous concretion below the optic nerves, and also at the base of the brain and cerebellum ; a similar substance, mixed with pus, also ex- isted below the medulla oblongata. The same author reports the case of a child aged eight months, who died on the 13th of March, ISIS, after having suffered from convulsions, which wore followed by coma. In the course of the disease there appeared a tumor at the anterior fontanelle ; it soon assumed a considerable size, and, at the end of three weeks, formed a soft, fluctuating, circumscribed eminence. When it was compressed, it produced convulsions; a small opening was made in it, from which flowed a puriform matter, afterwards bloody serum. This did not produce any alteration of the symp- toms, which continued until death. On examining the body, the opening made in the fontanelle was found closed by a thick layer of puriform matter, which extended between the dura mater and tunica arachnoidea to a considerable distance ; it was also, found between the pia mater and tunica arachnoidea.* From these considerations, it follows that meningitis appears in two stages or varieties. 1st, It is simple, consisting of nothing * Pathological and Practical Pvesearches on the Diseases of the Brain, etc. Edinb. ON THE DISEASES OF INFANTS. 483 more than a vascular injection or a spotted redness, with or with- out the formation of pellicular layers on the surface of the bram ; and in this case it gives rise to general convulsions, spasmodic agitation of the muscles of the face, and to violent cries, which are doubtless produced by extreme pain attending it. 2dly, It may be accompanied with a serous or sero-purulent effusion in the cerebral cavity, and then the restlessness and convulsions are redoubled, to give place, very soon, to a state of coma more or less profound, accompanied with a permanent dilatation of the pupils, rigidity of the limbs, soon followed by their flexibility ; a destruction of the intellectual faculties succeeds, if the child be of sufficient age to have them developed. These symptoms vary much with respect to their duration, intensity, remissions, and exacerbations ; sometimes they are to be seen on one side of the body, sometimes on both sides at once ; but whatsoever be their varieties of form, their fundamental character always exists, and the practitioner ought to be able to distinguish them in the midst of the epiphenomena which meningitis is constantly exhibiting, and which make this disease one of the most serious and insidi- ous which can attack a young infant. Indeed the irregularity in the duration and character of the symptoms, the sudden tran- sition from the exacerbations to the remissions, the numerous complications, rapid progress of the disease, all tend to deceive the physician, and to prevent a proper diagnosis, or to render the treatment unavailing. Let us add to this, that sometimes the most serious symptoms accompany a very circumscribed menin- gitis, whilst at other times the anatomical lesions exist to a great extent without producing any well-marked symptom, and we can readily conceive the difficulty of forming a diagnosis, and of treating this disease. There are cases where effusion of serosity appears to be very sudden, causing the immediate death of the patient. This variety has been denominated apoplexia hydrocephalica. But is effusion sudden ? May it not occur slowly, not producing any effect un- til it has become abundant.' Do we not also see that remissions for a greater or less time may be followed by sudden and unex- pected exacerbations? On this account, I think that this variety requires to be studied with more attention than has heretofore been the case. As to hydrocephalus, which appears to exist 484 ON THE DISEASES OF INFANTS. without inflammation, and which may be compared to ascitic dropsy, it must be placed in the class of chronic hydrocephalus, to be hereafter mentioned. The treatment of meningitis ought to be very decisive. We should apply, early in the disease, two, four, or six leeches at the base of the maxilla; the application of refrigerant compresses to the head, the administration of calomel or other purgatives, and finally the application of several blisters to the legs or arms, should form the base of the treatment. Gcelis especially recom- mends mercury in the second period of the disease. He gives it in doses of half or a quarter of a grain twice a day until it pro- duces a purgative effect. I have seen the application of a large blister either to the neck or thighs followed with success. § III. Inflammation of the spinal marrow and brain.—Inflammation of the spinal marrow, in infants at the breast, is less frequent than that of its membranes. Yet when the latter are inflamed, the spinal marrow becomes the seat of some alterations, which doubtless must be attributed to inflam- mation. These alterations are not constant; sometimes the medulla is excessively hard, at other times very soft. The first mentioned alteration is the result of recent inflammation; for 1 have -found it frequently in cases where meningitis had made but little progress. I once found this induration so great that I raised with the medulla, deprived of its membranes, a sub- stance which weighed nearly a pound. The child had been affected with convulsions of its limbs, and the meninges were found covered with a thick layer of pseudo-membranous concre- tions. In these cases of induration, the central substance is more or less soft, and of a dark color; it did not partake of the hard- ness of the medullary substance. The softening of the spinal marrow may be either general ©r partial. It is white, or mixed with a sanguineous effusion. General softening coexists with a similar state of the brain. The pulp of the medulla is then very soft, yellow, sometimes bloody, or mixed with streaks of blood. The more or less per- fect softening, of which I have spoken when considering its pas- sive congestions of the brain, is also found in the spinal marrow, but is of much less frequency; this affection of the medulla rarely exists independently .of that of the brain; it is much more ON THE DISEASES OF INFANTS. 485 common to meet with that of the brain without the softening of the medulla: lastly, in thirty cases of softening with disorganiza- tion of the cerebral pulp, I found but ten where the softening existed at the same time in the brain and spinal marrow. The softening of the medulla presents the same characters as that of the brain; it diffuses also a very evident odor of sulphuretted hydrogen, indicating an advanced state of decomposition; it is easily torn when touched, and the slightest washing reduces it to a soft mass. When this change is found, the child generally 1 has lived but a few days, respiring with pain, and with a smoth- ered cry; its motions are almost nothing, the limbs being in a state of flaccidity; integuments purple, face immoveable. This gene- ral sinking or depression is to be remarked in the most robust as well as the feeblest of children. It would appear that the circu- lation undergoes a great disturbance, for the pulse and beatings ofthe heart, constantly irregular, are scarcely perceptible. Con- gestions of blood in the lungs, effusion of blood in the abdo- men, cranium, or spine, are usually found. In general, disorgan- ization of the brain gives rise to fewer functional disorders than when the whole cerebro-spinal axis is diseased ; this softening appears always to spread from the brain to the medulla, and the symptoms are more evident as trrfe disorganization of the medulla is more advanced. I have frequently met with the brain in young infants entirely destroyed, without any external sign giv- ing evidence of its existence, whilst I never saw the same in softening of the medulla. The medulla spinalis is found more or less soft, without our being able to affirm that it is diseased, for it is not easy to indi- cate the degree of alteration when its pathological condition be- gins ; yet -the -two extremes of softness and hardness may be safely referred to a morbid state of the parts, since I have never met with them, at least in young infants, without the existence during life of some symptoms resulting from these lesions. It can be laid down as a general principle, that extreme softness is always attended with a general paralysis or loss of sensibility; and when the consistence ofthe nervous tissue is increased, there are either convulsions or an exaltation of sensibility. A partial softening of the medulla is often met with, that is to sav. in one half or one third of its length, whilst the remainder 486 ON THE DISEASES OF INFANTS. retains its natural consistence. This softness usually exists at the upper third, and always decreases towards the inferior ex- tremity. We may also find an induration to a limited extent; thus the portion in the lumbar region is often remarkable for its hardness, whilst the rest of the medulla is reduced almost to a soft mass. I have not observed any peculiar symptom which corresponds with this modification of the medullary tissue, and I do not know to what cause to attribute it.* The softening of the lower third is also met with, whilst the upper part is of the usual firmness. In a child aged six months, affected with me- ningitis, and who died in the eighteenth month, I found a very evident softening at the inferior part ofthe medulla. The lower extremities of this child were paralyzed, so that they could not afford him the least support. I have frequently observed this paralysis in children, at an age when they usually walk. This, I have no doubt, arises from an affection of the spinal marrow, and perhaps from chronic hydrorachis, an opinion which pro- bably would be confirmed by additional anatomical researches. It is very difficult to ascertain the presence of inflammation ofthe brain in young infants, besides it is of less frequent occur- rence than congestion, of which I have already given the history. Yet when hydrocephalus, accompanied with meningitis, exists, the species of turgescencc exhibited by the brain, the substance of which is of a gray ash color and always injected, should, I think, be attributed to inflammation. The brain in this case ap- pears to be closely invested in its membranes, and quickly es- capes when they are cut. This state may arise on the one hand from a serous effusion in the cavity ofthe ventricles, and on the other, from an inflammatory turgescence, as pointed out by MM. Jadelot and Guersnet, and which they have frequently seen in cases of hydrocephalus. Induration of the cerebral substance is often found without any symptoms indicating its existence during life. Yet I have, in two instances, seen some convulsive movements in the face, where the brain exhibited a very intense redness, with a firm consistence of its tissue. M. Bouillard has given an analogous * Further details will be found in a work of M. Ollivier. (Traite de la moelle epi- niere.) ON THE DISEASES OF INFANTS. 487 case in the Archives generates de medecine. Ke found in an infant five weeks old, that died after having exhibited a con- traction of its limbs and a spasmodic stiffness ofthe neck, a san- guineous congestion of the encephalon, the substance of which was also firm.* It is generally very difficult to detect in young infants the ex- istence of encephalitis from the symptoms. There is, however, a distinction founded on facts, which appears conclusive, much insisted upon by M. Lallemand, and which will enable us to make a diagnosis of the seat of the disease. The symptoms of inflammation ofthe cerebral mass are made known by aberration of the intellectual functions, whilst that of meningitis shows itself by convulsions with or without delirium ; but how can the effects and signs of delirium be seen in young infants, whose mental faculties scarcely exist? We have already seen that when there is an almost complete disorganization of the cere- bral mass, there will often be no symptom of this lesion, and that the child will perish without giving reason to suspect by any sign that encephalic disorganization was the disease with which it was affected : ought we then to be surprised that ence- phalitis should exist at this early age without any serious symp- toms ? Is not this phenomenon, which is peculiar to the age and pathology of young infants, explained by the little import- ance and use of the cerebral hemispheres, the organization of which is not yet complete? Aneucephalous monsters live with- out being affected with convulsions, as we have already ob- served. But it is not so with meningitis. The cerebro-spinal mem branes,when but slightly inflamed or irritated, immediately cause convulsions of the lace and limbs, more or less strong, tetanic contractions or pains, cries, and restlessness, which physicians ought carefully to consider ; for this assemblage of symptoms is almost always a certain indication of meningitis, and the cere- bral or medullary substance may participate in the inflammation, or be unaffected by it, without the possibility of distinguishing in which this complication exists from those in which it is not present. These remarks are applicable to most cases; but it is neces- * Archives general de medecine, 1828. 488 ON THE DISEASES OF INFANTS. sary to add that the rule is not universal or exclusive; there may be some exceptions, and symptoms of encephalitis may be no- ticed which, without being so well marked in infants as in adults, may yet be sufficient to excite the attention of the physician. CASE LXXXIV.—Gastro-enteritis and encephalo-myelitis.— Julien Bouvier, aged three days, entered the infirmary on the 28th of September. He was pale, but not thin ; he was affected with spasmodic contractions of the lips and eyelids, especially on the left side. The limbs on both sides were rigid and cedematous ; the cry was acute ; the pulse very slow ; the skin was of the natural tem- perature. (Sinapisms to the feet, three leeches to the left side of the head, sweetened tilia infusion.) On the twenty-ninth, the con- vulsions continued; the respiration became frequent; the child vomited and passed sanguineous matters from the nares ; the epigas- trium was slightly tense and painful when pressed, as was evident from the expression of the face ; pulse small and oppressed ; the skin exhibited a universal jaundice. (Barley-water, syrup of gum, four leeches to the epigastrium, diet.) On the 1st of October, the pulse had fallen to eighty-eight; the jaundiced hue in the face was less intense ; the convulsions scarcely perceptible ; but there was an increase of induration or cedema of the limbs. Death took place on the morning of the 2d of October. Post mortem examination.