WS 200 bbbll IBU UNIVERSITY OF CALIFORNIA SAN DIEGO B i-tf^. '*^fc^r.> i:''.''^ yl(L!'-'^,, DATE DUE 'APR n 8 R Ff^H APRii m CAYLORD PRINTED IN US A BM LIBRARY University •f Calif'ornjc San tieg* >< II llllllll IIJII ifi2'-"''"""A fffiirii 10^^ 01122 700: 22 7097 < J' I P I .-> K A 6 E S INTANCV AM> ( IIILDIIOOI). A TREATISE ON THE DISEASES OP INFANCY AND CHILDHOOD. SECOND EDITION, ENLARGED AND THOROUGHLY REVISED, BY J. LEWIS SMITH, M.D., CURATOR TO THE NURSERY AND CHILD'S ni)8PITAI,, NF.W VORK I PHV8ICIAN TO THE INFANTS' H08PITAI,, ward's island; consulting PHYBICIAN is THE CLASS OF CHILDREN'S DISEASES, OUT-DOOR DEPARTMENT OF BELLKVUE HOSPITAL; CLINICAL LECTURER ON DISEASED OP CHILDREN, AND PROFESSOR I.V BELLBVUB HOSPITAL MF.DICAL COLLEGE, NEW YORK. TMI I LA DELI' JI J A : n E N Tl Y O . LEA. 1872. Entered according to Act of Congress, in the year 1872, by HENRY C. LEA, in the Office of the Librarian of Congress, at Washington. All rights reserved. PHILADELPHIA: COLLI NS, PRINTER. PREFACE TO THE SECOND EDITION. The purpose of the author has been to present a description of the diseases of infancy and childhood succinctly, but at the same time in a sufficiently comprehensive manner to meet the require- ments of the medical student and practitioner. He has endeavored to incorporate in the treatise all recently ascertained facts relating to this branch of medical practice, and especially has it been his endeavor to recommend such modes of treatment as comport with and are suggested by our present knowledge of the pathology of early life, the efficacy of hygienic measures in the treatment of the young, and the recuperative powers of the system at this age. While the author has respected the opinions of previous writers, and has adopted them, so far as they appeared to be correct, he has depended much more for the material of his treatise on clinical observations and the inspection of the- cadaver. I^Tecessarily, as a result of independent investigations,, opinions are now and then expressed different from those which are commonly accepted. ISTovel views have not, however, been presented, unless the author was fully satisfiecj that they were substantiated by a sufficient number of observations. In presenting to the profession the second edition of his work,, the author gratefully acknowledges the favorable reception ac- corded to the first. He has endeavored to merit a continuance of this approbation by rendering the volume much more com- plete til an before. Nearly twenty additional diseases have been VI PREFACE TO THE SECOND EDITION. treated of, among which may be named Diseases Incidental to Birth, Rachitis, Tuberculosis, Scrofula, Intermittent, Remittent, and Typhoid Fevers, Chorea, and the various forms of Paralysis. Many new formulse, which experience has shown to be useful, have been introduced, portions of the text of a less practical nature have been condensed, and other portions, especially those relating to pathological histology, have'"been rewritten to correspond with recent discoveries. Every etfort has been made, however, to avoid an undue enlargement of the volume, but, notwithstanding this, and an increase in the size of the page, the number of pages has been enlarged by more than one hundred. 227 West 49Tn Street, New York, April, 1872. CONTENTS. PART I. CHAPTER I. PAGK Infancy and Childhood 17 CHAPTER II. Cake of the Mother in Pregnancy 20 CHAPTER III. Mortality of early Life — its Causes and Prevention ... 23 CHAPTER IV. Lactation 28 Hindrances to Lactation, and physical conditions rendering it Im- proper — Facts and Rules in reference to Lactation — Human Milk — Modifications of the Milk in consequence of the Diet — Modification of Milk from its retention in the Breast^ — Modification of Milk from Age and Nervous Impressions — Modification of Milk by the Catamenial Function and Pregnancy — Quantity of Breast Milk required by the Infant — Differences in Suckling Women as regards Quantity and Quality of Milk — Scantiness of Milk ; its Causes and Treatment. CHAPTER Y. Selection of a Wet-Nurse 49 CHAPTER VI. Course of Lactation — Weaning , 54: CHAPTER VII. Artificial Feeding 57 Composition of milk. CHAPTER VIII. Baths — Clothing 60 Vlll CONTENTS. CHAPTER IX. PAGE Accidents and Ailments incidental to the Birth of the Infant, and Detachment op the Cord 63 Apnoea (Aspliyxia) Neonatorum — Causes — Treatment — Caput Succe- daneum — Ceplialfematoma. CHAPTER X. Conjunctivitis op the New Born 65 Causes — Symptoms — Treatment. CHAPTER XI. Diseases op the Umbilicus 69 Inflammation of the Umbilical Vein and Arteries — Treatment — Inflam- mation and Ulceration of Umbilicus — Treatment — Umbilical Granula- tions or Fungus — Treatment. CHAPTER XII. Umbilical Hemorrhage 72 Sex, Age — Causes — Symptoms — Prognosis — Treatment. CHAPTER XIII. Diagnosis of Infantile Diseases 76 General Observations — Features, External Appearance of Head, Trunk, and Limbs in Disease — Attitude — Movements — Tlie Voice — Respiratory System — Respiration in Health — Respiration in Disease — Circulatory System — Pulse in Health — Pulse in Disease — Animal Heat — Digestive System — Nervous System, Pain. PART II. CONSTITUTIONAL DISEASES. SECTIOIn" I. DIATHETIC DISEASES. CHAPTER I. Rachitis 91 Age — Anatomical Characters — Craniotabes — Symptoms — Complica- tions — Diagnosis — Prognosis — Treatment. CHAPTER II. Scrofula 104 Causes — Anatomical Characters — Symptoms — Relation of Scrofula to Tuberculosis — Prognosis — Treatment : Prophylactic ; Curative. CONTENTS. IX CHAPTER III. PAGE Tuberculosis 122 Etiology — General Anatomical Characters of Tuberculosis — Anatomi- cal Characters in Infancy and Childhood— Lungs— Abdominal Viscera — Stomach and Intestines— Symptoms — Bronchial Glands — Physical Signs — Lungs — Pleura — Stomach and Intestines — Prognosis — Treat- ment : Prophylactic ; Curative. CHAPTER IV. Syphilis 149 Etiology— Clinical History— Manifestations— Coryza— Mucous Patches —Roseola— Pemphigus — Acne, Impetigo, and Ecthyma — Visceral Lesions — Prognosis— Treatment. SECTIOl^ II. ERUPTIVE FEVERS. CHAPTER I. Measles 159 Symptoms — Complications : Capillary Bronchitis, True Croup, Pneu- monitis — Anatomical Characters — Nature — Diagnosis — Prognosis — Ti'eatment. CHAPTER II. ScAKLET Fever 169 Symptoms, Regular Form ; Irregular Form ; Malignant Form — Com- plications : Gangrene of Mouth, Articular Rheumatism, Serous Inflam- mation — Sequelae : Nephritis, Otorrhcea — A Case — Anatomical Char- acters— Natvire — Diagnosis — Prognosis — Treatment — Prophylaxis. CHAPTER III. Variola — Varioloid 201 Incubative Period— Stage of Invasion— Stage of Eruption— Stage of Desiccation — Desquamation — Varioloid — Mode of Death — Anatomical Characters — Complications — Prognosis— Diagnosis — Treatment. CHAPTER IV. Vaccinia 212 History of Vaccination— Appearances, Symptoms, Anomalies, Compli- cations, and Sequelae — Subsequent Vaccinations — Protection from Vaccination — Revaccination — Selection of Virus. CHAPTER V. Varicella 224 Incubative Period— Symptoms— Diagnosis— Prognosis— Treatment. X CONTENTS. SECTIO]^ III. NON-ERUPTIVE CONTAGIOUS DISEASES. CHAPTER I. PAGE DiPHTHEKIA 237 Anatomical Characters — Symptoms — Nature — Sequelae — Prognosis — Diagnosis — Treatment. CHAPTER II. Pertussis 247 Symptoms — Comjilications — Convulsions — Bronchitis — Pneumonitis — Thrombosis — Diagnosis — Prognosis — Treatment. CHAPTER III. Parotiditis 261 Nature — Diagnosis — Treatment. SECTIOI^ IV. OTHER GENERAL DISEASES. CHAPTER I. Intermittent Fever 263 Symptoms — Prognosis — Treatment. CHAPTER II. Remittent Feter 267 Symptoms — Diagnosis — Treatment. CHAPTER III. Typhoid Fever 269 Causes — Anatomical Characters — Symptoms — Complications — Diagno- sis — Duration — Prognosis — Treatment. CHAPTER IV. Acute Rheumatism 277 Causes — Symptoms — Duration — Prognosis— Diagnosis — Treatment. CHAPTER V. Erysipelas 384 Table of Cases — Age — Point of Commencement— Causes — Premonitory Symptoms— Symptoms — Prognosis — Duration— Modes of Death — Pathological Anatomy — Treatment. CONTENTS. xi PART III. LOCAL DISEASES. SECTION" I. PAGE DISEASES OF THE CEREBRO-SPINAL SYSTEM . . 290 CHAPTER I. AcEPHALUs — Anencephalus 298 Anatomical Characters — Symptoms — Prognosis. CHAPTERII. Impekfect Bkain 299 A Case — Symptoms — Prognosis — Microceplialus — Atrophy of brain. CHAPTER III. Hypertrophy op Brain 303 Pathological Anatomy — Causes — Cretinism — Symptoms — A Case — Diagnosis — Prognosis — Treatment. CHAPTER lY. Thrombosis in the Cranial Sinuses (Phlebitis) 308 Anatomical Characters — Causes ; from Otitis — Symptoms — Diagnosis — Prognosis — Treatment. CHAPTER V. Congestion of Brain 314 Active and Passive — Causes — Symptoms — Anatomical Characters — Prognosis — Treatment. CHAPTER YI. Intra-Cranial Hemorrhage (Meningeal Hemorrhage — Cerebral Hemorrhage) 319 Causes — Anatomical Characters — Symptoms — Diagnosis — Prognosis — Treatment. CHAPTER YII. Congenital Hydrocephalus 380 Anatomical Characters — Symptoms — Diagnosis — Prognosis — Treat- ment. CHAPTER YIII. Acquired Hydrocephalus 338 Causes — Anatomical Characters — Location and Quantity of Fluid — Symptoms — Prognosis — Treatment. XU CONTENTS. CHAPTER IX. PAGE Meningitis, Simple and Tubercular 341 Age — Anatomical Characters — Causes — Premonitory Stage — Symp- toms — A Case — Diagnosis — Prognosis — Treatment. CHAPTER X. Spurious Hydrocephalus 363 Anatomical Characters — Symptoms — Cases — Diagnosis — Prognosis — Treatment. CHAPTER XI. Eclampsia 369 Essential, Symptomatic, Sympathetic, General, and Partial — Causes — Premonitory Stage — Symptoms — Anatomical Characters — Diagnosis — Prognosis — Treatment. CHAPTER XII. Tetanus Infantum 383 Table of Cases — Period of Commencement — Frequency in Certain Localities — Causes— Symptoms — Prognosis — Mode of Death — Duration in Fatal Cases — Duration in Favorable Cases — Diagnosis — Preventive Treatment — Treatment. CHAPTER XIII. Internal Convulsions 405 Different Forms — Causes — Anatomical Characters — Symptoms — Case — Diagnosis — Prognosis — Modes of Death — Treatment. CHAPTER XIV. Chorea 415 Age — Causes — Sex — Uterine Irritation — Anaemia — Rheumatism — Fright — Imitation — Intestinal Irritation — Lesions of Brain and Spinal Cord — Anatomical Characters — Symptoms — Prognosis — Course — Diagnosis — Treatment : Regimenal ; Medicinal. CHAPTER XV. Infantile Paralysis 431 Symptoms — Progress — Etiology — Anatomical Characters — Diagnosis — Prognosis — Treatment. ^Ci' CHAPTER XVI. Facial Paralysis 440 Causes — Symptoms — Prognosis— Treatment. Paralysis with Apparent Hypertrophy : Symptoms — Anatomical Characters — Causes— Progno- sis — Treatment. CONTENTS. xiii SECTION 11. DISEASES OF THE KESPIRATORY SYSTEM. CHAPTER I. PACK CORYZA 445 Causes — Anatomical Characters — Symptoms — Prognosis — Treatment. CHAPTER II. Simple Laryngitis 449 Symptoms — Chronic Form — Anatomical Characters — Treatment. Spasmodic Laryngitis : Causes — Symptoms — Anatomical Characters — Pathology — Diagnosis — Prognosis — Treatment. CHAPTER III. Pseudo-Membranotts Laryngitis 458 Causes — Anatomical Characters — Symptoms — Pathology — Diagnosis — Prognosis — Treatment — Tracheotomy. CHAPTER lY. Bronchitis 477 Causes — Anatomical Characters — Symptoms — Capillary Bronchitis — Diagnosis — Prognosis — Treatment. CHAPTER Y. Pneumonitis 490 Catarrhal, Croupous, and Interstitial — Causes — Hypostasis — Anatomi- cal Characters — Cheesy Pneumonitis — Symptoms — Physical Signs — Diagnosis — Prognosis — Treatment. CHAPTER YI. Pleuritis 507 Causes — Cases — Anatomical Characters — Empyema — Symptoms — Physical Signs — Case — Diagnosis — Prognosis — Treatment — Thoracen- tesis. SECTION" III. DISEASES OP THE DIGESTIVE APPARATUS. CHAPTER I. Simple Stomatitis ; Ulcerous Stomatitis ; Follicular Stomatitis . 525 Simple or Erythematic Stomatitis: Causes — Symptoms — Appearances — Treatment. Ulcerous Stomatitis : Anatomical Characters — Causes — Symptoms — Diagnosis— Prognosis — Treatment. Follicular Stoma- titis : Anatomical Characters — Causes — Symptoms — Diagnosis — Prog- nosis — Treatment. XIV CONTENTS, CHAPTER II. PAGE Thrush ' 533 Anatomical Characters — Description of the Oidium Albicans — Symp- toms — Causes — Diagnosis — Prognosis — Treatment. CHAPTER III. Gangrene of the Mouth 538 Anatomical Characters — Age — Causes — Symptoms — Diagnosis — Prog- nosis — Treatment. CHAPTER lY. Dentition 546 Pathological Results of Dentition — Diagnosis — Treatment — Scarifica- tion of the Gums — Second Dentition. CHAPTER y. Simple Pharyngitis ; Peri-Phaetngeal Abscess ; (Esophagitis . . 555 Pharyngitis : Anatomical Characters — Causes— Symptoms — Prognosis — Diagnosis — Treatment. Peri-Pharyngeal Abscess : Age — Cause — Anatomical Characters — Symptoms — Duration — Diagnosis — Prognosis — Treatment. (Esophagitis : Anatomical Characters — Treatment. CHAPTER VI. Indigestion ; Congestion op Stomach ; Gastritis ; Follicular Gas- tritis ; Diphtheritic Gastritis ; Post-Mortem Digestion ; Soft- ening 567 Indigestion : Causes — Symptoms — Prognosis — Treatment. Conges- tion of the Stomach. Gastritis : Causes — Age — Symptoms— Anatomi- cal Characters — Diagnosis — Prognosis — Treatment. Follicular Gas- tritis ; Diphtheritic Gastritis ; Post-Mortem Digestion ; Gelatinous Softening ; White Softening. CHA PTER YII. Diarrhoea 585 Non-Inflammatory Diarrhoea : Causes — Symptoms — Anatomical Char- acters — Diagnosis — Prognosis — Treatment. CHAPTER YIII. Intestinal Inflammation op Infancy 593 Causes — Age — Sj-mptoms — Microscopic Character of the Stools — Pulse — Anatomical Characters — Condition of the Liver — State of the Brain — Diagnosis — Prognosis — Treatment, Regimenal Measures, Medicinal Treatment ; Enemata, External Treatment. CHAPTER IX. Enteritis and Colitis in Childhood 630 Causes — Symptoms — Diagnosis — Prognosis — Treatment. CONTENTS. XV CHAPTER X. PAGE Cholera Infantum G24 Definition of the Term — Causes — Its Prevalence in tlie Cities — Symp- toms — Anatomical Characters — Diagnosis — Prognosis — Treatment. CHAPTER XI. Intestinal Worms 633 Five Kinds — Description of them — Causes— Symptoms of Lnmbrici — Diagnosis — Prognosis — Treatment — Use of Santonin, Spigelia, Cheno- podium. CHAPTER XII. Gastro-Intestinal Hemorrhage 646 Three Varieties — Causes — Prognosis — Treatment. CHAPTER XIII. Intussusception 652 Intussusception without Symptoms — Intussusception with Symptoms — Previous Health — Causes — Age — Seat and Pathological Anatomy — Intussusception in the Small Intestines — Cases — Intussusception in the Large Intestines — Symptoms — Diagnosis — Duration — Prognosis — Mode of Death — Treatment. SECTIOIvr IV. DISEASES OF THE CIRCULATORY SYSTEM. CHAPTER I. Cyanosis 674 Literature of Cyanosis — Sex — Causes of the Malformation — Symptoms — Prognosis — Mode of Death — Modes of Compensation — Morbid Anatomy — Theories Relating to the Etiology of Cyanosis — Treatment. SECTIOISr V. SKIN DISEASES. CHAPTER I. Erythematous Diseases 695 Erythema : Two Forms ; Idiopathic, Symptomatic — Prognosis — Diag- nosis — Treatment. Roseola : Symptoms — Causes — Prognosis — Diag- nosis — Treatment. Urticaria : Causes — Prognosis — Diagnosis — Treat- ment. CHAPTER II. Papular Diseases 703 Lichen — Prurigo — Stropliulus — Treatment. XVI CONTENTS. CHAPTER III. PAGE Eczema and Scabies 704 Eczema ; Simplex, Rubrum, and Impetiginodes— Symptoms — Diagno- sis — Treatment : General ; Local. Scabies : Diagnosis — Treatment, APPENDIX. A.— Dietary Formttl^ 714 Falkland's Method of Preparing Milk for Infants — Lobb's Method — Meigs' Preparation — Liebig's Soup — Hassell's Comments — Raw Meat — Beef-tea — Liebig's Beef-tea — Hogarth's Essence of Meat — Ronth's Comments. B. — Remarks on the Prevention op Scarlet Fever. By Wm. Budd, M.D 720 C. — Remarks on the Diphtheritic Membrane. By Dr. Edward Rind- fleisch 725 E. — Observations on the State of the Liver in Infantile Entero- colitis 726 F. — Cases of Intussusception 728 In the Small Intestines — Intussusception of Ileum into Colon — Invagi- nation of the Coecum, Ileum and Ccecum, or Ileum, Coecum, and Colon — Uncertain. DISEASES OF CHILDREN. PART I. CHAPTER I. INFANCY AND CHILDHOOD. Infancy and childhood are in certain respects the most important and interesting periods of life. To the physiologist they are espe- cially interesting, because they are the periods of development and of greatest functional activity ; to the pathologist, because in them many diseases occur which are rarely or never observed in the other periods, or which present in these periods peculiar features; to the physician and vital statistician, because in them there is the greatest amount of sickness, and largest number of deaths. Infancy extends from birth to the age of two and a half 3^ears, or till the completion of first dentition. In infancy the organs are delicately organized, containing a large proportion of water, and hence are easily injured. In this period the brain is rapidly de- veloped — more so than any other organ ; animal matter predomi- nates in the bones; the arteries are relatively large, the muscles small; the superficial veins are small. Fat is absent from the interior of the body, but abundant, in well-nourished infants, underneath the integument. The skin is delicate, and its temper- ature not much below that of the blood. At birth it has a red- dish hue, and is covered with soft fine hairs (lanugo). The reddish hue gradually fades into the healthy tint of infancy, and the hairs fall out. In the first two months the sweat glands have little functional activity, sensible perspiration being quite rare. Subse- quently i^erspiration is freer, and in certain diseased states is abundant (rachitis, etc.). The sebaceous glands in the first half of infancy are active, particularly upon the scalp, producing often 2 18 INFANCY AND CHILDHOOD. a pale yellow incrustation, consisting of sebaceous matter and epi- dermic cells. The secretions from the mucous surfaces commence at an early period. At birth the surface of the digestive tube is covered with more or less mucus, often in considerable quantity. The meconium is not considered, as formerly, to be a product of intestinal secre- tion. It consists of flat epithelial cells, fine hairs, oil globules, crystals of cholesterine, and brownish or yellowish masses of color- ing matter, probably from the liver. It is supposed that, with the exception of the coloring matter, the meconium is derived mainly from the amniotic fluid which the foetus has swallowed. The most wonderful change occurring in the system at birth, through the exigencies of the new life, is that in the circulation. The flow of blood being interrupted, thrombi form in the umbilical vein, and arteries, and in the ductus arteriosus, and ductus venosus, and these vessels gradually atrophy, becoming finally shrivelled but permanent cords. I have many times at autopsies removed the plug from the ductus arteriosus when death had occurred as late as the third week. The foramen ovale closes slowly. I have ordinarily found it open till near the end of the first half year, but the valve closes fully the aperture, so that there is no detriment to the circulation. Both the pulse and respiration are more frequent during infancy than childhood, and are more readily accelerated by moral and physical causes. The stomach is less elongated, and emesis more readily produced than in the adult. The liver is large, occupying at birth nearly half of the abdominal cavity, but growing smaller in successive months. The appetite is good and digestion active, so that hunger when appeased, soon returns. The thymus gland, at birth about the size of an unexpanded lung, slowly atrophies, but it does not totally disappear till after infancy. The kidneys, distinctly lobulated at birth, gradually change their form, so as to present in the last part of infancy nearly the shape of the organ in the adult. The renal secretion commences early, even before birth. The kidneys seldom undergo degenerative changes as in the adult, but they are liable to congestions and in- flammations. During the first month, and especially the first fort- night, crystals of uric acid, and the urates, are often found in the urine, in a state of apparent health, causing more or less fretfulness in their elimination, staining the diaper, and not infrequently being arrested in the tubules of the pyramids, where they can be seen as pink-colored spots or lines (uric acid infarction). These CHILDHOOD. 19 deposits of uric acid and the urates may even occur in the foetus, producing obstruction and inflammation of the renal tubes. Con- genital cystic degeneration of the kidneys is, in the opinion of Virchow, due to them. In early infancy the senses are imperfectly developed, the eyes being attracted only by bright objects, and the sense of hearing affected only by loud noises. Sleep is the normal state in the first weeks of life ; as the age of the infant advances, less and less sleep is required ; but the oldest infants need more than children, and several hours more than adults. The new-born infant is apparently destitute of mental faculties. It seeks the breast by instinct, and it exhibits no jDerception or reflection. The loud cries with which it commences its existence are not from anger or sufl:ering ; they appear to be normal, like the act of nursing, and providentially designed in order to expand the lungs. It is not till the close, or near the close, of the first month, that the gray substance of the brain begins to appear — the probable seat of the mind, and the source of all mental phenomena. Per- ception and curiosity are early manifested. The infant, as Edmund Burke has remarked, is constantly seeking new objects for its amusement, rejecting old playthings for such as possess more novelty. Heflection, a higher faculty of the mind, appears at a later period. The mind and the bodily organs in infancy are, in a high degree, impressionable. Anger is excited by trivial causes, but is easily appeased ; and the various functions in the system are disturbed by agencies which in youth or manhood would have no appreciable eftect. Childhood extends from infancy to the age of fifteen years or puberty. It is a period of great physical activity, and of rapid growth. The functions of the various organs are performed with more moderation than in infancy, and are less frequently deranged. The volume of the brain continues to increase rapidly, and it be- comes firmer than in infancy. It is estimated that by the seventh year the weight of this organ has doubled. The mind now exerts a controlling infiuence over the actions of the individual. The digestive organs have changed, so that solid food is required. Most of the glandular organs are less active than in the greater part of infancy, and some of them, as the liver, are relatively smaller. Tlie pulse and respiration gradually become less frequent as the child advances in age. N^'' \ V 20 CARE OF THE MOTHER IN PREGNANCY. CHAPTER II. CARE OF THE MOTHER IN PREGNANCY. The frequency of miscarriages and still-births, and the large number of ill-formed and puny infants, born to a precarious and short existence, render imperative, on the part of the mother, a strict observance of the laws of health, and an avoidance of all exciting or perturbating influences during the time when the foetus is being developed. The diet should be plain and easily digested, but nutritious. There is often a craving in pregnancy for unusual articles of food. These may sometimes be allowed within certain limits, provided they are such as do not derange the stomach. Meats and animal broths, together with vegetables and farinaceous food, should constitute the ordinary diet, and should be taken at reo:ular intervals. Daily exercise, never violent, but moderate and gentle, is re- quisite. ISTo exercise is better, none safer and more likely to con- tribute to cheerfulness and healthy functional activity of the organs, than the ordinary household duties. Lifting heavy weights, or work which, like washing and ironing, causes great and con- tinued action of the abdominal muscles, should be avoided. Such exercise is highly injurious, and is apt to produce premature labor. Exercise in the open air, on foot or by an easy conveyance, con- duces to the health of the mother, and the growth and develop- ment of the foetus. On the other hand, rapid riding over rough roads is one of the most dangerous modes of exercise. It has been known to destroy the foetus, which up to that time had been appa- v\ rently vigorous. "When such a result occurs, there is probably v /, more or less detachment of the placenta. ^ \ ' ■ It being a matter of the utmost importance that the health of the mother should continue good during gestation, any disease ^ which she may have in this period, and which afi'ects her nutrition or the character of her blood, should be promptly cured if practi- cable, and with the least possible reduction of the vital powers. Intermittent fever, occurring during gestation, should never be allowed to continue. It seriously retards foetal development, and MATERNAL IMPRESSIONS. 21 may produce miscarriage. Unless it is controlled by proper measures, the offspring, though born at term, is puny and emaci- ated. Syphilis, in the pregnant woman, also requires treatment. This disease, readily transmitted from the mother to the fcotus through the ovum or the uterine circulation, may be eradicated by anti-syphilitic treatment of the mother, or at least so modified that the infant is born vigorous and healthy. The pregnant woman should avoid all causes of undue mental excitement. This is almost as necessary as the avoidance of great physical exertiofi. There is, during pregnancy, unusual suscep- tibility to mental impressions, and this should be borne in mind not only by the woman herself, but by those who associate with her. Strong emotions, whether of joy, sorrow, or anger, affect pri- marily the nervous system, but indirectly most of the organs of the body. Observations have long established the fact, that such emotions influence the state and functions not only of the digestive and glandular, but muscular organs, as the heart and uterus. Physicians are familiar with cases in which vivid mental impres- sions produced uterine contractions, and even miscarriage, or have disturbed the catamenial function. Therefore, the associations and cares of pregnant women should be such as conduce to cheerfulness and equanimity. It is the popular belief, and the belief of many physicians, that vivid mental impressions sometimes have a direct effect on the de- velopment of the foetus. Many cases are on record in which infants were born with marks or deformities, corresponding in character with objects which had been seen and had made a strong impres- sion on the maternal mind at some period of gestation. Whether the mind of the mother exerts a controlling influence on the form and color of the foetus, is a subject of great interest to the psycho- logist as well as physiologist and physician, since it involves no less a question than the power and scope of the human mind. Violent emotions, it is admitted, may aflfect directly most of the important organs in the system. They may derange the liver, causing jaundice, accelerate, or for a moment suspend the heart's action, stimulate the kidneys, causing diuresis, or even the intes- tinal follicles, causing watery evacuations. But with all these organs the ])rain is connected by nerves which anatomy reveals. On the other hand, the mother and foetus have a distinct existence as regards their nervous systems, and even their blood. Still, the multitude of facts which have accumulated justify the belief that 22 CARE OF THE MOTHER IN PREGNANCY. deformity or other abnormal development of the foetus is, some- times, due to the emotions of the mother. Some of the eases related by Dr. Whitehead, in his work on hereditary diseases, are very striking and difficult to explain, on the ground of coincidence. I have met the following cases. An Irish woman of strong emotions and superstitions was passing along a street in the first months of her gestation, when she was accosted by a beggar, who raised her hand, destitute of thumb and fingers, and in " God's name" asked for alms. The woman passed on : but reflecting in whose name money was asked, felt that she had committed a great sin in refusing assistance. She returned to the place where she had met the beggar, and on difierent days, but never afterwards saw her. Harassed by the thought of her imaginary sin, so that for weeks, according to her statement, she was made wretched by it, she approached her confinement. A female infant was born, other- wise perfect, but lacking the fingers and thumb of one hand. The deformed limb was on the same side, and it seemed to the mother to resemble precisely that of the beggar. In another case which I met, a very similar malformation was attributed by the mother of the child to an accident occurring to a near relative, which necessi- tated amputation during the time of her gestation. I examined both of these children with defective limbs, and have no doubt of the truthfulness of the parents. In May, 1868, 1 removed a super- numerary thumb from an infant, whose mother, a baker's wife, gave me the following history: ISTo one of the family, and no an- cestor, to her knowledge, presented this deformity. In the early months of her gestation she sold bread from the counter, and nearly every day a child with double thumb came in for a penny roll, presenting the penny between the thumb and the finger. After the third month she left the bakery, but the malformation was so impressed upon her mind, that she was not surprised to see it reproduced in her infant. Professor William A. Hammond, of this city, in an interesting paper on the "Influence of the Maternal Mind," etc. {Quarterly Journal of Psychological Medicine^ January, 1868), says : " The chances of these instances, and others, which I have mentioned, being due to coincidence, are infinitesimally small, and though I am careful not to reason upon the principle of post hoc, ergo propter hoc, I cannot, nor do I think any other person can, no matter how logical may be his mind, reason fairly against the connection of cause and effect in such cases. The correctness of the facts can only be ques- tioned; if these be accepted, the probabilities are thousands of mil- MORTALITY OF EARLY LIFE. 23 lions to one, that the relation between the phenomena is direct." Professor Dalton also says {Human Physiology)^ "there is now little room for doubt that various deformities and deficiencies of the foetus, conformably to the popular belief, do really originate in certain cases from nervous impressions, such as disgust, fear, or anger, experienced by the mother." The observations on which this belief is based relate both to man and the lower animals. A very strong argument in its support is, as Professor Hammond remarks, the popular opinion, which dates back to the time of Jacob (Genesis xxx.). An almost universal sentiment, running through centuries, is rarely wholly fallacious. It has some truth for its foundation, especially when, as in this instance, the subject is one of observation. If maternal emotions affect the development of the exterior of the foetus, as observations show, and physiologists admit, the pre- sumption is strong, that they may affect also the proper develop- ment, and adjustment of the parts of the brain, an organ so com- plex and delicate, and may therefore give rise to idiocy. Dr. Seguin {Idiocy and its Treatment^ etc., New York, 1866) thus remarks on this point: "Impressions* will, sometimes, reach the foetus, in its recess, cut off its legs or arms, or inflict large flesh wounds, before birth, . . . from which we surmise that idiocy holds unknown though certain relations to maternal impressions, as modifications to placental nutrition." In view of such important facts, the duty of the pregnant woman is rendered the more imperative to avoid the presence of disagree- able and unsightly objects, as well as all causes of excitement, and to remove, as soon as possible, vivid and unpleasant impressions, by quiet diversion of the mind. CHAPTER III. MORTALITY OF EARLY LIFE— ITS CAUSES AND PREVENTION. No fact is better known in the profession, than that the first years of life constitute the period of greatest mortality. In England, where there is an accurate registration of births and deaths, statistics show fifteen deaths in every hundred infants in the first year of life, and between four and five deaths in the first 24 MORTALITY OF EARLY LIFE. month. Statistics on the continent correspond with those in Eng- land, as regards the periods of greatest mortality. Quetelet says, "... there die during the first month after birth, four times as many children as during the second month after birth, and almost as many as during the entirety of the two years that follow the first year, although even then the mortality is high. The tables of mortality prove, in fact, that one-tenth of children born, die before the first month has been completed." In this country, in consequence of deficient registration of births, the percentage of deaths to births cannot be accurately ascertained. In this city, 53 per cent, of the total number of deaths occur under the age of five years, and 26 per cent, under the age of one year. According to the census of 1865, there were in ISTew York city 95,020 children under the age of five years, and during the five years ending with 1865, 49,000 children five years old and under had died. Therefore, according to these statistics, more than one- third of all the infants born in this city die under the age of five years. An error, however, occurs from the fact that, while the death statistics were complete, it is known there were more children in the city than were embraced in the census returns. Still it may, I think, be safely stated that one-fourth of the children born in this city die before the age of five years. In less crowded cities and the rural districts, it is known that the percentage of deaths in the first years of life to the total num- ber of deaths is considerably less than in ]!Tew York city, but it is nevertheless large. As the child advances towards puberty, the liability to sickness and death gradually diminishes, but even the last years of child- hood present a considerably larger percentage of deaths to the population than does youth or manhood. The causes of this great mortality of infants and children, and the means of diminishing it, deserve careful consideration. Some of the causes which conspire to produce this mortality are in a measure unavoidable. Such are congenital vices of formation of internal organs. Many of the internal malformations neces- sarily occasion an early death. Cases of anencephalus, most cases of congenital hydrocephalus, of spina bifida, of cyanosis, are fatal before the close of infancy. These defects of formation we cannot detect before birth, and their causes are often obscure. Some of them seem to result from inflammation, believed to be, occasionally, syphilitic, develoj)ed at some period of foetal existence. Other in- ternal malformations are attributable to perturbating influences, CAUSES OF INFANTILE MORTALITY. 25 operating temporarily on the mother during gestation. But in a large proportion of cases, we cannot assign the cause. Obviously, only partial success can attend our efforts, as regards prevention in these cases, and almost no success, as regards the use of remedial measures. Another obvious cause of the great mortality of early life, is natural feebleness of system, especially in infancy. The younger the patient, prior to the middle period of life, the sooner are the vital powers exhausted by disease. Hence a larger proportion of infants succumb to the same malady than children, and a larger proportion of children than adults. This statement is true of in- fancy and childhood in general. It is a law in nature, and cannot be changed by art. But there are many infants born with heredi- tary disease, or a strong predisposition to disease, through a fault, which is, in a degree, remediable, in the system of one or Ijoth parents, as, for example, the syphilitic, scrofulous, or tubercular diathesis. Parents seriously affected by such diseases cannot, with- out corrective treatment, have healthy offspring. Their children are among the first to droop and die, either directly from the inherited disease, or from feebleness of constitution, which such disease entails, and which renders them an easy prey to other dis- eases. The duty of the physician, as regards such parents, is obvi- ous. He may, by therapeutic and hygienic measures, secure a more healthy progeny, and, so far as he can do this, he aids in diminish- ing the infantile mortality. He may sometimes, by timely mea- sures directed to the infant, establish a better state of health. The subject of hereditary disease is one of great interest and importance, especially as regards the city population. Inherited affections are less common in the country, but in the city they con- tribute largely to the number of deaths in early life. Another important cause of the great mortality of infants and children, is the fact that they are peculiarly liable to certain severe and fatal diseases. The zymotic diseases, which, as a rule, occur but once, are more common at this age than subsequently. Some of these, as scarlet fever, greatly increase the number of deaths. The zymotic diseases are for the most part infectious. Hence they are very prevalent and fatal in cities, where there is much greater intercourse of children than in the country. Scarlet fever is one of the six most fatal diseases in ISTew York city. The prevention of contagious diseases obviously depends, in great measure, on isolation, which it is the duty of the physician to advise. Boards of health, or civil authorities, may also do something as regards 26 MORTALITY OF EARLY LIFE. the scliools, to prevent the spread of these diseases. One of them, the most loathsome and dreaded of all, namely, smallpox, the phy- sician has the power to prevent. Some of the most fatal diseases of life, not contagions, as croup and capillary bronchitis, also occur in infancy and childhood, materially increasing the mortality. These local affections cannot be prevented by the physician, but only by judicious hygienic management on the part of families. Another obvious and important cause of the mortality of early life, is the anti-hygienic condition or state in which many children live in consequence of the poverty or gross negligence of parents. Residence in insalubrious localities, personal and domiciliary uncleanliness, exposure without proper protection to vicissitudes of weather, are fertile causes of sickness and death. Hence one reason of the great infantile mortality among the city poor, who live in damp and dark alleys, and in crowded and filthy tenement-houses, breathing night and day an atmosphere loaded with noxious gases. All physicians are aware how the malignant diseases, such as Asiatic cholera, cholera infantum, diphtheria, and typhus fever, seek the quarters of the city poor, and what terrible havoc they make there. All are aware, also, what wonderful recoveries occur when feeble and attenuated infants, gradually sinking with chronic disease, induced in great measure by this malaria, are transferred from such localities to the pure air of the country. Careless management of young children, as regards dress, in- creases greatly the liability to local diseases, such as commonly occur from exposure to cold. These are inflammatory affections, seated chiefly uj)on the mucous surfaces, but sometimes in paren- chymatous organs. Adults, aware of the effect of sudden change of temperature from warm to cold, or of exposure to currents of air, protect themselves by additional clothing. Such precautionary measures are often lacking in the management of young children, and hence one cause of their great liability to local afiections, both of the respiratory and digestive organs. Routh, in his excellent treatise on Infant Feeding, says : "Among the most pernicious influences to young children, however, we may include cold. The change of temperature from 45° to 4° or 5° below zero, as before stated, producing an increase of mortality in London alone of three to five hundred. As out of one hundred deaths, however, from all specified causes, nearly twenty-four occur to children under one, and thirty-six to children under five ; the great increase of mortality to children by cold, is thus, at once, made obvious. Indeed, it is a household word amongst us, IMPROPER FEEDING. 27 which takes its origin from the Registrar-General's returns, that a very cold week always increases the mortality of the very young and the very aged." Lastly, a very important cause of mortality in early life is the use of improper food. In infants, artificial feeding in place of the aliment which nature has provided for them, and, in children, the use of innutritions or indigestible articles of diet, give rise to diarrhoeal maladies, emaciation, and death in numerous instances. Sometimes, also, defective alimentation is the cause of scrofulous or tuberculous ailments, and sometimes it gives rise to a cachexia or feebleness of system, which, without engendering any positive disease, renders those thus affected less able to support disease induced by other causes. A committee, of which Prof. Austin Flint, Jr., was chairman, appointed in 1867 to revise the "dietary table of the Children's Nurseries on Randall's Island," state, with much truth and force : " Children .... are not capable of resist- ing bad alimentation, either as regards quantity, quality, or variety. At that age the demands of the system for nourishment are in excess of the waste ; the extra quantity being required for growth and development. If the proper quantity and variety of food be not provided, full development cannot take place, and the children grow up, if they survive, into puny men and women, incapable of the ordinary amount of labor, and liable to diseases of various kinds. This is frequently illustrated in the higher walks of life, particularly in females ; for many suffer through life from improper diet in boarding-schools, due to false and artificial notions of deli- cacy or refinement. After a certain period of improper and de- ficient diet in children, the appetite becomes permanently impaired, and the system is rendered incapable of appropriating the amount of matter necessary to proper development and growth." Improper feeding, like other causes of mortality, is much more injurious, much more frequently the cause of death, in the city than country. Statistics in Europe, as well as this side of the Atlantic, establish this fact. It is in infancy, and especially in the first year, that the use of unwholesome food entails the most serious conse- quences. 'No artificially prepared food is a good substitute for the mother's milk, and hence artificial feeding of the infant, unless under the most favorable circumstances, results disastrously. In the country, where salubrious air and sunlight conspire to invigo- rate the system, and a robust constitution is inherited, and where cow's milk fresh and of the best quality is readily obtained, lacta- 28 LACTATION. tion is not so necessary for the well-being of the infant ; but in the city its importance cannot be too strongly urged. The foundlings of the cities afibrd the most striking and con- vincing proofs of the advantage of lactation. In some cities found- lings are wet-nursed, while in others they are dry-nursed, and the result is always greatly in favor of the former. Thus, on the continent, in Lyons and Parthenay, where foundlings are wet- nursed almost from the time that they are received, the deaths are 33.7 and 85 per cent. On the other hand, in Paris, Rheims, and Aix, where the foundlings are wholly dry-nursed, their deaths are 50.3, 63.9, and 80 per cent. In this city the foundlings, amounting to several hundred a year, were, till recently, dry-nursed ; and, incredible as it may appear, their mortality, with this mode of alimentation, nearly reached 100 per cent. Recently wet-nurses have been employed, for a part of the foundlings, with a much more favorable result. These facts, to which others might be added from the experience of European cities, show the importance of lactation as a means of reducing infantile mortality in the cities. "What has been stated as regards the result of artificial feeding of foundlings, is true, in great measure, in reference to all city infants. The ill efiect of artificial feeding is well known in this city, and it is the common practice in families to employ a hired wet-nurse, if, for any reason, the mother's milk is insufficient. When the infant has reached the age at which it is proper to wean it, the digestive organs are less frequently deranged by errors of diet. More substantial food, and considerable variety in it, may now be not only safely allowed, but are required by the wants of the system. Still, the feeding of children in health, and much more in sickness, is a subject of great importance. Therefore lac- tation, and the diet of infancy and childhood, will occupy our attention in the following pages. CHAPTER IV. LACTATION. It is desirable that the infant, as soon as it requires nutriment, should receive breast milk. If it is fed, for a few days, with the bottle or spoon, it may be difficult finally to induce it to take the HINDRANCES TO LACTATION. 29 breast; therefore it is well to determine early whether the mother will be able to wet-nurse her infant, so that, if unable, suitable provision may be made. The matter of determining, beforehand, the capability of the mother for w'et-nursing has been investigated by Dr. Donnd, of Paris, and in his treatise on Mothers and Infants he describes the mode in which it may be ascertained. The desired information, in his opinion, may be acquired by examining the colostrum, which is secreted in small quantity, in the last months of gestation, and which can be squeezed from the breast in sufficient quantity for inspection. In some women, according to Dr. Donn^, the colostrum is so scanty that only a drop, or half a drop, can be obtained from the nipple by careful pressure. This will be found by the microscope to contain but few milk globules, ill-formed, and a few granular bodies, such as the colostrum ordinarily contains. Such women almost invariably furnish poor milk, and in small quantity. In other women the colostrum is abundant, but thin, resembling gum- water ; it lacks the yellow streaks and viscous character of ordinary colostrum, and it flows readily from the nipple. The milk of such w^omen is sometimes scanty, sometimes abundant, but it is watery and deficient in nutritive principles. In a third class of women, the colostrum is pretty abundant, and it contains yellowish streaks, of more or less consistence, which are found to be rich in milk globules, of good size, and without the admixture of mucous glo- bules. "Women furnishing such colostrum in the last weeks of gestation will have sufficient milk, and of good quality. These latter women make the best wet-nurses. Hindrances to Lactation and Physical Conditions Rendering it Improper. The primipara often experiences difficulty in wet-nursing in con- sequence of a depressed state of the nipple. It is not sufficiently prominent to be readily grasped by the mouth, and after inefiectual attempts the infant becomes fretful when applied to the breast and, perhaps, for a time refuses it altogether. Multiparas occasionally experience the same inconvenience, but it is not common when there has once been successful lactation. By calmness and perse- verance on the part of the mother, the infant can usually be made to seize the nipple in the course of a week. Depression of the nipple is, to a certain extent, the result of pressure upon it by the dress during gestation. The state of the 80 LACTATION". nipples should, indeed, in those who have never suckled, receive early attention, even before the birth of the infant. Tightness of dress around the breast, as indeed upon every part of the body, should be avoided, and from time to time gentle traction should be made upon the nipple, if it is depressed. It may be drawn out by the fingers of the mother several times each day, or by a com- mon breast-pump, or by suction with a tobacco-pipe, the edge of the bowl having been smoothed. Occasionally, in these cases of deficient nipple, the mother, fatigued and discouraged by her fre- quent ineffectual attempts to induce the infant to nurse, becomes feverish and excited, so that the quantity of her milk is sensibly diminished. The physician should assure her, as he usually can with confidence, that in a few days, as the baby becomes a little stronger, there will be no difficulty in its nursing. Some women are unremitting in their endeavors to procure nursing. This should be forbidden, since the lack of sleep, and the nervousness which such constant attention produces, tend to defeat the object which they have in view, by diminishing the secretion of milk. The application of the infant to the breast once in an hour and a half to two hours is quite sufficient. In some cases, when practicable, the aid of another woman, whose infant is a little older, is in- valuable. The exchange of infants for a few times may remedy the difficulty. Occasionally lactation is rendered difficult and painful by too long delay before applying the infant to the breast. "When the mother has rested a few hours after her confinement, from three to six in ordinary cases, lactation may commence. There is, at first, but very little milk, often only a few drops, but the secretion is promoted by nursing, so that the requisite amount is sooner ob- tained than when the infant is kept from the breast till the second or third day. If, as some j)hysicians advise, suckling is deferred till the breasts are full and tender, and if, as is often the case with primiparse, the nipples are also tender, many mothers lack the for- titude required to allow their infants to obtain a sufficient amount of milk. Excoriated and fissured nipples constitute a serious im- pediment to lactation. They are very sensitive on pressure, and are long in healing. They are fully described in works which relate to female diseases, and their treatment pointed out. Occa- sionally fissured nipples do harm to the infant by the blood which escaf»es and is swallowed with the milk. A case is related in which positive indigestion was caused in this way, the infant vomiting, after each nursing, milk mixed with blood. The local HINDRANCES TO LACTATION. 31 hindrances to lactation described above can, in most instances, be relieved in the course of a few weeks. There is, occasionally, a constitutional state of the mother which necessitates either the employment of a hired wet-nurse or wean- ing. This is the case when there is a strong tendency to tubercu- losis. If the complexion is pallid, and the system at all emaciated, and suckling is attended by more or less exhaustion, and if with fair trial of wine and tonics there is no improvement, the physician is justified in forbidding farther attempts at wet-nursing. If there is, under such circumstances, an hereditary tendency to tubercu- losis, it is his duty to interdict it positively. The opinion of the physician, in such a matter, should be formed after mature delibe- ration. There are many women who, suflering temporarily from depression, and discouraged, are ready at once to abandon their infants to the care of others, with the least encouragement on the part of the physician to do so, but who, by attention to their own health, and especially by taking more sleep, soon recover from their depression and become good wet-nurses. On the other hand, night- sweats, a cough, and progressive decline in health, show the need of immediate suspension of wet-nursing. Sometimes women, prior to pregnancy, present indubitable evi- dence of tuberculosis, but by the imx^roved general health which attends pregnancy, the disease is temporarily arrested. Such women should never suckle their infants. If they do, they soon lose all that was gained, and the disease advances rapidly. These objections to wet-nursing in such a state of health apply to the mother. There are also objections as regards the infant. The milk of those in decidedly infirm health, is deficient in nutritive prin- cij^les. Their infants, therefore, are ill-nourished, and, if they have inherited a predisposition to tuberculosis, there is great danger that this disease will be developed in them ; whereas with healthy wet-nursing, even a strong predisposition may remain latent. M. Donne relates the following instructive cases, which show the danger which sometimes attends suckling, and the imperative ne- cessity which may arise of discontinuing it. "A very light-com- plexioned young mother, in very good health, and of a good con- stitution, though somewhat delicate, was nursing for the third time, and as regarded the child successfully. All at once this young woman experienced a feeling of exhaustion. Her skin be- came constantly hot ; there were cough, oppression, night-sweats ; her strength visibly declined, and in less than a fortnight she pre- sented the ordinary symptoms of consumption. The nursing was 32 . LACTATION. immediately abandoned, and from the moment the secretion of milk had ceased, all the troubles disappeared." "A woman of forty years of age . . . having lost, one after another, several children, all of whom she had put out to nurse, determined to nurse the last one herself. . . . This woman, being vigorous and well-built, was eager for the work, and, filled with devotion and spirit, she gave herself up to the nursing of her child with a sort of fury. At nine months, she still nursed him from fifteen to twenty times a day. Having become extremely emaciated, she fell all at once into a state of weakness, from which nothing could raise her, and two days after the poor woman died of exhaustion."' Constitutional syphilis in the mother does not contra-indicate lactation. It is probable that the infant also has it. The mother should take anti-syphilitic remedies, which will eradicate the dis- ease in herself, and also, if it be present, in the infant. Febrile affections, also, do not in general contra-indicate lactation. They may, however, for a time, diminish the quantity of milk, or impair its quality. If, however, the mother is in a critical state, or much reduced, whatever the disease, suckling should cease. Whether or not the infant should be taken from the breast, if the mother is sufifering from one of the essential fevers, depends on the degree of her exhaustion. Twice I have known newly-born infants nurse their mothers through attacks of scarlet fever, without contracting it, but suffering immediately afterwards from severe and protracted eczema. In the country, where artificially-fed infants as a rule do well, it might be best to wean if the mother is affected with such a disease, but in the city eczema is less dangerous than the diarrhoeal aflJections, which early weaning is apt to entail. In most cases of typhus or typhoid, weaning or procuring a wet-nurse is necessary, on account of the depression of the vital powers which this disease produces. Inflammatory affections, unless of a dangerous character, do not ordinarily interfere with lactation, except that the quantity of milk may be somewhat diminished. In severe inflammation, it may be so necessary to husband the strength, or to keep the patient perfectly quiet, that suckling her infant would be injudicious. It ' A very similar case recently occurred in my practice. A young and healthy woman from the country, suckling her second infant, on coming to the city, lived in a dark and very imperfectly ventilated room, on the first floor, and in the rear of a crowded tenement-house. She soon lost her appetite, but continued suckling for three months, when she became so ansemic and feeble that she was compelled to seek medical advice. She died without local disease, notwithstanding the most nutritious diet and the free use of stimulants and tonics. FACTS AND RULES IN REFERENCE TO LACTATION. 33 should then be transferred to a wet-nurse or weaned. Inflamma- tion of tlie breast often presents an impediment to lactation. It is a common and painful aliection, suspending, or greatly diminish- ing the secretion of milk in the affected gland. Nursing should cease as soon as there are evident signs of inflammation, unless it is limited to a small part of the gland. General heat of the breast, tenderness and induration extending over a considerable part of it, are signs which indicate the immediate removal of the infant from it. Lactation must be restricted to the unaflected side. It is often the case that the volume of the inflamed gland is considerably increased from the afflux of blood to it, and from the interstitial exudation, while it contains little or no milk, and attempts at lac- tation, under such circumstances, are injurious to the mother as well as infant. The cause of the swelling should be explained to the mother, who commonly attributes it to the accumulation of milk, and worries herself and the infant, in attempting to make it nurse. As the inflammation abates, by resolution, or more com- monly by suppuration, and the normal secretion returns, the first milk, which is apt to be thick and stringy, should be rejected, after which the infant may nurse as usual. Occasionally, the abscess, which has formed in the breast, connects with a lactiferous tube, so that pus may, on suction, escape from the nipple. If this occur, of course, lactation should be interdicted, until pure milk is ob- tained. Pus in the milk can sometimes be detected by the naked eye. It presents a yellowish or greenish color, occurring in streaks, when not intimately mixed with the milk. When it is intimately mixed, and in small quantity, it cannot be detected by the naked eye, but the microscope reveals the pus globules. M. Donne relates a case in which he discovered pus globules by the microscope, although there were at first no other evidences of an abscess, and doubts were expressed in reference to the accuracy of his observa- tion. Finally, an abscess pointed and discharged. Sometimes, when the inflammation abates, the secretion does not return, and, worse still, occasionally the inflammation has occurred so near the nipple that the lactiferous tubes are perma- nently closed by it, so that, though milk forms in the breast, there is no escape for it. Thenceforth lactation must be entirely from one breast. Facts and Rules in reference to Lactation, The new-born infant should nurse every hour, or every second hour, during the day. At night, if the mother is delicate, and her 3 34 LACTATION. milk not abundant, it may be fed, once or twice, with a little cow's milk. It is better to select, for this purpose, the upper third of the milk, after it has stood two or three hours, and use it diluted with twice the quantity of water. If the mother is robust, she should not feed the infant, but allow it to nurse once or twice dur- ing the night. No nursling, in ordinary health, really requires the breast more than once during the hours which the mother needs for rest ; and by a little perseverance on her part its habits may be so established that it is satisfied if it receives the breast no oftener. Many young mothers commence the duty of suckling with too much ardor. Exerting themselves to the utmost for the good of their offspring, they are awake, night after night, giving their breast at every cry, till they find that their strength is failing, and with it, also, their milk. Their self-devotion necessitates early weaning, whereas, had they exercised more regard for their own health, and learned to hear with composure the cries, which often do not indicate any bodily want or distress, they might continue to suckle their infants during the usual period. The milk secreted during gestation, and immediately after the birth of the infant, differs in its gross appearance, as well as che- mical and microscopical characters, from that which is ordinarily secreted in a state of health. It is termed colostrum. It has a turbid and yellowish appearance, and is somewhat viscid. It is decidedly alkaline, and undergoes lactic acid fermentation more readily than common milk, and it also contains more solid matter. It has an excess of fat, of salts, and, according to Simon, also of sugar. It appears, from Simon's analysis, that the solid matter of colostrum is about seventeen per cent., while that of the ordinary breast-milk is about eleven per cent. cfo'^;?< _ Oo oo y^Q>, Milk Globules. Colostrum Corpuscles. Examined by the microscope, the colostrum is seen to contain oil globules and a viscid substance, which often assumes an ovoid or globular form, but which also exists in irregular masses of con- FACTS AND RULES IN REFERENCE TO LACTATION. 35 siderable size. This substance has been thouglit by some to be mucus, but it is dissolved by acetic acid and potash, and is tinged yellow by a watery solution of iodine. It is, therefore, to be regarded as albuminous. Imbedded in this substance are oil glo- bules, which are for the most part of small size, while the free oil globules of colostrum are larger than those occurring in healthy milk. This viscid substance, with the imprisoned oil globules, constitutes what has been designated the "colostrum corpuscles." Some have erroneously considered the "colostrum corpuscles" to be compound granular cells. The compound granular cell, or cor- puscle, is a cell which has undergone fatty degeneration. It is distended with oil globules to perhaps twice or thrice its normal size. On the other hand, examination of the "colostrum corpus- cles" fails to detect a cell-wall, and the large and irregular size of some of these corpuscles negatives the idea that they are cells. The oil globules contained in the viscid substance are more readily acted on by ether than are the free oil globules. The colostrum is replaced by milk of the normal character, in six to eight days ; sometimes as early as the third or fourth day after delivery. In exceptional instances, the colostrum does not disappear for several weeks, and it may reappear at any time dur- ing lactation, as a consequence of derangement of the system, or from disease. It is assimilated with difficulty by the digestive organs of the infant, producing usually a laxative effect. It, there- fore, aids in the removal of the meconium, and being a normal secretion in the first week of lactation, it is to be regarded as bene- ficial. Continuing longer than the first week, its effect is delete- rious. It produces evident derangement of the digestive organs, and the infant that habitually nurses it, never thrives. It has diarrhoea or vomiting, becomes more or less emaciated, and suffers from colicky pains. Sometimes an extreme degree of exhaustion is reached before the cause is suspected, for, if the milk is pretty abundant, the admixture of colostrum with it cannot be detected by the naked eye. The microscope alone reveals it. The following is an interesting example of this fact. In 1868 an infant six weeks old was brought to me, with the following history. The mother had for years been troubled more or less with dyspeptic symptoms, but had otherwise been in good health. The infant at birth was fleshy and strong, but after the first week it had never thriven like other infants. It nursed regularly, and the quantity of milk was apparently sufficient, but it vomited as soon as it ceased nursing ; it was much emaciated, and the bowels were habitually constipated. 86 LACTATION, The digestive organs of the infant had been in this unhealthy state, with little variation, from the first week, and it was very evident, from the emaciation and exhaustion, that it must soon perish, unless some change were efiected. The milk of the mother presented the usual appearance to the naked eye, but under the microscope colostrum corpuscles were observed. A wet-nurse was immediately obtained, and from that moment the gastro-intestinal symptoms disappeared, with a rapid recovery. This case shows at once the evil effects of the colostrum, and the need of a microscopic exami- nation of the milk whenever the nursling suffers from lactation. Human Milk. The specific gravity of human milk is about 1032. It has been carefully analyzed by difterent chemists, with nearly the same result. The following table, prepared by MM. Vernois and Bec- querel, gives the proportion of the various ingredients in 1000 parts : — Water 889.08 Sugar 43.64 Caseum and Extractive 39.24 Butter 26.66 Salts (ash) 1.38 1000.00 Milk being the sole food of early infancy, contains all the nutri- tive principles which are required for the growth and repair of the different tissues. The caseum is an albuminous principle, the butter and sugar are combustible substances, and most of the salts which occur in the difterent tissues exist primarily in the milk. Phos- phate of lime, phosphate of magnesia, phosphate of the peroxide of iron, chloride of potassium, chloride of sodium, and soda, known to exist in cow's milk, are believed to occur also in human milk. Epithelial cells are sometimes present, derived from the lining membrane of the lactiferous tubes. Modifications of the Milk in Consequence of the Diet. Fresh milk should give an alkaline reaction, but in certain states of ill health, or after the use of certain articles of food, the reaction is acid. Mothers are well aware of the ill effects, as regards the infant, which follow their use of indigestible, or acescent food ; and, if prudent, they avoid it. The milk, if the diet of the mother is improper, may become so strongly acid as to cause colicky pains MODIFICATIONS OF MILK IN CONSEQUENCE OF DIET. 37 and diarrhooa. The following observations in reference to cow's milk are instructive. "We may infer from them that the regimen of the mother exerts a decided influence on the alkalinity of her milk. According to Routh [Infant Feeding, page 285), stall-fed cows almost always give acid milk. Dr. Mayer, of Berlin, exam- ined the milk from a considerable number of cows, with the follow- ing result : — {a.) Of cows fed with brewers' lees, red potatoes, rye bran, and wild hay, in five instances the milk was slightly sour; in one very much so. {b.) Of forty cows fed with potato mash, barley husk, and clover and barley straw, in ten, which were examined, the milk was sour; in three very sour. {c.) From among fifty cows fed on j)otato husks, barley husks, and wild hay, five were examined, and in all the fresh milk was sour. {(I.) From forty-two cows fed on potato mash, husks, w^ild hay, and rye straw, out of twelve selected for examination, the fresh milk of all was sour. {e.) From six cows fed by a chief gardener on coarse beet-root, red potato, bran mash, and hay, the fresh milk was slightly sour. (/.) From five cows fed by a cow-feeder on lukewarm bran mash and hay, in four the fresh milk was quite neutral, in one it was decidedly alkaline. [Routh.) The above observations of Dr. Mayer were made in the winter season, and it is possible that the acidit}^ may have been partly due to the confinement of the cows in stalls. But that it was mainly due to the food is evident from the fact that it was greater with some kinds of food than others. Cows' milk is not so alkaline as human milk, and is therefore more readily rendered acid. Still, what Dr. Mayer observed in reference to the cow exemplified a fact of general applicability, namely, that certain kinds of food may affect the alkalinity of the milk, whether human milk or that of animals. The relative proportion of the different ingredients of the milk varies according to the diet. If the diet is poor, the amount of water increases, and that of butter and caseum diminishes. Leh- mann says [Phys. Chemistry, vol. ii. p. 65): "From experiments made on bitches, it would appear that a vegetable diet renders the milk richer in butter and sugar ; while the solid constituents are augmented when a sufficient quantity of mixed food is given. Peligot found the milk of an ass most rich in casein when the 88 LACtATION. animal had been fed on beet-root ; whilst it was richest in butter when the food had consisted of oats and lucerne. Fat food in- creases the quantity of the butter. Boussingault found the milk of a cow richer in casein when the animal had been fed on potatoes than when other food was taken. Eeiset found that the milk of cows which were at grass was much richer in fat than when the animals had stood all night in their stall without food ; but Plaj- fair found, on the contrary, that the quantity of butter in the milk increased during the nio-ht as much as during their stall-feedino;, but that the quantity of butter in the milk was considerably dimin- ished by the motion of the animals in the fields."^ Simon made the following analyses of the milk of a poor woman. She was suddenly, during the period of lactation, deprived of the means of support, so that her food was insufficient in quantity, and of poor quality. The amount of her milk was not diminished by priva- tion, but the solid constituents were reduced to 86 parts in 1000. After this, for a time, her diet was nutritious and abundant, the quantity of milk was increased, and the solid constituents amounted to 119 parts in 1000. Her diet was again reduced, with a reduction of the solid elements to 98 in 1000, and, at a later period, the diet was again nutritious, with an increase of the solid elements to 126. The chief variation observed in the milk of this woman was in the amount of butter. Modification of Milk from its Retention in the Breast. M. Peligot has clearly demonstrated, that the longer milk is retained in the breast the more watery it becomes. This is ex- plained on the supposition that the solid portion is first absorbed. Therefore, the milk is richer the more frequently it is removed from the breast. A similar fact, which has the same explanation, has long been known, namely, that the first milk taken from the breast is thinnest, while that which flows last is richest. That first removed has remained longest in the gland, while that which comes last is but recently secreted. A knowledge of this fact is of considerable practical importance. The milk, as M. Donnd has shown, may be too rich, so as to cause indigestion, with more or less enteralgia, in the infant. Some nurslings, if the milk is too rich and abundant, reject a part of it by vomiting, but others do not, and suft'er the consequence in de- ' Animal Chem., Sydenham Soc.'s Trans., vol. ii. p. 55. MODIFICATION OF MILK BY NERVOUS IMPRESSIONS. 39 rangoment of the digestive organs. For such cases the remedy is, to give the breast less frequently, by which a less amount of milk is taken, and milk of a poorer quality. On the other hand, if there is poverty of the milk, and the infant is insufficiently nourished, the milk is more nutritious if the nursing be at short intervals. Modification of Milk by Age and by Nervous Impressions. The composition of the milk varies, also, according to the age of the infant. Simon analyzed the milk of a woman at intervals for the period of about six months. In this case the amount of casein at first was small, but the quantity increased during the two months succeeding delivery, after which it was nearly stationary. A similar increase was observed in reference to the saline sub- stances. The sugar, on the other hand, diminished in quantity as the infant grew older, its maximum amount being in the first and second months. The quantity of butter in the milk varies from day to day more than the other elements. Many observations have been published which show that the composition of the milk may be materially changed by mental impressions. The infant has died suddenly in the act of nursing, after the mother had been violently excited. Such a case is related by Tourtnal. The infant ceased nursing, gasped, and died in the mother's lap. In other cases convulsions have occurred. MM. Becquerel and Vernois made the chemical analysis of the milk of a woman in a state of nervous excitement, and found that the solid constituents were diminished to 91 parts in 1000, the most marked diminution being in the butter, which was only about 5 parts. In a case related by Parmentier and Deyeux the milk became watery and viscid, and remained so till the nervous at- tacks, from which the patient sufiiered, had ceased. Dairymen are well aware how ill-treatment and the separation of the calf from the cow diminishes the milk which she yields. A new milk- man seldom obtains as much milk as one with whom the cow is familiar. Bouchut, alluding to the influence of the moral affec- tions on the secretion of milk, makes the following remark, the truth of which most mothers will acknowledge : " It is also a fact, that the sight of the nursling, the idea of seeing it at the breast, and the joy which certain mothers thence experience, exercise a moral influence over the secretion of the milk entirel}^ independent of their will. They feel the draught of milk as soon as they behold their child, or think of it too deeply ; and in a woman who saw 40 LACTATION. her cliild fall to the ground, the flow of milk ceased, and did not reappear until the child, having quite recovered, attempted to take the breast." Modification of Milk by the Catamenial Function and Pregnancy. The catamenia reappear in most women before the close of lacta- tion, often by the fifth or sixth month after delivery. If this function is re-established in the normal manner, that is, without any derangement of the system, without pain or undue profuse- ness, no unfavorable result ordinarily occurs with the infant. On the other hand, if the mother sufler any disturbance of the system, or if the menses are profuse, the lacteal secretion may be so changed, that the infant is injuriously affected by it. The symptoms pro- duced are those of indigestion, such as abdominal pains, more or less vomiting, and diarrhoea. This result is, however, in my ex- perience, quite exceptional. In rare, instances, more dangerous symptoms occur in the infant. A case has been reported to me in which, at each catamenial period, the nursling was seized with convulsions. MM. Becquerel and Vernois have investigated the character of the milk durins: the catamenia in three cases. Their examinations showed a moderate increase in the solid constituents. The butter and caseum were increased, while the sugar was diminished. The variation from normal milk was not, however, such as would be likely to cause any serious indisposition. If the menses reappear •vvith regularity, when the infant has attained the age of ten or twelve months, they should be considered as designed to supersede the secretion of milk, which, indeed, usually begins to diminish. Weaning is then proper. If the menses return early in the period of lactation, and give rise to symptoms in the infant in consequence of the altered quality of the milk, it is advisable to allow but little nursing during the catamenia, and to employ artificial feeding in place till the flow of blood ceases. The change produced in the milk by pregnancy is, in general, more injurious to the nursling than that caused by the reappear- ance of the menses. The milk of the pregnant woman is apt to contain more or less of that viscid substance which characterizes colostrum. Still, the milk of pregnancy does not, ordinarily, de- rano-e the dio;estive function as much as colostrum, in the first weeks of lactation, for pregnancy rarely occurs till after the infant is five or six months old, when the organs of digestion are less QUANTITY OF BKEAST MILK REQUIKED BY INFANT. 41 readily disturbed. The injurious effect of pregnancy on the infant is sliown by vomiting or diarrhoea, l)y restlessness and occasional abdominal pains, in fine, by symptoms of indigestion. In many cases, however, these symptoms do not occur, and the infant, though nursing regularly, continues to thrive. ISTo doubt, as a rule, the infant should be weaned when there are clear evidences of preg- nancy, but under certain circumstances weaning is injudicious. I have, on different occasions, been called to infants, in midsummer, dangerously sick with diarrhoeal attacks induced by this cause. These infants were, perhaps, doing well, or sufiering but little from indigestion, when the mothers suspecting themselves pregnant, at once withdrew them from the breast, and cholera infantum or a kindred disease was the result. ISTo infant in the city should be weaned in the hot months. It is much safer, though there are indubitable signs of pregnancy, that it continue nursing till the cold weather. The better method is, however, under such circum- stances, to employ a wet-nurse, or to remove the infant to the country, and wean it there. In cold weather, it is usually safe to wean an infant, in the city, after it has reached the age of five or six months. The milk frequently contains other ingredients in addition to those which have been mentioned. Thus a large number of medi- cinal substances, taken by the mother, may enter the milk, so as to produce their characteristic effect on the infant. It is a well-known fact, that the peculiar flavor of certain vegetables, taken as food, may be noticed in the milk. It is admitted, also, that the specific virus of the contagious diseases, at least certain of them, may enter the milk, so as to give rise to the same diseases in the infant. Quantity of Breast Milk required by the Infant. In a paper published by Dr. W. H. Gumming, in the American Journal of Medical Science, July, 1858, it is estimated that the amount of milk secreted per day by a healthy women is one and a half to two quarts, and double the quantity if two infants are suckled. Routh {Infant Feeding, P^^ge 87) believes that this is a somewhat exasrserated statement. He estimates the amount at a quart to a quart and a half daily. "A three months child,'" says he, " generally thrives very well on four, or, at the most, five meals a day, the quantity taken each time amounting to a half-pint. This would fix the quantity at two pounds to two and a half, i.e., thirty- two to forty fluidounces. ... A younger child, one to two months, 42 LACTATION. may need to take his meals more frequently — it may be every two hours, except when asleep — but then the quantity consumed does not exceed, as a rule, as I have often assured myself, two wine- glasses or three ounces every meal. This would raise the quantity taken in twenty-four hours to thirty-six ounces — a quart and a quarter. A child above three months may take about forty-eight ounces dail3^" Dr. Gumming, in consequence of his high estimate of the amount of milk which an infant requires, naturally concludes that few mothers can long endure the excessive drain upon their systems, and therefore, in order to prevent their exhaustion, and to satisfy the appetite of their infants, it is necessary, at an early period, to aid by artificial feeding. This opinion may do harm, since artificial feeding of the young infant, especially in the cities, is apt to give rise to indigestion, followed by vomiting and diarrhoea. The mother in good health, and furnishing an average quantity of milk, is competent to give all the nutriment which the infant requires until it has reached the age of four months, and most are till the age of six months. Drs. Merei and Whitehead examined 952 mothers in the Children's Hospital at Manchester, in reference to their physical condition. Of these, 629, or Q6 per cent., were in a healthy and robust state. Of this number, namely 629, 420 fur- nished suflicient milk till six months after delivery, and some till two years. Differences in Suckling Women as regards Quantity and Quality of Milk. There is, however, a great difference, in different women, as regards the quantit}^ and quality of their milk, and even the mode in which it is secreted. The best wet-nurses are usually robust without being corpulent. Their appetite is good, and their breasts are distended from the number and large size of the bloodvessels and milk-ducts. There is but a moderate amount of fat around the gland, and tortuous veins are observed passing over it. Such nurses do not experience a feeling of exhaustion and do not suffer from lactation. The nutriment which they consume is equally expended in their own sustenance and the supply of milk. There are other good wet-nurses who have the physical condition which I have described, but whose breasts are small. Still, the infant continues to nurse till it is satisfied, and it thrives. The milk is of good quality, and it appears to be secreted, mainly, during the time of suckling. SCANTINESS OF MILK. 43 Otlier mothers evidently decline in health during the time of lac- tation. They furnish milk of good quality and in abundance, and their infants thrive, but it is at their own expense. They them- selves say, and with truth, that what they eat goes to milk. They become thinner and paler, are perhaps troubled with palpitation, and are easily exhausted. They often find it necessary to wean before the end of the usual period of lactation. There is another class whose health is habitually poor, but who furnish the usual quantity of milk without the exhaustion experienced by the class which I have just described. The milk of these women is of poor quality. It is abundant, but watery. Their infants are pallid, having soft and flabby fibre. All these kinds of wet-nurses are met in practice. Occasionally, a considerable part of the milk is lost by oozing from the breast. This sometimes occurs in robust women, but it is more frequently associated with weakness. It is then due to a relaxed state of the orifices of the milk-ducts. Galactorrhoea, as the excessive secretion and flow of milk is designated, is said to be often associated with a menorrhagic diathesis ; that is, women whose menses have been profuse are apt to have too abundant a flow of milk corresponding with the menorrhagia. It is said that galactorrhoea is also apt to occur in those who are subject to dis- charges from parts which sustain no immediate relation to the breast, as in cases of hsemorrhoidal flux, diabetes insipidus, etc. Excitement, or irritation of the uterus or ovaries, may serve as an exciting cause of galactorrhcea in those predisposed to it, and excessive suckling may have the same eflect. Scantiness of Milk; its Causes and Treatment. Though the amount of breast-milk which the infant requires is less than was estimated by Gumming, still insuflSciency of this secretion is not uncommon, especially in the cities. According to the statistics of Drs. Merei and Whitehead, among healthy mothers there is insufiiciency in 16.5 per cent., while among mothers in feeble health the percentage is 46.6. In treating of this subject in the following pages, reference is not had to those cases in which there is temporary diminution of milk from acute disease or other perturbating causes, but to those cases in which there is habitual scantiness. One cause of scanty secretion of milk is a life of privation or of daily w^ork, which necessitates separation from the infant. Insuf- 44 LACTATION. ficient food may render the milk more watery, as has ah-eady been stated, or it may cause diminution in its quantity. The mother thus situated is pallid. She is subject to palpitation and attacks of faintness. Her condition, indeed, is that of anaemia. Working women have scantiness of milk, not only in consequence of hard- ships, but also because they are usiially separated for hours from their infants. Age is also a cause of scantiness of milk. Mothers at the age of forty years ordinarily furnish less milk than between twenty and thirty. And those who have not borne children till late in life, and whose mammary glands have therefore long been inactive, have less milk than those who commence bearing children at the usual period. Routh speaks of hyperemia as a cause of defective lactation. " This is a variety," says he, " which I have chiefly observed among hired wet-nurses, selected from the poorer classes, and admitted into wealthier families. . . . When feeding at the expense of a master or mistress, the amount they devour often surpasses all moderate imagination. They, in fact, gormandize. If in such instances a wet-nurse is given all she asks for, she will be found often to eat quite as much as any two men with large appetites ; and, as a result, she becomes gross, turgid, often covered with blotches or pimples, and generally too plethoric to fulfil the duties of her position. The plethora, as first induced, is of the sthenic variety, but it soon assumes an asthenic character, and, as the im- mediate result, the breast no longer secretes its quantum of milk. There may be good milk secreted, but it is in small quantity, and this quantity diminishes daily. The breast may also enlarge, but it is from a deposition of fatty tissue in and about it, as in other parts of the body. The veins on the surface become less apparent, always a bad feature in a suckling breast, till finally the flow of milk ceases altogether." Atrophy of the breast from the employment of iodine, or from long disuse, is also a cause of insufficiency of milk. It is so necessary for the health and development of the infant that the milk should be in proper quantity as well as quality, tliat it is proper in a work of this kind to consider the treatment of insufiicient secretion, and, on the other hand, of excessive secretion and loss of milk, or galactorrhoea. And first of insufiicient or scanty secretion. The most efficient mode of increasing the lacteal secretion is that which is also natural, namely, suction from the nipple. There are many cases on record in which this has produced the flow of SCANTINESS OF MILK. 45 milk in women who have never borne children, and even in men. Baudelocque mentions the case of a girl, eight years old, who snckled her brother for a month, and cases at the opposite extreme of life have been reported; one of a woman of seventy years, who wet-nursed a grandchild twentj^ years after her last confinement. Travellers among barbarous nations or tribes have often observed these cases of unnatural lactation. Humboldt saw a man, thirty- two years old, who gave the breast to his child for five months, and Captain Franklin, in the Arctic regions, met a similar case. Dr. Livingstone, in his account of Africa, says that he has examined several cases in which a grandchild has been suckled by a grand- mother, and equally remarkable instances of lactation occur among the negroes of the Southern and Middle States. Prof. Hall pre- sented to his class in Baltimore a male negro fifty-five years old who wet-nursed all the children of his mistress. In these cases of abnormal lactation, so far as we have complete records of them, it is ascertained that the breasts were torpid, and even sometimes, as in old people, atrophied till the nursing commenced. Titil- lation, or pressing of the nipple, caused an afilux of blood to the gland, and developed its functional activity, so that milk was pro- duced for the sustenance of the nursling. Therefore, in case of scanty secretion of milk, the mother may increase the quantity by applying the infant often to the breast. If, dissatisfied with the small amount of nutriment which it receives, it refuses to make the necessary suction, any other mode of gentle traction or pres- sure may be employed in addition. The occasional employment of another infant, or a pup, milking the breast with the thumb and fingers, or the gentle suction of a breast pump, aids in stimulating the secretion. Forcible rubbing or traction of the breast defeats the purpose for which it is employed. It produces too much irrita- tion and tenderness. The best mode of stimulation is by nursing, as it is the natural mode, and the moral effect of the infant at the breast aids in promoting the secretion. Another mode of increasing the functional activity of the mam- mary glands is by the electrical current. The fact is established by physiological experiments, that glandular organs can be made to secrete more actively by the stimulus of electricity, and, accord- ingly, this agent has been successfully employed to promote the secretion of milk. In Routh's Infant Feeding several cases are related which show the beneficial effects of this agent (page 149 et seq.). Among them are six reported by Dr. Skinner, of Liver- pool. In all these, one or two applications of the electrical current 46 LACTATION. sufficed ■ to restore the secretion. The following is Dr. Skinner's mode of employing this treatment : — " 1. Direct. — Both poles must terminate in cylinders, with sponges well moistened in tepid water. The positive pole is pressed deep into the axilla, while the negative is lightly applied to the nipple and the areola ; the current being no stronger than is agreeable to the patient's feelings. The poles are kept in this position for about two minutes. Both poles are then to be inserted into the axilla, and gradually brought together, the negative to the sternal, and the positive to the opposite of the organ. This latter step may occupy one or two minutes more. " 2. Intraynammary. — The poles are to be, as it were, imbedded in the mamma, and moved about, raising and depressing both poles at once in and around the organ for the space of another two minutes. The same is to be done to both breasts daily, until the secretion is properly established. Hitherto one or two sittings have always sufficed in my hands." {Communication of Dr. Skinner to Dr. Routh.) In all cases of scanty secretion of milk, the regimen of the mother is a matter of importance. Personal and domiciliary cleanliness is essential for successful wet-nursing. A certain amount of ex- ercise in the open air is conducive to the health of the mother, and to the secretion of abundant and healthy milk. A case is related to show the effect of fresh air and out-door exercise on the lacteal secretion. A lady of cleanly habits, living in London, had a very scanty supply of milk. She removed to the pure air of the sea- shore, and immediately the quantity became abundant, and con- tinued so for months. Such cases are not unfrequent. A mode of life that contributes to the general health of the mother will not fail to augment the quantity of her milk, if it is scanty, and to improve its quality. Much has been written in reference to the diet of women who suckle. It is a popular belief that certain articles of food promote the secretion of milk much more than other articles, though equally nutritious. No doubt, writers liave erred in recommending exclu- sively this or that kind of food, as most likely to produce milk. The exact kind of food which is preferable, in a certain case, de- pends partly on the physique of the individual, and partly on the character of the food to which she has been accustomed. A mixed diet contributes most to the sustenance of the mother, and to an abundant secretion of milk. Animal substances which furnish a due supply of nitrogenous aliment should be given with the fari- SCANTINESS OF MILK. 47 naceons. Mothers pallid, and inclining to an anaemic condition, require a larger proportion of animal diet than those in good general health. On the other hand, plethoric women, such as Routh describes, who with excellent appetites consume large quan- tities of food, and who become more and more full-blooded and corpulent while the milk diminishes, require a more -restricted animal diet, in connection with more exercise, especially in the open air. There are certain kinds of food which do ajDpear to have a galac- togogue effect with most wet-nurses. Oatmeal gruel is one of these. Wet-nurses often remark, after taking a bowl of this, that they feel the flow of milk. Cow's milk with some has a similar effect. Porter or ale, taken once or twice a day, also promotes the secretion of milk, especially in those who have poor appetite, and whose systems are somewhat reduced. A great variety of medicines have been used for their supposed galactogogue eflect. Medicines which improve the general health are, no doubt, sometimes useful for this purpose, such as the vege- table and ferruginous tonics, and perhaps cod-liver oil. But there are other medicines which it is claimed have a specific eflect on the mammary gland, promoting its secretion. Lettuce, winter-green, fennel, the broom tops (cytisus scoparius), marsh-mallow, castor oil plant, and many other plants, have been used for this purpose. There can be no doubt that the aromatic stimulants, as fennel, anise, and caraway seeds, given in soups, sometimes stimulate the lacteal secretion. But the medicine which of late has attracted most attention in the profession, as a galactogogue, is castor oil and the plant from which it is derived. The galactogogue effect of the leaves of the castor oil plant has been long known to the Spaniards in South America. At least as long ago as the commencement of the last century, the ricinus com- munis was applied by them externally to the breast, to promote the secretion of milk. It is now about twenty years since this use of the plant was brought prominently to the notice of the profession in this country and in Europe. In the London Journal of 31edi- cine, 1857, Dr. Tyler Smith relates the results of his experiments with the castor oil plant. He applied the bruised leaves over the breasts, and witnessed, as he thinks, an evident galactogogue effe'ct. Dr. Routh has also made pretty extensive use of the plant, both externally and internally. He was led, he says, to employ it in- ternally, from noticing, in suckling women, an increase of milk after taking a dose of castor oil. He prescribed a decoction of the 48 LACTATION. leaves and stalks, and says : " I have not been disappointed. The flow has been remarkably increased. Four objections against its use, however, should be mentioned." These are, first, a peculiar sensation in the eyes, with dimness of sight, an effect which he has observed only in weak women ; secondly, the necessity of increas- ing the dose as the patient becomes accustomed to it ; thirdly, scarcity of the plant ; fourthly, an occasional diuretic, sometimes without galactoo-oo-ue effect, and sometimes with it. The cases in which diuresis occurred were in the practice of other physicians, and Dr. Routh conjectures that this effect was produced by not keeping the breast warm during the time that the decoction was being employed. The breasts should at the time of its use be covered with a fomentation of leaves, or an extract of the leaves should be rubbed over the breasts in the same way in which extract of belladonna is used, and over this a warm poultice applied of the ordinary material. Dr. Routh remarks: "When the castor oil leaves are given as an infusion to women who are not suckling, I have observed two eft'ects, both of which seem to denote its specific action. First, it produces internal pain in the breasts, which lasts for three or four days. Then, secondly, a copious leucorrhoeal dis- charge takes place, after which the effect on the breasts entirely disappears." Dr. Gilfillan, of Brooklyn, has also employed the ricinus com- munis successfully as a galactogogue. He employed a poultice of the pulverized leaves, and gave internally the fluid extract of the leaves, a teaspoonful three times daily. The patient had been con- fined the year before with her first child, but had no milk for it, though her health Avas good, and measures were employed, as fric- tion and fomentations, to stimulate the secretion. The ricinus was prescri])ed the fourth day after her confinement with the second child, when there were no signs of secretion, and the breasts were small. "About two hours after the poultice was applied, and the first dose taken, she experienced a strange sensation in the breasts, and this increased after each dose of the medicine. The poultice was not renewedj but the extract was continued for three days, after which lactation was perfectly successful." So far observations have shown that the ricinus is the most efficient galactogogue which we possess among medicinal agents. In the treatment of galactorrhoea the object to be attained should be kept in view. There are medicines which cure this affection by diminishing the amount of milk. Belladonna, iodide of potassium, and colchicum are antigalactics. It is proper to use them in case SELECTION OF A WET-NURSE. 