—The mouth and oesophagus were healthy ; on the surface of the stomach there appeared several red streaks, with ulceration of the follicles ; the mucous membrane of the small intestines was of a dull white, and had begun to soften. This softening was more evident towards the ileo-caecal region. In the colon there existed an abundance of mucous follicles, which had not ulcerated. The liver was lighter colored than natural; the bile small in quantity and black ; the lungs were healthy; the foetal openings were partially closed ; the cavities of the heart were of equal di- mensions ; the brain was yelloAV, soft, and diffused a slight odor of sulphuretted hydrogen. A sanguineous effusion, with softening of a yellow color, was found in the cerebral substance, at the anterior part of the right hemisphere. This softening bore a great analogy to that described by M. Lallemand, occurring in adults ; its extent was about half an inch. The meninges were gorged with blood. The spinal marrow was very soft and yellow. A considerable sanguine- ous effusion was found throughout the spine, with a congestion of the spinal meninges, and a serous infiltration with gas between the ON THE DISEASES OF INFANTS. 489 pia mater and tunica arachnoidea, at the posterior part of the medulla spinalis. In this case we see how trifling were the symptoms which ac- companied the inflammation, and even the disorganization of the cerebrum. A few convulsive motions of the eyelids or of the ball of the eye, a slight muscular action in the face, are often the only symptoms of encephalitis in young infants. Inflamma- tion of the stomach was here, perhaps, one of the predisposing causes of encephalitis. This complication is not so common as at a more advanced age.* Let us endeavor now to ascertain the nature and probable seat of the symptoms which it appears natural to refer to the brain. Convidsions.—Cerebral or spinal meningitis is most frequently the cause of convulsions. If there exist cases where it is diffi- cult, on examining the body, to discover traces of inflammation of the meninges, it is because of the extreme difficulty of dis- tinguishing their passive congestion from phlegmasia, and also, on the other hand, it is easy to conceive that an irritation of the tissue of an organ may arise before the inflammation can mani- fest itself, at least to a sufficient degree to be evident to our senses. Besides, as it is much more common to find convulsions in infants with meningitis, than to meet with them without this inflamma- tion, analogy might produce the conviction that the convulsions of children, whatever be their form or degree, whether known as spasms, cramps, twitchings, etc., all arise from cerebral or spinal meningitis. This opinion has been fully demonstrated by M. Brachet, of Lyons.t Tetanus.—I am not in possession of sufficient facts to eluci- date the nature of this disease ; it occurs much more rarely in our climate than in hot countries, where a large number of chil- dren die from it. I am unable to give any opinion on the different views enter- tained by authors on the nature of this disease, having seen but two cases of it in young infants ; they were both characterized with rigidity of the vertebral column and of the jaw. I found, * Sablairolles, Influence des organs digestifs des enfans sur le cerveau. Paris, 1827. t Brachet, Memoire sur les causes des convulsions chez les enfans. Paris, 1834. 62 490 ON THE DISEASES OF INFANTS. on dissection, nothing more than an effusion of a quantity of co- agulated blood in the spine. This blood was effused l>etween the two laminae of the tunica arachnoidea, and filled the whole of the medullary canal, from the medulla oblongata to the sacral region. Were the symptoms of tetanus to be ascribed to this hem- orrhage ofthe spine? I am disposed to think they were. I shall not speak here of delirium, because it can only be observed when the intellectual functions are developed. The treatment of encephalitis does not differ from that of me- ningitis, which has already been described. Besides, encephalitis is almost always accompanied by meningitis. CHAPTER XI. DISEASES OF THE ORGANS OF LOCOMOTION. In a month or six weeks after conception, the limbs appear, under the form of small projections, slightly flattened laterally and inclining towards the trunk. The upper extremities appear first; at two months, the hand and forearm can be distinguished; the leg and foot show themselves at the third or fourth month. When the forearm and leg begin to appear, M. Beclard observes, they are smaller than the hand or foot; and even the thigh and arm are smaller than the leg and forearm. The upper extremi- ties are distinctly divided into two parts at seven weeks, and the lower at eight weeks ; the summits enlarge and divide into short fingers and toes, which remain attached by a soft substance until the third month. this substance then gradually disappears, be- ginning at the extremity. For a long time the superior extremi- ties, which are the first that are formed, continue the largest, but about the fourth month the superior and inferior extremities are about equal.* Malformations are very numerous ; the limbs may be deficient, or they may be supernumerary ; they may undergo an arrest in their formation ; may become divided, broken, or dislocated du- ring intra-uterine life. * Dissertation Inaugurate, p. (50. ON THE DISEASES OF INFANTS. 491 Haller has given a number of instances of absence or plurality of limbs, or of one or more parts of the same member. He has also recoided several cases of supernumerary limbs, implanted in different parts of the body.* Since his time the records of science have contained a great number of analogous facts, the details of which cannot here be given without exceeding our bounds, and, indeed, they do not comport with the nature of this treatise ; I must, therefore, refer to works specially devoted to pathological anatomy, for further information on this subject, and will confine myself to the consideration of solutions of conti- nuity, fractures, and dislocations which occur during the con- tinuance of the child within the womb, or which may take place at birth. It would appear as if gangrene might affect the limbs of a fcetus and produce a separation more or less complete, and the infant be bom with a limb divided, with the trace of a cicatrix on the stump. A child was born at the Maternite of Paris with but one arm ; the surface of the stump was cicatrized and a bony cylinder found implanted in the placenta, which probably was the other portion of the amputated humerus. Cruuissier was of opinion that this member had been separated by a species of sphacelus.! On the 29th of December, 1S24, Dr. Atkinson was called to attend a young woman aged twenty years, who had been married iu the mouth of April preceding. I found, says this physician, the membranes still entire; at eleven o'clock they broke, and half an hour after the child was born. I immediately perceived that the left foot was wanting, and that it had been separated from the leg a little below the calf. The amputated surface was cicatrized except at its centre, doubtless from the pro- jection of the bone. The child was living, but expired in about twenty minutes. After the labor had terminated, upon examin- ing the genital organs, I found the foot in the vagina, and im- mediatery removed it. The section was also cicatrized, except at the point where the bone projected. There existed nothing to indicate that any hemorrhage had been produced by the am- putation. This foot, which was much smaller than the right, exhibited no mark of putrefaction, and, on comparing it with the * Opera minora—De monstris, (partes deficientes,) t. iii. t Discourse delivered in 1812, at the distribution of the prizes at the Maternity 492 ON THE DISEASES OF INFANTS. other, I judged that it had been separated about two months. The mother, during her pregnancy, had not experienced any thing that could explain this lesion, nor of the time at which it occurred.* The limbs of a fcetus may sometimes be dislocated. Chaus- sier has observed in a fcetus both thighs, both knees, both feet, and three fingers of the left hand,.in this condition. Professor Dupuytren has recently published a very interesting paper upon the spontaneous dislocation of the os femoris, which, in the greatest number of cases, existed on both sides at once, although in some individuals it may occur on one side only. " In twenty cases of this affection which I have seen," says M. Dupuytren, " the luxation existed on one side only, in two or three individ- uals. I have now under my care a young infant who has a dislocation only on one side, and what renders this case the more curious is, that this child had a sister affected in the same man- ner, and which, like the other, existed on the right side."t The dislocation is not usually perceived at the time of birth ; but it is easily distinguished as the child advances in age. It becomes apparent, observes M. Dupuytren, when the pelvis acquires a greater width, and the child uses longer and more fatiguing ex- ercise. It is then that the want of support of the upper part of the body on the pelvis, and its inclination forward, the hollow- ness of the back, projection of the abdomen, arched movements of the extremities, defect in the flexibility of the head of the fe- mur, its alternate elevation and depression in the external iliac fossa, etc., begin to be very evident. This dislocation is generally upward and outward, and the head of the bone rests in the external iliac fossa. According to M. Dupuytren, this displacement appears to arise from the habit- ual position of the legs of the fcetus in the uterus. The thighs are closely flexed on the abdomen, and the head of the bones are continually pressing against the posterior and inferior part of the capsular ligament; this unceasing pressure, although without any effect in well-formed individuals, may produce a dislocation in others whose tissues are less resisting. With this fact before * London Medical and Physical Journal, July, 1825. t Repertoire general d'anatomie, tome v., page 110. ON THE DISEASES OF INFANTS. 493 us, we can understand how it happens that the posterior and in- ferior part of the capsular ligament yields to the pressure, and al- lows the head of the bone to pass, thus producing a luxation; and its displacement upward and outward is explained by the action ofthe most powerful muscles surrounding the joint, tend- ing constantly to cause the head of the bone to pass in that di- rection after its passage from the acetablum.* The treatment ought to be commenced as advised by M. Du- puytren, by rest and the use of means to strengthen the soft parts surrounding the articulation, and to prevent the passage of the head ofthe bone into the iliac fossa. It is very difficult to use these means to children at the breast; but we may at least ar- rest the too rapid progress of the disease by directing that the child be not made to stand, as is often done, to enable it, as it is said, to acquire strength ; for we can easily conceive that the ele- vation of the head of the fernur into the iliac fossa may be facili- tated by the weight of the body. I cannot here detail all the im- portant doctrines contained in this treatise, but must be contented to refer the reader to it for perusal.f Besides luxations, the bones of the foetus may be affected with solutions of continuity, either from an arrest in the development, or from a fracture analogous to what is seen in adults ; the fol- lowing case will demonstrate the possibility of solutions of con- tinuity from an arrest of development. CASE LXXXV.—A child, aged two months, died at the Hos- pice des Enfans Trouves on the 4th of June, 1826, of acute pneumo- nia. On examining the body, I perceived that the humerus was moveable at the middle, where there existed a species of false articu- lation ; a close examination of the part enabled me to ascertain that there was a solution of continuity at the centre of the bone, to the extent of about four lines; this space was filled with a cartilaginous substance of some thickness, the exterior of which was in contact with the extremities of the broken bones, in the same manner as the * Memoire sur un deplacement originel and congenital de la tete des femurs, par M. Dupuytren. t The cases and plates published by M. Cruveilhier may be consulted with advan- tage. They go to prove, according to the opinion of M. Dupuytren, that this deformity, as well as that of club-foot, depends on the situation ofthe limbs ofthe fetus in utero. (See Anatomie pathologique du corps humain, etc., 2d number, pi. 2.) 494 ON THE DISEASES OF INFANTS. epiphysis of the bones. This humerus was not longer than the one on the opposite side ; the space of which I spoke, therefore, was not formed by a substance deposited between the two fragments of bone, but was the rudiments of the bony cartilages, which, by a singular anomaly, had not become ossified. It is not improbable that children born with a number of frac- tures, of which Chaussier has given instances, may have been in a condition similar to this infant. I have seen a striking anal- ogy between the engraved representation ofthe solutions of con- tinuity in the bones of the skeleton, in the work of this learned anatomist, and that which I have recorded. It would seem as if the continuity of the osseous fibres had been interrupted by an arrest of development, and the part appeared as though filled by a number of cartilaginous intersections. All these fragments were applied to each other by points, the reciprocal surfaces of which were rough like the corresponding surface of the sphenoid and the basilary portion of the occipital bone in young children. Besides this species of solution of continuity, there also occurs in the fcetus real fractures, which, at the period of birth, exhibit the beginning of consolidation. M Devergie reported at the sit- ting of the Academie Royale de Medicine on the 4th of February 1825, the case of a woman who, in the sixth month of her preg- nancy, struck her abdomen violently against the corner of a ta- ble, falling from a high chair. The pain was extremely severe and continued a long time without any thing affording relief. It suddenly disappeared, and at the usual end of the period of gesta- tion she was delivered of a healthy, vigorous child, having a large tumor on the left clavicular region. The child died on the eighth day after birth, and on the examination of the body there was found a fracture ofthe clavicle, the fragments of which had united by a large and firm callus, forming the tumor above men- tioned. Do not the circumstances of this case produce the im- pression that there was a connection between the violent blow received by the mother two or three weeks before her confine- ment, and the consolidated fracture ofthe clavicle? The following case, taken from a German journal, and copied in the Archives generates de medicine for March, IS^S, is anal- ogous to the preceding: ON THE DISEASES OF INFANTS. 