49 of weaning or of death of the infant. They not only reduce the quantity of milk, but, continued, may prevent its secretion. They arc employed not to benefit the infant, but the mother. On the other hand, if it is our purpose to prevent the oozing of milk in order to save it for the infant, or, if it is abundant and watery, to" diminish somewhat its quantity and improve its quality, the treatment should be different. Iron, in cases of galactorrhoea, in which the condition of the system appears to indicate the need of it, Avill diminish the quantity of milk and render it richer. It is by many regarded as an antigalactic, and given long it might reduce too much the amount of the secretion, and even necessitate weaning. Its use should be discontinued if no more than the normal amount of milk is secreted. In most cases of true galactorrhoea the pathological state is that of weakness and relaxation of the tissues. The fault is not exces- sive secretion of milk so much as its non-retention, and the medi- cines which are the most useful to correct this state of the system and of the breasts are the vegetable tonics and astringents. If galactorrhoea occur in those who have an habitual discharge, and it appears to be due to the same cause which produces that dis- charge, and there are no evidences of weakness, laxative medicines and other derivatives may be employed. But such cases are not common. ISTux vomica has been recommended in galactorrhoea, in the belief that it diminishes the relaxation of the orifices of the lactiferous tubes. Local treatment in this affection is important. A cloth wrung out of cold water should be occasionally applied around the nipple, and removed as it becomes warm. Solutions of tannin or alum are likewise useful. Collodion applied around the nipple, by its retrac- tion, diminishes the orifices of the ducts, and thus aids in the reten- tion of the milk. CHAPTER Y. SELECTION OF A WET-NURSE. In the cities, cases are frequent in which mothers, with all pos- sible care or endeavor, find themselves unable to suckle their infants. Their health is too poor, or the milk possesses the properties of colos- trum, or it is no longer secreted on account of nervous excitement, 4 50 SELECTION OF A WET-NURSE. or exhaustion, or inflammation of the breasts. The number of such cases, in the city, would surprise physicians who are familiar only with the healthy and robust mothers of the country. The infant thus deprived of the mother's milk should, if practicable, be fur- nished a wet-nurse. The selection of a wet-nurse often devolves upon the physician, and it is a duty of great responsibility. It is better to select one between the ages of twenty and thirty years, and one who has suckled an infant previousl}^ A wet-nurse between the ages of twenty and thirty is usually more active, cheerful, and conciliatory than one of a more advanced age, and her milk is more apt to be abundant and nutritious. Those who have previously suckled and had charge of infants are obviously more competent to serve as wet- nurses than are primiparse. The milk of a wet-nurse, whose infant is under the age of six months, will ordinarily agree with a new- born infant. If above that age, it sometimes agrees, but often does not. The most diflScult and responsible task imposed on the physician, in the selection of a nurse, is to ascertain the exact condition of her health, and the quantity and quality of her milk. Constitutional syphilis is common in the class of women who present themselves for wet-nursing ; it is often latent, or its symptoms are easily con- cealed, and it is communicable by lactation. The virus may be re- ceived by the infant from fissures or excoriations of the nipple. The nursling tainted by syphilis may, on the other hand, communicate the disease to the nurse through the same source. It is not fully ascertained whether the syphilitic virus may be conveyed to the infant by the milk. But the cases which have accumulated in the records of medicine are numerous, in which infants born of healthy parents have been fully syphilized by lactation from diseased nurses (see article Syphilis). These infants have sometimes led a short and miserable existence, and have occasionally increased the misery of the household by imparting the disease to others. The duty is, therefore, imperative on the part of the physician to examine care- fully the wet-nurse, in reference to any evidences of the syphilitic taint. Acquainted with the symptoms of syphilis, he may usually, by shrewd questioning and by careful examination of the present appearance and condition of the woman, ascertain with consider- able certainty whether her system has ever been infected. Refer- ences should also be obtained and consulted, and, if practicable, the physician who has attended her be communicated with. EXAMINATION OF THE MILK. 51 There are, also, among the women who present themselves for wet-nursing in the cities, many of a scrofulous habit, many who possess an hereditary tendency to tuberculosis, if indeed they do not already have the incipient disease. Such applicants should be rejected, on account of the poverty of their milk and the proba- bility that they will not be able to endure the debilitating effect of lactation. The milk should be examined, in order to ascertain its richness and quantity, and whether it contains colostrum. If there is colos- trum after the eighth day, it is probable that there is some fault in the health or digestion of the wet-nurse, and that her milk may disagree with the infant. It is not necessary that the breasts should be large, in order to furnish a sufficient quantity of milk, since, as has been already stated, in some the secretory function is active during the time of each nursing, so that, although the breasts are of moderate size, a sufficient amount of milk is furnished. The nipples should be well formed and prominent, and preference is to be given to those wet-nurses in whom vessels are seen ramifying over the breasts. By examination of the milk, its degree of richness can be readily ascertained. A quantity of it should be placed in a test-tube, and the cream, which rises to the top, indicates, approximatively, the character of the milk. Good milk furnishes three per cent, of cream, and the caseum and sugar usually correspond in quantity with the cream. An instrument has been invented, called the lactometer, by which the exact amount of the cream can be ascer- tained. It is simply a tube graded into 100 divisions. It is placed upright, and filled with milk, and the number of divisions occupied by the cream indicates its proportion in 100 parts. The lactoscope is another instrument employed for the purpose of ascertaining the richness of the milk. It consists of two concentric tubes, which move upon each other. Milk which we wish to examine is poured within the tubes sufficient to obscure a light viewed through it, three feet distant. The column of milk is then diminished, till the lio;ht beo-ins to be visible. The size of the column indicates the degree of opacity and the richness. The lactoscope was in- vented by M. Donne, and is described by him. Dr. Minchin recommends a simple mode of determining the richness of cow's milk, and it would equally answer for the breast milk. A vessel holding about one ounce, and containing a gradu- ated enamel slab, passing diagonally from above downwards, is filled with milk. It is then covered with a glass slide carried over it in 52 SELECTION OF A WET-NUESE. sucli a way as to exclude bubbles. The number of degrees which can be read, indicates the character of the milk, as regards its richness. Examination of the milk with the microscope not only enables us to determine whether there are abnormal corpuscles or granular elements, but also its richness. It should be examined before the cream has separated. Oil globules of small size, and few, indicate poverty of the milk ; very large oil globules are said to indicate milk which is apt to be indigestible, especially in feeble infants. Such are the free globules of the colostrum. Numerous oil globules of medium size indicate nutritious milk. Yogel, in 1850, made the discovery of vibriones in human milk. The fact is established that these animalcules may be generated in the milk within the breast, though such cases are not frequent. Dr. Gibb describes a case which he met. {Ranking' s Abstract^ vol. xxxiv.) An infant, 7 weeks old, wet-nursed by its mother, who had the appearance of perfect health, was, nevertheless, ill-nourished and emaciated. It had no diarrhoea or other apparent disease, and the milk was therefore examined. Vibriones baculi were found in the milk immediately after it was obtained from the breast. The milk had the usual amount of cream, and seemed to the naked eye of good quality. According to Dr. Gibb, two genera of animalcules occur in the milk, namely, vibriones and monads. It is believed that the monads occur in consequence of fermentation of the sugar and the production of lactic acid. Vogel also attributed the production of the vibriones to fermentation occurring in consequence of heat and congestion of the breast, connected with sexual excitement. This explanation is probably not correct, because vibriones sometimes occur when there is no unusual heat of ln'east,and no evidence of fermentation. The fact that such organisms may occur in milk which seems of good quality to the naked eye, affords additional proof of the use- fulness of the microscope in the selection of a wet-nurse. Many wet-nurses have a return of the menses as early as the fourth or fifth month after delivery. The re-establishment of this function in some women impairs the quality of the milk, so as to render it less nutritious, and jDcrhaps less digestible; in other women it does not sensibly affect the character of the fluid or its quantity. In the selection of a wet-nurse, then, preference should be given to one who does not have the periodical sickness, but if she is already employed, and gives satisfaction, the reappearance of the catamenia does not indicate the need of a change of nurse, unless the diges- tion of the infant is disordered, or its nutrition is impaired. EXAMINATION OF THE MILK. 53 In the selection of a wet-nurse attention sliould also be given to her mental and moral traits. Cheerfulness, affection, veracity, and a proper appreciation of the resi^onsibility of her situation enhance greatly the value of a wet-nurse. Not less important are habits of temperance and cleanliness. I could cite cases of the most melan- choly results from the absence of these traits. In one case idiocy resulted from an infant falling upon the pavement from the arms of a reckless or intemperate wet-nurse. In most cases the mode of examination indicated above suffices to show the character of a wet-nurse, so far as her health and milk are concerned. It should be borne in mind, however, that the microscope does not always reveal deleterious properties in the milk. Elements which are in a state of solution, and are invisible, may occur in excess, so as to impair the quality of the milk, and render it indigestible. The following case, in which the saline ingredients seem to have been in excess, is related by Dr. Ilartmann {British and Foreign Medical Review^ vol. xii.) : "An infant whose mother was in good health, and had borne several children, exhibited a healthy appearance for the first five weeks after birth. The alvine evacuations then became copious, fluid, and discolored, and the child lost flesh and streno-th. After the usual remedies had been vainly administered for a fortnight, the mother remarked that the child did not take the right breast willingly, and so much did the unwillingness increase, that at length the mere application of the nipple to the child's lips occasioned loud crying. On exami- nation it was found that the milk of the right breast had a dis- tinctly saline taste ; whereas the milk of the opposite breast was of the ordinary sweetness ; no difference of consistence or color was discoverable. From that time the child was only allowed to nurse the left breast, and in a few days all diarrhoea and sickliness of appearance vanished." In this case there was no appreciable disease of the breast, although its secretion was perverted. The deleterious character of the milk was discovered, not by any change in its appearance, but by the taste. 54 COURSE OF LACTATION — WEANIXG. CHAPTER YI. COURSE OF LACTATION— WEANING. Regularity in nursing is required. The young infant in whom the milk is rapidly assimilated, may take the breast every two hours in the day, and two or three times in the night. Still, as M. Donne has said, mathematical exactness in this matter would he ridiculous. Quiet, natural sleep of a well-nourished infant should not be inter- rupted in order to give it the breast, unless the sleep be unusually protracted. It will usually awaken when the system requires more nutriment. Ill-nourished infants, according to my observations, sleep but little until they become much prostrated, when they are drowsy, in consequence of passive congestion of the brain. This drowsiness is evidently a pathological symptom. It shows the need of increased nutrition. It is due to scantiness of milk, or milk of poor quality, and the infant should be aroused frequently for the purpose of giving it nutriment or even stimulants. As the infant grows older the stomach receives a larger amount of milk, and it should nurse less frequently. The breast milk is sufficient for its nutrition till the age of six or eight mouths, pro- vided it is abundant and of good quality. If the mother is strong and experiences no exhaustion from suckling, the infant, therefore, need receive no other nutriment till that age, or indeed till the age of ten or twelve months. Many mothers, however, by the third or fourth month of lacta- tion find that they have not sufficient milk to meet the wants of the infant. The constant drain upon their systems sensibly impairs their health. In such cases it is proj)er to commence with kittle feeding from the spoon or bottle, and increase the quantity given as the infant grows older. Great care is, however, requisite in the preparation of food for so young an infant, whose digestive organs are still feeble and easily deranged. In the country, where diar- rhoeal affections and the so-called gastric derangements are not fre- quent, the danger from artificial feeding is less than in the city, and in the cool months in the city the danger is less than in the summer season. Infants of the city, between the months of May COURSE OF LACTATION — WEANIXG. 55 and October, have a strong predisposition to diarrhoeal attacks, the result of anti-hygienic influences wliich surround them. Errors of diet in their case readily provoke disease or derangement of the digestive organs, often of a severe and dangerous form. Moreover, experience has shown that these infants, if fed with the bottle, however carefully, during the period when nature designed that they should be nourished by lactation, very commonly are affected in the hot months with more or less vomiting and diarrhoea, fol- lowed by emaciation and other evidences of mal-nutrition. There- fore, an exception must be made in case of the city infant as regards the commencement of artificial feeding. If it is under the age of one year, it should be nourished exclusively, or almost exclusively, at the breast during the hot months, when practicable, even if the mother suffers somewhat in her health from the constant drain upon her system. The infant should, however, receive the amount of nutriment which it requires, and, if there is not sufficient breast milk, it will be necessary to supply the deficiency by arti- ficial feeding. The subject of artificial feeding will engage our attention in a separate chapter. It suffices, therefore, in this connection to state that nursing infants of three or four months may begin to take a little cow's milk, carefully prepared and of the best quality. It should be diluted, but the amount of dilution required obviously depends on the richness of the milk. Rich country milk is suffi- ciently diluted, if the infant is in good health, by adding half its quantity of water, while most samples of milk furnished in the city do not require more than one-third their quantity of water. A little sugar of milk, which is slowly soluble, should be dis- solved in the water before its mixture with the milk. One drachm of the sugar is sufficient for five or six ounces of the milk, and to the same quantity, if the stools are at all acid, two teaspoonfuls of lime-water should be added. An alkali taken with cow's milk retards the coagulation of casein in the stomach, and tends to pre- vent the formation of a large, thick curd in the stomach, which is with difficulty digested. If, therefore, the child vomits such curds, or passes fragments of them in the stools, a larger proportion of lime-water may be added, or the carbonate of soda as recommended by Vogel, who dissolves one drachm of the carbonate in six ounces of water, and adds a teaspoonful to the milk at each meal. It is proper, also, to allow farinaceous food to an infant of three or four months, if its digestive ' organs are in good condition. I prefer barley flour for this purpose to arrowroot, rice, or wheat flour. 56 COURSE OF LACTATION — WEANING. Barley-water should be jirepared from Robinson's or some other flour of good qualit}^, and mixed while still warm with an equal quantity of milk, and the sugar of milk added. The barley-water should be of about the consistence of milk, and prepared in the usual way by boiling. The milk should not be boiled. It may, indeed, be stated, as a rule, that it is not advisable to boil milk designed for infants, except in the city, where it may be boiled in order to its better preservation. Toast-water may be also employed for diluting the milk, but it is less nutritious than barley-water. At the age of six months, if the infant is in good condition, the milk need not be diluted. As the infant grows older, semi-liquid food may be given. Pap prepared with stale bread, or a rolled soda-cracker, may now be given, once or twice daily, between the times of nureing, and occa- sionally beef-tea or chicken-broth, thickened with cracker or bread, is taken with relish, and if well prepared, and given no oftener than once or twice a day, it is commonly readily digested, while it is highly nutritious. If the quantity of breast milk diminishes, as it often does, towards the close of the first year, artificial food should be given oftener, so as to supply the deficiency. Solid food requires considerable development of the digestive organs for its ready assimilation. It should not, therefore, be given till the close, or near the close, of the first year. "Weaning ought to take place, as a rule, between the ages of twelve and eighteen months. It is well, if the mother's health is good, and her milk is sufficient, to defer weaning till the canine teeth appear. The infant then, possessing sixteen teeth, is able to masticate the softer kinds of solid food. Weaning should be gra- dual. ]\Iothers often speak of weaning on a certain day. They have given but little artificial food, and have suckled at regular intervals, till at a fixed time they have denied the breast altogether. This abrupt change of diet should be discouraged. It should only be recommended under peculiar circumstances. It is apt to derange the digestive organs, and it causes fretfulness and sleeplessness on the part of the infant for a week or more. Weaning should com- mence by feeding with the spoon, a little oftener through the day, and nursing less, and by discontinuing the practice of suckling at night. The infant tolerates this gradual change of diet, while it rebels against sudden weaning, and by its fretfulness increases greatly the care and trouble of the mother. The infant in the city should not be weaned in warm weather, nor within a month immediately preceding it. If the mother's health fails or her milk ARTIFICIAL FEEDING. 67 becomes deficient, in the summer months, so that she cannot con- tinue suckling, the infant should bo sent immediately to the coun- try, or a wet-nurse be employed. Many infants are sacrificed in consequence of ignorance of the danger of weaning under the cir- cumstances mentioned. Severe diarrhoea, inflammatory or non- inflammatory, is apt to result. This subject will be considered elsewhere. CHAPTER VII. ARTIFICIAL FEEDING. Occasionally the mother is unable to suckle her infant, and a hired wet-nurse cannot be or is not obtained. Artificial feeding is then necessary. In the large cities, if I may judge from our iSTew York experience, this mode of alimentation for young infants should always be discouraged. It generally ends in death, pre- ceded by evidences of faulty nutrition. A considerable proportion of those nourished in this manner thrive during the cool months, but on the approach of the warm season they are the first to be aftected with diarrhoea and other symptoms indicating derange- ment of the digestive function. In my opinion, based on a pretty extended observation, more than half of the ]^ew York spoon-fed infants, who enter the summer months, die before the return of cool weather, unless saved by removal to the country. In the country, and in the small inland cities, the results of artificial feeding are much more favorable. The majority live, and in elevated farming sections, on account of the salubrity of the air, and the facility with which milk, fresh and of the best quality, is obtained, arti- ficial feeding appears to be nearly as favorable as wet-nursing. Young infants, fed by the hand, obviously require food prepared so as to resemble as closely as possible the human milk. The basis of such food must, therefore, be the milk of some animal. The following table, prepared by MM. Yernois and Becquerel, gives the proportion of the ingredients of human milk, and the milk of the four domestic animals which is most easily obtained and most frequently employed as food. 58 ARTIFICIAL FEEDING. Composition of Milk. Specific gravity. 100 parts contain — The solid corapoi lents consist of — Fluids. Solids. Sugar. Butter. Casein and extractive matters. Sails. Man 1032.67 1033.38 1034.57 1033.53 1040.98 889.08 864.06 890.12 844.90 832.33 110.92 135.94 109.88 155.10 167.68 43.64 38.03 50.46 36.91 39.43 26.66 36.12 18.53 56.87 54.31 39.24 55.15 35.65 55.14 69.78 1.38 Cow 6.64 Ass 5.34 Goat 6.18 Ewe 7.16 Cow's milk is most readily obtained, and is commonly used as a substitute for human milk, compared with which it contains less water and sugar, but more butter, casein, and salts. Its composi- tion, however, varies considerably according to the food of the cow and other circumstances. The variations in the milk of the cow, according to the nature of its food, have been considered in a pre- ceding chapter. It has been stated, also, that the milk first obtained in milking is most watery, since it is longer secreted than the last milk, or the "stripping." The stall-fed cow gives acid milk, while the cow grazing in a pasture gives milk that is alkaline. Again, the milk in the first months after calving is richer than after the lapse of several months. It is obvious from the above facts that the analysis of difierent specimens of cow's milk must dififer greatly, and the same is true of the milk of the goat and ass, and probably of the ewe. In fact, difierent samples of the milk of the same animal may difier more from each other, in their chemical character, thaix.the average milk of one animal from that of another. The milk of the goat and that of the ass have been recommended as food for infants in preference to cow's milk, on the ground, as is alleged, that they more nearly resemble himian milk. But by reference to the foregoing table it will be seen that more impor- tance has been attached to this supposed resemblance than the facts justified. Neither the milk of the ass nor goat, so far as its chemi- cal character is concerned, would seem to possess any advantages over cow's milk. The ass's milk is procured with difiiculty, and is seldom used. An objection to goat's milk is the unpleasant odor which it often possesses, due to the presence of hircic acid. It is stated, however, by Parmentier, that this odor is only noticed in tlie milk of goats that have horns. An important advantage, in the city, in the use of goat's milk, is that the animal can be ARTIFICIAL FEEDING. 59 kept at little expense, so that even poor families who are not able to purchase and feed a cow can generally possess a goat, from which fresh milk can be obtained at any time. Preference is to be given to goat's milk when fresh, over cow's milk brought from the country, perhaps watered on the way, and several hours old when received. If, however, as both chemical analysis and experience show, goat's milk is no better as food for infants than cow's milk when fresh and from healthy cows, the latter must continue in common use for this purpose. Milk used for infants should always be alkaline. If it is acid, as shown by the proper test, it should be rejected; or, if there is none better, should be rendered alkaline by the addition of lime- water or carbonate of soda. The nurse should test the milk at different periods through the day, and be taught to make the necessary addition. M. Donn^ prefers the first milking, when it is possible to obtain it. This contains a smaller proportion of solid elements than the average milk, bears a closer resemblance in its chemical character to human milk, and requires but little dilution. The upper third of the milk, after it has stood two or three hours, is also preferable, as the casein, which is digested with more diffi- culty than the other elements, has a high specific gravity and tends to settle towards the bottom. If the infant is under the age of two or three months, the milk should be diluted with one-third or one-half its quantity of water. After the age of three or four months, it requires no dilution. It should always be given at a uniform temperature, namely, a little warmer than the body. Employed habitually too hot or too cold, it is apt to cause stoma- titis, if not more serious disease of the digestive organs. After the fourth month, the infant may be allowed crushed soda cracker, or stale bread upon which boiling water is poured and then drained off, and afterwards milk added. Porridge made with rice, barley flour, or arrowroot is also a proper article of diet at this age. After the fifth or sixth month, milk with crumbled soda cracker or stale bread may also be allowed. The shops contain various preparations of food for infants, and most of them have been employed in the institutions of this city sufficiently to ascertain their effects. The one which has given most satisfaction is known as IsTestle's Lacteous Farina, prepared by Henri Nestle, a Swiss chemist. It is preferred in the IN'ursery and Child's Hospital, and Infant's Hospital, to Liebig's Soup, but the latter, so highly extolled by the German physicians, and a description of which will be found in the appendix, may not have 60 BATHS — CLOTHING. been well prepared in these institutions. ISTestle's food is, however, expensive, and althongh infants thrive well on it in the cooler months, I am of opinion, from my own observations, that in the hottest weather, when diarrhceal aifections are so prevalent and fatal, it has too laxative an effect. I do not, therefore, recommend as the ordinary diet of healthy infants any other food than the mother is able to prepare readily, with milk, or, under certain cir- cumstances, barley-water, as its basis. In the first half year it is most convenient and otherwise prefer- able to give the food through a sucking-bottle, after which the infant may be fed with a spoon, or taught to drink from a cup. The physician should positively forbid the use of sugar teats and various sweetened admixtures which nurses are so apt to em- ploy, as they tend to produce simple stomatitis, sprue, and, if much employed, even indigestion and diarrhoea. Between the ages of one and two years the teeth have become sufiiciently developed for the mastication of light food. Tender and finely cut meat, potato baked and mashed, bread and butter, and even certain fruits carefully selected, may then be allowed. After the age of two years less rigid surveillance of the food is required, but the variety is sufiicient if all dishes except the most bland and unirritating are excluded till after the first years of childhood. The reader is referred to Appendix A for various dietary formulae and directions relating to the choice and prepara- tion of food, which will be found useful in the treatment of young children, in those diseases especially in which the digestive func- tion is seriously impaired. CHAPTER YIII. BATHS— CLOTHING. Daily ablution of the infant conduces to its comfort and health. If under the age of two months, it should be bathed daily in water of about the temperature of 92°. As it grows older the tempera- ture should be gradually reduced, a bath at 88° to 90° being proper for an infant between the ages of three and six months, and one at 86° for an infant between six and twelve months. In the second and third years the temperature of the bath should be about 84°. After the bath, which should continue from five to ten minutes, BATHS — CLOTHING. 61 the surface should be gently rubbed with a soft towel to produce reaction and a glow of the skin, which would prevent danger of taking cold. The clothing of children, especially in our variable climate of the north, is a matter of importance, and one in regard to which the parents often require instruction. It may be stated, as a rule, that the chest and abdomen of the infant should be so covered with flannel that there is no danger of producing chilliness by a sudden reduction of the external temperature or exposure to a current of air. By this precaution many cases of laryngitis, bronchitis, and diar- rhoeal affections, now so common in infancy, might be avoided. In winter the flannel should be thick, and in the summer thin. Even in the hottest weather the abdomen should have a light flannel covering, which increases the comfort, if the surface is in the nor- mal state. If lichen, which is not uncommon in the warm months, appear upon the surface, I would not remove the flannel, but place under it linen or soft muslin. The popular idea that children may be hardened by exposure to the weather in scanty clothing, and by being bathed, even at the most tender age, in water at so low a temperature as to pro- duce chilliness, cannot be too strongly combated. The hygienic management of the child should always be such as insures present comfort. If it do not, if it is regarded with aversion and dread by the child, the me1,hod is wrong. The dress should always be so loose as to allow free movements, and not embarrass in the least any of the functions. This is a matter which is left too much to the discretion and intelligence of the nurse, who is usually so ignorant of the important facts in physiology that she unwittingly, and with the best intentions, in- jures her charge. I have often interposed to loosen the dress of the new-born, which was so tight as to sensibly embarrass respiration ; and one case has been reported to me in which it appeared that death resulted from this cause. Infants, especially, who are so liable to pulmonary collapse and intestinal hernias, should have loose covering of both chest and abdomen. The feet of children should always be warm. Infants require flannel stockings, thick or thin, according to the season Care should be taken that the shoes produce no compression, and they should be exchanged for those of a larger size as often as is required by the growth of the feet. Deformity of the feet or toes, ingrow- ing toe-nail, and induration of the skin, can sometimes be traced back to tightness of a shoe in childhood. 62 ACCIDENTS AND AILMENTS INCIDENTAL TO INFANTS. Physicians are so well aware of the importance of domiciliary cleanliness and ventilation, of the free admission into the nursery of solar light, and of the importance of out-door exercise as a means of invigorating the system and promoting healthy func- tional activity, that nothing need be stated in reference to these subjects in this connection. CHAPTER IX. ACCIDENTS AND AILMENTS INCIDENTAL TO THE BIRTH OF THE INFANT, AND DETACHMENT OF THE CORD. Apnoea (Asphyxia) Neonatorum. In the healthy infant, born under favorable circumstances, the two important functions of life, respiration and circulation, are established within the first minute. But it not infrequently hap- pens, in consequence of some unfavorable circumstance, that the heart and lungs fail to act, and the infant lies motionless as one dead. Sometimes in these cases an occasional pulsation of the heart can be detected when the fingers press under the left ribs, but there is no respiration. According to the nature of the cause, the surface is exsanguine or cyanotic and livid. Causes. — These are various. The fault may be partly in the infant ; it may be feeble in its development ; but the common causes are compression of the cord during birth, from breech presentation or otherwise, powerful, frequent, and long-continued uterine con- tractions, often induced by ergot, but sometimes occurring nor- mally, which compress the placenta, and consequently obstruct the fcetal circulation ; detachment of the placenta before birth, and protracted labor, from pelvic malformation or otherwise, even when there is no unusual severity of the pains. Tkeatment. — Obviously the treatment must be prompt. Mucus should be removed from the mouth and fauces with the finger, and, except in those cases in which there has been placental hem- orrhage or anaemia from other causes, as exhibited by pallor of the surface, a few drops of blood should be allowed to run from the cut extremity of the cord. The flow induced aids in establishing the circulation, and, in the large proportion of cases in which there is congestion of internal organs, gives partial relief to it. Brisk rubbing of the body, slapping the buttocks, blowing in the face. APNCEA NEONATORUM. 63 sprinkling water upon it, alternately transferring the body from a tub of hot to cold water may be tried in quick succession, and, if there are no signs of returning animation, no time should be lost in resorting to artificial respiration. The child should be placed on its side upon the edge of a table, with a blanket underneath it, and the head in such a position that the epiglottis falls forward ; a towel or napkin should be placed over its face, having a hole of sufficient size to blow through cor- responding with its mouth. The physician compressing firmly the epigastrium with his thumb, blows a full breath through the hole. A little of the air, notwithstanding the compression, enters the stomach, some may escape by the nostrils, and the rest enters the lungs. Immediately, the hand passing from the ej^igastrium to the thorax, compresses it gently though with sufficient force to produce expiration. This should be repeated six or eight times per minute. The action of the heart, previously slow, becomes quicker by the artificial respiration, and I am confident that I have been able to produce pulsations by this method when the heart had ceased to beat, and death, to all appearance, had occurred. Some recom- mend placing the infant on the right side, on account of the posi- tion of the valve between the auricles, but I think it is better to change it from one side to the other, in order to prevent conges- tions, which are so apt to occur when the circulation is imperfect. The circulation always commences sooner than respiration. The first respirations are mere gasps, not more than one or two per minute in cases of decided asphyxia, but as they become more frequent they are also deeper. Artificial respiration should be continued ten or fifteen minutes in cases in which no action of the heart can be detected by pressing the fingers under the ribs, when, if there are no signs of returning animation, the case is hopeless. If there is any pulsation, how- ever feeble, we should not cease in the attempt at resuscitation. Some prefer insuffiation through a tube (as the segment of a catheter) introduced into the larynx, and pressure upon the thyroid carti- lage so as to close the pharynx, instead of upon the epigastrium. The principle of treatment is similar, but the mode which I have recommended above I have found successful beyond expectation. Thus, in one case in my practice in which pulsation in the um- bilical cord had ceased from ten to fifteen minutes before birth in consequence of its prolapse, I employed artificial respiration nearly a quarter of an hour before there was any appreciable pul- sation, but by perseverance the circulatory and respiratory func- 64 ACCIDENTS AND AILMENTS INCIDENTAL TO INFANTS. tions were fully re-established, and the child lived and was vigorous. When respiration commences insufflation may cease, but it is pro- per to aid the respiratory movements a little longer by compress- ing the thorax after each inspiration. Still, the physician may be disappointed in the result. In not a small proportion of cases the respiration continues gasping, and after a few hours, perhaps even a day, death ensues. I have made post-mortem examination of several infants who have died under such circumstances, chiefly in the ISTursery and Child's Hospital, about six from recollection, and have found considerable uniformity in the appearance of the viscera. Only a small portion of the lungs, sometimes almost none at all, was found inflated, even when the cries had for a time been strong, and extravasated blood usually in considerable quantity lay upon the surface of the brain, evidently having escaped from the meningeal vessels, which were in a state of extreme congestion in consequence of the protracted or difiicuit birth. Meningeal apoplexy therefore seems to me the chief cause of the ill-success attendino- our eflorts to save those Avho are so far resuscitated as to be able to breathe. Caput Succedaneum— Cephalaematoma. During the birth of the child, extravasation of blood not infre- quently occurs in the part of the scalp which presents. This results from the passive congestion, more or less intense' according to the duration of labor and severity of the labor-pains, which occurs in the presenting part, whether scalp, arm, or breech. Caput succe- DANEUM is the term employed to designate the swelling thus caused. Its seat is the loose connective tissue of the scalp external to the pericranium. The tumor is soft, painless, and usually located upon the occiput. It consists partly of extravasated blood, but largely of serum which has transuded from the congested vessels before that degree of congestion was reached required to eflect the transudation of the corpuscles. I have repeatedly had an oppor- tunity to examine this tumor in stillborn infants brought from the lying-in wards attached to the K"ursery and Child's Hospital, and have found when it was slight that it consisted almost entirely of serum, but ordinarily when dissected it presented the appear- ance of a bruise, with a large proportion of serum, the blood and serum infiltrating the scalp to a greater or less distance beyond the appreciable limits of the tumor. Caput succedaneum requires no treatment. As it lies in the loose connective tissue of the scalp, CONJUNCTIVITIS NEONATORUM. 65 its li(prKl permeates the open areolte in every direction, to be rapidly absorbed, while the tumor disappears. The subsidence of the swelling is usually complete within forty-eight hours. Occasionally blood is extravasated under the pericranium, detach- ing it from the bone. This occurs in connection with caput succeda- neum, and is observed when the latter declines. The tumor thus produced is designated cephalhematoma. It is situated upon the occipital or parietal bone, near the posterior fontanelle. Its base corresponding with the denuded bone is circular or oval, and it rarely crosses a suture. In rare instances two cephal^ematomata occur, located upon the occipital and one parietal, or upon both parietal bones. The liquid, being surrounded by the firmly attached pericranium, does not escape in the surrounding tissues, as the caput succedaneum, and is therefore much more permanent. It flattens slowly by absorption, and does not disappear till after several weeks. At the age of six months a slight prominence can sometimes be detected, indicating the seat of the tumor. As the pericranium elevated by the blood does not lose its vitality, it soon begins to produce bone, so that after some days a ring of new bone can be detected by the finger surrounding the base of the tumor, and on the inside of the detached membrane a layer of bone is produced, thin at first and flexible, but gradually approximating the old bone, and becoming firmer as absorption occurs. Some time since, a specimen was presented by me to the IST. Y. Pathological Society, showing this accident and the mode of cure. The child died about two months after birth, and the blood consti- tuting the tumor, which had been in great part absorbed, was com- pletely encased by the old bone below and the new thin formation above. The cavity at length becomes obliterated, and there only remains some thickening of that part of the cranium which corre- sponds with the location of the tumor. CHAPTER X. CONJUNCTIVITIS NEONxVTORUM. Inflammation of the conjunctiva in the new-born is not an un- usual disease. We distinguish two forms of it, diflering in gravity. It commences in the first week, and commonly about the third day. 66 CONJUNCTIVITIS NEONATOEUM. Causes. — The causes of conjunctivitis neonatorum are not the same in all cases. The grave form, which has been designated purulent ophthalmia, has been known to occur during ei^idemics of puerperal fever, probably from the epidemic influence. Another cause, one which is easily understood, and which is universally recognized by the profession, is the introduction under the eyelids, during the birth of the child, of a particle of the vaginal secretion of the mother. The ordinary leucorrhoeal, and still more gonor- rhoea!, secretion has this efi:ect. Moreover, all accoucheurs meet occasional sporadic cases in cleanly and highly respectable families, occurring from some unknown cause, though perhaps in a certain proportion of these cases also a little of the leucorrhoeal discharge coming in contact with the conjunctiva has produced the inflam- mation. Certainly in private practice gonorrhoeal infection is in only a small proportion of cases the cause of purulent ophthalmia of the new-born. Some observers, as Prof. Gross, believe that the most frequent cause of purulent ophthalmia of the new-born is at- mospheric. The causes of the mild form are different also in diflferent cases. Prominent among them are bad hygienic conditions, exposure of the eyes to a current of cold air, and the introduction of a little of the vernix caseosa or soap under the lids in the first washing. Symptoms. Severe Form. — In the beginning the palpebral con- junctiva is observed to be red, a little swollen, and its cutaneous surface presenting a faint reddish tinge. The light appears to be painful, and the child is fretful and sleeps but little; but the eye itself presents its normal appearance. The progress of the disease, however, is rapid, and in twenty-four or thirty-six hours there is so much tumefaction that the upper lid extends over the lower, and it may be impossible to separate them sufficiently to obtain a view of the eye. The tumefaction is due to oedematous infiltra- tion. The conjunctiva, both palpebral and ocular, now presents a deep red hue, is thickened and swollen, and numerous fine granula- tions appear upon it: occasionally also flakes of very delicate pseudo- membrane can be observed in addition. There is an abundant pro- duction of pus of a creamy appearance, sometimes tinged with , blood, which oozes out when the lids arc separated. A critical period has now arrived, one which may involve the destruction of the cornea unless the case is promptly and judiciously treated. Indeed, the gravity of the disease relates chiefly to the state of the cornea, which up to the present time, notwithstanding the severity of the inflammation and the amount of surrounding infiltration, has CONJUNCTIVITIS NEONATORUM. 67 remained transparent and apparently unaffected. But witliin an- other twenty-four hours the cornea may lose its polish, and grayish, opaque spots of softening appear upon it. Soon perforation occurs, the aqueous humor escapes, and the iris falls forward, closing the aperture and preventing further loss of the liquids of the eye. I have observed destruction of the cornea and loss of sight chiefly, first, in cases of true gonorrhoeal infection, in which there is the maximum amount of inflammation and tumefaction, extending even over the malar bone and supra-orbital ridge, with marked redness and elevation of temperature of the lids ; and, secondly, with a less degree of inflammation in those who were highly scro- fulous. In other cases I am of opinion that the cornea can ordi- narily be preserved with proper treatment, although there may be so much purulent discharge and oedema that it may be impossible to see it for several days. Occasionally the cornea, instead of slough- ing, becomes infiltrated to a greater or less extent, and ulcerates, but without perforation. As the patient recovers, cicatrization occurs. The inflammation soon begins to decline. The swelling, heat, and redness of the lids and conjunctiva, and the granulations, gradually disappear, and recovery is complete, except so far as the cornea may have been injured. Mild Form. — The inflammation is from the first of a mild grade, pertaining chiefly to the palpebral conjunctiva, with but a slight discharge of purulent matter, and with little swelling or increase of heat in the lids. Attention is directed to the complaint chiefly by the secretion which collects in the angles of the lids or upon their border. There may be slight intolerance of light, and ordi- narily minute granulations appear upon the inflamed mucous surface. This form of the disease may disappear within a few days, or it may be protracted. The conjunctivitis of the new-born is contagious, some forms of it highly so. It commences on one side, and, without precautions, commonly within a few days extends to the other. Treatment. — As soon as the inflammation occurs, the opposite sound eye should be covered with a compress, kept in place by strips of adhesive plaster. This eye should be examined, however, once or twice daily, in order to detect the commencement of in- flammation, and the bandage reapplied. The mild form of conjunctivitis requires very simj^le treatment. Frequently bathing the lids with lukewarm water, or milk and water, so as to remove the secretion from between the lids, suflices 68 CONJUNCTIVITIS NEONATOEUM. ill a large proportion of cases. Among the poor tlie mothers ordi- narily bathe the lids with breast milk, and by this simple treat- ment effect a cure. If the inflammation should not abate soon by this treatment, a mild collyrium of one-eighth grain of nitrate of silver to one ounce of water should be applied between the lids and allowed to run under them. The severe form, or purulent ophthalmia, on the other hand, re- quires prompt and judicious management. There is scarcely a dis- ease in which delay is more disastrous. The frequent removing of the pus is very important, which is confined in large quantity underneath the closely compressed lids, and by its pressure and irritation increases greatly the danger of destruction of the cornea. Therefore the lids during the height of the inflammation should be pressed apart every hour, so as to allow the pus to escape, and the space between the lids be freed from pus by a camel-hair pencil. Occasionally warm water may be thrown under the lids by a small glass syringe, to wash away pus and any flakes of pseudo-membrane. Probably three or four drops of carbolic acid to each ounce of the water would be beneficial, from the known good effect of this agent on suppurating surfaces, but I have never employed it. Medicinal applications to the inflamed conjunctiva should, in my opinion, be simple and mild, but frequently applied. It is known that Von Grafe recommended the application of nitrate of silver as a caustic ; but the operation is painful and difficult, for it requires eversion of the lids. I much prefer, in the treatment of purulent ophthalmia, the application of a weak solution of corro- sive sublimate every three hours between and under the lids, the pus, so far as practicable, having been first removed by the brush and syringe. I employ the following formula, and the result has, in my practice, been so favorable that I have not felt justified in trying another: — I^. Hyd. chlor. corros. gr. j ; AqufE rosarum gij ; Aqutc ^vj. Misce. Still, the beneficial result which I have obseiwed in cases treated with this collyrium was no doubt partly due to the frequent re- moval of the pus, the importance of which cannot, in my opinion, be too highly estimated. In ordinary or mild cases of purulent ophthalmia, a light poultice of ground slippery elm, mixed with sugar of lead water, will be found useful ; but if there is great heat and swelling of the lids, a preferable application, while the inflam- DISEASES OF THE UMBILICUS. 69 mation is intense, are pieces of a single thickness or two thick- nesses of muslin or linen an inch and a half square, taken from a cake of ice on which they lie, and renewed every two or three minutes when they begin to be warm. When the inflammation has become less intense, and the danger of the destruction of the cornea is passed, the poultice or sugar of lead wash may be em- ployed instead. The decline of the inflammation is gradual, though generally pretty rapid. Occasionally granulations remain upon the lids. If they do not diminish and disappear when the purulent inflammation has ceased, I would not practise excision, as recom- mended by Vogel, but, having everted the lids, apply a solution of nitrate of silver, five or ten grains to the ounce, to the granulations each second day, and immediately wash away the solution by a camel-hair pencil with lukewarm water, and apply a little sweet oil before the lid is returned. If the granulations do not disap- pear with this treatment, they may be lightly touched with the smooth surface of a crystal of sulphate of copper, followed by the application of water and sweet oil. By this mode of treatment, employed from the commencement of the inflammation, a large proportion even of the severest cases recover with good vision. CHAPTER XI. DISEASES OF THE UMBILICUS. "When properly managed, the cord desiccates and falls off between the third and ninth days. The nurse should not be allowed to oil it, which she will sometimes do unless forbidden, as this retards desic- cation. If the dressing of the cord is allowed to remain Avet from the urine or otherwise, the cord does not desiccate, but decom- poses. This is not infrequent in poor, intemperate, and slovenly families. The decaying cord is apt to produce inflammation of the navel. Some southern physicians, prior to the late war, attributed the prevalence of trismus neonatorum among the slaves to the lesion of the navel produced by this cause, the trismus being then essen- tially traumatic. Inflammation of the Umbilical Vein and Arteries. When at birth the cord is ligated, if the child is in its normal state, clots form in the umbilical vessels from the navel inwards. 70 DISEASES OF THE UMBILICUS. Atrophy of the vessels follows, and by the twenty-fifth clay they are represented by small, firm, fibrous cords. Sometimes, though rarely, a true phlebitis or arteritis occurs in these vessels in the first days after birth, due either to the low vitality of the child and decomposition of the fibrinous plugs and gelatinous substance of the cord, or the entrance into the vessels of purulent or decaying matter from the fossa of the umbilicus. "We are sometimes able, by pressing along the abdominal walls towards the umbilicus, to squeeze out a few drops of the decaying and purulent substance. The navel itself is usuallv inflamed at the same time. This is a very serious disease. Pus, with particles of disintegrated fibrin, is apt to pass along the vessels and enter the circulation, and, being intercepted in distant jiarts, gives rise to embolismal inflammations. This seemed to be the cause of several subcutaneous inflammations, and points of embolismal pneumonitis in a new-born infant which I attended in 1868. The infant belonged to a family highly scrofulous and prone to scrofulous inflammations. Umbilical phlebitis and arteritis are said to occur most frequently in Ij-ing-in institutions during epidemics of puerperal fever. Treatment. — In the manner already indicated we should attempt gently to press out any purulent and decomposing substance from the vessels, and the infant should be placed with its abdomen de- pendent so far as it can be done without rendering it uncomfort- able, so as to aid in the escape of the liquids b}^ gravity. The um- bilical fossa should be kept clean, and warm water containing a little carbolic acid may be dropped upon it several times daily. The abdomen should be covered with a soft and warm poultice. Inflammation and Ulceration of Umbilicus. Inflammation of the umbilicus sometimes occurs in the new- born about the time of the detachment of the cord, or soon after. It probably results from uncleanliness, or carelessness in the man- agement of the cord, by which irritating and decomposing sub- stances remain in the umbilical fossa. Sometimes decomposing particles from the cord are the probable irritant. This disease is also most apt to occur in cachectic infants, or those of scrofulous parentage, whose general condition renders them liable to inflam- mations. The umbilicus becomes red, slightly swollen, and moist by a secretion. Often the inflammation remains two or three days in this mild form, receiving no treatment except from the nurse, and disappearing by the use of the dusting powder which she UMBILICAL GRANULATIONS OK FUNGUS. 71* employs. In other instances, the inflammation extends over a radius of an inch or even more, the walls of the umbilicus become swollen and infiltrated, and ulceration succeeds. The ulcer is cir- cular, occupying the site of the navel, and attended by a purulent discharge. The inliammation may now gradually abate, and the ulcer heal with a cicatrix in place of the umbilicus. But in other instances, especially if there is a decided cachexia, the ulcer ex- tends in breadth and width, till finally, in the worst cases, the peritoneum becomes involved, and perforation or peritonitis occurs, with death. Under unfavorable hygienic circumstances, the blood of the infant being vitiated, the ulcer may become gangrenous, or the inflammation may terminate directly in mortification, without the formation of an ulcer. In eitljer case the prognosis is unfavorable, if dark brown slough occupies the site of the umbilicus, and a sero-sanguineous discharge exudes from underneath. The common result is perforation, peritonitis, and death in from one to two weeks. Treatment. — Inflammation of the umbilicus, if at all severe, and especially when attended by any destruction of the tissues in- volved, rapidly reduces the strength. In such cases three or four drops of brandy should be administered every two hours in the breast milk. In the simple inflammation the navel should be bathed with lukewarm water three or four times daily, and the ointment of the oxide of zinc be constantly applied ; or if there is little or no dis- charge, the navel may be dusted with the powdered oxide of zinc. In case of ulceration the navel should be gently washed three or four times daily with lukewarm water, to which carbolic acid is added — five or six drops to the ounce ; and if there is much inflam- mation, a light poultice of pulverized slippery elm should be ap. plied in the interval, or if the in^ammation is moderate, the balsam of Peru. If gangrene supervene, the parts should be frequently bathed with the carbolic acid water, and a cloth soaked with it be applied over it. The slough should be detached as soon as it is so far separated that its removal causes no hemorrhage, after which the treatment for ulceration is appropriate. Umbilical Granulations or Fungus. "When the cord falls, granulations sometimes sprout out from the exposed raw surface, and complete cicatrization is impossible till 72 UMBILICAL HEMOERHAGE. they are removed. Tliey form a rounded mass of a pale reddish hue, at the centre of the umbilical fossa, bleeding when rubbed, and causing constant moisture of the umbilicus. The largest which I have seen had perhaps twice the size of a large pea, and they may be of any smaller size. Treatment. — By pressing upon the umbilical parietes the tumor rises from the fossa, so that a silk ligature can be applied around its base, when the mass can be readily removed with the scissors. If the granulations are small, they may be removed by the scissors, Avithout the ligature, and hemorrhage prevented by touching the surface with lunar caustic. CHAPTER XII. UMBILICAL HEMORRHAGE. The granulations which have been described above sometimes cause considerable hemorrhage when injured. The profuse and even fatal hemorrhage which occurs at birth, or soon after, from too loose a ligature of the umbilical cord, or from laceration or other injury, is so well known, and its cause so apparent, that it need only be alluded to in this connection. Bouchut details a case in which death occurred even before birth, from this form of hemorrhage. The child was attached to the j)lacenta by a very short cord, which prevented delivery till it parted by the traction of the forceps ; but the bleeding from the umbilical vessels was so profuse, that the child was pallid and lifeless when born. There is another form of umbilical hemorrhage, cases of which have been from time to time observed for more than a century (one of the first on record was reported in the Gentleman'' s Maga- zine, April, 1852, by Mr. Watts, a physician in Kent, England), but little was done to elucidate its nature till three American phy- sicians made it the subject of careful study, and the monographs which they have published upon it are the best which the litera- ture of the profession affords. Dr. Francis Minot read his paper, containing the statistics of 46 cases, before the Boston Society for Medical Improvement, in April, 1852. Prof. Stephen Smith pre- pared his paper, containing the statistics of 79 cases, for the JN'ew York Statistical Society, in 1855. It was published in the Neio York Journal of 3Iedicine for that year. Dr. J. Foster Jenkins UMBILICAL nEMOERIIAGE. 73 presented his monograpli as a report to the United States ISIedieal Association in 1858, and it was published in the Transactions of the Association for that year. This paper is very vahiable on account of its statistics, as the writer succeeded in collecting the records of 178 cases, from medical journals, and gentlemen of the Association. These three papers contain nearly all that is known in reference to this disease. Sex, Age. — Females are less liable than males to this hemor- rhage. In Jenkins's cases, 31| per cent. Avere females, 65 1- males. The followino; table o-ives the ag-e at which the hemorrhage com- menced in 99 cases: — Ag a Nos Under 1 dciy • •■•••• 5 " 2 days • • • • • • • 7 " 3 ■ •••••• 6 " 4 • •••■(■ 3 5 to 7 (inclusive) .... 33 8 "10 K 25 11 "15 U 16 16 "21 (( 4 56 • ...*•. 1 99 Ordinarily the hemorrhage commenced very soon after detach- ment of the cord, but in not a few the cord was still adherent. Causes. — The common proximate cause is feeble coagulability of the blood. In the normal state, when the cord is ligated, the fibrin of the blood, which now ceases to flow in the umbilical ves- sels, forms coagula so firm that, by the time the cord is detached, hemorrhage is impossible. But in the majority of those aftected with this disease the clots are so soft and loose that they do not present any effectual barrier to the pressure of blood, which there- fore oozes through them or presses them away. This lack of co- agulability is easily demonstrated, for if a little blood, as it escapes, is caught in a vessel, it will be found to remain liquid a long time. This dyscrasia, or morbid s^te of the blood, which we therefore recognize as a chief cause of the hemorrhage, does not have the same origin in all cases. It is sometimes due to inherited syphilis. The infant aftected with it may be plump, and appear well at birth, but, in most instances, when the hemorrhage is to occur, it is puny and cachectic, exhibiting also local manifestations of the dis- ease with which it is aftected. Thus, in a case in my practice, the infant, puny, and apparently born before term, was observed to have several blebs of pemphigus on the first day, fi'om some of 74 UMBILICAL HEMORRHAGE. which blood soon began to ooze, but the fatal umbilical hemorrhage did not commence till after two weeks. In about one-fifth of the cases ecchymoses or petechite have been observed upon various parts of the surface, aflbrding additional proof of the general blood disease. Jaundice is another cause of impoverishment of the blood in the new-born, and therefore of umbilical hemorrhage. The writers who have collected records of the hemorrhage, all remark the fre- quent occurrence of the icteric hue, both before and during the bleeding. It is not improbable that, in certain instances, the jaundice is hematogenous, arising from destruction of the red cor- puscles, and liberation of the h?ematin, a not unusual result of a profound d^^scrasia, whether S3'philitic or originating in some other cause. But in other, and probably most instances, the jaun- dice i^roceeds from the liver, and is the cause of the change in the blood. Thus, in five of Jenkins's cases, there was occlusion of the hepatic or common bile-ducts, and jaundice, from the presence of biliary acids in the blood, causes diminution in the amount of fibrin and red corpuscles. In the ordinary form of icterus neonatorum, the cause of which is found in the relative fulness of the capillaries and minute bile-ducts in the acini of the liver, the coagulability of the blood must evidently be impaired in proportion to the degree and duration of the jaundice. Poor health of the mother, and impoverishment of her blood during gestation, whether from chronic disease, as tuberculosis, or anti-hygienic conditions, also causes impoverishment and dimin- ished coagulability of the blood of the child, and is therefore a cause of the hemorrhao;e. The excessive use of diluent drinks or alkalies by the mother is believed by some to have a similar efiect. In certain cases the hemorrhao;e is due to an inherited hemorrhao;ic diathesis. In nine of Jenkins's cases the mothers were subject to menorrhagia, and lial)le to bleed freely after parturition, and from injuries; and seventeen other mothers had each lost more than one infant from umbilical hemorrhage. Probably in those cases in which the hemorrhage commenced bCTore detachment of the cord, and external to the point of insertion, the hemorrhagic diathesis is the main cause of the flow. Although the cause of umbilical hemorrhage in the majority of cases is the vitiated state of the blood itself, high authorities, among others Sir James Y. Simpson, have met cases in which the hemorrhage was referable to the state of the vessels. In order UMBILICAL HEMORRHAGE. 75 that the vessels Ue eftcctually closed by the fibrinous coagula, their walls should have their normal contractility, but this is in great part lost, by inflammation (arteritis or phlebitis) which sometimes occurs in these vessels, as we have already seen. Inflammation, whether of artery or vein, causes thickening and infiltration of its parietes, loss of tone on the part of the fibres of which they are composed, and therefore a patulous state of the vessel. Moreover, the inflammation is apt to be suppurative, and the presence of pus in the vessel obvitDusly hinders the formation of a firm and efiective coagulum. Symptoms. — Ordinarily umbilical hemorrhage occurs without any premonition, but sometimes it is preceded by jaundice. Jenkins ascertained that jaundice was a prodromic symptom in 41 out of 178 cases, and, with the icteric hue, constipation, clay-colored stools, deeply tinged urine, etc., were sometimes recorded. Rarely colicky pains and vomiting preceded the hemorrhage. The blood may be arterial or venous, or both. It oozes slowly or rapidly, rarely escaping in a jet, even when there is reason to believe that it is arterial. Prognosis. — This is unfavorable. Statistics show that five in every six perish. The prognosis is most unfavorable when jaun- dice or purpura is present. Those are most likely to recover who have a healthy parentage, no obvious dyscrasia, and in whom the hemorrhage occurs late and is not profuse. The average duration of the hemorrhage in 82 fatal cases in Jenkins's collection was 3| days, the minimum being only three hours. After the arrest of the hemorrhage, death may occur from exhaustion or the dyscrasia. Treatment. — The treatment should be both constitutional and local. It is important, so far as time will permit, to treat the dys- crasia, and as the stools are apt to be constipated, a laxative is ordinarily indicated. A laxative is not only useful for its effect on the hepatic circulation, but as a derivative. Both Smith and Jenkins recommend calomel for this purpose. The modes of treat- ing the bleeding part have been various. Those most deserving of mention are the following: injecting a styptic into the open vessels, applying a styptic by compress or sponge to the navel, covering the navel with dry or wet plaster of Paris, constant pres- sure with the finger, which is tedious, but which maternal solici- tude willingly provides, and lastly the use of needles with ligature. All of these methods have been more or less successful in arresting the hemorrhage, but the last is most effectual, though painful. 76 DIAGNOSIS OF INFANTILE DISEASES. Two needles should be passed through the umbilicus at right angles, and a waxed thread wound around each in the form of fio-ure 8. In four or jS.ve days the needles should be removed, and a poultice or simple dressing applied. CHAPTER XIII. • DIAGNOSIS OF INFANTILE DISEASES. General Observations. Diseases in early life differ in important particulars from those occurring in maturity. Some which are common in the former age are unknown or are rare in the latter, and those which occur equally at all ages often present peculiar symptoms and a peculiar clinical history in the young. Therefore physicians who are skil- ful in treating adults, may be unskilful in treating children. Ex- cellence as a physician of children can only be achieved by special and continued study of their ailments. Again, as regards the diseases of infancy, in which period there is a great amount of sickness and a large mortality, diagnosis must evidently be made from the objective symptoms ; from examining the features, attitude, utterances, the pulse, resi)iration, etc., and inspecting the surfaces, so far as they are accessible to view, and the eliminative products. We lack for this age the important information which speech affords. Some general remarks, there- fore, in reference to the appearances and functions of the system in early life, and the changes which they undergo in various patho- logical states, seem requisite, in order to a clearer appreciation of the symptoms, and more ready diagnosis of individual diseases. Features, External Appearance of Head, Trunk, and Limbs in Disease. In the new-born, as soon as respiration and the new circulation are established, the cutaneous capillaries become distended with blood, and the skin presents a congested appearance. By the close of the first week this external hypersemia begins to abate, and is soon replaced by the normal capillary circulation. Icterus is common in the first and second week. Bouchut attri- butes it to mild hepatitis. A much more plausil^le view of its FEATURES, EXTERNAL APPEARANCE OF HEAD, ETC. 77 causation, and probably the correct one, is that of Frerichs, who attributes it to the effect on the hepatic circulation of ligation of the umbilical cord. By ligation the current of blood through the umbilical vein to the liver ceases, the amount of blood in the hepatic capillaries, which connect with the branches of the vein, diminishes, and then, according to Frerichs, diversion occurs of a part of the bile from the hepatic cells into the capillaries, while the rest flows in the normal manner in the bile-ducts. The dc2i;ree of jaundice is proportionate to the amount of bile which enters the circulation. Icterus neonatorum is not a disease of importance. It subsides without medicine in the course of one or two weeks, when the circulation through the liver becomes equalized and regular. The surface, or portions of the surface, of the new-born often pre- sent for a few hours a livid color due to the mode of delivery. Protracted lividity occurs from atelectasis or malformation in the heart or great vessels ; lividity induced by exertion or excitement while the respiration is normal, indicates malformation of the heart or vessels ; temporary lividity sometimes occurs in severe acute diseases, especially those of the respiratory organs ; lividity, whether temporary or permanent, is a sign of imperfect decarbonization of the blood. The cheeks of children are congested in febrile and inflamma- tory diseases, except in cachectic or prostrated state of system. Transient circumscribed congestion of the face, ears, or forehead constitutes a reliable sign of cerebral disease. Strabismus occurring in connection with febrile reaction, oscillation of iris, inequality of pupils, and drooping of upper eyelids, also denote cerebral disease. The pupils are contracted during sleep ; evenly dilated in death. Dilation of the alse nasi during inspiration, with contraction of the eyebrows and a countenance indicative of suflering, attends severe inflammation of the respiratory organs. Absence of tears during the act of crying shows a severe and probably fatal form of disease in infants over the age of four months. Rapid wasting of the features, causing deep suborbital depres- sions, prominence and pointedness of the cheek-bones and chin, and hollowness of the cheeks, is a sign of a severe diarrhoeal affection ; the most striking examples of this sudden collapse of features are afforded by patients affected with cholera infantum. In severe cases of this disease, the physiognomy, from a state of fulness and health, presents in a few hours such a wasted and senile appearance that the friends with difficulty recognize the features with which they 78 DIAGNOSIS OF INFANTILE DISEASES. are familiar. Muscular tonicity is also greatly impaired in this disease, that of the orbicular muscles of the lips and eyelids to such an extent that the mouth is open and eyeballs exposed during sleep. Great emaciation occurring gradually, is a symptom of sub- acute or chronic disease of a grave character, often of tuberculosis or chronic entero-colitis. Strabismus sometimes occurs in children who have no serious disease. It is then due to simple paralysis of one or more of the motor muscles of the eye. But when supervening upon other symptoms of a neuropathic character, it is a grave symptom, indi- cating organic disease of the encephalon, as effusion, meningitis, etc. A permanently downward direction of the axes of the eyes, with smallness of the face and great expansion of the cranium, is a sign of congenital hydrocephalus. The scalp in this disease is tense, bald, or sparingly covered with hair, the fontanelles and sutures open and enlarged, and the cranial bones yielding to pressure. Great expansion of the cranium above the ears, while the frontal portion is not enlarged, or but slightly, denotes hypertrophy of the brain. The appearance of the general cutaneous surface possesses much greater diagnostic value in the diseases of infancy and childhood than in those of adult life. The eruptive fevers so common in the young, and comparatively rare in the adult, reveal themselves to us in great part by the changes which they cause in the appearance of the integument. The peculiar color of the skin in constitutional syphilis, hereafter to be described, and which is more marked in infancy and early childhood than at any other age, is a diagnostic sign of great value in obscure cases. In the infant the cold stage of intermittent fever is manifested, not by muscular tremors, but by lividity, pallor, and the goose-skin appearance of the surface. Bulbous enlargement of the fingers and incurvation of the nails are signs of cyanosis, and therefore of malformation at the centre of the circulatory apparatus, or of tuberculosis, or chronic pulmo- nary disease attended by malnutrition. Enlargement of the spongy portions of bones, causing prominences, softness, and bending of the bones, and consequent deformity of the limbs, patency of the fonta- nelles, a large and square shape of the head from calcareous deposit external to the cranium, arc among the signs of rachitis. In early infancy the glands of the skin and mucous surfaces, or which connect by their orifices with these surfaces, are slightly developed. Therefore sensible perspiration and lachrymation are rare under the age of three months. A thick ^Meibomian secretion ATTITUDE — MOVEMENTS— THE VOICE. 79 of a piiriform appearance collecting between the eyelids, is an un- favorable prognostic sign ; it indicates a state of great depression ; it is observed most frequently in cerebral and intestinal affections a little before death. Passive congestion of the vessels of the conjunctiva sometimes occurs under the same circumstances, due to feebleness of the heart's action, and imperfect capillary circula- tion. It indicates the near approach of death. Attitude— Movements — The Voice. A sharp, piercing cry, head firmly retracted, flexure of the limbs with a degree of rigidity, adduction of the great toe, clonic or tonic spasm of the muscles, irregular movements of one or more limbs, with consciousness impaired, or with mental hallucinations, are symptoms of grave disease of the cerebro-spinal system. Irregular muscular movements partly controlled by the will, and occurring during full consciousness, are symptoms of chorea, a disease nearly always ending favorably in children, though incurable in the adult. Contraction of the eyebrows, turning of the eyes and face from light, avoidance of noises, as if painful, are signs of headache. Frequent carrying of the hand to the ear, and pressing with the ear against the breast of the mother or nurse, are symptoms of otalgia. Frequent carrying of the fingers to the mouth, in connection with fretfulness or other symptoms of suftering, indicates stomatitis, gengivitis whether from difiicult dentition or other causes, painful pharyngitis, or some obstructive disease of the larynx. Frequent rubbing or pressing the nose may be due to intestinal worms or intestinal irritation from other causes. It may be due to coryza or headache. Frequent forcible rubbing or striking the nose should lead to a careful examination and perhaps guarded prognosis. It often indicates grave cerebral disease, and may be a precursor of convulsions. In severe obstructive disease of the larynx, the child is restless, moving from side to side. In most inflammations of the respira- tory organs, a semi-erect position gives most relief. The voice in severe laryngitis is often hoarse or indistinct, and usually so in the pseudo-membranous form; in pleuritis or pneumonitis it is re- strained and abrupt, since the movements of the walls of the chest give pain. The voice in severe diseases of the abdominal organs is feeble and plaintive. It is sometimes short and restrained in acute dys- pepsia, in peritonitis, and in cases of great abdominal distension. 80 DIAGNOSIS OF INFANTILE DISEASES. The horizontal position gives most relief in abdominal diseases. In case of abdominal pain the patient often presses his hand upon the abdomen and flexes his thigh over it. Perfect quietude, with features sunken, and unchanged by smile or crying, is a symptom of severe and exhausting diarrhoeal affections. Respiratory System. The respiration of the infant under the age of six months is very irregular, and it is more irregular the nearer the time to birth. If the new-born infant is closely observed, it will be seen to sigh often ; it breathes pretty uniformly and regularly for a moment, and then, without appreciable cause, the respiration is intermitted ; it holds its breath when it smiles or moves its head, or even its limbs; it is very subject to hiccup; this is more common the first week of life than at any other age. So much is the breathing of the young infant disturbed by these causes, that the number of resj^irations ordinarily varies in consecutive minutes. In order, therefore, to determine with accuracy the frequency of the normal respiration for this time of life, it is necessary to take the average of several observations. At birth, while the function of the heart has for months been regularly performed, the lungs are still quiescent. The one organ has been active during the greater part of foetal development, the other is yet untried. Hereafter, the new order of things, so inti- mate is the relation between the heart and lungs, that the proper performance of the function of one is essential to that of the other. Therefore the commencement of respiration and the return of cir- culation, which is modified and temporarily arrested at birth, are nearly simultaneous. Respiration commences in the first half- minute of independent existence ; often, indeed, attempts to inspire occur before the delivery is completed. The exceptions to this early establishment of respiration are, after tedious or unnatural births. The return of circulation is a moment later. Eespiration IN Health. — As the air-cells at birth are closed, the establishment of respiration is difiicult. The air at first pene- trates a few pulmonary cells, but gradually more and more are inflated through the forcible inspirations which the crying of the infant produces, till after a variable time respiration becomes easy and complete. If the cry is feeble, and especially if with this feebleness there is considerable congestion of the brain, the result RESPIRATORY SYSTEM. 81 of tedious birth, the full establishment of respiration is in a cor- responding degree gradual and slow. The frequency of the respiration in health should be ascertained, in order to determine whether, in a given case, it is abnormally accelerated. The following table embodies the result of observa- tions Avhich I have made, in order to determine the normal fre- quency of respiration in the first year of life. Normal Infantile liesjnration {number ])er minute). AGE. From first From close From close of Close of Close of half hour to of first week first mouth third to clo.se sixth month close of first to close of to close of of sixth to close of First half hour. week. first month. third. month. first year. 6 < TOMS. 113 themselves, or the joints, are common in childhood. They some- times occur without apparent exciting cause, but most frequently result from injuries of a trivial character. Some of the best ob- servers and highest authorities, as regards the surgical diseases of children, both in this country and Europe, state that they do not consider these aifections to be of a strumous nature; while others regard them as manifestations of struma. After carefully examin- ing the reasons for this variance in opinion, I am convinced that the difference of views in reference to this matter occurs from a different understanding of the nature of scrofula. Those who state that the aifections alluded to are not scrofulous, believe, so f\ir as I have been able to ascertain, that scrofula and the tubercular dia- thesis are identical. As tubercles are not, as a rule, present in children who suifer from these afiections, it is therefore held that these afiections are not scrofulous. If those holding this belief were told, or could be made to believe, that scrofula is entirely dis- tinct from the tubercular diathesis, that it is merely a name applied to a diathetic condition in which the tissues are easily wounded, there would probably be but one opinion as regards the scrofulous nature of these inflammations. For, as I have often had an op- portunity to observe, they occur in a large proportion of cases from very trivial injuries, showing a highly vulnerable state of the tissues. Holmes, in his useful and eminently practical Treatise on the Surgical Diseases of Children, says of one of the most common of the affections alluded to, namel}^, morbus coxarius : " The affection in question occurs very frequently in strumous children, a circum- stance which has led to its being denominated strumous. * ^ * If by strumous be meant a state of the system which, renders the subject of it prone to the deposit of tubercle in the viscera, I think that there is good reason for asserting that morbus coxarius often attacks children w^io are not strumous, i.e., who display no such tendency to the deposit of tubercle." Still, Mr. Holmes states " that there is that condition of the system which disposes its subjects to the development of low inflammations of various kinds," which is almost the full definition of scrofula, as understood by us. The stubbornness and frequent disastrous consequence of scrofu- lous inflammation of the skeleton is well known. I^early every bone, as well as its periosteum, is liable to this form of inflamma- tion, but some are more frequently afi'ected than others. Inflam- mation of the bone may terminate by resolution, by the formation 8 114 SCROFULA. of an abscess, or, and frequently, by carious or necrotic destruction of tbe bone itself, l^ecrosis is most apt to occur in the shafts of the long bones, caries in the spongy extremities of these bones, and in the spongy portions of the short bones. If abscesses form, the pus may finally escape from the system by a tedious ulcerative process, or, retained, may undergo cheesy degeneration. Scrofu- lous arthritis, if early detected and properly treated, may resolve, leaving no ill effect; otherwise, there is apt to be suppuration, ulceration, cartilaginous and osseous, and anchylosis. Scrofulous children are perhaps no more liable to inflammation of the internal organs than other children, but the inflammatory products are more liable to cheesy degeneration, and the prognosis is therefore less favorable. The most frequent of these inflamma- tions, and the one of chief interest, is pneumonia. Catarrhal pneu- monia, so frequent in early life, whether primary or secondary, in connection with measles, pertussis, etc., is a disease often involving grave consequences in those who are decidedly scrofulous ; since, instead of resolving, the affected lung-tissue gii'esents strong ten- dency to caseous degeneration, ending in consumption of the lungs and death. I have most frequently noticed cheesy pneumonia during extensive epidemics of measles, as a complication or sequel of this disease. It may occur in those who are not scrofulous, if the vital powers are greatly reduced, but it is so much more com- mon in the scrofulous, that some recent writers have designated this form of inflammation by the term scrofulous, instead of cheesy, pneumonia. From the fact, however, of its sometimes occurring in the non-scrofulous, the term cheesy or caseous, especially, too, as it expresses the anatomical state, seems more appropriate. Relation of Scrofula to Tuberculosis. — It is now almost uni- versally admitted that rachitis is entirely distinct in its nature from scrofula, although, till a recent period, some of the best writers upon diseases of children, as Barrier, held that it was one of the manifestations of the scrofulous diathesis. Although the peculiar anatomical changes in rachitis occur chiefly in the osseous system, Avhich is so often the seat of scrofulous disease, yet the character of these changes is so diflerent from those which are admitted to be of a scrofulous nature, and especially as a large pro- portion of the rachitic do not present evidences of a strumous diathesis, struma and rachitis are justly regarded as distinct dis- eases, and their coexistence in the same individual as a coinci- dence- Pathologists and writers on diseases of children are not agreed RELATION OF SCEOFULA TO TUBERCULOSIS. 115 as to the relation of scrofula to tuberculosis. Some, as M. Bouchut, hold that the scroftilous and tuberculous diatheses are identical, believing tubercles a late manifestation of scrofula, while others, among whom occur the illustrious names of Jenner, Virchow, and Villcmin, deny their identity, though admitting their close rela- tionship. Let us consider the facts, some of which are of recent discovery, which show in what manner, or to what extent, scrofula and tuberculosis are related. Ist. In scrofula the lymphatic glands are more frequently af- fected than any other part, a true hyperplasia of their cellular elements occurring. This hyperplasia occurs to a greater or less extent in the majority of marked cases, and, when persistent, is the most reliable sign of the diathesis. The cells, which are pro- duced so abundantly in scrofulous glands, are, to all appearance, identical in character with the cells of which tubercles are com- posed. In other words, the physiological type of the tubercle cell is the normal cell of the lymphatic gland, and the proliferation of this cell, as we have already stated, produces the enlarged gland of scrofula. But it is to be observed, as showing the difierence between scrofula and tuberculosis, that this cell is never found in the affections admitted to be scrofulous, in any other situation than in these glands, where they exist normally ; whereas, in tuber- culosis, they are produced abundantly, not only in the lymphatic glands, but in various organs and tissues throughout the system, which contain no such cell in their normal state. Moreover, the origin of this cell in the lymphatic gland is, according to Virchow, difl'erent in scrofula and tuberculosis. AVhile in the former it is produced by segmentation of the lymphatic cells, in the latter it is produced from the cells or nuclei existing in the connective* tissue of the gland, as it is in other situations. 2d. It has already been stated that the products of scrofulous inflammation are very liable to cheesy degeneration. In children, indeed, cheesy degeneration more frequently results from the scro- fulous affections than from any or all other diseases. Take, in connection with this fact, the very important recent discovery that tubercles are caused, in a large proportion of cases, by particles of cheesy matter, detached from the main mass, and conveyed to the lungs or other organs, and we see another intimate relation between scrofula and tuberculosis. 3d. While the above facts show the close relationship of scrofula and tuberculosis, other facts relating to their hereditary transmis- sion show, in my opinion, their non-identity. The children of 116 SCROFULA. syphilitic parents are very apt to acquire thereby a scrofulous diathesis, and be affected by scrofulous ailments, while they cannot, as a rule, be said to possess the tubercular diathesis, or exhibit any more tendency to tubercles than other children who are in a state of equal cachexia. This does not comport with the doctrine that scrofula and tuberculosis are identical. Again, the infant of the parent who has advanced tuberculosis exhibits a great liability to tubercles, and less in degree to scrofulous ailments. If the dia- thesis of scrofula and tuberculosis were identical, we would expect that a larger proportion of these infants w^ould exhibit scrofulous manifestations, and a smaller proportionate number become tuber- cular, since scrofulous ai&ctions are so much more frequent than tubercles. 4th. As favoring the view that there are two diatheses, writers have stated the fact, that the greatest liability to tubercles is at an age when scrofulous affections are rare, namely, from the age of twenty to thirty years. M. Bouchut attempts to reconcile this fact with his theory of one diathesis, by analogical reasoning, which does not seem to me to be sound. He holds that there are distinct groups of manifestations of the diathesis, according to the age or the time of its continuance, as in syphilis, and that tubercles are the last manifestation. But tubercles may occur at any age, even in infants of a few months. Indeed, they are more common at the age of two or three years than at ten or twelve. The rea- soning of M. Bouchut does not, therefore, appear to invalidate the argument, for how can we consider tuberculosis an advanced stage of scrofula, when it may occur at any age or at any period of those affected with scrofula ? 