495 A young woman, aged twenty-five years, of a strong constitu- tion, iu the sixth month of her pregnancy, fell on the abdomen; she immediately felt the child move with great force ; these movements continued for sometime. The period of her confine- ment arrived,and she was delivered without accident of a very thin and feeble child, giving but few signs of life, and exhibiting on the right leg a transverse wound, nine lines in length. This wound, the lips of which were pale and flaccid, extended from one malleolus to the other, and involved both the skin and subja- cent muscles, and was accompanied with a fracture of the tibia. The body of this bone was entirely separated from its lower epi- physis ; it projected from the wound, and was without its perios- teum, and exhibited a very unhealthy appearance. The re- duction was attempted in vain. It was abandoned on acount of the edges of the wound becoming sphacelated, and necrosis having made some progress. The sphacelus extended rap- idly, and the child died on the thirteenth day. Dr. Cams, to whom we are indebted for this case, regarded it as a new proof that a child may endure a disease for a long time in the uterus, which may, after birth, quickly become mortal. It is not unusual to see fractures occurring during labor or af- ter birth ; they may be known by the same signs which they ex- hibit in adults, and require the same treatment to preserve them in a proper position while uniting. Deformities ofthe joints are not unfrequently observed ; the twisting ofthe feet or hands in a direction opposite to what is na- tural, is one which often occurs. This distortion takes place principally in the ankle or wrist, which are at this period still - cartilaginous. It has been the custom to suffer the child to con- tinue with this deformity until a more advanced age, when meas- ures are taken for its relief; but would it not be much better to attempt at an early period the removal of this distortion, by gen- tle compression, which, slowly affecting the cartilaginous parts, is more likely to be effectual than when these parts have under- gone the processes of ossification? Such are the general details which I have to offer on the sub- ject of fractures and dislocations ofthe limbs. The muscles are rarely affected with diseases, in young infants, worthy ofthe atten- tion of the physician ; in a state of health, the muscles of a child 496 ON THE DISEASES OF INFANTS. at birth are of a rose color ; they are of a lighter red than those of an adult; their consistence is firm, and the direction of their fibres is analogous to the general form and function of the partic- ular muscle. Their varieties of aspect are : 1st, extreme pale- ness : 2dly, sanguineous congestion. I have several times found ecchymoses in the muscles ; and it is not unusual to meet with several small petechial spots, varying considerably in their form 1 and number; 3dly, a yellow color; I have seen this in one in- stance of jaundice. CHAPTER XII. DISEASES OF THE ORGANS OF GENERATION. I have little to say with respect to these organs. Their mal- formations, as they occur in male children, have been already in part described, in the article on the diseases of the urinary pas- sages. As to those occurring in females, they produce no mor- bid symptoms until the period of puberty, when the genital functions are developed, and the catamenia appear. n The testicles are sometimes found at the abdominal ring, or they may to a greater or less degree have passed it, at the time of birth; their continuance at this place sometimes gives rise to inflammatory affections, having a resemblance to peritonitis: they will require the application of emollient cataplasms, and the use of simple or mucilaginous bathing. As these organs descend, they become enveloped in the tunica vaginalis. A dropsy of the spermatic cord may be mistaken for a testicle at the abdominal ring; this affection consists of small globular cysts in the substance of the cord. When the peritoneal mem- brane, which descends with the testicle in order to form the tu- nica vaginalis, is not immediately closed above, a quantity of serosity may accumulate in the sac, and thus form congenital hydrocele, which may be recognised by its round shape, fluctua- tion, and transparency, but more particularly by the facility with ON THE DISEASES OF INFANTS. 497 which the fluid passes into the abdomen. Another aqueous tu- mor of the scrotum, formed by a serous infiltration ofthe cellular tissue, has been confounded with this species of hydrocele: it is frequently observed in induration or cedema of the cellelur tis- sue. For the treatment of the first mentioned hydrocele, it will be necessary to use compression ou the tumor, in order to cause the fluid to flow into the abdomen, and to maintain a moderate pressure by means of an appropriate bandage. With respect to infiltration ofthe scrotum, the best applications are refrigerants, made either with simple or vegeto-mineral water. The testicles of an infant at birth are of a pale rose color; their consistence is firm, and their filamentous texture can easily be distinguished. I have sometimes found them ecchymosed and yellow in young subjects that had been affected with jaun- dice. The uterus is small in size, and its central cavity is also very narrow. The sides, however, which are usually covered with a mucous internal surface, are not absolutely in contact. In two instances I have seen blood effused and clotted in the cavity of the uterus in two children that died a few days after birth.* The vagina is usually very much developed; it presents a large elongated cavity, covered with a mucous membrane, the secre- tion from which is very abundant, for there is always found in this part, in young infants, a large quantity of white, adherent mucosity. This secretion, which might be considered as the effect of a diseased condition of the vagina, such as gonorrhoea co nmunicatcd by the mother to the child, exists in almost all female infants, and appears to be a necessary secretion, judging from the abundance ofthe discharge. * It is not unusual to observe red and fluid blood flow continually from the vulva for some days or weeks after birth. From the observations of Dr. Ollivier, of Angers, this discharge, which is somewhat like the catamenia in adult females, continues some- times a week, fifteen days, or more, without any inconvenience being experienced by the child. It ceases of itself, and requires no other care than is usually necessary for the infant. This sanguineous discharge is unaccompanied by redness, swelling, or any other symptom of irritation in the external parts of generation. The child has no diffi- culty in urinating, the alvine evacuations are neither more nor less frequent than in the normal state, and the genera! health ofthe child undergoes no derangement. It would seem as if nature had anticipated, in some sort, the establishment ofthe function which is developed and regulated at a later period of life. 498 ON THE DISEASES OF INFANTS. The clitoris is large, and is sometimes even of so great a size as to be taken for a penis, and thus confounding the sex at the time of birth. The external labia are very prominent; they become infiltrated, tumefied, and inflamed, with the greatest facility, when constantly covered with the excretions.* * Gangrene of the vulva.—In the article on gangrene of the mouth, (page 192,) it was observed that gangrenous inflammation may be developed in the external and internal parts of generation, with characters closely resembling those which are seen in the parietes of the buccal cavity. The analogous structure of these parts will account for the analogy of their diseases. Gangrene ofthe vulva has been noticed by Dr. Olli- vier, of Angers, under circumstances similar to those which have been pointed out as coincident with gangrene of the mouth, or as preceding and favoring its development; as certain cutaneous phlegmasia, variola, or measles. This disease is rare in young infants, and will sometimes occur in such a manner as to render its diagnosis obscure. The child of Madame ——, aged twenty-one months, of a vigorous and robust con- stitution, had enjoyed the best health, but was observed to carry her hand, from time to time, to the thighs, as if she experienced a slight inconvenience at the orifice of the vulva. The child, however, retained her liveliness and appetite. Her little brother had been affected with measles, which had passed through its stages wit' out any seri- ous consequences. The distress experienced by this child decided us to examine the condition of the affected part, when there was found on the internal surface of the right labium a round superficial uber, gray at the bottom, and surrounded by a bright red circle. On the following day measles appeared, when the ulcer, which had the appearance of an aptha, rapidly increased during the course of the two succeeding days; several others precisely similar showed themselves on the internal surface of the left labium, and around the vulva. Their sinuous borders, their grayish aspect, and the absence of any odor or foetid discharge, imparted to these ulcers a character very closely resembling a primitive venereal affection. Topical emollient applications of every kind produced no arrest in the progress of this inflammation, while the dryness of the dis- eased surfaces, the hollow excavations extending through the substance of the labium first affected, and the gangrenous odor now apparent, rerroved all doubts as to the na- ture of this affection. In the space of twenty-four hours, the whole ofthe vulva was converted into a black eschar, surrounded by a red livid circle, and its cedematous condition gave a dry and shining appearance to the skin. The measles disappeared at the end of two days. From the first appearance of this gangrenous inflammation, cerebral disturbance was very evident, and there existed at the same time an intense fever; while the rest- lessness, cries, convulsive movements, all announced that the progress of the disor- ganization was accompanied with great pain. There were, however, no alteration of the features; the abdomen was soft and without pain on pressure, and the stools pro- cured by injections were of a soft consistence; urine limpid and small in quantity. The means employed in the treatment, until the termination of the disease, were acid- ulated drinks, injection of sulphate of quinine, warm baths, lotions, and injections of chloride of lime and of soda, and pledgets of lint saturated with a similar solution. This treatment was unsuccessful, and the child died, after unheard of sufferings, on the twelfth day. ON THE DISEASES OF INFANTS. 499 The breasts of young infants are often the seat of a swelling caused by the accumulation of a milky fluid, the quantity of which is often so great as to be thrown out with considerable force when the breasts are pressed. This tumescence, the cause of which it is difficult to explain, gives rise in some cases to in- flammation, often followed by an abscess. This fluid is really secreted by the maxillary gland, which is often more completely developed than the salivary gland ; but this development, or rather the turgescence, is but transitory. CHAPTER XIII. DISEASES OF THE LYMPHATIC SYSTEM. Diseases of the lymphntic system are not so common in the first eight or ten months as they are after that period. I will not, therefore, stop to describe them, but will simply remark that The insidious progress of this disease in the early period of its existence, without doubt, prevented the employment of stimulating topical applications. In cases of this kind, the ulcerations ought to be cauterized, and local measures freely used, in order, if possible, to prevent the extension of the gangrene. The general phenomena are here different from those accompanying gangrene ofthe mouth; instead of an extreme fee- bleness of the pulse, discoloration of the skin, hiccup, tympanitis, and diarrhcea, the child continued to have a rosy hue ofthe skin, a frequent pulse, soft abdomen, and a firm and plump state of the muscles; a difference resulting, in all probability, from the different seat of the affection. In gangrene of the mouth, all the gaseous products of the local disorganization are exhaled at the orifice of the respiratory passages, and perhaps this pulmonary absorption ofthe putrid emanations ofthe gangrenous part may be the cause of the symptoms of debility accompanying this disease. Indeed, all the phenomena appear which arise from the injection of putrid matters into the veins. In gangrene ofthe vulva, nothing of this kind is to be seen ; but there are present a con- stant febrile action, cries, and restlessness ; the intensity of which increases with the progress of the disorder ; the disorganized part being isolated, and not in the vicinity of the opening to the respiratory organs, the inspired air is not charged with deleterious principles. Without doubt, the analogy here attempted to be established between these two dis- eases might be disputed, on the ground of the different state exhibited by a child in these affections: but whatever opinion be adopted, it seems to us rational to attribute the great< ; rapidity ofthe approach of death in the onec.se to the particular seat ofthe local affection, which thus contributes directly to vitiate the blood, turougb. the medium of respiration. 500 ON THE DISEASES OF INFANTS. the lymphatic glands of the mesentery, which so easily become affected with chronic inflammation, and even with tuberculous disorganization, in children above the age of a year, affected with chronic inflammation ofthe intestines, do not in very young in- fants become the seat of phlegmasia?; but the only alteration observed is a slight tumefaction : and when the sdand is cut, it is found to be a little more condensed than natural, and of a rose or even deep red color. The changes which age effects in the nutrition and texture of these organs dispose them particularly to chronic phlegmasia, known under the name of tubes mesenterica. It would not therefore be proper to place this disease among those which are peculiar to infants at the breast. I do not say that they are at this period of life exempt from it, but only remark that it is of very rare occurrence. The lymphatic ganglia ofthe neck and those surrounding the bronchial divisions and root of the lungs are, in young infants, much more frequently infkmed or enlarged than those of the mesentery. The mesenteric gan- glia are but slightly developed at this early period of life; but they increase considerably in the course of a year ; and it is to be observed that their diseases and alterations become more fre- quent in proportion as their development acquires a marked pre- dominance in the system. CHAPTER XIV. DISEASES OF THE EYES. Art. 1.— Development and Congenital Malformation. The eyes very early exhibit the projections which correspond with the form of this organ, but they are not organized in a man- ner that will enable them to perform the function of vision until towards the termination of pregnancy ; and they undergo suc- cessively the changes which insensibly conduct them to perfect organization. The eyelids are joined until the seventh month ; and at first the tunica sclerotica is very thin and transparent. ON THE DISEASES OF INFANTS. 