5th. Recent investie-ations demonstrate that tuberculosis is less a diathesis than was formerly supposed, or than scrofula is admitted to be. That there is, and was previously, a tubercular diathesis in a majority who are affected with tubercles, cannot be denied ; but, on the other hand, there are those, and not a few, who become affected with tubercles from the operation of local causes solely, when there was no diathetic predisposition to them. Thus, an individual who has never presented any evidences of scrofula or tuberculosis, but whose system is perhaps in a reduced state from some cause, takes a pneumonia, and the inflammatory products, instead of undergoing absorption, become cheesy, and from this cheesy substance tubercles result in the manner already described. Local causes have developed a tuberculosis unaided by a diathesis. Such cases are not very unusual. Contrast with this the fact that TROGNOSIS. 117 iu the causation of scrofulous ailments the scrofulous diathesis always plays a conspicuous part. 6th. The following fact may be inferred from the foregoing, but it is so important in this connection, as showing the difference be- tween scrofula and tuberculosis, that it is proper to consider it under a separate heading. Scrofula simply modifies the ordinary physiological or pathological processes, while in tuberculosis there occurs, in the tissue attccted, a pathological process which is pecu- liar. Thus in tuberculosis there is produced from the connective tissue, or more rarely from epithelial cells, a cell which under no other circumstances is produced in these parts; whereas if scrofula aft'ects the same tissues, there is simply an increase in the normal histological elements or inflammation, with inflammatory products. Prognosis. — As scrofula may be acquired through anti-hygienic influences, so it may disappear or become latent through influences of an opposite character. Therefore the manifestations of scrofula may be limited to a brief period, or they may occur at intervals through the whole of childhood and the first years of youth. When the diathesis is inherited, and fostered by unfavorable cir- cumstances, the scrofulous affections appear earliest, are the most varied and severe, and continue longest. In most cases, with proper treatment, the prognosis is good, pro- vided there are no serious local ailments. Scrofulous manifesta- tions gradually disappear, the diathesis ceases or becomes latent, and the health is fully re-established. Though the general health is restored, certain scrofulous inflammations, continuing for a certain time, and reaching a certain grade of intensity, produce perma- nent deformity or impairment of function. In unfavorable cases, death may occur from exhaustion due to protracted suppurative inflammation, or from tuberculosis resulting from the cheesy pro- duct of a scrofulous inflammation. Again, if the function of a vital organ is permanently impaired by scrofulous disease, the prog- nosis of any subsequent inflammatory affection of that organ is rendered much less favorable. Treatment. Prophylactic. — Measures designed to prevent scro- fula are impossible without the co-operation of willing and intelli- gent parents. It is obvious that the prevention of congenital scrofula requires the treatment of disease or impaired health in the parent. If parents should be taught or should remember that good health in themselves is the necessary condition of the inheri- tance of a sound constitution in the child, and should adopt such 118 SCROFULA. therapeutic and regimenal measures as would procure this, the number of cases of inherited scrofula would be materially reduced. As the first years of life are very important, both for correcting the diathesis when inherited, and for preventing its development in those of sound constitution, care should be taken that the regi- men of the child be such as would in no way produce deterioration of the general health. The nursing infant, if the mother is in poor health, should be provided with a healthy wet-nurse, for in young children the diathesis may be acquired solely by the use of food that is scanty or of poor quality. Those old enough to be weaned should have plain and nutritious diet, with a proper ad- mixture of animal food. More or less out-door exercise, and a residence in a salubrious locality with sufficient air and sunlight, are requisite. Curative. — As scrofula originates in a state of weakness exist- ing in the parent in the congenital, and in the child in the acquired, form of the disease, and is characterized by feeble resistance of the tissues to irritating agents, the inference is reasonable that all tonics have, to a certain extent, an anti-scrofulous effect upon the system. The ordinary vegetable tonics, and sometimes the ferru- ginous, are indeed useful in the treatment of scrofula. Employed in connection with proper regimenal measures, they are sufficient, in many cases, to remove the diathesis after a time, or render it latent. Besides these medicinal agents, which tend to correct the scrofulous diathesis by their general tonic eftect, there are certain others which experience has shown to be beneficial in the treat- ment of scrofulous affections, and which are, therefore, largely used. One of these is cod-liver oil, which contains iodine with numerous other in2:redients. Cod-liver oil is useless or nearly so in the torpid form of the diathesis, which is characterized by an increased deposit of fat in the subcutaneous connective tissue, slow circulation, and sluggish muscular movements. On the other hand, in the treatment of the erythitic form it possesses real value. Its protracted use in such cases does so modify the molecular condition of the tissues that they are less liable to inflammation, and the diathesis is, therefore, rendered milder or removed. From one to three teaspoonfuls, ac- cording to the age, should be given three times daily. While we frequently experience so much difficulty in administering it to adults affected with tuberculosis, and sometimes find it necessary to discontinue its use on account of its nauseating effect, scrofu- TREATMENT. 119 lous children rarely refuse to take it, and it does not seem to di- minisli their appetite. Iodine is justly celebrated as a remedy in the treatment of scrofu- lous aftections,but it is a qnestion whether it has not been overrated as a remedy for the diathesis itself. Iodine employed internally is especially serviceable in glandular hyperplasia, and in scrofulous thickening and induration of the connective tissue and periosteum. In general, it should not be administered to children in its isolated state, on account of its irritating properties, but one of its com- pounds should be employed. The compounds which are chiefly prescribed in the treatment of sci'ofula are the iodides of starch, iron, potassium, and sodium. If, as is frequently the case, the patient is pallid, and his appetite poor, the iodide of iron should be preferred; if not in this cachectic state, the iodide of starch. Pharmaceutists prepare syrups of both these iodides, so that they can be readily administered to the youngest child. The iodide of starch may be administered by dropping from one to five drops of the officinal tincture of iodine on a little powdered starch, and giving it in syrup. These iodides are preferable to the iodides of potassium and sodium for internal administration to children, as they are not irritating to the mucous membrane, and the iodine is readily set free. Prof. Dalton has, indeed, demonstrated that the iodide of starch is decomposed in most of the liquids of the body, and ^the iodine liberated. In this city a large proportion of the scrofulous children are cachectic, and need iron, and the iodide of iron is more frequently employed than any other iodine compounds. In the Out-door Department at Bellevue it is daily prescribed for the scrofulous children, and with the best results. It is taken readily, and for a lengthened period without producing gastric symptoms. To a child of six months we give at this institution one drop three times daily, and to one of two years three drops, with or without cod-liver oil. The internal use of mercury as an antidote for scrofula is now generally discarded. Unless, perhaps, in those cases in which the diathesis is immediately dependent on syphilis, its use for this purpose, from what we know of its therapeutic effects, would pro- bably be more injurious than beneficial. Walnut leaves, employed in various ways, either as a decoction, infusion, wine, or extract, have been highly extolled for the treatment of scrofula, but their use has not met with favor in the profession, and comparatively few can speak from their own observations of their effect. 120 SCROFULA. Among the medicines which have been from time to time em- l^loyed for the cure of scrofula, some of which have had consider- able reputation, but which have nearly fallen into disuse, may be mentioned sarsaparilla, elecampane, conium, digitalis, horseradish, and certain compounds of silver, gold, arsenic, baryta, and bro- mine. From what we know of the nature of scrofula, it is proba- ble that none of these has any effect upon the diathesis or upon scrofulous ailments, except such as improve the appetite and general health, like horseradish. The same hygienic measures are required in the treatment of scrofula as are demanded in the prophylaxis of it. The scrofulous affections require additional and special treatment. It would transcend the proposed limits of this paper to speak of the various measures, medicinal, mechanical, etc., which are de- manded for their cure. I shall only describe the treatment of the affection, which is especially characteristic of scrofula, namely, glandular hyperplasia. It is the common practice to treat these glands, if they are sub- cutaneous, by daily application over them of the officinal tincture, the compound tincture, or the compound ointment of iodine. It is my opinion, from observing the effects of these agents, that they are too irritating for ordinary cases. Applied daily, they cause proliferation of the cells of the epidermis, bo that in two or three days the thickening of the cuticle is greatly increased, and its ex- ternal layer begins to exfoliate. It has appeared to me that what we observe in the epidermis illustrates, to a certain extent, what occurs in the gland underneath, as a result of active counter-irri- tation. The gland does not resolve, its superfluous cells are not destroyed and absorbed, as was desired, but the treatment tends rather to increase the proliferation of the cells of the gland, or the formation in it of true leucocytes. We have seen that a local cuta- neous inflammation, as eczema or impetigo, is apt to cause the neighboring lymphatic glands to enlarge. How, therefore, can we expect to reduce a glandular swelling by a mode of treatment which establishes a similar condition. I once produced, partly by accident, such an amount of vesication over an enlarged, hard, and apparently somewhat indolent gland, in an infant of fourteen months, that for a week I was very anxious lest a sore would result, which would heal with difficulty, or leave a permanent cicatrix, and yet, instead of dispersion of the glandular swelling, the pathological processes were so promoted that suppuration and discharge of pus occurred by the time that the cuticle had re- TREATMENT. 121 formed. If hyperplasia of the lymphatic glands could be cured by counter-irritation, it should have been in this case. The correct mode of treating these glands, therefore, as regards external measures, I hold to be, to apply the iodine preparations in such a manner that the largest amount of iodine will reach the glands by absorption, with little irritation of the skin. I am not prepared to state what is the best formula for the application of this agent. During the last few months, we have been attempting to determine this in the children's class at the Out-door Depart- ment at Bellevue, but our statistics of cases are not at present suf- ficiently complete or numerous to enable me to make a positive statement. I feel justified, however, from the observations already made, in recommending the following formulae, as preferable to the ofiicinal preparations which are commonly employed: — 1st. R. Potas. iodidi 3j ; Ung. stramouii ^j. Misce. To be rubbed over the gland several times daily. It should not be applied as a plaster, as it is too irritating and will vesicate. I have known a glandular swelling, which had continued about three months, to disappear in as many weeks, under its use in connection with internal remedies. Glycerine may be employed in place of stramonium ointment. It makes a nicer preparation. 2d. R. Liq. iodinii compositi, Glycerinse, equal parts. To be applied three times daily with thorough friction, but less frequently if the skin becomes irritated. In place of Lugol's solution, tincture of iodine may be employed, with perhaps a little larger proportion of glycerine. One of the chief advantages from the employment of glycerine with the stronger iodine preparations is that it prevents to a great extent the shrivelling and desiccating efi^ect on the cuticle, rendering it soft and in a favorable state for absorption. 3d. R. Liquoris iodinii compositi §ss ; Aquse ^xv. Misce. To be kept constantly upon the skin over the gland by lint soaked with it, over which oil-silk may be applied to prevent evaporation. 4th. In the Medical Press and Circular of August 3d, 1870, J. "Waring Curran states that he has used with great success what he designates a new iodine paint, consisting of half an ounce of iodine, the same quantity of iodide of ammonium, 20 ounces of rectified spirits, and 4 ounces of glycerine. I have never employed it, but 122 TUBERCULOSIS. presume from its composition tliat it is useful. If too irritating, it can, of course, be diluted. Mercurial ointments have been recommended by writers of repu- tation for the treatment of these glands. I have employed them, and known them to be employed, but cannot say that I have ever observed any benefit from their use whatever. In the children's class at the Out-door Department at Bellevue we have discarded them entirely for this purpose, although both the citrine and white precipitate ointments, diluted with an equal quantity of lard, have been used with great apparent benefit for chronic coryza of a strumous nature, and also occasionally for external otitis of the same nature. In a paper read at the meeting of the British Medical Associa- tion in 1870, b}^ Mr. Jordan, the writer recommends, as attended with success, vesication, not over the gland, but at a little distance from it, as, for example, behind the neck, for treatment of the cer- vical glands. But a mode of treatment which seems so unlikely to be beneficial requires stronger proof of its utility than has yet been presented. "When the gland becomes actively inflamed, as indicated by in- creased heat and tenderness, and redness of the skin, applications of iodine are no longer proper. They increase the local disease. There is no longer any probability of resolution of the glands, and poultices should be applied. CHAPTER III. TUBERCULOSIS. Tuberculosis occurs at any period of life. It is, indeed, more frequent in early manhood than previously ; but it presents pecu- liar features in children, and especially in infants. Like most other general diseases, tuberculosis has a local manifestation which serves for diagnosis. This is a small, round, nearl}'^ transparent granula- tion, designated tubercle, which is developed within a tissue, or upon its surface. In certain situations it departs from its typical rounded form, and is more or less flattened. It is firm to the feel, and, when fully developed, varies in size from a pin's head to a small pea. It has recently, in its various phases, been studied with TUBERCULOSIS. 123 great interest by pathologists in Europe, and to a certain extent in this country, and tlieso investigations have already thrown con- siderable additional light on the nature of tuberculosis. The statistics of tuberculosis, previously to the last ten years, were not strictly accurate, since cheesy degeneration, of whatever part, was regarded by most pathologists as always a tubercular lesion, and its presence in the cadaver was therefore considered sufficient proof that the disease of which the patient died was tuberculosis, whereas it is now known to be, in many instances, a degenerated product of simple inflammation. I have records of the histories and post-mortem examinations of thirty-six cases of tuberculosis occurring under the age of five years, having rejected all cases of cheesy degeneration when not accompanied by other evidence of tuberculosis. Thus caries of the vertebrae, with cheesy substance in the bony excavations, I have not considered tubercu- lar. I have rejected one case in which three large cheesy bronchial glands lay in front of the carious vertebrae, inasmuch as there were no tubercles in the lungs or elsewhere. In another rejected case, the only lesions were empyema of the left pleural cavity, hyper- plasia, and cheesy degeneration of the bronchial glands, and a single large cheesy nodule in the right lung. Etiology. — The tubercular diathesis may be inherited. Hence the well-known fact of tubercular families. Cases are not infre- quent in which hereditary tuberculosis proves fatal before the death of the afiected parent. The offspring of a tubercular parent does not, as a rule, have tubercles at birth ; but the tubercular dia- thesis, at first latent as in syphilis, manifests itself in a few weeks or months in the formation of tubercles, and in the consequent cough and emaciation. In two cases, however, in my collection, a cough was observed, according to the statement of friends, as early as the second or third week. Under good hygienic conditions, the inherited diathesis may remain latent or be removed. If both parents are tubercular, the offspring almost necessarily becomes so. Tuberculosis frequently results from prolonged anti-hygienic conditions in those previously healthy and of healthy parentage. It may result from residence in damp, dark, and dirty apartments, from scanty or unwholesome food, protracted and exhausting dis- eases, in fine, from any agency which gives rise to great and con- tinued impoverishment of the blood. Age is a predisposing cause. Tuberculosis is comparatively rare under the age of one year, while it is not uncommon in wasted infants between the ages of two and five years. This remark is fully substantiated by the statistics of 124 TUBERCULOSIS. the llTursery and Child's Hospital and Infant's Hospital of this city. Is tuberculosis propagated by infection? Most physicians would answer in the negative, though in some countries, as in Italy, it is stated that the profession have long regarded it as mildly infec- tious. Every physician of experience must have remarked the frequency with which tuberculosis occurs in those not predisposed to the disease, but who have been in intimate relation with con- sumptive patients. This has been commonly regarded as due in no way to infection, but has been thought to be a coincidence, or has been attributed to an influence not fully understood, which the emotions or imagination exerts in the causation of diseases. But recent discoveries concerning the etiology of tuberculosis, which will presently be related, afl:ord ground for the opinion which some of our best authorities in the pathology of tuberculosis, as Wal- denburg, now hold, that minute particles exhaled or expectorated from the lungs may be the medium of infection. In December, 1865, M. Villemin read before the Academy of Medicine of Paris and published his celebrated memoir, which contained the results of his experiments in inoculating certain lower animals with tubercular matter. Since then the fact has been established by many experiments, that tubercle may be pro- duced in the rabbit and other animals by inserting under their skin various pathological products, whether tubercular or non-tubercu- lar, as gray tubercles, cheesy products, thickened pus, etc., and by inserting finely divided foreign substances, not animal, as aniline blue, and also by traumatic irritations which give rise to the for- mation of inflammatory products under the skin, as the use of a seton. The coloring matter, whether introduced alone or in com- bination with a pathological substance, is found in the tubercle which results in the lung-s or elsewhere. Therefore it is inferred tliat tubercle in these experimental cases is produced by minute particles of the inserted substance, which enter the circulation and are deposited in the lungs or other organs. "VYhere they are de- posited, inflammation (formative irritation) occurs, with prolifera- tion of the cellular elements of the part. This corpusculation produces the tubercle. The importance of these discoveries is apparent. Cheesy sub- stances produced in the system, whether in the lungs, lymphatic glands, bones — as in vertebral caries — or elsewhere, and also long- retained purulent collections, as in empyema, may give rise to ETIOLOGY. 125 tuberculosis, provided particles of the morbid substance gain ad- mittance into the circulation. Blood extra vasated in the alveoli of the lungs, and undergoing degenerative changes, is considered a cause of tuberculosis ; but such extravasations are rare prior to the age of puberty. Protracted inflammation of the air-passages, as bronchitis or laryngitis, is stated to give rise to tubercles in certain cases, but it is not easy to see how this could occur except when the inflammation has ex- tended to the lungs or given rise to cheesy degeneration of the con- tiguous glands. In infancy and childhood the common cause is a diathesis inherited, or acquired through impoverishment of the blood by previous disease or anti-hygienic conditions, or it is in- fection of the system from cheesy glands or purulent collections. Post-mortem examinations in connection with these recent dis- coveries demonstrate that the immediate cause of the formation of tubercles in the lungs, spleen, and other viscera, in certain cases, is hyperplasia and cheesy degeneration of the bronchial and mesen- teric glands, whether or not this glandular affection is To be con- sidered tubercular. Thus in the last two cases which I have ex- amined there were minute transparent tubercles in the lungs, some becoming yellow, evidently of very recent formation, and also in one of the cases in the spleen, while in both cases the bronchial glands were enlarged and cheesy, and in one also the mesenteric. In another case, occurring in the Child's Hospital, the bronchial and mesenteric glands were cheesy, with all the thoracic and ab- dominal viscera healthy, while there were granulations nearly the size of a pin's head, due to cell proliferatioii, as ascertained by the microscope (tubercular), in the pia mater at the base of the brain, along its sides, and between the hemispheres. Cases are less frequent, but are occasionally met, in which re- tained purulent collections appear to be the cause of the formation of tubercles. Thus, in 1870, I presented to the ISTew York Patho- logical Society the lungs, containing minute, recent tubercles, re- moved from an infant, who had died when a few months old. The lungs were otherwise healthy, and there were no cheesy glands, for which a careful examination was instituted; but in the left thigh was a large deep-seated abscess, which had been detected a month before death. Another, and probably the most frequent local cause of tubercu- losis, is cheesy pneumonia. Caseous degeneration of the inflam- matory products is common in young and feeble infants affected with pulmonary inflammation, and the supposition is reasonable 126 TUBERCULOSIS. that particles are more readily detached from a caseous mass in tlie lungs than in most other situations. Certainly, in this city, cases are not infrequent of young children presenting the history of pneumonia, cheesy degeneration, and finally tubercles, especially during epidemics of measles. General Anatomical Characters of Tuberculosis. — Analysis of the blood of tubercular patients shows an increase in the water, albumen, fats, and white corpuscles, and a decrease in the number of red corpuscles. The fibrin is slightly diminished, except in cases complicated by inflammation, in which it may be in excess. The chief interest, however, as regards the anatomical characters of tuberculosis, pertains to the tubercle. The tubercle is as cha- racteristic of tuberculosis as the eruption is of an exanthematic fever. It is produced, as already stated, by a local proliferation or corpusculation. It is, therefore, a cell-growth, and not a deposit. If we examine with a microscope a thin section of a recent tubercle, we will observe in its peripheral portion, in which pro- liferation was active at the time of death, large mother cells, spin- dle-shaped fibro-plastic cells, and small round cells, which have been released from the mother cells. This zone of proliferation often has considerable extent. Passing towards the central portion of the tubercle, we find these small round cells in great abundance. They represent a more advanced stage of the tubercle, since the central part is oldest. They are the most numerous cells in the tubercle, and they have been designated the tubercle cells. They resemble closely in appearance the smaller of the white corpuscles of the blood, and cannot be distinguished from the normal cells of the lymphatic glands, each consisting of a single large nucleus surrounded by protoplasm. They are among the most fragile of pathological cells. The cells are held together by a transparent adhesive substance, which is firm and resisting. Every tubercle tends to undergo a molecular change by which its transparence is lost. This consists in a decay of the cells and the intercellular substance. Granules of fat are deposited within them, and the cells shrivel and disintegrate. Fragments of cells, and shrunken cells, and cell-nuclei, are thus produced, which Lebert described as the tubercle cells, and which were accepted as such by all observers till Virchow ascertained their true character. The molecular change which I have described commences in the interior of the tubercle, and extends outward till the whole tubercle becomes opaque and yellow, and at the same time so friable as to be readily ANATOMICAL CHARACTERS. 127 crushed between the fingers. The yellow tubercle is therefore only an advanced stage of the gray semi-transparent. It is evident that tubercle in its first period possesses vitality, and, like all neoplasms, has its bloodvessels. These are soon closed by coagula or granular fibrin, mixed with white blood corpuscles. When the tubercle has reached the yellow transformation, its vessels are no longer pervious, but it is surrounded by a vascular zone, in which circulation continues. The subsequent history of tubercle is well known. It is seldom, perhaps never, absorbed. It softens, and henceforth, as has been said by a German patholo- gist, its history is that of an abscess. It is an irritant, producing inflammation in the surrounding tissues, with thickening and induration, and abundant production of pus cells, which mingle with the tubercle elements. Ulceration and discharge of the li- quefied substance upon one of the free surfaces is the common result. In exceptional cases, instead of softening, the tubercle may undero-o fibroid defeneration or cretification. Anatomical Characters in Infancy and Childhood. — The ana- tomical characters of tuberculosis in the first years of life vary in certain particulars from the form which they present in the adult, but after the age of three years the difterences are fewer and less pronounced than previously. Tubercular laryngitis, so common in the adult, is absent in a large proportion of cases under the age of three years, and when present has little intensity; and ulceration of the larynx very seldom occurs. This has been attributed to the fact that there is so little expectoration in young children, the sputum being an irritant. Niemeyer, however, does not consider the sputum of tuberculosis sufficiently irritating to cause laryngitis and laryn- geal ulceration ; but the arguments in favor of this mode of causa- tion, in my opinion, more than counterbalance those which have been presei^tecl against it. I have never met a case of tubercular ulceration of the larynx or trachea in the post-mortem examination of young children, nor do I recollect ever treating a case in which there was that degree of dysphonia which indicated ulceration. Rilliet and Barthez, in more than 300 necropsies of tubercular cases, found no ulcers in the larynx or trachea under the age of three years ; 8 cases between the ages of three and ten years, and 8 between ten and fourteen years. The ulcers, whether seated in the larynx or in the trachea — and they are in most cases in the former, since the inequalities upon the surface of the larynx favor the retention of the sputum — are 128 TUBERCULOSIS. commonly small, superficial, round or elongated, and with little thickening or inflammation of their borders. Occurring in the folds of the mucous membrane, for example, around the vocal cords, their form is usually elongated. Bronchitis is not infrequent. This inflammation is due to, and dependent on, the pulmonary tubercles, and is therefore most in- tense in the part of the lung where the tubercles are most abundant and furthest advanced. Consequently it is more intense on one side than on the other, and it may be unilateral. It differs in this respect from idiopathic bronchitis, which is commonly pretty uniform on the two sides. It differs also in the fact that it is sometimes accompanied by ulcerations. The ulcers are round or elongated in the direction of the axis of the tubes, and, like those of the larynx or trachea, are superficial. Idiopathic bronchitis of infancy and childhood does not cause ulceration. Circumscribed inflammation may attack a bronchial tube, as, indeed, the trachea, and gives rise to ulceration and perforation, from the presence and pressure of a diseased lymphatic gland external to the tube. This subject will be treated of hereafter. Lungs. — It is well known that in the adult tubercles are alwavs present in the lungs, if they occur in any part of the system. I have met two cases in which the lungs w^ere free from tubercles in 36 post-mortem examinations of children who died of tuberculosis. One of the two was an infant, but its exact age is not stated in the records. It had cheesy degeneration of thymus and bronchial glands, enlargement of mesenteric glands, but without cheesy de- generation, and disseminated tubercles in liver and spleen. The other, fifteen months old at death, had tubercular meningitis, with numerous granulations upon the convexity of the brain, and the other usual lesions of meningeal inflammation, with bronchial and mesenteric glands slightly enlarged and cheesy, and one of the former softened. In one case, then, in 18, the lungs had escaped the disease. Rilliet and Barthez state that they found the lungs non-tubercular in 47 cases in 312, and Ilillier did in 25 cases in 160. In their cases, therefore, the lungs were exempt from tubercles in about 1 case in 7. But it is to be recollected that the statistics of these observers were prepared at the time when all chees}' degene- rations were thought to be tubercular, and the bronchial and mesenteric glands are sometimes cheesy when there are no tuber- cles or lesions referable to tuberculosis in any other part of the system. I have records of two such cases, which I reject from my statistics of tuberculosis, as there is no evidence that the disease LUNGS. 129 was anything else than simple inflammation. Did I include these cases, my statistics would correspond with theirs. I'ulmonary tuhercles in children under the age of tliree years are, as a rule, discrete, and disseminated through the lungs. In cases at this age, which have advanced to a fatal termination, we commonly find yellow tuhercles from the size of a pin's head to a shot in the different lobes, many still semi-transparent if the dis- ease has been of short duration, but if protracted most of them yellow, and here and there one softened and surrounded by con- densed fibrous tissue. Around the semi-transparent or gray tuber- cles, many of which were growing, and therefore were in the state of active cell proliferation at the time of death, narrow vascular zones can often be detected by the naked eye. Under the age of three years, tuberculosis exhibits but little tendency, perhaps none, to aflect the upper lobes sooner or in greater degree than the lower. The following are the statistics relating to the site of the tuber- cles in the lungs in the cases which I have examined. All, it is to be remembered, were under the age of three years: — • Cases. Tubercles disseminated throughout the lungs . . .26 Tubercles disseminated throughout the two upper lobes . 3 Tubercles disseminated through right middle lobe and left lower lobe only 1 Tubercles disseminated through left upper lobe only . . 3 Tubercles disseminated (few and semi-transparent) in left lung only 1 Tubercles disseminated in three points in right, and two in left lung 1 No tubercles in lungs 3 36 Between the ages of three and fifteen years, statistics show that the upper lobes are more liable to tubercles than the lower ; but the difierence in liability is not great. In many cases occurring in this period, the difl:erent lobes are aflected nearly simultaneously, and not very infrequently the upper lobe is the last which is in volved. In October, 1866, I made the post-mortem examination of a boy who died in the Children's Service of Charity Hospital, at the age of fifteen years, and small scattered tubercles were found in the lower lobe of the left lung, while all other portions of these organs were healthy. Rilliet and Barthez, who include in the same statistics all cases from birth to the age of fifteen years, found gray semi-transparent tubercles 9 130 TUBERCULOSIS. In the right superior lobe in In the right middle lobe in In the right lower lobe in In the left superior lobe in In the left inferior lobe in The same observers found yellow tubercles in the Cases. 63 43 55 65 54 Right superior lobe in 40 Right middle lobe in 28 Right inferior lobe in 89 Left superior lobe in 35 Left inferior lobe in 31 It has already been stated that tubercle originates in a circum- scribed inflammation. On the other hand, tubercle, especially when softening commences, is itself an irritant, exciting inflammation around it. Inflammation occurring from this cause is obviously likely to be protracted, continuing for weeks or months, unless the tubercular matter is eliminated by ulceration. The highly vascu- lar and delicate lungs of the young child are very liable to inflam- mation when they are the seat of tubercles, and as the tubercles are disseminated, the pneumonia is commonly more extensive than when it occurs from ordinary causes. In fifteen, or nearly one- half of the cases, there was pneumonia affecting portions of one or more lobes, or an entire lobe. From the extent and position of the solidified portions, it was obvious that in most cases the inflamma- tion originated from the irritating effect of the tubercular matter, while in others it was due to hypostatic congestion, occurring in consequence of the long-continued recumbent position and the fee- bleness of circulation. In these fifteen cases the seat and extent of the inflammation were as follows: — Nearly entire right lung .... Nearly entire middle and lower lobe Entire left upper lobe .... A considerable part of both lungs . Posterior parts of both lower lobes Posterior part of left lung Left lower lobe, and right middle and lower lobes Left upper lobe (contained a large cavity) and posterior part of left lower lobe Nodules of inflamed lung around tubercles Cases. 3 1 3 1 4 1 1 1 3 The inflammation in about one-third of the cases was due to hypo- stasis, as it occurred in depending portions, extended but little into the lungs, and sustained no relation to the amount of tubercle. It was in the stage of red, or more rarely of gray, hepatization. LUNGS. 131 In seven of the cases there were pulmonary cavities as large in proportion as we ordinarily find in tuberculosis of the adult. The seat of one was in the right lower lobe ; of two, the left upper lobe ; of one, the right upper lobe ; of another, the right lung, its exact seat not stated; and in the remaining case the cavity, which was the largest of all, occupied the interior of all three lobes on the right side. Some idea of the size of these cavities may be learned by the following extracts from the records. 1st Case. — " A small superficial cavity communicating on one side with a bronchial tube, and on the other side with a small circumscribed collection of pus in the pleural cavity." 2d Case. — "Cavity of the size of a hickory-nut." 3d Case. — "Cavity of the size of a large hickory- nut." 4th Case. — "Cavity three-fourths of an inch in diameter." 5th Case. — "A large abscess." 6th Case. — "The cavity occupied nearly the whole of the interior of the left upper lobe." 7th Case. — " About half the right lung excavated into a cavity which ex- tended through the three lobes." Circumscribed pleuritis, produced by tubercles underneath the pleura, was observed in seven cases. It was ordinarily attended by little exudation except the fibrin, but in one case a suflicient amount of serum had been exuded to compress considerably the lung. Pus was not observed in any notable quantity. Emphysema was present in several cases, chiefly in the upper lobes, sometimes vesicular, with fulness or bulging of the lung, an ansemic appearance of it, and doughy, inelastic feel. In other cases emphysema was interstitial, producing little bladders of air under the pleura, especially towards the root of the lung, or sepa- rating the lobules by wedge-shaped or irregular interspaces filled with air. In one case air had escaped from an emphysematous bladder into the right pleural cavity, causing pneumothorax and collapse of the lung, 'Next to the lungs, the bronchial glands are more frequently dis- eased than any other organs, in the tuberculosis of infancy and childhood. They undergo the successive structural changes which characterize glandular inflammations, namely, hyperplasia, and more or fewer of them cheesy degeneration and softening. In the state of hyperplasia the firmness is diminished, and they have a pale flesh-color. Cheesy degeneration commences in one or more points in the gland, sometimes in the peripheral, sometimes in the central portion, and it extends till the whole gland presents the well-known cheesy appearance. When the gland softens, the thick liquid presents a puriform appearance, consisting of amorphous 132 TUBERCULOSIS. matter, fatty particles, and the shrivelled and disintegrated cells of the gland. Soon pus cells occur, and their number increases. Microscopy shows no anatomical difference between the hyper- plasia or cheesy degeneration of the lymphatic glands occurring from inflammation, and that from tubercle ; but since the bronchial and mesenteric glands are not often cheesy or greatly hyperplastic from simple inflamriiation, and are commonly not only greatly enlarged but chees}^ in the tuberculosis of young children, we con- clude that the inflammation which gives rise to this hyperplasia and degeneration in such cases is of a tubercular character. Rilliet and Barthez state that the bronchial glands were tuber- cular in 249 cases in children, while the lungs were tubercular in 265 cases. All cheesy glands, it is to be recollected, they consi- dered tubercular. In 4 of the 36 cases which I have examined, no record was preserved of the state of the bronchial glands ; in one case there was no perceptible hyperplasia and no cheesy degenera- tion; in two there was hyperplasia, but no cheesy degeneration, while in the remaining twenty-nine cases there was cheesy degen- eration of more or fewer of the enlarged glands, or parts of them, with occasional softening. In the fact that the bronchial glands are tubercular and enlarged, we have an explanation in part of the fact, that the symptoms in the tuberculosis of young children differ from those in the adult, since Louis found the bronchial glands tubercular in only twenty-eight per cent, of the adult cases of tuberculosis which he examined, and Lombard in only nine per cent. A gland pressing upon the recurrent laryngeal or pneumo- gastric nerve, or the trachea, may give rise to dyspna-a and a cough ; or on the descending vena cava or one of the vense innominatse, to congestion of the brain and meninges, intra-cranial serous effusion, and even thrombosis in the cranial sinuses. The fact that a soft- ened bronchial gland not infrequently is eliminated from the sys- tem, by ulceration, into a bronchial tube or the trachea, is well known. In one case which I observed the ulceration had destroyed portions of three of the cartilaginous rings of a bronchus, and the aperture was plugged by a cheesy fragment of a softened gland Avhich protruded. Occasionally, it is stated by authors, the ulcera- tion is into one of the large vessels of the mediastinum, or even into the oesophagus. In no case did I find tubercles in the heart or pericardium, though they have been observed in rare instances in the latter. The mesenteric glands were enlarged by hyperplasia, and more or less cheesy, in 30 cases; in their normal state, to appearance, in ABDOMINAL VISCERA. 133 two cases, and in the remaining four cases their condition was not stated. In most of the cases the mesenteric glands were smaller and less cheesy than the bronchial, but in a few instances they were larger than the bronchial and more cheesy. 'It is a noteworthy fact, as bearing on the causative relation of these glands to tubercles, that not infrequently the amount of hy- perplasia and cheesy degeneration of the former was very consi- derable, while the tubercles in the lungs or elsewhere were small, even minute, semi-transparent, and evidently of recent formation. Abdominal Viscera. — In children, tubercles in the solid organs of the abdomen rarely give rise to appreciable symptoms, as they are small and disseminated, not impairing materially the function of the part in which they are located. On the other hand, peritoneal and intestinal tubercles, and the enlarged and cheesy mesenteric glands, give rise to symptoms which require description. The most frequent seat of peritoneal tubercles is upon the attached surface of the peri- toneum, where they are formed from the connective tissue. They are distinctly seen through the peritoneum, and cause some pro- minence of it. Exceptionally their seat is upon its free surface. Every portion of the peritoneum, whether visceral, parietal, or omental, is liable to tubercles, but general tuberculization of so extensive a surface does not occur in any one case. The tubercles are spherical or lenticular, and most of them small. Sometimes they are very numerous, but so minute as to be scarcely visible. They are gray or yellow, according to the age. Peritoneal tuber- cles often produce circumscribed peritonitis, causing adhesion of opposite surfaces. The tubercles in themselves cannot be detected by palpation ; but masses or jjlaques composed of tubercles and in- flammatory products are sometimes so large that they can be felt through the abdominal walls. The symptoms of peritoneal tuberculosis are attributable, for the most part, to the peritonitis. Among them may be enumerated abdominal tenderness or pain, meteorism, ascites — usually slight — and derangement of the bowels, commonly diarrhoea. As tuber- cles in this situation occur, in most cases, subsequently to tuber- cles elsewhere, the symptoms which have been described are asso- ciated with and are subordinate to others. Stomach and Intestines. — The most common seat of gastro-intes- tinal tubercles is the small intestine, and more frequently its lower portion, near the ileo-coecal valve, than its upper or central. They are rare in the duodenum or contiguous part of the jejunum. They 134 TUBEECULOSIS. are developed ordinarily in the connective tissue, either that lying under the mucous or the serous surface. Gastro-intestinal tubercles are often accompanied by ulceration of the adjacent mucous membrane. But in a certain proportion of cases there is probably no causative relation of the tubercles to the ulcers, for ulceration of this membrane is not infrequent in the tuberculosis of children, when there are no tubercles in the walls of the stomach or intestines. The following statistics of Rilliet and Barthez, relating to this point, will aid in an under- standing of the symptoms: — Tubercles in walls of stomach, 7 cases, { ^'^^ "^^^^•^' ^ ^^«^^- I without " 1 case. Ulcers of gastric mucous membrane, without gastric tubercles, 14 cases. Tubercles in small intestines, 82 cases, | ^^*^ "^^"■'' ^^ ^^'^'• (without " 12 " Ulcers without tubercles in small intestines, 51 cases. Tubercles in large intestine, 15 cases, -j ^^*^ ^^'^^^«' ^^ *^^^^^- (without " 5 " Ulcers in large intestine, without tubercles, 47 cases. The ulcers have vascular, thickened, and infiltrated borders. Their diameters vary from a line to half an inch or more, and their general form is circular, or, if two or more unite, irregular. Tuber- cular ulcers of the stomach are mostly in the great curvature, those of the small intestines in the ileum and lower part of the jejunum, and those of the large intestine in the ccecum. The following table exhibits the state of the principal abdominal viscera in the 36 cases: — Liver. Spleen. Kidneys. Tubercular 12 23 1 Non-tubercular 16 6 21 Not stated 8 8 14 Fatty 5 In no instance did I observe tubercular softening in the abdomi- nal organs, and a large proportion of the tubercles in the liver, spleen, and kidneys were still in the first stage. In the five cases in which the liver was recorded fatty, this state of the organ was obvious to the sight, as it is in tuberculosis of the adult. A moderate excess of fat in the heiDatic cells may have been present in some of the other cases, but it was not sufiicient to be apprecia- ble without the microscope. It is to be remarked that in the five cases in which the liver was recorded fatty, this organ contained no tubercles. The spleen is seen to have been the most frequent seat of tubercles of all the viscera, except the lungs. In fourteen cases SYMPTOMS. 135 the intestines were examined; and in five, tubercles discovered developed in the connective tissue. The intestinal tubercles were small, and ulceration had occurred of the mucous membrane which covered them. The brain was examined in fifteen cases. In twelve cases the amount of cerebro-spinal fluid varied from ^ss to v, by estimation. In two others the records state that there was a considerable amount of this fluid, the exact quantity not being given, while in the re- maining case congestion of the brain and meninges was noticed, but nothing was recorded in regard to the amount of cerebro- spinal liquid. The increase of the cerebro-spinal fluid in tubercu- losis is attributable to wasting of the brain, a hydrocephalus ex vacuo, and in some cases to passive congestion and serous transuda- tion, due to feeble circulation, or obstructed flow from the pressure of bronchial glands on the vessels within the thorax, as already stated. Tubercles were present in the pia mater in three cases: in two with fibrinous exudation; in the other without fibrin or other evidence of inflammation. Symptoms. — The symptoms in tuberculosis of children arise in part from the diathesis, and in part from the tubercles. Before the period of tubercles, there are signs of failing health, such as loss of appetite, flabbiness of the soft parts, or emaciation, lassi- tude, and loss of strength. These symptoms continue after the formation of tubercles, and increase. The features are ordinarily pallid, but during the paroxysms of fever, to which tubercular patients are subject, they may be flushed. Lividity of the features, due to imperfect decarboniza- tion of the blood, occurs, if there are enlarged bronchial glands which compress the vessels within the thorax, or if there is ex- tensive pulmonary tuberculization, or pulmonary tuberculization, whether extensive or not, which is complicated by capillary bron- chitis or pneumonia. The skin is nearly natural, or it loses its flexibility and softness, and becomes dry and rough. In some patients there is, at times, general or partial furfuraceous desquamation of the skin, due to exaggerated development of the epidermis. Children, like adults, notwithstanding the general dryness of the surface, are liable to perspirations at night and in sleep. This symptom is less frequent at the commencement than at an advanced period, and in acute than in chronic cases, in the very young, namely, those under three or four months, than in older children. It is more abundant about 136 TUBEECULOSIS. the head and limbs than elsewhere, and is sometimes confined to these parts. Anasarca is not infrequent. It sometimes arises from obstructed circulation, in consequence of compression of the thoracic vessels by enlarged lymphatic glands ; in other cases it is due to dimin- ished plasticity of the blood, a result of the tubercular cachexia. The latter is the more common cause. It is not an important symptom, on account of the small amount of serous transudation, and the character of the parts in which it occurs. Emaciation, already alluded to, is early, constant, and progres- sive. Under the age of six or eight months it is less marked than in older children, many preserving considerable rotundity of fea- tures and form even in advanced tuberculosis. The failure of the strength corresponds in amount and progress with the emaciation. Slight at first, and exhibited only by a degree of lassitude, it gra- dually increases, till for weeks before death the little patient is fatigued by the ordinary muscular movements, and is disposed to keep quiet. The nervous system is not ordinarily affected except in cases of intra-cranial tubercles. In acute tuberculosis, or tuberculosis com- plicated by severe inflammation, there may be agitation and deli- rium, especially at night. In most patients the mucous membrane of the buccal cavity presents its normal appearance, with the exception of a moist fur upon the tongue, and a paler hue than normal of its surface gene- rally. In acute tuberculosis, and in cases complicated by inflam- mation, the tongue is sometimes dry and brown. The appetite may be normal till the close of life, or it is j)Oor or changeable. Occasionally it is increased, although the disease is progressing. The bowels are regular or relaxed. Diarrhoea may be a prominent symptom, even when there are no intestinal tubercles or ulceration. Meteorism and fulness of the abdomen are common. Fever, constant, but usually with evening exacerbations, is rarely absent. It continues for weeks or months. During the exacerba- tion the pulse rises to 120, 140, or even to 180 beats per minute, and there is a corresponding exaltation of the temperature, which in the latter part of the day, without inflammatory complication, ranges from 100° to 102° or 103°. The fever is a symptom of diagnostic value as regards the nature of the disease, though it does not indicate the seat of the tubercles. In addition to the symptoms noAv described, there are special symptoms, due to tuberculization of the different organs. In young SYMPTOMS. 137 children, on account of the fact ah-eady referred to, namely, the tendency to a generalization of tubercles, there is apt to be a blend- ing of the symptoms which arise from different organs, but with care it is not difficult in most instances to isolate and refer them to their proper source. The following are the symptoms which arise from tuberculization of the more important organs. 1st. En- CEPHALON. The symptoms produced by tubercles of the encephalon vary according to their seat and size, and the structural changes in surrounding parts to which they give rise. Meningeal tubercles, which are located for the most part in the meshes of the pia mater, and by preference along the course of the small arteries, are ordi- narily small, not more than a line in diameter, and they may remain latent for a considerable time. In the majority of cases, however, they sooner or later cause meningitis, the symptoms of which are well known and need not be described. But tubercles in this situation do sometimes give rise to symptoms when there is no meningeal inflammation. They occasion congestion of the sur- rounding vessels, and serous transudation-, and if developed on the under surface of the pia mater they may produce symptoms by encroaching upon and irritating the brain ; for they are sometimes so much imbedded in the convolutions that careful examination is required in order to determine that they are meningeal, and not cerebral. Among these symptoms may be mentioned headache, frontal or occipital, sometimes intermittent, nausea, melancholy, and in certain cases the symptoms produced by the serous transu- dation. The symptoms of cerebral are in part similar to those of menin- geal tubercles, but in most cases others of a neuropathic character are present, which serve for differential diagnosis. The differences as regards the symptoms of dift'erent patients affected with cerebral tubercles are attributable in part to the fact that their size and rapidity of growth vary, but more to the difference in their seat; for any part of the brain may be the seat of tubercles, though cer- tain portions, as the cerebellum, are more frequently affected than others. The child with cerebral tubercles is quiet, but irritable and easily excited. Delirium is not common, but many before the close of life exhibit a degree of mental dulness. The headache, common in cases of cerebral as well as meningeal tubercles, may be nearly general, or it is frontal, parietal, or occipital, according to the seat of the tubercles. It is often lancinating, often intermittent. Clonic convulsions occur towards the close of life. Exception- 188 TUBERCULOSIS. ally they are among the earliest symptoms. Observations have failed to establish any relation between the seat of the tubercles and the localization of the convulsions. The convulsions may be unilateral, while the tubercles are in both hemispheres ; or general, while the tubercles are on one side only. The severity and duration of the convulsive attacks, and the frequency of their occurrence in tuberculosis of the brain, vary greatly in different patients. They have been attributed to soften- ing of the cerebral substance, which sometimes occurs immediately around the tubercles, to local congestions excited by them, and also to serous effusion in the ventricles. The convulsions, sooner or later, end in paralysis or coma. Contraction^ or tonic convulsion of certain muscles, is sometimes observed. Its most frequent seat is the muscles of the back, and of one or both of the lower extremities. It is a late symptom. It occurs in those cases in which there is softening around the tuber- cles, and usually in the muscles of the opposite side. Paralysis is also a late,' but not an unfrequent symptom. It is preceded by headache, and sometimes, as already stated, by con- vulsions. Occurring as a symptom of tuberculosis of the brain, it is due either to pressure on a cranial nerve, or to compression and perhaps softening of the cerebral substance. The paralysis may be paraplegic, commencing as feebleness of the lower extremities, and increasing until it becomes complete, or a more or less complete hemiplegia. In paraplegia due to tubercles of the brain, the cere- bellum is, as a rule, their seat, while paralysis of one side, or of certain muscles of one side, indicates tubercles of the opposite cere- bral hemisphere ; but there are exceptions. Paralysis of the third cranial nerve gives rise to ptosis, of the sixth to paralysis of the external motor nerves of the eye, and therefore to internal stra- bismus. Feebleness or loss of vision, inequality, oscillation, and finally dilatation of the pupils, are not infrequent symptoms of tubercu- losis of the brain, and they possess great diagnostic value. Atrophy of the optic nerve, causing amaurosis, sometimes results from tuber- cles as well as other tumors of the brain. Atrophy of this nerve occurs not only when the tubercles are so located as to press on the optic tract, in which case the explanation is apparent, but also, in certain patients, when the tubercles are in other parts of the brain. In these last cases it is thought by Brown-Sequard and others that the imperfect nutrition of the nerve is due to contraction of its nutrient vessels, produced by the tubercles through reflex action. BRONCHIAL GLANDS. 139 111 tuberculosis of tlio brain, symptoms pertaining to the respira- tory, circulatory, and digestive systems arc either absent or are quite subordinate to those of a neuropathic character. Slowness of the pulse, with or without intermittence, has sometimes been observed, and it is therefore a symptom of some diagnostic value. Towards the close of life both pulse and res2')iration are apt to be accelerated. Vomiting, constipation, and retraction of the abdo- men, which are so common in meningitis, are only occasional symptoms. Bronchial Glands. — During the progress of tuberculosis, hyper- plasia, cheesy degeneration, and softening may occur of various lymphatic glands throughout the body, but the bronchial and mesenteric are not only those which are most frequently affected, but they are the only glands, unless in exceptional instances, which materially increase the danger or give rise to special sj^mptoms. These symptoms either have a mechanical cause, namely, the pres- sure exerted by the enlarged glands on contiguous parts, or they are due to softening of the glands and consecutive inflammation and ulceration. The following are the principal symptoms due to compression. Some of them are not infrequent ; others are rare. Compression of the pulmonary veins retards the flow of blood from the lungs to the left auricle, giving rise to congestion, and, in extreme cases, oedema of the lungs, with sanguineous extravasations into the lung substance, congestion of the right cavities of the heart, hepatic veins, and of the systemic capillaries generally. Compression of the pneumogastric nerve, or of the recurrent laryngeal, which is the motor nerve of the laryngeal muscles, produces a cough which is apt to be spasmodic, and modifies the voice. The cough resem- bles that of pertussis, and has been mistaken for it, but it is not so violent or protracted. The voice, clear and natural at first, becomes by degrees hoarse or feeble from deficient innervation of the laryn- geal muscles. An enlarged gland, or mass of glands, lying against the trachea or one of the bronchial tubes (this may occur with tubes up to the third or fourth division), and pressing its walls inward, obviously obstructs more or less the current of air. If there is considerable obstruction, a loud sonorous rale is produced, which is heard dis- tinctly at a distance from the chest, obscuring other rales. It is loudest when the patient is agitated, and it sometimes intermits. Feeble respiratory murmur, dyspnoea, and a cough are not infre- quent in bronchial phthisis. Diminished intensity of the respira- 140 TUBERCULOSIS. tory murmur is general or partial, according to the seat of the com- pression. It has been most frequently observed at the summit of the lungs. In certain patients this symptom is not constant, the respiration being for a time feeble and then normal. The dyspnoea may be a prominent and distressing symptom, the alee nasi dilating, and the infra-mammary region sinking with each inspiration. The cough which occurs when a gland presses on the trachea or bron- chial tube, is due to the tracheitis or bronchitis to which the pres- sure gives rise. If ulceration occur at the point of pressure, the cough continues as long as the ulcer remains. Compression of the large veins within the thorax, which return blood from the head and upper extremities, causes more or less congestion of these parts, with, perhaps, transudation of serum in the subcutaneous cellular tissue, and within the cranium. Rarely a softened gland by ulcera- tion gives rise to other symptoms than those mentioned, namely, hemorrhage by ulceration into a vessel, or pleuritis or pneumonitis if the ulceration is towards the lungs. Improvement in the condition of the patient affected with bron- chial phthisis is not unusual. It may be permanent, but in most patients it is temporary, so that in a few weeks or months the symptoms are as severe as before. The improvement is due to soft- ening and elimination of a gland which had given rise to symp- toms by its mechanical effect, or by the inflammation which it had excited. Physical Signs. — These are absent or obscure in the inciyuent disease, when the glands are small, and they are most marked in those cases in which the glands are so large as to press on the thoracic walls, since the glands then become the medium for the transmission of sounds to the ear. The part of the thorax against which they most frequently press is the dorsal vertebrae, from the first to the sixth, and each side of the vertebrae, and less frequently the upper third of the sternum. The physical signs are dulness on percussion over the interscapular space, and perhaps, though to a less extent, over the upper part of the sternum, and bronchial respira- tion in the same situations. Occasionally a bruit can be detected, due to the pressure of a gland on one of the large vessels of the chest. Lungs. — A cough is one of the earliest and most persistent of the symptoms of pulmonary tuberculosis. It is so rarely absent, that those of largest experience do not meet with more than one or two such cases. It varies in severity and frequency. If the tuberculosis is acute and its course rapid, the cough, even from its PHYSICAL SIGNS. 141 comincncerncnt, is frequent, so as to weary the patient and deprive him of needed rest. But in ordinary cases, namely, when the din- ease is chronic, the cough commences gradually, attracting little attention by its infrequency, but becoming more frequent and painful as the disease advances. Ordinarily the cough is dry in the first weeks or months, but it becomes looser in the course of the disease, from the greater amount of bronchial inflammation. In exceptional instances the cough has a spasmodic character, like that produced by pressure of an enlarged bronchial gland on the pneumogastric or recurrent laryn- geal nerve. This occurs from the accumulation of viscid mucus in one or more of the bronchial tubes, usually in dilated portions of them, from which it is with difliculty expectorated. The respiration in pulmonary tuberculosis is accelerated in pro- portion to the degree of tuberculization. Tuberculization of a considerable part of both lungs gives rise to dyspnoea, especially when, as is ordinarily the case, bronchial, pulmonary, or pleuritic inflammation has supervened. Pneumonitis or pleuritis gives rise to the expiratory moan, and as these inflammations, when induced by tubercles, are protracted, this symptom may continue for weeks or months. Patients under the age of six years do not expectorate, or but rare\y. After this age expectoration is not common in the com- mencement of pulmonary tuberculosis, but in the confirmed disease it is a pretty constant attendant of the cough. Hpemoptysis is also rare under the age of six years, and less frequent subsequently than in the adult. It is most apt to occur in those cases in which there is already passive congestion of the lungs, produced by the pressure of enlarged bronchial glands in the manner already described. Patients old enough to make known the subjective symptoms, sometimes complain of fugitive pains under the sternum or between the shoulders. Physical Signs. — In young children the physical signs of in- cipient pulmonary tuberculosis are wanting, or are so obscure as not to be readily recognized. This is due to the small size and dissemination of the tubercles. In older children, because, as a rule, the tubercles are aggregated, and are more frequently at the apices of the lungs than elsewhere, as in the adult, the physical signs api^ear early, and are readily recognized. In the advanced disease, whether in infancy or childhood, when inflammation and more or less destruction of the lung substance have occurred, the physical signs, so far from being obscure, enable us in most cases, 142 TUBEECULOSIS. in connection witli the history, to make an immediate and positive diagnosis. In most children affected with pulmonary tuherculosis the irregular and imperfect expansion of the lungs produces by de- grees changes in the shape of the thorax, which are apparent on inspection. In some, the lungs being habitually imperfectly inflated, the obliquity of the ribs is increased, and the thorax consequently elongated, while its antero-posterior and transverse diameters are diminished. This obviously increases the convexity or arch of the diaphragm, so that this muscle sometimes lies against the thoracic walls as high as the ninth or even eighth rib. If the costal cartilages are yielding, there is anterior flattening of the chest and depression of the sternum; if they are firm, on account of the more advanced age, the chest remains circular. Another shape of the thorax is not infrequent in feeble tuber- cular children, especially infants, who have suffered from repeated attacks of bronchitis. It occurs also in the non-tubercular, if the conditions which favor it are present. The conditions are, on the one hand, feebleness of the patient, with diminished force of respi- ration and impaired resiliency of the ribs; and, on the other, ob- struction by mucus of one or more of the bronchial tubes. Occlu- sion, more or less complete, of a bronchial tube, and consequent obstruction to the current of air, produces a corresponding degree of collapse in the portion of lung to which the tube leads. The portions which collapse are, in most cases, the lower lobes, and the thin anterior margins of the upper lobes. This causes lateral de- pression of the lower ribs, except such as are pressed outward by the abdominal viscera, and an anterior projection of the lower part of the sternum. The shape of the thorax in these cases differs from that in rachitis, in the fact that the lateral depression does not extend to the uj^per ribs, nor does the upper part of the sternum project. Certain precautions should be observed in examining the chest by percussion and auscultation. The child should sit or recline, with the arms and shoulders in the same position, and the axis of the trunk straight. Inclination of the trunk to either side, raising or depressing a shoulder, may produce an appreciable difference in the two sides as regards the physical signs. Percussion of the two sides should be practised at the same stage of respiration. A slight difference in the degree of resonance does not afford proof of disease, unless it is observed at different examinations ; for in feeble children it often happens that all portions of the lungs do not ex- PLEURA. 143 pand alike, so that where we liave noticed sliglit dulness at one visit, it may by the next have disappeared, or even at the same visit if forcible inspirations are excited. The physical signs ascertained by palpation, auscultation, and percussion are, as in the adult, vocal fremitus, bronchial respiration, bronchophony, and dulness on percussion. In those cases in which the tubercles are mainly at the apices of the lungs, diminished ex- pansion of the infra-clavicular region is observed during inspira- tion, and this part of the thoracic wall is permanently depressed, so that the clavicles are unusually prominent. If there is emphy- sema, this flattening does not occur, or is slight. Dulness on per- cussion, though more frequently observed in the infra-clavicular region than elsewhere, may be present in different isolated places. If pneumonia supervene, the dulness not infrequently extends over a considerable part of one lung. The crack-pot sound is often observed on percussion, but it possesses no diagnostic value. It can be produced, when there is no pulmonary disease, by percussing over a bronchus. Bronchial respiration and bronchophony are important signs, as indicating solidification of the lung, but they do not show whether the solidification is tubercular or pneumonic, or the two conjoined. This must be determined by the history of the case, the extent of surface over which these signs are heard, and their persistence. When the tubercles begin to soften, and the lung tissue breaks up, moist rales appear, often hoarse and gurgling, obscuring the bron- chial respiration. A cavity in the lung, or pneumothorax, is attended by the same physical signs as in the adult. Pleura. — Little need be said in reference to the symptoms and physical signs of tuberculosis of the pleura, since this aftection is in most instances associated with tuberculosis of the lungs, and is not distinguishable from it. But now and then the pleural tuber- cles are numerous and large, giving rise to, symptoms, while those of the lungs are small, few, and without symptoms, or attended by symptoms which are quite subordinate. Either the costal or vis- ceral portion of the pleura may be the seat of tubercles. They are developed directly under the pleura, or upon its free surface. They are very apt to occur in the newly-formed connective tissue which results from pleuritis. Those located upon the free surface, or under the costal pleura, rarely soften, while those under the visceral pleura sometimes soften and cause ulceration. Occasionally nu- merous aggregated tubercles form a firm continuous layer upon the surface of the pleura, preventing, if upon the visceral pleura, full 144 TUBEKCULOSIS. expansion of the lung. This may give rise to a degree of diilness on percussion, and feebleness of the respiratory murmur. Ordi- narily, however, in this form of tuberculosis, the symptoms and physical signs, so far as any are observed, are due to the pleuritic inflammation which the tubercles excite. Stomach and Intestines. — The symptoms in tuberculosis of the stomach and intestines vary according to the seat and stage of the tubercles. Tubercles, whether gastric or intestinal, are not at first accom- panied by symptoms, or the symptoms are obscure and ill-defined. S3'"mi3toms arise when inflammation occurs in the adjacent tissues. Diarrhoea is one of the most common and persistent of the symp- toms. The alvine discharges are brown and thin, and sometimes in advanced cases very oft'ensive. They may be streaked with blood which has escaped from the ulcers. Intestinal tubercles, de- veloped immediately underneath the peritoneal coat, sometimes cause local peritonitis, usually of little extent. This gives rise to circumscribed pain, tenderness, and more or less meteorism. Diagnosis. — It is evident from the foregoing description of symptoms that the diagnosis of incipient tuberculosis is much more difl&cult in children than adults. Before commencing the examination, it is advisable to learn the hereditary tendencies of the family and the history of the patient, especially as regards antecedent diseases or debilitating agencies, and the duration of the symptoms. Tuberculosis of the encephalon is diagnosticated with more difficulty than that of the thoracic or abdominal organs ; but certain of these organs are in most cases tubercular at the same time, and the knowledge of the fact that they are aftected aids in the diagnosis of the disease of the brain or its meninges. Among the symptoms which possess diagnostic value may be mentioned ' cephalalgia and more or less fever, with exacerbations in the com- mencement of the disease, and at a more advanced period strabis- mus, inequality or irregular action of the pupils, impairment of vision, retraction of the head, and convulsive movements or paralysis. In certain cases careful observation and discrimination of symp- toms are requisite, in order to determine whether they arise from intra-cranial tubercles, or from congestion of the brain caused by obstruction in the venous circulation by the pressure of enlarged bronchial glands. The diagnosis of bronchial phthisis, when the glands are still DIAGNOSIS. 145 small, is necessarily uncertain, on account of the absence of symp- toms. When thoy have increased in size and are so located as to press on the pneumogastric or recurrent lar^mgeal nerve, producing the spasmodic cough already described, the diflf'erential diagnosis between that disease and pertussis may be made by attention to the following facts : Bronchial phthisis occurs singly, and is non- contagious, while pertussis occurs as an epidemic, and with evi- dences of contagion. There are no successive stages, namely, those of catarrh, paroxysmal cough, and decline, as in that disease, and the cough, though paroxysmal, is short, and without hoop or vomiting. In feeble children, with inherited tubercular diathesis, emacia- tion, sweats, and a chronic cough, with the absence of pulmonary symptoms, should excite suspicions that the bronchial glands are involved. The evidence is almost conclusive if the cough becomes paroxysmal, and there is a loud, persistent, tracheal, or bronchial rale. In certain of the patients affected with this form of the disease, we have seen that the prominent symptoms are due to compression of one or more of the large vessels in the chest. Compression of these vessels, and consequent retarded circulation, may be con- fidently referred to enlarged bronchial glands, since aneurism, carcinomatous or other tumors, which would produce a similar result, are very rare before puberty. Sometimes the diagnosis is rendered certain by the physical signs observed by auscultation, and percussion over the sternum and the interscapular space. The condition of the external glands should also be observed, as those of the axilla, neck, and groin. The diagnosis of pulmonary, though more readily made than that of intra-cranial and bronchial tuberculosis, is often difficult and uncertain. This is, in part, explained by the fact that the tubercles are so frequently disseminated, while emaciation and a chronic cough are not infrequent from other causes than tubercles. Rachitis, intestinal worms, dentition, simple tracheal or bronchial inflammation, may be attended both by a chronic cough and emaciation. Caution is therefore requisite in order to avoid a grave error in diagnosis. Precipitancy in the diagnosis of doubtful cases is worse than indecision, and it is often best to postpone an expression of opinion as to the nature of the disease till the case has been observed for a few days. The significance and importance of the symptoms, physical signs, and other facts on which a diagnosis must be based, have already 10 146 TUBERCULOSIS. been sufficiently pointed out. It is difficult, in fact in certain cases impossible, to discriminate between simple cheesy pneumonia and cheesy pneumonia which has ended in the formation of tubercles. The patient has an attack of catarrhal pneumonia ; but, instead of absorption of the inflammatory product, cheesy infiltration occurs, and the lung in places becomes infiltrated with pus, softens, and breaks down. The patient presents the symptoms and physical signs of phthisis. He may recover after a protracted sickness, or may die. The disease may, and often does, remain a pneumonia ; but this is a condition of the lungs which favors the develo]3ment of tubercles, and in a certain ]3roportion of cases tubercles do form in the last weeks of life. Though the difl:erential diagnosis in such cases between simple pneumonia and tuberculosis supervening on pneumonia is impossible, practically the discrimination is unim- portant, as the same treatment is required. Advanced pulmonary tuberculosis, except when it supervenes upon pneumonia, can in most instances be readily diagnosticated by a careful examination. Still, it is to be recollected, as already pointed out, that certain of the symptoms and physical signs, which occurring in the adult would afford almost positive proof of pul- monary tuberculosis, in children not infrequently have a different origin. The diagnosis of tubercles in the abdominal orgaiis is facilitated by the presence of symptoms which indicate at the same time tuberculosis of the lungs. Among the chief diagnostic signs of tuberculosis of the peritoneum may be mentioned meteorism and a degree of tenderness on pressure. But there is danger of mistaking the tympanitic state of the intestines common in ill-nourished in- fants and the rachitic, or the fulness due to enlarged spleen or liver, to that occasioned by peritoneal tuberculization, and vice versa. The history of the case, and a careful examination of accompanying sympt<>ms, and the shape and feel of the abdomen, usually suffice to establish tlie diagnosis. In simple gaseous disten- sion of the abdomen there is an absence of the symptoms, general and local, which attend tuberculosis; rachitis occurs at an earlier age than peritoneal tuberculosis, and digital examination, aided by percussion, enables us to diagnosticate enlargement of the liver or spleen. Tubercular enlargement of the mesentei'ic glands cannot be positively diagnosticated when they are small. When they have attained such a size that they can be felt through the abdominal walls, palpation in connection with the history and symptoms of tu- TREATMENT. 147 berciilosis suffices to establish the diagnosis. Tlie glandular tumors can be diagnosticated from other tumors by the fact that they are tender on j^ressure, and occupy the umbilical region, while fecal tumors are not tender, and are located in the iliac or lumbar region. Gastro-intestinal tuberculosis cannot be positively diagnosticated. Protracted diarrhoea, or frequent attacks of diarrhoea, not readily controlled by medicine, and occurring in tubercular cases, are probably associated with intestinal ulceration; but in only a certain proportion of cases of ulceration are there also tubercles in the walls of the intestines. Prognosis. — Death is the ordinarj^ result of tuberculosis in the child, as it is in the adult ; but now and then one recovers. Hos- pital statistics show that the average duration of the disease is from three to seven months. Under favorable circumstances it is more protracted, even to two or three years. Those succumb soonest who inherit a strongly-marked tubercular diathesis, live in damp, dark, and ill-ventilated apartments, and whose diet is scanty or of poor quality. Therefore in the poor quarters of the city tuberculosis presents a worse form and pursues a more rapid course than among families in better circumstances. Favorable prognostic signs are absence of tubercular diathesis, good appetite and general health, with little emaciation, infrequency of cough, with respiration, pulse, and temperature nearly normal. Such symptoms may aiford hope of recovery with judicious regi- menal and therapeutic measures. On the other hand, if the symp- toms are grave, death is inevitable, unless in bronchial phthisis, in which, even when there is considerable urgency of symptoms, the offending gland is sometimes eliminated by softening and ulcera- tion, and the patient improves temporarily, if he does not ulti- mately recover. Complete and permanent recovery is, however, quite exceptional. Death in tuberculosis of children may occur from exhaustion induced by the general disease, or from the local efifect of the tubercles. Thus, in intra-cranial tuberculosis it may result from coma; in pulmonary tuberculosis, from dyspnoea, though more fre- quently from exhaustion; in that of the bronchial glands, from coma, dyspnoea, exhaustion, or even from hemorrhage; in that of the abdominal organs, from peritonitis or protracted diarrhoea. Treatment. Proiihyladk. — Though tuberculosis is so obstinate and fatal, it is often in our power, if forewarned, to avert it. A nursing infant, whose mother has the disease, should be immedi- ately taken from the breast and intrusted to a wet-nurse. The 14:8 TUBERCULOSIS. health of the mother as well as infant requires this. If the father has the disease, and the mother's milk is inadequate or of poor quality, and the infant is under the age of six months, the same change should be made, rather than supply the deficiency by arti- ficial feeding. Children who are weaned should have plain but nutritious and easily digested diet, a part of which should be milk. If the predisposition to tuberculosis is strong, a little alcoholic stim- ulant may be allowed three or four times daily in the milk, though with the risk of creating an appetite for it. To an infant two or three drops of Bourbon whisky may be given for each month of its age, and to children of three to five years a teaspoonful. Resi- dence in an airy and salubrious locality, out-door exercise, a scru- pulous avoidance of exposure by which a cold might be contracted, are necessary in order to the continued latency of the diathesis. Loss of flesh or appetite, or other evidences of failing health, indi- cate the need of additional measures of a therapeutic character. Iron, with cod-liver oil, citrate of iron and quinine, elixir of cal- isaya bark, or other tonic, should be employed in connection with the alcoholic stimulant and suitable regimen. By the employment of such precautionary measures as soon as indicated, multitudes of children might be saved from this disease who now perish. Curative. — The treatment of the general disease should be the same in children as in adults. The medicinal curative agents which are required in ordinary cases are cod-liver oil, iron, or other tonic, and an alcoholic stimulant given three or four times daily. The oil is less unpleasant and more readily taken when combined with the stimulant. An eligible mixture is equal parts of cod- liver oil and wine of iron, or cod-liver oil with half its quantity of Bourbon whisky, and a few drops of the tincture of chloride of iron. It sliould be given after nursing or the meals. At the age of one year two drops of the tincture of iron and a teaspoonful of cod-liver oil would constitute an ordinary dose. If the cod-liver oil is not tolerated, or if it impairs the appe- tite, it should be discontinued. In cases of diarrlioea it is of little or no benefit, and may do harm. Under such circumstances pa- tients sometimes do better with simple regjimenal measures, aided by alcoholic stimulants, and one of the least unpleasant of the tonics, as wine of iron or the calisaya bark. The regimen already recommended for prevention, is also required as a part of the cura- tive treatment. Certain modifications of treatment are demanded on account of the localization of the tubercles. Intra-cranial tuberculosis, as soon SYPHILIS. 149 as diagnosticated, slioiild be treated by pretty decided doses of iodide of potassium, though, unfortunately, there is little prospect of improvement. The glandular disease, whether bronchial or mesenteric, requires the iodide of iron, with or without that of potassium. Pneumonitis- or pleuritis, so frequent a complication of pulmonary tuberculosis, requires emollient poultices, with mode- rate counter-irritation, and the judicious use of opiates with stim- ulants. The peritonitis occurring in abdominal tuberculosis, which is usually circumscribed, is best treated by fomentations and poul- tices, with opiates, and the diarrhoea by subnitrate of bismuth and chalk, five to ten grains *of each, or the bismuth with Dover's powder; or a more active astringent. CHAPTER IV. SYPHILIS. Syphilis in infancy and childhood presents itself under two forms, namely, the congenital and acquired ; the former is the more fre- quent. Etiology. — Congenital syphilis may be derived from either father or mother. Either parent, having previously had syphilis, may transmit it to the offspring, although at the time free from syphi- litic symptoms. The mother, healthy at the time of conception, but infected with syphilis prior to the eighth month of gestation, may communicate the disease to the foetus; syphilis contracted in the eighth or ninth month does not affect the fcetus. If both pa- rents have syphilis, the infant is almost necessarily syphilitic; on the other hand, if only one parent is affected, the infant may or may not be contaminated. Sometimes, with such parentage, a part of the children are syphilitic, and a part healthy. Acquired syphilis in infancy and childhood may be received through primary lesions — that is, by reception of the virus from a chancre or bubo ; or it may be derived from certain of the secondary lesions. Inoculation by primary lesions may occur at the birth of the infant, from a syphilitic sore in the vagina or upon the vulva of the mother; inoculation in this manner is, however, rare. Chil- dren may also receive the virus from primary lesions on the persons of nurses or companions. Infection in this manner is sometimes 150 SYPHILIS. accidental, and sometimes the result of criminal conduct. A chancre on the breast of the wet-nurse not very infrequently communicates syphilis to the nursling. The contagiousness of " secondary manifestations," for a long time doubted, is now fully established. S\'philis may be communi- cated by the secretion or exudation of a mucous patch, or a second- ary sore. Hence the danger of lactation by unhealthy wet-nurses, though they present no symptoms of recent syphilis. Excoriations or sores upon the nipple or breast of an infected wet-nurse may communicate the disease to the nursling; and, on the other hand, mucous tubercles or fissures upon the lips or tongue of the infected infant may be the means of contaminating a healthy wet-nurse. Many such cases are now contained in the records of medicine. Vaccination by means of the scab is also a mode by which consti- tutional syphilis may be communicated. For further particulars in reference to this subject the reader is referred to our remarks on vaccination. Clinical History. — Syphilis occurring in the fcetus often destroys its life and produces miscarriage. The foetus has a shrivelled and diseased appearance, its skin peels, the liver is occasionally indu- rated, and abscesses with spots of inflammation are sometimes ob- served in the thymus gland. So frequently is syphilis a cause of non-viability, that, as Trousseau has remarked, this disease should be suspected as the cause whenever a woman repeatedly aborts. Abortion from syphilis commonly occurs at or about the sixth month of gestation. The viable infant, affected with syphilis, ordinarily presents, at birth, no symptoms or appearances which indicate the nature of the disease with which it is contaminated. But there are exceptions. Recently I was enabled to diagnosticate syphilis in an infant within a day after birth, by its small size and feebleness, and the appear- ance of large blebs of pemphigus upon the hands and feet, fingers and toes, over which the skin soon broke, leaving troublesome and bleeding sores; coryza commenced about the twelfth day. The parents of this child appeared healthy, but I could finally trace the syphilitic taint to the mother. Well-marked pemphigvis in the new-born may be considered pathognomonic of syphilis. Bouchut saw a seven and a half months' infant born alive with an erup- tion of a copper-color upon the legs and arms, and onyxis upon the fingers and toes. Condylomata, mucous patches, and stains of a copper-color are the principal syphilitic afi:ections, besides pem- phigus, which have been observed at birth on the bodies of con- CLINICAL HISTORY. 151 taniinated infants. It is stated that M. CuUerier, in ten years' attendance at the Hopital de Louraine, met only two cases of syphi- litic manifestations at birth, and Victor de Meric only two cases in forty-six infants, who were affected with congenital syphilis (Bumstead) ; but in the practice of others a larger proportion have exhibited symptoms at birth. Ordinarily the period in which congenital syphilis is first revealed by symptoms is between the fifteenth and fortieth days. Rarely the manifestation of the dis- ease is delayed several months. M. Diday ascertained the time of the commencement of symptoms in 158 cases, as follows: — Before the completion of one month after birth, in ... 86 " " two months " ... 45 " " three " " ... 15 At four months 7 " five " 1 " six " 1 " eight " 1 " one year 1 " two years 1 In cases of tardy commencement of syphilitic symptoms it is probable that the disease has been partially eradicated from the afiected parent by appropriate treatment. The nutrition of the infant who has inherited the syphilitic taint, but does not exhibit it at birth, is for a time good, but it begins to be impaired when the local manifestations of syphilis appear, or soon after. The system gradually wastes ; the skin loses its fresh and healthy appearance, and becomes sallow, and, after a time, more or less wrinkled; the features become pinched or con- tracted, and wear a sad expression. M. Diday says : " Next to this look of little old men, so common in new-born children doomed to syphilis, the most characteristic sign is the color of the skin." Trousseau thus describes this discoloration of the surface: " Before the health becomes afiected, the child has already a peculiar appear- ance ; the skin, especially that of the face, loses its transparency ; it becomes dull, even when there is neither pufliness nor emacia- tion ; its rosy color disappears, and is replaced by a sooty tint, which resembles that of Asiatics. It is yellow or like coffee mixed with milk, or looks as if it had been exposed to smoke ; it has an empyreumatic color, similar to that which exists on the fingers of persons who are in the habit of smoking cigarettes. It appears as if a layer of coloring had been laid on unequally; it sometimes occupies the whole of the skin, l)ut is more marked in certain favorite spots, as the foreliead, eyebrows, chin, nose, eyelids — in 152 SYPHILIS. short, the most prominent parts of tlie face ; the deeper parts, such as the internal angle of the orbit, the hollow of the cheek, and that which separates the lower lip from the chin, almost always remain free from it. Although the face is commonly the part most atiected, the rest of the body always participates more or less in this tint. The child becomes pale and wan." The infant whose system is profoundly affected by syphilis rarely smiles, and its voice is feeble and plaintive ; its fre(,iuent whimpering cry is quite characteristic. CoRYZA is one of the earliest and most constant of the local affec- tions which occur in infantile syphilis. It is slight at first, attracting little attention from the parents, who are not aware of its signifi- cance, and usually attribute it to a slight cold ; but it gradually increases. It gives rise to a secretion from the Schneiderian mem- brane, at first thin, but which becomes more consistent, and is attended bv the formation of scabs. The thickening of the mucous membrane in consequence of the inflammation and the presence of crusts narrows the passage through the nostrils so as to produce snufiling respiration, and sometimes render nursing ditficult. In severe cases respiration through the nostrils is almost wholly pre- vented, so that death may occur from inanition, unless the breast is milked into the intant's mouth or it is fed with a spoon ; but ordinarily, eyen in o-rave corvza, it continues to nurse, thou2;h obliged often to release its hold of the nipple to obtain breath. It is when coryza begins to interfere with lactation that it first alarms the parents. The inflammation at the same time may aflect the throat and larvnx, causinsr hoarseness of the voice. Ulceration of the Schneiderian membrane and the subjacent cartilage or bone is rare in infancy or childhood, although cases occur which are even attended with more or less flattening of the nose. Diday believes that the discharge which accompanies coryza is in great part due to mucous patches developed on the Schneiderian membrane. The upper lip, over which the discharge flows, becomes red, excoriated, and more or less incrusted. The coryza, in most cases, coexists with other local syphilitic attections. Occasionally it occui-s alone, and is the only evidence of the presence of the specific taint, except such as is attbrded by the mal-nutrition and general appearance of the patient. Mucous PATCHES occur in most patients. They are developed either upon the mucous surfaces, or upon parts of the skin which are thin and exposed to friction, and such as are moistened by secretion or transudation from the vessels underneath. The most common ACNE, IMPETIGO, AND ECTHYMA. 