501 The cornea, which also appears soon, is at first soft and opaque and does not exhibit the solidity and transparency which belono- to it until about six months. At the commencement, it is in contact with the anterior surface of the crystalline lens, from which it is only separated when the aqueous humor is secreted. The iris is closed, until about the seventh month, by the pupillary membrane, which then separates in the middle and retracts to- wards the circumference, from the disposition of its vessels; their situation is well described by M. Cloquet. At the time the pupil opens, the aqueous humor which was situated behind the iris interposes itself between the cornea and the iris, and thus forms the space which constitutes the anterior chamber. The vitreous humor, which at first is red, gradually loses this hue, and assumes its proper transparency. The crystalline lens, consisting originally of a fluid, enclosed in a sort of thin cyst, thickens by degrees, preserving still its transparency, and takes a lenticular form. Tbe continuance of the closure of the eyelids constitutes a malformation which it is necessary to relieve immediately, by dividing them along the line where the borders of the eyelids are in contact. Congenital cataract and imperforation of the iris require sur- gical operations, which it is safer to defer to a later period of life. For the further consideration of this subject, I must refer to the various works devoted to surgical operations, where will also be found, in detail, descriptions of congenital cataract. Malformations of the globe of the eye, its greater or less pro- jection, its minuteness, compression, union with that on the op- posite side, or its blending into one eye on the median line, an anomaly known by the name of cyclopia or monopsia, are usually the result of malformation of the orbits, which are found com- pressed, deformed, or united into one, with malformations of the bones ofthe cranium or nasal fossae. At the time of birth, all the parts constituting the eye are suffi- ciently perfect for the purpose of vision, but the imperfection of this sense undoubtedly arises from the imperfect organization of the brain. As the latter becomes more completely organized, the sight improves ; the axis ofthe eyes, at first indeterminate, is fixed on surrounding objects, but the attention of the child is 502 ON THE DISEASES OF INFANTS. more especially directed to those of a brilliant nature; and we should consequently avoid placing the light in such a situation as will cause its rays to strike the eyes obliquely, and thus force the child to make the axis of vision to depart from its natural direction. The habit acquired at this time may continue during the whole life, and produce strabismus. 'Art. 2.—Ophthalmia of Infants. It is sometimes very difficult to account for ophthalmia in in- fants ; yet the length and difficulty of the labor, and the conse- quent compression of the head, may be regarded as a cause of this affection. Mothers who have gonorrhoea may communicate purulent ophthalmia to their children ; yet as there are numbers of children that have ophthalmia, born of mothers who have not been affected with any kind of syphilitic disease, gonorrhoea ought not to be considered as its sole cause. It would seem that the accumulation of a number of children in a hospital disposes them to this disease, for it always prevails to a greater extent among children in hospitals than in large cities. Badly shel- tered habitiitions, on atmosphere filled with smoke, little attention bestowed on the child in neglecting to wash the eyes upon the appearance of any redness in them, are evident causes of the development ofthe disease. Dr. Heurteloup has truly observed, that the frequency of this disease in the Hospice des Enfans Trouves may arise from the number of children crowded in badly-aired wards.* It appears in two distinct stages: once developed, it produces a number of alterations in the appendages of the eye; and it may indeed successively destroy every part of the organ of vision. At the commencement of the first stage, the eyelids are slightly red and tumefied, and nothing more is seen than a red trans- verse line in the centre of the eyelid. The child canifot bear the light, but turns its head in an opposite direction whenever the caudle or other shining object is brought before it, and also cries when the eyelids are touched. Pain or itching will sometimes * Inflammation de la membrane muq. gastro-pulm. chez les novvA.u-nes. Paris, 1823. p. 16. ON THE DISEASES OF INFANTS. 503 excite continual crying, and deprive it of sleep. The edges of the eyelids, particularly at the internal angle, then begin to ap- pear red ; and if the internal surface be examined, it will be found to be either of a deep red, or considerably injected with blood. The globe of the eye exhibits no change. This is the first stage of infantile ophthalmia ; it occurs on the third, fourth, or sixth day after birth, and will continue a very little time in the same condition, if left to itself. The second stage is known by the formation of pus ; all the preceding symptoms are increased in intensity; the injection of the bloodvessels is extended to the globe of the eye ; the redness exteriorly is greater; a large quantity of pus is discharged, and causes the edges of the eyelids to adhere, and the pus accumu- lates in the sac thus formed, and when the lids are separated pus immediately flows out; the child is unable to open the eyes, both on account of swelling and the impossibility of bearino- the light. The conjunctiva, which is also inflamed in this stage of the disease, becomes of a deep red ; the folds of this membrane, whicli exist between the globe and the eyelid, swell, and are cov- ered with a number of very small granulations; and as these folds compress and force out the tarsal cartilages, they thereby cause an inversion of the eyelids to a greater or less extent whenever the child cries : two red fungous rings are observed between the eyelids. While the inflammation increases, the sup- puration becomes more abundant; it varies much as to its color and consistence: it is usually thick and of a light yellow, and sometimes mixed with blood, occasionally in large quantities. In an advanced stage of the disease it assumes a green color- and I have also seen it, in children affected with jaundice, of a deep yellow. I remarked that the inflammation passed from the eyelids to the globe of the eye. When it affects the latter it produces some very serious lesions, which sometimes terminate iu the total loss of sight, even in the youngest infants. Let us take a rapid view of these complications. Inflammation of the cornea, or keratitis, is the most common ;* * Mirault, Dissertation inaugurate sur la keratitc, ou inflammation de la cornet. Paris, 1823. 504 ON THE DISEASES OF INFANTS. and several kinds of lesions are its effects, such as ils opacity, softening, ulceration, and perforation. Opacity, as in adults, arises in consequence of an effusion of puriform matter between the laminne ofthe cornea, or in the sub- stance ofthe conjunctiva, which covers the globe ofthe eye. It spreads to a greater or less extent, and I consider it as the lenst serious effect of puriform ophthalmia, as it usually disappears upon the yielding ofthe inflammation. Softening is not of unfrequent occurrence, and is a much more serious termination. When it commences, the cornea loses its lustre, and exhibits at one or several points a grayish or brown tint, and the line of demarcation which separates the healthy part from the diseased portion may easily be distinguished. The centre of this softening soon becomes perforated, and a commu- nication is established between the external air and the anterior chamber of the eye, so that, as soon as the perforntion is complete, there flows out a certain quantity of aqueous humor. This opening appears even at the centre ofthe globe ofthe eye that is opposite the pupil. It may be of sufficient size to allow ofthe es- cape of the crystalline lens with the aqueous humor, and which is followed by some of the vitreous humor. The globe of the eye shrinks, the eyelids, on healing, close, and vision is complete- ly lost. I have, in several instances, seen the iris project beyond the borders of the opening, and partially obliterate it, and thus prevent the flowing of any more ofthe humors ofthe eye. Ulceration diffi.-rs in some respects from softening; it usually occurs at the opaque parts ofthe cornea; the edges are tumefied, and it consists of small solutions of continuity, the sides of which are a little prominent, more round and regular than in softening. The same effects follow both these varieties ofthe disease. When the inflammation diminishes, the swelling of the eyelids graduallyceases. Suppuration is less abundant,and lessgreen, and thinner. The child is better able to bear the light, and can open the eyelids with much more facility ; but tbe lesions with which the membranes were affected continue, and children with this de- rangement of parts may become either partially or totnlly blind, from the continuance ofthe opacity of the cornea, staphyloma, or the complete evacuation of the aqueous humor and crystalline lens. The pupils remain more or less deformed, according to the ON THE DISEASES OF INFANTS. 505 adhesions thoy have contracted with some of the surrounding parts. As a general rule, the prognosis of ophthalmia of infants is unfavorable iu proportion as the globe ofthe eye is involved in the inflammation, and as the constituent parts of this organ are altered. The continuance of this inflammation is very variable. When it is simple, it lasts but for a few days; when complicated, with organic alterations of the globe of the eye, it may continue for several weeks or months. Opacity and softening of the cornea are not always produced by puriform ophthalmia alone. 1 have seen several children, who had been Tcduced to complete marasmus by gastro intestinal disorders of long duration, affected, without palpebral inflamma- tion, with softening of the cornea, which was followed by a per- foration and a discharge of the humors of the eye and the crys- talline lens. This species of spontaneous softening reminds me ofthe fact noticed by M. Magendie iu a dog, which, being fed for a long time with sugar, died after having been reduced to great emaciation. "There appeared," says M. Magendie, "on one eye, and afterwards on the other,a small ulcer on the centre of the transparent cornea; it rapidly increased in size, and at the end of a few days it was about a line in diameter, and its depth increased iu the same proportion ; the cornea was soon perfora- ted, and the humors ofthe eye escaped. This singular phenome- non was accompanied with an abundant secretion from the glands of the eyelids."* Was defect iu alimentation a cause of the softening ofthe cornea? The first object to be considered in the treatment of this dis- ease is the relieving of the inflammation. It has been recom- mended for this purpose to apply leeches to the middle ofthe up- per eyelid. One, however, is sufficient; Mr. Lawrence observes that a larger nuu:her produces the discharge of too large a quan- tity of blood, and that the most robust infant is reduced, even by the use of one single leech, to a state of debility and paleness.f M. Baron usually applies one leech to the external angle of each eye, and I have seen the most happy effects result from this me- thod even while the eyelids were very much tumefied. At the same time the eyes ought to be washed with a collyrium, made * Precis elementaire de physiologic, t. ii., p. 203. t Practical Treatise on Diseases ofthe Eyes. 64 606 ON THE DISEASES OF INFANTS. with a decoction of marshmallows or of rosewr.ter. It is the practice in the children's hospital at Vienna, to have compresses saturated with cold water kept continually applied to the eyes. The edges of the eyelids should also be frequently anointed with some mild ointment, to prevent their adhering, or to promote their separation when they have become united. Mr. Lawrence advises, immediately on the removal of the inflam- matory symptoms, the use of astringent collyria. A wash, con- sisting of two, three, or four grains of alum in an ounce of water, is usually employed fortius purpose at the ophthalmic infirmary. This solution should be carefully injected between the eyelids, three or four times in twenty-four hours, so as to remove entirely all the pus. In some cases, and where the conjunctiva has not become inflamed, astringents may be employed from the com- mencement. All that is done at the infirmary in London is to wash the eyes with a solution of alum, and to give a little mag- nesia—a course of treatment which has been very successful. A solution of the nitrate of silver may also be advantageously used, in the proportion of one or two grains to an ounce of water, and increasing it to six grains to the ounce. CHAPTER XV. JAUNDICE OF INFANTS. Jaundice is a yellow coloring of the integuments, or of the proper tissue of one or more of the organs. This definition em- braces all the varieties of form, aspect, and extent of jaundice, but this denomination is not applicable to every case of yellow col- oring of the skin : we shall presently see that it may be observed in many parts of the body; that it may be general or local, and exhibit various shades of color in different subjects. I have remarked the yellow coloring which constitutes jaun- dice, in four instances, in the brain and spinal marrow ; the brain, which was of moderate firmness, presented a uniform and bright yellow in two of these subjects, while the color was in isolated patches in the other two. In three of these cases the substance ON THE DISEASES OF INFANTS. 