153 seat of mucous jtatches is at the termination of mucous canals ; but in infancy, on account of the peculiar delicacy of the skin, they may occur upon almost any part of the cutaneous surface. They are most common, however, around the anus, upon the vulva, scrotum, umbilicus, laljial commissures, in the axillae, and behind the ears. Mucous patches upon the skin present a rounded border, and are slightly elevated. Their color has been compared to that of the skin which has been softened by the prolonged application of a poultice. Erosions and cracks sometimes occur in the patches, from which a thin liquid exudes. Upon mucous surfaces they are less elevated than upon the skin, and are prone to ulcerate. These ulcerations, commencing at the centre, extend, and soon the mucous patch disappears, and its site is occupied by an ulcer. The ulcer may be circular, oval, elliptical, crescentic, or irregular. The arches of the fauces are a common seat of mucous patches. Roseola is an occasional symptom of infantile syphilis. "It is distinguished," says Diday, " by patches of a bright rose-color, cir- cumscribed, irregularly rounded, of various sizes (most frequently about as large as one of the nails); appearing, by preference, on the belly, lower part of the chest, neck, and inner surface of the extremities." The spots do not readily and fully disappear by pres- sure. Pemphigus appearing soon after birth has already been alluded to. Its most frequent seat, whether occurring after birth or as a subsequent manifestation, is the palms of the hands, soles of the feet, the fingers, and toes. This eruption commences by a violet tint of the skin, and in the course of twenty-four to forty eight hours a watery fluid collects underneath, which soon becomes turbid. The skin peels oft', and sometimes an angry sore results,* which bleeds readily when rubbed or pressed. In other and more favorable cases new skin takes the place of that which is lost. Pemphigus at birth is a precursor of death, but when it appears for the first time some weeks after birth, it is a less unfavorable prognostic. In cases of recovery it disappears, with projjer treat- ment, in two or three weeks. Acne, impetigo, and ecthyma are occasionally observed in children afflicted with syphilis. The indurated pustules of acne occur most frequently upon the shoulders, back, chest, and buttocks. The pus is sometimes absorbed, and in other cases discharged, leaving a small cicatrix, which, after a time, disappears. Impetigo appears 154: SYPHILIS. most frequently upon the face, and occasionally upon the chest, neck, axilla, and groins. Unlike simple impetigo, the sj-philitic impetiginous eruption is surrounded by a copper-colored areola. Ecthyma occurs upon the legs and buttocks chiefly. It com- mences as violet-colored spots, which are soon transformed into pustules. Ulcers succeed, which, in reduced states of the system, are apt to enlarge, and endanger the safety of the child. Of the three pustular eruptions, acne, according to Diday, is the least serious — indicating a " less confirmed diathesis." Ecthyma is the most serious, on account of the reduced state of system with which it is apt to be associated. Syphilitic papulpe and squam?e are rare in infants, but cases have been observed. Onychia occa- sionally occurs, though less frequently than in syphilis of the adult. Visceral Lesions. — The visceral lesions which occur in the syphilis of infancy and childhood are, suppuration in the thymus gland ; gummy tumors in certain organs, most frequently the lungs and liver; increase of the connective tissue of the liver, known as syphilitic cirrhosis; partial perihepatitis, with depressions resem- l)ling cicatrices on the surface of the liver; peritonitis; periostitis, with thickening of the bone and exostosis. Suppurative inflammation in the thymus gland is not common, or has not been frequently observed. "When it is present, the gland sometimes presents its normal appearance externally, and the abscess is only discovered by incisions. Gummy tumors are white and spheroidal ; some are as small or smaller than a pin's head, while others are as large as a pea, or even a hazel-nut. I have seen a considerable number of them not as large as a pin's head, in the liver of an infant. Gummy tumors, according to Lebert, consist "of loose fibrous tissue, made up of pale elastic . fibres, inclosing in their large interspaces a homogeneous granu- lar substance, the elements of which are less adherent to each other than in deposits of true tubercle." Lebert also, with other microscopists, discovered round granular cells in these tumors. According to Robin, gummy tumors "are made up of rounded nuclei belonging to fibro-plastic cells, or cytoblastions ; of a finely granular, semi-transparent and amorphous substance ; and, finally, of isolated fibres of cellular tissue, a small number of elastic fibres, and a few capillary bloodvessels." Constitutional sj-philis is one of the principal causes of waxy degeneration, and the spleen and liver of infants may be enlarged from this cause. Dr. Samuel Gee has expressed the opinion that in VISCERAL LESIONS. 155 half the cases of hereditary syphilis the spleen is enlarged. (Lond, Lancet, April 13, 1867.) Infiltration of the liver by fibrous substance was first noticed by Giibler. It is not common in the infant. A specimen, showing this lesion, was presented to the London Pathological Society in 1866, by Dr. Samuel Wilks. The following remarks by Dr. Wilks convey a good idea of the appearance and state of the liver in syphilitic cirrhosis: "Having dissected the bodies of several in- fants, who have died of congenital syphilis, I have found fetty livers, and an inflammation of the capsule ; but in only two have I discovered adventitious products of a fibrous character. The pre- sent example, however, corresponds in every particular with the disease described by Giibler. It must be distinguislied (at least as far as the naked eye appearance reaches) from the syphilitic disease of adults, of which many specimens have been before the Society. In these the organ is cicatrized on the surface, and con- tains distinct nodules of fibrous tissue; whilst in the disease of children, as in the present specimen, the whole organ is infiltrated by a new material, and it consequently becomes, as described by Giibler, hypertrophied, globular, and hard, resistant to pressure, and even when torn by the fingers, its surface receives no indenta- tion from them ; it is also elastic, and when cut creaks slightly under the scalpel. This was the form of disease in the present specimen. It came from a syphilitic child, a month old, in whom the liver could be felt enlarged during life, and when removed weighed a pound and a half. It was smooth on the surface, and so hard that it resembled rather a fibrous tumor than a liver." It is seen that the liver in the syphilitic child is liable to three distinct pathological processes, namely, gummy tumors, cirrhosis or fibroid degeneration, and waxy degeneration. Syphilitic perihepatitis and periostitis are more rare in infanc}'- and childhood than in adult life, but they occasionally occur. Prof. Simpson, of Edinburgh, considers peritonitis in the foetus one of the results of syphilis, and the cause of its death. Mr. Hutchinson, of London, has called the attention of the pro- fession to certain observations of his, which, if corroborated, are important. According to him, hereditary syphilis becoming latent, sometimes manifests itself again after the age of five years, by another set of symptoms. One of these manifestations is a dwarf- ing of the incisor teeth, which are rounded and peg-like, with notched edges. On account of the shape and small size of the teeth, there are interspaces between them. This malformation is most 156 SYPHILIS. marked in the central incisors of the upper jaw, and in dertain cases it is limited to them, and it never appears in the other in- cisors unless it does also in them. Another symptom, which only appears in hereditary syphilis, is an interstitial keratitis occur- ring on both sides, and attended by the deposition of fibrin in the substance of the cornea. In a few weeks the inflammation de- clines, but a slight opacity of the cornea remains. The cerebral nerves may become affected, usually a single pair — if the audi- tory, deafness resulting; if the optic, dimness of sight. Occasion- ally there are other manifestations of syphilis in this period, as enlargement of spleen and liver, and nodes upon the long bones. Prognosis. — This depends in great part on the general condition of the patient. If there is much emaciation, and the symptoms indicate a deeply-seated cachexia, a considerable proportion perish. On the other hand, if the general health is not greatly impaired, although the local affections are pretty severe, the prognosis with correct treatment is good. The younger the infant, when the symjjtoms of syphilis appear, the more unfavorable, as a rule, is the prognosis. Treatjiext. — Parents who beget syphilitic children ought, from a due regard for their offspring, to make use of anti-syphilitic reme- dies, although they present in their persons no evidences of syphi- litic taint. A good prescription for the parents is one-sixteenth of a grain of corrosive sublimate in the compound tincture of bark, given twice or three times dailj' for several weeks. If the father has had syphilis, both parents should be subjected to this treat- ment, and it may be continued, at least on the part of the mother, during the first months of her gestation. So small a dose of the mercurial does not, in my opinion, materially increase the liability to miscarry. There is much more danger of miscarrying from allowing the syphilitic taint to remain uncontrolled. Some prefer the use of mercurial ointment in the treatment of pregnant women for syphilis, in the belief that it is less likely to produce abortion. It is used for this purpose in the proportion of one drachm to the ounce. It is equally eftectual in the eradication of the syphilitic taint with the small dose of corrosive sublimate, recommended above for internal administration; but it is impossible to deter- mine the quantity of mercury which enters the circulation when inunction is employed, and salivation is more likely to occur. Syphilis in the infant requires mercurial treatment as in the adult. Mercury may be employed internally or by inunction. Some prefer inunction in the treatment of ordinary cases, in the TREATMENT. 157 manner recommended by Sir Benjamin Brodie. "I liave spread,"' says he, "mercurial ointment, made in the proportion of a drachm to an ounce, over a flannel roller, and bound it round the child, once a day. The child kicks about, and, the cuticle being thin, the mercury is absorbed. It does not either gripe or purge, nor does it make the gums sore, but it cures the disease. I have adopted this practice in a great many cases, with the most signal success." Trousseau, on the other hand, discountenances the use of inunction, as mercurial ointment applied to the skin produces irritation, and increases the suifering and restlessness of the child. He prefers the following solution, which is known as Yan Swie- ten's, for internal treatment: — R. Hydrarg. bichlorid. 1 part; Aquae 900 parts; Spts. rectific. 100 parts. Misce. Dose, one, or at most, two grammes (23 to 46 gr.) in milk, daily. As regards the choice between inunction and internal treatment, it may be said that the former is preferable in very reduced states of system, and in those who are affected with diarrhoea. The ointment should not be applied to much of the surface; two or three square inches are sufficient. To avoid inflaming the surface, the position of it may be varied from time to time, and it need not be continuously applied. In cases other than those excepted above, I prefer internal treatment. Yan Swieten's liquid may be given, or one of the following formulae may be employed : — R. Hydrarg. cum creta gr. iij-vj; Sacch. alb. 9j. Misce. Divid. in chart. No. xii. One powder 3 times dail3^ R. Hydrarg. chlor. corros. gr. i-ij ; Syr. sarsse comp. gij ; Aquae 5viij. Misce. One teaspoonful 3 times daily. Mercury, in whatever way employed, should not be discontinued entirely till several weeks after the syphilitic symptoms have dis- appeared ; it is proper to continue it for a time, in diminished quantity, after the health seems fully restored. When the mercurial is omitted, tonics are often required. The preparations of cinchona are useful in certain cases, as are also those of iron. If the patient remain feeble and pallid, present- ing evidences of struma, cod-liver oil and syrup of the iodide of iron will be found beneficial continued for some weeks or months after the mercurial is discontinued. Attention should always be 158 SYPHILIS. given to cleanliness and the hygienic management of the child. In some instances direct treatment of the local afl'ections is service- able. Injections of a solution of chlorate of potash into the nos- trils have a good eifect in syphilitic coryza, and the application to the inflamed surface daily of citrine or white precipitate ointment diluted with an equal amount of lard. Condylomata or mucous patches sealed upon the cutaneous surface may be dusted with calo- mel. At my clinique in April, 1871, a child two years and ten months old was presented, with a large condylomatous outgrowth near the anus. The history of the child showed that in all proba- bility the disease had been contracted within a year from syphilitic cliildren in one of the public institutions. Within three weeks this afteetion nearly disappeared by dusting upon it calomel daily, with appropriate internal treatment. sectio:n" II. ERUPTIVE FEVERS. CHAPTER I. MEASLES. The disease known in the vernacular as measles lias also the names rubeola and morbilli. It is a common exanthematic aiFec- tion, occurring at any age, but most frequently in childhood. It affects once the majority of mankind. Writers recognize three stages of measles: first, that of invasion, which ends with the appearance of the eruption; secondly, the eruptive stage; and thirdly, the stage of decline or desquamation. Symptoms. — This disease commences with such symptoms as usu- ally occur in mild but pretty general inflammation of the air-pas- sages, namely, cough, fever, anorexia, and thirst. The eyes present a suffused, moderately injected, and brilliant appearance, and the buccal and faucial surface is injected. The Schneiderian mem- brane, and that lining the larjaix, trachea, and bronchial tubes, participate in the increased vascularity. The cough at first is dry, and sometimes distinctly croupy. Catarrhal or false croup, indeed, is not infrequent in the initial period of measles. The cough is attended by little acceleration of respiration, and by little or no pain in the respiratory movements. If auscultation is practised at this early stage, we observe the vesicular murmur, somewhat harsh in character, and sometimes sonorous and sibilant rales. A little later, rales of a moist character appear. The patient, if old enough, commonly complains of headache, and of dull pain in the epigastric region or the centre of the ster- num, due to the bronchitis. With these local symptoms febrile reaction occurs. The temperature rises to about 102° or 103°, as indicated by the thermometer in the axilla. The pulse numbers from 110 to 130 per minute. The fever is somewhat greater than 160 MEASLES. ill primary traclieo-bronchitis, except when the bronchitis becomes capillary, but it is less than in most cases of scarlet fever. The fever in the premonitory stage of measles after the first day is not uniform. It is attended by remissions and exacerbations, the former occurring in the first part of the day, the latter in the evening. Sometimes two exacerbations occur in the day. The face is flushed and somewhat swollen, especially during the times of increase in the fever, and the child is drowsy or restless. Vom- iting, so common a symptom in the commencement of scarlet fever, occasionally occurs in measles. While in scarlet fever this takes place in the first twenty-four hours, in measles it occurs with about equal frequency at any period previously to the eruption. It was present during the first stage, sometimes almost as late as the erup- tive period, in thirteen, and was absent in twenty-three cases, of which I have preserved records. The duration of the first stage varies in different cases. It is usually from two to five days, with an average of about four. Oc- casionally it is more protracted on account of some disturbance in the economy, either from exposure to cold or other cause, which prevents the necessary afflux of blood towards the surface, and re- tards the eruption. In eighteen cases in my practice in which the duration of the cough previously to the appearance of rash was accurately ascertained, the time varied from one to five days, with an average of three and one-third; in ten other cases it had con- tinued, the parents stated, about a week, and in five, from one to two weeks, previously to the eruption. The eruption commences, when the disease pursues its normal course, upon the forehead and neck, then the face, and gradually extends downwards, occupying from twenty-four to thirty-six hours in passing over the trunk and limbs. It appears first as indistinct red points not more than a line in diameter, which in- crease in size and become more distinct. Their borders are uneven or irregular, or they are finely notched ; their general shape is, how- ever, circular, except as two or more unite, when they may assume any form. The crescentic form which writers describe is due to the union of two jDoints of eruption. The largest of these spots, when there is no coalescence, do not exceed a quarter of an inch in diam- eter, and many are much smaller. Frequently in plethoric chil- dren, if there is much fever, there is continuous redness over seve- ral inches of surface. The eruption is then confluent. This form is often observed upon parts of the surface where the capillary circu- lation is most active, when it is discrete elsewhere. In some of SYMPTOMS. IGl these cases, diagnosis of measles from scarlet fever is attended with difficulty. The rubeolons eruption is slightly elevated. This is not appre- ciable to the sight, but can be ascertained by passing the finger slowly over the skin, when a little roughness is felt at the point of eruption. Sometimes the elevation, especially in the connnence- ment of the eruption, is not appreciable, even to the touch. The eruption is broad and flat, never acuminate, never changing its form to the vesicular or pustular. It disappears by pressure, and imme- diately reappears when the pressure is removed. It has been com- pared in appearance to flea-bites. Small, pointed, papular, vesicular, or pustular eruptions are sometimes seen in connection with those of measles, but they are accidental, occurring in other states of sys- tem as well as in measles, if there is the same augmented tempera- ture. In the commencement of the eruptive period, the severity of the constitutional and local symptoms increases. The pulse and tem- perature correspond with the character which they presented during the exacerbations of the first stage. The features are slightly swollen; the eyes still watery and sensitive to light; the conjnnc- tiva, ocular and palpebral, and the mucous membrane of the cavity of the mouth and of the air-passages, continue injected. The tongue is covered with a moist thin fur, and its papillae are promi- nent, though less so than in scarlet fever. The cough continues frequent, and is seldom attended with much expectoration, in un- complicated cases ; often there is no expectoration whatever. The appetite is lost, but drinks are readily taken on account of the thirst. Diarrhoea sometimes occurs on the first day of the eruption, but it lasts only a few hours, and, if the disease pursues its usual course, abates of itself. With the exception of this, the bowels are regular, or a little constipated during the eruptive period. On the second day of the eruption, or sixth of the fever, the symptoms begin to abate. The pulse is less accelerated, and the temperature diminishes ; the cough is less frequent and is easier, and the flushed and swollen appearance of the face declines. By the close of the third or on the fourth day, the rash has disappeared in the order in which it extended over the hody. There only re- main faint maculse, which in the course of a day or two fade completely. "With the disappearance of the rash, the fever nearly or quite ceases, but a slight and painless cough continues for several days. Occasionally the eruption presents a livid appearance ; this is 11 162 MEASLES. the rubeola nigra of writers. From cases which I have observed, it is my opinion that this should not be considered a distinct species in the vast majority of cases, but that the dark color is due to in- ternal inflammation, usually capillary bronchitis or pneumonia, which prevents full oxygenation of the blood. Rarely rubeola nigra is due to the vitiated state of the blood, or the malignant nature of the disease. The course of the eruption in this form of measles is somewhat different ; it continues longer, fades more slowly, and does not disappear so readily on pressure. Traces of it are observed a week or more after its first appearance ; it is apt to be fatal. Measles may present this form from the beginning, or commencing as vulgaris, it may pass into rubeola nigra. Measles may be irregular in form, but aberrations are less fre- quent than in scarlet fever. "Writers describe measles without catarrh, and, on the other hand, measles without the eruption. But positive diagnosis in such cases must be difficult. It is pro- bable that simple catarrh and roseola have sometimes been mis- taken for the two forms of irregularity mentioned. But when a child, in a family of children aflected with measles, presents all the symptoms of that disease, except the catarrh or except the eruption, the diagnosis of irregular measles would, as a rule, be correct. Occasionally the stage of invasion is very short, or even absent. In one case the parents informed me that the catarrhal symptoms began on the day when the eruption appeared. Convulsions some- times occur at the commencement of measles, as well as during its progress. A single convulsive attack at the commencement of measles is usually not dangerous ; when repeated, it is more serious; it is also more serious when it occurs in the course of measles. In certain cases the eruption appears in an irregular and partial manner, occurring, perhaps, at a late period, and indistinctly upon the trunk alone, or upon the trunk and partially upon the legs. In many cases of deferred or partial eruption there is internal congestion or inflammation of some part, which causes withdrawal of blood from the surface, and thus prevents the normal develop- ment of the rash. When the eruption disappears, the third stage commences, that of desquamation. It is characterized by a scanty furfuraceous exfoliation of the epidermis. The desquamation is seldom as great as in scarlet fever, and it occurs most where the eruption has been thickest and the epidermis most inflamed. Exfoliation occui*s between the fourth and seventh days after the commencement of COMPLICATIONS. 163 the eruption, the eighth and eleventh of the disease. In some chiklren it does not take place, or is so slight, as not to be observed. With the disappearance of the rash, the symptoms rapidly abate. The pulse becomes more natural, the temperature is reduced, the digestive organs return to their normal state, and convalescence is established. The cough continues several days after the other symptoms abate, but it is less and less frequent, and is not painful. Complications. — The complications of this disease are important. Much of the success of the physician in the management of measles depends on a correct diagnosis and understanding of them. The most frequent of these complications are bronchitis and broncho- pneumonia. Slight bronchitis is common in measles, but if it in- crease so as to cause embarrassment of respiration, and become a source of danger, it is properly a complication. This complication, as well as pneumonia, may occur at any period of measles, but it commences most frequently in the first stage. Occurring in the fi.rst stage, it may prevent the regular appearance of the rash ; if in the second, it often causes retrocession of it. "When bronchitis becomes really serious, it usually has invaded the minute bronchial tubes. This disease, designated capillary bronchitis or sufibcative catarrh, I have elsewhere described. The clinical history of fatal bronchitis, as a complication of measles, is as follows: The respiration, at first not notably altered, becomes, by degrees, accelerated, and the j^atient more and more fretful. The pulse, instead of becoming less accelerated, as after the first days of simple measles, is daily more rapid, and the respiration more frequent and labored. The dyspnoea gradually increases, the infra-mammary region is depressed during each inspiration, and the subcrepitant rale is heard on both sides of the chest. There is, probably, collapse or inflammation of some of the lobules. Finally the prolabia and fingers become livid, and death occurs from apnoea. Capillary bronchitis is diagnosticated from pneumonitis by the physical signs. It is in the young child more dangerous than that disease, unless perchance the latter be double. A large majority of those afi[*ected under the age of three years, die. The anatomi- cal characters of fatal bronchitis occurring in connection with measles, I have had an opportunity to inspect. In an infant who died with this complication in the Infants' Hospital in the spring of 1867, there were evidences of continuous inflammation from the epiglottis to the minutest bronchial tubes. Pneumonia as a complication does not differ materially from the idiopathic form, except that it is more protracted and fatal. Its 164 MEASLES. form is in most cases catarrlial, resulting from an extension of the bronchial inflammation. The next most frequent serious complication of measles is entero- colitis. This may commence at any period during the course of the disease. If the colon is more especially the seat of inflammation, the evacuations contain mucus and blood, unless in young children, in whom the stools, even in severe colitis, commonly have a green color. The anatomical character of this complication varies in diiferent cases, like the idiopathic form of inflammation. Sometimes there is simple arborescence of the intestinal mucous membrane, with tume- faction of its follicles ; in other cases, in addition to increased vas- cularity, the mucous coat is softened and thickened ; and in others still, especially if the inflammatory action has been somewhat pro- tracted, ulceration occurs, for the most part in the site of the soli- tary glands. Exceptionally, in fatal cases of measles attended with diarrhcea, no vascularity is observed after death, although the intestine may be somewhat thickened and softened. In these cases the diarrhoea may have been non-inflammatory or inflammatory, the injection of the vessels having disappeared after death. Severe and obstinate diarrhoeal afl:ectious occurring with measles, usually commence as the primary disease is about declining. They then become sequelae, ending fatally in many instances several days or perhaps weeks after the disappearance of the eruption. Diar- rhoeal attacks, occurring in, or previously to, the eruptive stage, are, as a rule, mild and easily relieved. In some grave cases, measles have a tendency from the first to affect the internal organs more than the surface. There then co- exist bronchitis, pneumonia, and entero-colitis, with indistinctness of the eruption on the skin. Such complications render a fatal result highly probable. Another very fatal complication and sequel is true croup, com- mencing when rubeola is beginning to decline ; but it is less frequent than pneumonia or entero-colitis. In catarrhal or false croup, which, as has been previously stated, is not infrequent at the commencement of measles, the cough has a loud, ringing character. In true croup, on the other hand, it is hoarse or harsh, and less distinct, on account of the presence of the pseudo-membrane in the larynx. True croup, always a grave disease, is more serious when it occurs as a compli- cation of measles than in the idiopathic form, not only because the blood is vitiated and the system reduced by the primary affection, but because the inflammation of the mucous surface is in general more extensive, as is also, I believe, the pseudo-membrane. This ANATOMICAL CHARACTERS. 165 membrane in the croup of measles I have seen extend so far clown the air-passages, that tracheotomy could not have been attended by any decided amelioration of symptoms. This complication, though always grave, is not, however, necessarily fatal. I have known cases recover by ordinary treatment, when for days there had been dysp- noea and other evidences of a pretty firm pseudo-membrane. True croup causes continuation of the fever, which had perhaps begun to abate. Diphtheria, when epidemic, also frequently complicates measles. Much of the mortalit}' from measles in this city, between the years 1860 and 1865, was due to this cause. In cases observed by myself, diphtheria usually began while the fauces were still inflamed, and sometimes before the eruption had begun to fade. These are the most common complications of measles. There are others of less frequent occurrence, among which may be men- tioned congestion of the brain, with or without serous eflCusion. Stomatitis, pharyngitis, and otitis are occasional complications. Rarely, also, purpura, attended by hemorrhages from the different mucous surfaces, occurs in connection wdth measles. This compli- cation is, however, more frequent in certain other constitutional diseases, as scarlet fever, and especially variola. It is seen that the inflammations which are apt to occur in the course of measles are chiefly of the mucous surfaces. In scarlet fever, on the other hand, the inflammations are serous. There are other affections, originating in measles, which are rather sequelae than complications. Gangrene of the mouth is one which, as stated in another part of the work, is more apt to occur after measles than any other disease. Ophthalmia commencing in measles often persists for weeks or months. It may give rise to granulations of the lids, and cases have been reported of violent inflammation of a purulent character, producing ulceration of the cornea, and destroying vision. The ophthalmia is sometimes very intractable. Inflammation of the Schneiderian membrane, com- monly present during measles, sometimes continues as a sequel, ex- tending back as far as the Eustachian tube, where it may cause swelling, with impairment of hearing, and forward to the lip, where it may produce chronic eczema. Anatomical Characters. — I have made, or witnessed, according to remembrance, some six post-mortem examinations of those who have died in, or immediately after, an attack of measles. In all there were lesions due to complications. Indeed, death directly from measles is so rare that few have had an opportunity of study- 166 MEASLES. ing the anatomical characters which are peculiar to this affection. In those who have died without any obvious coexisting disease, and these cases chiefly occur in the malignant form, there has been congestion of the internal organs, especially marked in the lungs, and sometimes the tissues appeared softened. The blood, also, in the malignant form, has a darker hue than natural, and ecchymotic patches have been observed upon the mucous surfaces and elsewhere, corresponding in character with the petechise under the skin which sometimes occur in this form of measles. In cases resulting fatally from bronchitis or pneumonia the bronchial glands are commonly tumefied in the same manner as the mesenteric glands are enlarged in enteritis, and the glands of the meso-colon in dysentery. I!s'ature. — Rubeola, like the other exanthematic fevers, is due to a materies morbi, the exact nature of which is unknown. It is both inoculable and infectious. It has been inoculated by the serum from vesicles which sometimes occur in connection with the rubeolous eruption, and also by the blood from a patient. Inocu- lation does not appear to moderate the disease, and as measles, when contracted in the ordinary way, is not in itself dangerous, but dangerous only from complications, inoculation is not per- formed, except as a matter of scientific interest. The usual mode of propagation is by infection. It is communicated both by the breath and clothing. By fomites the virus is sometimes conveyed a long distance. The question is still undecided whether rubeola does not sometimes occur spontaneously. I have met cases, and have been informed of others, one especially, occurring in a sparsely settled portion of the country, in which there was apparently no exposure, and I incline to the opinion that its origin de novo is possible, though not frequent. The period of incubation of measles is usually from ten to four- teen days. In cases observed in the children's department of Charity Hospital, this period was ascertained to be about twelve days. In those who have been inoculated, the incubative period is said to have been about one week. Rubeola prevails epidemi- cally, like the whole class of infectious diseases, and in dififerent epidemics the type varies somewhat, as well as the character of the complications. Diagnosis. — The diagnosis of measles, previously to the eruption, is often difficult. The catarrhal symptoms then predominate, and these are such as may occur independently Qf any constitutional or blood disease. The first stage, therefore, of measles, is often mistaken for coryza, or mild bronchitis. The points of difterential PROGNOSIS — TREATMENT. 167 diagnosis are the suffused appearance of the eyes, tlie greater degree of fever on tlie first day than would be likely to arise from so moderate an amount of local disease, and on subsequent days re- mission and exacerbation of the fever. Measles in the first stage has been mistaken for remittent fever. The catarrhal symptoms should prevent such an error. Sometimes roseola closely resembles measles in appearance, but the rash of roseola appears within a few hours after the commence- ment of febrile symptoms, and almost simultaneously over the whole body, and without those local symptoms referable to the mucous surfaces, which characterize measles. Variola on the first day of the eruption has sometimes been diagnosticated as measles. I recollect once being called to an in- fant with fatal confluent smallpox, who was said to have measles. A physician, a few days previously, observing the red points in the commencement of the eruption, had made this absurd diagnosis, and, predicting a favorable result, had not thought it necessary to repeat his visit. In case of doubt, it is the part of prudence to defer making a positive diagnosis. A few hours sufiice to show the distinctive characters of the rubeolous and variolous eruptions. But the anxiety of friends often. necessitates the expression of an opinion. The absence of catarrhal symptoms, the earlier appear- ance of the eruption, and its papular feel under the finger in smallpox, enable us to discriminate between the two diseases in the commencement of the eruptive stage. Moreover, the symp- toms in the initial periods are different, as will be seen in our description of smallpox. Prognosis. — This is favorable, provided that there is no serious complication. "With internal inflammatory complication, on the other hand, the disease becomes much more grave. A large pro- portion thus affected die. The prognosis is also less favorable in feeble children with scanty eruption, or an eruption appearing at a late period and irregularly. Dyspnoea, persistent and great, acceleration of pulse, and coma, indicate an unfavorable ending. Convulsions occur much more rarely in the course of measles than in scarlet fever, and when they occur after the initial period they usually end in coma and death. Treatment. — ^Uncomplicated measles requires no medicinal treat- ment except to palliate symptoms. The child should be kept in an airy apartment, at a uniform temperature of about 68°. A temperature so elevated as to be uncomfortable to the nurse is injurious to the patient. But while the popular idea is erroneous, 168 MEASLES. that Le should be kept in a heated atmosphere, it is correct that currents of air and sudden reduction of temperature are dangerous. A violent and fatal attack of croup occurred in my practice in a girl of fifteen, in consequence of exposure at an open window during the j)eriod of desquamation.. The diet should be mild, and for the most part liquid. The patient, indeed, refuses solid food, but, on account of the thirst, takes liquids more readily. Farina- ceous substances, with milk, afford sufficient nutriment in ordinary cases. If the previous health has been poor and the vital powers reduced, or if there is a complication, more sustaining diet is re- quired. Stimulation by wine or brandy is needed in some of these cases. During the two or three weeks succeeding an attack of measles, care should be taken to avoid exposure to cold, or changes of temperature, since during this period mucous inflammations are so apt to occur. The cough in most cases requires treatment, inasmuch as the suffering of the child and loss of sleep are largely due to this symptom. Demulcent drinks, as flaxseed tea, infusion of slippery- elm bark, or solution of gum Arabic, are useful, to which, to render them more palatable, lemon-juice may be added. A small Dover's powder, or the following mixture given occasionally, relieves the severity and diminishes the frequency of the cough : — I^. Tinct. opii camphorat., Syr. scillse, Syr. ipecac, aa 533; Spts. fetlier. nitr. 5ij-' Misce. Dose, one teaspoonful to a child of five years, repeated according to circumstances. As the chief danger in measles is from inflammation of the respi- ratory organs, local treatment directed to the chest is important. The chest should be covered with oil-silk, unless in the mildest cases. This increases the amount of eruption upon the surface underneath, and, I believe, tends greatly to prevent complication by bronchitis and pneumonia. If the eruption is tardy in its appearance, or indistinct, it is well to produce moderate counter- irritation by some gentle irritant underneath, as camphorated oil, to which one-third part of turpentine is added. Affections, which complicate measles, should receive, for the most part, such treatment as is approj^riate for them when idio- pathic. Secondary diseases, however, require sustaining measures more than primary. In bronchial and pulmonary inflammations, which, if they occur early in measles, prevent the regular appear- ance of the eruption, or, if in the eruptive stage, cause its disap- SCARLET FEVER. 169 pearance, itrompt counter-irritation over the chest, by sinapisms or otherwise, is required. Trousseau states that he has derived benefit in tliese cases, from what he designates urtication. This is pro- duced by stroking the chest two or three times daily with the nettle (urtica dioica or urtica urens). This causes a prompt and abundant eruption, and with a less amount of suffering than one would suppose. The fever abates, and the respiration becomes more natural in proportion to the amount of nettle-rash. On the second day the effect is less than on the first, and after three or four days, says Trousseau, no further irritation results from the nettle. When counter-irritation is produced, by whatever method, the chest should be covered with a warm and soft poultice, as the ground flaxseed; derivatives to the extremities are useful in such cases. In capillary bronchitis and pneumonia stimulating expec- torants are required, as senega and carbonate of ammonia. As regards the treatment of other complications, the appro- priate measures are detailed elsewhere. CHAPTERIL SCARLET FEVER. The terms scarlet fever, scarlet rash, and scarlatina are identical. They are employed to designate one of the most frequent and fatal of the contagious diseases, a disease which may occur at any age, but is' most common in childhood, an exanthem attended with more or less pharyngitis. In this city, on account of its great frequency, and its large percentage of fatal cases, it causes more deaths than any other contagious affection. Though not more common than measles, it is attended, with us, by more than double its mortality. There is no disease that presents a greater difference, as regards character and severity of symptoms, than scarlet fever, and this has led to the recognition of different forms of it. Rilliet and Barthez describe two, the normal and abnormal ; Meigs two, the mild and grave ; and most other writers, three or more. I shall, for convenience, follow Bouchut, who makes three varieties, namely, the regular, irregular, and malignant. Symptoms. Begular Form. — Scarlet fever usually begins ab- ruj)tly. It is possible, often, to tell the exact time of its com- 170 SCARLET FEVER. mencement. If there are premonitory symptoms, they are ordi- narily slight, so as scarcely to attract attention, amounting to little more than dulness, or the appearance of fatigue. In some the first symptom is chilliness, and occasionally a distinct chill is experi- enced. This is the ordinary mode of commencement in the adult. With or without the chilliness, fever, usually intense, arises, , accompanied by such symptoms as ordinarily occur in a febrile state of system, such as cephalalgia, perhaps delirium, anorexia, thirst. The pulse rises to 110, 120, or more, per minute; the skin is hot, face flushed, the eyes bright, and occasionally more or less suffused. In many, there is sudden starting or twitching, with a degree of stupor, showing that the cerebro-spinal system is pro- foundly affected. In most cases there occurs within the first twenty-four hours a symptom which has considerable diagnostic value, namely, vomiting. In 117 cases in which I have recorded its presence or absence, it occurred in 90, usually not at the very commencement, but within the first twelve or eighteen hours. It commonly occurred before the appearance of the rash, but not always. In a few of the cases it is recorded as a symptom of the second da3^ Vomiting at this period is, probably, in most cases, sympathetic, due to the effect of the specific virus of the disease on the brain. It is not a severe symptom, occurring in most cases but once or twice. Great and persistent irritability of stomach indicates a serious form of scarlet fever, and is, therefore, prognostic of an unfavorable ending. "When this symptom is absent or slight, or there is merely nausea, I have found the case ordinarily mild, so that, as regards the frequency of vomiting, the statistics of differ- ent epidemics vary according to the mildness or gravity of the type. The bowels are regular or somewhat constipated in this form of scarlet fever, or if diarrhoea occur, it is slight and tran- sient. When the symptoms described above have continued six to eigh- teen hours, the rash appears. It is first observed about the ears, neck, and shoulders, in reddish indistinct patches, fading into the normal hue. These patches extend and unite, and in the course of a few hours the trunk and upper extremities, and finally the legs, are covered. The scarlatinous rash bears considerable resemblance to that produced by external heat or the redness from a sinapism, but there are numerous minute points of a deeper or duskier red than the surface generally. On passing the finger over the erup- tion, no distinct prominences are observed, but a sensation of rough- SYMPTOMS. 171 noss is sometimes imparted from engorgement of the cutaneous pa- pilljie. The rash disappears by pressure, but in robust children, and in favorable cases, it immediately returns when the pressure is removed. Slow return of the rash is evidence of sluijirish circula- tion, and, when marked, it indicates the malignant form of the disease. The rash gives rise to an itching or burning sensation, which adds greatly to the discomfort of the patient. The degree of redness is not uniform over the surface, and sometimes, especially in mild cases, it is absent in places. Early in the disease, even before the cutaneous eruption, the buc- cal and faucial mucous membrane presents a pretty general red appearance, and the papillae of the tongue are elevated. Pharyn- gitis has already commenced, with more or less stomatitis and tonsil- litis. The inflammation renders deglutition painful, so that diffi- culty is often experienced in giving the necessary drinks. This state of the buccal and faucial membrane continues through the disease. There is sometimes a slight fibrinous exudation over the tonsils ; the tongue is covered with a moist fur, and the secretion from the follicles of the inflamed surface is increased and muco- purulent. The Schneiderian membrane also participates in the inflammation, and, as the disease advances, a thin, irritating dis- charge, containing pus cells, flows from the nostrils. The temperature in the first days of scarlet fever is ordinarily from 102° to 105°, sometimes as high as 107°. The cutaneous trans- piration during this period is nearly checked, so that the skin is hot and dry. The respiration is moderately accelerated, but not so as to attract attention, unless there is a complication ; often there is slio-ht couo-h from mucus in the throat or bronchial tubes. Bron- chitis, common in measles, and giving rise to prominent symp- toms in that disease, is either absent or slight in scarlet fever. The symptoms pertaining to the digestive system during the initial period of scarlet fever have been sufficiently described. The subsequent symptoms do not difl'er materially in regular scarlet fever, except that there is no vomiting. The lips are dry and often cracked. The inflammation of the mouth and throat continues unabated, with anorexia and thirst. The urine is high-colored, and in robust children, during the first days of scarlet fever, it fre- quently deposits the urates on cooling. The symptoms continue with undiminished intensity for a period of from four to six days, when the fever begins to abate, the pun- gent heat becomes less, and the rash fainter. There is a gradual 172 SCARLET FEVER. decline of the disease, which, in its inception, was so abrupt. In mild, and even pretty severe cases, which pursue a regular and favorable course, convalescence commences by the close of the first or beginning of the second week. In the second week, the rash, becoming less and less distinct, finally disappears, as do also the redness and swelling of the buccal and faucial membrane. The engorgement of the papillae of the tongue and that of the tonsils subsides; the appetite returns; the countenance brightens, and be- comes natural, and the child who, during the height of the fever, scarcely noticed objects, or noticed them with indifference, or even repugnance, can be amused as'before his sickness. The period of desquamation succeeds. Exfoliation of the epi- dermis occurs over the whole body. This commences about the face and neck, and it occupies several days, during which there is progressive improvement in the condition of the child. Where the skin is thin, the epidermis, as it is detached, presents a furfu- raceous appearance; where it is thick, as upon the palms of the hands, and soles of the feet, it separates in a layer of considerable thickness. Sach is a brief account of scarlet fever, when it pursues its nor- mal course, without complication or sequelee. But there is no dis- ease which has so many unfavorable complications and sequelee as this. The liability to these renders the prognosis in all cases doubt- ful, and in many instances they are the immediate cause of death. They occur both in mild and severe cases of scarlet fever. The great difference in different cases of scarlet fever, as regards intensity of symptoms, is well known. It is sometimes so mild, its characteristic features so slight, that diagnosis is necessarily uncertain. Examples in corroboration of this statement are not infrequent. In the spring of 1866 I was called to an infant thir- teen months old, who had slight pharyngitis, and an indistinct rash over a part of the surface. In two days the eruption had disappeared, and soon after the health was apparently fully restored. Diagnosis would have remained doubtful, except for sequelse. In another instance, two children passed through the entire course of scarlet fever, playing every day in the street. Although the intel- ligent grandmother saw the rash upon them, its nature was not suspected till nearly two weeks afterwards, when one was taken with fatal nephritis and general anasarca. In cases so mild as these, the heat of surface is not greatly increased, nor is the pulse much accelerated. There is no restlessness, nor is the digestive function materially impaired. The rash does not have so deep a SYMPTOMS. 173 color, nor is it so continuous over the surface, as in cases of ordinary gravity. The patient begins to improve in from two to four days, and is soon well. So mild a form of scarlet fever is, however, quite exceptional, but there are all gradations, from this mildness to that malignant form which I shall presently describe. There is usually considerable faucial inflammation, even when scarlet fever pursues a regular and favorable course. If the pharyn- gitis is intense and protracted, many writers designate the disease scarlatina anginosa. There is, in these cases, not only general and pretty severe inflammation of the mucous membrane of the fauces, with swelling of the tonsils, and submucous infiltration, but also more or less tumefaction around the angle of the jaw, due to exten- sion of the inflammation to the lymphatic glands, and cellular tissue of the neck. In these cases, the suflering of the patient is greatly increased by the amount of local disease. The adenitis and cellu- litis, unless slight, do not subside with the disappearance of the rash, or they subside more slowly. They render the febrile move- ment more protracted. The swelling due to these inflammations often continues one or two weeks after the disappearance of the rash, or even longer, when it disappears by resolution, or more rarely by suppuration, the abscess opening externally. Irregular Form. — The irregular form of scarlet fever is commonly due to some perturbating cause. This cause is often a pre-existing or coexisting disease, or, if not actual disease, at least disordered state of system. For example, a little girl, in my practice, had the symptoms of scarlet fever, such as febrile movement and inflamma- tion of the buccal and faucial surface, nearly a week before the scarlatinous eruption appeared. During this period there were symptoms of enteritis, which declined when the rash occurred. The abdominal affection was the apparent cause of the irregularity in the fever. If scarlet fever occurs during an attack of entero-colitis, there is frequently no eruption. Most practitioners have met cases like the following, which I now recall to mind: In a family where scarlet fever was prevailing, a little child, early after the commence- ment of symptoms which seemed to be plainly referable to the ex- anthematic affection, was seized with vomiting and purging, and the latter continued two or perhaps three days, when death occurred. There were the symptoms and appearances of severe scarlet fever, but without the eruption. In another instance, an infant in the warm months having protracted entero-colitis, the usual summer epidemic of this city, was apparently affected with scarlet fever, 174 SCARLET FEVER. which was present in the family. There were the characteristic symptoms, but the diarrhoea continued, and there was no rash. In those that are much reduced by any antecedent disease, as phthisis, or that have a disease, chronic or acute, which produces a decided afflux of blood towards an internal organ, the eruption is commonly tardy in its appearance, indistinct, or wholly absent. The diseases which most frequently render scarlet fever irregular are those of an inflammatory nature. Some affections, occurring in connection with scarlet fever, do not change its symptoms, but themselves undergo modification. Scarlet fever occurring in a child having pertussis does not itself undergo any material change. The cough, not the fever, is modified (rendered milder) during the coexistence of the two. Scarlet fever may, also, be irregular in those that are robust and free from any other disease assuming this form, without any appre- ciable perturbating cause. In 1867 I attended a young lady, whose previous health was excellent, and whose brother was sick at the time with scarlet fever. This patient had considerable fever, with pretty severe pharyngitis, and though her surface was repeatedly examined, no eruption could be discovered. Two weeks subse- quently she became affected with severe nephritis, anasarca, effu- sion into at least one of the pleural cavities, and probably into the pericardium, the case ending fatally. Rilliet and Barthez mention the irregular and incomplete char- acter of the eruption in second attacks of scarlet fever, which, though uncommon, are met from time to time. Scarlet fever occurring a second time, sometimes presents all the features of the regular disease, and pursues its normal course, but it is much more apt to be incomplete and irregular than the first attack. It is more apt to be irregular if the interval between the two has been short, than if several years have elapsed. Malignant Form. — This form of scarlet fever is in some epidemics common, while in others it is rare. It usually commences with severe symptoms, those pertaining to the nervous system predomi- nating, such as intense cephalalgia, with delirium. Many pass rapidly into coma, and die within two or three days. They suc- cumb to the virulence of the scarlatinous poison, while the disease is still in its commencement. The rash in malignant scarlet fever is dusky. It disappears by pressure, and returns slowly when the pressure is removed. Tliere is, therefore, extreme sluggishness of the capillary circulation. In some there is great restlessness. If placed in one position on the bed, they soon throw themselves, in a COMPLICATIONS. 175 half-conscious or . unconscious state, into another. They do not speak at all, or they mutter like those affected hy the graver forms of typhus, calling the names of playmates, or talking about things which interested them when well. There is great elevation of temperature, the thermometer, placed in the axilla, indicating 103°, 105°, or even 107°, and the heat of surface is pungent, except when the case approaches a fatal termination. The pulse from the first is rapid, numbering from 130 to 160 per minute. Sometimes there is great heat of head and body, while the limbs are cool. This is an unfavorable sign. Severe and dangerous nervous symptoms, as convulsions and coma, occur chiefly within the first three or four days. After this period the danger is mainly from exhaustion. Those who survive the onset of the disease, often have, in the course of a few days, severe pharyngitis, with inflammation of the lymphatic glands, and cellular tissue around the angle of the jaw, accompanied by external swelling. The pharyngitis is attended by more or less secretion of mucus or muco-pus, which, sometimes collecting around the en- trance of the larynx, causes noisy respiration, or even, if the system is greatly prostrated, embarrasses respiration by entering the larynx. The chief danger, however, from the pharyngitis, is due to the exhaustion which it causes. By rendering deglutition difficult, it interferes seriously with nutrition. Complications. — Complications may occur in any form of scarlet fever, but they are most frequent in malignant or grave cases. The most common and serious complication, as regards the nervous system, is clonic convulsions. These occasionally occur at the com- mencement of the disease, before the appearance of the rash, and many then recover, but I have not seen, nor have I heard, in nly intercourse with physicians, of any case which recovered when con- vulsions occurred after the complete development of the eruption. On the other hand, some of the physicians of this city, of largest experience, inform me that they consider convulsions during the eruptive stage an almost certain precursor of death. Convulsive attacks in scarlatina are probably due, in part, to congestion of the nervous centres, for we sometimes find, in young children, at the time of the seizure, and immediately before it, the anterior fonta- nelle prominent, and forcibly pulsating. The convulsions uniformly increase the congestion, but, as the latter antedates the former, its causative relation seems to be established. But the most important element in the causation of convulsions in scarlet fever is, probably, the presence in the blood of the scarlatinous virus. This, whatever 176 SCARLET FEVER. its exact nature, may, in my opinion, cause convulsions, with or without the co-operating influence of congestion, as urea gives rise to them in cases of uraemia. Convulsions occurring at the com- mencement of scarlet fever are usually single. If repeated, they become more serious. Convulsions after the appearance of the eruption, either end at once in coma, or they return at short inter- vals, with gradually increasing drowsiness, till coma supervenes. The anginose aftection in scarlet fever may be so severe, or assume such features, as to constitute a complication. It may become more serious than the primary disease itself, so as to require the chief treatment. During the recent epidemic of diphtheria in this city many cases were observed in which diphtheria and scarlet fever coexisted. As has been stated elsewhere, a pseudo-membranous formation upon the faucial surface, especially over the tonsils, is not uncommon in severe anginose scarlet fever, but is soft or pulta- ceous, in isolated points or patches, and easily detached. On the other hand, in the cases to which I have alluded, of diphtheritic complication, the pseudo-membrane is firm and thick, penetrating the mucous membrane so as to produce bleeding when forcibly de- tached, as in primary diphtheria. In one instance in my practice the coexistence of diphtheria and scarlet fever was very apparent. Two children in a family died after a short attack of malignant scarlet fever. Their throats were not examined. Another child took the disease, and, being longer sick, it was more carefully ex- amined. The diphtheritic pseudo-membrane was found on both tonsils, at the same time that there was a distinct scarlatinous rash, and, as additional proof of the coexistence of the two diseases, the father became aifected with diphtheria without scarlatina. An occasional result of severe pharyngitis in scarlet fever is suppuration, or gangrene occurring in the subcutaneous cellular tissue of the neck. Whether suppuration occur, and an abscess form, or gangrene result, this complication is often serious. Sup- puration or gangrene indicates an intense grade of inflammation or a low vitality ; but many with this complication recover through protracted convalescence. If suppuration is extensive, it may so increase the debility that death occurs in consequence. Gangrene is a more serious compli- cation; unless slight, it renders a fatal termination highly probable. The areolar tissue, subcutaneous or intermuscular, is the part which primarily sloughs. The skin over the gangrene becomes brown or dark, and separates with the slough. In the majority of cases the slough is not large. Exceptionally it extends so deeply I COMPLICATIONS. 177 that, when it separates, the muscles and even vessels of the neck arc laid bare, and the appearance is hideous. In a case of this sort, which I saw a few years since in the practice of another physician, the cavity, after the slough had separated, was irregular, and sufficiently large to admit a hen's egg. It extended a considerable distance out of sight under the skin, and finally opened a vessel from which fatal hemorrhage occurred. Gangrene of the mouth also occurs in rare instances, either as a complication or sequel. I have met it in two cases, one of which recovered. In the fatal case it began while the patient was still under treatment for the fever, and was first discovered by the loss of two incisors. The one that recovered also lost two in- cisors, and a part of the superior maxillary bone. The one that died was scrofulous, though its regimen was good ; the other lived in a tenement-house, and was ill cared for. Rilliet and Barthez relate three cases of gangrene of the mouth, occurring, however, not as a complication, but sequel, of scarlet fever. One of these patients had, within eighteen days, varioloid, scarlet fever, and measles ; these diseases ending in fatal gangrene of the pharynx and mouth. The second child was taken, on the seventeenth day after the commencement of scarlet fever, with gangrene of the pharynx, succeeded by that of the mouth, and died on the twenty- fourth day. In the third case the gangrene was preceded by small- pox as well as scarlatina. Other observers have recorded similar CclSGS, Another complication, to which allusion has already been made, is entero-colitis. This may antedate the zymotic affection. In other cases, entero-colitis commences either with the scarlet fever, or during its course. Diarrhoea often occurs in connection with the vomiting, in the first hours of the fever; and it commonly ceases during the first or second day. Occasionally it continues with greater or less severity, when it constitutes a serious comijli- cation ; it is in these cases due to intestinal inflammation. Bron- chitis and pneumonia, so common in measles, do not often compli- cate scarlet fever. A not infrequent complication is articular rheumatism, occurring when the fever begins to decline. Mild cases are more liable to it than those having a severe form. Attention is called to it by the complaint of the child of pain or tenderness in the affected joints; or, if he is too young to speak, by evidences of pain when the joints are pressed or moved. There are usually but little swelling and redness, and there are fewer joints aftected than in 12 178 SCARLET FEVER. most cases of acute primary rlieumatism. In my practice, a com- mon seat of scarlatinous rheumatism lias been the areolar tissue of the wrist. The inflammation and infiltration are less than in primary acute rheumatism. This complication is not, ordinarily, serious; nor does it, as a rule, materially retard convalescence. A physician of this city, however, informs me of two cases in which cardiac inflammation occurred in connection with the articular affection, as it so frequentl}^ does in idiopathic rheumatism. The urates are not so commonly present in the urine in scarlatinous as in ordinary acute rheumatism. Serous inflammation, especially that affecting the peritoneum, pleura, or pericardium, is a common complication, independently of the rheumatic affection. It occurs during the desquamative period, and, continuing afterwards, becomes a sequel. Many such cases are fatal. Pericarditis may be with difliculty diagnosticated, if it is slight, and attended by only a moderate amount of effusion, and it is, doubtless, often the cause of death in those who die suddenly and unexpectedly during or soon after an attack of scarlet fever. Pleuritis occurring in scarlet fever is apt to be suppurative. In 1865 I attended a little girl in a mild attack of the fever. When it had nearly ceased, and the case was about being discharged, she was taken with severe pleurisy of the right side. The pleural cavity was soon half filled with liquid, and after a long sickness, extending over two months, this liquid, mainly pus, established a communication with a bronchial tube, and was expectorated. She immediately recovered. In the folloAving case, the records of which are from my note- book, pericardial and peritoneal inflammation occurred as a com- plication of scarlet fever: — ■ Case April 7th, 1860, C — , girl, five years and ten months old, had measles two years, and hooping-cough one year ago. With the excep- tion of a slight cough, she has since remained well, till the present sickness. Scarlatina commenced April 4th, and on the 5th the eruption appeared. Symptoms severe, but regular ; pulse 158, full; surface hot, ' and covered with tlie eruption; delirium at night; stomach irritable; constipation. April 8th to 10th, symptoms about the same; no delirium, however; pulse varying from 124 to 153 per minute ; a deposit of urates in the urine. 11th. To-day, for the first, has severe pain in the epigastrium, ac- companied by tenderness on pressure, and moderate distension at this point. The symptoms otherwise are favorable, though pretty severe ; pulse 140; respiration moderately accelerated, but the rhythm natural; respiratory murmur distinctl}^ heard in all parts of the chest, vesicular in character, and without rales. Has taken till to-day mainly diapho- retic mixtures; to-day pulv. ipecac, comp. gr. iij, every three or four SEQUELS. 179 hours, is ordered; a flaxseed poultici9 to be applied to tlic epigastrium ; diet nutritious, with moderate use of stimulants. 12th. Epigastric pain still severe ; great tenderness on pressure ; con- siderable distension at this point, and percussion elicits a dull sound; passed a restless night ; when asked where she feels pain, she points to the throat and epigastric region; pulse 130 to 140 per minute; rash fading; surface warm ; bowels somewhat relaxed; urine passed in usutd quantity-. The treatment by Dover's powder and poultices is continued, and a leech is to-da}^ applied to the epigastrium. 13th. Pain less severe, but considerable tenderness on pressure; pulse about the same as yesterday ; has had through her sickness a slight cough. She talks rationally, and sits much of the time in bed. 14th. Continued in the same state as described in yesterday's records, till 3 P. M. yesterday, when she became suddenly worse ; her respiration was short and gasping ; she spoke, with an effort, in a whisper, but continued conscious ; and her pulse was strong. Death occurred at 5 P, M., apparently from obstructed respiration. In the last days of her sickness there was but little pharjaigitis, and little or no external swelling. Autopsy ticenty-four hours after death. — Body a little emaciated ; heart large for a child of five years ; about one ounce of turbid serum in the pericardium ; a soft deposit of lymph within the pericardial sac at the base of the heart, around the origin of the great vessels evidence of recent circumscribed pericarditis ; from four to eight ounces of trans- parent serum in each pleural cavit}' ; no fibrin upon or opacity of the pleural surfaces ; mucous membrane of bronchial tubes injected in streaks, and muco-pus can be pressed from them ; both lungs can be readily in- flated, with the exception of small portions of both the lower lobes, which are hepatized, and can be but partially inflated ; liver enlarged, presenting a congested appearance, and extending some four inches be- low the free border of the ribs ; upon its convex surface in the epigas- trium, corresponding with the seat of the pain, is a white rough patch of fibrin about one and a half inches in diameter; kidneys congested; stomach and small intestines apparently healthy; mesenteric glands moderately enlarged; mucous membrane of transverse and descending colon somewhat injected and thickened, showing mild colitis; no ulcera- tion noticed ; brain not examined. Microscopic examination was made of the blood, hepatized portions of lung, etc., but nothing of special interest in this connection was observed. Tliis case is instructive as sliowing the liability which exists in and after scarlet fever to inflammations, and the difficulty of diao-nosticatino; theni in certain cases on account of their circum- scribed character. Sequelje. — The complications described above jnay occur as sequchie, but there is another pathological state which may be a complication, and is a common and serious sequel. I refer to nephritis with albuminuria. This occasionally commences in scar- let fever, but usually not till the disappearance of the rash. There is sometimes, during the course of scarlet fever, and even subse- 180 ' SCAELET FEVER. qiientlj, slight albnminiiria due to simple congestion of the kid« neys, but the albuminuria to which I allude, and which requires treatment, is more serious. Its anatomical character is as follows : hyperfemia, and perceptible increase in volume of the kidneys ; proliferation of the renal epithelial cells like that of the epidermis, and a granular deposit in them ; the escape of albumen from the engorged capillaries, and its appearance in the urine ; the forma- tion of fibrinous casts in the tubuli uriniferi, these casts often con- taining more or fewer epithelial cells ; the escape of the casts from the kidneys with the urine ; diminution of amount of urea ex- creted, and, therefore, its accumulation in the blood ; and finally rupture of the engorged capillaries of the kidneys, and mingling of the elements of the blood with the urine. The presence, therefore, of this renal aflfection can be readily ascertained by examining the urine. The quantity of albumen which this liquid contains can be aj^proximatively ascertained by adding nitric acid or applying heat. If the quantity is small, simple cloudiness is produced ; if large, the urine becomes thick and white, and in extreme cases almost semi-solid from coagulation of the albu- men. The character of the urine can, however, be more accurately ascertained by the microscope than by the tests which have been mentioned, since by it we discover the fibrinous casts, altered epi- thelial cells, and blood corpuscles. Nephritis, with the consequent uraemia, soon gives rise to evident symptoms. Serous eftusion takes place in consequence of the altered state of the blood, the most common form of which is anasarca, occurring upon the face and limbs, and sometimes in the areolar tissue of the trunk. Often the effusion occurs only in the external areolar tissue, and the result is then favorable; but in other cases it occurs, and in the order mentioned as regards frequency, in the lungs (oedema pulmonum), serous cavities, and, lastly, in the submu- cous connective tissue of the larynx (oedema glottidis). The internal effusion should excite the gravest apprehensions, as it is often fatal. Fortunately, it is in most cases preceded as well as accompanied by anasarca, which is easily detected, so that there is sufficient forewarning. The fact of an occasional exception to this rule should be borne in mind. Scarlatinous nephritis, with consequent uraemia, is due to the direct effect of the scarlatinous poison on the kidneys. I have known it occur in the nurse who attended a child through the fever, but did not suffer from the fever herself. It sometimes occurs quite abruptly, and often when the patient has been progressively I SEQUELJil. 181 convalescing, and, perhaps, lias seemed out of danger. In most cases, however, there are well-marked premonitory symptoms, as fever, restlessness, loss of appetite. The anasarca is first observed in the face or about the ankles. Sometimes it remains inconsider- able, but in other cases it increases day by day, more or less rapidly, till the appearance of the patient is much altered. In marked cases of anasarca the features are so bloated that their natural expression is lost. The volume of the trunk and legs is augmented, and, more slowly, that of the arms. In the male child the penis and scrotum frequently attain three or four times their normal dimensions, in consequence of serous infiltration. The duration of the anasarca or dropsy is very dift'erent in dif- ferent cases. If the form be oedema pulmonum, oedema glottidis, or intra-cranial effusion, deatli is speedy. It may occur even witliin a day. Hydrothorax and hydropericardium are also ordinarily fatal, though not so speedily ; while in ascites the prognosis is much more favorable. The duration of anasarca under the most favorable circumstances, unless it is very slight, is commonly not less than two or three weeks, and is often much longer. There is another and an important source of danger apart from the serous effusions, namely, the retention of urea in the blood. Convulsions, coma, and death may occur from urtemic poisoning, as in Bright's disease. In those cases there is great and continued scantiness of urine, in consequence of obstruction in the tubuli uriniferi from fibrinous casts and granular and swollen epithelial cells. • The liability to this renal affection is greatly increased, and in some cases is mainly attributable to the close relationship, as re- gards their functions, which exists between the skin and kidneys. A common exciting cause is exposure to vicissitudes of tempera- ture or currents of air, by which the surface is chilled, and cutane- ous transpiration checked, at the time when the old epidermis is being detached. The increased burden thrown upon the kidneys results in the pathological state which has been described. This remark does not conflict with the statement already made, that the nephritis is due to the direct effect of the scarlatinous principle on the kidneys, the disturbance of the function of the skin merely in- creasing the functional activity of these organs and rendering them more susceptible to the disease. All who have seen much of scarlet fever can recall to mind cases in which the patients had nearly recovered, when from some needless exposure in the streets, or by chilling of the body in a cold room, or open window, this affection occurred, with perhaps a fatal result. Elsewhere I have alluded 182 SCARLET FEVER. to a case in which scarlet fever was only detected by this sequel, which began when the child was daily exposed in the open air. But many children who have been attended with the utmost care, and who, through the whole desquamative period, are kept in a uniform temperature, nevertheless become affected with albumi- nuria and dropsy, so that there is sufficient cause of this sequel in the state of the child and the nature of the disease through which he has passed, apart from extraneous influences. It is an interest- ing fact that albuminuria is more ajrt to occur after mild than severe cases of scarlet fever, and observations show that this difference in liability to albuminuria is intrinsic ; in other words, that it does not dejDend, as some have supposed, on a difference in the hygienic manao-ement of mild and severe scarlatina. The symptoms in scarlatinous nephritis vary not only according to the degree of the inflammation, but also according to the amount and seat of the effusion. I have stated that it usually commences with languor and more or less fever. The pulse remains accelerated, the skin is hot and dry, and the appetite poor. This affection, if slight, may occur without appreciable effusion, either in the cellular tissue or the cavities, but ordinarily in these mild cases a little puffiness is observed around the eyes or upon the extremities. In the majority of cases more extensive anasarca results. The skin is then pallid, distended, and pitting on pressure. The anasarca does not, in most instances, give rise to any marked symptoms. If oedema glottidis or pulmonum occur, the respiration becomes rapidly more embarrassed, till soon the blood is no longer suffi- ciently oxygenated for the purposes of life. The chief symptom in hydrothorax is accelerated and difficult respiration ; in hydroperi- cardium the symptoms are such as arise from embarrassed action of the heart ; in ascites there are either no marked symptoms, or, if the amount of liquid is large, there may be more or less embar- rassment of respiration from compression of the lungs. Otorrhoea. — Inflammation of the external ear, giving rise to otorrhoea, is a frequent sequel of scarlet fever. It sometimes commences as a complication in the last stages of the fever; at other times it begins during convalescence. It often produces a degree of deafness, which, in most instances, soon passes off. A thin, purulent discharge from the ear may remain for months or even years, and hence the name which designates this affection. In exceptional cases, internal otitis occurs. This is a more serious sequel ; it may impair the hearing permanently. There are cases in which not only the drum of the ear is destroyed, but the ossicles NATURE. 183 are detached, and lost through the external ear. Complete deaf- ness then results. I have met one case, in which hoth ears were 80 injured by scarlet fever in infancy, that the child grew up a nnite. The result is sometimes still more serious. The inflamma- tion may extend inwards, causing caries of the petrous portion of the temporal bone, till it reaches the lateral or petrosal sinuses. The inflammation then causes thickenins: and bulo-ino; of the walls of the sinuses, and, consequently, partial obstruction to the circulation, congestion in the veins and sinuses, the formation of thrombi, and finally coma and death. Fortunately, this melan- choly termination of scarlatinous otitis is not frequent. Anatomical Characters. — There is some difiiculty in determin- ing what are the anatomical characters of scarlet fever, since so many who die of this disease have a complication, and the lesions of this are superadded to those of the fever. The following, how- ever, are the facts which have been ascertained in reference to this point. In many the brain, its membranes, and the lungs are congested; often, also, the Peyerian, solitary, and mesenteric glands are enlarged, and the spleen enlarged and softened. The liver and kidneys do not present any notable alteration, though the latter are so often affected during the period of convalescence. Dr. Samuel Fenwick {London Lancet^ J^ily 23, 1864) has made post- mortem examinations in sixteen cases of scarlet fever, and concludes from them that there is inflammation of the mucous membrane of the stomach and intestines like that of the skin, and that there is desquamation of the epithelial cells from those portions of the digestive tube like that of the epidermis. I have had opportunity of examining the stomach and intestines in those who died in the eruptive stage during epidemics, in the ITursery and Child's Hospital, and have never found any unusual hypersemia of the gastro-intestinal surface, unless when gastro-intestinal inflammation had occurred as a complication. In malignant cases the blood is dark, and the heart-clots soft and small ; in other cases the color of the blood may be nearly normal, and the heart-clots of the usual size and firmness. Mature. — Scarlet fever presents in a marked degree the distin- guishing features of the contagious afiections. It is highly infec- tious ; it is also inoculable. Stoll, d'Amboise, and others successfully inoculated with the scarlatinous virus, using the blood, but without diminishing the intensity of the disease. Whether scarlatina ever originates spontaneously is uncertain; but if it do, such cases are rare. It ordinarily spreads through a community by infection, 18-i SCAELET FEVEE. though the distance to which it is infectious is short, probably not more than two or three yards. Some consider the distance to be even less than one yard. Knowledge of this fact is important, as by isolating in a family a child attacked by scarlet fever, and allowing no communication with the nurse, the other children often escape. A very common mode of communication is by clothing, so that a third j^erson is the medium of transmission. I have noticed that when scarlet fever, as well as measles, is epidemic in this city, a large proportion of the cases, nearly all, indeed, of the first cases, can be traced to the public schools. Exposure occurs through those children who come from apartments where cases are under treatment. Physicians, and especially nurses, are sometimes the medium of communication. A medical friend of mine went directly from some children with scarlet fever, whom he was attending, to another family, where he took a little girl upon his knee. This girl in a few days became affected with scarlet fever and died. The two remaining children in the family were then attacked, and one died. Murchison alludes to similar cases {London Lancet, August 13, 1864). In one instance in my practice scarlet fever was communicated to an infant by a washer- woman whose own child had the disease, and who, on reaching the house where she had been engaged to work, threw her shawl over the cradle where the infant was sleeping. Six days later the infant was attacked. Mason Good cites a case where a box of toys was the medium of communication; and it is said that also a letter has been. The scarlatinous virus may remain for weeks and even months in apartments, clothing, or in or upon the person of one who has been affected, without any appreciable diminution in its effective- ness. A physician of this city, in whose family scarlet fever occurred, excluded a child from the room occupied by the patients, and from the patients themselves, for a month after the last case occurred, and yet, although ^jrecautions had been taken in reference to clothes and bedding, this child was taken with scarlet fever soon after it was allowed to mingle with the other children. The father believes that the exposure was through the otorrhoea of one of the children. Observations, indeed, appear fully to establish the fact that the discharge from the ear or nostrils, and the particles of epidermis which have exfoliated, may retain the virus and be the medium of communicating the disease several weeks after the fever has terminated. In a case in my practice a little girl returned home six weeks after her brother had scarlet fever, and, within a few days, took the disease. A more striking example occurred NATURE. 185 in tlic practice of Dr. Kearney Rogers, formerly a prominent and much esteemed surgeon of this city, and was related to me by an intelligent friend of the family since the doctor's death. Six children in a family had scarlet fever. Three and a half months subsequently another child, living at a distance, was allowed to visit them in the apartments where they had been sick. One week from that day this child became affected with the disease. Dr. Elliotson states that a patient with scarlet fever was admitted into one of the wards of St. Thomas's hospital, and, for two years subsequently, young persons who were admitted into this ward wei^e apt to take the disease. Dr. Richardson relates the case of a family of four children, residing in the country. One died of malignant scarlet fever, and the rest, who had been removed, escaped. Some weeks subsequently one of the children returned, but within twenty-four hours took the disorder and died. The cottage was now thoroughly cleaned, whitewashed, and the clothing destroyed. Four months then elapsed, when the third child returned home, who also took scarlet fever in a malignant form and died. It was believed that the virus remained attached to the thatch, which extended close to the children's bed. Other similar examples might be mentioned, sufficient to establish the fact of the great permanence of the scarlatinous virus. The period of incubation in scarlet fever varies. It is seen in the remarkable example of contagion, given above, that it was only twenty-four hours. Trousseau also relates an interesting example of short incubation. " An English gentleman with his daughter was returning from Pau to London, and was joined at Paris by another daughter, who came direct from London. Scarlet fever was prevalent in London, but there was not a cas^ of it at Pau. The second daughter was seized with scarlet fever in crossing the channel, and joined her relatives in Paris seven or eight hours later. She occupied the same room in the hotel as her sister, who was also attacked within twenty-four hours." The incubative period is, however, seldom so short. It is usually from three to eight days. I might cite several cases in which this was its duration. Some writers allude to cases in which two, three, or even four weeks elapsed from the time of exposure to the appearance of the disease. It is, however, a question whether in such cases there may not have been a second and more recent exposure. Rostan alludes to cases in which scarlet fever was communicated by inocu- lation, and in which the period of incubation was seven days. Scarlet fever occurs most frequently between the ages of three 186 SCARLET FEVER. and ten years. It is infrequent under the age of one year, and infants under the age of three months may be ^considered safe from an attack of it, though fully exposed. Cases have been reported of scarlet fever occurring in the foetus, and manifesting itself by the usual signs at birth. But a clear diagnosis in such instances is necessarily difficult, on account of the character of the scarla- tinous eruption on the one hand, and the nature of the cutaneous circulation in the newly-born on the other. It is probable that, in the cases alluded to, there was an error of diagnosis. Certainly in two instances I have known women immediately after their con- finement (within a week) take scarlet fever, and although they communicated the disease to others, did not to their infants. Murchison states that twice he has known women with scarlet fever to be confined, and in both instances the infants were healthy. Most adults possess immunity from scarlet fever, although not protected by an attack of it in childhood. Parturient women, however, are liable to it, and there is considerable danger that the physicians who attend them, if at the same time visiting cases of scarlet fever, may communicate the disease to them. Scarlet fever is sometimes sporadic, but, as we meet it in this country, it occurs most frequently as an epidemic. The epidemic^ vary greatly in type. Some are mild, and attended by few com- plications, so that the result of treatment is eminently satisfactory. In other epidemics the type is malignant, the complications fre- quent, and the percentage of deaths large. There is sometimes a succession of epidemics of one type, and then the character of the disease changes. This fact of a variable type is important as re- gards the value of statistics relating to treatment. Each epidemic has its prevailing character, but when the form is mild, there is now and then a case of severity, and when it is malignant, now and then one of unusual mildness. The epidemic influence is some- times manifested in those exposfed to scarlet fever by the occurrence of pharyngitis, and, as we have seen, nephritis. Professor George B. Wood, of Philadelphia, says ( Treatise on the Practice of Med.) : " I seldom attend cases of scarlet fever without having sore throat." Scarlatina usually occurs but once in the same individual, but a second attack after the lapse of several years is not uncommon, and there are even eases on record of a third attack. But physicians sometimes mistake roseola or erythema for scarlet fever, and, though afterwards aware of their mistake, do not correct their diagnosis. Hence there is a belief in the community that second attacks of scarlet fever are more frequent than they really are. DIAGNOSIS. 187 DiAGTrosTS. — In the commencement of scarlet fever, prior to the eruption, there are no symptoms or appearances which will enable us to make a positive diagnosis. Positive statement in reference to the nature of the disease might better be deferred, for the credit of the physician. Still, if a child with regular bowels, and no appreciable local disease, a few days after exposure to scarlet fever, is suddenly seized with intense fever, the pulse rising to 110, 120, or more, and the temperature to 102°, 103°, or 105°, there is little doubt that the disease is scarlet fever. The dias-nosis is rendered more certain if there is vomiting, and especially if, as is often the case, there is, at this early period, a blush of redness upon the fauces. When the eruption has appeared, the nature of the affection is, in most cases, apparent. Still, roseola or erythema, due to intes- tinal derangement or other causes, has often, as already stated, been mistaken for scarlet fever. A day or two suffices to show the error. In scarlet fever there is more inflammation of the faucial and buccal surface, more continuous and persistent redness of the skin, and greater intensity and persistence of symptoms, than in those diseases. Scarlet fever is also further distino-uished from them by the papular elevations upon the tongue, and the minute papulae upon the skin. Besides, in scarlet fever, except in the mildest cases, there is from the first the aspect of serious sickness, which roseola and- erythema do not present. Scarlet fever and measles were long considered identical by the profession, and, though the ordinary forms of the two diseases can be readily distinguished from each other, there are instances in which the differential diagnosis is attended by some difficulty. Measles occurring in a robust child, with an active cutaneous cir- culation, sometimes presents a continuous eruj^tion over a consid- erable part of the surface, like the eruption of scarlet fever. But the longer period of invasion, the coryza and bronchitis, and the absence or slight degree of pharyngitis, in connection with other symptoms, enable us to distinguish these cases from scarlatina. Moreover, in those cases of measles in which there is continuous redness of surface where the circulation is most active, as upon the face, the characteristic rubeolous eruption is present in other parts, so that, with care in examination, error of diagnosis may be avoided. Scarlet fever and measles may indeed occur together, but such a complication is rare. The greatest difficulty of diagnosis occurs in abnormal scarlatina, especially when the rash is partial and indistinct. There is apt to be, in this form of the disease, an inflammatory complication, which 188 SCAKLET FEVER. causes witlidra-wal of blood from tlie surface, and it is sometimes very puzzling to decide whether this is a complication, or the sole disease. The points involved in diagnosis are numerous, but they are sometimes not sufficient to show the character of the aiFection. Grcnerally, however, by observing the clinical history from day to day, the diagnosis is established. In cases of doubt it is safest to adopt such hygienic management as is appropriate to scarlet fever'. Prognosis. — The prognosis depends on the form of the disease, whether mild or severe, the presence or absence of complications, and the strength of the patient. The mortality varies greatly in different epidemics. In epidemics of a mild type, the mortality is sometimes not more than one in twelve, and the ratio may be less ; whereas, if a severe form is prevailing, not more than one recovers in every two, three, or four. The mortality is greater in the city than country, in hospital than in private practice. Rilliet and Barthez, in hospital practice, lost forty-six out of eighty-seven. Scarlatina is, of itself, less fatal than statistics would lead us to suppose, since a large proportion of those who die in consequence of it die from complications or from sequelee, rather than from the primary disease. The symptoms, in the first days of scarlet fever, which indicate an unfavorable termination, are convulsions, except at the very commencement, great drowsiness, with jactitation, great elevation of temperature, a rapid pulse, duskiness of the eruption, and feeble capillary circulation. At a later period, particularly in the second week, other unfavorable symptoms may occur in malignant and fatal cases. Violent pharyngeal inflammation, with great external swelling from the adenitis and cellulitis, is apt to be present at this stage of the disease. Severe inflammation of this character, as indicated by the tumefaction, greatly increases the danger. As there are several complications and sequelae of a dangerous character, and as these are apt to occur suddenly, and often without appreciable existing cause, in mild as well as severe cases, it is unwise ever to make an unconditional favorable prognosis. The patient is not to be considered entirely safe till two or three weeks have elapsed after the eruption. Some patients who have passed through scarlet fever, die of asthenia, in consequence of the ansemic state which the fever has produced. They have not sufficient vigor of system to recover, although no serious complication or sequel has occurred. In other cases the pharyngitis and cellulitis, attended with tumefaction, rendering deglutition painful, and keeping up the febrile movement TREATMENT. 189 after the primary disease has run its course, have much to do in producing a state of exhaustion and death. But the mortality in the desquamative stage, and subsequently, is more frequently due to the renal affection, which is so common, than to any other cause. This affection gives rise to dropsies, which are fatal, or to ursemic convulsions, and coma. Sudden and unexpected deaths are not uncommon in scarlet fever, and it is probable that, in many of these cases, the immediate cause is uraemia, which, not having produced any conspicuous symptoms till near the close of life, is not discovered. Treatment. — Scarlet fever, when mild, and without complica- tion, requires little treatment. A gentle cathartic, like the citrate of magnesia, should be given from time to time, if there is a tendency to constipation, and a simple diaphoretic mixture in addition, is all that the case requires. R. Spts. aether, nitr., Syr. ipecac, aa 5ij ; Syr. simplic. 3J. Misce. Dose, one teaspoonful every three hours to a child of three to five years. If there is restlessness, an occasional warm mustard foot-bath will give relief; and if there is considerable fever, as indicated by flushed face, heat of head, cephalalgia, or other nervous symptoms, cool applications should be made to the head, and the face and forehead occasionally bathed with cool water, bay rum, or other cooling lotion. The mildest cases indeed commonly do well with- out treatment, except hygienic, though it may be necessary, in consequence of the impatience of the family, to prescribe a placebo. When the fever has begun to abate, in such cases, if the appetite returns, and there is no complication, and no symptom of feeble- ness, there is little for the physician to do. But if, as is sometimes the case, even when the disease has been mild, the appetite remains poor, and the aspect is anaemic, tonics are required, especially chalybeates. The majority of cases, however, demand more decided measures than those described above. We pass to the consideration of cases of moderate severity, and those of a grave character. Trousseau recommends cold affusions as an important part of the treatment. They should be employed in the first stages of sthenic cases. They are especially beneficial, it is stated, in those cases in which nervous symptoms predominate. The patient is placed naked in a bathing- tub, and three or four pails of water are thrown over him, in a space of time varying from a quarter of a minute to one minute, 190 SCARLET FEVER. after which he is covered with bedclothes, without being wiped. Reaction immediately occurs, often with more or less perspiration. This treatment is repeated once or twice daily, according to the gravity of the symptoms. " Dr. Currie," says Trousseau, " was the first who made use of this treatment, and he established its applicability, as a general rule, in scarlatina accompanied by grave nervous accidents, such as delirium, convulsions, diarrhoea, excessive vomiting, considerable exaltation of the heat of surface." Trousseau believes that cold allusions diminish the febrile movement, and calm the nervous excitement, and he further adds: "* -^^ I have never adminis- tered it without deriving some benefit." Public opinion is, how- ever, so averse to such treatment of the eruptive fevers, that one of less authority than Trousseau would scarcely be able to employ it. The shock of such treatment to a child not sufficiently old to ))e reasoned with must be considerable, and it would seem question- able whether the excitement from such a measure may not increase the liability to clonic convulsions. In the cases alluded to by Trousseau, in which there is great heat of surface, and nervous symptoms predominate, though cold affu- sions are not used, there is no doubt of the beneficial efl:ect of cold applications to the head, and sponging the face and arms. This may be frequently repeated if there is great elevation of temperature. The medicinal treatment of scarlet fever has varied greatly at different j^eriods, according to the theory which happened to pre- vail, and it is even now far from uniform. Phj'sicians, however, generally prescribe sustaining measures. If catalysis occur, as the fundamental pathological process, in scarlet fever, and the other so-called zymotic diseases, and if we possess safe anti-catylitic medicines, which will arrest this process, these agents are in all cases required. But the use of anti-catylitics is still experimental, and they are not, therefore, to be recommended in place of remedies which have been long employed, and are knoAvn to be of real value. Depletion is rarely required in scarlet fever ; on the other hand, sustaining measures are indicated from the first. Bloodletting, formerly more or less employed in the treatment of this disease, is now almost obsolete. In no instance is venesection required. In rare instances, in robust children, having an active circulation and a decidedly sthenic form of the disease, there might be a con- dition in which one or tw^o leeches would be serviceable; as, for example, leeches applied to the temple, if there is evidence of dangerous cerebral congestion. But in these cases a sufficiently TKEATMENT. 191 sedative or tranquillizing effect can, ordinarily, ])e produced by the application of cold to the head, cold ablutions to the face and hands, and by an occasional warm general or foot bath. In all malignant cases, measures which reduce the vital powers cannot fail to be injurious. In those cases which are properly designated by that name, there are often evidences of prostration from the first, as drowsiness, jactitation, delirium, languid circulation, evinced by the dusky hue of the surface. These symptoms indi- cate the need of stimulants. In the ordinary as well as severe forms of scarlet fever, carbonate of ammonia, administered with a tonic, is one of the best remedies. It is, moreover, recommended by the best authorities. It may be prescribed at the first visit of the physician, and continued at regular intervals. It is used as a main remedy by many judicious and skilful practitioners. I ordinarily prescribe it in combination with citrate of iron and ammonia. R. Amnion, carbouat., Ferri et ammou. citrat., aa 333; Syr. simplic. gij. Misce. Dose, one teaspoonful every three hours to a child of five years. The preparations of cinchona are also useful tonics. The reader is referred to our remarks on the use of carbolic acid, under the head of Prophylaxis. It promises to be not only a prophylactic, but remedial agent of great value in scarlet fever. An unpleasant symptom in most cases, and one which increases greatly the restlessness of the patient, is itching of the skin. The safest and best remedy for this is inunction. Fresh lard has sometimes been employed for this purpose. It relieves the dry- ness, and in a measure the heat of surface, and at the same time diminishes the itching. The odor from the lard is, however, offensive after it has been used for a day or two. An equally eflica- cious, more agreeable, but more costly substance for the inunction is glycerine, which may be applied pure, or scented with one of the essential oils. Dr. J. F. Meigs recommends the followins:: — R. Glycerinse 5j ; Ung. aq. rosse §j. Misce. I prefer to either of these applications the employment of sweet oil or glycerine, to each ounce of which about six or eight drops of carbolic acid are added. The inunction should be made with the palm of the hand, or with muslin or linen. Those parts of the surface which are the seat of 192 SCARLET FEVER. itching sliould be frequently treated in this way, and occasionally the application may be made over the entire surface. 'Not only does inunction have the local effect which has been described, but it is stated to diminish sensibly the ra^^idity of the pulse and the general temperature of the body. The cases which require the closest watching and the most judi- cious manag-ement are those of an ataxic character. These cases are characterized by nervous symptoms, as jactitation, drowsiness, delirium. There is great heat of surface, while the capillary circulation is sluggish. Sometimes the rash is indistinct. In such cases a general warm bath is useful, to which mustard is added in sufficient quantity to cause some irritation of the surface. This not only quickens the capillary circulation, producing a better color of the rash, or causing it to appear, if its development is retarded, but it calms the nervous excitement, and is often instru- mental in preventing convulsions. If convulsions occur, which are attended by disappearance of the eruption, the bath should be employed at once. In grave cases, in which the rash is indistinct, some physicians, whose opinions are entitled to consideration, em- ploy belladonna in sufficient dose to cause an eruption. I am not aware, however, that the severity of scarlet fever is diminished by this agent, as thus employed, although the disease is apparently rendered more normal by its use, so far as the rash is concerned. The pharyngitis demands attention in most patients. Various modes of treating this have been recommended. The application of leeches to the throat, once a common practice in severe scar- latinous pharyngitis, has fortunately fallen into disuse. If the pharyngitis might be diminished by leeching, which is doubtful for this form of inflammation, the benefit is more than counter- balanced by the evil effect, as regards loss of strength, which results from depletion. The application to the throat of a cloth wrung out of cold water, or containing pounded ice, has been recommended; but the continued wetting of the patient which such treatment necessitates, and the danger from constant cold applications of chilling the body and causing retrocession of the eruption, would deter the prudent ^practitioner from employing such measures. After making use of various applications, I have been led to regard with most favor the use of a slice of salt pork, cut as thin as possible, and stitched to a single thickness of muslin or linen. The pork should pass from ear to ear, the cloth being tied or pinned over the vertex. It is best to sprinkle salt, or salt and TREATMENT. 193 pulverized camplior, upon tlie pork, in order to secure a more prompt etfect. If the application is properly made, the surface usually begins to he reddened in twenty-four hours, and, by the second day, an impetiginous eruption appears upon the part cov- ered by the pork. Counter-irritation gradually produced in this manner causes little sufiering. Patients, ordinarily, do not com- plain of it at all. This application should he continued through the fever, being occasionally left off for a day or two, as too much soreness is produced, and a linen cloth smeared with sweet oil or some simple ointment applied in its place. This simple external treatment diminishes the inflammation of the mucous membrane underneath, and also to a certain extent that of the connective tissue, in those severe cases complicated with cervical, cellulitis so that tumefaction and suppuration about the angle of the jaw are less likely to occur. A well-known phj^si- cian of this city, who has had ample experience in the treatment of children's diseases, ordinarily applies a small blister over the most prominent part of the swelling at the earliest moment, and by the vesication believes that he often succeeds in materially diminishing the inflammation. But counter-irritation in the manner which I have advised has the advantage of being less painful while it is equally effectual, and the irritated surface heals readily. I have never known the eruj)tion produced by pork assume a gangrenous, phagedenic, or otherwise unhealthy appearance. This treatment does not always prevent a considerable degree of inflammation and tumefaction, but, if properly employed, it does diminish more or less this local affection. If there is external swelling which counter-irritation does not remove, and it becomes red and painful, irritating applications are no longer proper. Emollient poultices are now required. Mild cases of scarlet fever do not require direct applications to the inflamed faucial surface. Gargles of a saturated solution of chlorate of potash, to which one of the astringent preparations of iron is added, or, better, carbolic acid in the proportion of about six drops to the ounce, should be employed by those old enough to use them, in cases of moderate or severe pharyngitis. In younger children, and in all cases in which the pharyngeal symptoms are urgent, we cannot rely on gargles, but must make direct applica- tions to the throat with a probang or a large camel's-hair pencil. I advise, in such cases, the application every three or four hours of the carbolic acid and chlorate of potassa, directing, also, the nos- trils to be syringed with the same three or four times daily : — 13 194 SCAELET FEVER. K. Acid, carbolic. 5ss; Potas. chlorat. 5iij ; Glycerinfe §ij ; Aquae §iv. Misce. For the throat. The effect of carbolic acid, in checking the muco-purulent dis- charge and relieving the inflammation is often very decided. Occa- sionally, in severe cases, I apply once or twice daily in addition — R. Liq. ferri subsulphat. 5j ; Glycerinse 3iij. Misce. There is no application more effectual than this in removing any pseudo-membrane, and by its powerful astringent effect diminish- ing the turgescence of the inflamed surface. Yeast is also useful in many of these cases, given in the quantity of half a teaspoonful to a teaspoonful several times daily. As it is swallowed it touches each part of the throat, and, if no drink is allowed for a few minutes afterwards, it produces a healthy, stimulating eftect on the dis- eased surface. Sometimes, in feeble children, viscid mucus collects in the pharynx and around the aperture of the glottis, so as to interfere with' inspiration. In these cases there is danger of death from apnoea. Prompt interference is required. Swabbing the throat removes the mucus, which is attached to the swab, or is expecto- rated by the forced cough which the operation causes. The swab- bing may be performed by a piece of whalebone, bent at the end and wound with linen or soft muslin. I usually employ it dipped in the solution of carbolic acid and chlorate of potash. I have sometimes relieved the most urgent dyspnoea by this means. An accumulation of mucus in the pharynx or larynx, so as to require mechanical interference, is most frequent in infants. The diet in scarlatina should be nutritious, consisting of animal broths, milk porridge, and the like. The patient will rarely take solid food, except in the mildest cases. Those affected with grave forms of the disease require nutriment as regularly, night and day, as in typhus and typhoid fevers. In mild cases, alcoholic stimulants are not required, unless in moderate quantity towards the close of the disease. In severe cases, attended from the first Avitli great prostration, they are needed throughout the entire course of the fever. Wine-whey or milk-j^unch. should be regularly administered, in quantity ac- cording to the age of the child. The presence of severe nervous symptoms, as jactitation or delirium, in these asthenic cases, should TREATMENT. 195 not deter from its employment. Convulsions and coma are, indeed, less likely to occur if stimulants arc used, since the scarlatinous virus is, in a measure, counteracted by such agents. The apart- ment in which the patient is treated should be airy, and ventilated without exposure to currents of air. The temperature of the room should be uniform, about 68° for robust children with high fever, about 70° for feeble children. It should be a little more elevated after the fever has abated, and the desquamative period com- menced, than during the fever. The patient is, indeed, especially liable to be affected by changes of temperature, and currents of air, in the two or three weeks succeeding scarlet fever, and this expo- sure is very apt to result in inflammations, such as have been de- scribed. Therefore great care should be exercised in reference to the hygienic management of the patient during convalescence. In stormy weather he should be kept in-door for a month or six weeks. The nephritic affection which is so common a sequel of scarlet fever is often more dangerous than the primary disease itself. A clear appreciation of its therapeutic indications is important, since by judicious treatment many recover whose lives would inevitably be sacrificed by improper measures. As there is in these cases active hypertemia of the kidneys, having in most cases an inflam- matory character, diuretics which stimulate these organs should not ordinarily be given, at least till this pathological state has, in a measure, abated. As the eliminative functions of the skin and of the intestinal mucous surface are to a considerable extent vica- rious with that of the kidneys, diaphoretic and purgative remedies are required. By free diaphoresis, the ill eftect of arrested or diminished renal secretion is, for a time, averted. Treatment to produce diaphoresis should vary somewhat in different cases. It should in most patients be commenced by the use of a warm general or foot bath, and the patient then be covered in bed. If free per- spiration is not produced, it may be promoted by placing against the patient one or more bottles of hot water, surrounded by a wet cloth. The steam arising from this, and enveloping the body and limbs, produces a prompt sudorific eftect. There is in use in this city, in the treatment of these and similar cases requiring diapho- resis, a convenient apparatus for generating steam. It consists of a cylinder pierced with holes for the admission of air, and con- taining a spirit-lamp over which is a pan or pail holding a little water. The patient, nearly denuded, is placed in a chair, with the apparatus by his side, and is covered with a blanket so that the 196 SCARLET FEVER. steam surronuds the body. This gives rise to free perspiration, which continues after the patient is phiced in bed. This treatment may be repeated each day, if the patient require it, while diapho- retics or cathartics are given. The diaphoretics which are most serviceable in this aifection are the acetates of ammonia and potassa, the bitartrate and citrate of potassa. Spiritus fetheris nitrici, combined with either of these, increases the effect, if the surface is warm, especially if there is already diaphoresis from the bath or steam. Spiritus Mindereri may be given to a child of five years, in doses of two teaspoonfuls every two or three hours, either alone, or in combination with sweet spirits of nitre, as in the following formula : — R. Spts. fetlier. nitrici 5SS ; Liq. ammou. acetat. 5iv. Misce. The acetate of potash is a more agreeable medicine, and it is generally quite as effectual. It should be given, dissolved in water or syrup, in doses of about one grain for each year of the child's age. "Wliatever diaphoretic is used, has more effect, as has already been stated, if given in connection with the external measures designed to produce diaphoresis, which have been described above. If perspiration is not produced, the action of the medicine is proba- blv on the kidnevs ; and if diuresis do not result, there is danger that the hyperssmia of the kidneys will be increased. In such cases diaphoretics should be omitted, and cathartic medicines given in place ; or, if there is much exhaustion, it is sometimes better to give no eliminative medicine, and to treat the renal affection mainly by local and external measures. 1 In robust children suffering from scarlatinous ura?mia and serous effusions, no medicines afford so much relief in the commencement as cathartics of a hvdras-oo-ue nature. A mixture of ialap and cream of tartar, pulvis jalapae compositus of the pharmacopoeia, meets the indication. Even in children somewhat reduced, medi- cines of this nature are often required. Cathartics are more certain in their effects than either diaphoretics or diuretics, and therefore they should be given in urgent cases in which it is necessary to remove the urea or serum as speedily as possible. An excellent prescription in many of these cases, and one from which I have obtained a good result, is the following: — E. Podophyllin gr. j ; Sacch. alb. 9j. Misce. Divid. in chart, no. viii-xii. Dose, one po\vder, according to circumstances. TREATMENT. 197 "When cathartic or laxative agents have been used two or three days, the kidneys, being less congested in consequence of the diver- sion that has occurred, often begin to excrete more freely. Sub- sequently to the employment of medicines of this kind, or in con- nection with them, diaphoretics are in most cases required. The physician's experience, and his discrimination in reference to the condition of the patient, will guide him in the selection of proper remedies to meet the indications. In a large proportion of cases, when this renal aifection has continued one, two, or three weeks, the treatment which has been recommended above is no longer appropriate. There may be more or less anasarca and albuminuria, but the patient is ansemic, and evidently in need of sustaining measures, while there are no symp- toms which indicate immediate danger from retention of urea or the excess of liquid in the system. In these cases the tincture of the chloride of iron is a most useful medicine. While it serves as a tonic, it seems also to have a diuretic effect. To a child of five years it should be given in doses of five drops, every three or four hours. If the patient is decidedly anfemic and feeble when the renal affection commences, and the symptoms are not urgent, it is best not to administer diaphoretics and cathartics, or to administer them sparingly, and to commence early with sustaining remedies. Cases like the following from my note-book are not infrequent. A little boy, pale and scrofulous, began to have anasarca, after scarlet fever, chiefly of the scrotum, and accompanied by a moderate de- gree of ascites. The urine, which was passed in nearly the normal quantity, contained albumen. This patient gradually and fully recovered, with no treatment except the use of an oil-silk jacket over the kidneys and abdomen, to promote diaphoresis, and the use of iron. Such a case actively treated by eliminatives would, proba- bly, have proved fatal. Uniform treatment for scarlatinous nephri- tis is therefore injudicious ; considerable variation in measures is demanded, according to the state of the patients. The otorrhoea of scarlet fever should not be neglected. It is apt to continue for months unless treated, and the hearing may become permanently impaired. There is danger, indeed, that the inflam- mation may extend inwards, with a most disastrous result. For this ailment there is, in my opinion, no remedy so useful as the following, which should be either dropped or syringed into the ear three times daily : — 198 SCARLET FEVER. ^. Acid, carbolic, o^s-j ; Glycerinre ^ij ; Aquse ^iv. Misce. It is also very beneficial when the otorrhoea occurs from scrofula or other cause. When the remedial agents required for the fever are discontinued, and the otorrhoea persists, cod-liver oil and the syrup of the iodide of iron, given in appropriate doses, will often be found useful, not only for the general health, but the otorrhoea. {See Lond. Lancet, Dec. 3, 1870.) It is evident, from what has been said, that every possible pre- caution should be taken to prevent the patient's catching cold during the period of convalescence. He should not be allowed to go in the open air in unpropitious weather till a month after the fever. An oil-silk protection of the body, worn from the time that the febrile symptoms begin to decline, and covering the lumbar region, diminishes, in my opinion, the liability to nephritis and uraemia. Prophylaxis. — Since the period of Jenner's discovery of the pro- phylactic power of vaccination, as regards smallpox, the attention of the profession has been frequently directed to the prevention of scarlet fever. A medicine has been sought which would antago- nize and mollify, if not entirely prevent, the disease. Of late years it has been claimed that belladonna, given during the period of exposure, and subsequently, is a preventive. The first employment of this agent for such a purpose was based entirely on theoretical grounds, it being presumed that, as it produces an eruption of the skin and dryness of the throat, like those of scarlet fever, it is there- fore antidotal. Wli ether or not belladonna does have such an effect can only be determined by experience, and latterly, as observations accumulate, the number does not seem to increase of those who be- lieve in its prophylactic power. Still, there is difference of opinion among good observers. The ditficulty of determining positively the matter of prophylaxis is apparent when we consider that many children who are exposed to scarlet fever do not take it, although nothing is done for the purpose of prevention. Burnett made use of the following prescription as a preventive : — I^. Ext. bellad. gr. j ; Aq. canella; gij. Misce. Two or three drops were given morning and evening to a child of one year, and one drop more for every year for children of a TREATMENT. 199 more advanced age. He administered it to 120 infants, of whom only five contracted the disease. Schcnck, lialf a century since, stated that, in the course of an epidemic, out of 525 persons wlio took belladonna only three contracted the disease. M. Biett, whose observations were made during the epidemic prevalence of scarlet fever in Switzerland, states that those to whom belladoima was given usually escaped. On the other hand, Lchmann and Wagner may be mentioned among others on the continent, who believe that they have derived no benefit from the use of this medicine. These physicians have seen one-fourth to one-third of those to whom belladonna had been given take scarlet fever. In this country, observers differ in their estimate of the preventive effect of belladonna. Dr. Irwin, of South Carolina, as quoted by Dr. Condie, gave it to 250 children, and less than half a dozen took the affection. He employed a solution of three grains of the ex- tract in an ounce of cinnamon-water, giving two or three drops to a child under the age of one year, and one additional drop for each year. Dr. Condie himself, however, has had a different experience. He has prescribed belladonna, " but, although redness and dryness of the throat, and a diffuse scarlet efflorescence, were produced in the majority of cases, we never," says he, " found it in any to exert the slightest influence in mitigating the character or preventing the occurrence of scarlatina. The experiments were made during the prevalence of the disease, and in numerous instances the sub- jects of them were attacked. In one case the efilorescence was kept up by the use of belladonna forty-eight hours. In a week afterwards this individual took the disease in its most violent form, and died on the fourth day." My observations in reference to this use of belladonna are few, and they are not at all favorable to its emi^loyment. I have known scarlet fever occur, without appa- rently any modification, though belladonna was administered daily. Those who have made trial of this medicine have administered it in very different doses. Hahnemann employed it in so small a dose, that it would seem, a jyriori, that it could have had no effect. Hufeland employed the following formula : — ]^. Ext. bellad. gr. iij ; Alcohol ^j ; Aq. destillat. §ss. Misce. Dose, one drop morning and evening for each year of the child's age. So small a dose would certainly do no harm, so that the medicine might be safely tried. Still, if belladonna is at all a prophylactic, 200 SCAKLET FEVER. it is reasonable to suppose that a larger dose would be more de- cidedly so. The great importance of the prophylaxis of scarlet fever has induced me to state what is known of the effect of belladonna employed for this purpose. I am, however, strongly of opinion that by far the most reliable prophylactic, of which we have any knowledge, is carbolic acid. Our experience in Il^ew York city, in reference to the employment of this agent as a means of prevention, has not been sufficient to enable us to make a positive statement, but it has been largely employed by the 'New York physicians under the direction of the Health Board, in the apartments of those sick with infectious diseases, and the result, as regards at least scarlet fever, has been highly satisfactory. The Health Board employ largely carbolic acid, but other disinfectants in addition to it. (Appendix B.) The impure carbolic acid is preferable to the purified. Old rags soaked with it may be suspended in the room, or it may be sprinkled in the corners of the room, or placed on plates two or three times daily with water added. A positive statement in regard to the effect in a matter of such importance should be based on accurate and sufficient statistics, but it appears to me, from cases which I have observed, that the acid thus em- ployed not only destroys in great part the infectiousness of scarlet fever, but also renders the disease milder in patients who constantly inhale its vapor during their sickness. I have been creditably in- formed that certain at least of the Sanitary Inspectors of the Health Board of Xew York, whose opportunities for observation are ample, entertain similar views. I take pleasure in referring the reader to the opinions in reference to the prevention of scarlatina of a British practitioner, of candor and great experience, who is favorably known to the profession on both continents. For a knowledge of the views of this gentleman I am indebted to Dr. Elisha Harris, the well-known sanitarian of this city. (Appendix B.) STAGE OF INVASION. 201 CHAPTER III. VARIOLA — VARIOLOID. Vakiola, or smallpox, is a specific febrile affection, accompanied by a vesiculo-pustular eruption of the skin. Since the discovery of the protective power of vaccination, it has been shorn of much of its terror, but it is still the most loathsome and most dreaded of all the fevers. Two forms of this disease are recognized, depending on the fact whether there has been previous vaccination. If the patient has been vaccinated at some period in his life, the disease, which is rendered milder in consequence, is designated varioloid. If there has been no vaccination, it is called variola or smallpox. Both forms are identical in nature, the one communicating the other : they differ only in gravity. Smallpox presents four stages: the initial, or that of invasion; the eruptive; that of desiccation; and, lastly, that of desquamation. It is called discrete when the pustules remain separated from each other; confluent when they unite. This division is made accord- ing to the character of the eruption upon the face and hands. There are parts of the surface, as the abdomen, where the pustules are always discrete, even in the confluent form. Incubative Period. — During the last half of the last century inoculation with variolous matter was extensively practised in Great Britain and on the Continent, as it was found that smallpox thus communicated was milder than when received by infection. This operation enabled physicians to determine the period of incu- bation, which was found to be from eight to eleven days. When variola is communicated by infection, the incubative period is some- what longer, namely, from twelve to fourteen days. Stage of Invasion. — -Smallpox begins abruptly with chilliness. In children of an advanced age, there is often, as in the adult, a distinct chill. This is followed by fever, and such symptoms as usually accompany febrile movement, namely, lassitude, anorexia, and thirst. There are, in addition, symptoms which, though not peculiar to smallpox, are so marked in the commencement of this disease, that they possess considerable diagnostic value. These 202 VAEIOLA. symptoms pertain to the nervous system. There are in most cases of varioloid as well as variola, in the initial stage, severe frontal headache, pain in the small of the back, and great drowsiness, sometimes with delirium. In many children convulsions occur, preceded and followed by a degree of stupor which is almost as profound as coma. Trousseau suggests the name rachialgia for the pain in the back, as he believes that it is located in or around the spinal cord. This belief is based on the fact, which he, as well as other observers, has noticed, that there is sometimes in connection with this symptom an incomplete paraplegia, indicated by numb- ness of the legs, or even inability to use them, and sometimes more or less paralysis of the bladder. These para];»legic symptoms pass off in a few days. Vomiting is also a common symptom in this stage, and one also of diagnostic value. It occurs at short intervals for twenty-four to thirty-six hours. The same symptom is common in scarlet fever, and not infrequent in measles, but in both these afiections irritability of stomach is much less persistent than in smallpox ; vomiting does not occur in normal rubeolous and scar- latinous cases more than once or twice. The tongue is covered with a moist fur. If the disease is to be discrete, constipation is commonly present in the stage of inva- sion ; if confluent, diarrhoea is a common symptom, continuing till the fourth or fifth day, or even longer. Roseola or erythema sometimes occurs in this stage, and this may lead to error of diag- nosis, the disease being mistaken for one of these cutaneous affec- tions, or even for scarlet fever. The symptoms in the stage of invasion are usually more violent in confluent than in discrete variola, but there are exceptions. Stage of Eruption. — The eruption commences about the third day, earlier in some cases, later in others. The average duration, therefore, of the first stage is somewhat shorter than in measles, but considerably longer than in scarlet fever. Sydenham has stated, and observations show the truth of the remark, that the shorter the first stage, the more severe the disease will prove to be; and, conversely, the longer the period, the milder will be its form. Therefore, if the eruption begins on the second day, it will, as a rule, be confluent ; if not till the fifth or sixth day, it will be scanty, and the disease lio-ht. The eruption commences in minute red spots, somewhat like those of lichen, which gradually enlarge. It is first observed around the lips and upon the neck, then upon the face, scalp, upper part of chest, arms, and finally upon the lower part of the chest, the STAGE OF ERUPTION. 203 abdomen, and legs. It is sometimes, especially in young children, first observed in the folds of the skin, as about the genitals or in the groin. If the cuticle is irritated, as by a sinapism, the erup- tion often appears first upon this part of the surface, and in greater abundance than elsewhere. The eruption commencing in a minute reddish point, as stated above, rapidly enlarges, and soon its cen_ tral part begins to be indurated and raised. It feels round and hard to the finger, is tender, and its diameter does not ordinarily exceed two lines. This is the papular stage. The papulae increase, and become more elevated, and in twenty -four to forty-eight hours from the commencement of the eruptive stage they become vesicu- lar. On the fifth day of the eruption, or eighth of the disease, the vesicle has attained its full size. Its diameter is then about one-fourth of an inch, and its elevation is two or three lines. Its base is circular and indurated, and it is surrounded by a narrow zone of inflammation, indicated by redness and tenderness of the skin. The pock commonly, as it passes from the papular to the vesicular stage, loses its acuminate form, and becomes depressed in the centre, but in most cases, mixed with the umbilicated vesicles, are some which remain acuminate. In proportion as the eruption becomes developed in discrete variola, and in varioloid, the symptoms w^iich accompanied the stage of invasion abate; the fever, headache, pain in the back, and thirst cease, and the appetite returns. In the confluent form, the febrile action continues with little abatement. Simultaneously with the eruption upon the skin, an eruption also occurs upon the buccal and faucial surface, and often upon that of the air-passages. It occurs sometimes, also, upon the con- junctiva, producing dangerous ophthalmia, and even ulceration, with loss of sight; and upon the mucous surface of the genital organs. The form which it presents upon mucous surfaces is some- what different from that upon the skin. There is at first a deposit of fibrin, producing a small, round, grayish spot at the point of eruption — firm, slightly elevated, and covered, if not by the entire mucous membrane, at least by its epithelial layer. Ulceration soon occurs, as in ulcerous stomatitis, and if the patient live, the repai'ative process succeeds, as in simple ulcers. The eruption upon mucous surfixces increases considerably the suffering of the patient, in consequence of the tenderness of the ulcers ; and if its seat be the surface of the larynx or trachea, it may be the immediate cause of death, especially in young children, by obstructing respi- ration. 204: VARIOLA. The cutaneous eruption has been traced to the vesicular stage. On or about the fifth day of the eruptive period, or eightli of small- pox, the vesicles gradually change their character, their contents becoming thicker and turbid. At the same time they increase somewhat in size, and the central depression disappears. This is designated the stage of maturation, or of suppuration, though it is known that the turbidity is due chiefly to another substance than pus. The pock having undergone these changes, is termed the pustule. In discrete variola, and in varioloid, the fever returns during the pustular stage ; or, if the form of the disease is confluent, and the fever has continued, it now becomes more intense. The return of fever, or its increase, is denoted by increased frequency of pulse, elevation of temperature, dryness of skin, anorexia, and thirst. A tendency to constipation remains throughout the disease in vario- loid and discrete variola; in the confluent form, diarrhoea more frequently occurs, which, if it continue, is an unfavorable prognos- tic sign. Other changes occur. The pustules increase somewhat in size, and become more globular. Some of them, when most distended, break through friction of the clothes, or scratching of the child, and their contents escaping, add to the loathsomeness of the dis- ease. There is in the pustular stage more or less redness of the surface between the eruptions, and, except in the mildest cases, there is tumefaction from subcutaneous infiltration. In the con- fluent form, at this period, the features are often so swollen that the friends would not recognize the patient. The eyelids may be so cedematous that the eyes are for a time concealed from view. This oedema of the surface is not altogether absent in the vesicular stage, but it increases during the time of maturation, after which it subsides. Stage of Desiccation. — This immediately succeeds the full de- velopment of the pustules. The liquid portion of the contents of the pustules, which are broken, evaporates, leaving a crust. If there is no rupture, the liquid is absorbed, and a scab results, which, though smaller, preserves in a measure the form of the pustule. While the pustule desiccates, the surrounding inflammation rapidly abates. The crusts occur first upon the face, and on other parts in the order in which the eruption appeared. The odor from the pa- tient, at this time, is peculiar. In the confluent form, especially, it is very oftensive, and can be noticed at a distance from the bed- side. Rilliet and Barthez call it nauseous and fetid. As desicca- STAGE OF DESICCATION. 205 tion progresses, the symptoms, local and general, abate. The pnlse and temperature, if the case is favorable, return to their normal standard. The cough, hoarseness, and thirst disappear, while the appetite returns; the sleep is more tranquil, and the functions, generally, are more regularly performed. The last stage is that of desquamation; it commences between the eleventh and sixteenth days. The scabs, which present a dark or brownish appearance, are successively detached. This period lasts several days ; sometimes two or three weeks even elapse before all the crusts separate. In the meantime the patient gradually re- covers his health and former strength. After the fall of the crust, the cicatrix underneath presents a reddish appearance. This color gradually fades, and there remains an irregular depression, or pit, of a lighter color than the surrounding surface; and if there has been a full development of the eruption, disfiguring the patient for life. Such is the clinical history of variola, when it is favorable, and its course is regular. The disease is sometimes irregular. In rare instances the eruption occurs almost at the commencement of the disease. The form is then very apt to be confluent. There are irregularities, also, in consequence of diarrhcea, hemorrhages, or other complications. I have known the eruption appear first on the limbs, and last on the trunk and face, and the appearance of the eruption is not always the same. In the ancemic and feeble child it often presents a pale color, with some induration at its base, but without the red areola around it, or with this quite in- distinct. In rare instances the vesicles have a reddish color, their contents beins; tinned with blood. This form of variola is desip-- nated hemorrhagic. It indicates a profoundly altered state of the blood. The eruption in this form is of small size, and if the jjock is broken, blood oozes from it. Varioloid. — The course of varioloid is similar to that of variola, but it is somewhat shorter. It commences with rigors, followed by fever, headache, pain in the back, vomiting, drowsiness, and sometimes delirium, or even convulsions. The symptoms in the stage of invasion are, indeed, the same in character, and often nearly as severe as in variola. With the initial symptoms, there is also sometimes a scarlatiniform eruption, so that the disease may at first be mistaken for scarlatina. On the third or fourth day the variolous eruption commences. The number of pocks is commonly few, often not more than twelve to twenty. In the mildest form of varioloid, if the physician is not summoned in the 206 VARIOLOID. stage of invasion, lie is not apt to be called at all, so that the pa- tient may pass through the disease in ignorance of its nature. I have known this occur, the true character of the affection not being ascertained till others were affected, either with variola or vario- loid. The eruption pursues a more rapid course in varioloid than in the unmodified disease. By the fifth or sixth day the pustules are fully developed, though often smaller and less likely to be ruptured than in variola. Often, in varioloid, the eruption aborts. It re- mains papular two or three days, and then declines, or it may reach the vesicular stage, and decline without pustulation. The constitutional symptoms in varioloid decline with the com- mencement of the eruptive stage. The secondary fever is slight or absent. Such is the usual mild course of varioloid, but not always. If several years have elapsed since the vaccination, its j^i'otective power is greatly impaired, and varioloid may then exhibit as severe a form as ordinary smallpox. In some instances it is fatal. The term varioloid is, as has been stated, applied to cases of variolous disease where there has been previous vaccination. It is also applied by writers to second attacks, whether the first occurred from infection or from variolous inoculation, but such cases are rare. Mode of Death. — Death in smallpox occurs in several different ways. The most fatal period is the pustular stage. Feeble chil- dren not unfrequently die from exhaustion at or about the time that the pustules attain their greatest size. The eruption appears and becomes developed as usual, but there are evidences of weak- ness in the patient, and suddenly the progress of the vesicle or pus- tule ceases. It begins to subside, and its walls shrivel. There is evidently absorption, in part, of the liquid contents. These pheno- mena are of the gravest character. Death is the common result, and within twenty-four hours. In other cases death occurs from apnoea. The pock increasing in size in the larynx and trachea, obstructs inspiration, or there may be the formation of a pseudo- membrane, as in true croup. This is not an unusual mode of death in young children, in whom the calibre of the larynx and trachea is small. Sometimes convulsions iind coma occur in the last hours of life. In other cases the stage of desquamation is reached, but convalescence does not occur. The patient each day becomes more anpemic and feeble, and finally death results from failure of the vital powers. Again, after smallpox has run its course, purpura ANATOMICAL CHARACTERS. 207 hfemorrliagica may be developed. Hemorrhages occur from the gums, throat, nostrils. Elood is vomited, and evacuated in the stools. I have known death to occur in all these ways, but that from purpura is least frequent. Sometimes, as in scai'let fever, death occurs suddenly and unexpectedly in confluent, and even in discrete variola, when the previous s3miptoms had apparently been favorable. The patient is overpowered by the intensity of the virus. Anatomical Characters. — In those who have died of variola, without inflammatory or other complication, the heart-clots have been found small, dark, and soft. The blood is dark and thin. The vessels of the brain and its membranes are injected, so that numerous red points appear on the cut surface of this organ. The vessels of the lungs and the abdominal organs are congested, while the muscles present a deep red color. The variolous eruption pene- trates more deeply than that of any other exanthematic fever. It has been stated elsewhere that it occurs not only on the skin, but often on the surface of the mouth, fauces, and air-passages. The mucous membrane in these situations is frequently also the seat of erythematic inflammation, being thickened and softened, and in some parts, as the larynx, a pseudo-membrane is occasionally pro- duced, as in croup. This inflammation, erythematic or pseudo- membranous, may occur without as well as with the presence of the specific eruption. The eruption very seldom, perhaps never, appears upon the gastro- intestinal surface, but the solitary follicles and patches of Peyer are often enlarged, as in some other zymotic aftections. The liver, spleen, and kidneys are commonly congested in those who have died of variola. The spleen, especially, is increased in volume and soft- ened ; the kidneys are enlarged, as if from commencing nephritis, and sometimes softened. The minute structure of the pock is described by Rilliet and Barthez, and others. The vesicle is multilocular, consisting of at least five or six compartments, with distinct partitions. Its centre is united by fibrous bands to the derm beneath, which union gives rise to the umbilicated appearance. The giving way of these minute bands in the pustular stage occurs when the form changes from the umbilicated to the convex. In the pustular stage also, according to some, a fibrinous formation occurs within the pustule ; according to others, this substance is of the nature of the epidermis, presenting the appearance of the cuticle when macerated. Mixed with this epidermic or fibrinous formation are pus cells. 208 VARIOLOID. Complications. — There are several different complications of va- riola. One is salivation. This is common in the adult, but rare in the child. When it occurs in the child, it is slight, commencing with or about the time of the eruption, and disappearing in from one to four or five days. Ophthalmia is another complication. Sim- ple conjunctivitis, often quite intense, may occur in consequence of pustules developed under the lids. This inflammation subsides without injury to the eye, as the primary disease abates. A more serious inflammation occurs at an advanced stage of the disease, commencing in or near the desquamative period. This produces more or less chemosis, and sometimes opacity or ulceration of the cornea. A similar inflammation may occur in the ear, giving rise to otorrhcea, and even in some patients to rupture of the drum of the ear. Abscesses in the subcutaneous cellular tissue have been occasionally observed, especially in the confluent form. Subcutane- ous infiltration and feebleness of constitution favor their occurrence. Suppuration within the joints is a somewhat rare complication or sequel, rendering convalescence protracted, if, indeed, the case is not fatal. M. Beraud has published a memoir to show that orchitis com- plicates variola in the male, and ovaritis in the female. These inflammations are believed to be accompanied by a small and im- perfect variolous eruption upon the tunica vaginalis and the peri- toneal covering of the ovary. Trousseau states that he has often met this complication in the male, since his attention was called to it. It is mild, and subsides with the disappearance of the eruption. Laryngitis, simple or diphtheritic, bronchitis, pneumonia, pharyn- gitis, purpuric hemorrhages, gangrene of the mouth or other parts, oedema pulmonum, and oedema glottidis are occasional complica- tions, some of which are frequent, others rare. Prognosis. — This depends on the age, vigor of system, form of the disease, and the presence or absence of complications. The younger the child, the greater the danger. Trousseau says : " Con- fluent variola, and even discrete variola, are almost always fatal in individuals less than two years old." Above the age of three or four years discrete variola usually ends favorably, but the confluent form is still, as a rule, fatal. Varioloid in the child is a mild disease, terminating favorably in a large proportion of cases. It is milder at this age than in the adult, on account of the more recent period of vaccination, and if a case of supposed varioloid is severe, and the eruption abundant, it is probable that the vaccination was spurious. TREATMEXT, 209 It is not necessary, from wliat lias been said, to specify tlie favorable prognostic signs. The unfavorable prognostics are, great violence of the initial symptoms ; early appearance of the eruption ; an abundant eruption, especially if pale, and without swelling of the surface ; rapid decline of the eruption in the vesicular or pus- tular stage ; hemorrhagic eruption, or hemorrhages from the sur- faces ; fever continuing after the appearance of the eruption ; diarrhoea persisting beyond the third or fourth day ; delirium or great drowsiness ; a frequent and feeble pulse ; and, finally, ob- structed respiration — if slow, indicating a pseudo-membrane or variolous eruption in the larynx or trachea — if rapid, indicating bronchitis or pneumonia. Diagnosis. — The diagnosis cannot be made with certainty prior to the eruptive stage. If, however, smallpox is prevalent, if the patient has not been vaccinated, and the symptoms which pertain to the period of invasion are present, as headache, pain in small of back, repeated vomiting, drowsiness, and perhaps convulsions, there is ground for the gravest suspicion. If, in addition to these symp- toms, reddish points begin to appear on the second or third day, the diagnosis may be made with confidence. At this early period, even before there is any distinct cutaneous eruption, ash-colored spots may sometimes be observed on the buccal or faucial surface, the commencement of the variolous eruption ; these possess con- siderable diagnostic value. The scarlatiniform efflorescence, in the first stage of variola, sometimes leads to the belief that the disease is scarlet fever. The absence of the pharyngitis, and the appearance of the variolous eruption soon after the efflorescence, correct the diagnosis. Small- pox has, in the beginning of the eruptive period, sometimes been mistaken for measles. The points involved in the differential diagnosis have been presented in treating of that disease. After the development of the eruption it may be mistaken for varicella. The eruption of varicella is, however, preceded by symptoms which are milder and of shorter duration, and its appearance is different. It is irregular, instead of round; is not umbilicated, and it does not have the round, inflamed, and indurated base, which characterizes the variolous eruption. The eruption of ecthyma is sometimes umbilicated, but the symjDtoms of ecthyma and variola, and the progress of the eruptions in the two diseases, are ver}^ different. Treatment. — Smallpox, like the other essential fevers, is self- limited, and therefore the constitutional treatment should be sustaining and palliative." In the first stages of the disease, the 14 210 VAEIOLOID. diet should be simple ; gentle laxatives and refrigerant drinks are required if there is much febrile excitement. Lemonade is a grateful drink, and may be given in moderate quantity. Spiritus Mindereri or carbonic acid water may be allowed. As the disease advances, more nutritious food should be recommended; and in severe cases carbonate of ammonia, and even alcoholic stimulants, are required. As confluent smallpox is nearly always, and the discrete form often, fatal in infancy, the physician should carefully watch the progress of the case in the infant. By judicious treatment, some, in this period of life, may be saved, who otherwise would perish. In the infant, depressing measures should be avoided. A laxative may be given, at first, if there is much fever, and the bowels are constipated; but the diet should be nutritious, and many soon re- quire tonics and stimulants. If the pulse become more frequent and feeble, or if, with frequency of the pulse, the face and extremities become cool, or if, in the vesicular or pustular stage, the eruption suddenly subsides, alcoholic stimulants must be immediately em- ployed, or the patient dies. Such is an outline of the constitutional treatment required in smallpox. Sydenham inculcated a mode of treatment which experience has shown to be injurious in infancy and childhood. He had observed that the severity of the disease was ordinarily proportionate to the amount of eruption, and concluded from this fact that measures which retarded the development of the eruption were salutary ; cold drinks, a cold apartment, scanty covering of the body, cathartics that caused derivation of blood from the sur- face, even sometimes the abstraction of blood, were considered, according to Sydenham's theory, to be useful as means of preventing full development of the eruption. Sydenham's treatment, however appropriate it might sometimes be in case of robust adults, is unsuitable for children, because they do not, as a rule, tolerate, in this disease, measures which reduce the strength. Moreover, smallpox is rendered more dangerous by what Rilliet and Barthez designate perturbating treatment — treatment which renders it abnormal. The regular appearance and development of the eruption are requisite in order that the case may progress favorably. On the other hand, the opposite plan of treatment, which families, if left to themselves, are apt to adopt — namely, the employment of measures to promote perspira- tion, as hot drinks, and confinement in a heated room — is also injurious. TREATMENT. 211 The patient should be kept in a temperature such as lie lias been accustomed to, and such as is agreeable to him; his diet sliould be simple and nutritious ; laxative medicine should only be given to procure the natural evacuations. In smallpox, as in all infectious diseases, free ventilation of the apartment is required. While the general eruption in smallpox should not Ije interfered with, it is proper to endeavor to diminish, so far as possible, the size of the pocks, on parts exposed to view, so as to prevent dis- figurement. Prof. Flint, in his Treatise on the Practice of 3Iedicine^ has published an excellent summary of the various measures which have been recommended for accomplishing this end. First: The opening and breaking up of the vesicle by means of a fine needle. This is tedious practice in confluent variola, but it can readily be performed in the discrete form — at least as regards the vesicles upon the face. This treatment Avas proposed by Rayer, and it is recommended by many who have tried it. Secondly : After the evac- uation of the liquid, the cauterization of the vesicle by a pointed stick of nitrate of silver. Rilliet and Barthez say, in reference to this mode of treatment, " Individual cauterization of the pustules is, on the other hand, an almost infallible means of causing them to abort. To be successful, it is necessary to penetrate into the interior of the pustule with a pointed craj^on of nitrate of silver, in order to cauterize the derm. ... It is only the first or second day of the eruption that it (cauterization) has certain success; nevertheless, we have often seen it succeed the third or the fourth day, or even the fifth." Thirdly: The application of tincture of iodine once or twice daily over the eruption when in the papular stage. Some writers, who have employed iodine, state that it does not prevent pitting, but diminishes it. Fourthly: The exclusion of light and air by means of a plaster. A mixture containing tannate of iron has; been employed for this purpose in one of our hospitals. This pro- duces a black mask. Light and air may also be excluded by- smearing the face with sweet oil, and dusting twice daily upon the oiled surface a powder containing equal parts of subnitrate of' bis- muth and prepared chalk. Fifthly: The application of mild mer- curial ointment upon the face or other parts of the surface, where it is desirable to render the eruption abortive. This mode of treat- ment does diminish the size of the vesicles and the pitting,, but I should not recommend it for children. I have known in the adult severe mercurialization from its employment for four or five days, and, though young children do not exhibit so readily the effects of 212 VACCINIA. mercury, the use of the ointment, unless for a very limited period, increases, in my opinion, their feebleness, and diminishes the chance of their recovery. Calamine made into a paste with sweet oil is said to be equally effectual with mercurial ointment, and it jiroduces no constitutional effect. Its, effect is obviously similar to that of the bismuth and chalk employed with sweet oil as stated above. Of late, I have employed pulverized charcoal made into a thin paste with sweet oil or glycerine, and applied daily or twice daily to the face. It effectually excludes the light, and the result has been so good as regards pitting, that I shall continue to use it. Poultices, collodion, a solution of gutta percha in chloroform, have been recommended, among other substances, by good observers. If fissures or excoriations occur, an application may be made of oxide or carbonate "of zinc in glycerine, one drachm to the ounce. The prevention of smallpox, so far as practicable, is one of the important incidental duties of the physician. Isolation of the patient, and precautions in reference to his clothes and bedding, are imperatively required, so great is the infectiousness of this dis- ease. The only certain means of prevention is confessedly vacci- nation, and providentially the incubative period of the vaccine disease is much less than that of variola. Therefore, smallpox may be prevented after the virus is received in the system, by timely and successful vaccination. Vaccination, at any period between the time of exposure and the commencement of the symp- toms of invasion, will either prevent the occurrence of smallpox or modify it. If the symptoms of invasion have already commenced, it is uncertain whether it produces any modifying effect. CHAPTER IV. VACCINIA. Vaccixia is a mild eruptive disease, which occasionally occurs among cattle, and has been propagated from them to man. It is characterized by the appearance upon the surface of one or more papules, which soon become vesicular, and then pustular. It is communicable by contact, but, unlike the other eruptive fevers, it is not infectious in man. It is inoculable, both by tbe liquid con- VACCINIA. 213 tained in the vesicle, wliich is designated vaccine lymph, and l»y the scab which results from the desiccation of the pustule. To Gloucestershire, England, the honor belongs of discovering and popularizing the fact that vaccinia, a mild and comparatively harmless disease, is transmissible from the cow to man, and that it affords protection from smallpox. It appears that a vague opinion prevailed among the farmers of this dairying section, that a dis- ease, which has since been designated vaccinia, was occasionally received from the cow in milking, the virus passing from a pustule on the teat to a sore or chap on the hand of the milker, and that those who thus contract the disease receive immunity from small- pox. As usually happens with important discoveries, so dull of apprehension is human intellect, these people, to whom Providence had revealed so important a fact, were blind to its real value. Finally, in the year 1774, Benjamin Jesty, whom the world has not sufficiently honored, " an honest and upright man," according to his epitaph, a farmer of Gloucestershire, had the courage to vaccinate his wife and two children. His excellent moral character did not shield him. He was regarded by his neighbors as an inhu- man brute, who had performed an experiment on his own family, the tendency of which might be to transform them into beasts with horns. The first essay in vaccination appears to have been entirely suc- cessful, but the prejudice against the operation continued. A fifth of a century passed, during which there was no extension of the benefits of this great discovery. At last, towards the close of the last century. Dr. Edward Jenner, a physician of Gloucester- shire, and inoculator of his district, began to investigate this disease of the cow, about which little was known, and the grounds for the belief that it aftbrded protection from smallpox. Fortu- nately for the world, Jenner had been educated under John Hunter, and had learned from his great master to study nature rather than books, to be guided by experience and observations rather than by the dogmas of his predecessors or of the schools. Jenner performed his first vaccination on the 14th of May, 1796, twenty-two 3^ears after Benjamin Jesty had lost his good name among his neighbors for vaccinating his own family. The popu- larizing of vaccination, mainly through Jenner's perseverance, aftbrds one of the most interesting and instructive chapters in the history of medical science. How he went up to London, full of the importance of the discovery, and was there advised by his medical friends to desist from his wild schemes, lest he should 214 VACCINIA. injure the reputation which he had gained by publishing a credit- able paper on the cuckoo ; how he was allowed to vaccinate in the hospital wards, and gained some adherents to the new faith among the leading physicians of the metropolis; and finally, how, as the claims of vaccination began to be recognized, at the close of the last century and commencement of the present, a most acrimo- nious discussion arose, which filled all the medical journals of that period. The opponents of vaccination resorted to every device to prevent the acceptance of Jenner's views. They attempted to pre- judice the people against them by specious arguments, by ridicule, and even by pictures. One of the leading journals contained the caricature of a cow covered with sores, and devouring children, and it was urged that vaccination was a bestial operation, de- grading man to the level of the brute. But the truth had gained a firm hold, and the practice of vaccination extended. The discovery of vaccinia, and of its protective power, cannot be too highly appreciated. It has, probably, done more to relieve human suffering than any other discovery of the last one hundred years, unless we except that of anaesthetics, and more to save human life than any other instrumentality of a purely ph^'sical kind. The fact was established in the time of Jenner that the virus of smallpox inoculated in the cow produced vaccinia, which in its propagation back to man never returned to its original form, but always remained vaccinia. Moreover, Jenner believed that the disease known in the horse as the grease was identical in nature with vaccinia in the cow. He failed, however, in his experiments to communicate vaccinia from the horse, but other experimenters have been more successful. In 1801, a Dr. Loy, of the county of York, England, met two cases of vaccinia in persons who had taken care of a horse afi:ected with the grease, and, from the lymph which he obtained, was able to produce vaccinia in the cow. In 1805, Viborg, a Danish veterinary surgeon, after many failures, succeeded also in communicating vaccinia to the cow by means of the virus taken from a horse. From this time little light was thrown on this subject till within the last twelve years. Although Loy and Viborg, and perhaps a few 'others, had recorded their success, other experimenters had failed to communicate vaccinia from the horse. In the absence of additional cases, the profession began to question whether there might not have been some error in the observations of the gentle- men whose names I have mentioned, and the problem was still VACCINIA. 215 regarded as undetermined, whether a disease identical wilh vac- cinia occurred in the horse, or a disease which might communicate vaccinia to the cow or to man. Observations confirmatory of those of Loy and Viborg were at length, however, made, which must be regarded as conclusive. In 1856, in the department d'Eure-et-Loir, France, M. Pichot was consulted by a boy who had on the back of his hands vaccine pus- tules, which had apparently reached the eiglith or ninth day. He had not taken care of nor been in contact with a cow, but had a few days before taken care of a horse affected with the grease. Vaccination was performed by means of tlie lymph taken from these pustules, and genuine vaccinia was produced. Again, in 1860, an epidemic prevailed among the horses in Rieumes and Toulouse, France. A mare sickened with the dis- ease, and there was swelling of the hough, with discharge of sa- nious matter. M. Delafosse vaccinated two cows with this matter, and communicated genuine vaccinia. This epidemic was believed by the veterinary surgeons to be an eruptive fever, differing in its nature somewhat from the disease or diseases which have ordina- rily been designated the grease. It has been conjectured that two or more distinct affections of the horse have the same appellation, one of which, it is now admitted, is identical with vaccinia of the cow, and may communicate it. And the reason why so many ex- perimenters have failed to vaccinate the cow from the horse is that they have used the virus of the wrong disease, or have taken mat- ter from horses which had been affected with the true disease, but from ulcers which had lost their specific character. Prior to the time of Jenner variolous inoculation was practised in most civilized countries, as variola produced in this way was found to be milder than when arising from infection. This prac- tice is now obsolete ; forbidden in some places by legislative enact- ments. It is superseded by vaccination. Vaccination, or the in- troduction of vaccine lymph into the system, is quickly and con- venientl}^ performed by scarifying with a lancet, and pressing into the incisions the lymph, or a little of the scab pulverized, and dis- solved in a drop of cold water. It may also be performed by scraping off the epidermis with the edge of the instrument till the blood begins to ooze ; and also, though with less certainty of suc- cess, by puncturing the skin with the point of the lancet, or by an instrument called the vaccinator. If the child has a vascular npevus, this may be selected as the point of vaccination. Unless of large size, it can usually be cured 216 VACCINIA. by the inflammation whicli vaccinia produces. Statistics collected by Simon, as well as Marson, show that of those who contract varioloid, the larger the number of vaccine cicatrices the milder the disease, and the less the proportionate number of deaths. In Simon's statistics of those who stated that they had been vacci- nated, but who presented no cicatrix, 21f per cent, died; of those who had one cicatrix, 7| per cent, died ; of those who had two, 4|- per cent, died; of those who had three, If per cent, died; while of those who had four or more cicatrices, only | per cent. died. These statistics would seem to indicate the propriety of vaccinating in several places. But, so far as appears, when two or more cica- trices were observed, the patients may have been vaccinated at different times, at intervals, perhaps, of several years, and if so, the inference would not follow that more complete protection is produced by vaccinating in several places, than in one. Moreover, if vaccination is performed in the usual manner by several inci- sions on the arm, and the virus is fresh and active, usually two or more distinct vesicles arise, which miite in their development, and probably protect the system as much as if they were separated by a wider space. Appearances, Symptoms. — In genuine vaccination no effect is observed, except the slight inflammation due to the operation, till the close of the third day. Then the specific inflammation com- mences. This is indicated by a small red point, at first scarcely visible, indurated and slightly elevated, as determined by the touch, rather than by the eye. This increases, and on the fifth day the cuticle over the inflamed part begins to be raised by a transparent and thin liquid. The vesicle increases in diameter, and by the sixth day presents an umbilicated appearance, and is surrounded by a faint and narrow red zone. At the close of the eighth day the vesicle is fully developed. Its size varies consider- ably. It is usually from a sixth to a third of an inch in diameter, and oval or circular. If the vaccination has been performed by incisions, the size of the matured vesicle may be considerably larger, and its shape irregular, in consequence of the union of two or more vesicles. Tlie eruption now presents a whitish or pearl- colored appearance, due to the whiteness of the cuticle, and the transparence of the liquid underneath. If the vaccination was performed by incisions, it is not unusual to observe over the centre of the vesicle, and adhering to it, a small yellowish scab, which has resulted from the scarification, and which contains none of the virus. ANOMALIES, COMPLICATION'S, AND SEQUELS. 217 The vaccine vesicle, like that of variola, consists of compartments, commonly eight or ten, with complete partitions, so that there is no intercommunication. On the ninth day the inflamed areola l)e- comcs more distinct, and its diameter rapidly increases. Its color is deep red, its temperature is considerably elevated, and it is ac- companied by more or less induration of the subcutaneous tissue, and it is tender to the touch. On the tenth da}^ the pock has reached its full development. The areola then extends from one to two inches away from the vesicle, becoming fainter at its outer circumference, and gradually disappearing in the healthy skin. The shape of the outer circumference of the areola is irregular, projecting further at one point than another, though its general form is circular. On the tenth day, when the inflammation has reached its maxi- mum, the heat, itching, and tenderness in and around the pock are such that the child is often feverish and restless. Occasion- ally the glands of the axilla become swollen and tender. In other cases, in which there is but a moderate amount of inflammation, the constitutional disturbance is slight. At the close of the tenth day, or on the eleventh, the inflamma- tion begins to decline ; the areola becomes narrower and then dis- appears ; the induration and tenderness abate; and with this change the jDUstule desiccates, its liquid is absorbed, and there results a brownish or a dark mahogany-colored scab, which is detached, ordinarily, between the fourteenth and twenty-first days. The cicatrix, at first reddish, like all recent cicatrices, gradually be- comes paler, and remains whiter than the surrounding integument. It presents several minute depressions or pits, which indicate the genuineness of the vaccination. Anomalies, Complications, and Sequels. — The vesicle is often broken, accidentally, or by the nails of the child. If the top of the vesicle is destroyed, or most of the compartments are opened, the inflammation is commonly increased, considerable suppuration occurs, and there results a large, irregular, yellowish scab, consist- ing of the virus mixed with desiccated pus. This scab is entirely unreliable, and unfit for the purpose of vaccination, though the protective power of the disease is not diminished by injurj^ of the vesicles, even if it is totally destroyed. The cicatrix which results from extensive injury of the vesicle is apt to be large, and with- out the indented points which characterize the normal cicatrix. In rare cases, when the inflammation which surrounds the vesi- cle is intense and deep-seated, suppuration occurs in the subjacent 218 VACCINIA. cellular tissue, giving rise to an abscess. This abscess is commonly of small size, Ijut it increases the frotfulness and constitutional disturbance which attend vaccinia. This subcutaneous suppvira- tion is believed to occur most frequently in those who have a scrofulous or vitiated state of system. Inflammation of the lym- phatic glands of the axilla I have spoken of as not infrequent in vaccinia. This sometimes proceeds to suppuration, producing an unpleasant, though not serious, complication. It sometimes happens that vesicles appear in other parts besides the points where the virus was inserted. These supernumerary vesicles commonly occur where the cuticle has been removed by scalds or injuries. Trousseau relates the case of an infant whom he had vaccinated. On the eleventh day he was astonished to find twenty-seven vac- cine pustules on the face, trunk, and limbs. This infant had, how- ever, before the vaccination, a simple non-specific eruption over the whole body, and it was believed that it had produced these vaccinations by transferring the lymph, with its nails, to the various parts where the cuticle was denuded. It is not unusual, also, to observe minute papules appearing on parts of the surface simultaneously with or soon after the vesicle, and in a few days declining. These seem to be abortive vaccine eruptions. One of the most serious complications is erysipelas. This may occur directly from the operation, or from the inflammation caused by the vesicle, when the virus possesses no deleterious property ; and, again, it may result from some unknown element in the virus. It may occur immediately after the operation, when it commonly prevents the working of the virus, or during the vesicular or pus- tular stage; or, again, after desiccation and separation of the scab. I have observed it commencing at all these periods. Erysipelas, occurring as a complication of vaccinia, is invaria- bly referred by the friends to the virus employed, and the phy- sician who has had the misfortune to vaccinate is often unjustly blamed. In many of these cases there was a strong predisposition to erysipelas at the time of the vaccination, and the operation or the inflammation which accompanied the normal development of the vesicle served simply as an exciting cause. Erysipelas would occur as soon from a non-specific sore ; indeed, we not unfrequently are called to cases of this disease in young children, which com- menced from non-specific sores upon the genitals, or one of the limbs. That the fault is not in the virus employed, is evident J ANOMALIES, COMPLICATIONS, AND SEQUELS. 219 from tlic fiict that otlier children, vaccinated with the same, have simple uncomplicated vaccinia. Sometimes, on the other hand, the cause of erysipelas, whatever it may he, exists in the virus. For further facts in reference to this suhject, the reader is referred to our remarks on erysipelas. The fact is established by many observations that syphilis is communicable by vaccination. The symptoms of it may not appear till vaccinia has terminated, or for a little time subsequently, but it then constitutes a very serious sequel. A physician of this city, well known in this community as skilful in the diagnosis and treatment of skin diseases, and therefore not likely to be mistaken as regards the nature of the diseases, states that he communicated syphilis to two infants by vaccinating with the same scab. Both had the characteristic syphilitic eruption. Recently (January, 1868) an infant was brought to Prof. Alonzo Clark's clinique, in this city, having syphilitic rupia, which, in the opinion of the physicians present, was undoubtedly the result of vaccination. ' Trousseau relates the case of a young woman, eighteen years old, who was vaccinated with virus taken from an infant appa- rently in perfect health. The vaccination was unsuccessful ; but twenty-three days subsequently his attention was called to an eruption which had appeared in two places on the woman's arm, corresponding with the points where the virus had been inserted. The eruption was that of ecthyma, which, by the next examina- tion, which was five days subsequently, had been transformed into rupia. The axillary lymphatic glands were tumefied and indo- lent, and, finally, roseola appeared, which removed all doubts as to the syphilitic character of the disease. There was syphilitic infection, which first manifested itself in the points where vacci- nation had been performed [Article de la Vaccine). It is not ascer- tained in Prof. Clark's case, nor is it stated in Trousseau's, whether the lymph or scab was employed for vaccination ; but it is proba- ble that the danger of syphilitic infection is much greater from the scab than from the lymph, on account of the amount of animal matter which it contains. The vesicle in genuine vaccinia is sometimes very small, not having a diameter of more than two lines. Occasionally the de- velopment of the vesicle is retarded. It does not appear till two or three days later than the usual time, or even a longer period. Vaccinia is modified by certain diseases. It is arrested by measles and scarlet fever, pursuing its course after the subsidence of the exanthem. On the other hand, it arrests the paroxysmal 220 VACCIXIA. cough of pertussis, which returns when the pock begins to desic- cate. Eczematous eruptions sometimes occur after vaccinia, as they often do after the other eruptive fevers ; or, if ah-eadj pre- sent, they may be aggravated. Subsequent Vaccinations. A second vaccination, performed prior to the ninth day after the first vaccination, is successfuh A genuine vaccine eruption results, which is smaller the more advanced the primary disease. This second eruption overtakes the first. On the ninth day the suscep- tibility to vaccinia is, in most cases, lost ; so that vaccination per- formed on the tenth, or subsequent days, is unsuccessful. As a rule, a zymotic disease occurs only once in the same indi- vidual. Vaccinia is an exception. In most cases, after a few years, it can be produced a second time ; and cases of a third or fourth successful vaccination, at intervals of a few years, are not uncommon. ISTow, subsequent cases of vaccinia dift'er from the first, which has been described above. The period of incubation is shorter, and the vesicular, pustular, and desiccative stages suc- ceed each other more rapidly, so that the whole period of the disease is less. The variation from the appearance and course of the first vesicle is proportionate to the degree of protection which the first vaccination still aftbrds, both as regards smallpox and vaccinia. If several years have elapsed since the first vaccination, and the protective power which it aftbrded is nearly lost, the second vaccinia differs but little from the first. If, on the other hand, the first vaccination still atfords nearly complete protection, the result of the second is slight; the eruption is insignificant, lacking the characteristic appearance of the vaccine vesicle, resembling a com- mon sore, and disappearing within a week. It is accompanied by no inflamed areola, and by no constitutional disturbance. Vaccination often produces no result. This is sometimes due to the fact that the lymph or scab employed is useless. It has spoiled by keeping, or never has been good. In other cases it is due to a lack of susceptibility in the person. Some take vaccinia with diffi- culty, and only after several vaccinations; just as children, though fully exposed, often fail to take measles or scarlet fever, on account of a condition of the system which prevents the reception of the virus, or antagonizes and controls its action. In some instances, after vaccination, an eruption is produced, which may or may not be genuine; but it immediately becomes purulent, and is soon PROTECTION FROM VACCINATION. 221 broken. A large, yellow, uneven scab results, Laving none of the appearance, and containing little or none of the vaccine virus. This scab, as well as the liquid matter which preceded the formation of the scab, is utterly useless for the purpose of vaccination, and, if so employed, will probably cause a sore from its irritating effect, but not of a specific character. If, in place of the true vaccine vesicle, the eruption presents the appearance which I have described, namely, that of a pustule, soon breaking, and forming a large, irregular, yellowish scab, the vaccinia — if it is correct so to desig- nate it — must be considered spurious. A sore has been produced by the animal matter which was employed in the vaccination along with the virus, which has modified the action of the virus, and probably has rendered it useless as a means of protection ; or there may have been no virus inserted with this animal matter. The physician should in such cases insist on a second vaccination. Cases like the above are of frequent occurrence, and the parents of the child are often satisfied with the result. They see an erup- tion following the vaccination, accompanied by considerable inflam- mation, and leaving a cicatrix. Unless undeceived by the physi- cian, they are apt to remain in the belief of the child's security, until, perhaps, it takes smallpox. Such cases, obviously, tend to diminish the confidence which the public should have in vaccina- tion as a means of protection from smallpox, and on account of their frequent occurrence it is important in all cases that the phy- sician should see the result of his vaccination. It has been pro- posed, as a means of determining the genuineness of the vaccinia, , to revaccinate when the eruption begins, and if the first is genu- ine, the second will overtake it. This is called Brice's test ; but it is not necessary, since the physician, familiar with the appearance of the true vesicle, can determine at once its genuineness by the sight. Protection from Vaccnation— Revaccination. It was believed by the early advocates of vaccination that the general performance of this operatiort would soon eradicate small- pox from the community, so that it would be regarded as a disease of the past, rather than of the present time. This result, however, is not achieved. As a rule, the greater the benefit of any measure designed to ameliorate the condition of mankind, the greater and more numerous are the obstacles which diminish its eflfectiveness. Science is full of examples of this. Fortunately these obstacles, 222 VACCINIA. as regards vaccination, are not such as to impair the confidence of physicians in its protective power, and it is not too much to expect that this simple operation will yet be the means of rendering small- pox a disease almost unknown, unless in its modified form. Vaccination should be performed in the first year of life. In the country, where there is little danger of exposure to smallpox, it may be deferred till the age of ten or twelve months. In the city, on the other hand, where there is constant intercourse of people, and where contagious diseases are often contracted without its being known when exposure occurred, an earlier vaccination is advisable. Some physicians recommend performance of the opera- tion as early as the age of four to six weeks. The objection to this is, that if erysipelas occur, so young an infant is apt to perish from it, whereas an infant three or four months old ordinarily recovers. For this reason I believe that the most suitable ao;e is about four months for the city infant, in ordinary times ; but if smallpox is epidemic, vaccination should be performed at an earlier age. I have vaccinated even the new-born infant when smallpox had broken out in adjoining apartments. Vaccinia usually extinguishes, for a time, the susceptibility to smallpox. According to M. Gintrac, varioloid does not occur A\Hthin two years in those who have been vaccinated. It may, however, in exceptional instances, occur in a mild form within a few months after vaccination. The protection afforded by vaccination gradually diminishes by time, but it does not, probably, as a rule, cease entirely. Varioloid, however, occurring thirty or forty years after a successful vaccination, is apt to be severe, and it may even be fatal, showing that it has been but slightly modified. In other eases, even after so long an interval, the symptoms present a degree of mildness which indicates that the protective power of the vacci- nation is not entirely lost. If a second vaccination is practised soon after the scab from the first vaccination has fallen, it will usually produce no result, but in other cases it gives rise to a little redness, swelling, and induration, which show that vaccinia has been reproduced, though in a very mild and insignificant form. It is probable that in these cases varioloid might also occur by exposure, though with a mildness corresponding with that of the vaccinia. The longer the period after the first vaccination, the greater the number of those in whom a second vaccination is effective, and, as has already been intimated, the greater also the liability to the variolous disease if a second vaccination is not performed. It is recommended, therefore, to SELECTION OF VIRUS. 223 perform a second vaccirmtion not iater than the sixth or eighth year, and again in cliiklhood. And if smallpox is epidemic, it is proper to vaccinate all who have not heen vaccinated within three or four years. Selection of Virus. The l^aiiph is preferable to the scab for vaccination, provided that it can be obtained fresh. The scab is more easily preserved, and, therefore, if the lymph and scab are old, the latter is to be preferred. The lymph should, if the vesicle is sufficientl}^ de- veloped, be taken on the fifth day. It may also be taken on the sixth, seventh, or even eighth day, provided that the areola has not formed. The lymph of the fifth day acts with greater energy, though that of the sixth or seventh day is not much inferior. Lymph obtained after the formation of the areola is less eflicient, though it may communicate the genuine disease. There is no mode of vaccination so reliable as the use of lymph, taken directly from the arm and immediately inserted — the arm to arm vaccination. Lymph can be preserved for a few days on a flat- tened surface of whalebone, or the segment of a quill ; the former I prefer, and if employed within a week, it will usually communi- cate vaccinia. Lymph may be preserved a longer period between two surfaces of glass, but the best way of preserving it is in capil- lary glass tubes. The end of the tube is placed within the vesicle, and the lymph ascends by capillary attraction. When a sufficient quantity is received, the ends are sealed, by holding them for a moment in a flame. Care is requisite in doing this, so as not to heat the lymph, as it is spoiled by a temperature much above the body. AVhen the lymph is used, the ends of the tube are broken, and by blowing gently through it, a sufiicient quantity is received on the point of a lancet. If the scab is genuine, it presents a dark-brown or mahogany color, and has a circular, oval, or at least a rounded form; it is firm, or compact, and has a lustre. Soft, j-ellowish, and irregular scabs are not genuine, and those of a dull appearance, or without lustre, have usually spoiled in the keeping. It is the belief of many that the vaccine virus gradually becomes weaker by passing successively through the human system (Condie, American Jouryial of the Medical Sciences, April, 1865), and that therefore different specimens of virus work with different energy, according to the degree of removal from the cow. To what extent this view is cor- rect is not fully ascertained, but, certainly, if the virus employed 224: VARICELLA. continues to produce a small vesicle, and attended only by little inflammation, there is reason to believe that the protection which it imparts is less than that from virus which works with greater energy, and it should be exchanged for such. The scab is best pre- served in soft beeswax, which excludes the air, and it should be kejDt in a cool place. CHAPTER V. VARICELLA. Varicella, chickenpox or swinepox, is the shortest and mildest of the eruptive fevers. It is highly infectious, so that few children escape who are exposed to it. Its period of incubation is from fif- teen to seventeen days. It is not inoculable, or at least those who have attempted to inoculate with the lymph of varicella have failed. I endeavored to communicate the disease in this way some years ago, but without result. It attacks the same individual but once, and it occurs as an epidemic. It has been thought by some to prevail most immediately before, during, or after epidemics of smallpox, and it has been conjectured that it is a modified form of variola, and hence its name, which signifies little variola. This idea is, however, entertained by few, and it is opposed by the fol- lowing facts. Varicella may occur after variola, or variola after varicella, without any modification, and the two diseases are very dissimilar as regards gravity of symptoms and duration. The va- riolous disease, whether smallpox or varioloid, often occurs in the adult; varicella, on the other hand, is a disease of infancy and childhood. Professor Flint states that he has observed it in the adult, but its occurrence at this period of life is rare. Moreover varicella and variola have been known to occur simultaneously in the same individual. Such a case was reported by M. Delpech, in a memoir published in 1845. Symptoms. — Varicella usually commences with such symptoms as usher in ordinary mild febrile attacks, namely, headache, languor, chilliness, and sometimes aching in the back and limbs. Fever supervenes, which is usually moderate, the pulse rising perhaps to 100 or 112, and the thermometer showing an increase of tempera- ture, but less than occurs in the other eruptive fevers. These DIAGNOSIS. 