5Q7 of the medulla was of a deep yellow, and its consistence very soft; and in the two subjects where the yellow color ofthe brain was uniform, there existed, at the same time, a general jaundiced affection ofthe skin. This yellow coloring is analogous to that which M. Lobstein has observed in an embryo, and which he has named kirronosis. I have never seen it in the lungs, but have only found them in- filtrated with a large quantity of yellow serosity ; the tissue of the heart, however, and the pericardium, are sometimes of a deep saffron color. The thymus gland also is colored to a greater or less degree. The intestinal tube, which very often has, at its in- ternal surface, a yellow color, owing to the contact of bile, in two instances which I have examined, exhibited a yellow colorino- both on the internal and external surfaces, and which also ap- peared on the mesentery and on the external layer of the perito- neum. I dissected and preserved a portion of this intestinal tube, and observed no change in the color. I have already spo- ken ofthe yellow color which exists m streaks on the kidneys; even the bladder is sometimes of the same color on its internal surface. The liver is very often yellow in young infants, and I have even on some occasions found it deeply colored, in subjects where there existed but little of the jaundice exteriorly; this, however, is very rarely observed. The muscles are also colored yellow, butthe cellular tissue, and adipose substance surrounding them, are perfectly white. At other times, the whole adipose system is yellow, while neither the integuments, muscles, nor any of the organs exhibit this color. I have, in two instances, es- pecially noticed this in young infants, and when the thigh was cut transversely the stump appeared yellow in circular line be- neath the skin, while neither the skin nor the muscles presented any thing of this color. I have also found the periosteum aid the osseous tissue possessing this tint, with or without a general affection of a similar nature. The external integuments are the most ordinary seat of this disease. Their color varies from a light to a greenish yellow; and it is sometimes confined to the face, and sometimes to the limbs and trunk; it spreads successively from one of these parts to another, or makes its appearance in some point after having disappeared at another. In the cutaneous affection, the conjunc- 603 ON THE DISEASES OF INFANTS. tiva is also very often yellow ; hut this coincidence is much less frequent in children than in adults. It is very common to find the serosity ofthe cellular tissue ofthe pleura and pericardium, and also of the peritoneum, tinged with yellow. The color of the urine and fcecal matter varies considerably; the pus se- creted from inflamed organs is often ofthe same hue; the serum of the blood is almost always yellow. In eighty cases of jaundice, 1 found in fifty the liver and the abdominal vessels engorged with blood, and I have recorded forty cases of hepatic congestion without jaundice. In the eighty cases just mentioned, 1 found the bile more yellow and more abundant than oidinary iu only two. I have remarked that icterous affection of the skin follows the red color, so com- mon in infants, and always in a gradual manner. While the skin of the child is still veiy red, there is to be seen a yellow shade, and if the finger be applied so as to make a little pressure, instead of becoming white it exhibits a yellow tinge, and returns to the red color when the pressure is withdrawn : the jaundice becomes slowly more evident, and about the third, fourth, or eighth day, it takes the place of the red, and is in its turn re- placed by the white, or delicate rose color peculiar to the skin of young infants: it would appear, then, that jaundice was a shade or intermediate color between the tcgumcutary congestion of new-born children, and the proper white color of their in- teguments. From this exposition of facts, it results, 1st, That jaundice, being sometimes local, cannot arise from a general cause, which would extend its morbid influence over every part of the body, as diseases of the liver, for example, to which it has been usual to attribute it; and M. Lobstein has remarked, besides, that the medulla spinalis is sometimes colored yellow, at a period anterior to the secretion of bile. 2dly, The liver and the bile are found to be in cases of jaundice in very variable conditions, and it would he difficult to explain what would be the pathological state of this organ, or of its secretion, to produce the disease in question. 3dly, Notwithstanding the sanguineous congestion of the liver and integuments coexisting with jaundice iu the greatest number of instances, it is probable that the retention of this fluid in the organs, and the deposition of serum, which is ON THE DISEASES OF INFANTS. 5Q9 almost always yellow, is the cause of jaundice ; a color owing either to the coloring principle of the bile, as appears to be proved from the experiments of M. Chevreul, or to a source still un- known. In every instance, the jaundice of infants cannot be considered as a disease ; it may safely be left to nature, and it will of itself disappear; the use of medicine is unnecessary, unless there should arise some affection of the cerebral, thoracic, or abdomi- nal organs. The English pathologists, Armstrong, Underwood, together with Dr. Dewees and others, have made a distinction between jaundice of new-born children, and that which is symptomatic of affections of the liver: they have founded this distinction on the appearance of the alvine evacuations, which in the latter disease are white or yellowish ; the tears also and other secre- tions are tinged of the same color. These symptoms, however, indicate nothing more than a greater degree of ordinary j mndice, but do not establish a sufficient difference in the disease to war- rant the employment of any additional therapeutic means. CHAPTER XVI. ACCIDENTAL TISSUES IN INFANTS. Accidental tissues are not of very common occurrence in young infants; for they appear to be produced by the oro-anic modifications occurring in the organs during their growth in the course of life. I have found but two kinds of accidental tissues in the great number of bodies that I examined in the year 1S2G. These were scirrhous and tuberculous. One of these cases, that of scirrhous, occurred in an organ where it is seldom or ever found in an adult,—that of the heart. The following is the history of this curious fact. CASE LXXXVI.—Scirrhvs ofthe heart.—Courtini, aged three days, was brought to the Hospice des Enfans Trouves on the 4th of November, 1S2G, and died the next day. The post mortem ex- 510 ON THE DISEASES OF INFANTS. amination was made twenty-four hours after death ; externally, the body exhibited a considerable embonpoint, and the integuments were violet colored. A general passive congestion was found in the in- testinal tube. The lungs were healthy ; the heart, which was of the usual size, exhibited at its anterior part three white prominences of unequal volume, and flattened anteriorly and very near each other. The largest was near the base ofthe heart; the one next in size was nearer the summit of the organ, and the smallest between them. They were imbedded in the substance ofthe left ventricle and ofthe septum, and projected on the internal surface of the heart. This was very hard when cut, and exhibited fibres crossing each other, the appearance and form of which were analogous to the tissue of scirrhous. When placed in contact with nitric acid, this substance became crisp and black ; the same phenomena occurred when placed on live coals, it did not melt like fat. The surrounding tissue of the heart was perfectly healthy; and every thing led to the belief that these tumors were not formed by the adipose tissue. I do not know to what cause to attribute the formation of this tissue in an infant who must have necessarily been born with this disorganization. I was unable to obtain any account ofthe mother's health. Tubercles.—There have been several instances reported ofthe existence of tubercles in various parts of the body of a fcetus. I have found tubercular granulations in the peritoneum of a child that died four days after birth ; in two still-born children I saw an evident tubercular disease of some of the mesenteric glands. OElher has found the mesenteric glands tumefied, hard- ened, and in a word scrofulous, not only in children born of scrofulous mothers, hut also in those whose mothers exhibited no sign of this disease.* Tubercular granulations of the spleen are not very rare in young infants; I have sceh them in five children, where there existed at the same time in two of them tubercles in the lungs We should be careful not to mistake tumors arising from duplicate monstrosity, in which may be dis- covered the fragments of a fcetus, for an accidental organic transformation. Tubercles in the lungs have been seen both in stillborn chil- dren and those born before the full tixe. M. Husson reported * Art, OEuf. (path.) Diet, de Medic, t. x\., p. 402. ON THE DISEASES OF INFANTS. 511 to the Academic royale de medecine the cases of two children that he dissected, the one born at the seventh month, the other at the full time, and that lived eight days, where the tubercles were found softened, and already in a state of suppuration, in the former case in the lungs, although the mother had not been affected with phthisis, and the latter in the liver.* During the year 1820, I met with four cases of pulmonary tubercles in infants that died at the age of one, two, and five months. They all at the time of birth exhibited an activity and embonpoint which would not allow of the supposition that there existed the organic alterations with which they were affected. They gradually fell into a stale of debility and marasmus; the abdomen became tympanitic, theircry was changed, and in two of them percussion was not followed by the sound which is na- tural to this age ; this circumstance induced the belief that there existed tubercles, which were found in great numbers on a post mortem examination. Neither of these children were affected with the symptoms peculiar to phthisis of adults, such as bron- chial catarrh, hoemoptysis, sweating, and coliquative diarrhcea; one only had diarrhoea ; the mesenteric glands in this case were found in a tuberculous condition, with follicular ulceration in the intestines; the child thus affected was the one aged five months. One of the others had, for three days, symptoms which appeared to indicate the existence of a severe laryngitis: it died from suffocation. On examining the dead body, the trachea, bronchias, and lungs were found in the following condition: the pleura was covered with a large number of small, slightly prominent, white granulations; the larynx and trachea were healthy; the bronchiae contained, at their commencement, some frothy mucosity ; the left bronchia was filled with a thick puri- form fluid. There existed at the root ofthe left lung an irregu- lar tubercular mass still in a crude state, compressing the oppo- site branch in such a manner as scarcely to permit the air to pass. The internal membrane of this bronchia was red and tumefied at the place of its stricture. The pulmonary tissue was white and flabby, and the bronchial ramifications shrunk. The other lung was quite permeable to the air, and was per- * Art. OEuf. (path.) Diet, de Medic., t. xv,, p. 402. 512 ON THE DISEASES OF INFANTS. feetly healthy, with the exception of some very small, transpa- rent, tubercular granulations scattered throughout its tissue. Pulmonary tubercles, for the most part, in those children that I have dissected, appear under the form of small, round, trans- parent granulations, disseminated on the surface and tissue of the lungs, either at the extreme branches of the bronchia), or in the spaces between them; whilst tubercles in a more advanced stage, and even in a stale of suppuration, appear at the root of the bronchia?, or in the trachea. It would seem from this that the tubercular transformation of the lymphatic ganglia, situated at the root ofthe lungs and in the vicinity ofthe bronchial ram- ifications, takes piece first, and that a similar transformation afterwards occurs in the lungs; can wc not also suppose that, in the beginning, the pulmonary tubercles consist of small granu- lations, appearing at first transparent and soft, but when in- creased in number unite, and thus form the tubercular masses which we meet with in the lungs at a more advanced age? This form of pulmonary tubercles, more common than any other at the early period of life, appears to reveal the primitive mode of development of pulmonary tubercles. CHAPTER XVII. ALTERATION OF THE BLOOD. In the bodies of three stillborn children, that were in a state of o-eneral decomposition, and to which 1 was at a loss to assign a cause, I discovered what appeared to me to he a well-marked alteration in the blood.* The small number of wella?certained * In these three cases, it was impossible to ascertain the state of the mothers at the time of labor. There is no doul>t that the health ofthe mothers had a direct influence on that of their children ; numerous examples have long since demonstrated this fact, and in the presei.t instances, there is in all probability an analogous coincidence. There is a case recorded in the Archives gen de med., torn, xv., p. 9'2, of decomposition ofthe blood, accompanied with general petechie, in a woman that died just before the full time of her pregnancy. The condition ofthe fortus was as follows: it was, as usual, covered with a quantity of ca^seous matter; the epidermis was raised at the feet, hands, ON THE DISEASES OF INFANTS. 513 facts published on the alterations of the fluids in diseases, will not permit at present ofthe establishment of any fixed and posi- tive theory; I will therefore merely point out the facts which I have observed, as a contribution to the history of the diseases of the fluids. Iu eight children, who had not lived beyond the eleventh day, and who had sunk under pneumonia and gastro-enteritis, I found a general discoloration of the body, accompanied with complete marasmus, without decomposition ofthe integuments or destruc- tion of the epidermis. When incisions were made in different parts ofthe body, there flowed out a large quantity of very fluid chocolate-colored blood; the mucous membrane of the digestive tube exhibited in almost all the cases the discoloration and white softening which I have described in the chapter on diseases of the digestive tube. The liver was gorged with fluid blood, and similar in color to that of the integuments; the lungs were in the same condition, and quite soft; the heart also was pale and flabby, and in the same state of congestion. The foetal openings were obliterated in almost all ; in some the brain was firm and without injection; in the greatest number it was softened, and in two I found it decomposed, and diffusing an odor of sulphu- retted hydrogen. In four others, I found the liver also softened, exhibiting the same odor. The bile did not present any thing peculiar. The whole of the tissues were remarkable for their softness, flaccidity, and their near approach to a true decomposi- tion. In several others, the limbs were cedematous, and the skin had the appearance of wax. They had all been affected with an extreme slowness of the circulation, and great prostra- tion ; their cries were feeble, and they continued for two or three days in a kind of agony, which death soon terminated, without giving rise to any particular symptom. and scrotum. There was no ecchymosis on any part of the body. The brain was injected with fluid blood; the lungs, pericardium, heart, and origin ofthe great vessels, were covered with purple spots of a small size. The liver, spleen, intestinal canal, kidneys, and bladder were in a healthy state. All the blood that flowed from the cut parts, together with that which was contained in the different vessels, both of the mother and fcetus, was fluid and violet, resembling a mixture of carmine and water. In no part ofthe body was there found the smallest clot. 6& 514 ON THE DISEASES OF INFANTS. Death in these children appeared to be caused more by n kind of spontaneous decomposition of the solids and fluids, than by the progress of any inflammatory disease, or of any organic lesion. Does not this species of death bear some resemblance to the withering and disorganization of vegetables, rather than to those alterations which occur in the organs of a being in pos- session of all the plenitude of life ? And the patient, when sink- ing under them, manifests symptoms of reaction which may, in a metaphoric sense, be considered as the effect of a kind of strug- gle between death and life.* * Although the important remarks of Dr. Joerg, in his work on diseases of children, p. 310, may perhaps have but an indirect reference to the preceding facts, yet from their interesting character we shall place them here. A very important disease of the skin in young infants, says he, is that which is characterized by a peculiar state of the epi- dermis, which is detached on the slightest touch from the sole of the foot, toes, palm ofthe hands, fingers, and even sometimes from the entire surface of the body. I have only once seen this general separation ofthe skin in a child in perfect health, and born at the full time; but have frequently met with it on the hands and feet. In every case the mother had been affected with syphilis during pregnancy. None of the children thus affected lived longer than four or five days, and although born in the ninth month, they were all thin and debilitated. The part deprived ofthe epidermis became inflamed, and this circumstance, joined to the extreme debility of the individuals, con- tributed greatly to shorten their lives. I am entirely ignorant of the nature of this disease. This state of the skin on the hands and feet is sometimes accompanied with a pustular eruption on various parts of the body, differing essentially from the small- pox in the form and appearance of the pustules. They bear some resemblance, how- ever, to the pustules of vaccinia on the twelfth or thirteenth day. It has been likewise impossible for me to ascertain any thing satisfactory as to the nature and progress of this eruption, from the extreme rapidity with which all children die that are affected with this singular disease. (Archives gen de med., torn, xxiii., p. 560. A MEDICO-LEGAL DISSERTATION ON VIABILITY, CONSIDERED WITH REFERENCE TO THE PATIIOLOOY OF NEW- BORN CHILDREN. Viability is the capability of extra-uterine life; it should consist not only in the normal state of the organs of the infant, but likewise in the absence of all physiological and pathological causes, capable of opposing the establishment or prolongation of independent existence. Thus, as Professor Orfila has observed, an infant may have lived, and yet not have been regarded as viable,' because some organic malformation may have prevented the prolongation of life ; another child, born living, may perish in the first period of its life, although it was viable.* The question of viability, then, must be considered with ref- erence to the pathological causes which may be adverse to the establishment of life, and it is therefore necessary to have a pro- per estimate of these causes. It appears to me useful to ascertain how far congenital malformations and diseases of the new-born child may embarrass the establishment of life, for all congenital diseases are not productive of non-viability ; some offer no im pediment to the establishment and continuance of independent life, while others clog and embarrass its development; the latter are the inevitable causes of the death of the child, and the study of their nature is the object of this dissertation. The various apparatuses and principal organs of the system will be reviewed, and the congenital malformations and diseases which may be developed during the evolution of the fcetus ex- * Lecons d* Medecine Legale, 2d edit., p. 511. 516 DISSERTATION ON VIABILITY. nmincd. I shall divide this subject into two parts; the first will comprise the study of congenital diseases, and that of their influ- ence upon the development of life; and the second the applica- tion of these data to legal medicine.* PART FIRST. ON CONGENITAL MALFORMATIONS AND DISEASES. § I. Congenital malformations of the skin.—Care must be talcen not to mistake for a congenital disease the intense redness of the skin of a new-born child, and the epidermic exfo- liation which occurs several days after birth ; both of these are natural phenomena. Absence of the skin in one or more parts of the body has been noticed from the highest antiquity, an account of this lesion being found in the writings of Hippocrates, who has made it the sub- ject of some very judicious observations.t This congenital mal- formation is not adverse to the establishment of life in an infant, except when there coexists some other deformity, or when an organ is exposed which is essential to life. Thus, absence ofthe skin, with a wound on the limbs or face, is susceptible of cicatri- zation after birth, and can oppose no obstacle to the execution of the functions of life ; but when absence of the skin results from an arrest of the development of the thoracic, abdominal, or cranial parietes, this malformation must be fatal, for important organs are thereby deprived of their integuments, and the child is exposed to the most serious and fatal affections. Cutaneous excrescences, which are met with on the face, hands, and feet, are not causes of non-viability, at least if unaccompa- nied with a defective development in some other part; which, however, as Meckel observes, is of common occurrence. Thus, * The facts which furnish the matter for this dissertation being contained in the nu- merous cases throughout this work, it is impossible to avoid some repetitions; but on reflection, it will be seen that it was indispensable to recal all the examples which con- cur in the demonstration of the various points we have undertaken to elucidate. t De Gcnitura, cap. 6. dissertation on viability. 517 the cutaneous excrescence which is seen on the forehead of a foetal cyclops is not a dangerous deformity, except when it co- exists with some other congenital malformation. Those cutane- ous excrescences which are met with on the face alone, may be removed and cured without injury to the health of the child. It is the same with horny excrescences ; but their existence on the human fcetus is scarcely yet proved, and the passage which Haller has devoted to these extraordinary growths has no foun- dation but in facts very slightly authenticated. The excessive development of the pilous system at birth, must be considered as an abnormal persistence of the hairs which cover the fcetus about the middle of the intra-uterine life, and which generally fall off before birth. Far from considering these infants as animals deprived of their faculties, and consequently of the rights of civilization, as some ignorant persons have done, ac- cording to the account of Haller,* they ought to be examined with care, to see if there exist no other organic aberration or some disease ofthe internal organs, which are adverse to the establish- ment of life, for this simple abnormal development of the pilous system cannot be a cause of non-viability. These hairs fall off some time after birth, and the infant then no longer exhibits this superficial and transitory anomaly, which ignorance alone could confound with the integuments of animals. Alterations in the color of the skin may be referred to petechiae, albinism, and cyanosis. Albinism can have no influence on via- bility ; petechias and cyanosis, which are frequently seen in in- fants at birth, are ordinarily the symptoms of affections more or less serious, which doubtless may oppose the establishment of life : but attention must be paid more to these lesions than to the modification of the cutaneous pigment, which is of but little im- portance when separately considered. As to albinism, it exerts no influence in opposition to the prolongation of life, and albinos have been seen at an advanced age.t Ecchymoses, sanguineous tumors, contusions ofthe integu- ments, which ordinarily result from a local or general sanguine- ous co'no-estion, ought always to be considered with reference to * Opera minora.—De monstris, lib. i. t}. Geoffroy-Saint-Hilaire, Histoire generate et particuliere des anomalies de l'organi- sation dans 1'homme et lea animaux. Paris, 1832. 518 dissertation on viability. the causes which produce them; of themselves they are of no consequence. The spots and erectile tumors, which are described under the name of ncevi materni, have no power over the via- bility of children, because they may live a long time with this deformity, which does not become mortal unless it is of great extent, or makes rapid progress. Congenital inflammations of the skin deserve the attention of the medical jurist. Infants have been born with measles or smallpox. Examples are given by Bartholin, Boerhaave, Van Swieten, Vogel, Jenner, Mauriceau, MM. Rayer, Duges, and others. Some of them were feeole and premature, and died a short time after birth. Children have been cured of these affec- tions and lived a long time after. Consequently, if these inflam- mations of the skin are unaccompanied with any congenital mal- formation, or any other serious disease, they ought not to be con- sidered as an obstacle to the establishment of independent life. Induration or oedema of the cellular tissue never exists alone, but is almost always accompanied with a state of congestion of the principal organs, and particularly of the respiratory and cir- culatory apparatus. This congestion is evidently adverse to the establishment of life, and offers, as we shall see below, a great hindrance to the viability of the child. It is not, therefore, to the cedema alone that we ought to direct our attention, when about to pronounce a judgment on the viability of an infant thus affected, but we ought to ascend to the examination of the accom- panying lesions. As to those infants described by Uzembezius, that were born so cold and hard that they might have been mis- taken for marble statues, no doubt can exist as to their non-via- bility, since they are almost always born dead. This kind of in- duration of the cellular and adipose tissue is generally the effect of decomposition. § II. Digestive apparatus.—Absence ofthe buccal cavity, and also the absence of the anterior opening of the mouth, re- placed sometimes only by an irregular orifice, situated at some part of the buccal cavity, ought to be considered as a cause of non-viability ; as it is impossible for the child to exercise suction or deglutition, and it is even impossible to introduce drinks into the digestive passages. It is not so, however, with the more or less perfect occlusion of the mouth, in consequence of adhesions dissertation on viability. 519 of the lips; this deformity does not necessarily affect the viabili- ty; for, by means of an operation, a passage may be established to the digestive organs. But when the absence ofthe mouth co- exists with a congenital malformation of the face and cranium, this deformity ought to be regarded as a cause of non-viability. The same may be observed with regard to congenital division ofthe lips, palatine arch, and velum. The child may live a long time, whether no effort be made to relieve the infirmity, or an operation, which is most frequently successful, be performed for that purpose. A monstrous development of the tongue is not an insurmountable obstacle to the functions of life. In the 15th volume of the Journal de Medecine de Vandermonde, is record- ed an account of a child born with a tongue of enormous size, the inferior extremity of which adhered to the gums of the lower jaw, by a spongy tumor about the size of a filbert. After a while, this tumor became confounded with the tissue of the tongue, which steadily increased in size as the infant advanced in age. During this time, the child was sustained only by liquid aliments; it had become habituated to the practice of sucking by drawing the lower jaw considerably backward; at last, in- structed by its wants, it was enabled to arrange the tongue and jaw so as to chew and articulate sounds. This child, therefore, in spite of this infirmity, was viable, and was much more so be- cause the tongue might have been reduced in size by an opera- tion, and the proper form and use of the organ restored. Children are sometimes born with passive congestions of the mouth and tongue, which can have no influence on the development of life. The extreme narrowness of the pharynx I have observed to coexist with that ofthe tongue ; it interferes much with degluti- tion, but cannot be considered as a cause of non-viability. Congenital malformations of the oesophagus are almost always mortal; oue species, that of stricture of the oesophagus, may al- low the infant to swallow drinks, although with difficulty ; but it is not so with obliteration, fissure, or duplicity of the oesophageal canal. Infants affected with obliteration of the oesophagus may exhibit congenital malformations externally, and which alone would remove all doubts that might be raised upon the medico- legal question of which we are treating ; such is the case in the instance given by M. Lallemand, of Montpelier, in his inaugural 520 dissertation on viability. dissertation. Dr. Sunderland, of Barmen, has given the history of a child born at the full time, and to appearance in good condi- tion, that died at the end of eight days, after having continually vomited the aliments which had been given. On opening the body, the cardia was found wanting; the stomach adhered at this place to the diaphragm by means of the cellular tissue.* With such a malformation an infant must necessarily perish. The same fatal result will always occur when the oesophageal canal is obstructed, interrupted, has a deviation from its natural direction, or is divided into several parts. Congenital inflammation ofthe oesophagus, without complete- ly opposing the viability ofthe child, may very much disturb the exercise of life, and at last terminate fatally. I have seen, in two infants that died a short time after birth, ulcerations which were doubtless developed in the oesophagus during the latter part of the intra-uterine life, and which, by the progress they made after birth, contributed greatly to hasten the death of these infants. It is possible to meet with a gelatinous softening of the oesophagus in a new-born child ; in such an affection the infant vomits all that is given to it, and becomes rapidly emaciated from default in nutrition ; and as the progress of the disorganization is contin- ually increasing, perforations of the oesophagus are found upon examining the body after death. The gelatinous softening being a disorganization of tissue, and this disorganization having com- menced or terminated before birth, cannot be cured and cicatri- zed. I am therefore of opinion that it ought to be regarded as an inevitable cause of death; consequently infants that are born thus affected are not viable; the chances of life for them are very uncertain. The stomach exhibits no anomalies except with reference to its situation and form. Displacement of the stomach offers no obstacle to life; it can discharge its functions when it is situated upon the right side as well as the left of the abdomen, or even when it is in the cavity of the thorax. The essential condition is, that the orifices be free; yet if it be adherent to those parts with which in a natural state it has no communication; if, for example, it should open into the colon, or occupy the place ofthe * Journal Complementaire du Dictionaire des sciences medicates, tome viii., p. 3C9. dissertation on viability. 