225 symptoms, which precede the eruption, are sometimes absent, or are so mild as to escape notice. The fever usually ceases on the second day, but it may return on the following night. The appe- tite is rarely lost, and most children continue, more or less, at their amusements. The eruption commences in about twenty-four hours, appearing as small red points, first over the trunk, and soon afterwards over the face and limbs. These points, which are at first minute pap- ules, become vesicular in the course of a few hours. The occur- rence of the vesicular stage is nearly simultaneous on all parts of the surface. The vesicles lack the hard, indurated base of the variolous eruption, though they are sometimes surrounded by a faint zone of redness. They differ also from the variolous erup- tion in the absence of umbilication, and in irregularity of shape. Some are small and acuminate, some hemispherical, and of medium size, and others oval or elongated, and of large size. The inflam- mation is quite superficial, not involving the subcutaneous tissue, and scarcely affecting the deepest layer of the skin. • The vesicles vary in size from the diameter of half a line to that of even three lines. They occasionally give rise to slight itching. On the second day of the eruption, or third of the dis- ease, the vesicles are still fully developed, their liquid contents being nearly transparent. At the close of this day the liquid be- gins to be somewhat cloudy, and its absorption commences. On the fourth day of the disease desiccation progresses rapidly, and by the fifth the liquid has for the most part disappeared, and there results a scab, small and thin, of a yellowish-brown color. The scabs are soon detached, the redness which indicated their seat dis- appears, the epiderm which had been raised and removed by the eruption is reproduced in its normal state, and in a few days all evidence of varicella is effaced. A cicatrix occasionally results, but it is due not to the simple varicellar eruption, but to a sore produced from the eruption by the scratching of the child. The number of vesicles varies considerably in different cases. They are never, so far as I have observed, confluent ; but they are sometimes so abundant in young children that, if the disease were variola, it would be called severe discrete. Diagnosis. — Obviously the only diseases with which varicella is liable to be confounded are such as present vesicles at some stage of their course. From the local vesicular eruptions this disease is diagnosticated by the fact that the vesicles appear on all parts of the surface. It is sometimes mistaken for variola or varioloid, or 15 226 VARICELLA. vice versd — a mistake very damaging to the reputation of the phy- sician. The points of differential diagnosis are the symptoms of invasion — severe, and lasting three or four days in the one ; mild, and continuing only one day in the other — an eruption passing slowly through its stages from the papulae to the pustulse, umbili- cated, with circular, raised, and inflamed base, appearing first on the face and neck, and not till a day later on the legs, in the one disease ; while in the other the evolution, shape, and course of the eruption, as described above, are materially different. By proper attention to these distinctive features it is rarely difficult to diao-nosticate the two diseases. The PROGNOSIS in varicella is always favorable. It does not, of itself, endanger life, nor seriously incommode the patient ; nor does it give rise to complications nor sequels. The treatment, there- fore, is the simplest possible. Mild diet, and a laxative, may be prescribed during the febrile period ; but nothing further is re- quired. SECTION HI. NON-ERUPTIVE CONTAGIOUS DISEASES. CHAPTER I. DIPHTHERIA. The term diphtheria, or cliphtheritis, is apj^lied to a blood disease, which, like measles or scarlet fever, has a local inflammatory mani- festation. The inflammation occurs on mucous surfaces, and the skin when denuded of its epidermis, and is attended by fibrinous exudation. Diphtheria has of late years attracted much attention on the part of physicians as well as the public, on account of its epidemic visitation in many diflerent localities, and the great mor- tality which has uniformly attended it. It has, of late years, been the subject of frequent discussion in the medical societies of Europe and this country, and the journals during this period contain nume- rous reports of cases, and many monographs designed to elucidate its nature. Though there is much that is still obscure in reference to diphtheria, the great interest which it has awakened has led to a better understanding of its nature, and a more judicious use of therapeutic agents. Diphtheria presents itself under two forms, primary and second- ary. The primary is more common. The secondary is usually a complication or a sequel of scarlet fever or measles, or more rarely of typhoid fever, and this form is, therefore, chiefly observed when these diseases are epidemic. The two forms are identical in nature, symptoms, and appearance ; the difference consisting in the fact that diphtheria, when occurring as a complication or sequel, is more serious, and apt to be fatal. Ordinarilj^ this secondarj^ form com- mences before the primary aflfection abates, so that there is no inter- mission between the two pathological states. The fevers which we have mentioned probably predispose to diphtheria, not only from the affinity which exists between them and that disease in conse- 228 DIPHTHERIA. quence of their zymotic nature, but from the fact that diphtheria is more apt to occur if there is pre-existing faucial inflammation. In both measles and scarlet fever the pharyngitis is still present, and in many has not begun to decline when the diphtheria com- mences. Thus, in a case occurring in my practice, death resulted from diphtheria eight days after the commencement of the rubeo- lous eruption, the pseudo-membrane being first observed while the rash was still present. Anatomical Characters. — Before considering the anatomical changes which occur in diphtheria, it is well to state what cases I consider to be diphtheritic. When this disease is prevailing, most observers have remarked the frequent occurrence of pharyn- gitis without the pseudo-membrane ; and some hold that these cases, as they seem to be due to the epidemic influence, should be called diphtheritic. But this would only lead to confusion. We might with equal propriety consider the sore-throat, which many physicians experience when attending cases of scarlet fever, as that disease. The term diphtheria should be limited to those cases in which the pharyngitis or other mucous inflammation is attended by the formation of patches of pseudo-membrane, for it is only by the presence of these that we are enabled to distinguish diphtheria from simple inflammation, the constitutional from the local disease. By employing the term diphtheria with great latitude, some ob- servers have rendered the statistics of this disease, which they have published, almost useless. The first departure from the state of health doubtless occurs in the blood, but the exact changes which this fluid undergoes, as in other contagious diseases, have not been fully ascertained. I shall hereafter describe the appearance of the blood, as ascertained at the autopsies of those who have died of this disease. Immediately upon the invasion of diphtheria, redness is observed on some part of the faucial mucous membrane, usually that part covering a tonsil or in its immediate vicinity. The inflammation thus commencing as a faint blush, rapidly extends. The color of the inflamed sur- face is sometimes a deep, bright red, almost like arterial blood ; in others it is dusky red, which indicates a vitiated state of the blood, and is an unfavorable prognostic sign. The dusky-red appearance is most common in the secondary form. In a large proportion of cases, in the course of a few hours almost the entire faucial surface is involved in the inflammatory process. The mucous membrane of this part is thickened and softened, its follicles tumefied and actively secreting, and there is more or less submucous infiltration. ANATOMICAL CHARACTERS. 229 The intensity as well as the extent of the phlegmasia varies, liow- ever, considerably in different patients. In a mild attack it is often limited to a part of the fauces, and in these cases there are few ex- ceptions to the rule that the tonsillar portion is affected, the redness gradually fading away in the healthy membrane beyond. There is swetling of the tonsils themselves, so that often they nearly touch each other. If the pharyngitis is general, the passage through this portion of the digestive tube is greatly diminished, but in most cases no more, and in many children not so much as in severe simple pharyngitis. "Within a day, and usually within a few hours, from the com- mencement of the inHammation, a small semi-transparent and almost diffluent point is observed upon the part most inflamed, or a thin film, of little importance, did the disease stop here, but very significant as a diagnostic sign, and as a forerunner of what is to happen. This substance, which is fibrinous, gradually becomes firmer, and at the same time thicker and broader, presenting a grayish or a grayish-white color. Sometimes different points or patches are observed, which extend and coalesce so that the fauces are almost entirely concealed from view. The pseudo-membrane is closely attached to the mucous surface, which it penetrates, be- coming firm, and not easily detached. Attempts to separate it often lacerate the engorged capillaries, producing a free flow of blood. It does not ordinarily attain a greater thickness than one- eighth to one-sixth of an inch. I have seen it, however, not far from one-third of an inch thick. The same pseudo-membrane is often firmer in one part than another, the outer and central portions being more compact and tough for a time than that underneath, which is more recent, and in which there is less fibrillation. After a few days, however, decomposition commences, and then that which was first formed becomes softer than the more recent production. When this occurs, the color of the exudation changes from a whitish or a grayish-white to a dirty brown, and its exposed surface is uneven and jagged from the partial separation of shreds and fibres. The escape of the liquor sanguinis from the engorged vessels diminishes somewhat the turgescence of the inflamed tissue. If this is considerable, the pseudo-membrane often sinks below the level of the surrounding surface, producing an appearance very much like that of an ulcer, or even of gangrene. Though there is no loss of substance in this particular state of the surface, it does, how- ever, often occur, being produced by the presence and contraction 230 DIPHTHERIA. of the fibrin with which it is infiltrated. Sometimes the pseudo- membrane has a reddish tinge. This is due to rupture of the capil- laries, and the escape of the blood corpuscles. It occurs in those cases in which the inflammation is intense, and the capillaries are greatly engorged. Sometimes the lower part of the exudation is blood-strained, while the exposed surface has the usual grayish- white hue. (Appendix C.) During the height of the inflammation it is astonishing often to see with what rapidity the diphtheritic membrane returns, when removed by force. A few hours often sufiice to restore it as firm and extensive as before the interference. If the exudation is examined with the microscope as soon as it aj^pears upon the faucial surface, it is seen to consist largely of cells, to wit, plastic nuclei and pus cells mixed with epithelia ; with these elements, we find amorphous matter, and ordinarily delicate interlacing fibrillse. Subsequently fibrillation is more complete, and the false membrane consequently more firm and resisting. In feeble children fibrilla- tion is sometimes lacking, or is so slight as not to be observed with the microscope. In these cases the pseudo-membrane is cellular and amorphous, and is easily detached. Such was its microscopic character in a case which occurred in the Kursery and Child's Hospital of this city; the inflammatory product in this patient covered the mucous membrane of the stomach, as well as those parts which are commonly the seat of it. This case I shall allude to again. By the microscope we are able to detect, in some instances, a confervoid growth in or upon the pseudo-membrane. This is com- monly the oidium albicans, or a plant closely allied to it, or the lepothrix buccalis, and its presence has led some observers to think that the primary and essential part of the adventitious formation is parasitic. Fortunately, so erroneous an idea of the pathology* of diphtheria is easily disproved, for in most cases of this disease no vegetable growth can be detected. The pseudo-membrane does, however, constitute a favorable nidus for the growth of confervse, like any animal matter of low vitality, or of no vitality, and hence the cause of their appearance upon the fauces in this disease. Confervae sometimes also grow upon the inflamed surface in simple pharyngitis, producing an appearance which simulates closely that of the diphtheritic membrane, and it is apt to be mistaken for it unless its true character is determined by the microscope. As an example of the simple inflammation simulating the pseudo- membranous, may be mentioned the case of a little girl in this ANATOMICAt CHARACTERS. 231 city, whom I was called to attend when diphtheria was prevailing. There was in this patient intense faucial inflammation, with a grayish-white substance like fibrin over one tonsil. This sub- stance, examined with the microscope, was found to consist of the lepothrix buccalis, with epithelia and amorphous matter. The disease, which was speedily cured, would without microscopic examination have passed for diphtheria. In favorable cases the false membrane is detached in a few days, and is either expectorated or swallowed with the ingesta. Its separation is promoted by the secretions underneath, especially by pus, which is formed in abundance between it and the surface on which it lies and which it penetrates. In many, perhaps a majority of cases, however, it does not separate in mass, but by progressive liquefaction. A little less of the pseudo-membrane is observed at each visit, until it entirely disappears. Such are the appearance, character, and history of the pseudo-membrane in this disease. Its common seat is upon the fauces, and in mild cases it is ordinarily found there alone. Unfortunately, the nature of diphtheria as a blood disease renders all the mucous surfaces liable to be attacked by the inflammation, and therefore in severe cases, and even in cases of moderate severity, we often find this product elsewhere, as well as upon the fauces, and in localities where, from its mechanical efi'ect, it greatly increases the danger, and even compromises life. The mucous membrane of the nostrils, mouth, larynx, trachea, oesophagus, stomach, conjunctiva, vagina, and even the delicate lining of the external ear, are at times the seat of diphtheritic inflammation, with the characteristic product. If the exudation occur in the larynx, or air-passages below the larynx, we have the phenomena and result of true croup; if upon a surface concerned in the digestive process, this function is more or less interfered with. I have already alluded to a case which occurred in the Nursery and Child's Hospital of this city, in which patient the surface of the stomach was almost completely lined with the diphtheritic formation, so that the function of this organ was appa- rently nearly or quite abolished. The occurrence of the pseudo- membrane in the nares is common, and is attended by the discharge of thin mucus and pus ; but though inconvenient to the patient, its presence in this situation is not dangerous, except in the nursing infant, in whom it interferes more or less with lactation. The thin irritating discharge produces excoriation around the nostrils and upon the upper lip. Diphtheria is ordinarily attended by inflammation of the cervical 232 DIPHTHERIA. glands, wliicli lie in the connective tissue behind and below the angle of the lower jaw, and in cases of great severity this tissue is also involved, becoming swollen and indurated. The adenitis begins early, and corresponds in degree with the pharyngeal inflammation. It is never or very seldom as great in simple pharyngitis as in this disease. Great external swelling of the neck, indicating a grave form of diphtheria, is, therefore, to be regarded as an unfavorable sign. The inflamed glands and connective tissue are hard and tender on pressure, but they less frequently suppurate than when similarly afiiected in scarlet fever. I have known but two instances of sup- puration, the pus in both escaping externally through the skin. The exudation occurs also on the cutaneous surface when blis- tered or abraded, and upon the edges of the wound produced by tracheotomy. This fact is interesting, as showing the pervading character of the diphtheritic virus. Bronchitis is often present in diphtheria, with or without fibri- nous exudation in the tube. Pneumonia is also so often present, that its occurrence is somethins; more than mere coincidence. In those who have died of diphtheria the blood has been found of a dark-red color, sometimes almost brown. Its appearance has been compared, on account of its color, to prune-juice. This color is due, partly, in those who have died from apncea in consequence of exudation in the larynx, to imperfect oxygenation of the blood, but it is also due to the malignant nature of the disease, as in the worst forms of scarlet and typhus fevers. The heart-clots are dark and soft. Apart from inflammation of the tonsils and cervical glands, the glandular organs are not changed in their anatomical character, so far as ascertained, with the exception of the kidneys. The state of the kidneys, and character of the urine, will be described here- after. Symptoms. — As with other contagious diseases, the symptoms vary greatly in intensity in different cases. In general, in the com- mencement of an epidemic, diphtheria is more severe and fatal, and its symptoms more violent, than when the epidemic influence is abating. The prominent symptoms are, however, often dispropor- tionate to the gravity of the attack. Striking examples of this fact might be given from cases in my practice, the friends not sup- posing that there was any serious ailment, and not seeking medical advice till the fatal termination had nearly arrived. Diphtheria corresponds, in this respect, with all those affections in which the blood -is profoundly altered. ^ SYMPTOMS. 233 The invasion of this disease may be gradual. There is a degree of chilliness, with rigors, often slight, succeeded hy more or less fever, headache, languor, and loss of appetite. Still, the patient, if old enough, continues to walk about as if affected with a slight and temporary ailment. The sj^mptoms are like those of a cold, for which, indeed, the initial stage of diphtheria is often mistaken. "With many, one of the first symptoms is slight tenderness or a sensation of fulness in the fauces. A distinguished clergjnnan of the Pacific coast, who fell a victim to this disease, dreamed a few nights before he complained of illness that his throat was cut. Doubtless the diphtheritic inflammation had already commenced, so that what seemed a forewarning had a natural explanation. So insidious was the commencement in this case, that the disease had advanced beyond all hope of relief when medical advice was first sought. In other cases the invasion is more abrupt and severe. Great febrile reaction, headache, pain in the ear, aching of the limbs, and loss of strength, compel the patient to take to bed from the first. Delirium may be present, but it is unusual. The symptoms of invasion have but little prognostic value. I have met cases with a severe commencement, attended by delirium, which terminated in complete restoration to health in less than a week, the presence of the membrane upon the fauces, and the occur- rence of diphtheria in other members of the family, rendering the diagnosis certain. On the other hand, the milder commencement frequently ushers in a fatal form of the disease. The slight soreness of the throat or sensation of fulness, which accompanies the initial stage of diphtheria, does not ordinarily become any more severe during the course of the attack, and it often disappears within a few daj^s. The pain on swallowing, and the tenderness when pressure is made upon the throat, are usually less than in quinsy or simple pharyngitis. The absence or mild- ness of local symptoms is the main reason why the disease is so often overlooked in its first stages. I have known more than once, in consequence of the slight tenderness in the throat, the large ex- ternal swelling to be mistaken for that of mumps, till an incurable stage of the affection was reached. I was once asked to see a little girl about ten years old, on account of this external swelling, which was limited to one side, and the character of which the parents did not understand. A physician visiting near by a few days pre- viously, had been asked to see this patient, and, without examining the fauces, attributed the swelling to inflammation of the foot of 234 DIPHTHERIA. a tooth, and had not thought it necessary to repeat his visit. This child, now within three or four days of her death, was walking about, not complaining of her throat, but with poor appetite, and with the pale, cachectic aspect so common in advanced diphtheria, and having severe inflammation of the fauces, with a thick and firm pseudo-membrane extending from the pharynx forward to the arch of the mouth. The mildness of subjective symptoms was strikingly shown in another case which came to my notice. A little girl had been ailing a few days, and had the external cervical swelling, but continued about the house and amused herself with playthings, even jumping the rope a few times on the day of her death. Finally, she sank rapidly of exhaustion, dying before a physician could arrive. These sudden and unexpected deaths in diphtheria are due to the profoundly altered state of the blood. If the inflamma- tion invade the larynx, then the symptoms are immediately con- spicuous and alarming. The tongue in diphtheria is covered with a moist fur ; sometimes more or less of the exudation appears upon it; the apj)etite is poor; bowels regular. The pulse in different cases varies greatly in vol- ume and frequency. It is often full and strong in the first days of the disease, but in the latter part, when death from asthenia ap- proaches, it is feeble and frequent. At first there are no marked symptoms referable to the respiratory apparatus. There is only that degree of acceleration of respiration which corresponds with the amount of fever. In many cases, favorable as well as unfavorable, there is no cough and no embarrassment of respiration throughout the entire sickness, though the inflammation of the faucial surface may be general and severe, and the constitutional disturbance very decided. But ordinarily, in the course of a few days from the inception of the disease, the swelling of the nasal mucous mem- brane, and the occurrence of exudation upon it, produce snuflHing respiration. The occurrence of the phlegmasia upon the laryngo- tracheal surface is indicated by hoarseness of the voice, and an occa- sional dry cough, and as the inflammation extends and the pseudo- membrane forms, the cough becomes more frequent, and harsh or raucous, as in true croup. Indeed, the condition of the patient, as regards the larynx and trachea in diphtheria, when they are the seat of fibrinous exudation, resembles that in true croup. As the inflammation in the larynx and trachea, when accompanied by fibrinous exudation, is rarely amenable to treatment, the symptoms of obstructed respiration become more continuous and severe as the disease advances, till finally the dyspnoea is extreme; the inspira- 4 SYMPTOMS. 235 tion is protracted and whistling, and accompanied by great depres- sion of the ribs; the countenance is anxious and pallid; the prola- bia and fingers livid, and the little patient in vain seeks for relief by change of position. Occasionally, by great effort on the part of the child, or by fortunate treatment, a portion of the pseudo- membrane is expectorated, and for some hours there is apparently marked improvement, but it is only in exceptional cases that the membranous formation is not speedily and fully reproduced. As death draws near, the cough diminishes both in frequency and force. In cases of a severe type the breath is ordinarily offensive, having a gangrenous odor. There is in such patients intense pharyngitis, with a pseudo-membrane which, from its low vitality, rapidly un- dergoes decay, and also great external swelling from the adenitis and cellulitis. An efflorescence is sometimes observed upon the surface during the period when the temperature of the skin is exalted. This rash does not difier from ordinar}^ erythema so common in the febrile and inflammatory aflfections of infancy and early childhood. It is not attended by the minute papulte which produce roughness of the surface in scarlet fever. It is the erythema fugax of dermatolo- gists suddenly appearing, and after some hours as suddenly disap- pearing. In many patients it is absent, and it is seldom if ever observed, except in the first days, when there is an active circula- tion. The symptoms pertaining to the nervous system, which are ordi- narily most prominent, I have already described. I have described the cephalalgia and muscular pains, which are present in the initial period, but they soon abate. Convulsions may occur in young children, but not oftener than in other diseases attended by febrile reaction. The heat of surface is in most cases less than in scarlet fever ; it abates in a few days, and in advanced stages of the disease the temperature is natural or less than natural. The abdominal organs are seldom much affected in diphtheria, so far as ascertained, with the exception of the kidneys. There have not been many chemical examinations of the urine in this disease, but in a few which have been made (Sanderson, British and Foreign Medico-Chir. Rev., Jan- uary, 1860), the quantity of urea excreted daily was found to be considerably more than when convalescence had commenced. The most interesting and important change, however, in the constitution of the urine, is the occurrence of albumen in it. This element was first discovered by Mr. Wade, of Birmingham, in 1857, and since 236 DIPHTHEEIA. then various observations in different epidemics and localities establish the fact that albuminuria occurs in the majority of cases of severe diphtheria, and in many of a mild form. It often occurs at an early period, but in other patients it does not appear till the close of the first week, or commencement of the second. It con- tinues three or four days to as many weeks, when in favorable cases it gradually becomes less and soon disappears. While albuminuria is more common in diphtheria than in scarlet fever, the quantity of albumen in the urine is ordinarily less than in that disease. The albuminuria of diphtheria is further distinguished from that of scarlet fever in the fact already stated, that it ordinarily occurs in the midst of the disease, and is attended by slight anasarca, often by none, whereas in scarlet fever it occurs after the subsidence of the fever, is attended by greater anasarca, and even serous eft'usion in the cavities. If we examine the albuminous urine of diphtheria with the microscope, we find in it fibrinous casts and altered renal epithelial cells. These cells are opaque or granular, mainly from the deposit of fatty particles in their interior. But this appearance of the cells is not peculiar to diphtheritic albuminuria. Albuminuria in diphtheritic patients is, in the present state of our knowledge, rather a matter of scientific interest than of prac- tical importance. It does not seem to be an unfavorable prognostic sign, and in most cases it requires no special treatment. Occasion- ally there is a considerable amount of albumen in the urine in cases which are not severe, and the quantity in the same patient may vary from day to day. In some grave cases of diphtheria the urine is scanty, and there is then danger of ursemic poisoning. If there is great and continued deficiency, death may occur from this cause in convulsions and coma. The course of diphtheria, like the intensity of its symptoms varies greatly in dift'erent cases, whether the result be favorable or unfavorable. Complete recovery may occur within a few days, less indeed than a week, but in other and perhaps a majority of favora- ble cases weeks elapse before the health is completely restored. When the disease is so protracted, the pseudo-membrane is detached slowly, or being detached, it is reproduced again and again. In these lingering cases, the countenance bears the appearance of marked cachexia, the appetite remains poor or capricious, the features are pallid, the body more or less wasted, and the strength reduced. Convalescence of such patients is slow and jDrotracted, even after the inflammation has entirely disappeared. The course of diphtheria lacks uniformity in fatal not less than in i NATURE. 237 favorable cases. I have known death to occur in a robust child of two years and three months on the fourth day, without cough, and entirely from the malignant nature of the affection. The strength was overpowered, and life so suddenly extinguished by the intensity of the diphtheritic virus. In this case there was great external swelling and intense pharyngitis. In other cases, as has been pre- viously stated, death occurs from diphtheritic croup. In other, and a large proportion of fatal cases, the disease is more protracted. Without embarrassment of respiration, and often apparently with but moderate inflammation, the patient gradually loses flesh and strength. The face presents a pallid and cachectic aspect, and sometimes there is a general flabby or cedematous appearance ; the appetite is poor, and is improved but little by tonics ; the pulse is accelerated, and is day by day more feeble, till, finally, death occurs from asthenia. In these lingering and dubious cases, all hope of recovery is sometimes dissipated by the occurrence of abundant hemorrhage from the throat, in consequence of detach- ment of the pseudo-membrane and consequent rupture of the capillaries, or possibly sometimes from ulcers in the throat. I was once treating a little girl about nine years old with diphtheria accompanied by pretty severe pharyngitis, and she had entered the third week, with prospect of a favorable issue of the disease, when she was suddenly seized with profuse hemorrhage from the fauces, which was repeated, and death occurred in forty-eight hours. So unexpected a result was apparently due to separation of the false membrane. Nature. — Though the inflammatory lesions in diphtheria are so severe and dangerous, they sustain a secondary relation to the disease itself. Diphtheria must be placed in the same category with smallpox, scarlet fever, measles, and other infectious diseases. Like them, it is due to a specific virus. These diseases, though dissimilar in nature and appearance, are controlled by the same general laws, so that they are very similar as regards the mode of their occurrence. That there is a miasm generated in the persons of those afl'ected, and which propagates the disease, is shown by numerous observations. The infectious nature of diphtheria is, however, doubted by some, though admitted by most pathologists. Facts such as those which prove the communicability of scarlet fever and measles, have been repeatedly observed in reference to diphtheria. Diphtheria, if it enters a family of children during its epidemic prevalence, usually attacks more than one. It attacks those who remain in the same room with a diphtheritic patient, 238 DIPHTHERIA. wliile those staying in separate apartments escape. In the late epidemic of diphtheria in this city, I was asked to see a boy about ten years old with diphtheria. The father had left home a few days previously, and escaped the disease. A servant girl, who was much frightened and remained in a distant jiart of the house, also escaped. Three sisters, who were daily exposed to the boy, took the disease within the ensuing week, in a mild form. All had the pseudo-membrane, though of limited extent. Such facts, and there are many of a similar nature contained in the literature of diphtheria, establish the doctrine of the communicability of this disease as securely as almost any doctrine in pathology. It is not known certainly whether diphtheria is inoeulable, but it is believed by many that the saliva and pseudo-membrane of a diphtheritic patient, applied to the abraded cutaneous surface or to the mucous membrane, may communicate the disease. The illus- trious Yalleix, whose writings hold so conspicuous a place in the literature of children's diseases, was attending a child with diph- theria. One day, on examining the throat of his patient, he re- ceived in his mouth a little of the saliva, ejected in the effort of coughing. The next day a small concretion appeared on one tonsil. The inflammation and the pseudo-membrane extended, and in forty-eight hours Valleix died, though his patient recovered. This case and others similar to it, which have been published, do not prove the inoculability of diphtheria, for the same result might have occurred in the ordinary mode in which contagious diseases are transmitted, namely, by infection. But as all who have seen much of diphtheria, from the time of Bretonneau, have now and then observed cases analogous to that of Yalleix, it is the part of prudence, till the question of inoculability is settled, to avoid all needless exposure. Bretonneau believed not only in the inocula- bility, but that this was the only way in which diphtheria is com- municated. Diphtheria also, like typhus fever, often occurs without exposure. Whenever it visits a region, it commences in localities remote from each other, some of which are so secluded as to negative the idea of importation. For example, in this country as well as in Great Britain, during the recent epidemic, it prevailed in remote farming sections as early and sometimes earlier than in the commercial centres. Children who had lived for months secluded in farm- houses were sometimes the first to be affected. Infectious diseases have a period of incubation. Observations show that this is short in diphtheria, though, as in scarlet fever, it SEQUEL.E. 239 seems to vary in difFerent cases. Tliis period is usually from two to seven days. Diplitheria, whatever the local manifestations, is always essen- tially the same disease. A mild may communicate a severe form, and vice versa, and cases, which at first view might appear to he different on account of difference in the seat of the phlegmasia, are shown to be identical in nature by occurring together, and in conse- quence of the same exposure. Allusions have already been made to the epidemic character of diphtheria. Sporadic cases occasionally occur. The epidemic form is more severe and fatal than the sporadic. The history of the various epidemics shows the universality of the specific virus, for diphtheria has prevailed in all seasons, in all or nearly all climates, in the rural districts, remote and sparsely settled, as well as in cities, and in mountainous regions as well as in valleys. It is, however, most prevalent and fatal where anti-hygienic conditions prevail, as in the tenement-houses of the city, and especially in such apartments as are dark and damp, but which necessity compels the poor to occupy. A large proportion of the severe cases seen by myself, during the recent epidemic in 'New York, occurred in the upper part of the city, along the old watercourses, where, in conse- quence of grading of the streets, there was more or less stagnant water, which was impregnated with decaying animal and vegetable matter. In these localities, even where the population was sparse, some of the first as well as last cases of the epidemic occurred, and a large portion of those aflected died. Diphtheria occurs at any age. I have known the infant of three months die of it, and many adults fall victims when it prevails as an epidemic. Much the largest number of cases, however, occur between the ages of two years and eight or ten. The occurrence of this disease at so early an age as three months, and, on the other hand, in adult life, affords one point of contrast between diphtheria and scarlet fever, as well as true croup, both which rarely occur at so early and so advanced an age. Sequels. — Those who recover from a severe attack of diphtheria, remain often for weeks with a pale and cachectic appearance. The blood is evidently profoundly altered, so that there is a deficiency of red corpuscles or a state of spansemia, which slowly disappears. This is a common result of protracted constitutional diseases, but it is more noticeable after this than most kindred affections. The excretion of albumen from the kidneys no doubt increases mate- rially the impoverishment of the blood. 2-iO DIPHTHERIA. There is another sequel, which possesses great interest, as it is common in diphtheria, and as its etiology is not fully understood. This sequel is paralysis. Paralysis does not occur till after the abatement of the inflammatory symptoms. The patient seems fully convalescent. The fever has ceased ; the appetite is returning ; the ansemia is becoming less, and there is prospect of speedy restoration to health, when this nervous affection is developed. The interval between the subsidence of the inflammation and the commencement of the paralysis is usually two or three weeks. The muscles most frequently affected are those of the pharynx, so that deglutition is rendered difficult, to such a degree often, that nutrition is seriously interfered with. The aliment taken passes back through the nos- trils, or is not swallowed till after several successive efforts. In the attempt to swallow, a portion of the food sometimes enters the larynx, so as to produce violent coughing. As we observe the dys- phagia, it seems as if there must be pharyngitis, which renders deglutition difficult, but on inspecting the fauces we find no evi- dences of inflammation. The mucous membrane has recovered its normal appearance, and the nerves only are affected. The velum palati hangs flaccid and motionless, like a curtain. In some there is only pharyngeal paralysis, but in many this nervous affection occurs in other parts. Whenever it occurs elsewhere, the pharj^ngeal muscles are nearly always involved at the same time. Diphtheritic paralysis may affect the motor muscles of the eye, causing strabis- mus; the muscles of one side, causing hemiplegia; of the legs, caus- ing paraplegia ; or of an arm on one side and leg on the opposite. It does not commence simultaneously in the various muscles which are affected, but in succession, those first affected being for the most part the muscles of the pharynx. In some the muscles of the blad- der have been paralyzed, leading to retention of urine or difficulty in passing it. Paralysis in the limbs is frequently preceded by tingling or a sensation of formication. There is often not a total loss of sensation or of motion in the paralyzed part, but there is numbness with great difficulty rather than impossibility of motion. A few cases have been reported in which the paralysis was almost general, and some believe that they have met cases in which the heart was paralyzed, death occurring suddenly and unexpectedly. Dr. J. B. Reynolds relates a case in the Nexo York Journ. of Med.^ May, 1860, in which there was not only strabismus, partial paralysis of the limbs, and paralysis of the muscles of the pharynx, so that food was regurgitated, but the head dropped forward so that the chin rested on the sternum. PROGNOSIS. 241 A majority of those affected with paralysis recover, although few regain the complete use of their muscles in less than one month, and many do not till between two and four months. Defect of vision is an occasional result of diphtheria; some have presbyopia ; others myopia ; some see douhle ; some are amaurotic ; while in others one pupil is more dilated than the other, or both pupils are dilated, and feebly sensitive to light. This impairment or perversion of vision gradually disappears as the vigor of system returns. Prognosis. — The prognosis in diphtheria is more favorable when it occurs sporadically, or at the close of an epidemic, than when the epidemic influence is prevailing. Though a constitutional disease, its gravity is in a majority of cases proportionate to the local symp- toms. Therefore, intense pharyngitis, an extensive pseudo-mem- brane, and great cervical cellulitis and adenitis, indicate a form of the disease which usually proves fatal in the robust as well as weakly. When the inflammation extends to the larynx, and the phenomena of croup arise, there is slight prospect of recovery. Pseudo-membranous laryngitis is then present in addition to the depressing influence of the diphtheritic virus. The local disease, apart from the constitutional, we know to be ordinarily fatal. Much more unfavorable, then, is the prognosis if the two are com- bined. When the croupy cough, voice, and respiration are observed, he will seldom err who predicts a fatal result within a week, and often death follows in two or three days. Great acceleration of the pulse continuing after the first week, a countenance pallid, with softness or flabbiness of the tissues, the occurrence of hemorrhage from the fauces or other parts, are prog- nostic of an unfavorable ending. The secondary form of diphtheria is more apt to prove fatal than the primary, in consequence of the depressing effect of the antecedent disease. From what has already been stated, it is obviously injudicious to predict a favorable or an unfavorable termination from the cha- racter of the initial symptoms, since an obstinate and fatal case often commences mildly, and cases easily managed may commence with violent symptoms. But if the inflammations, mucous and glandular, remain of a mild grade, if the pulse is not greatly accele- rated, if the constitution is good, and there are no laryngeal sym[>- toms, a good result is highly probable. In many cases, after the active symptoms have somewhat abated, the result for days or even weeks is uncertain on account of the ana3mia. A majority, however, who have passed through diph- 16 242 DIPHTHERIA. theria, recover, even if there is great impoverishment of the hlood, provided that there are no serious local symi^toms. Diphtheritic paralysis, which is so alarming to friends, may continue several months, but it is very seldom permanent, perhaps never. Only in exceptional instances do patients afl'ected with it die. This result is probably due in general to imperfect nutrition, resulting directly from the diphtheria, or from the dysphagia, which is present in consequence of the paralysis. Diagnosis. — The liability of mistaking simple pharyngitis, when attended by the growth of conferva, for diphtheria, has been already sufficiently pointed out. By the microscope the diagnosis in such cases is rendered easy. The greater amount of external swelling in pseudo-membranous pharyngitis is also a means of distinguishing this disease from the simple form. There is, in some cases, a close resemblance of diphtheria to scarlet fever, especially as regards the condition of the system generally, the pharyngitis, and the external glandular swelling. The rash upon the skin, and the ab- sence of a pseudo-membrane upon the fauces, in scarlet fever, are usually sufficient to establish the diagnosis. In almost all cases of diphtheria, this pseudo-membrane can be seen on inspecting the fauces. The cases in which it is not visible, during the active period of the disease, are so few that no account need be taken of them. The superficial gangrenous state of the throat, occasionally present in scarlet fever, can be distinguished by careful examination from the pseudo-membranous pharyngitis of diphtheria. Occasion- ally anginose scarlet fever is attended by a fibrinous exudation, especially upon the tonsils, but the quantity is small, unless, in- deed, there is at the same time diphtheria. Practically, however, it matters little whether we make a differential diagnosis of scarlet fever and diphtheria, as the two require very similar therapeutic measures. Diphtheria, with the pseudo-membranous laryngitis, and true croup, present great similarity as regards symptoms. One has often been mistaken for the other, to the detriment of the patient, for these two diseases require different treatment. With proper care, however, in examination, with a knowledge of the history of the case, the character of the affection can generally be ascertained. The inflammation of croup generally begins in the larynx, and the pharynx, though inflamed, is inflamed secondarily; whereas the inflammation of diphtheria begins in the pharynx, the laryngitis occurring some days later. Therefore, in diphtheria there is usually the fever, with tenderness and tumefaction of the faucial surface, TREATMENT. 243 and fibrinous exudation, before the cough or other symptoms of laryngitis occur. In croup the characteristic voice and cough are present from the first, and if we inspect the fauces in the com- mencement of the disease, we find only a degree of redness, and though at a later period points or patches of pseudo-membrane may be observed, the inflammation of the pharynx remains less intense throughout the disease than that of the larynx, as shown by the symptoms. The pseudo-membrane of diphtheria penetrates the mucous coat, and is fibrinous; while that of croup lies on the surface, and consists chiefly, if not entirely, of degenerated epi- thelial cells, with mucus and pus. By attending to these par- ticulars, a correct diagnosis of croup and diphtheria can ordinarily be made. Treatment. — It has been proposed, in the treatment of this and other infectious diseases, to give medicines to prevent the supposed fermentative processes going on in the economy, and by this means to ameliorate, if not entirely control, the morbid action. Prof. Polli, of Milan, has recommended for this purpose the use of the sulphites, in the belief that the sulphurous acid set free in the sys- tem by their decomposition, prevents, or tends to prevent, catalysis. Experiments have shown that this agent does check fermentation without the system, and the theory of Polli possesses a degree of plausibility. But in such matters the only reliable guide is expe- rience. The doctrine of catalysis in disease is indeed merely, as yet, an hypothesis, having the appearance of correctness. If expe- rience show that the sulphites are beneficial in the treatment of the so-called zymotic affections, we are then, and only then, justified in employing them. In our present imperfect knowledge of pathology and of the action of medicines, theorizing should succeed observa- tion. It is difiicult to determine the exact value of any medicine in the treatment of zymotic diseases, since so many cases terminate favorably without medicines, but some of the physicians of this city who have used the sulphites speak favorably of their effect. My own experience with them has been limited. I have seen im- provement in severe scarlet fever when these agents were employed but remained in doubt whether the same result would not have fol- lowed with the use of other measures. The most eligible of the sulphites is the bisulphite of soda, since this gives a large amount of sulphurous acid, has no purgative efi'ect, like some of the sul- phites, or other injurious action, and, from its name, insures against any mistake on the part of the druggist. The word sul|ihite has been mistaken in a prescription for sulphate, the error not being 244 DIPHTHERIA. detected till the child was weakened by purgation. Bisulphite of soda is readily soluble in water as well as alcohol, and to a child of three to five years one to two drachms may be given in twenty- four hours, in doses of five to ten grains. R. Sodse bisulphit. gj-ij ; Tinct. aurant. ^^ij ; Aquse 5x. Misce. Dose, one teaspoonful every two hours. Sometimes in place of water a bitter infusion like that of quassia has been employed. Death in diphtheria, as we have seen, ordinarily occurs from ex- haustion or from obstructed respiration. Knowledge of this fact aids in the choice of therapeutic measures. Diphtheria is decidedly an asthenic disease; therefore sustaining treatment is required. From the first, although the pulse is strong, the surface hot, and features flushed, all measures of a^ depressing nature must be care- fully avoided. Great febrile excitement, in connection with robust- ness of system, may incline us to the use of cardiac sedatives, but they should not be administered, or if administered, only the mild- est should be given and with caution, since diphtheria, if it con- tinue a few days, is attended by evident symptoms of prostration, whatever the mode of commencement. Nutritious food, like the animal broths, should be given often and in a concentrated form, on account of the diificulty of swallowing, and recourse should be had to alcoholic stimulants, as wine-whey or milk-punch, as soon as there are any indications of feebleness. An extensive pseudo- membrane and great glandular swelling show a form of the disease which requires immediate and active sustaining measures. The apartment occupied by the patient should be kept clean and dry, as indeed it should be in the treatment of any infectious disease. A change of apartments during the day is also advisable, particularly in those cases in which there is a gangrenous odor. As the sulphites have not been employed sufficiently long to de- termine their value, or whether, indeed, they have any eftect in controlling diphtheria, it does not seem judicious until they are more fully tested, and are found to accomplish what is claimed for them on theoretical grounds, to discard, in cases that are at all critical, those remedies which appear to be indicated from the nature of the disease, and which have met general approval of the profession. These remedies are the tonics, vegetable and ferrugi- nous. A large number of these medicinal agents might be mentioned, all of which would be likely to result in more or less benefit, but TREATMENT. 245 I will only mention such combinations as are well adapted to meet the various indications. Chlorate of potash or soda, and tincture of the chloride of iron, are the two remedies which have been most employed in this country and in Europe, on account of their supposed local effect on the inflamed surface, and the latter on account of its eminently tonic properties. Prescribed in combination, these medicines are not unpleasant to the taste, and I consider this mixture one of the very best for ordinary cases of diphtheria: — R. Tinct. ferri chloridi 3j ; Potas. chlorat. 5j ; Syr. simplic. 3ij. Misce. Dose, one teaspoonful every two or three hours to a child of three years. I have usually given directions to allow no drinks to the patient for a few minutes after each dose, in order that the full local effect may be obtained. The tincture of the chloride of iron alone, the wine of iron, or any of the other ferruginous preparations, may be advantageously administered, especially in ansemic cases, in place of the mixture mentioned above. In those of full habit and florid complexion, iron is not so imperatively required. In such cases the elixir of Calisaya bark, in doses of one teaspoonful to a table- spoonful, according to the age, is a useful and not unpleasant remedy. The fluid extract of cinchona or col umbo also meets the indication. There is difference of opinion as regards the value of local treat- ment in diphtheria. Some hold that as it is a constitutional malady, and that as death in it is ordinarily due either to exhaus- tion or to inflammation of the larynx, which we cannot subject to any reliable local treatment, therefore topical measures directed to the throat, which worry and fatigue the child, are not advisable. But, as Trousseau has remarked, the gravity of diphtheria is usu- ally proportionate to the amount of local disease, and if, therefore, we can moderate the intensity of the inflammation, we increase the chances of a favorable issue. The local disease reacts on and intensi- fies the constitutional, increasing the febrile movement, and ex- hausting the strength of the patient. Again, it is probable, though this opinion is not held by some, that the laryngitis of diphtheria often results from extension downward of thefaucial inflammation. For these reasons, direct treatment calculated to diminish the intensity of the faucial inflammation is proper, and yet those severe caustic applications, formerly much employed, and still used by some practitioners, by causing great pain and restlessness, weaken 246 DIPHTHERIA. the child, and do more harm than good. Great gentleness on the part of the. physician, in making applications to the throat, cannot be too strongly insisted on. Harshness towards a patient is always to be condemned, and in no disease more than in this. By gentle- ness and a little tact, much of the repugnance to the ojDcration, on the part of friends, may be prevented. The formulae recommended in the topical treatment of the larynx in croup are proper for the pharynx as well as larynx in diphtheria. For these formulae the reader is referred to the article on croup. The tincture of the chloride of iron has been advantageously prescribed as a gargle with chlorate of potash in those old enough to employ such treatment. For this purpose a drachm of the tinc- ture should be added to a tablespoonful of a saturated solution of chlorate of potash, and gargled every hour or two. I prefer, how- ever, a gargle consisting of carbolic acid, six or eight drops to one ounce of solution of chlorate of potassa, particularly if there is decomposition of the pseudo-membrane and an offensive odor. The local treatment should, of course, vary according to the extent and character of the inflammation. When the pseudo-membrane is removed, and the inflammation has begun to abate, there is less need of active topical measures. They should soon be discontinued. When croupy cough is observed in diphtheria, it is well to administer, if the patient is robust, an emetic which causes the least possible prostration. The sulphate of copper or of zinc is one of the best emetics of this class. At the same time general sustaining treatment is required. Quinine is given by many prac- titioners when croup supervenes, in sufficient quantity to reduce the frequency of the pulse. A child from three to five years old may take a grain every two hours. I know no better medicine for such cases, though, unfortunately, with this or any other treat- ment, a large proportion die. Moisture in the apartment is desira- ble, as in the treatment of true croup. If the laryngeal symptoms continue to increase, and the respiration becomes so embarrassed that livid ity occurs, the propriety of tracheotomy becomes a serious consideration. It is only in exceptional cases that it saves life, but it renders death more easy. If the patient has passed through diphtheria, and entered upon convalescence, attention should be given to his hygienic condition, and often therapeutic measures of a tonic character are still re- quired. That most interesting and important of the sequelae, namely, paralysis, gradually abates, without special treatment, as the tone of the system is restored. Strychnine may be given or PERTUSSIS. 247 the galvano-clectric current employed, as a means of expediting recovery. The following will be found a good formula for those affected with paralysis: — I^. Strychnife gr. j ; Acid, pliosphor. dilut. 5ij ; Syr. zingib. ^vj. Misce. Dose, three to five drops in a dessertspoonful of water three times daily to a child of three years. The anaemic state which succeeds diphtheria requires the use of iron for several weeks. CHAPTER II. PERTUSSIS. Pertussis, or hooping-cough, is a contagious disease. It is manifested by inflammation of the mucous membrane of the air- passages, and a spasmodic cough to which this inflammation gives rise. It is due to a specific cause, a materies rnorbi, the exact nature of which is not known. It may occur both in the epidemic and sporadic form. It is probably not inoculable, although it is highly infectious, either through the breath of the patient, or by exhala- tions from his surface. With rare exceptions, it afl:ects the same individual but once. Rilliet and Barthez report a case of its second occurrence, and a case is also reported by Dr. West. I have never attended a patient in two attacks, though I can recall to mind two individuals, both women of intelligence, who stated that they had previous attacks in early life. It occasionally afi:ects young infants, even those less than one month old; and, on the other hand, adults, and rarely even old people; but most cases are between the ages of one and seven years. Symptoms. — Pertussis consists of three stages: first, the ca- tarrhal ; secondly, the stage of spasmodic cough — or, for brevity, the spasmodic stage ; thirdly, the stage of decline. The first period is characterized by the symptoms of coryza and bronchitis. The eyes present a moderatel}^ suff'used and injected appearance. There is sneezing, with defluxion from the nostrils ; and there is also more or less cough, dependent on bronchitic in- flammation. The cough does not differ in character from that in the first stages of simple bronchitis, and there is little or no ex- 248 PERTUSSIS. pectoration. Trousseau has known the cough to be repeated forty or fifty times per minute ; but such great frequency is rare. The pulse and respiration are moderately accelerated, and such other symptoms as commonly accompany inflammatory aiiections of a mild grade are present, namely, increased heat of surface, thirst, and impaired appetite. The duration of the first stage is various. It may, in rare in- stances, last only two or three days ; or, on the other hand, be pro- tracted even to six weeks. Its ordinary duration is from eight to fifteen days. In fifty-five cases observed by Dr. West, its average duration was twelve days and seven-tenths of a day. I have met two cases, both girls over the age of six years, in whom no spas- modic cough was noticed. If there was any, it was limited to a few paroxysms, and it might, therefore, be said that there was but one stage, namely, the catarrhal. They had the symptoms of the catarrhal stage, but instead of the occurrence of the spasmodic cough at the usual period, the inflammatory symptoms abated somewhat, and there remained an occasional easy cough, like that of simple subacute bronchitis. This continued during a period which corresponded with the duration of pertussis. The diagnosis in these cases would have been doubtful, except for the simultane- ous occurrence of pertussis, with its regular stages, in other children of the same families. Second Period. — This supervenes gradually. At first, while the cough ordinarily has the character presented in the first stage, it is now and then observed to be more severe and spasmodic. The spasmodic element increases gradually, so that in the course of a week all doubt as to the nature of the disease, if any previously existed, is removed. The severity of the cough in the second stage varies considerably in difterent cases. It sometimes occurs quite abruptly, but com- monly there is premonition of it. The patient endeavors to re- press it. If a child, he leaves his playthings, and rests his head on Lis mother's lap, or takes hold of some firm object for support; his face has a grave or even anxious appearance, while the pulse and respiration are somewhat accelerated. Immediately the cough commences. It consists in a succession of short and hurried expi- rations, which expel a large part of the air contained in the lungs, followed by a rapid and deep inspiration. There may be a single series of expirations, terminating in the manner mentioned ; but often there are two, three, or more such series embraced in a paroxysm. The paroxysm commonly ends in the expulsion of SECOND PERIOD. 2i9 frothy mucus from the bronchial tubes, and sometimes in vomiting. The rapid passage of air through tlie glottis, in the inspiration which terminates the cough, is sometimes accompanied by a sound, which is called the hoop. During the cough there is temporary arrest of blood in the lungs, leading to congestion in the right cavi- ties of the heart and throughout the systemic circulation ; there- fore the face is flushed and swollen, and occasionally hemorrhage occurs under the conjunctiva, or from one of the mucous surfaces. The most frequent hemorrhage is epistaxis. When the cough ceases, and normal respiration is restored, the fulness of the vessels immediately abates ; but often pufiiness of the features is observed, due to serous infiltration of the subcutaneous cellular tissue, and continuing for days or weeks during the period when the cough is most severe. The paroxysm lasts from a quarter to a half or even a whole minute, and in that time, in severe cases, there are often as many as fifteen to twenty series of expirations. The hoop is not as loud in infants as in children, and in young infants, especially those under the age of six months, it is often lacking, although the cough may be severe. At the close of the paroxj'-sm, if there is no complication, the symptoms soon abate ; the temperature, pulse, and respiration become normal, and there is no evidence of disease. The cough in the second stage is much more frequent in one case than another. At the height of this stage it is generally more severe if it occurs at long intervals than when frequent. During the weeks in which pertussis is most severe there is, in the average, about one paroxysm of coughing to each hour. The cough increases in severity till the third week of the second stage, or the thirtieth to thirty-fifth day of the disease, after which it remains stationary for a certain time. It is apt to be more frequent in the night than daytime. Sometimes it occurs while the child is quiet ; it may even awaken him from sleep, but it is often also produced by mental excitement or by physical exertion. Anger or fright gives rise to it, and therefore the child is apt to cough when being examined by the physician, or when his wishes are not complied with. The ordinary duration of the second stage is from thirty to sixty days. It may, however, be considerably longer or shorter than this. The third stage, which commences at the time when the spas- modic cough begins to abate, is short, not continuing longer than two or three weeks. A protracted stage of decline indicates some 250 PERTUSSIS. complication. While the sputum in the second stage is mucous and frothy, that in the third stage is more opaque and puriform. In the third as in the second stage, if there is no complication, the pulse and respiration in the intervals of the paroxysms are nearly or quite natural. Febrile excitement may, however, now and then occur from trifling causes, or, indeed, without any appa- rent cause. The digestion and the general health in uncompli- cated pertussis remain unimpaired, with the exception of more or less emaciation, which is apt to occur in all hut the mildest cases, in consequence of the frequent vomiting. After complete recovery, it is not unusual for the spasmodic cough to reappear, at times, for one or even two years. The cough of ordinary simple laryngitis, or bronchitis, assumes this character. CoMPLiCATioxs. — These, like the symptoms, are chiefly of a two- fold character, namely, inflammatory and neuropathic. From the nature of the cough in this disease, it would naturally be supposed that the spasmodic affection, which is now designated internal convulsions, and which is characterized by spasm of certain muscles of respiration, would be a frequent complication. It does sometimes occur in young children, but it is not common. Clonic convulsions affecting the external muscles are, on the other hand, not infre- quent. They occur chiefly in the second stage, when the cough is most severe, and in infancy much more frequently than in child- hood. They are apt to be general and severe, or, if not of this character at first, to become such. The convulsions commence, in most instances, in or directly after the paroxysm of coughing ; but they sometimes occur in the interval when the child is quiet. Rilliet and Barthez remark : " Almost all infants succumb to this complication, ordinarily in the twenty-four hours which follow the first attack ; nevertheless, life may be prolonged during two or three days" (Article Coqueluche). In my own practice this compli- cation of hooping-cough has usually terminated fatally, but I have known recovery to occur somewhat unexpectedly under the use of bromide of potassium. In the month of June, 1867, 1 was attend- ing a little girl two years and four months old, who had reached the fifth week of pertussis, when she was seized with general clonic convulsions. The mother, who was requested to keep a record of the number of convulsions, stated that there were twenty in all, occurring within forty-eight hours. They affected both sides, the shortest lasting only three or four minutes, the longest seventy-five minutes. The treatment in this case, which eventuated favorably, will be noticed hereafter. COMPLICATIONS. 251 111 those wlio die of convulsions occurring in hooping-cough, the most constant lesion is congestion of the cerebral veins and sinuses, often with transudation of serum. This congestion is due in part to the cough which precedes the convulsions, and in part to the convulsions themselves. At the autopsies which I have made of two infants, who died in hospital practice from hooping-cough, accompanied by convulsions, all the cerebral sinuses were filled with clots, which were generally soft and dark ; but in the lateral sinuses clots were found, which were light-colored. The light color of a clot, either in a vein or sinus, indicates its ante-mortem formation. The gravity of the convulsive attack can be ascertained by ob- serving whether the patient readily recovers consciousness. Its return indicates that there is no serious congestion. On the other hand, great drowsiness remaining, or a semi-comatose state, indi- cates persistent congestion, and perhaps even the formation of clots in the sinuses of the brain. Death from convulsions is usually preceded by coma. Occasionally meningeal apoplexy supervenes upon the congestion, and death is immediate. The most frequent inflammatory complications are bronchitis and pneumonitis. Inflammation of the larger bronchial tubes, we have seen, is a common accompaniment of pertussis, but when it extends to the minuter tubes, or becomes so severe as to cause acceleration of respiration, it is, properly, a complication. Both bronchitis and pneumonitis, occurring as complications, are de- veloped, with few exceptions, in the second stage. Bronchitis is accompanied by accelerated respiration and pulse, and increased temperature. The danger is proportionate to the amount of dyspnoea. Pneumonitis is a less common complication than bronchitis, but it occurs more frequently in pertussis than in any other constitu- tional aftection of early life, excepting measles. The congestion, which occurs and remains in the lung when the cough is frequent and severe, favors the development of pneumonia. The symptoms and physical signs which accompany this inflammation and serve for its diagnosis are the same as in the primary form of the dis- ease, and are described elsewhere. Bronchitis or pneumonia usually moderates the severity of the spasmodic cough, for when the inflam- matory element in pertussis increases, the spasmodic abates. On the abatement of the inflammation, however, the cough usually regains its former convulsive character. The fact may be stated in this connection, that any complication or intercurrent disease, 252 PERTUSSIS. which is attended by decided febrile reaction, ordinarily renders the cough for the time less spasmodic. The occurrence of bronchitis or pneumonia is shown by the elevated temperature, acceleration of pulse and respiration, short and frequent cough. These symptoms do not cease as long as the inflammation continues, whereas in uncomplicated pertussis the patient seems nearly or quite well between the coughs. In pneu- monia the respiration is accompanied by the expiratory moan, and in both bronchitis and pneumonia there is more or less depression of the infra-mammary region during inspiration. These symptoms, in connection with the physical signs, render diagnosis in most instances easy. Although the general character of the cough is changed, a cough now and then occurs, even when the inflamma- tion is pretty severe, sufliciently spasmodic to indicate the nature of the primary afl'ection. Capillary bronchitis and pneumonia are always serious complications. It is stated by certain writers that the spasmodic cough of per- tussis occasionally gives rise to emphysema, and dilatation of the bronchial tubes. Rilliet and Barthez do not believe that these structural changes occur from such a cause, because the spasmodic character of the cough of pertussis pertains to expiration. Later observations, however, demonstrate that emphysema in certain cases does result from forcible expirations (Niemeyer and others). Emphysema is a common lesion in young and feeble infants, even when there is no history of any previous severe disease of the respiratory organs. I have found it one of the most common lesions in infants of feeble constitutions who die in the Infant's Hos- pital and ISTursery and Child's Hospital of this city. The chief cause of the emphysema in these cases appears to be the impaired nutrition and chano-e in the molecular condition of the tissues. The same condition arises in severe and protracted pertussis, in which the child becomes enfeebled and cachectic. If severe bron- chitis arises, we have still another factor in the production of emphysema. At the meeting of the New York Pathological Society, October 14th, 1868, I exhibited emphysematous lungs removed from an infant who died at the age of nineteen months, and at the com- mencement of the fourth week of pertussis. Death occurred from thrombosis in the lateral sinuses of the cranium, resulting from the severe spasmodic cough, clonic convulsions, and from feebleness of the circulation, as the infant was previously in a reduced state from chronic entero-colitis. At the autopsy the superior lobes of DIAGNOSIS. 253 both lungs were found exsanguine, doughy to the feel, and enlarged 80 as to rise above the level of the other lobes. The resiliency of the elastic tissue of those lobes was evidently greatly impaired, and their air-cells in a state of over-distension. The other lobes were healthy, except that one of them was the seat of lobular pneumonia. In the history of this case it did not appear that there had been any pathological state affecting the respiratory system previousl}^ to the pertussis, so that the commencing emphy- sema was referable to this disease. The forcible and irregular res- pirations which accompany the cough of pertussis appear, there- fore, sufficient for the production of emphysema in the infant. I have occasionally met cases in which partial collapse of certain portions of the lungs had occurred, and the mechanism of the cough is such that this would be a more probable result than enlargement of either the tubes or air-cells. Collapse, like emphysema, may continue for weeks or months subsequently to pertussis, and then gradually disappear. Diagnosis. — During the period of invasion it is impossible to diagnosticate pertussis. Its nature can only be conjectured from a known exposure, or from the epidemic occurrence of the disease. In the second stage, which is characterized by the spasmodic cough, diagnosis is ordinarily easy, and often the parents are able to announce the nature of the disease when the phj^sician is called. Still, a mistake is sometimes made: a spasmodic cough very similar to that of pertussis occasionally occurs in other maladies. Young infants with bronchitis frequently experience great difficulty in the expectoration of mucus, which collects in the air-passages and provokes a suffocative cough. The following facts will aid in making the diagnosis. Bronchitis, accompanied by a suffocative cough, is an acute disease, and the cough occurs at an early period, usually in the first week. It lacks the inspiratory sound or the hoop, and is associated with constantly accelerated respiration and well-marked febrile symptoms, dependent on the inflammation. Moreover, the cough is only occasionally suffocative, according to the amount of mucus in the tubes. The spasmodic cough of jDcr- tussis, on the other hand, is preceded by the stage of invasion. This cough occurs in the second stage, when the febrile symptoms have abated; if the disease is uncomplicated, it is accompanied by a hoop, and its ordinary character is spasmodic. Again, the suffo- cative cough of bronchitis rarely ends in vomiting, which has been seen to be so common in the cough of pertussis. The only other disease with which there is much likelihood of 254 PERTUSSIS. confounding pertussis is bronchial phthisis. The points of differ- ential diagnosis are the following: the one epidemic, and spreading by contagion; the other non-contagious, and isolated: the one em- braced in three distinct stages, and much shorter; the other chronic, and presenting no stages, but commencing with mild non-febrile symptoms, and progressively becoming more severe : in the one an absence of symptoms in the intervals of the cough, provided there is no complication; in the other constant symptoms, such as are common in tubercular disease. The previous health, and the pre- sence or absence of a tubercular cachexia, should be considered in determining the nature of the disease, and usually, in bronchial phthisis, the lungs are also affected, so that auscultation and per- cussion may furnish positive proof of the nature of the cough. Prognosis. — This is ordinarily favorable. Xearly all recover, unless some complication arises. In rare instances death may occur in or immediately after a paroxysm of coughing, in consequence of the rupture of cerebral capillaries, and the occurrence of apo- plexy. Most fatal cases, however, are complicated with either clonic convulsions, bronchitis, pneumonia, or, in the summer season, entero-colitis, and death is due to the complication rather than the pertussis. It has been stated elsewhere that clonic convulsions render the prognosis unfavorable, but the case detailed above shows that some may recover. If the convulsion is succeeded by marked drowsiness, the prognosis is very unfavorable. It is probable that other convulsions will occur, ending in coma. Immediate recovery of consciousness shows a less dangerous form of convulsions, and one which, with proper treatment, may terminate favorably. The danger in bronchitis and pneumonia depends on the extent of the inflammation, the amount of dyspnoea, the age and strength of the patient. Capillary bronchitis and pneumonia are always serious complications. They have been the cause of death in a large proportion of the fatal cases which I have attended. Per- tussis sometimes is attended with so much emaciation and loss of strength, in consequence of the vomiting, that intercurrent diseases, which, in favorable states of the system, would probably end favora- bly, are very apt to prove fatal. In this city epidemics of the diar- rhoeal affections, so common among infants in the summer, are much more fatal if at the same time there. is an epidemic of pertussis. In my practice, an infant affected at the same time wdth the " summer complaint" and hooping-cough has generally perished, unless re- moved to the country. If there is much emaciation and an heredi- TREATMENT. 255 tary tendency to tuberculosis, the prognosis is more unfavorable, on account of the probable occurrence of this disease. Trp:atment. — In the catarrhal stage the treatment should be the same as in idiopathic catarrh. It should consist of mild counter- irritation to the chest. If there is much bronchitis, with accele- rated breathing, the oil-silk jacket may be applied. Demulcent, laxative, and gentle expectorant mixtures are proper. Care should be taken to employ nothing which would reduce the strength, or in any way impair the general health. Therapeutic measures are most beneficial in the second stage, or that of convulsive cough. Proper treatment may prevent or con- trol complications, which arise chiefly in this stage, and may mod- erate the intensity of the cough. Many formulae have been recom- mended for the treatment of pertussis, most of them containing some antispasmodic. Oxide of zinc, musk, assafcetida, valerian, cochineal, the anaesthetics, and many other medicinal agents, have been employed, and there are physicians with whom each of these has had its season of repute. The three medicines which are most in favor with the profession, both in this country and Europe, and properly so, are hydrocyanic acid, balladonna, and bromide of am- monium. The employment of the last of these is comparatively recent. The others are old remedies, and their therapeutic effects are more fully ascertained. In my opinion, the treatment by bella- donna is usually most successful, and this agent is more employed than any other. Some of the belladonna of the shops, as is true likewise of hydrocyanic acid, is of inferior quality, either from its mode of preparation, or the manner in which it has been kept, and is therefore not reliable. But if good, and prescribed properly, it will ordinarily render the cough milder. The first dose of belladonna should be smaller than will probably be required to ameliorate the disease. The child, however, requires a larger proportionate dose of belladonna than an adult to produce the same effect. Trousseau's great experience in the treatment of children's diseases, and his successful practice, render his views in reference to the employment of this agent deserving of careful con- sideration. For young children he directed pills to be made, each containing about one-tenth of a grain of extract of belladonna mixed with an equal quantity, of the powder of the leaves of bella- donna. For children over the age of four years, the pills contained one- fifth of a grain of the extract and the same quantity of the powder. He directed that one of these pills should be taken in the morning 256 PERTUSSIS. when the stomach was empty, and a second on the following morn- ing. The nurse marked on a card each paroxysm of coughing, so that the effect of the medicine could be ascertained. If the number of paroxysms was diminished, or the cough rendered less severe, 80 that there was evidently decided amelioration, the same dose was administered each day. If, on the other hand, there was no improvement in the number or severity of the paroxysms, two pills were given on the following morning, three on the next, and so on till an appreciable effect was produced. Trousseau considered it important to give at one dose whatever belladonna is administered during the day. The same quantity per day given in small doses, at intervals, he believed to be less effectual. The dose which he found to produce amelioration of the symp- toms he ordered to be repeated daily during the succeeding six or eight days. Then, if the improvement continued, the dose was gradually diminished by one pill each day, back to the first dose ; but if the cough increased, the dose was again increased. Finally, when the spasmodic cough had entirely ceased. Trous- seau advised the continuance of the medicine six or eight days longer before its complete suspension. Trousseau sometimes employed atropine in place of belladonna, since the medicinal properties of the plant reside in this alkaloid, and, being crystalline, its strength is always uniform. He gave the neutral sulphate of atropia in dose of about j^? P'^^i't of a grain, dissolved in distilled water, to infants or young children, in the same manner as he prescribed belladonna. For older children he ordered a dose proportionately larger. Brown-Sequard, in remarks made before the United States Medical Association in May, 1866, maintained that the duration of pertussis, so far as the neuropathic element is concerned, might be abridged to a few days by doses of atropia sufficiently large to produce toxical effects. He recom- mends a dose which will cause, and repeated will maintain, deli- rium for three days; after which, he states, the cough is no longer spasmodic. The older physicians who first advised the employment of bel- ladonna in pertussis, as Schacffer, Guersant, Goclis, and Wcndt, used it with caution, and in small or moderate doses, apparently believing that its use involved considerable danger. It is now, however, considered a safe as well as eflUcient remedy, and it is admitted that in pertussis the full benefit of the drug can only be obtained from doses which produce a decided impression on the system. If there is no amelioration of symptoms from smaller TREATMENT. 257 doses, it is proper to give it in a quantity which will cause dry- ness of the fauces and eiHorescence U2:)on the skin. The tincture of belladonna is most convenient for use. The doses which I have found to be sufficient to modify the cough, at the same time producing efflorescence, are as follows: To a child of two years three drops, to one of six to eight years ten drops, morning and evening. I always commence, however, with a smaller dose, and continue to administer for a few days the dose which is found to produce the local eiiects alluded to. In the majority of cases I have noticed no decided effect till the rash was produced, when the symptoms improved, the cough becoming either less frequent or less severe. I have by means of this treatment been able to curtail the duration of the disease to four weeks from the beg-innins: of the catarrhal stage, even when the paroxysms were unusually severe. The dose which proves sufficient to control the disease should be administered daily for a time, and then gradually di- minished as the cough declines. Hydrocyanic acid possesses the power of controlling the spasmodic cough of pertussis. It is re- commended by Dr. West. " I usually begin," says he, " with a dose of half a minim of the acid of the London Pharmacoposia (that of the U. S. Ph. is the same) every four hours for a child nine months old ; and so in proportion for older children. The specific influence of the remedy is, I think, both more safely and efficiently exerted by increasing the frequency of its administration than by adding to the dose, and I should therefore prefer to give half a dose every two hours, rather than to double the dose without in- creasing the frequency of its repetition. This remedy sometimes exerts an almost magical influence on the cough, diminishing the frequency and severity of its paroxysms almost immediately ; while in other cases it seems perfectly inert." Dr. AVest has employed this remedy several hundred times, and only once has observed alarming symptoms from its use. The patient was two and a half years old, and had been ordered one minim of the dilute acid every four hours. He took the acid for four days without any effect being produced, either on his system generally, or on the cough ; but at the end of that time, after taking the dose, he ut- tered a cry, became quite faint, and would have fallen, if not sup- ported. Hydrocyanic acid, given in safe doses, does not appear to pro- duce amelioration of symptoms in so large a proportion of cases as belladonna, and I do not know any advantages which it possesses over that agent. Belladonna never produces sudden alarming 17 258 PERTUSSIS. symptoms, like the acid. If, throngli mistake, more than the pre- scribed quantity is administered, it may cause delirium, and the characteristic eftect on the mucous membrane of the fauces and upon the skin; but a gradual disax»pearance of these symj^toms may be confidently expected, without any injury to the patient. Even poisonous doses, unless excessive, are rarely fatal. If for any reason it is thought best to prescribe hydrocyanic acid, the fol- lowing formulae from "West may be employed: — R. Acid, liydrocy. dil. ^.iv ; Syrupi simplicis 5J ; Aqufe destillat. 3'^ij- ^^■ A teaspoonful to be taken every six hours by a child nine months old. R. Acid, hydrocy. dilut. iTLiv ; Mistur. amygdalae 5j. M. Dose the same. The bromides have, within a few years, been used in the treat- ment of pertussis. They were first recommended by Br. Gibbs, and subsequently by Prof. Harley, of London. It is claimed for them that they produce an auajsthetic efiect on the mucous mem- brane of the larynx. The bromide employed by the above and other physicians has commonly been that of ammonium, but some prescribe that of iwtassium, or the two in combination. Prof. Harley gives one grain of the bromide of ammonium for each year of the patient's age, three times daily ; Dr. Gibbs gives two or three grains every eight hours to infants, and from four to ten grains to older children. Dr. Ritchie, physician to the Royal Edinburgh Hospital for Sick Children, says of it {Edin. 31ed. Journ., June, 1864): "In my experience, the remedy appears to be most successful in children whose age exceeds two years. . . . The quan- tity I have generally given has been from three to twelve grains a day, in divided doses, administered every six hours. . . . Having used the preparation in upwards of twenty cases, if I may be allowed to express an opinion on this head, it would be that the great efficacy of the drug is in uncomplicated cases; that in those complicated with acute bronchitis, or pneumonia, the benefit is so trifling that I prefer other methods of treatment; for an acute congested condition of the air-passages appears to lessen the eftect of the bromide as a laryngeal anaesthetic ; that the more frequent the paroxysms of hooping, the more marked and rapid is the relief; that greater relief appears to be experienced in those of some continuance than in recent cases; and, lastly, that when chronic bronchitis is present, the bromide should not be given alone, but TREATMENT. 259 combined with squill and ipccacuaidia mixture, and occasionally with an emetic." I have employed the bromides, though not largely, in the treat- ment of pertussis, but have not, in ordinary cases, observed that benefit which I had been led to expect. In recent cases, belladonna is a much more efficient remedy. I would use the bromides chiefly in advanced cases, and in cases, whatever the period of pertussis, in which there seems to be imminent danger of clonic convulsions. In these last cases, the bromide of potassium, with or without that of ammonium, may, in certain cases, prevent the convulsive seizure. The hydrate of chloral has been employed for pertussis, in the children's class, in the out-door department at Bellevue. It produces prolonged sleep, and consequently diminishes the fre- quency of the cough as long as the narcotic effect lasts, otherwise it does not seem to exert any influence on the symptoms or progress of the disease. There are many other remedies which have been vaunted in the treatment of pertussis, and which do moderate the severity of the cough. Some, it seems to me, have this effect by producing febrile excitement. Such is the use of cantharides, so as to produce active congestion of the urinary passages and strangury; severe counter- irritation over the chest by tartar emetic, namely, Autenrieth''s treatment, etc. Emetics have sometimes been prescribed in the first stage of pertussis, in the belief that they moderated the severity of the disease. They are more frequently employed on the Conti- nent than in this country. Laennec says: "j^ot any measure is more useful in the commencement of pertussis than vomiting, repeated every day or every two days, during one or two weeks." Some physicians have given for this purpose ipecacuanha, and others sulphate of zinc. Trousseau employed sulphate of copper. The loss of strength, however, which necessarily attends the em- ployment of emetics, even the mildest, more than counterbalances any good effect of their use, except when there is considerable accumulation of mucus in the tubes, which an emetic assists in expelling. A remedy long in use, and still a favorite with many families, consists of half a scruple of cochineal, one scruple of carbonate of potassa, one drachm of sugar, and four ounces of water. The dose for a child one year old is a dessertspoonful three times daily ; for older children the dose is increased in a corresponding degree. It is believed by some that the cochineal is inert, and that the bene- 260 PERTUSSIS. ficial effect of the above mixture is due to the potassa, which modifies the accompanying bronchitis. Alum, in doses of one to six grains, according to the age, is recommended by Dr. J. F. Meigs {Treatise on Diseases of Children). Inhalation of the fumes arising from the purification of gas, has been recommended in Paris as an effectual remedy in the declining stage of pertussis; but, on the other hand, it is alleged that the benefit is due to the out-door exercise required by this treatment. M. Eoger employed these fumes in the wards of the Children's Hos- pital, Paris ; but apparently without benefit. IS^itric acid has also been used internally, and applications of nitrate of silver to the throat; both, it is stated, with improvement in certain cases. Change of air is always beneficial in advanced hooping-cough. In uncomplicated cases the child should be carried daily into the open air; but, on account of the inflammatory affection of the air-pas- sages, should never be exposed to cold or wet, or sudden changes of temperature. For the same reason the temperature of the apart- ment should be moderately warm and uniform. Great benefit, as regards the severity of the cough, often accrues, especially in the advanced period of the disease, by removing the child to the coun- try, or to another locality. Severe bronchitis, or pneumonia, which often complicates per- tussis, requires the treatment which is elsewhere recommended for the secondary form of this inflammation, namely, the use of the oil-silk jacket, poultices, counter-irritation, and, internally, carbon- ate of ammonia, with perhaps a tonic. As mild bronchitis is present from the commencement of the disease, the oil-silk jacket is useful even before the inflammation becomes so severe as to constitute a complication. Clonic convulsions, which we have seen are a com- mon and very serious complication, should be treated by cold to the head, a warm foot-bath, and laxatives in certain cases. The medi- cine which, in my opinion, is most likely to control the spasmodic movements, is bromide of potassium. The mode of administering this agent will be sufficiently explained in our remarks relating to the treatment of eclampsia. In the case alluded to in the pre- ceding pages, in which there were twenty convulsions within forty- eight hours, and the patient, two years and four months old, recovered, the bromide of potassium was given in combination with the iodide. The dose was about two grains of each every two or three hours. PAKOTIDITIS. 261 CHAPTER V. PAROTIDITIS. Ordinarily, parotiditis, or parotitis, or mumps, has no premo- nitory stage; but in exceptional cases, languor with fever pre- cedes the disease for a few hours. Mumps commences with ten- derness in the parotid region, followed soon after by tumefaction. The swelling gradually increases ; it fills the depression under the ear, extends forward and upward upon the cheek, and downward to a greater or less extent upon the neck. It has been demonstrated in case of symptomatic parotiditis, and the same is probably true of the idiopathic disease, or mumps (Virchow), that the swelling is due to inflammation of the gland-ducts, and consequent cedema of the interstitial tissue. The inflammation is specific, due to a mate- ries morbi in the blood, and hence its decline after a fixed period. It reaches its maximum from the third to the sixth day. The most prominent point at this time is immediately underneath the lobule of the ear. The tumor, which is firm but slightly elastic, presses outward the lobule. In most cases the skin preserves its normal appearance over the swelling, but occasionally it presents a faint blush. The pressure which movements of the jaw produce on the gland renders mastication and even talking painful. Febrile movement more or less intense occurs, lasting, in ordinary cases, not more than forty-eight hours, but occasionally it is more pro- tracted. Vomiting and epistaxis are sometimes present. Tlie swelling having attained its maximum size, remains stationary a short time, when it begins to decline, and by the sixth to tenth day it has entirely subsided. In most cases parotiditis is double ; it commences on one side, more frequently the left than right, and in from one to four days the opposite gland is involved. In those exceptional cases in which only one parotid is affected, the opposite gland may be the seat of the disease at some subsequent period. It has been estimated that the proportion of unilateral to double mumps is as one to ten. Tlie total duration of this disease is usually from eight to ten days; in the mildest cases it may not be more than five days. The submaxillary glands are often involved in connection with the parotids, and sometimes also the sublingual, although, from their 262 PAKOTIDITIS. small size and concealed position, their tumefaction escapes notice. Rarely the tonsils are also tumefied. Sometimes free perspiration occurs at the commencement of convalescence. The swelling of the parotids sometimes abates suddenly, and in the male the testicle, epididymis, and tunica vaginalis become inflamed ; while in the female, the mammary glands, ovaries, or the labia majora, are the seat of the so-called metastasis. Occa- sionally these inflammations, which are less frequent in young children than those near the age of puberty, when the sexual organs are becoming more developed, occur without sjuibsidence of the parotid swelling. They cause considerable increase in the fever and constitutional disturbance, but with proper treatment decline in six to eight days, pursuing the same course as the parotid inflammation. Nature. — Parotiditis is contagious. It is rare in infancy and after the middle period of life, occurring chiefly in childhood, youth, and early manhood. An incubative period of about twelve days was ascertained by me in cases occurring in the Protestant Episcopal Orphan Asylum of this city. The observations of others give a similar result. Parotiditis is a blood disease, having the local manifestation described above, and which is our only means of diagnosis. Diagnosis. — If the physician has seen but few cases of mumps, there is danger that he may mistake the swelling for an inflamed cervical gland, or vice versa^ but an inflamed cervical gland presents to the finger a hardness almost like that of cartilage, and it is cir- cumscribed or round, and does not invest the ear. These charac- teristics contrast with the elasticity, seat, and shape of the parotid swelling, which extends forward on the cheek, and surrounds and elevates the lobule of the ear. Tumefaction resulting from diph- theritic or any other form of faucial inflammation, or from peri- ostitis affecting the root of the posterior molar, may be detected by examinino; the fauces and interior of the mouth. Treatment. — This is very simple. Oakum or carded wool may be bound over the swelling, and the surface occasionally rubbed with sweet oil. Mild laxative, and diaphoretic drinks, such as bitartrate of potash or lemonade, are useful. If metastasis occur, the new local affection should receive chief attention. It should be treated in the same manner as if it occurred independently of the mumps. The employment of irritants over the parotid in order to cause a return of the inflammation from the sexual organ to this gland, does not have the effect desired, and is injurious. sectio:n' iy. OTHER GENERAL DISEASES. CHAPTER I. INTERMITTENT FEVER. Intermittent fever is a constitutional disease, due to a specific cause emanating from the soil. It spares no age. Even infants of a few months are not exempt from it, and it is said that a preg- nant woman affected with it occasionally observes a periodical tremor of the foetus. Stokes, of Dublin, recorded such a case; and, according to Bouchut, cases have been observed in which new-born infants, whose mothers were affected, had not only the characteristic paroxysms, but also enlarged spleens, showing that intra-uterine life is not always shielded from the influence of the specific cause. It is not fully ascertained whether a nursing infant may contract intermittent fever by lactation, but if it is admitted that it is some- times communicated to the foetus through the maternal circulation, it does not seem improbable that the specific principle occasionally enters the milk as well as other secretions. I have frequently remarked the presence of the disease in nursing infants whose mothers were affected, and in one instance an infant at the breast, whose mother had the ague, having contracted it in a suburban village, but was since living in a non-malarious part of the city, presented evident symptoms of the disease. Similar observations by Frank, Burdel, and others, do not indeed fully prove the com- municability of intermittent fever by lactation, but render it highly probable. 'No ascertained facts relating to intermittent fever in children CD throw any light upon the ;*emarkable and much discussed observa- tions and experiments of Prof. Salisbury, relating to the etiology of intermittent fever. Certainly, if the cause is a vegetable cell enter- ing the blood through respiration, it sometimes adheres to it most 26-i INTEKMITTENT FEVER. tenaciously, and is probably reproduced in it, even under circum- stances favorable for its elimination. Thus, at one of my cliniques at Bellevue Hospital Medical College in 1871, a child ten years old was presented, who had had every year for seven years attacks of intermittent fever. The disease was contracted at the asre of three years in Harlem, and the subsequent residence of the family had been in a part of the city where there was no malaria. Symptoms. — In infancy, and especially prior to the age of eighteen months, the symptoms differ in certain respects from those which characterize the disease in the adult, and are universally known. In childhood the symptoms are similar to those in the adult, and need not, therefore, be described in this connection. In the nursing infant the type is ordinarily quotidian, but now and then tertian. Advancing beyond the age of eighteen months, we meet more and more cases of the tertian type, and in childhood it is the common form. I have known the quotidian in the infant, when cured, to reappear a few weeks after as a tertian, but ordi- narily it remains quotidian unless the patient has reached the age at which the tertian type predominates. The paroxysm in the young infant presents three stages, as in the adult, but while the second, or febrile, is well marked, the first and third are much less pronounced. The patient does not shake (ex- ceptionally one does even within the first year) in the first stage, but a slight tremor may or may not be observed. The countenance presents a sunken appearance; the lips and fingere are livid, while portions of the surface not livid are pallid, with the goose-flesh ap- pearance, which is, however, less marked than in children of a more advanced age. The blood leaves the surface, which consequently shrinks, while it accumulates in the veins and internal organs ; the pulse is feeble, and readily compressed ; the surface grows cool from the diminished supply of blood, but the breath is warm, and the internal temperature, so far from being reduced, is elevated two or three degrees. The parents may be alarmed at the sudden sinking of the vital powers, and seek medical advice, but in other instances the first stage is so slight that it passes unperceived till they have been taught to watch for it, and the second stage first attracts attention. In the second or febrile stage, which immediately succeeds, the pulse becomes full and rapid, 120 to 130 or 140 beats per minute, and the external as well as internal temperature is elevated as in few other diseases (104°-108°). The face is flushed, surface dry, and head painful, as evinced by the features. This stage lasts about two SYMPTOMS. 265 hours or somewhat longer. The third stage, or that of perspiration, succeeds, which terminates the suffering of the patient till the fol- lowing paroxysm. In infancy the perspiration is not abundant, and in the first half of this period is nearly absent. In the interval of the paroxysms the patient appears well, except a degree of languor. During the cold stage, passive congestion of the internal organs occurs to a greater or less extent, but the circulation is equalized during the reaction of the second stage. The spleen, whose cap- sule is distensible, soon enlarges in many patients, in consequence, probably, of the frequent congestions, constituting the " ague cake." This enlargement is more common in children than adults. Since my attention has been particularly directed to this subject, I have been able to feel the enlarged spleen, by examination through the abdominal walls, in about half of the cases under the age of ten years. The organ returns to the normal size after the ague is cured. From the intimate relation of the spleen to the composition of the blood, it is evident that the character of this fluid must be aflfected if intermittent fever be protracted. The blood becomes more and more impoverished, and a state of decided hydremia supervenes. A few weeks' continuance of the ague suflaces to produce decided pallor of the features, and surface generally, and as all watery blood is prone to transudation, such patients not infrequently present more or less oedema of the face, ankles, and other parts. Some- times, also, especially under unfavorable hygienic circumstances, purpuric spots (purpura hremorrhagica) appear under the skin, affording additional proof of the change which the blood has un- dergone. Intermittent fever in children, if proper remedial measures are employed at an early period, is ordinarily not dangerous, and is quite amenable to treatment; but that comparatively infrequent and fatal form of it, designated the pernicious, occurs more fre- quently in children than adults. In Kew York city, where the type of malarial diseases is mild, I have never met a case of perni- cious intermittent in the adult, but I can recall to mind such cases in children, two of them fatal. This form of the fever occurs in a smaller proportionate number of cases in infancy than in child- hood, probably because the cold stage is less pronounced. In the pernicious ague, the system is overpowered — it does not react in a degree commensurate with the intensity of the disease. The patient enters the paroxysm, becomes stujDid, and, if not relieved by prompt and efficient measures, enters into a fatal coma. A type of the dis- ease, therefore, which would not be pernicious in a robust individual. 266 INTERMITTENT FEVER. may be such in one of a broken-down constitution and feeble reac- tive power. In most cases occurring in children the coma is pre- ceded by eclampsia, which is apt to be general and protracted. A nice discrimination would no doubt exclude from the list of the pernicious aifection certain of those cases in which coma succeeded clonic convulsions, for convulsions occurring from other causes fre- quently end in coma, and in all probability eclampsia complicating intermittent fever has, in many instances, additional and distinct causes quite as potent as the malarial poison or state. But practi- cally this discrimination would subserve no useful purpose. It is better to consider as pernicious all those cases in which alarming prostration and stupor supervene in the paroxysm, requiring ener- getic measures to produce reaction and consciousness, whether con- vulsions have occurred or not. Protracted intermittent fever in the adult occasionally produces waxy degeneration of organs, and also a greater or less amount of pigmentary matter in the blood (melansemia). In children both these results are more rare. Treatment. — The same mode of treatment is required for chil- dren as for adults, namely, the employment of the alkaline prin- ciples of cinchona. The sulphates of quinia and cinchonia are most frequently prescribed. From observations made in the class of children's diseases in the out-door department at Bellevue, two grains of the sulphate of quinia seem to have about the effect of three grains of the sulphate of cinchonia in the treatment of ague. They may be given in the same manner, both requiring an acid for solution, but it is impossible to disguise their intense bitterness. The vehicle which I prefer for their administration is the syrup of raspberry, which, though not officinal, is easily obtained. The following formula is for a child of three years: — R. Qui. sulphat. gr. xij. Acid, sulpliur. dilut. gtt. xviij. Syr. rubi. idoei §jss. Miscc. One teaspoonful three times daily. The first dose should be ad- ministered immediately after the fever abates. In this climate two or three days suffice to cure the disease, after which one dose daily should be administered for a week, and then every second day for two or three weeks longer. If any difliculty is experienced in administering the medicine on account of its bitterness, the dragees may be employed, if the child is old enough to swallow them, or the tannate of quinine. REMITTENT FEVER. 267 The tannate may bo adniinisterccl by substituting tannic acid for the sulpliuric. One grain of tannic acid is sufficient to form a tannate with four grains of the sulphate of quinire. The tannate, liowever, is not as reliable as the sulphate, and it is necessary to administer it in a somewhat larger dose. CHAPTER II. EEMITTENT FEVEE. If a physician were to consult the standard treatises on diseases of children in order to ascertain the nature of remittent fever, he would rise from the perusal with no clear idea of it. One tells us that the remittent fever of children is identical with typhoid fever of adults; another, that it is a gastro-intestinal inflammation; and, finally, Hillier believes that there is properly no such disease, and that the term should be dropped from the nosology of children. There is, however, a remittent fever of children as well as adults, and much of the confusion wdiich exists in reference to it arises from the fact that writers have not kept in view what constitutes a fever. Febrile action which has a local cause is not an essential fever, and should not be described as such. It happens that in children a symptomatic remittent fever arises from a variety of local causes, as dentition, intestinal worms, subacute gastro-intestinal inflam- mation, etc. But all such cases should be excluded from our con- sideration of remittent fever, as clearly as we distinguish the con- tinued fever of pneumonia or bronchitis from that of typhus or typhoid. There is an essential remittent fever of children due to malaria. The same conditions which produce intermittent fever, do, in a certain proportion of cases, produce a fever which does not in- termit, but continues with more or less pronounced exacerbations a certain number of days, when it ceases or becomes intermittent. Cases, too, are not infrequent in localities not malarious, of a remit- tent fever, occurring more frequently in the spring and autumn than in other seasons. Some of these cases are perhaps a mild type of typhus, but in most instances the conditions do not appear to be present which ordinarily give rise to typhus, and they do not occur 268 REMITTENT FEVER. m connection with cases of typhus in adults. The cause, though obscure^ is apparently atmospheric. The SYMPTOMS of remittent fever vary in different cases. The exacerbations and remissions are more pronounced in some than others. Even in those cases in which the fever is due to paludal emanations, and occurs in connection with cases of the intermittent, the febrile movement may be almost uniform, slight exacerbations occurring in the latter part of the day. In other cases the exacer- bations and remissions are pronounced, the febrile excitement abating in a perspiration. Occasionally the fever is higher on each second day. Cephalalgia is common, and in severe cases delirium and stupor are not infrequent. There may be distinct remissions in the beginning, and afterwards, for a few days, the fever be pretty uniform, when it again remits or ceases. The tongue is covered with a light fur. Thirst, loss of appetite, a tendency to constipa- tion, scanty and high-colored urine, containing perhaps urates, and a cough due to mild bronchitis, are common symptoms. When remittent fever is due to marsh emanations, the same ana- tomical characters are doubtless present as in the adult, namely, blood containing more or less pigmentary matter, enlargement of the spleen, bronzing of the spleen, and, in severe cases, of the liver, and sometimes of the brain. The DIAGNOSIS is not always easy. On the one hand, local diseases with symptomatic remittent fever are to be excluded, and, on the other, typhus and typhoid. The discrimination of it from typhus and typhoid fevers is practically of little moment, but it is a mat- ter of vital importance to make a differential diagnosis between it and the local diseases. I have known one of the acutest dias^nos- ticians and most eminent physicians of 'New York mistake incipi- ent meningitis for it, a mistake indeed not uncommon. The points involved in a differential diagnosis will be considered in our descrip- tions of the local diseases. Treatment. — If we have ascertained by a careful examination that the fever is remittent, and not symptomatic but essential, there is one remedy which is required in nearly all cases, namely, quinia, or its equivalent, cinchonia. Mild febrifuge medicines,with light diet, may be first employed in sthenic cases, in which the pulse is full and strong, and the quinia given when the fever has somewhat abated. The diet should be bland but nutritious, and the bowels be kept regularly open by citrate of magnesia or other mild ape- rient. Bromide of potassium or hydrate of chloral may be occa- TYPHOID FEVER. 269 sionnlly employed as recommended in the treatment of typlioid fever, to produce quietude or sleep, in cases attended by delirium or insomnia. A warm mustard foot-bath, and cool applications to tlie head, are useful in such cases. CHAPTER III. TYPHOID FEVER. Typhus and ty]3hoid fevers occur in children, but the former is mild and infrequent, rarely occurring except when adults of the same household are affected. It requires little treatment, except good nursing. Typhoid fever, on the other hand, is not infrequent in children, and, as it presents certain peculiarities prior to the age of puberty, it is proper to describe it in this connection. This dis- ease is much less frequent in infancy than in childhood, and in the first half of infancy is believed to be rare. Still, there can be no doubt that many cases in the first years of life are not diagnosticated, being mistaken for subacute and protracted entero-colitis. It may, therefore, be more common in the infant than is commonly sup- posed. Its period of greatest frequency in children is between the ages of six and twelve years. Causes. — It is now generally admitted that typhoid fever is mildly contagious, and that its specific principle abounds largely in the dejections and excretions of the patient. It is uncertain whether it is communicable by the breath of the patient, or exha- lations from his surface. If it is, it is slightly so, while numerous observations demonstrate its communicability through the use of night-stools or privies which contain the evacuations. There is little doiibt also that typhoid fever originates de 7iovo, caused by the miasm produced by decaying animal or vegetable matter. Nume- rous cases have been observed in which it originated from defective sewerage, or decaying vegetables in cellars, in localities in which no case had previously been observed. The germs of the disease may not only be received into the system by inspiration, but also through the stomach, for the use of well-water which contains the drainage of sewers has repeatedly been known to cause it. Boys are more frequently attacked than girls, according to some statistics in the proportion of three to one. Deterioration of the health from gene- 270 TYPHOID FEVER. ral causes increases tlie liability to be attacked. On the other hand, those having tuberculosis, carcinoma, heart disease, and probably certain other visceral lesions, are more apt to escape than those in health. Anatomical Charactees. — As typhoid fever is a constitutional disease, we would expect to find earl}^ and important changes in the blood, l^o alteration, however, has been discovered in this fluid peculiar to typhoid fever. The amount of fibrin is diminished as in most of the essential fevers, and its. coagulation is feeble, forming, when the blood stands, soft, small and dark clots. When the fever has continued for some time, a state of antemia more or less decided supervenes, in which the amount of albumen and blood corpuscles is diminished. Although there are often decided symp- toms referable to the nervous system, no constant changes have been discovered in the brain or spinal cord. The changes observed in them when death has occurred in the course of typhoid fever have been for the most part due to other causes. It is different with the respiratory system. After the first week of typhoid fever bronchitis is almost as constant as inflammation of the fauces in scarlet fever, and accordingly we find in fatal cases redness and thickening of the bronchial mucous membrane, which is covered with a viscid and ordinarily scanty secretion. Hypostatic con- gestion of the lungs, with more or less oedema, and in severe and enfeebled cases hypostatic pneumonia, are not uncommon. In the bronchitis and state of feebleness we have the causes of pulmonary collapse, and this lesion is not infrequent over limited portions of the lungs, especially if the bronchitis is unusually severe. The lesions occurring in the digestive system are important. The mucous membrane of the small intestine is more or less in- jected, and at an early period, even by the second or third day, the patches of Peyer, solitary glands, and at the same time the mesen- teric, begin to enlarge. It has been stated by high authorities that the enlargement is due to infiltration with a peculiar substance, which has been termed the typhous material. I have made micro- scopic examination of these glands in typhoid fever of the adult, and have found a notable increase of the small round granular cells of which these glands are composed. I do not, therefore, doubt that the enlargement is due mainly to hyperplasia of the cellular elements of the glands, though there is probably infiltra- tion to a certain extent of inflammatory products between the cells. The mucous membrane over the glands undergoes inflammatory thickening and softening. In the adult, sloughing of this mem- SYMPTOMS. 271 brane is frequent, witli the disintegration of the glands and their elimination into the intestines, producing ulcers, small and circular, corresponding with the site of the solitary glands, large and oval or irregular, corresponding with the site of the agminate. Disin- tegration of these glands and the formation of ulcers are less fre- quent in children than adults. In the adult, who recovers, the mesenteric glands, and those of the solitary and agminate which are not destroyed, return to their normal state by fatty degene- ration, liquefaction and absorption of the redundant cells. In the child this is the common result, instead of sloughing and disinte- gration, as regards both the solitary and agminate glands, and uniform result as regards the mesenteric, and I may add bronchial glands, which are also in a state of hyperplasia. The absence of ulceration or its slight extent affords explanation of the fact that intestinal perforation is very rare in children. The spleen gradually enlarges, often to twice the normal size, has a dark red color, and is softened. Enlargement of the spleen pos- sesses o-reat diae-nostic vakie in those cases in which the diaguosis is obscure. For while very similar intestinal lesions may occur in chronic entero-colitis, the coexistence of these lesions with the splenic enlargement and softening shows the constitutional nature of the afi'ection. In cases which are severe, and presenting a decidedly adynamic type, the muscles become soft and flabby, and the action of the heart is feeble, more or less passive congestion of the viscera is the result. In such cases congestion of the kidneys and albuminuria are not infrequent. Symptoms. — Typhoid fever has a prodromic stage of a few days, sometimes of a week or more, in which the child appears languid, indisposed to play, and has little appetite, but complains of no pain unless occasional slight headache, and has no symptom which would lead the friends or even physicians to suspect the grave nature of the disease which impended. By and by a slight fever occurs. The febrile movement, which gradually becomes more pro- nounced, remits, but does not cease in the morning, and has even- ing exacerbations. After the first week of fever the remissions are less marked, but the fever is not uniform at any period in its course. ' Hence some of our ablest writers on diseases of children continue to designate typhoid fever of children remittent fever, fully aware of its identity with typhoid fever of the adult. As the case advances, the appetite fails, all solid food being refused, and liquid food being taken more from thirst than hunger. The tongue in the first week 272 TYPHOID FEVER. is covered with a light moist fur, and in some patients throughout the course of the disease, but in others having a graver type of the fever the tongue after the first week is dry and brown. During the prodromic period, and in the first week, the bowels act regu- larly, or are slightly relaxed, and they are readily afiected by pur- gative medicines. After the first week there is in most children a tendency to diarrhoea, which requires now and then the use of astringents, the stools being watery and brown, or dark yellow. The abdominal walls are seldom retracted, but prominent, especially after the first week, in consequence of meteorism which is present in children as well as adults. Sometimes there is apparent tender- ness, when pressure is made over the right iliac region, but this must not be confounded with hyperfesthesia, which is common in the commencement of febrile diseases in children, and which is observed especially upon the abdomen, chest, and inner part of the thighs. The respiration in the first week is slightly accelerated, as it is in all febrile diseases. In the second week, and subsequently when bronchitis is developed, the respiration is ordinarily more accele- rated, though not in a marked degree, unless in those exceptional instances in which there is an abundant collection of mucus in the smaller bronchial tubes. A cough is always present, dependent on the bronchitis, and varying in character according to the degree and stage of the inflammation. In the first days of the fever it is infrequent, and hacking ; at a later stage it is more frequent, and not so dry, though in cases of ordinary severity the amount of ex- pectoration is inconsiderable. Hypostatic congestion, oedema, hypo- static pneumonia, splenization, or thickening of the alveolar walls, and collapse, which may and some of which not infrequently do occur in the advanced disease, increase more or less the frequency of the respiration and the cough, and modify the physical signs. The pulse in the first week, in ordinary cases, is from 100 to 110 or 115. It gradually becomes more accelerated, numbering in the second week 120 or more; in grave cases even 160. The more frequent the pulse, the greater the danger and more unfavorable the prognosis. During the exacerbations the number of pulsations per minute is 15 or 20 more than in the remissions. The change in temperature corresponds with that of the pulse, being from 1° to 2° higher in the exacerbation than remission. The extremes of temperature in cases of ordinary severity are about 101° and 104°. A temperature above 105° shows a grave, probably a malignant, type of the disease, or else a serious complication. COMPLICATIONS. 273 Tlicrc is great variation as regards the symptoms referable to the nervous system. Headache is common in the prodromic and initial stages, after which it ceases. A few arc delirious even from an early period, screaming loudly, or muttering incoherently, but the majority are quiet, having, indeed, a degree of mental dulness, but being able to appreciate questions when aroused, and answering correctly. Subsultus tendinum and carphologia, which some ex- hibit, show that there is profound disturbance of the nervous system. Epistaxis occurs occasionally in the first week as in the adult, but is not abundant. The rose-colored eruption appears in children as well as adults between the sixth and twelfth days, but is more frequently absent in the former than latter, sometimes the number of sj^ots is less than half a dozen. Sudamina are common in the second and third weeks, and perspirations may occur at anj^ time in the course of the fever, but without amelioration of symptoms. More or less deafness is common, being in most instances a purely nervous symptom, without, therefore, any structural change in the ear, but it is possible, as has been suggested by certain writers, that it sometimes results from inflammatory thickening of the Eustachian tube or external meatus, or to a weakened and flabby state of the muscles of the ear. The duration of typhoid fever is not uniform; while mild cases may end in two weeks, those of a severer type continue three or even four, the patient becoming progressively more emaciated and feeble. In protracted and severe cases his condition seems very unpromising to one not familiar with the clinical history of the fever. Pale, emaciated, and feeble, probably passing his evacua- tions in bed, taking little notice of objects around him, he presents, at the close of the third week, an appearance of helplessness, not- withstanding the best of nursing, and the constant employment of sustaining measures, which is truly discouraging. Complications. — The chief complications of typhoid fever are broncho-pneumonia, already sufficiently described, enteritis, intes- tinal hemorrhage, peritonitis, otitis, parotiditis, and muguet. In one instance I lost a patient about ten years old, in whom the fever had nearly terminated, by the sudden accession of croup. There is, as we have seen, in ordinary cases, a degree of inflammation of the mucous membrane of the air-passages, and of the intestines especially in the vicinity of the patches of Peyer. It is easy to understand how, under circumstances which may arise in the fever favorable to the development of mucous inflammations, the bron- 18 274 TYPHOID FEVER. cliitis and enteritis may so increase as to constitute complications. They are the most frequent of the serious com^ilications. Intestinal hemorrhage is an occasional complication. Hillier met four cases in thirty of the fever. It indicates the presence of ulcers upon the surface of the intestines. It is one of the most serious of the complications. Some, in whom it has occurred, recover, but others die. Otitis, commencing with pain, and pro- ducing a discharge which may continue for weeks, is not rare, though less frequent than in scarlet fever. The otitis is commonly external, but it may, in scrofulous subjects, extend to the middle ear. Intestinal perforation is more rare in children than in adults, as might be inferred from the statement already made, that intestinal ulceration is less frequent and extensive in them. Statistics show that "perforation occurs only once in 232 cases. Therefore, as per- foration is the common cause of peritonitis in this disease, this inflammation is a rare complication. Peritonitis may, however, occur in typhoid fever without j^erforation. In one such case (an adult) in the fever wards attached to Charity Hospital, local peri- tonitis with fibrinous exudation occurred opposite two ulcerated patches of Peyer, the ulcers extending nearly to the peritoneum, ])ut not perforating. The lesions observed in this case throw light on those cases of peritonitis complicating typhoid fever which recover, the cause of which has received a diiFerent explanation. In advanced and greatly debilitated cases, thrush sometimes appears in the interior of the mouth, and upon the fauces. It is always an unfavorable prognostic symptom in children sufifering from chronic or protracted disease. Parotiditis is also a rare com- plication. Diagnosis. — This is more difficult in children than in adults, and the younger the child the greater the difficulty. In infants pro- tracted entero-colitis, with febrile action and dry furred tongue, cannot in certain cases be positively diagnosticated from typhoid fever by the symptoms and clinical history. Typlioid fever is believed, however, to be rare at this age. When, however, as now and then happens, a young child presents the symptoms character- istic of protracted subacute entero-colitis, or typhoid fever, and older members of the household have the fever, it is highly probable that the case is one of the latter disease, and it should be treated accordingly. Even in older children typhoid fever is apt to be mistaken for simple subacute enteritis, or entero-colitis, or vice versa. The fol- PROGNOSIS. 275 lowing facts aid in the dift'erential diagnosis. In typhoid fever there is total loss of ai»petite, while in the suhacute intestinal inflam- mation food is not entirely refused. Diarrhoea commences early in the inflammation, while in the fever it is not ordinarily till after the lapse of a few days. The tenderness of the fever is either not appreciable, or it is located in the right iliac region ; in the other disease it is general over the abdomen, or located in the umbilical region. In typhoid fever there is bronchitis with a cough which is absent in the inflammation. In typhoid fever there are certain other symptoms, more or fewer of which are present in most cases, and which do not occur in the intestinal diseases, except as a coinci- dence. For example, headache, epistaxis, stupor, delirium, and perhaps the rose-colored spots. T^^phoid fever may be mistaken for meningitis, during the first week, but in meningitis there is more constipation, irritability of stomach, and less elevation of temperature; moreover, in menin- gitis, at a comparatively early stage, we are able to detect patches of congestion of the features coming and disappearing suddenly; slight inequality of the pupils, or their oscillation when the light is uniform ; signs which are lacking in tj'^phoid fever. In a doubtful case the ophthalmoscope might be employed, which in meningitis discloses congestion of the vessels of the retina, cedema, etc., ana- tomical changes which do not pertain to typhoid fever. The differential diagnosis of typhoid fever and acute tuberculosis may be made by attention to the following points. In tuberculosis there is cough, with some acceleration of respiration from the first, without epistaxis, stupor, or other nervous symptoms, and without the abdominal symptoms which are so prominent in the fever. Duration. — The duration of typhoid fever varies from two to about four weeks, and complications which may arise greatly retard convalescence. Recovery from a severe and protracted attack is slow, several weeks or even months elapsing before complete resto- ration to health. A tendency to diarrhoea may continue several weeks after the fever proper ceases, necessitating a rigid oversight of the diet, and the occasional employment of astringents. Prognosis. — A much larger percentage of children recover than of adults. Although there is great emaciation with loss of strength, recovery may be confidently predicted, provided no serious compli- cation occurs. In the fatal cases which I have met, the unfavorable result occurred as a rule from the complications, rather than directly from the fever. The condition in which severe typhoid fever leaves a patient is favorable to the development of .tubercles, and now and 276 TYPHOID FEVER. then they occur, disappointing our expectations and prediction of recovery. Treatment. — As typhoid fever is self-limited, the treatment re- quired in ordinary cases is simple. It should be of a sustaining nature, both as regards diet and medicinal agents, and any untoward symptoms should be promptly met by appropriate measures. The food should be in the liquid form ; solid food is, indeed, in most cases, refused. Beef-tea, milk, rice or barley-water, with milk, may be allowed from the first. Mild cases require no stimulants, still the moderate use of wine is not contraindicated in such cases, and may be allowed at an early period. In grave cases, characterized by a dry and furred tongue, and quick and compressible pulse, milk- punch or wine-whey should be employed in suitable quantity at reo;ular intervals. When the fever is mild and pursuing its normal course, a simple febrifuge may be employed, as spts. setheris nitrosi, with syrup of ipecacuanha. 5. Spts. aether, nit. gij ; Syr. ipecac. 5iij ; Syr. simplic. §jss. Misce. Dose, one teaspoonful every three liours to a child of six years. If the fever has distinct evening exacerbations, quinine is indi- cated as an antiperiodic, and in cases of an asthenic type, it may be employed in smaller doses as a tonic. In either of these conditions it will be found useful. In cases attended with great restlessness or delirium, an appropriate dose of bromide of potassium or hydrate of chloral at night, will procure rest, and be followed by no unfa- vorable result. I prefer the hydrate of chloral given in a small dose. A single dose of two or three grains of this agent will gene- rally be sufficient. For the diarrhoea, I ordinarily prescribe pare- goric, with half its quantity of the fluid extract of catechu in chalk mixture. The state of anaemia which is present in the advanced disease and in convalescence requires the employment of iron. The citrate of iron and quinine will, under such circumstances, be found useful. ACUTE RHEUMATISM. 277 CIIArTER IV. ACUTE RHEUMATISM. Rheumatism is a constitutional disease with a local manifesta- tion, namely, an inflammation of the sero-fibrous tissues chiefly in and around the articulations, but occasionally in other parts. It is less frequent prior to puberty than in the years succeeding it ; still, it is not uncommon in children after the fifth year. Under this age it is comparatively rare, but is, probably, not so infrequent as is commonly supposed. For while in the adult the diagnosis of rheumatism is easy, in children this disease is likely to be over- looked, if, as is true in a large proportion of cases in early life, the swelling and redness of the affected joints are slight, and only a few joints are inflamed. If there is cardiac inflammation, the articular affection may be nearly absent, thus rendering the diag- nosis more obscure. That rheumatism is not so very rare under the age of five years, I infer from the fact that we now and then meet with cases of valvular disease in children of this a^e or older, which, there can be little doubt, had its origin in rheumatism, although the parents are not aware that there has ever been an at- tack of this disease. Several such cases have recently been brought to the children's class in the Out-door Department at Bellevue. Thus, in January, 1871, a little girl, three years old, was presented, having distinct aortic direct, and mitral regurgitant murmurs. The mother was not aware that she had had rheumatism, but at the age of twenty months she had for several days pretty active febrile symptoms, which the physician attributed to disease of the lungs. In April, 1(S71, another girl, of the same age, was brought to the clinique, having a distinct mitral regurgitant murmur. The mother stated that she had been well till a month previously, when she was confined to her bed for a few days, having a high fever. She was attended by a homoeopathic physician, and the exact character of her sickness the mother was not able to state. Further medical advice was sought, as the child remained delicate> thousch her health was better than at first. There can be little doubt that the obscure fever in this case had been rheumatic. In 278 ACUTE RHEUMATISM. another child treated elsewhere, not old enough to relate the subjective symptoms, there was, in addition to an intense fever, evident pain in one foot or leg, when the limb was moved. Still, the nature of the disease was not diagnosticated till some time after recovery, when a valvular murmur was accidentally discov- ered. Such histories, which I do not think are rare, show, if my opinion of them is correct, that rheumatism may occur not very rarely in young children, even infants, for which purpose they are here introduced, but they inculcate the important practical lesson, that the disease at this age may be so obscure, or latent, as to be overlooked even by good diagnosticians. Some observers, meeting cases of valvular disease in children, without the history of rheumatism, have concluded that rheumatism is not the chief cause of endocarditis at this age (Dr. A. Steifen, Jahrhuch fur Kinder k.^ 1870); but the explanation which I have given seems to me more in consonance with the facts. Scarlet fever not infrequently causes endocarditis, but this exanthem is not apt to occur without detection, and it has been as often absent as has rheumatism from the histories as given by the parents of young children with valvular disease, whom I have examined. Moreover, it is a question whether the endocarditis of scarlet fever is not, properly speaking, of a rheumatic origin. Rheumatism in children is primary or secondary. The secondary form occurs chiefly in the declining stage of scarlet fever and variola. It is stated, also, to occur occasionally in new-born infants during epidemics of puerperal fever. I have not observed such cases. Causes. — The important cause of rheumatism is a predisposition, which, in a large proportion of cases, is inherited. Hence the fact that it is apt to occur in different members of the same family. When the family history shows a strong predisposition to rheuma- tism, it occurs in the child from a slight exciting cause; if no such predisposition exists, it only occurs through unusual circum- stances of exposure. The ordinary exciting cause is the same as in most idiopathic inflammations, namely, exposure to cold; but a strong rheumatic diathesis appears to be sufficient in itself to pro- duce an outbreak of the disease. Children who have had one attack are especially liable to another. Symptoms. — The commencement of acute idiopathic rheumatism is in most cases sudden; occasionally fever, and a degree of sour- ness or stiffness, precede the articular affection for a few hours or days. The inflammation, slight at first, increases gradually, attain- SYMPTOMS. 279 ing its maximum intensity within one or two days. The joint is painful, red, hot, and swollen. The swelling is due to inflamma- tory cedema of the tissues surrounding the joint and effusion within the joint. As in all inflammations, the vascularity of the parts involved is increased, the synovial membrane loses more or less its lustre, and the effused fluid, which is mainly serum, has been found, in most of the cases in which an opportunity was pre- sented to examine it, to contain, like the pleuritic exudation, a few globules of pus. Rarely, in a reduced state of the system, so much pus is produced within the joint as to constitute a true abscess, and rarely also fibrin is exuded, producing a rubbing sen- sation when the joint is moved, and endangering permanent adhe- sion of the articular surfaces. Fortunately, however, in the vast majority of cases, the substance exuded both without and within the joint is mainly serum, and therefore the rapid subsidence of the swelling when the inflammation ceases. The pain is commonly not severe when the child is quiet, but it is greatly increased if the joint is pressed or the limb moved. The joints of the extremities are most frequently the seat of rheumatic inflammation, but occasionally those of the trunk, as the intervertebral, the symphysis pubis, etc., are involved. As the inflammation abates in the articulations first aft'ected it reappears in others, unless the materies morbi has been eliminated from the system. It is seldom that more than two or three of the joints are in a state of active inflammation at the same time. The temperature in acute rheumatism is elevated two or three degrees above that of health, and the pulse varies from 120 to 140, its frequency depending on the age of the patient, as well as the gravity of the disease. Perspiration is a common symptom. The appetite is impaired, the tongue slightly coated, and the bowels constipated. The watery element in the urine is diminished, as in most febrile diseases. There is no corresponding reduction in the solid elements, so that the urine is rendered more dense, and its specific gravity is high. The amount of urea and coloring matter excreted from the kidneys is augmented during the active period of rheumatism, and the urine, when it cools, deposits urates. In ordinary cases there is no prominent symptom referable to the nervous system, with the exception of the pain in the affected joint. Acute rheumatism, if only the articulations were involved, would be a disease of little danger, however painful, but unfortu- nately, in its proneness to produce specific inflammation of the sero-fibrous tissues, the heart frequently becomes involved, less 280 ACUTE RHEUMATISM. frequently the lungs and pleura, and in rare instances the cerebra^ or spinal meninges. Endocarditis is the most frequent of the heart inflammations occurring in rheumatism; pericarditis, though less common, is not infrequent, while in rare instances myocarditis occurs, usually associated with the other inflammations. Endo- carditis is limited to the left side of the heart, and seldom continues long without engaging the valves, aortic or mitral, or both, causing their infiltration, fibroid degeneration, with consequent thickening, and sometimes adhesion. The valvular lesion thus produced is in most instances permanent, so impairing the action of the valves as to obstruct in greater or less degree the flow of blood through the orifice or allow its regurgitation. The mitral valve is more frequently affected than the aortic, at least bruits produced by this lesion are more frequent in the mitral than aortic orifice, and when they are heard in both orifices they are commonly loudest in the mitral. This fact, noticed by difierent observers, I have repeatedly verified by observations in this city. While the articular aftection pertains to the clinical history of rheumatism, the internal inflammation, whether of the heart, lungs, pleura, or meninges, though similar as regards its pathological cha- racter, is properly regarded as a complication. Acute rheumatism is so frequently complicated by one or the other of these afiections, that any disproportionate severity in the general symptoms, as compared with the inflammation of the joints, or any sudden and unexpected increase in the symptoms, should always lead the physician to examine thoroughly the condition of those organs which are most frequently affected. Inflammatory complications occur, as a rule, during the active period of rheumatism, when the inflammation is passing from joint to joint. If the general symptoms begin to improve, and no new joints are involved, the liability to complications is greatly diminished. Secondary rheumatism, occurring in most instances in connection with certain eruptive fevers, especially scarlatina, commonh^ affects only a few joints, often only one or two, as the wrist, and, though painful, is attended by slight swelling and redness. Duration, Prognosis. — "With proper treatment and without complication the febrile action in a few days begins to abate, and the disease commonly terminates within two weeks. Its duration is ordinarily shorter than in rheumatism of the adult. Fluctua- tions, however, are liable to occur. The disease may appear to be abating, and the articular inflammations nearly cease, when they DIAGNOSIS. 281 return for a time, often without new exposure and witliout appre- ciable cause. The prognosis, even when cardiac inflammation has supervened, is in most cases favorable, except so far as the lesion resulting from this inflammation is concerned, which being perma- nent may entail much subsequent suffering, and occasion death after months or years. Indeed, what is most to be dreaded in cases of acute rheumatism is valvular disease or pericardial adhesion with its remoter consequences, namely, hypertrophy of heart, congestion and oedema of the lungs, dropsies, etc. Secondary rheumatism occurring in scarlet fever is sometimes also complicated with, or rather coexists with, cardiac inflammation, pleuritis, or pneumonitis, rendering the prognosis more unfavorable. In rare instances the acute symptoms of rheumatism abate, but the joints remain stiflf and more or less swollen, and painful when moved. The acute has lapsed into a subacute or chronic rheumatism. Such a case, represented in the accompanying figure, was brought to the children's class in the Out-door Depart- ment at Bellevue Hospital, in February 1871. E. H., female, 3| years old, had intermittent fever from the age of nine to fifteen months. From this time she remained well till the age of two years, when she was taken with acute rheumatism, commencing in her ankles and extending to other joints. The knee and hip joints on both sides have only partially re- covered their mobility, and both legs and both thighs are permanently flexed, so that the gait is slow and unsteady. It is impossible to straighten either limb without causing great pain, and attempts to straighten the thigh produce the arch in the back very similar to that in coxalgia. Diagnosis. — This is not difficult in ordinary cases, if a proper examination is made. In the commencement, if the aftection of the joints is slight, rheumatism might be mistaken for remittent, typhoid, one of the eruptive fevers, or meningitis; but, on careful examination, tenderness will be observed of one or more of the articulations, and probably some swelling. This tenderness is readily distinguished from the hypersesthesia which is common in the first stage of the essential fevers, and which is observed when pressure is made upon the chest or abdomen as well as upon the 282 ACUTE RHEUMATISM. limbs, and is more marked between the joints than in them. Any doubt which may at first exist, whether the patient may not have one of those diseases, is soon dispelled, since their clinical history presents notable difterences from that of rheumatism. I have known scrofulous arthritis, or scrofulous ostitis near the joint, present so close a resemblance to acute rheumatism as to be at first mistaken for it. In one instance this inflammation commenced in three distinct points, so that the difl'erential diag- nosis at first was difficult. But scrofulous inflammation as well as that from pyaemia can be diagnosticated from rheumatic disease of the joints, by its greater persistence, less induration and symmetry in 4;he swelling, and by the history of the case. Chronic rheuma- tism may produce deformity similar to that from chronic scrofulous inflammation, as in the case detailed above, but the rheumatic history, number of joints aflected, bilateral character of the in- flammation, good general health, etc., are sufficient to establish a clear diagnosis. Treatment. — The theory of the pathology of a disease deter- mines the mode of treatment. It is believed that rheumatism is due to an acid, probably lactic, in the blood, and hence alkaline remedies are commonly employed, with the apparent eftect of diminishing the severity of the disease and shortening its dura- tion. The tartrate of soda and potassa, acetate of potassa, and the bicarbonate of soda or potassa, may be given singly or combined, according to the condition of the patient. The following is a good formula for a previously healthy child of six or eight years: — R. Potas. et sodse tart, ^^ss ; Potas. acetat. 5ij ; Syr. limonum, Aquae, aii §iij. Misce. Dose, two teaspoonfuls every two or three hours. Sulphate of morphia, Dover's powder, or other opiate, is ordina- rily required in the evening to procure rest and prevent any undue purgative effect of the medicine. If there is considerable pain in the joints, one or two doses of the same should be given through the day. If there is a tendency to diarrhoea, or a state of debility, measures of a more sustaining nature are required. For such cases the bicarbonate of soda or potassa is preferable to the other alkalies. In a few days, by the alkaline treatment, the urates cease to appear in the urine, and the disease begins to decline. There is now little danger that any complication will occur if the internal TREATMENT. 283 organs have so far escaped. I know no remedies so effectual in relieving not only rheumatic inflammations of the joints, but the general muscular tenderness which occurs from taking cold, and which is often present in the commencement of rheumatism, as the Rochelle salts and acetate of potash. During the declining period of rheumatism and in convalescence, quinine or some preparation of cinchona should be employed, and the alkali given less frequently. This tonic does indeed appear to exert a beneficial effect on the course of rheumatism, and it is employed by some judicious and experienced physicians from the commencement, as the main remedy. Certainly, in all cases of debility, it, or a similar medicine, should be early employed, unless contraindicated by some complication. Rheumatism impoverishes the blood, and the patient often begins to present an anaemic appearance, when he requires iron in addi- tion to the vegetable tonic. The citrate of iron and quinine may then be employed. Secondary rheumatism requires sustaining treatment from the first. Cases occurring in my practice have done well without alkalies, and with the general supporting measures employed for the primary disease. Pneumonitis complicating rheumatism is best treated by mode- rate counter-irritation and emollient poultices, and the internal use of carbonate of ammonia; or, if there is aneemia, carbonate of ammonia with citrate of iron and ammonia. The other internal inflammations which are liable to arise as complications require iodide of potassium in decided doses. In pericarditis or endo- carditis, if, as is commonly the case, the movements of the heart are accelerated, the tincture of aconite root, or, in young and debilitated children, tincture of digitalis, is required to the extent of reducing the number of pulsations to near the normal fre- quency. A child of six years can take one drop of aconite, or three or four times the quantity of digitalis, to be repeated, if necessary, in three hours, till the required reduction of the pulse is effected. Patients often express the relief from the palpitation and dyspnoea which they experience by the use of these agents. The patient should be kept quiet, in a room of uniform tempera- ture, and not exposed to draughts of air. By such precaution the danger of complications is greatly diminished. Repellent applica- tions, as cold or irritants, should not be applied to the joints, as long as the disease is acute, for they also increase the danger of complications. The affected joints should be enveloped in flannel or cotton, and the pain, if intense, may be diminished by applying 28-i ERYSIPELAS. flannel wrung out of warm water. If the disease becomes sub- acute or chronic, if the urates have disappeared from the urine, and the inflammation ceases to pass from joint to joint, the tinc- ture of iodine, or moderately stimulating embrocations, applied to the joints, involve no danger and are useful. CHAPTER Y. ERYSIPELAS. The term erysipelas is applied to a constitutional or blood dis- ease, which is characterized by inflammation of the skin and subcutaneous cellular tissue, and by a tendency to spread. It is accompanied by a burning and pricking sensation, swelling, and subcutaneous infiltration. In rare instances, in young infants, an inflammation which has been designated erysipelas occurs in and around the umbilicus. It commences about the time of the detachment of the umbilical cord, and is accompanied by redness of the skin, tumefaction, and hardness of the cellular tissue surrounding the umbilicus. It usually causes ulceration of the umbilical fossa, and, in fatal cases, pus is sometimes found in the umbilical vessels. This disease does not show any tendency to spread ; the diameter of the inflamed surface is not more than three or four inches, with the umbilicus at the centre. It is generally fatal ; but two favorable cases have been reported to me, in one of which there was considerable ulcera- tion, and after recovery a firm cicatrix occupied the site of the umbilicus. The most reasonable view is that this disease is pri- marily an inflammation of the umbilical fossa and vessels, induced by uncleanliness, cachexia, or other cause. It lacks the distin- guishing feature of erysipelatous inflammations, namely, the t.en- dency to spread, and I shall therefore take no further notice of it in this connection. (See Diseases of the Umbilicus.) Erysipelas seldom occurs in childhood ; the few cases which are met in this period present nearly the same features, and pursue nearly the same course, as in the adult. In infancy, on the other hand, erysipelas is not a rare disease. Every practitioner is called to cases, from time to time. The following remarks relate to ery- sipelas occurring in this period of life. My views have been derived mainly from the records of cases which occurred in this city, some in my own practice, but most in the practice of other ERYSIPELAS. 285 physicians. The points of chief interest in forty-one cases are embraced in the following table : — Cases of Infantile Erysipelas. Q X Age. Point of Parts affected. Duration. Result. ti eg M. ( jommencement. 1 5 muaths Right knee Entire surface, except face aud scalp H weeks and Recovered. 3 days 2 M. 2 years Left kneo From a littlo above the knee to the ankle 7 days Recovered. 3 M. 10 mouths Elhow Whole arm aud forearm .... Recovered. 4 F. 1 yeai- iSi 8 mouths 13olow right kuee Euiiro leg, thigh, aud trunk to the um- bilicus 7 days Itccovered. 5 F. 9 mouths Vulva Abdomeu, chest, aud all the extremities 8 days Recovered. 6 M. 9 days Genitals Both lower extremities, abdomen to the umbilicus tj days Died. 7 F. 1 year Vulva Entire surface, except face 6 weeks Recovered. S F. 6 weeks At or near the ear Forehead and side of face 1 week Died in tetanic spasms. 9 ' • 9 months Epigastric re- gion Trunk and lower extremities 2 weeks Died in tetanic spasms. 10 F. 10 months At angle of mouth Entire face and scalp 10 days Recovered. 11 F. 4 weeks Vulva Entire surface, except face 3 weeks Died. 12 F. 3 months Vulva Surface of abdomen to umbilicus and right lower extremity 2 weeks Recovered. 13 F. 4 toSmos. Vulva All the limbs and the trunk, except the chest 3 to 4 weeks Died. 14 F. 6 months From syphilitic sores around auus Trunk and both lower extremities ■ • • • .... 13 F. 3 months Vulva Entire trunk and both upper extremities 3 weeks Recovered. lb M. 8 months Face near nos- trils Entire truuk and both upper extremities About 2 Weeks Recovered. 17 F. 4 months Vulva Entire truuk and all the extremities 1 week Died. 18 F. 7 months Knee A portion of trunk and both lower ex- tremities 3 weeks Recovered. 19 F. 6 months Near the ear Entire face and forehead 10 days Recovered. 20 M. 7 days Left eyelid Left side of face :< days Died. 21 M. 14 days Genitals Extended to knees, over abdomen to the chest 4 days Died. 22 M. 3 months Under the chin Chin, left cheek, neck, left side of trunk, left thigh, aud leg .... .... 23 F. 2 years & 4 mouths Right shoulder Arm and forearm 1 day Died in con- vulsions. 24 F. 3 or 4 days Vulva Body and all the limbs 12 days Died. 25 F. 3^ months Under left ear Neck, chest, and arms About 2 weeks Died. 26 •• 7 months Below right knee Trunk, neck, and head, and all the limbs 2 weeks Died coma- tose. 27 F. 6 months Vulva Both thighs, and nearly entire trunk 3 days Died coma- tose. 28 M. 19 months Near point of vaccination Shoulder, arm, and forearm 21 days Recovered. 29 M. 4 months Near point of vaccination Chest, and both upper limbs 2 weeks Recovered. 30 F. 2 months Near vaccine vesicle Trunk, and all the limbs 10 days Died. 31 •• 3 to4mos. Near vaccine vesicle Arm, forearm, and shoulder on one side 2 to 3 weeks Died. 32 F. 4 months Near vaccine vesicle Arm, forearm, and truuk 2 mouths Died. 33 M. 2 months Near vaccine vesicle Nearly entire surface 1 week Died with peritonitis. 34 M. 5^ months Near poiut of vaccination Arm and forearm .... Recovered. 35 M. 2i months Near poiut of vaccination Arm 7 days Died prob- ably of peritonitis. 3f ) M. 8 months Near vaccine vesicle Arm and forearm 17 days Died. 3' 5 months Left foot Leg, thigh, and lower part of trunk 2 weeks Died with pueumo- nitis. 3f ) . . 5 weeks At one ear Entire surface 2 weeks Recovered. 31 4 .. 2 mouths ^ Left leg Truuk, and all the limbs 2 weeks Recovered. 4( ) .. 4 month i Near point of vaeciuaiion Trunk, and all the limbs 2 weeks Died. 4 . M. 14 month i Face Trunk, and all the limbs 4 weeks Recovered. 286 ERYSIPELAS. Age. — Of the above cases, 27 were under the age of six months ; 9 from six montlis to twelve, and only 5 above the latter age. A large majority, therefore, of cases of infantile erysipelas occur in the first year of life. Point of Commencement. — In 58 cases in which I have ascer- tained the point of commencement, it was in 13 cases the vulva, 17 the arm after vaccination, 7 the leg, 6 the face, 3 the male genital organs, 3 at or near the ear, 1 the elbow, 1 the shoulder, 1 the nates, 1 the foot. In the adult, idiopathic erysipelas commonly commences upon the face, and aflects only the face, ears, forehead and scalp. On the other hand, in infantile erysipelas, statistics show that the rash commences upon the face only in a small pro- portion of cases, one in nine, and that it rarely extends to the face when it commences in other parts. Causes. — In erysipelas the first departure from the healthy state occurs in the blood, or the system generally. This undergoes cer- tain changes which predispose to erysipelas, or are sufficient in themselves to give rise to it. Among the causes which produce this state of system, uncleanliness, residence in damp, dark, and crowded apartments, and defective alimentation, hold a principal place. Hence this disease is more common in the poor quarters of the city than in the country, and in dispensary and hospital than in civil practice. In a large proportion of cases there is a local exciting cause of the erysipelatous eruption, namely, an irritation or inflammation at some point, generally trivial, but which is sufiicient to develop the disease in the system already prepared for it. It is very apt to commence at or near a simple ecthymatous or impetiginous erup- tion, around burns or suppurating sores or syphilitic eruptions ; it frequently commences, as is seen by the above table, near the point of vaccination immediately after vaccination, or when the pock is developed, or again when it has run its course and been detached. In a considerable proportion of cases it commences at a point where the skin is thin and delicate, or where it unites with a mucous surface, probably from some uncleanliness or irritation of those parts. Thus, I have records of cases in which it commenced at the external ear, commissure of the mouth, and at the vulva. In- deed, the frequency with which it commences at the vulva renders female infants more liable to it than males. In some instances erysipelas begins without any local exciting causes, upon smooth and sound skin, even when there are sores upon various parts of the surface. CAUSES. 287 Vaccination, as an exciting cause of erysipelas, demands particu- lar notice. Often, doubtless, it is the inflammation, wliicli neces- sarily arises from tlic cut or the vesicle, which operates as an exciting cause of the erysipelatous affection, and not any delete- rious property contained in the virus which is employed, so that an equal degree of inflammation occurring in any other way, as from a burn, would be attended by a like result. But facts show that the virus itself occasionally contains a latent noxious prin- ciple, which, introduced into the system, operates as a cause of erysipelas. Thus, a little girl was vaccinated by me in ISTovember, 1860, and about the time when the vesicle began to fill she was seized with severe inflammation of the fauces, attended by tume- faction and infiltration of the submucous connective tissue. The inflammation rapidly subsided, and within a week from its com- mencement the throat affection had nearly or quite disappeared. I now believe that the disease of the fauces was erysipelatous, although it was not suspected at the time to have this character. As the girl was otherwise healthy, and the vaccine vesicle passed through its usual stages, and presented the usual appearance, the scab was employed six weeks afterwards to vaccinate two infants. Within twenty-four hours after vaccination both these infants were seized with high fever, ushering in severe erysipelas, commencing in one around the point of vaccination, and in the other around syphi- litic sores near the anus. In the former case the erysipelatous rash extended from the shoulder over the entire limb, and was obstinate, twice reappearing, and extending over the same surface ; in the latter (a mulatto child) it extended over both lower extremities and a considerable part of the trunk, when the case passed into the hands of another physician, and the result is not known. The instrument with which the vaccinations were performed was clean. The vaccine disease did not appear in either of these cases. Again, a well-known physician of this city vaccinated three infants, one his own [l^o. 32 of the table), with part of a scab which had been pronounced good, but was taken from a child that he had not seen, and with whose state he was not familiar. These infants were all affected with erysipelas from the vaccination, his own dying. He had taken the precaution to rub the lancet on his boot before using it. Another physician of this city has informed me that he vaccinated two children in the same family with a scab, with all the precautions that he had ever used, and both were soon after aft'ected with erysipelas of a severe form, extending from the point of vaccination ; the vaccine disease did not appear. 288 ERYSIPELAS. I know of no case in which the vaccine lymj^h gave rise to ery- sipelas, and, probably, it rarely or never does. In the lymph there is no admixture of foreign substances, whereas in the scab there is a large proportion of animal matter. There is a form of erysipelas which occurs in the infant imme- diately after birth, and which is sometimes met in private prac- tice, but is most frequently observed as an epidemic in lying-in wards. It is associated with severe, and commonly fatal, puer- peral fever (metro-peritonitis), or erysipelas of the mother. This form of erysipelas is fatal, almost without exception, and its con- tagiousness is generally admitted by those who have had an oppor- tunity to observe cases. A case showing this relation of erysipelas in the newly-born infant to disease of the mother occurred in the practice of Dr. Leaming, of this city. A woman gave birth to a healthy infant, on the 27th of July, 1860. A few days subsequently she was seized with a chill, followed by erysipelas, commencing on the thighs, and terminating fatally August 17th. As no autopsy was allowed, the state of the internal organs was not ascertained. A few days be- fore her death the same disease commenced on the infant. It ex- tended around the neck, upon the ears, down the arms, and termi- nated fatally August 24th. But erysipelas in the new-born infant occurring in connection with erysipelas in the mother, is more rare than its occurrence with puerperal fever. The records of lying-in asylums furnish many examples of epidemics of puerperal fever, in which the infants of aftected mothers perish of erysipelas. The late Dr. Folsom, of this city, furnished me the following sketch of cases which occurred in his practice and that of his partner: "About the year 1840, being then in practice in !N"ew Bedford, Mass., I was called to visit a man who complained of pain in the knee. The next morning he was easier, but the fol- lowing evening his symptoms grew worse, and as I was engaged in a case of obstetrics, my partner. Dr. E. C, now dead, visited him. At my call, next morning, I unexpectedly found the patient dying. The disease was obscure, and at the autopsy next day no lesion was discovered. In making the examination. Dr. C. pricked his finger, and experiencing little inconvenience from it at first, he attended a case of confinement on the following morning. A few hours subsequently he was taken sick, and I took charge of the lady, who died in three days, having the tumid abdomen and symptoms of childbed fever. The infant of the patient was seized, PREMONITORY SYMPTOMS. 289 when two clays old, witli erysipelas, appearing on the face and in spots on the trunk and limbs, and terminating fatally in one day. Dr. C.'s finger became swollen and painful, and the lymphatics of the forearm and arm became inflamed, presenting red lines, and the axillary glands suppurated. Though feverish and much pros- trated, there was no appearance of erysipelas in his case. In about two weeks he resumed practice, and as at that time ph3'sicians in this country were not fully aware of the danger of communicating puerperal fever, he attended two, three, or four obstetrical cases each week, until the number reached fifteen. All the mothers died with symptoms of metro-peritonitis, and all the infants had erysipelas, commencing on the face or some part of the body, generally on the second or third day after birth, and in all termi- nating fatally within a week. This sad record was finally ended by the doctor's temporarily retiring from practice." Dr. Condie, in his Treatise on Diseases of Children, says : " Ery- sipelas of infants very commonly occurs during the prevalence of epidemic puerperal fever. Children of mothers who become af- fected with the fever are often born with erysipelatous inflamma- tion ; others are attacked almost immediately after birth. Whether, in these cases, the disease is to be referred to a morbid matter ap- plied to the skin in the womb, or to the same epidemic or endemic influence which gives rise to the disease of the parent, it is diffi- cult to say. According to M. Trousseau, infantile erj^sipelas is principally observed when puerperal fever prevails in the wards of the lying-in hospitals at Paris." In private practice it is rare that we meet erysipelas of the infant associated with erj'sipelas or with puerperal fever in the mother. Some of the oldest physicians of this city, with whom I have conversed, and who are engaged in extensive general practice, state that they have never met a case in which there was this relation. Cases like those observed by Drs. Folsom and Leaming only occur when epidemic erysipelas or puer- peral fever is prevailing. Premonitory Symptoms. — Infantile erysipelas in certain cases has no premonitory stage, or, if present, it escapes notice. In other in- stances there are well-marked precursory symptoms, as drowsiness, or restlessness, febrile movement, oppressed respiration, with per- haps vomiting, and starting or twitching of the limbs. In Cases 28 and 37 of the table, which occurred in my practice, the febrile movement, restlessness, and o^jpressed respiration were so great for three days before the appearance of the eruption, as to cause much anxiety. In the adult, pharyngitis often precedes the occurrence 19 290 ERYSIPELAS. of the rash upon the skin. The same inflammation may be present in the premonitory period of infantile erysipelas, as well as during the period of erysipelatous eruption. The hurried and diflicult resj)iration, which is present in the commencement of some cases, is probably due to an erysipelatous turgescence of the bronchial mucous membrane. Symptoms. — The patient with this disease is usually restless, in consequence of the burning pain which accompanies the eruption. In severe cases there is little sleep, night or day, except from medi- cine. The sleep is short, and is often interrupted by sudden start- ing, or twitching of the limbs. Convulsions may occur, but are not common. Febrile movement is constant, and is proportionate to the extent and gravity of the erysipelas. I have notes of cases in which the pulse was more than 200 per minute, although other symptoms did not indicate immediate danger. The skin not aifected by ery- sipelas is dry and hot, though not possessing the pungent heat of the inflamed portion ; face often flushed ; tongue moist, and covered with a light fur; stomach usually retentive. The state of the bowels varies ; sometimes they are regular, sometimes variable, while in other cases the stools are green, and more frequent than natural. I have records relating to the state of the bowels in twenty cases, as follows : in seven, regular ; in nine, loose ; in two, constipated ; in one, constipated, then loose ; and in one, consti- pated, then regular. Diarrhoea, when present, is usually mild, requiring little or no treatment. The erysipelatous redness is not in all cases so pronounced as in the adult, but otherwise there is nothing peculiar in its appearance. In feeble infants, with an im- poverished state of the blood, its color is pink, instead of the deep red which characterizes the inflammation in the robust. Points of vesication may occur where the inflammation is most severe, as in the adult, and subsequently the same desquamation and oedema. If the infant is debilitated, there is great danger of the forma- tion of abscesses, around which the inflammation lingers after it has disappeared from every other part of the body. Sometimes also, in very young infants, gangrene occurs, especially of the geni- tal organs in the male. Several of these cases have been related to me, all under the age of a month or six weeks, and all fatal. Oc- casionally the sloughing is so great as to denude the testicles. A noteworthy feature of erysipelas in infants is its proneness to return. "When it has been progressively subsiding, and hope is entertained of its speedy disappearance, it not infrequently is sud- PROGNOSIS — DURATION. 2P1 denly relighted from some unknown cause, travelling again over the same, or parts of the same, surface. In one case the disease, arising from vaccination, extended three times over the arm and forearm ; and in another case, a second time over both legs and a considerable part of the trunk. The internal inflammations, which most frequently complicate erysipelas, and give rise to symptoms which are superadded to those pertaining to the erysipelas, are pharyngitis and peritonitis ; and more rarely broncho-pneumonia or enteritis. In a case which I ex- amined after death, in the Nursery and Child's Hospital, and in which the erysipelatous inflammation having extended over the abdomen, the lesions of peritonitis were present, it seemed probable, from the thinness of the abdominal walls, that the inflammation had extended through the parietes from the external to the internal surface. Prognosis. — Erysipelas is much more fatal in infancy than in adult life. In the death statistics of this city for three years, I find eighty deaths from erysipelas of infants under the age of one year, to eighty-three deaths from this disease above that age. Age greatly influences the prognosis. Infants under the age of three weeks usually die ; from the age of three weeks to six months the result is doubtful ; while above the age of six months a majority recover with correct treatment. It will be seen by the foregoing table that seven infants under the age of six weeks had erysipelas, and six died ; from the age of six weeks to six months, six recov- ered and nine died ; and above the age of six months, nine recovered and four died. With the exception of a case of the so-called umbilical erysipe- las, the youngest child who recovered, of whom I have obtained information, was three weeks old. In this case the rash extended nearly over the entire surface, beginning with the face. Case 38 of the table, treated by myself, was very similar as regards the extent of the erysipelatous eruption and the result. This infant was five weeks old. It is scarcely necessary to state that erysipelas is more favorable when it aflfects the limbs than when it invades the head, neck, or body ; when it spreads slowly than rapidly ; when it is superficial than when phlegmonous. In those cases in which the connective tissue is much involved, the infant is not always safe after the disease has run its course ; he sometimes dies exhausted from the discharge of abscesses : I have records of two such cases. Duration. — In sixteen cases that recovered, the disease termi- 292 ERYSIPELAS. nated within the first week in two, the second week in six, the third week in five, fourth week in one, and in two cases it lasted five and six weeks. The average duration was fi/teen days. In nine- teen fatal cases, ten died within the first week, five the second week, three the third week, and one in the fourth week. The average duration of fatal cases was about ten days. Modes of Death. — Death occurs in dififerent ways ; in clonic or tonic convulsions followed by coma, from exhaustion, and from internal inflammation, that from exhaustion being probably the most common. Pathological Anatomy. — The blood doubtless in this disease undergoes certain pathological alterations previously to the oc- currence of the eruption, but the exact changes are not known. Our knowledge of the morbid anatomy of erysipelas relates chiefly to the local affections, which, with the exception of the inflamma- tion of the skin, are not constant, and may, therefore, be regarded as complications. The cutaneous inflammation affects all the structures of the skin, and in greater or less degree also the sub- cutaneous connective tissue. The inflammation is accompanied by more or less serous effusion or oedema. The not infrequent occurrence of peritonitis in connection with erysipelas has long been known. In Heberdeu's Epitome Morbo- rum Pueriliumy the anatomical character of erysipelas is expressed in one sentence: "When the body has been opened after death, the intestines have been found glued together and covered with coagulable lymph." Since Heberden's time, nearly all who have written on diseases of infancy and childhood have mentioned peritonitis as one of the most common complications. Under- wood says : " Upon examining several bodies after death, the con- tents of the body have frequently been found glued together and their surface covered with inflammatory exudation, exactly similar to that of women who have died of puerperal fever." Similar remarks in reference to the frequency of peritonitis in this disease are made by recent writers. The statistics in reference to this disease appear to demonstrate that in infants in hospital practice, and in those affected by ery- sipelas during epidemics of puerperal fever, peritonitis is a not infrequent complication. On the other hand, as wo commonly meet cases of infantile erysipelas occurring sporadically in private practice, there is not sufficient abdominal distension and tender- ness for peritoneal inflammation. In only one of the cases em- braced in the foregoing table was a post-mortem examination TREATMENT, 293 made, and in that there had l)ecn no peritonitis. The occurrence of pharj^ngitis in connection with erysipelas has been ah'cady al- luded to. Enteritis has been alluded to as another complication in infants. Diarrhcea has been stated to be a symptom in certain cases ; it has been found to be dependent on enteritis of a mild grade. Billard made post-mortem examinations of sixteen cases of infants dying of erysipelas, and "found in two gastro-enteritis, in ten enteritis, in three pneumonia complicated with enteritis and cerebral con- gestion, and in one pleuro-pneumonia." Treatment. — On this side of the Atlantic great uniformity pre- vails as regards the treatment of erysipelas. Sustaining measures are prescribed, and the tincture of the chloride of iron is the tonic generally preferred. Whatever the intensity of the febrile reac- tion and the stage of the disease, if there is no intestinal compli- cation, ferruginous or other tonics should be administered. The largest doses of the tincture of the chloride of iron given in any of the cases in the above table were in case ISTo. 4, namely, ten drops every two hours, and this patient recovered in seven days from a pretty severe attack. Probably, however, nothing is gained by such large doses, and they may irritate the intestinal surface, and increase the liability to enteritis, which, we have seen, complicates a certain proportion of cases. Two drops may be given every three hours to a child from one to two years of age. Instead of the iron, or in addition to it, one of the preparations of cinchona may be prescribed. Beef-tea, and in most cases wine-whey or other alcoholic stimulant, are required. The depressing measures recommended by certain writers cannot be too strongly censured. Bouchut says: "We should endeavor from the first to allay the inflammation of the skin by energetic treatment. . . . Local abstraction of blood, by means of one or two leeches applied at the circumference of the primary seat of the erysipelas, should be put in force, provided the power of the constitution of the children permits." Such treatment may ex- plain one of Bouchut's aphorisms, namely, the erysipelas of infants is a fatal disease. Local treatment may be employed to arrest the extension of the inflammation, but the result in most cases is not encourao'ino-. Solid nitrate of silver was employed in two cases, of which I have records, and in both the result was pernicious. Troublesome sores were produced, from which blood escaped, and in one of the cases, 29-i ERYSIPELAS. at least, death was attributed by the parents to this treatment, rather than to the disease. Tincture of iodine is a better remedy for arresting the exten- sion of erysipelas. It should be applied from the margin of the inflammation, over the sound skin, to the distance of about two inches. It may be ineffectual, but it does not produce any unfa- vorable result. Soothing applications, like rye flour, or a lotion of sugar of lead, may be made to the inflamed surface, as in erysipe- las of the adult. I prefer, however, for local treatment, the con- stant application of glycerine, or glycerine and water, to which a few drops of carbolic acid are added. PART III. SECTIONS" I. DISEASES OF THE CEEEBRO-SPINAL SYSTEM. Diseases of the brain and spinal cord are less frequent than those of the respiratory and digestive systems. They are also less amenable to treatment, and are much more fatal. They largely increase the aggregate of deaths. They contrast with the diseases of the other systems in their greater relative frequency in infancy and childhood than in adult life. This is explained, as regards the brain, by the rapid develojjment of this organ in early life, its feeble consistence, its great impressibility by the emotions, and the thinness of the covering which protects it from external agencies. Some of the most interesting of the cerebro-spinal diseases which are to engage our attention, are peculiar to early life, as tetanus nascentium. The diseases of this system also contrast with other local afiections in their greater obscurity, especially in their commencement ; for while diseases of the thorax can be readily ascertained by auscultation and percussion, or those of the abdomen by the nature of the evacuations or the degree of tender- ness or distension, our means of conducting examination through the bony encasement of the cerebro-spinal axis are meagre and unsatisfactory. The condition of the brain and spinal cord must be determined, chiefly, by the study of symptoms, and not by direct examination. The condition of the anterior fontanelle in young infants, however, enables us to determine the presence or absence of active cono-estion of the brain. If there is an excess of arterial blood, it is convex. Prominence of the fontanelle is com- mon in inflammatory and febrile diseases, and is a sign of con- siderable diagnostic and prognostic value. Within a few years, the ophthalmoscope has been employed as a means of diagnosis in cerebral diseases, and although the employ- ment of this instrument for such purpose is but recent, enough has 296 DISEASES OF THE CEREBEO -SPINAL SYSTEM. been elicited to prove its great value as an aid in determining the state of the brain. Prof. H. D. l^oves remarks on this subject : "... The argument for making ophthalmoscopic examination in all cases of brain disease, becomes irresistible. Indeed, a moment's reflection would lead to this conclusion without any considerations drawn from pathology. The optic nerve is only an outlying por- tion of the brain ; its extremity is fully exposed to view. Situated within about two inches of the brain, it is the only nerve in the body which we can inspect ; it contains bloodvessels which com- municate directly with the intra-cranial circulation. We thus come into relation with the cerebrum, by continuity of nerve- structure and also of bloodvessels." Structural changes in the optic nerve and retina have been discovered by means of the ophthalmoscope in meningitis, hydro- cephalus, phlebitis of the sinuses, apoplexy, etc. Among the lesions which have been observed by this instrument, are hype- reemia, more or less opacity and tumefaction of the optic nerve, engorgement of the vessels of the retina, with serous or sero- fibrinous exudation and ecchymotic points. In certain protracted diseases, as chronic hydrocephalus, in which dimness or loss of sight occurs, the ophthalmoscope discloses a state of atrophy of the optic nerve. Heretofore the ophthalmoscope has been chiefly employed by oculists, but as it comes into more general use, there can be little doubt that it will be recognized as an important aid in the diagnosis of obscure cerebral diseases. Still, with all possible aids to diagnosis, the obscurity which attends the invasion of many of the cerebro-spinal diseases must be acknowledged. To the hasty and careless physician, their symptoms are often deceptive. Careful weighing of the phe- nomena, and thorough and protracted examination, are requisite in order to insure correct diagnosis and proper treatment. Some of the cerebro-spinal affections are, in reality, sequelae of other dis- eases, as, for example, spurious hydrocephalus; and some are, strictly speaking, only symptoms, as convulsions ; but, on account of their importance, and because they require special treatment, it is proper to consider them as diseases ])er se. The brain presents certain peculiarities in infancy and childhood. In the foetus, while the other oi*gans are well formed, the brain, especially its cerebral portion, is still diffluent, and at birth it has so little consistence tliat it must be handled carefully to prevent laceration. This softness is due to the large proportion of water DISEASES OF THE CEREBRO- SPINAL SYSTEM. 297 which it contains. The following analyses show the composition of the hrain in the three periods of life: — Infant. Youth. Adult. Albumen 7.00 10.20 9,40 Cerebral fats 3.45 5.30 6.10 Phospliorus 80 1.65 1.80 Osmazone, salts 5.9G 8.59 10.19 Water 82.79 74.26 72.51 At birth the brain has a nearly uniform white color. The gray substance, in which the nervous power originates, is undeveloped. The date of its appearance corresponds with the first exhibition of emotion or intelligence, and the decided gray color which we observe in the brain of the adult does not appear until the age of full mental activity. In the new-born the brain is large in proportion to the rest of the body, and its growth during infancy and childhood is rapid. Until the fifth year, as appears from the observations of Dr. Pea- cock, its Aveight is about one-seventh or one-eighth that of the entire system, the proportions varying somewhat in diflerent cases. The brain does not attain its full size, as stated by Dr. West, at * the age of seven years, but, according to Dr. Peacock's statistics, it continues to increase till the age of twenty-five or thirty, although its growth is less rapid after the age of seven years than previously. The membranous covering of the cerebro-spinal axis is scarcely less interesting to the pathologist than the axis itself. I shall speak in the following pages of the arachnoid and cavity of the arachnoid, for convenience of description, although aware of the fact that some eminent authorities, as Vircliow and Kdlliker, whose opinions in reference to the minute anatomy of the system always command attention, if not assent, believe that there is no arach- noid, but what has heretofore been called by this name is on the one side the smooth surface of the dura mater, and on the other of the pia mater. The dura mater is seldom involved in the diseases of early life, except as it is aflected by pressure, while the pia mater and arach- noid are the seat and source of some of the most important diseases, as meningitis, meningeal apoplexy, etc. The more complicated and delicate the structure of an organ, the more liable it is to errors of nutrition and o-rowth. There is, therefore, no organ which is so liable to irregular development as the brain. It may be entirely wanting ; or it may be partially developed, certain portions being absent; or, lastly, its growth may be excessive, constituting a true hypertrophy. 293 ACEPHALUS — ANENCEPHALUS. CHAPTER I. ACEPHALUS— ANENCEPHALUS. Entire absence of the encephalon is not common, but there are many cases of this monstrosity on record. In extreme cases the head and i3art of the neck, as well as the brain and medulla oblon- gata, are absent. When there is great deficiency, there is often a twin, the presence of which has interfered with the full develop- ment of the system. Sometimes the growth of other organs besides the brain is imperfect. Anatomical Character. — In the ordinary form of anencephalus, the brain and sometimes the medulla are absent, with the absence or imperfect development of their membranous and osseous cover- ing. The vault of the cranium is absent. There is deficiency of the frontal, parietal, and occipital bones, except those portions which are near the base of the cranium. These portions are very thick and closely united, as if there were the usual amount of osseous substance, but instead of expanding into the arch, it had collected in an irregular mass at the base of the cranium. The absence of the brain and the cranial arch gives a remarka- ble appearance. The eyes are prominent, the neck thick and short, while the body and limbs are ordi- narily well developed. The physiog- nomy has been compared to that of some of the lower animals. Tlie base of the cranium is often occupied by a vascular tumor, not larsce, but of different size in differ- ent cases, and continuous below with the spinal pia mater. This vascular tumor is the representative of the cranial pia mater, and its smooth sur- face is the analogue of the arachnoid. The dura mater and the scalp being absent, the exposed mass re- sembles very much in appearance, as it does m structure, the pla- centa, and the sensation which it imparts to the finger pressed upon IMPERFECT BRAIN. 299 it is very similar. Sometimes small portions of cerebral matter arc found among the vessels of tliis tumor, but they are so discon- nected or isolated that they do not perform, in any way, the func- tion of a brain. Occasionally the vascular tumor is absent, and the medulla or upper extremity of the spine is exposed, or it terminates in a little papilla at the back of the neck. Those portions of the cranial nerves which lie external to the cranium are well developed, although the intra-cranial parts may be absent. Symptoms. — The respiration in anencephalous monsters is irre- gular. They can be made to cry, but their cry is a sort of sob or hiccup, and, occasionally, they even nurse. The digestive function is well performed, and regular urinary and fecal evacuations occur. There is a tendency in anencephalous monsters to convulsions. Blowing upon them, and pressure upon the projecting medulla, if this is present, frequently produce this effect. Prognosis. — Fortunately these monsters are short-lived. If the medulla oblongata, which is essential to the maintenance of respi- ration, is absent, extra-uterine life is impossible. Stillbirth is the result. If the medulla oblongata is present, although respiration and circulation are established, death commonly takes place within two or three days, and almost always within the first week. Con- vulsions sooner or later occur, ending in fatal coma. CHAPTER II. IMPERFECT BRAIN. Between the absent and complete brain there are various grades of deficiency. Parts of the brain may be perfect, while other portions are either absent or imperfectly formed. The deficiency is usually in the superior parts of the brain, especially in the hem- ispheres of the cerebrum, while the base of the organ is perfect. Both hemispheres may be absent, or one may be absent, while the other hemisphere is shrivelled or rudimentary. Occasionally the cranium preserves its normal shape and size, in consequence of an increase in the cerebro-spinal fluid proportionate to the lack of brain-substance. The imperfect development is not then apparent to the observer. The rudimentary hemispheres in these cases are 300 IMPERFECT BRAIN. spread out, forming tlie walls of a sac inclosing tlie liquid. The post-mortem examination of the following case was made in the K'urseiy and Child's Hospital, of this city, in 1862. Case. — Female ; parentage healthy ; she was plump and well formed at birth, and nothing unusual was observed in her condition, as she nursed and throve like other children, till she reached the age when there is, usually, the first manifestation of intelligence. With her there was no evidence of an intellect, or if any, it was very indistinct. She nursed, or took food when placed in her mouth, but apparently witliout relish, as if instinctively. She never reached her hands towards the nurse, or towards plaj^things. So indifferent and apparently uncon- scious was she of objects around her, that it was thought for some time that she was blind. She never smiled, except when her hands were gently rubbed or shaken ; and then the smile seemed to be more a reflex movement than emotional. The smile was immediately succeeded by a fixed vacant look. She usually lay quietly, with her arms crossed ; and during the last months of her life she sometimes uttered a scream, like children with cerebral diseases. Her evacuations were regular, and she was not subject to vomiting, before she was attacked with the acute dis- ease of which she died. The size of her head was rather less than usual at her age, but not less than is often seen in well-formed children. The forehead was small in proportion to the rest of the head, but the differ- ence was not such as to attract attention. Fortunately, the existence of this idiot Avas terminated by an attack of entero-colitis. Sectio Caclav. — The head was measured, but the measurements were lost. They did not seein to differ materially from the normal standard. The sutures were united, and the fontanelles nearly, if not quite, closed. The frontal bone la}^ a little lower than the plane of the parietal. The meninges of the brain presented nearly' their normal appearance, but were distended with transparent serum. The quantity of fluid was esti- mated at about two-thirds of a pint, and when it was evacuated, the floor of the lateral ventricles was brought into view. There was almost an entire absence of that part of the brain which lies above the floor of the ventricles. On close inspection, rudimentary cerebral hemispheres were found in a thin layer forming a part of the walls of the sac. The whole amount of brain-substance above the ventricles did not exceed the size of a small egg. The cerebellum, the base of the brain, and cranial nerves presented their usual appearance. The entire brain, after being a few days in diluted alcohol, weighed six and a quarter ounces. In this case, the fluid was only suflicient to compensate for the deficiency of the brain. In other, and probably the larger number of cases of incomplete brain, the cerebro-spinal fluid is not mate- rially increased. There is then but slight elevation of the frontal l)one, the forehead is low, or retreating, or even almost absent. This is that shape of head which is universally regarded as char- acteristic of idiocy. Symptoms. — The symptoms in cases of deficient brain relate to the mind. If the cerebral hemispheres are absent, there is no in- telligence. The individual, as regards mental endowments, does MICKOCEPHALUS — ATKOPHY OF BRAIN. 