521 rectum, of which deviation instances have been reported, al- though they are very incredible, it will be easily conceived that this infirmity would be regarded as one cause of non-viability. The diseases ofthe stomach consist of different degrees of san- guineous congestion or of inflammation. Congestions of the stom- ach are of very common occurrence in young infants, and con- sequently but little importance ought to be attached to them with reference to the subject before us. As to congenital inflamma- tions, they are generally the causes of very serious symptoms. Congenital gastritis consists almost always of a number of ulcer- ations, the borders of which are of a very shining carmine hue, and the bottom of a deep yellow. These ulcers result from the disorganization of the muciparous follicles of the stomach. The portion of the mucous membrane surrounding them remains white, notwithstanding the existence of inflammation, and the stomach generally contains a quantity of black sanguinolent mat- ters, resulting from the sanguineous exhalation which takes place from these ulcers on the surface ofthe ventricle. When thus af- fected, the child exhibits no external sign of phlegmasia, and preserves its rotundity of form ; but as soon as it is separated from the mother, and the gastric digestion becomes a process of the greatest importance, it then falls into a state of marasmus, and vomits all that is given to drink; brown matters, such as I have observed to exist in the surface of the organ, are discharged by vomiting ; and it soon perishes if the ulcers, in place of cicatri- zing, enlarge and become more numerous. This alteration of the stomach ought to be arranged among the causes which interfere with the development of life. Gelatinous softening of the stomach occurs sometimes very soon after birth, so that one is led to believe that it has already existed during intra-uterine life. If such an alteration should be found in an infant which had died on the first or second day af- ter birth, ought it to be pronounced viable 1 I think not; for according to all probability this alteration existed at the time of birth; and it is generally so rapid in its progress, and so fatal in its results, that a child born with this affection should be consid- ered necessarily dying, and consequently as not born viable. Congenital malformations ofthe intestinal tube are very numer- ous. A great number of instances are recorded in various ' 522 dissertation on viability. works, particularly in the learned one of M. Meckel.* Doctor Schaefer has published a memoir, in which also the principal anomalies of the digestive tube are pointed out.t Thosetwhich more particularly deserve our attention are interruptions ff con- tinuity, strictures, and obliterations. Every interruption of the intestinal canal ought to be considered as a cause of death. Ob- literation will be more dangerous according to its position. Thus an infant having an obliteration at the duodenum, or some other part of the small intestines, at the caecum, colon, and the upper two thirds of the rectum, ought to be regarded as non-viable; but when the rectum exists, and the obliteration is near the orifice of the anus, the child might still be considered as viable, since an opening into the anus has been several times made by an inci- sion through the cul-de-sac, formed by the obliteration of the rec- tum. When this intestine is wanting, although it is possible to form an artificial anus at the sigmoid flexure of the colon, yet I regard this condition as a cause of non-viability, inasmuch as the operation resorted to in similar cases has, to this day, almost always caused the death of children, while it is not so when a *■ superficial incision is made at the perinaeum. Strictures more* or less numerous throughout the extent of the digestive canal,, are only embarrassments to the establishment of life, but ought not to be considered as an inevitable cause of death. Congestions and intestinal hemorrhages, which are observed in infants at birth, phlegmasic alterations, such as inflammation and ulceration ofthe muciparous follicles, are also serious symp- toms, but not absolutely mortal in young infants. It is not uncommon to see infants pass by stool, with or without the evac- uation of the meconium, a greater or less quantity of blood, the- result of intestinal exhalation arising from congestion of the intes- tines. Infants do not always die from this cause, especially m our climate ; but this species of dysentery cuts off, on the contra- ry, avast number in America, where cholera infantum prevails epidemically. If it be proved that a child can survive this disease^ it must be admitted that it is not essentially mortal. This, how- * Manual of Descriptive and Pathological Anatomy. Translated by Dr. Doanfc. London, 1838. t Journal complementaire r*v Diet, des sciences medical's, t. 34. DISSERTATION ON VIABILITY. 523 ever, is not so with the white or pultaceous softening of the mu- cous membrane of the intestines. I have, in three instances, seen this disorganization of the mucous membrane in children that w the result of a vast accumulation of expe- rience, obtained where the prevalence of the disease is coextensive with the boundaries of the land, and where its appearance is annually anticipated with the same certainty as that of the season which gives it existence. Those who have recorded this experience are men who have distinguished themselves in the fields of science, and who are unsurpassed in sagacity, and in the attainment ofthe object of all intellectual culture when applied to medical science,—a solid philo- sophical judgment. It would be impossible, as it would indeed be unnecessary, to attempt to exhibit at length the professional charac- ter of some of our distinguished countrymen ; but a reference to our numerous medical treatises may with confidence be made, in proof ofthe industry, erudition, and genius displayed in the cultivation of the science of medical philosophy. SUSPENSION AND RETENTION OF URINE. Note to page 351. When it is ascertained that there is a suspension of the urinary secretion, and that the bladder is empty, we ought to avail ourselves of those means which will excite the secretory function of the kid- neys. A small quantity of infusion of parsley root, with a few drops 75 594 APPENDIX. of Spts. Nit. D. will almost always succeed in effecting this object, particularly if assisted with the warm bath and enemata. Retention of urine immediately after birth not unfrequently arises from mucus, which may be removed with a small probe. Fomenta- tions with hops, or flannel dipped in warm water, and applied to the pubic region, or frictions with camphorated oil, will often relieve it, when arising from spasm of the neck of the bladder. If, however, these measures should not speedily relieve the retention, no time should be los,t in vain attempts to relieve this dangerous affection by a reliance on these applications, but a small-sized flexible catheter ought to be carefully passed into the bladder, as the only efficient means in our power of procuring an evacuation of urine. It is of great importance to ascertain the existence of this disease, for doubtless, as Dr. Dewees correctly remarks, some infants have perished from this affeetion without its having been suspected. No reliance, therefore, should be placed on the representation of nurses, that the urine is regularly discharged ; but, when there is reason to suspect the disease, the physician ought carefully to examine the abdomen and pubic region for the symptoms which indicate a reten- tion of urine. CROUP. Note to page 388. Having for a number of years been in the habit of treating this disease with uniform success, according to the views and principles taught by the late Dr. David Hosack, when professor of the theory and practice of physic in the College of Physicians and Surgeons of the University of the State of New York, the translator, by permis- sion, avails himself of the opportunity afforded by the publication of the lectures of Dr. Hosack, (Philadelphia, 1838,) to copy a portion of his lecture on the treatment of croup: " Writers upon this subject differ as widely as they do about the nature or character of the disease ;' but none, in my opinion, ap- pear to have sufficiently discriminated between the different stages in which the remedies they severally recommend ought to be em- ployed ; even Dr. Cheyne's late valuable Avork, and which contains the best pathology of this disease, is in some degree defective in this respect. I have been led at the bedside to distinguish three distinct stages of croup: the first may be denominated the forming stage of the disease ; in this the affection is local; the irritation has not APPENDIX. 595 yet extended to the whole system ; the child even sits laughing and playing upon the lap of its mother, manifesting a very unusual but morbid degree of exhilaration ; its skin is cool and moist, its pulse not perceptibly accelerated ; but its hoarse, hollow sounding, and frequently-returning cough, its wheezing inspiration, its restlessness, and especially its cries after a fit of coughing, all denote, to the phy- sician and parent acquainted with the disease, the consequences that will soon ensue, if active means be not employed to prevent the second, or febrile stage. " In this stage the whole system partakes of the irritation ; the pulse is frequent, the skin hot and dry, the respiration hurried, the tongue covered with the usual white fur indicative of inflammation, the lips and chseks remarkably florid, the cough frequent, but at- tended with a more acute sound than that of the first stage; every inspiration, too, is attended with more uniform wheezing than that which appears in the first, when occasionally an interval occurs, in which the child breathes as if in health. But in this second stage no such interval is perceived; the trachea, bronchiae, and lungs be- come so surcharged by the circulating fluids, that the child has not even a momentary relief from its oppression ; and in a short time, if left to itself, especially if the patient be plethoric, the countenance exhibits a purple, livid color, not unlike that of apoplexy, and is even attended Avith a degree of stupor, or propensity to sleep. This loaded state of the lungs, and interruption to the free return of blood from the head, I have frequently witnessed in this stage of croup: if the patient be now neglected, or the evacuations be sparing and insufficient, an effusion from the exhalent vessels opening into the windpipe, bronchia3, and surface of the lungs, inevitably takes place. In the two former, the effused matter assumes a membranous ap- pearance, probably owing to the forcible passing and repassing of the air through the preternaturally constricted tubes ; but in the lungs themselves, it appears in the form of a viscid fluid, partly resembling both phlegm and pus. When this effusion has actually taken place, the febrile symptoms sensibly abate, and sometimes dis- appear altogether ; the child is also apparently free from pain, but it suffers violent paroxysms of cough and difficult breathing, attended with an irregular and spasmodic respiration, as in asthma or dropsy of the chest, and with similar intervals of ease. These paroxysms, in young children, continue but a few hours before dissolution. But in children arrived at eight or ten years of age, they frequently con- tinue several days." " This stage, in which the membranous effu- 596 APPENDIX. sion takes place, I denominate the membranous, or purulent stage ; from this advanced state of the disease recovery is so rare, that it is not to be expected ; it might almost be denominated the fatal stage of croup. These distinctions it is, in my opinion, important for the practitioner to keep in view, as they lead to important conclusions in practice. They teach us, during the first or forming stage of this disease, to adopt the most active means of restoring the suppressed secretions ofthe trachea and surface ofthe limes, and by open bow- els and perspiration to guard against the general excitement of the system. For this purpose, when called to a patient laboring under the first symptoms, in which the disease appears to be confined to parts primarily affected, it is my practice to administer an emetic composed of tartarized antimony and ipecacuanha; to a child under two years of age, I direct from one to two grains of emetic tartar, with from five to ten grains of ipecacuanha, every fifteen minutes, until it operates to such a degree as to induce a plentiful secretion from the trachea and lungs. It is surprising, in some instances in this disease, to see the immense quantity of viscid, ropy phlegm dis- charged by the operation of an active emetic at this period of the complaint; but Avhen this discharge has been accomplished, and the cough become loose, which is an evidence of the natural secretion being restored upon the surface of the parts affected, we may, in most cases, consider the patient secure from danger." "In this second stage of croup, such is the determination of the circulating fluids to the part affected, and such the general febrile excitement ofthe system, that the most efficient means of diminishing the ple- thora of the bloodvessels, and of diverting the irritation from the part affected, become necessary. With this view, the patient should be bled freely, in proportion to its age and powers of constitution ; say, for a child under two years of age, from two to four ounces; from two to six years, from four to six or eight ounces, and to be repeated as the urgency of the symptoms may require." " Although I am not an advocate for small bleedings in croup, let me here take occasion to express my disapprobation ofthe practice of some phy- sicians, especially that recommended by the late Dr. Bayley, of this city, Dr. Ferriar, of Manchester, and Dr. Dick, of Alexandria, (see third Supplement to Dr. Barton's Med. and Physical Journal, for May, 1809, p. 242,) I mean that of bleeding the patient until faint- ing be produced. The relaxing effects of bloodletting upon the system are no doubt desirable in this complaint, and were probably the objects which the advocates of this mode of treatment had in APPENDIX. 597 vieAV ; but having observed, in some instances, very serious and permanent evils to the constitution, occasioned by the debility which this profuse evacuation had produced, and knowing that even the most violent attacks of croup will yield to a less excessive evacua- tion by the lancet when conjoined with other remedies, I have hith- erto objected to this practice in the extent it has been recommended. After bloodletting generally some partial relief is immediately ob- tained ; respiration is less frequent; the peculiar noise of inspiration is also diminished ; the cough becomes more loose and yielding; the skin is rendered moist, and the pulse less tense and frequent. " But these favorable symptoms are oftentimes deceptive, and of short duration : the cough, labored respiration, and heat of skin, are perhaps all renewed in the course of an hour. In that case, the an- timonial emetic must be immediately employed. Although the force of the disease may have been greatly subdued by bloodletting, the alarming symptoms so frequently return, that I am now in the con- stant practice of prescribing the emetic immediately after blood- .etting has been performed, without waiting to ascertain the effects which the bleeding alone might produce ; if, however, after the oper- ation of the emetic, the symptoms still continue violent, I usually repeat the bleeding, immerse the patient in a warm bath, apply a large blister to the throat, covering the larynx and trachea, and ad- minister a cathartic of calomel, from five to ten grains, repeating this medicine every two hours, until it produces some sensible effect in this respect, at the same time soliciting its operation upon the bowels by injections occasionally administered. , " These several remedies have been employed, and having failed completely to subdue the febrile symptoms, and to divert the irrita- tion from the trachea and lungs, I next direct small doses of calomel and James's powder, from two to five grains of each, to be given every two hours, to a child under four years of age ; but when suf- ficient evacuation from the bowels may have been procured, I fre- quently prescribe the antiinonial wine, or a solution of tartar emetic, in such doses as to excite a considerable degree of nausea and relax- ation ; Avith these I occasionally blend a small portion of laudanum, where it may be indicated either in consequence ofthe profuse evac- uation by the bowels, or when the couoh may be very harassing to the patient, which is sometimes the case when the febrile symptoms are greatly moderated; in other respects laudanum should be ad- ministered with great caution in this disease. " The physician is sometimes called upon at a late period of the 598 APPENDIX. disease, where the means Avhich have been described have not been employed ; or if they have been, may not have succeeded, and in which the third stage of the disease has become apparent. Respira- tion, as in the two preceding stages, is still laborious, accompanied with the same wheezing noise upon every inspiration ; the cough also continues violent, without the least expectoration, and returns in paroxysms, in which the patient is threatened with immediate suffocation ; the countenance exhibits a blueish livid appearance, at the same time that the patient manifests the greatest anxiety and distress ; occasionally, hoAvever, it has intervals of ease, in Avhich its sufferings are apparently inconsiderable; but these intervals are of short duration, and afford no prospect of relief, for the effusion men- tioned, and the consequent formation of a membranous matter lining the trachea and bronchia, has already taken place. In this stage of the disease, it has occasionally happened that portions of the mem- brane have been throAvn off by coughing, by which the patient has happily been preserved." " Calomel, in small but repeated doses, squills, the syrup of onions, the seneka snakeroot, ammoniae, and asafcetida, and the vapor of vinegar and water, are the medicines in Avhich I am inclined to place most reliance at this advanced period of croup. As they are a class of remedies calculated to excite the secretions from the lungs, without impairing the general poAvers of the system, they afford, if steadily persisted in, the means of loosening and of ejecting the membranous matter, as well as the fluid materials effused over the surface of the lungs." "Dr. Archer, of Maryland, has rendered an important service to medicine by reviving, not in- troducing, (see Woodville Drinker's remedy,) into general use the polygala senega, as a remedy in croup. " Hitherto, however, it has certainly disappointed the expectations of most practitioners, because it has been prescribed indiscriminately in every stage of the disease; whereas, for the very reason that it is so useful in exciting, the vessels of the trachea and lungs to a powerful excretion of the materials oppressing them in the last stage of croup, it is certainly a hazardous prescription Avhen those organs are preternaturally excited, as they are both in the forming and fe- brile stages of this disease." Vitriolic emetics have of late yea^-s been much used in the mem- branous stage of croup. Three cases under the most unpromising circumstances, successfully treated by sulphate of zinc, are recorded in the 3rd volume of the New York Medical and Physical Journal. APPENDIX. 599 HOOPINGCOUGII. When there are present any symptoms of inflammatory action, it is obvious that the proper remedy is the abstraction of blood by the lancet or by leeches ; and in case of plethora Avith threatened con- gestion of the brain, bleeding is an important and even a necessary remedy. When the inflammatory irritation is in some measure sub- dued, a sedative mixture Avill be found of great efficacy in allaying the distressing fits of coughing. ' As the child is constantly annoyed Avith a quantity of viscid mucus, emetics will be found useful, and will almost always shorten the par- oxysm of coughing; small doses of ipecacuanha or tartar emetic given during the interval for the purpose of allaying the febrile action, will on the accession of a cough often act as an emetic. Tar- tar emetic combined with testaceous poAvder is an old and favorite prescription. There is evidently a disordered condition ofthe stom- ach and bowels, generally accompanied Avith acidity, as the altered state of the secretions show. It will therefore be necessary to attend to the primae viae, and administer laxatives throughout the disease: soda, rhubarb, and ipecacuanha will be found a good combination for this purpose. Narcotics have been found highly necessary in the spasmodic or chronic stage of the disease ; and opium, conium, hysoscyamus, lac- tuca, belladonna, &c, have all been used with various success. Bel- ladonna has within a few years been highly successful, in the hands of Bonda, Hufeland, and Alibert, and more recently by Dr. Wel- deck, of Berlin. Dr..Eberle speaks Avith great confidence as to the value of this remedy from the experience of a number of years; lim- iting its use to those cases in Avhich there is absence of fever and bronchial inflammation, and where the disease is purely of a spas- modic *brm. Hydro-cyanic acid has of late been much used in the treatment of hoopingcough, Avith great success in a number of cases ; but, like every other remedy in this disease, it has sometimes failed in giving relief. Dr. Hamilton Roe, hoAvever, observes, " that the cases are so very numerous in which this medicine succeeds,—especially if it be given at the commencement of the disease,—and so very few in which it fails of speedily producing a beneficial effect upon the cough, that my first impression on hearing that a child Avho has been using it is no better is, that the acid cannot have been good." 600 APPENDIX. (Treat, on the Nat. and Treat, of Hoopingcough, j. This bath differs from the artificial Ba- rege water, in containing half the quantity of sulphuret of potass. Used in psora. H. des Enfans. Sulph. sublim. Acetatis plunbi, a a 3j. Zinci sulph., 3ss. Used in psora. H. de la Maternite. Syrup papav., 3ij. Decoc. amyli, Iviij In diarrhcea of infants. H. de la MaternitS. ft Cap. papav., No. j. Decoc. lini, ftjjj H. de la Maternite. fy Cap. papav., 3iij. Aquae, lbj. ft Amyli, gj. Aquae, lbij. H. des Edfans. H. des Enfans. ft Flor. anthemidis, 3ij. Aquae, lbj. Ft. enema. For infantile colic. APPENDIX. 617 PURGATIVES. ft Pulv. rad. jalap., gr. xxiv. Calomelanos, gr. iv. Sacchar. alb., 3ij. M. Ft. pulvis divid in xij partes aequa- les. A teaspoonful twice a day for a six months infant, in obstruction of the bow els. Wendt. ft Calomelanos, gr. iij. Pulv. rhei, Oleo-sacch. foenic, aa 3j. Ft. pulvis. One third of the above quantity is a dose for an infant, as a laxa- tive. Fischer. ft 01. ricini, 3iij—iv. Pulv. acaciae, q. s. Aq foenic , 3ij. Mannae, Sss. Fiat emulsio. A dessert spoonful, repeated every hour until it operates. Berends. ft 01. ricini, Iss. Syrup, rosae, Iss. Vitel. ovi, un. Tinct. sennae, 3iss. One or two teaspoonsful for an infant. ft Mannae, Iss. Emulsio. Arab., fss. Syrup, violae, 3ij. Bene admisce, et adde, Aquae menth:, Ij. M. S. From 3j to 3ij every third hour, until an effect is produced. Evanson and Maunsell. ft Infusi sennae, Ij. Aqus menthae, §ss. Mannae, 3ij. Magnesia, 3j. Tinct. rhei, 3j. Syrup, rosae, 3jj. M. S. From 3j to 3ij every third hour. Evanson and Maunsell. ft Sulph. sub , gr. x—xx. Mist, acaciae, 3ij. Sacchar. alb. gss. Aq rosae, 3j. A teaspoonful hourly, shaking the vial well each time; for an infant in the first year- Kopp. ft Fol. sennae, Sss. Aquae ferv, lbj. Sodae sulph., Iss. To be used as an enema. H. des Enfans. ft Magn. calcin., 3ss. Pulv. rhei, gr. vj. Sacchar. albi, 3j. 01. menth , gt. vj. Aquae, §iss. A dessert spoonful every two hours. H. d'Amer. ft Mannae, liij. 01. amygd., Syrup, gum., aa §j. From one to fcur drachms to be given to young infants, as a mild laxative. H. d'Allem. ft Decocti hordei, Iv. Muriatis sodae, 3iij. 01. olivarum, 3v. M. To be used as an enema. ft Vini antim., Iss. S}'rup. althaeae, §j. A teaspoonful every quarter of an hour, to a child three or four months old. Wendt. ft Pulv. ipecac, gr. xij. Syrup, simpl., §j. A teaspoonful every quarter of an hour, to an infant five or six months old. 78 ft Vin. antim., Iss. Oxymel scillae, 3ij. 618 APPENDIX. A teaspoonful for an infant at the breast. Frdnkel. & Aquae, Ij. Vini ipecac, §ss. Syrupi, Iss. One or two drachms frequently, till vom- iting ensue. Evanson and Maunsell. ft Pulv. chel. cancror., 3ss. Antim. tart., gr. ij. M. In hoopingcough, one half to two grains, according to the age of the child. Fothcrgill. TONICS AND STIMULANTS. ft Ferri tart., 3j. Syrup, simpl, q. s. M. Ft. bol, No. iij. As a tonic for debilitated infants. H. des Enfans. ft Cinchonas, Iss. Aquae, lbj. M. To be used as an enema when the stom- ach rejects cinchona. H. des Enfans. ft Aquae destillat, liss. GUrnae dissulph , gT. ij. Acid, sulph. arom., gtts. xvj. Syrupi caryoph., Iss. M. From one to two drachms thrice a day. Evanson and Maunsell. ft Sal martis, gr. ij. Acid, sulph., gt. x. Sacch. alb., 3j. Aquae font. M. Dose, 3j, in chronic stage of cholera in- fantum. Chapman. WINE WHEY. ft Lactis vacc, Oss. Vin. alb., Ij vel Iij. Boil the milk, then add the wine. EXTERNAL APPLICATIONS. fy Unguent, cetacei, Ij. Oxidi zinci, Pulv. lycopodii, aa 3ss. Useful in ulceration of the eyelids. Hufeland. Ifc Croci sativ., 3j. Aquae fervent., liv. Vin. opii, 3j. Anodyne collyrium. To be used when there is great pain. Jadelot. ft Infus. sambuci, lbj. Zinci sulph, 3j. Astringent collyrium. Much used in scrofulous ophthalmia, which is usually ac- companied Avith puriform exudation. D'Huc. ft Hydr. deuto-chlorid., gr. iv. Aq. purae, Iviij. Used in syphilitic ophthalmia. D'Huc. ft Rad. althaeae, 3ij. Aquae, lbj. Emollient collyrium. Used in inflamed conjunctivae. D'Huc. ft Cerat. simpl., Iij. Antim. tart., 3ij. Camphorae, 3j. To be used by friction, to excite the skin; it is a powerful irritant in hooping- cough. D'Huc. ft Flores anthemidis, Acet. commun., aa liv. A common revulsive. H. des Enfans. ft Cataplasm emoll., lbij. Ung. resinos, Ij. M. Useful to hasten the suppuration of a phlegmonous tumor. APPENDIX. 619 ft Pulv. lini, q. s. Decoc. rad. alth., q. s. M. An emollient cataplasm. BATH OP BARGES WATER. Potassae sulphur, 3ij. Aquae, Ibc. For psora and other cutaneous affec- tions. i7. des Enfans. ft Cataplasm, emol.. liv, Farinae sinap., 3iv. M. Used as a revulsive. H. des Enfans. ft Sp. ammon. arom., 3ss. Syrup, althaeae, Aquae fceniculi, 3j. M. A teaspoontiil for an infant every hour, if necessary Frdnkel. Cinnamon, 1 drachm. Water, 1 pint. Boil them until well mixed, then add grated nutmeg and sugar. Another receipt. Boil a few slices of the crumb of bread with a blade of mace in a quart of water about two minutes; then taking the bread and bruising it finely, mix it with as much water as will make it of a proper consist- ence, and sweeten it. If wine be required, which is seldom the case, it ought not to be boiled with the water, but should be added afterwards. TAPIOCA JELLY. Tapioca, 2 spoonsful. Water, 1 pint. Boil it until it assumes an appearance of jelly, then add sugar, lemon juice, or wine, ALTERATIVE. ft Calomelanos, gr. iij. Amyli, 3ss. Sacch. albi, 3iss. M. Ft. pulvis divid. in xii partes aequa- les. One thrice a day in infantile syphilis. Wendt. DIETETICS. RICE WATER. Rice, 2 ounces. Water, 2 quarts. Boil for an hour and a half, then add as much sugar and nutmeg as may be re- quired. PANADA. Wheat bread, 1 ounce. PREPARED ARROWROOT. Arrowroot, 1 tablespoonful. < Sweet milk, £ pint. Boil them over the fire a few minutes, then sweeten them with loaf sugar. Lean beef in shreds, Water, 1 lb. 1 quart. Boil for twenty minutes, taking off the scum as it rises; when cold, strain. CHICKEN WATER. Take half a chicken, divested of all fat, and break its bones; add to this half a gal- lon of water, and boil fifteen minutes; then season with salt. STARCH WATER. Starch, Cinnamon, 1 ounce. 1 drachm. 620 APPENDIX. Boiling water, 3 pints. Boil until reduced one third, and strain. TOAST WATER. Take the crumb of bread toasted, any quantity, and add one quart of boiling water. WHITE DECOCTION OF SYDENHAM. Crumb of bread, 6 drachms. Calcined hartshorn shavings, 2 drach. Sugar, 1 ounce. Water, 1 quart. Boil for a quarter of an hour, and add infusion of canella, 2 drachms. COMPOUND DECOCTION OP HARTSHORN, OR WHITE DECOCTION. Hartshorn shavings, li ounce. Crumb of bread, 1 ounce. Water, 1 quart and 1 pint. Boil until reduced to a third, and add 2 ounces syrup of quinces. > H. de la Ch. DOSES OF MEDICINE. Hufeland has drawn up the following scale of the doses of medi- cine for different ages : Years......25 20 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Doses.....40 35 30 29 28 27 26 25 24 23 22 21 20 18 16 13 10 Months...ll 10 987654321^ 9 8 7 6 5 4 2 1 Suppose the dose at the end of the first year to be 1, then at the fifth it will be 2 ; at the fifteenth 3 ; and at the twenty-fifth 4. In the above table the dose for an adult is supposed to be 40 grains. THE END. NLM041399476