301 not rise above the instincts of the lower animals. If the hemi- spheres are partially developed, there is a degree of intelligence proportionate to the amount of cerebral substance present. If the deficiency is confined to one side, there is no apparent lack of intel- ligence or mental capacity, since, the brain being a double organ, one side performs the function of both. Prognosis. — The prognosis as regards life, in cases of imperfect brain, depends not so much on the amount of deficiency as the exact seat of arrested growth. If only the cerebrum is partially, or even entirely absent, the infant may live and thrive. But if those portions lying at the base of the brain, which control the functions of animal life, are lacking, or are imperfectly formed, life is very uncertain, and probably short. It is evident that no therapeutic treatment can remedy a con- genital deficiencj'. The services of the physician are not required. The philanthropic and patient teacher may impart a degree of intel- ligence to the idiotic, and the instruction of these unfortunates has of late years been very successful. Microcephalus— Atrophy of Brain. An abnormally small brain, or microcephalus, as it is termed, sometimes results from premature closing of the sutures and fon- tanelles. If ossification is so rapid that the cranial bones are firmly united, and are of such thickness as to be unyielding at the time when the growth of the brain is most active, the full devel- opment of this organ is necessarily prevented. The brain is com- pressed, its convolutions flattened, and the functions of the organ are imperfectly performed. Death, sooner or later, is the common result ; life ends in convulsions and coma. Again, the brain of the child, when undergoing develoj)ment, with the cranial bones sufficiently yielding, may not only cease to grow, but may even diminish in size, in consequence of protracted and exhausting diseases. Diminution in the size of the brain occurs especially after fevers and diarrhoeal afiections of long standing and attended with much emaciation. The waste of the brain corresponds with the general loss of flesh. If the cranial sutures are not united, the occipital and sometimes the frontal bones are depressed, according to the diminished size of the brain, and are overlaid by the parietal. In foundlings of two or three months, this loss of brain-substance is often very striking. In infants of this class who have died of protracted diarrhoea, it is not unusual 302 HYPERTROPHY OF BRAIN. to observe the occipital bone not only depressed, but extending one, two, or even three lines underneath the parietal. If the child with shrunken brain, from protracted and exhaus- tive disease, is old enough to express its thoughts, it often seems foolish, talks but little, and perhaj)s says the same thing over and over again. In one case in my practice, a litle girl, having passed through a long course of typhus, persistently repeated during her convalescence, with a silly smile, the questions addressed to her. This peculiarity continued two or three weeks, although her appe- tite was good, and her restoration to health rapid. In another case a little boy, during convalescence, was wont to laugh heartily at the appearance of the ordinary articles of furniture in the room. Both showed more derangement of mind during convalescence than in the midst of the fever. The friends of such children are in a state of great anxiety lest their minds are permanently impaired, but, as the appetite and strength return, the nutrition of the brain is re-established, and the mind regains its former vigor. In cases of wasted brain, with cranial bones united, the deficiency is sup- plied by serous effusion, which is gradually absorbed as the health of the patient is re-established, and the brain enlarges. This effu- sion occurs not only over the convexity of the brain, but also at its base, and sometimes in the ventricles. Dr. "West states that in atrophy of the brain, from protracted disease, its texture is firmer than usual. I have not noticed this in infants, but my attention has not been directed particularly to this point. It is probable that there is some change in the anatomical character of the brain, aside from mere waste. Partial atrophy of the brain sometimes, also, occurs from pri- mary disease located in this organ ; the affected portion wastes, while the rest retains its normal development. CHATTER III. HYPERTROPHY OF BRAIN. In contrast with atrophy of the brain is the opposite state, or hypertrophy. The size of this organ within the limits of health varies greatly in different individuals, but sometimes there is so great an increase in volume as to properly constitute a disease. PATHOLOGICAL ANATOMY. 303 Pathological Anatomy. — The excess of growth which charac- terizes this disease has heen ascertained to be confined to the white portion of the brain, and ordinarily to that part contained in the cerebral hemispheres. Hypertrophy of the brain is attended by induration, which exists in diftcrent degrees in difibrcnt cases. It is in some so slight as to be scarcely appreciable ; while in others it IS apparent at once by pressure with the finger, or incision with the scalpel. Rilliet and Barthez state that the induration in some cases resembles in degree and appearance that produced by the action of alcohol. The white substance of the cerebrum is not only resisting and elastic, but its color is unusually pale ; it presents even a brilliant or polished appearance. At the same time the gray substance is more or less faded, and its depth in the convolutions is less than in the normal state of the organ. Roki- tansky says : " The cineritious matter is generally of a pale gray- ish-red color. The medullary is always dazzling white, and remark- ably pale and anjemic." An unusual case is related by Burnet, in which the gray substance in the corpora striata retained its usual color, and was indurated like the white substance. In exceptional cases the cerel^ellum as w^ell as cerebrum undergoes hypertrophy, becoming at the same time more or less indurated. In Burnet's case there was induration of the optic nerves. " The internal struc- ture," he says, " of the optic nerves, especially in their bulbs, had the polish, homogeneous appearance, elasticity, and almost the hardness of cartilage." Rilliet and Barthez state that in two cases the spinal cord presented even more marked induration than the encephalon. Congestion is not a feature of hypertrophy. On the other hand, there is often less vascularity of the brain and its membranes than in the healthy state. If the cranial bones are completely ossified at the time when hypertrophy commences, and firmly united, enlargement of the brain is partially prevented. The convolutions are then thin, much flattened, the sulci more or less efiaced, the membranes pale and dry, and the ventricles are small and nearly destitute of serum. At the autopsy of such a case, when the dura mater is incised,, the expansion of the brain prevents the proper refitting of the skullcap. Occasionally hyper- trophy causes more or less absorption of the cranium, and perhaps the sutures already united are pressed apart. If hyj)ertrophy commences in young infants with the fontanelles and sutures still open, they usually remain open, or are a long time in uniting. The interspaces continue, not only in consequence of the growth of the brain, which tends to separate the bones, but 304 HYPEETROPHY OF BRAIN. also in consequence of feeble ossification. The shape of the head . arrests attention. Hypertrophy usually produces most enlargement between and above the ears, while the frontal portion of the head, though somewhat enlarged, is less developed. The direction of the eyes is not changed, as is common in con- genital hydrocephalus. Rokitansky says (vol. iii. page 285): "With regard to the question to be decided by the theory and microscopic examination, as to the nature of the added material upon which the increase of volume depends, I have formed the following opinion from repeated investigations : — • "1. The disease is genuine hypertrophy. "2. It consists, as such, not in an increase in the number of nerve-tubes in the brain, from new ones being formed, nor in an increase in the dimensions of those which already exist, either as thickening of their sheaths, or as augmentation of their contents, by either of which the nerve-tubes would become more bulky ; but, " 3. It is an excessive accumulation of the intervening and con- necting; nucleated substance." It is now generally admitted that the views of Rokitansky are correct, that hypertrophy of the brain is due to an augmentation in the amount of connective tissue, which lies between and unites the tubules. Causes. — Hypertrophy of the brain is commonly associated with rachitis or scrofula, or some error in the nutritive process, which shows itself in other parts of the system as well as the brain. Rilliet and Barthez consider frequent congestion of the brain as a common cause of hypertrophy. This disease is not common in this country. It is most frequently met in hospitals for children, and among the poor of the cities, whose systems are rendered cachectic by residence in damp and dark localities, and by unwhole- some diet. In the deep valleys of Switzerland, and in parts of South America and Asia, hypertrophy of the brain is common, under the name cretinism. It is associated with rachitis and stunted growth. The abnormal development which occurs in cre- tinism begins in infancy or early childhood, and the unfortunate subjects of it are short-lived. Cretinism has been attributed to a residence in localities wet and deprived in great measure of solar light, and to general disregard of the laws of health on the part of those affected as well as their parents. A recent thorough examination of the subject lends support to the view that it is SYMPTOMS. 305 caused by the use of water containing one of the combinations of vsuljiliiir and iron. The observations of different pliysicians also establish a connec- tion between some cases of hypertrophy and the saturation of the system by lead. In what way lead-poisoning leads to hyper- trophy is obscure, but the concurrent testimony of different ob- servers is so strong, that we cannot doubt that it does sometimes have that effect. Symptoms. — The symptoms, as is the case with most organic diseases of the brain, vary considerably in different cases. Some- times there is, at tirst, more or less depression or languor. If the child is old enough to speak, he may complain of pain in the abdomen or limbs, evidently neuralgic, or of headache. After a variable time vomiting succeeds, and finally convulsions, affecting the muscles of the face, as well as extremities ; the convulsions are usually clonic, but sometimes, as regards at least the extremi- ties, of a tonic character. The pupils may be contracted or dilated ; there is restlessness alternating with drowsiness, and finally coma succeeds. Hypertrophy may continue a considerable time before serious symptoms arise ; but when once developed, these symptoms ordi- narily continue with more or less severity till death. Death commonly results within a week after their commencement, but sometimes not till several weeks have elapsed. When death oc- curs at an early period in the disease, there is usually firm ossifi- cation and union of the cranial bones, and, therefore, but moderate enlargement of the cranium. If hypertrophy commences at a period not far removed from l)irth, the bones, of course, yield more readily to the pressure, and acute symptoms do not occur so soon. After a time, however, in all or nearly all cases, convulsions supervene. These indicate the gravity of the disease, and are prognostic of its fatal termination. In a patient observed by Burnet, violent convulsions, followed by loss of consciousness, marked the commencement of acute symp- toms. Five days subsequently, the following symptoms were recorded: mobility of the eyes, without expression; pupils con- tracted, and directed upwards; divergent strabismus of the left eye ; the senses in their normal state, with the exception of sight ; the limbs move by volition. For a month there was little change. Then occurred drowsiness, and increased prostration, and five weeks later the child succumbed with the symptoms of double pneumonia. 20 306 HYPERTROPHY OF BRAIN. Such is the clinical history of hypertrophy. In cases of firm ossification of the cranial bones, and, therefore, no marked enlarge- ment of the skull, the symptoms are similar to those which occur if the dimensions of the head are increased, only compression and death result sooner. The following case, in which the sutures were firmly united, I attended in 1864. The head was large, but not so large as to attract attention from its disproportion. Case. — A boy, aged two years and two months, had, when about one year old, fever and ague, and since then his countenance was uniformly l^aliid, and his flesh soft. Weaned at the usual time, he remained well till the first of January, 1864. In the beginning of this month he was observed to be feverish for some days, and his appetite poor. His health then graduall}'- improved, and he was thought to be entirely well. On the 26th of February he was suddenly seized with convulsions, general at first, but most severe and continuing longest on the left side. The convulsions lasted a little more than three hours. He recovered fuU}^ his consciousness by the following daj^, but his appetite remained poor; he was no longer amused bj' his pla3'things, and was very fretful. The surface was pallid; bowels constipated; pulse but little, perhaps not at all, accelerated. He continued in this state till the 6th of March, when he had another slight convulsive attack, and from this time he never fully recovered his consciousness. He was fretful if disturbed, his face generall}^ pallid, while the pulse and respiration were not per- ceptibly altered. On the following day, the Vth, the left pupil was somewhat larger than the right, but both were sensitive to light. The difference in size continued till near the close of life. Although vision was imperfect, if not altogether lost, the sense of hearing was not impaired. When questioned, he uniformly answered "No," with a drawling voice, evidently not understanding what he said. As the disease advanced, the respiration became at times sighing; but the rhythm of the pulse was not materially altered. The temperature of the surface was changeable, sometimes cool, sometimes warm, and the congested spots or patches, so common in cerebral affections, were also observed at times on the face, ears, or forehead. Througli most of his sickness, he took drinks readily, and the urine was freely dis- charged, probably from the iodide of potassium, which he took in one and a half grain doses every two hours. He became more and more drowsy, again had slight convulsive move- ments, and finally died, with much apparent suffering, on the 14th of March. The pulse became more accelerated during the last two or three days. On the day preceding his death, the pupils were contracted, and not affected b}' the light. Sectio Cadav. — Body somewhat emaciated, and eyes sunken; occipito- frontal circumference of head nineteen and a half iiiches ; distance from one auditory meatus to the other over the vertex, thirteen and a half inches; convolutions over the surface of the brain much flattened and compressed; brain generally deficient in blood; medullar}'- substance firm, and of a pure white color; meninges healthy; no other abnormal appearances were observed; weight of brain forty-two ounces. DIAGNOSIS — PROGNOSIS. 307 Diagnosis. — Tlie diagnosis of hypertrophy is not always easy. The symptoms are, in tlic main, such as occur in other pathological states, especially congenital hydrocephalus. There is most danger of mistaking the overgrowth for this disease. Hypertrophy has, indeed, often been treated for hydrocephalus. There are, however, certain signs by which we may distinguish one from the other. In the ordinary form of congenital hydrocephalus, even when the amount of liquid is small, the orbital plates of the frontal bones are pressed in such a way that the axis of the eyes is changed so as to have a downward direction. The white of the eye can be seen between the iris and the upper eyelid. This gives a charac- teristic and striking expression to the face. The exception to this is in those rare cases in which the liquid is external to the brain. In hypertrophy this peculiar change in the axis of the eyes does not occur. Moreover, in hyjoertrophy there is not that uniform expan- sion of the head which is observed in hydrocephalus, as has been stated above. There are, commonly, greater enlargement, more prominence of the anterior fontanelle, and wider separation of the cranial bones, in hydrocephalus than in hypertrophy. Hypertrophy with consolidation of the cranial bones, and, therefore, little enlargement of the head, may be mistaken for meningitis. The history of the case, and the means by which we diagnosticate the latter afiection, which will be described in their proper place, will usually enable the physician to make a correct diagnosis. Prognosis. — In forming an opinion as to the probable termination of the disease, we must have regard to the age and general condi- tion of the child, as well as to the degree of hypertrophy. If the disease commence at an early age, when the cranial bones are not firmly united, it is probable that there will be no compression of the brain, so as to endanger life, for a considerable period. "We may then hope by proper measures to remove the constitutional state which gives rise to the hypertrophy, before the enlargement is such as to cause cerebral symptoms. If the bones have already united when the disease commences, even slight hypertrophy will produce symptoms, and a speedily fatal result is inevitable. Evi- dently, also, a child in a marked degree rachitic or scrofulous is much less likely to recover than one whose general health and constitution are less impaired. Treatment. — The treatment in hypertrophy should be directed mainly to the constitution. Measures calculated to improve the nutritive process are those most likely to check the abnormal 308 THROMBOSIS IX THE CRAXIAL SINUSES. growth of the brain. As the disease is one of perverted nutrition, and usually coexists with a vitiated or impoverished state of the blood, tonic and alterative remedies are required. The liquor ferri iodidi is, therefore, useful, as it is both tonic and alterative. This may be given in doses of three or four drops to a child one year old, three times daily. Cod-liver oil, with or without the iron, is beneficial in some cases. Another remedy is iodide of potassium in <;ombination with a tonic, as the compound tincture of bark. ^. Potas. iodid. 3j ; Tinct. cincbon comp., Syr. limonum, aa §ij. Misce. One teaspoonful, three times daily, to a child of three years. The hygienic treatment is not less important than the medicinal. There is little hope of a favorable issue in any case, unless the regimen is such as will conduce to a more robust and healthy state of system. The diet should be plain and nutritious, the apartments clean and airy, and all undue excitement should be avoided. CHAPTER IV, THROMBOSIS IN THE CRANIAL SINUSES (PHLEBITIS). The formation of fibrinous coagula within a vein or sinus is designated thrombosis {thrombus, clot). Coagulation of fibrin in the cranial sinuses occasionally occurs, constituting a very serious pathological state. This may result from local disease in the sinuses or in their vicinitv, or from disease external to the cranium. The immediate cause of thrombosis, whatever its location, is suffi- cient arrest of the circulation to allow the fibrin to coagulate. _ Tubercular and enlarged bronchial glands, compressing more or less the ven?e innominatse or the descending vena cava, sometimes give rise to thrombosis in the cranial sinuses, the fibrin coagulating in consequence of retardation in the current of blood. I have known thrombosis, in the same situation, also to result from clonic convulsions, occurring in connection with severe spasmodic cough in pertussis, since both the cough and convulsions retard the flow of blood in the veins and sinuses within the cranium. At the ANATOMICAL CHARACTERS. 309 post-mortem examination of two sucli cases I found firm whitish clots in the lateral sinuses. Thrombosis, in the cranial sinuses, may also occur from inflam- mation either in the walls of the sinuses, or immediately exterior to them. This is the disease which writers have designated phlebitis of the cranial sinuses, and for a correct understanding of the morbid anatomy of which the profession are indebted to Virchow. Anatomical Characters. — If a child die with the cranial sinuses and the veins of the brain and of the meninges in their normal state, the blood in these vessels is found at the autopsy dark but liquid, or there are small, dark, and soft clots in the larger sinuses. If there was congestion, but no coagulation, in these vessels in the last hours of life, the clots are more numerous, larger, and longer, sometimes extending from the sinuses into the larger veins which empty into them, but they are still dark and soft, readily falling to pieces when handled. If, again, there has been that degree of congestion and stasis which has resulted in ante-mortem coagulation, or in thrombosis, the clots are, in part at least, whitish, and of a fibrinous or gelatinous appearance ; they were formed while the red corpuscles were still carried along in the circulation. Most of the clots in thrombosis are free, while others are at- tached lightly to the internal surface of the sinus ; occasionally they are so large as to distend the vessel. They extend also in many cases into the cerebral veins which connect with the sinuses, producing prominence and firmness, so as to resemble (Rilliet and Barthez) an artificial injection. The clots do not present a uniform character. In parts of a sinus they consist of almost pure fibrin, of a yellowish- white color, while in other portions they present a gelatinous appearance from the large number of white corpuscles, while other portions are more or less tinged from the presence of red corpuscles. The central part of the clot, after a time, if the case is sufficiently protracted, softens, and presents a puriform appearance. This substance, which is only disintegrated fibrin, was supjwsed to be pus, till the microscope revealed its true character. It is obvious that small clots forming within a sinus, and having no attachment to its walls, are liable to be carried by the current of blood into the general circulation, unless there is complete obstruc- tion. Virchow has also shown how a thrombus may extend, by gradual prolongation, nearer and nearer the heart, so that one commencing in a sinus may, after a time, reach into the jugular 3i0 THEOMBOSIS IN THE CRANIAL SINUSES. vein. Different observers, as M. Tonneld, and also Rilliet and Barthez, have traced the fibrinous masses as far as the cava. The latter writers relate the case of a girl, four and a half years old, in whom the sinuses on the left side, especially those nearest the petrous portion of the temporal bone, were completely filled with clots of a yellowish-white color, intermixed with central dark spots. Similar coagula were also found in the left jugular vein as far as the brachio-cephalic trunk. "Whether the walls of the sinus undergo any change depends on the nature of the disease which causes the thrombosis. If it be phlebitis, the coats are thickened from infiltration and injected, and the internal coat has lost its polish. If it be some obstructive disease in the course of the circulation, or a general cause, the coats of the vessel are unaltered, except that they may be stained by imbibition of the coloring matter of the blood. In an infant who died of this disease in the practice of Dr. West, "the sinuses on the left side were healthy, but the blood was almost entirely coagulated. The posterior half of the longitudinal sinus, the torcular, the left lateral, and the left occipital sinuses, were blocked up with fibrinous coagulum, pre- ciselv such as one sees in inflamed veins, and the clot extended into the internal jugular vein. The coats of the longitudinal, and of the inner half of the lateral sinus, were much thickened, and their lining membrane had lost its polish, was uneven, and presented a dirty appearance." The mode in which congestion and coagulation occur within a sinus, in consequence of the pressure of a tumor upon this vessel, or upon a vein into which the blood from this sinus flows, is suffi- ciently obvious. The mode of the production of thrombosis, as a result of clonic convulsions, or of the spasmodic cough of pertussis, is also apparent. How it results from inflammation of the walls of a sinus, that is, from phlebitis, was not understood till explained by Virchow. The fibrinous coagula which fill the sinus are not an exudative product, as was formerly supposed. Inflammation (in most cases otitis, with caries of the petrous portion of the temporal bone) approaches a sinus. The inflammatory products pressing against the walls of the sinus diminish its calibre at that point, and hence the retardation of the current of blood and the coagulation. Or the walls of the sinus may be thickened by inflammatory infiltra- tion, or even by the formation of little abscesses within the coats in consequence of the inflammation, so as to produce bulging inwards, and the result, as regards the circulation, is the same. CAUSES. 311 Whether, therefore, tlie inflammation occur without a sinus, or within its walls, thrombosis equally results, provided that the diameter of the vessel is sufficiently narrowed by the presence and pressure of inflammatory products. There is no exudation on the internal surface of a sinus or vein when inflamed, as there is upon serous surfaces. "On the con- trary" {Cellular P«y great-er restlessness, fretfulness, intolerance of light, and greater variation of symptoms than most other diseases. One familiar with the physiognomy of infancy and childhood, will discover in the features indication of greater suffering, of more PROGNOSIS. 357 serious sickness, than is commonly present in other aiul distinct affections whose symptoms are similar. Sometimes the snddcn disappearance of a chronic eruption npon the scalp will aid in the diagnosis. This is a sign of importance, taken in connection with the symptoms. Headache and vomiting, symptoms of early occurrence, should especially arrest attention, or, in absence of headache, pain of a neuralgic character in some other part. If there is doubt at first, careful and repeated exami- nations, if we are familiar with the various signs and symptoms of meningitis, will soon remove all uncertainty. When the eyes become aifected, the respiration and circulation irregular, and especially when convulsive attacks begin, diagnosis is eas}^. In fact, an incorrect diagnosis would then be unpardonable; but, unfortunatel}'-, if proper treatment has not been commenced till this period, it will be of little service. Prognosis. — Meningitis is one of the most fatal diseases of early life. Whether the form is simple or tubercular, if the initial stage has passed without proper treatment, death may be considered inevitable. Tubercular meningitis, however early recognized, is rarely amenable to treatment. M. Guersant {Die. Med.., t. xix. p. 403) believes that recovery from the first stage of tubercular meningitis is possible. "In the second stage," says he, "I have not seen one child recover out of a hundred, and even those who seemed to have recovered have either sunk afterwards under a return of the same disease in its acute form, or have died of phthisis. As to patients in whom the disease has reached its third stage, I have never seen them improve even for a moment." The very few reported cases which resulted favorably may have been, as M. Gruersant has intimated in the context, cases of the simple form. Rilliet and Barthez believe that in a few instances tuber- cular meningitis has been cured in its first stages, but they state also that the disease is apt to return. The prognosis in simple meningitis is not so unfavorable, pro- vided treatment is commenced at a sufiiciently early period. It is now generally admitted that the simple form may not infre- quently be averted, when threatening, and even arrested in its incipiency. In many such cases we cannot, from the nature of the disease, be certain that the diagnosis is correct. But when we see children relieved, who present precisely those premonitory and even initial symptoms which occur in meningitis, we must believe that at least some of them would have had the genuine disease if not relieved by the measures employed. That recovery is possible from 3-3S MEXIXGITIS, SIMPLE AXP TUBERCULAR. simple menhiiritis in its commenoomont, is also obvious from the fact that a few recover eveu from the advanced stage, when there can he no error of diagnosis. I have known but two recoveries from meningitis when it had continued so long and had reached that degree that the function of the brain and cmnial nerves was impjiired. One of these re- covered with the permanent loss of sight, the other with the loss of hearinir. Both seem to have ordinary intelligence. Another case has been communicated to me. in which the jxitient, a little girl, recovered completely, but for several months after the attack seemed nearly idiotic. Sometimes even in the second stage of meningitis, treatment properly employed is attended by amelioration of symptoms. Though such improvement may serve to encourage physician and friends, it should not be the basis of a favorable prognosis unless it continue three or four days. Apparent improvement during a few houi"s or a considerable part of a day is not unusual in those who Unally die. Thus, in an infiint whose bowels were previously confined, I have known the pulse and respiration to become more regular and the symp- toms generally improve, though only for a brief period, by the action of a purgative. Dr. AVatson says of the advanced stages of this disease, it is " often attended with remissions, sometimes sudden, and sometimes gradual, deceitful appearances of conva- lescence. The child reo^ains the use of its senses, recoornizes those about him again, appears to his anxious parents to be recovering, but in a day or two it relapses into a state of deeper coma than before. And these tallacious symptoms of improvement may occur more than once." Most fatal cases of meninoritis terminate between the third or fourth and the twentieth dav, the duration varvinff accordiu!? to the extent and intensitv of the inflammation, and the vio^or and age of the patient. But there are cases in which it may continue much longer. It is surprising sometimes how long the patient lives, when the symptoms are such that death seems impending. Sensation and consciousness mav be extiuijuished, convulsions occur at intervals, and the surface have acquired almost a cadaveric aspect, and yet the patient lives on. Rilliet and Barthez say, "Often have we inscribed upon our notes death iynmhient, and been astonished the next day to find still alive children to whom we had scarcely allowed two houi-s of life." The symptom which I have found to be the most reliable prognostic of the near approach TREATMENT. 3o9 of death, has been a pulse gradually becoming more frequent and feeble, though other symptoms remain as before. This change in the pulse is usually very apparent during the last twenty-four hours of life. Treatment. — Such remedial measures should be prescribed during the premonitory stage as are calculated to relieve the fretfulness or irritability of temper, and quiet the action of the brain, and, at the same time, produce a derivative effect from this organ. To this end the jjatient should be kept from all causes of excitement, and the bowels should be opened daily, if not naturally, by the use of proper medicines. A mustard foot-bath at night and occasion- ally through the day is useful, as it produces both a derivative and soothing effect. It will commonly produce a few hours' undis- turbed rest, w^iile all other measures except medicine fail. If den- tition is taking place and the gums are swollen, it is sometimes pro- per to scarify them. This operation, by diminishing the swelling and tenderness, may diminish the irritability of system. In most cases in which there are symptoms threatening meningitis, mode- rate counter-irritation behind the ears is required. The fact that the disease sometimes follows the recession of cutaneous eruptions of the scalp shows the importance of this remedy ; but it is not advisable to produce counter-irritation over a large surface, since this may increase the restlessness of the child, and aggravate rather than relieve the state of the head. West says: "Another inquiry that you may put is, wdien are you to employ blisters? Certainly not at the beginning of the disease, when they would increase the general irritation, and do more harm than good. At a later period they may be of service, when the excitement is about to yield to that stupor which usually precedes the state of complete coma. They should then be applied to the nape of the neck or to the vertex." Vesication produced at so late a period as Dr. West recommends, can produce little effect in arresting the disease ; besides, counter-irritation at the vertex or back of the neck is too far removed from the seat of the disease. I have never known it, when employed in the manner which I shall advise, to increase the restlessness. I have many times prescribed vesication — Bometimes when the symptoms passed off and there was restoration to health; at other times, when meningitis supervened with its usual result — and I have never regretted the prescription. Cantha- ridal collodion applied with a brush answers the purpose, and from the convenience of its application is to be preferred. It does not vesi- cate deeply, or produce a troublesome sore. If symptoms indicating 360 MENINGITIS, SIMPLE AND TUBERCULAR. the approach of meningitis continue, iodide of potassium should be given in decided doses. We will speak more of this in our re- marks on the treatment of the disease. Many children who are threatened with meningitis are scrofulous. They have already shown symptoms of tubercular disease. They are, perhaps, to a certain extent, emaciated, and may have been aitected with a cough. The premonitory symptoms in these chil- dren indicate the approach of the tubercular form of meningitis, and a more sustaining course of treatment is required than in those who are robust. To such children cod-liver oil may be profitably given, three times daily, together with the syrup of the iodide of iron, or iodide of potassium. They should also be taken into the open air, with proper precautions, and every hygienic measure should be employed which will be likely to invigorate the system without exciting the brain. Loss of blood is not, in general, required during the prodromic period nor in the disease. Those of a strumous cachexia, or those, whether strumous or not, who are under the age of two years, do not, unless in very rare instances, require depletion by leeches, much less by venesection. There is one class of patients in whom the early loss of blood may, doubtless, be of service, namely, those who in a state of robust health are suddenly seized with the in- flammation. Leeches should then be applied to the head of the patient, if he is seen at an early period. The propriety of using opium to allay irritability of system in those threatened with meningitis is viewed diiierentl}'- by physi- cians. Bouchut says : " Opiates have the inconvenience of increas- ing constipation, but they are very useful in calming the state of cerebral excitement of young infants. Laudanum should be given in a draught in a narcotic dose, at short intervals, gradually in- creasing the dose of it until sleep is obtained." I prefer, in order to relieve the restlessness, the use of hydrate of chloral. From one to three, or even five, grains may be given, and, if necessary, repeated after some hours. Often, notwithstanding the measures employed, the patient grows worse, the symptoms become more continuous, others more alarm- ing arise, and meningitis declares itself. For internal treatment, there are two medicines which are extensively used by the pro- fession — in fact, to the exclusion of nearly all others — the one calo- mel, the other iodide of potassium. Those who employ the iodide as the main remedy, commonly also prescribe single doses of calo- mel occasionally, as an eligible purgative when there is constipa- TREATMENT. 3G1 tioii, SO that half a dozen or more doses may be given in the course of the disease. By those who depend upon cak^mel as the main remedy, it is given not only to keep up a relaxed state of the bowels, but also in the belief that it arrests the exudation from the menin- ges. These last give it daily in small doses. My observations have not been favorable to the use of calomel, except as an occasional purgative. When administered dail}', it has a very depressing eflect, and it is to be recollected that this is a disease in which the vital powers rapidly sink in consequence of the loss of appetite and the frequent vomiting. In tubercular meningitis, it is obvious that any remedy which greatly reduces the strength may promote the formation of tubercles, and thereby diminish the chances of recovery. Cases have occurred in which calomel was given at short intervals for several successive days, and though the meningitis seemed to be relieved, death resulted from sheer exhaustion or from some intercurrent affection, the result of exhaustion, or of the remedy. In one case related to me, fatal gangrene of the mouth, the result of the mercurial treatment, supervened after the meningitis had apparently subsided. Unless, therefore, statistics show that a larger proportion recover by the use of calomel than by iodide of potassium, we should prefer the safer agent. I^ow, while certain patients recover who exhibit symptoms which are premonitory of meningitis, and a few from meningitis itself, by the use of iodide of potassium, restoration to health by the calomel treatment is certainly very rare, if there are unequivocal evidences of meningeal inflammation. Dr. Whytt, who lived in the time when calomel and loss of blood were com- monly prescribed not only in this but in other diseases, never saw a favorable case. Moreover, physicians of the present time incline more and more to the use of iodide of potassium, and the rejection of calomel, as the main remedy. The iodide of potassium should be given early in the premonitory period. If, by a careful examination, the absence of any other local disease or of a constitutional aifection which might give rise to similar symptoms is ascertained, this agent should immediately be prescribed. The symptoms at this early period are often so obscure that a positive diagnosis cannot be made ; but it is better to give the iodide even if the diagnosis is wrong, and no meningeal disease is threatening, than to err on the other side and withhold its use in the prodromic and initial period of the true disease. An infant from six to twelve months old should take two grains every two hours, and older children a proportionate dose. Larger doses may 862 MENINGITIS, SIMPLE AND TUBERCULAR. in some cases be administered. "When thus given, the iodide soon produces an impression on the system, and especially on the renal secretion, the quantity of urine, previously scanty, being largely increased. If with the regular and continued use of potassium there is no improvement, the case is without remedy. Throughout the disease, as well as in its commencement, the iodide of potassium should, therefore, be employed until it is obvi- ous that there is no chance whatever of improvement, when medi- cation may proj^erly be discontinued. The best remedy for the convulsions which sooner or later occur in most cases, is hydrate of chloral given in small doses. The apartment should be dark and quiet ; a moderate degree of vesication should be produced behind the ears, and the head be kept cool. In simple meningitis occur- ring in children three or four years of age or older, previously healthy and robust, it is proper to place a bladder with pounded ice over the head, separated perhaps by two or three thicknesses of muslin, provided that the temperature is elevated, as it ordinarily is. If there is not much heat, or if the child is considerably pros- trated, a cloth wrung out of cool water will be sufficient. Bouchut recommends irrigation, and condemns the mode of applying cold which is recommended above. Says he, " Refrigerants external to the cranium are often employed, and their use appears very ra- tional ; still they do not possess a very great efficacy. The appli- cation of compresses moistened with cold water, ice in a bladder and laid on the forehead, are bad remedies, which, by causing too considerable alternations of heat and cold, are rather noxious than useful to the child. If it is wished to employ refrigerants, recourse should be had to continual irrigation. The patient is not to be disturbed in its bed; the head should be placed on a cushion, the hair being cut very short ; the neck is bound moderately tight by an impermeable stuff, so placed on each side as to form a gutter, so that the water which has been used in the irrigation can run off from each side of the bed without wetting the body of the child. Having arranged these, a jar filled with water of a moderate tem- perature, 64° Fahr., is placed above the patient; a siphon with a tap is to be placed in the jar, to moderate at will the flow of the liquid. To this tap is fastened a skein of loose thread for the purpose of conducting the water to the forehead, so as to avoid the continuous dropping of the liquid, which would be insupportable." If, how- ever, there is an attentive nurse, who renews the wet cloth suffi- ciently often, there does not seem to be any danger from reaction, as feared by Bouchut. Irrigation requires as constant attention, 1 SPURIOUS HYDROCEPHALUS. 3(33 in consequence of the restlessness of the child, as does the treat- ment by a wet cloth, in order that there be no interruption in the employment of it. Few children will remain quiet with a descent of water upon the head, except those who have become entirely insensible, and in such neither a wet cloth nor irrigation aftbrds any material benefit. In simple meningitis in its first stages, the diet should be mild and rather scanty ; in the tubercular form it should be more nourishing; beef-tea and milk-porridge are required. In both the simple and tubercular form, at an advanced stage, the most nourishing food is required, but stimulants should not be given unless near the close of life, when the vital powers are failing. CHAPTER X. SPURIOUS HYDROCEPHALUS. The disease known as spurious hydrocephalus might with more propriety be called spurious meningitis. It received its appella- tion at the time when meningitis of early life was believed to be essentially a hydrocephalus, and was so called. Attention was first directed to this affection by London physicians of the last generation, particularly Drs. Gooch, Abercrombie, and Marshall Hall, and little can be added to their description of its symptoms. Anatomical Characters. — This disease, though resembling me- ningitis in certain of its phenomena, is not in its nature inflam- matory, nor is it primary. It is the result of some affection often chronic, but occasionally acute, which has produced exhaustion, especially of the nervous system. When it commences, there is usually more or less emaciation, and the symptoms of the primary disease are present. To this disease the lesions pertain which are found in other organs besides the brain. The state of the brain in spurious hydrocephalus is not the same in all cases. In some there is no appreciable anatomical alteration in this organ. There is no apparent difference, either in the meninges or the brain itself, from the condition which we often observe in those who have died of diseases which do not affect the cerebro-spinal system. In such cases the pathological state is simply deficient innervation, or if there is a structural change in 864 SPURIOUS HYDROCEPHALUS. the minute anatomy of the brain, pathologists have not yet discovered it. The following case, which occurred in the Child's Hospital of this city, is an example of this form of spurious hydrocephalus: — Case. — A female infant, six months old, died on the 24th day of April, 18G2, with the following history: It was wet-nursed, fleshj'-, and apparently well, till six days before death, w^hen symptoms of gastro- intestinal inflammation were suddenly developed. The vomiting, espe- cially, was severe, continuing forty-eight hours. When it ceased, drow- siness supervened, and continued till the close of life. The face during the four days of stupor was pallid and cool ; e^^es parth' open, pupils sluggish, but of equal size; bowels rather torpid, anterior fontanelle depressed. When aroused, the infant noticed objects for a moment, and immediatel}'' relapsed into sleep; pulse accelerated and not intermittent, the day before death numbering one hundred and fifty; respiration accelerated, without sighing, numbering on the same day thirt}'. There were no convulsions, and death occurred quietly. The brain weighed twenty and a half ounces, and its appearance was perfectly healthy, both as regards consistence and vascularity. The amount of cerebro- spinal fluid in the ventricles and at the base of the brain was not notably increased. The stomach, small and large intestines, were vascular in streaks and patches. In this case the cerebral symptoms were obviously due to exhaustion occurring at an early period, in consequence of the severity of the gastro-intestinal affection. In a majority of cases, however, of spurious hydrocephalus, according to my observation, there is an anatomical alteration in the state of the brain and meninges. This consists in passive con- gestion of the veins, often with transudation of serum. At the same time the cranial sinuses are congested, and are found at the post-mortem examination to contain larger and more numerous clots than are present in those who die of diseases which do not aifect the encephalon. Cases might be cited as examples. The cause of this congestion and eifusion is, in great measure, feeble- ness of the circulation due to the general exhaustion of the patient. But there is another cause. In protracted diseases, especially those of a diarrhceal character, there is more or less wasting of the brain as well as of other parts. This naturally, by way of compensation, gives rise to congestion of the cerebral veins and to transudation of serum. The transudation commonly occurs in this disease over the superior surface of the brain and in the subarachnoidal space, perhaps also more or less in the lateral ventricles. So common is it in the last stage of infantile entero-colitis, the summer epidemic of the cities, that this stage, which is really spurious hydrocephalus, has been SYMPTOMS. 365 called the stage of effusion. I shall relate ni another place examples which show the anatomical characters of this intestinal disease. Symptoms. — Spurious hydrocephalus most frequently results from protracted diarrheal comi^laints. It may, however, result from any disease which is attended hy great prostration. As it ordi- narily occurs, the patient has for days or weeks been gradually losing flesh and strength. Finally drowsiness supervenes, or before the drowsiness there is sometimes a stage of irritability. Marshall Hall describes two stages of spurious hydrocephalus. In the first, he says, "the infant becomes irritable, restless, and feverish; the face flushed, the surface hot, and the pulse frequent; there is an undue sensitiveness of the nerves of feeling, and the little patient starts on being touched, or from any sudden noise; there are sighing and moaning during sleep, and screaming; the bowels are flatulent and loose, and the evacuations are mucous and disordered." The second stage he describes as that of torpor. The first stage often, however, does not present those prominent symptoms which have been described by Dr. Hall, and this stage may even be absent, or not appreciable, especially in young infants. Whether or not commencing with the stage of irritability, the disease, if not checked, gradually increases. The child soon be- comes drowsy. He may be aroused for a moment, but, unless con- stantly disturbed, immediately relapses into sleep. He is sometimes fretful when aroused, but in other instances is quite indift'erent, observing without apparent interest objects employed for the pur- pose of amusing him. Often there are indications of cerebral pain or distress, as contraction of the eyebrows, etc., but many of those affected are too young to make known their sensations. Convul- sions sometimes occur towards the close of life, but they are not so common in this disease as in meningitis. When they do occur, they are generally partial and often slight. The pulse is accelerated in most patients prior to and in the commencement of spurious hydrocephalus. As the disease advances it becomes irregular and intermittent, and towards the close of life it is progressively more .frequent and feeble. The respiration at first is not much disturbed, but at length it becomes irregular, like the pulse. It is feeble and accompanied by sighs. Occasionally there is slight cough. The eyelids are partly open, the pupils no longer respond to light, and in advanced cases they have a bleared appearance. The diarrhoea, which in most instances precedes and causes the disease, continues 366 SPURIOUS HYDROCEPHALUS. till the stage of stupor arrives, when the evacuations become less frequent or cease altogether. In infants the stools are frequently green, in older children brown and sometimes slimy. The febrile heat of surface, which j)receded the disease and was present in'its commencement, disappears ; the face and hands become cool, the features pallid, and the anterior fontanelle, if open, is depressed. Death finally occurs in a state of coma, or, if the disease is recog- nized and proper remedial measures employed, the result may be favorable, even when the symptoms are such that if meningeal inflammation were the disease we would consider the case neces- sarily fatal. The following case is an example of spurious meningitis as we often meet it in practice: — Case. — On the 13tli day of March, 1859, I was asked to see a male child t\vent3^-two months old, the records of whose case are as follows: — "Was well till about three weeks ago, since which time he has had diarrhffia, with febrile symptoms; pulse 162, respiration 52; has a slight cough, with a few mucous rales; resonance on percussion of chest good; is somewhat emaciated, and appears languid; tongue moist and slightly furred. Has all the incisor and three anterior molar teeth, and the gum is swollen over the remaining anterior molar and two canine teeth." From the 14th to the 18th there was no material alteration in his symptoms, with the exception that the diarrhoea was partially restrained by Dover's powder in one and a half grain doses. On these five days the dejections numbered daily from one to six. The pulse was uniformly frequent, var3'ing from 124 to 156, and the respiration on two da^'s, when its frequency was ascertained, numbered 56 and 46. "March 19th, pulse 124; has become drowsy since j-esterday, and when aroused is fretful. Omit Dover's powder. Treatment, cold appli- cations to the head, mustard pediluvia. "Evening, pulse 136; eyes constantly closed and head reclining; surface generally warm ; tongue dr^^ and furred ; vomited at first, but has not in three or four days. Apply cantharidal collodion behind each ear, and continue the local treatment. " 20th, pulse 130, is constantly sleeping, and when aroused is very fretful and soon relapses into sleep; no unnatural heat of head and no dejection since yesterday. Treatment, a dose of castor oil, nourishing diet. "21st, drowsiness as before; cheeks sometimes flushed, sometimes pale ; pupils sensitive to light ; margins of eyelids covered with secre- tion. The bowels have been opened by the oil." On the 22d and 23d there Avas no material change in the symptoms. He was constantly sleeping, except for a moment when shaken. More active stimulation was now employed. Brandy was prescribed, to be given every two hours ; beef-tea and milk-porridge frequently. On the following day, the 24th, he was more fretful, and less drowsy. Brand}- and beef-tea were continued. On the 25th, with the same treatment, there was still further improve- ment ; drowsiness nearly gone and lessfretfulness than yesterday ; rolls SYMPTOMS. 367 tlie head occasionally and does not appear to see distinctl}' ; has a slight cough; bowels nearly regular; i)ulse 100; respiration natural; surface warm, and no unnatural heat of head. The same treatment was con- tinued, and he rapidly and i'nlly recovered. This case is interesting on account of the long duration of marked drowsiness, which continued five clays, and yet tlic patient recovered fully in the space of two or three days under the use of brandy and beef-tea. In May, 1860, 1 was called to treat a very similar case. A cliild, twenty months old, had diarrhcca for two weeks, the stools being of a dark-brown color, thin and offensive. He was at first very irritable. The pulse was constantly above 130, and the respiration was correspondingly increased. The stage of drowsiness finally supervened, and for two days he was constantly asleep unless aroused by being shaken. During the somnolent stage the pulse numbered 140, respiration 36. The face and extremities were cool and he finally had a slight convulsion. By stimulants and nutri- tious diet he began immediately to improve, and was soon out of danger. In the folio wino; case the result was unfavorable. This case is interestino; on account of the anatomical characters of the disease as disclosed by the post-mortem examination. It is an example of that large class of cases in which spurious hydrocephalus is asso- ciated with congestion of the cerebral vessels and serous eff'usion. It is exceptional, however, as regards the long duration of drowsi- ness. Ordinarily, protracted cliarrhoeal maladies which end in con- gestion and eff'usion, terminate fatally in two or three days after the drowsy period arrives. Case. — " 13th, 1861, called to-day to a German infant eighteen months old. It has had diarrhoea four weeks without regular and proper medi- cal attendance; stools from the first brown and thin; during the last eight or nine days has been drowsy ; when aroused, opens his eyes and is very fretful, but immediately the upper eyelids gradually droop, and, unless disturbed, he remains asleep with his eyes partially open ; forehead warm, face cool and pallid, and limbs also rather cool; pulse 164, respi- ration 32; has had a slight cough about one week, and slight dulness on percussion over the left infra-scapular region ; depression of infra-mam- mary region on inspiration. Treatment : Ammon, carbonat. gr. 1 every two hours; nourishing diet. " Dec. 20th, has continued drowsy since the last record; pupils mode- rately dilated ; a thick secretion between eyelids; right pupil consider- ably larger than the left ; vision apparently lost during the three last days ; pulse over 140; respiration 44 per minute, accompanied by sighing since the 18th; moans much when awake; rolls the head frequently; during the last six days the surface back of the ears has been constantly 308 SPUEIOUS HYDROCEPHALUS. sore by vesication ; takes tlie most nutritions diet, with bran(l3\ The dejections remain thin and brown, and number three or four daily. " From this date the diarrhoea continued, except as it was restrained by vegetable astringents. The pulse continued frequent, and a slight cough remained. There was on the 21st and 22d partial abatement of the drowsiness, but on the 23d it was greater than ever. The body was somewhat reduced at the commencement of the cerebral symptoms, but it was now considerably emaciated. The prostration increased daily, and the hands were observed to tremble. The face and hands became more cold, while the head was warm. On the 24th partial convulsions occurred, followed by coma and death. '^ The cerebral veins and sinuses were generally congested, except in the anterior portion of the brain, where the appearance was normal. Between the brain and its membranous covering, chiefly at the vertex and the base, was an effusion of clear serum. The whole amount of this fluid was estimated at two ounces. On slicing the brain, the puncta were numerous and large, both in the gray and white portions. With the exception of the congestion, the substance of the brain pre- sented the normal appearance. No inflammatory lesions were present. We were not permitted to examine the condition of the intestines." Diagnosis. — The only disease witli wliicli spurious hydrocephalus is liable to be confounded is meningitis. The points of differential diagnosis are the history of the case, especially the antecedent diarrhcea or other exhausting ailment, evidence of prostration when the cerebral affection commenced, the depression of the ante- rior fontanelle in young children, and the cool face and extremities. Prognosis. — If the pathological state of the brain is simple ex- haustion, the disease can often be arrested by judicious treatment. If an incorrect diagnosis be made, and the treatment employed is that appropriate for meningitis, the disease which it simulates, death is almost inevitable. If transudation of serum has occurred, unless slight, the result is apt to be unfavorable, whatever may be the treatment. This disease in childhood is more easily managed than in infancy, but is less frequent. The prognosis is better in the cool months than during the heat of summer. It is more favorable if the child is over than if under the age of one year. The occurrence of an irregular and intermittent j^ulse, of respira- tion accompanied by sighs, of inequality in the pupils or their sluggish movements, with increasing stupor, indicates an unfavor- able issue. The cure of the primary disease, with the pulse and respiration still natural, or accelerated, without change of rhythm, pupils sensitive to light, drowsiness from which the patient is easily aroused to a state of entire consciousness, render recovery probable, with proper medication and alimentation. Treatment. — The indications of treatment are twofold: first, to remove the primary pathological state which is the cause of ECLAMPSIA. 369 the cerebral afFection; and, secondly, to cure that affection. The first is important, since the successful treatment of a disease re- quires the removal of the cause. The measures employed for this purpose are pointed out in our description of the diarrlujcal and other maladies which produce spurious hydrocephalus. AVe may here say that as this disease is due in a very large proportion of cases to the exhausting effect of long-continued loose- ness of the bowels, astringents and alkalies are required in a majority of cases in the stage of irritability, and sometimes also opiates. Active sustaining measures are indicated. Exhausted nervous power, as well as passive cerebral congestion, requires this. The diet should be highly nutritious, comprising such substances as milk and animal broths, and should be given frequently. Brandy is required at short intervals. Dr. Gooch was in the habit of giving the aromatic spirits of ammonia, properly diluted, as a quick and active stimulant. Six or eight drops may be given in sweetened water to a child one year old, and repeated every hour in cases of urgency. If, by proper treatment of the cause, and by the use of stimulants and nutritious food, the patient does not within a few hours become less stupid and more conscious, there is that degree of nervous exhaustion or of serous transudation from tlie engorged cerebral veins which will render death inevitable. In some cases it is proper to produce moderate vesication behind the ears. CHAPTER XI. ECLAMPSIA. The term eclampsia is used in a more restricted sense by some writers than by others. It is used in the following pages to desig- nate those convulsive seizures, clonic in their character, sometimes general, sometimes partial, which affect the external muscles. Eclampsia is therefore synonymous with clonic convulsions. It consists in a rapid, forcible, and involuntary muscular contraction, alternating with relaxation. It is distinguished from chorea in the fact that the latter is a more permanent state, and is charac- terized by muscular movements which are partially under the control of the will, and are not so violent. 24 370 ECLAMPSIA. Eclampsia occurs in a great variety of diseases, some of which are located in the cerebro-spinal system, some in other parts of the body, and some are constitutional. It may also be produced by temporary derangements of system, not sufficiently severe to be considered disease, and by powerful mental impressions, those of an emotional nature affecting the delicate and sensitive nervous system of the child. Pathologists recognize three distinct forms of eclampsia. The term essential or idiopathic is used when the convulsions have no appreciable anatomical character, that is, when there is no apparent pathological state in the brain or elsewhere which gives rise to the attack. For example, if a child dies in convulsions from fright, and all the organs, including the brain, are found in their normal state, the eclampsia is called idiopathic or essential. If the cause is disease of the brain or spinal cord, it is termed symptomatic. If it arises from disease elsewhere, as from pneumonia, the term sympathetic is employed. This is in the main a good division, but eclampsia may be at the same time sympathetic and symptomatic, as when it occurs in consequence of congestion of brain, which is induced by severe and frequent paroxysms of hooping-cough. Causes. — Eclampsia occurs at any period of infancy and child- hood, but it is much more rare after the period of six or seven years than previously. Some children are more liable to it than others. It is produced in one by an agency which in another has no ap- preciable eifect. There are some, generally those of an impressible nervous system, who are seized with convulsions whenever there is any slight derangement in the digestive or other organs. Eclampsia is frequent in certain families. Thus, Bouchut mentions a family of ten persons, all of whom had convulsions in their infancy. One of them married, and had ten children, all which, with one excep- tion, had convulsions. The exciting causes of eclampsia are too numerous to be men- tioned in full. It is a symptom in nearly all cerebral diseases. It is produced in the nursling by changes in the milk with which it is nourished. These changes are usually due to violent emotions of the mother, as anger, fright, and grief, to the use of acescent or indigestible food, or to derangement, temporary or permanent, in her health. Thus, in a case related to me, the catamenia so afl'ected the milk that the child was seized with eclampsia at each monthly period. In childhood the most common cause of clonic convulsions is the presence of some irritant in the primes vise. All kinds of fruit, even the mildest, may produce the disease, especially PREMONITORY STAGE. 371 when eaten unripe or taken in undue quantity. I have known an infant to he seized wltli convulsions from eating strawherries, which parents usually regard as harmless, and one of the most violent and protracted cases of eclampsia which I have witnessed, occurred in a child over the age of six years, from swallowing, in considerahle quantity, the parenchymatous portion of an orange. Constipation, worms, dysentery, intussusception, and painful denti- tion are also causes which are located in the digestive apparatus. Inilannnation in some part of the respiratory apparatus is a not infrequent cause. Thus eclampsia occurs occasionally in severe coryza, in consequence, according to some, of the proximity of the inflamed surface to the brain, and the consequent afflux of blood to this organ. It is a common complication also of pertussis and pneumonia. It occurs often at the commencement of two of the eruptive fevers, namely, smallpox and scarlet fever, and in the course of the latter disease. Violent emotions of the child may also cause eclampsia. Bouchut relates the case of a girl, five years old, who was corrected before her companions, and was so aftected by anger that convulsions occurred. Residence in close and overheated apartments, or in streets where the air is loaded with offensive vapors and is stifling, is a predisposing cause, so that there is a larger proportion of deaths from convulsions in the cities than in the country. In young children, burns, even when not very severe, are apt to terminate suddenly in eclampsia, succeeded by coma and death. Urinary calculi, both renal and vesical, frequently produce the same result. Such are the more common causes of eclampsia. It is seen that they are of two kinds, predisposing and exciting. An excitable or impressible state of the nervous system constitutes the chief predisposition to the disease. Plethora, or its opposite state, angemia, increases the liability to an attack. Premonitory Stage. — In the majority of cases there are pro- dromic symptoms, which the experienced and careful physician can detect, so as to forewarn friends. The child is perhaps more or less drowsy, and, when disturbed, fretful. The eyes often have a wild or unnatural appearance ; occasionally they are fixed for a moment on an object, and yet apparently without noticing it. The sleep is disturbed ; in some there is unusual heat of head, and, if old enough, complaint of headache. At times, especially if the primary disease is febrile or inflammatory, there is incoherence of thought or expression, or even actual delirium. In some children, 372 ECLAMPSIA. when eclampsia is tlireatening, the thumbs are seen to be carried often across the palms. I have observed this especially during the convulsive cough of pertussis. A very important prognostic symptom is a sudden starting, or twitching of the limbs. This shows that the nervous system is profoundly impressed, and but slight additional excitation is required to develop eclampsia. This sudden starting not infrequently precedes the attack several hours, and gives sufficient forewarning. The prodromic symptoms are often disregarded by friends who do not understand their significance. Even physicians, in the haste of their visits, in many instances do not notice them. The symp- toms which precede symptomatic and sympathetic eclampsia are, moreover, blended with those of the primary aftection, and hence another reason why they are apt to be overlooked. When the convulsions are about to commence, the child generally lies quiet ; the eyes are open and fixed. If spoken to or shaken, he takes no notice, and does not speak. The direction of the eyes is then changed; often they are turned up; sometimes there is strabismus. The face may be pale or flushed, and often, especially in cerebral diseases, the features present patches or streaks of a flushed appear- ance, while around them the natural color is preserved. Immedi- ately before the spasmodic movements the child occasionally utters a piercing scream, which is probably involuntary, though it seems like a supplication for help. The duration of the prodromic stage is very difierent in dififerent cases. It may last from a few minutes to several hours, or even more than a day. Symptoms. — Eclampsia is general or partial, li general^ the mus- cles of the face, eyes, eyelids, and of all the limbs, are in a state of rapid involuntary contraction, alternating with relaxation. The features lose their natural expression, and are distorted ; the mouth is drawn out of shape, often to one side, by the violent muscular action ; the teeth are pressed together by tonic contraction of the masseters, and may be violently struck together, so as to lacerate the tongue, if it protrude, or are ground upon each other. Unless the attack is of short duration, frothy saliva, perhaps tinged with blood from the injured tongue, collects between the lips. The eye- lids are usually open, and in severe cases the eyes are turned so that the pupils are lost under the upper eyelids, or the muscles of the eyes are involved in the spasmodic movements, so that the eye- balls are forcibly drawn from side to side. Occasionally, strabismus occurs. "While the features are thus distorted, the head is forcibly retracted, or is turned to one side; the forearms are alternately SYMPTOMS, 373 pronatcd and supinated ; the thumbs and fingers are convulsively flexed, so that the thumbs lie across the palms, and are covered by the fingers ; the great toe is adducted, the other toes flexed; and the toes, as well as legs, participate more or less in the spasmodic movements. In general convulsions, consciousness is usually lost. The head is hot previously to and during the attack — at least in the first part of it — and the face flushed. In exceptional cases, especially in sympathetic eclampsia, the head is cool and the face pale. The pulse is somewhat accelerated, as well as the respiration, and the latter is rendered irregular if the respiratory muscles, especially those of the larynx, are involved, as they generally arc. The sphincters arc relaxed during the convulsive attack, so that in many cases the urine and stools are passed involuntarily. Partial eclampsia is more common than the general form ; it occurs in the muscles of the face, including those of the eye, of the face, and of one or both upper extremities, or of the face and the extremities on one side. The spasmodic movements may be even limited to the muscles of the eyes, and they often occur only in these muscles and those of the face. Rarely, if ever, does eclampsia affect the legs without affecting also the muscles of the arms and face. In partial convulsive attacks, sensation and consciousness are in some not entirely lost, but in others they are not manifested if present. The duration of an attack of eclampsia varies in different cases from a few minutes to several hours. The average is not more than from five to fifteen minutes. It does not often continue longer than three or four hours in the severest cases. It is some- times said to last a much longer time, even for days, but there are in these cases intermissions. Violent attacks are usually short. "When the convulsion ends favorably, the spasmodic movements become less and less strong, and finally cease. The child then takes a deep inspiration, after which it lies quiet, and the respi- ration remains regular or moderately accelerated. Some fully re- cover in a few minutes if the eclampsia has been light and the cause transient, and seem to experience no inconvenience except soreness of the muscles and fatigue. Others soon recover conscious- ness, and their temperature, respiration, and circulation become natural, but they remain dull for a time, their minds are bewil- dered, and they are perhaps unable to speak. In a few hours these untoward symptoms pass away. In essential, and in a large proportion of cases of sympathetic eclampsia, if properly treated, 374 ECLAMPSIA. and if the cause is recognized and removed, there is no recurrence of the convulsion ; with others it is different. In many cases, es- peciall}'' of symptomatic eclampsia and of sympathetic, in which the cause is grave and persistent, the convulsions return after a varia- ble period of a few minutes or a few hours. Six or eight or more convulsions may occur within twenty-four hours. Rarely they occur several times daily for several consecutive days, but severe convulsions, repeated at short intervals for twenty-four or forty- eight hours, usually end in fatal congestion of the brain or serous effusion. I once attended an infant about six months old, who had from four to twelve convulsions daily for eleven days, caused prob- ably by a vesical calculus, as there was dysuria, and, at times, bloody urine. Some days after the convulsions were controlled, while we were deferring exploration of the bladder, death occurred suddenly, and the autopsy was not permitted. This case will be detailed elsewhere. Bouchut has witnessed a case of hooping- cough in which there were daily convulsions for eighteen days. In severe eclampsia, the respiration is so embarrassed and cir- culation so retarded that congestion of various organs results. This passive congestion in the respiratory organs is indicated by moist rales in the larynx and bronchial tubes ; occurring in the brain, it is indicated by profound stupor. It has already been stated that death may occur from the cerebral congestion, which, continuing, is apt to end in effusion of serum or extravasation of blood. In these cases the convulsive movements cease, but there is no return of consciousness. The child lies quiet, as if in sleep, with pupils not readily acted upon by light, and often somewhat dilated ; gradually the limbs grow cool and the pulse feeble, and fatal coma supervenes. Death does not ordinarily occur from one attack. There are several at intervals, during which the stupor is gradually becoming more and more profound, till, finally, there is total loss of con- sciousness and sensation. This is the most frequent mode of death, namely, death from coma. Apnoea may occur in the first attack, ending life abruptly and unexpectedly, but in other instances it does not result till after several seizures, when, at length, one more violent than the others interrupts the respiratory function and causes death. Occasionally, when life is preserved, there is some permanent ill effect of eclampsia. Bouchut says : " The origin of certain perma- nent contractions which bring on deviation of the head or of other parts, retraction of the limbs, paralysis, etc., must be referred to ANATOMICAL CHARACTERS. 375 the convnlsions of the muscles. I have seen several children in whom torticollis had no other cause. The drooping of the upper eyelid, stral)ismus, irregularity of the mouth, severe contractions of the limbs, often depend on this influence. These accidents are consequences of essential as well as of symptomatic convulsions." Anatomical Characters. — The morbid anatomy pertaining to eclampsia is in most cases twofold : first, the pathological states which precede and cause the convulsive movements ; secondly, those which result from them. We have seen that in sympathetic eclampsia the diseases which sustain a causative relation are very numerous ; some are constitutional, others local, and the latter may have their seat in almost any part of the economy, distinct from the cerebro-spinal axis. In some cases of sympathetic eclampsia the immediate cause is too active a circulation, a state of hypersemia of the cerebral vessels. It has already been stated that this hj-perremia may be diagnosti- cated in young infants in whom the anterior fontanelle is open. Such infants, seized with acute inflammation of the mucous surfaces or of the lungs, often present a full and rapid pulse and a convex and forcibly pulsating fontanelle before the eclampsia begins. In other cases of sympathetic eclampsia the primary disease induces passive congestion of the brain, and this in turn gives rise to convulsions. Eclampsia occurring during the paroxysms of hooping-cough aflfords an example. In the contagious diseases, as smallpox and scarlet fever, eclampsia is doubtless often produced by the direct action of the; specific virus on the cerebro-spinal system. There- fore, in a considerable proportion of cases of eclampsia due to diseases not located in the cerebro-spinal system — in other words, of sympathetic eclampsia— the primary disease induces a pathological state of the cerebral vessels or of the blood which circulates through them, which state immediately precedes and accompanies the convulsions. In other cases of s^mipathetic eclampsia the convulsive move- ments are produced by the primary disease, acting directly on the nervous system, through the medium of the nerves, without caus- ing any appreciable alteration in the state of the cerebro-spinal axis. Thus Barrier relates three fatal cases of convulsions occurring in pneumonia, in none of which was there anj- thing abnormal in the condition of the brain or its membranes. The pathological state preceding symptomatic eclampsia difiJers in different cases, since convulsions occur in almost every disease of the brain and its membranes. The immediate cause of this form 376 ECLAMPSIA. of eclampsia may be active or passive cerebral congestion, with or without effusion ; it may be compression of the brain from various causes ; it may be a deficiency as well as excess of the cerebro- spinal fluid. In essential eclampsia the cause sometimes produces congestion of the brain prior to the convulsive seizure. In other cases, as when convulsions occur immediately from the effect of anger or fright, there- is no appreciable change in the state of the nervous centres previously to the attack. Again, eclampsia, especially when severe and protracted, and when occurring in successive attacks, may be the cause of certain lesions. It produces congestion of the brain and membranes, and perhaps of the spinal cord. Sometimes, if the congestion is great, there is also escape of serum from the distended capillaries, and the fibrin in the larger vessels, as the sinuses, may coagulate. The congestion resulting from eclampsia may give rise to extra- vasation of blood and the formation of a clot. If this accident occur, there is often paralysis affecting more or less of one side, permanent or gradually disappearing. It may be difiicult to decide whether the cerebral congestion precedes the eclampsia or is its result ; but in those cases in which it precedes and operates as a cause, it is no doubt increased dui-ing the convulsive period. The spasmodic muscular action, b}' render- ing respiration irregular and imperfect, also leads to congestion of the lungs and sometimes of the abdominal organs. Diagnosis. — The only disease for which there is danger of mis- taking eclampsia is epilepsy. M. Ozanam mentions the following means of distinguishing the two: "Eclampsia difiers from epilepsy in the frequent occurrence of prodromic symptoms ; the clonic form of the convulsions, the rare appearance of froth in the mouth, the absence of a hideous livid aspect of the countenance, the spas- modic and sobbing character of the respiration, frequency of the pulse, and a state of quiet without snoring which succeeds an attack." In the young child, however, the above points of dis- tinction are not reliable as a means of differential diagnosis. Some patients, who seem to have genuine attacks of eclampsia in infancy and childhood, prove to be epileptic in subsequent years. The usual period of eclampsia is prior to the age of eight years, and if convulsions occur after this age without apparent exciting cause, or from trifling causes, the disease is probably epilepsy ; if prior to the age of eight years, and especially of three or four, they are in the vast majority of cases the convulsions of eclampsia. PROGNOSIS. 377 It is often difficult to ascertain the form of eclampsia, whether essential, symptomatic, or sympathetic — in other words, to deter- mine the cause — till after the convulsions cease. This is especially true when, as is frequently the case, the physician is not sum- moned till the convulsive movements hegin, and it is necessary that he should act promptly, with but little knowledge of the child's previous history. If there is an obvious antecedent disease, as hooping-cough or meningitis, the cause is apparent ; but if the previous health has been good, or but slightly disturbed, it may be necessary to make more than one visit or examination in order to ascertain the scat and character of the cause. In the majority of cases of convulsions occurring suddenly in a state of previous good health, the cause is seated in the intestines, but sudden and unexpected attacks may be due to the commencement of some inflammatory affection, as pneumonia, or of a febrile disease, as smallpox. Unless the eclampsia is speedily fatal, the physician, if he examine carefully, will, in most cases, soon be able to ascer- tain the nature of the cause, and diagnosticate the form of the disease. Peognosis. — Symptomatic eclampsia is always serious. If con- vulsions occur in the course of a cerebral disease, it indicates the approach of death, but if at the commencement, some recover. The recurrence of it, whatever the cerebral disease, is an almost certain prognostic of death. In idiopathic or essential convulsions the prognosis depends on the severity of the attack, and on the age, strength, and previous condition of the child. If there are predisposing or co-operating causes, as a nervous or excitable temperament, or dentition, the prognosis is less favorable than when such causes are absent. In sympathetic eclampsia the prognosis varies greatly, according to the nature of the primary disease, and often according to the stao-e of that disease. If convulsions occur at the commencement of an eruptive fever, they generally subside without untoward symptoms, and the fever pursues a favorable course. Eclampsia, after the appearance of the eruption, is premonitory of a fatal result. I have not yet known a patient with scarlet fever recover who had convulsions after the rash had covered the body, and ex- perienced physicians of this city tell me that their observations correspond with mine. Dr. J. F. Meigs, however, relates one favorable case. If the cause of the eclampsia is located in or upon the mucous surfaces, a majority recover with judicious treatment. 378 ECLAMPSIA. In convulsions consequent on pneumonia or a burn, more die than recover. The prognosis in eclampsia is more favorable if the parallelism of the eyes is retained, the pupils remain sensitive to light, and consciousness soon returns. A fatal termination may be predicted, if, after the convulsion, the child remains stupid, without any evidence of returning consciousness. Treatjient, — Fortunately, inasmuch as the physician is often required to treat eclampsia in ignorance of the cause, the same measures are demanded, to a considerable extent, in all cases, whether the form be essential, symptomatic, or sympathetic. As early as possible in the attack the feet should be placed in hot water to which mustard is added, or, if it can be procured with little delay, a general warm bath may be used in place. This has a soothing effect upon the nervous system and promotes muscular relaxation, while it also produces derivation of blood from the cerebro-spinal axis. It is, therefore, useful, especially in those cases in which active or passive congestion precedes the eclampsia; it is also useful as a preventive of passive congestion and consequent oedema of the brain, lungs, and other organs, which are the most serious results of eclampsia. It should be continued from six to fifteen or twenty minutes, according to the severity and duration of the attack ; at the same time cold applications should be made to the head, until its temperature, which is usually increased, is reduced. The application of a cloth, fre- quently wu'ung out of cold water, is the most convenient and ready mode of employing this agent. Cold thus employed acts promptly in contracting the vessels of the brain and meninges, and diminishing the cerebral congestion. It tends, therefore, to remove one of the chief dans-ers. As a large proportion of convulsive attacks originate in the con- dition of the bowels, either solely or in part, it is advisable, unless there is a previous diarrhoial affection, to prescribe an aperient. The common enema of soap and water will usually produce a free and speedy evacuation, and will sometimes disclose the cause of the eclampsia in the expulsion of seeds, or other indigestible substances or scybala. A cathartic is also often required, especially if the enema fail to produce suilicient evacuations. In those that are robust, and especially in those beyond the age of two or three years, calomel is an excellent purgative, is easily given, and is prompt in its action. If the symptoms indicate intestinal inflam- mation, the milder purgatives, as castor oil, are preferable, as they TREATMENT. 379 also are in young or feeble children. Tf the recent ingesta of the patient consisted of fruit or of sul)stances of an indigestible character, an emetic is appropriate; a teaspoonful of the syrnp of ipecacuanha, repeated if necessary in fifteen or twenty minutes, may be given to a young (fluid, or this syrup in combination with hive syrup to one older and more robust. Aside from the ejection of the offending substance which it produces, an emetic has some effect in controlling the convulsive movements. Convulsions sometimes cease, apparently, in consequence of the muscular relaxation caused by the emetic. By such measures, or even without them, the attack usually terminates in a short time ; but if it continue, and there is considerable heat of head or other indication of active congestion of this organ, we may try compression of the carotids by the fingers, as recommended by Trousseau. This distino-uished observer believed that he succeeded in diminishing the afflux of blood to the brain, and thereby shortening eclampsia, by this simple expedient. Brown-Sequard (Remarks before the United States Medical Association, 1866) has stated that this result is due, not so much to compression of the carotid, as to pressure on the cervical portion of the sympathetic nerve, which (pressure) causes contraction of the cerebral vessels. If the convulsions do not cease by the employment of the measures recommended above, one or two leeches may be applied to the temples if the child is robust, and there is increased heat of face or head. The abstraction of blood directly from the head has the obvious effect of diminishing cerebral congestion, and has been the means of shortening the attack and saving life. Antispasmodics have been used for a long period in cases of eclampsia, and they are recommended in our standard works. I have never observed any benefit from the use in clonic convulsions of either assafoetida or valerian ; though I have occasionally ordered the use of such agents both by the mouth and by enema. Chloro- form, whether inhaled or swallowed, does control the convulsive movements. In protracted or frequently recurring eclampsia, especially when it is due to a highly sensitive nervous tempera- ment, and there is probabl}^ little or no cerebral congestion, this is one of the most reliable agents employed by inhalation, and it is not unsafe if cautiousl}^ used by the physician himself. It should be employed only in the convulsion, and withheld the moment the spasmodic movements cease. In symptomatic eclamp- sia, or in the other forms, if there are indications of cerebral congestion, I would not recommend its use. Dr. A. P. Merrill 380 ECLAMPSIA. {Amer. Journ. of 3Icd. Sei., Oct. 1865) gives chloroform hj the mouth in the treatment of this disease, and in doses which most practitioners would hesitate to prescribe. He has given even a teaspoonful at a dose, to a child a few years old, with satisfactory result. In most of those cases, however, in which chloroform is useful, the hydrate of chloral promises to be a safer and efficient substitute, and it is more easily administered. I have already S]3okcn of the employment of chloral in the convulsions of menin- gitis. The propriety of prescribing opium in any form of convulsive attacks in children is doubted by many on account of the drowsi- ness which it produces. There can be no doubt, however, of the propriety and the good effect of its use in certain cases of essential and of sympathetic eclampsia. I refer to those cases in which attacks of eclampsia occur with intervals during which there is no stupor, and the patient preserves consciousness. Opiates may occa- sionally be of service in other cases, but in such they are especially indicated. Thus, recentl}^, in my practice, an infant six weeks old, in whom there was an hereditary predisposition to eclampsia, was taken with diarrhcea, and soon after with convulsions. The attack was short, but after a brief interval it returned, and during the subsequent twelve hours there were about twenty convulsions. There was no unusual heat of head or prominence of the anterior fontanelle, or other evidence of cerebral congestion. The green and unhealthy appearance of the stools showed that the cause was located in the intestines. After trial of various remedies, among which were antispasmodics, these convulsive seizures were soon relieved by the use of paregoric in doses of five drops, which also had a salutary eftect on the cause of the eclampsia, and in a few days there was complete restoration to health. In recent times the attention of the profession has been directed to the bromide of potassium as a remedy in convulsive disorders. It is ordinarily prescribed alone, in powder or solution. I can speak favorably of its use in obstinate cases, not only in children approaching the age of puberty, but in infants, especially when the cause is obscure or beyond our reach. It produces a decided impres- sion on the nervous system, so as to diminish the liability to spas- modic aftectious. In the following interesting case, already alluded to, this agent was employed with the effect of relieving entirely the convulsive seizures, although the cause continued. On the 29th of January, 1866, I was asked to see an infant six months old, who, during the preceding week, had had an average of eight convulsions TREATMENT. 381 dail}^; eacli convulsion lasted about eight or ten minutes, and was general ; tlie child was nursing, and had no teeth, and no decided swellini!" of the gums. A careful examination could detect no cause, though the infant was fretful and seemingly in considerable pain. Some days subsequently it was observed to pass, with appa- rent pain, urine in less quantity than when in health, and occasion- ally tinged with blood. The cause of the eclampsia was therefore probably a vesical calculus. Various remedies were made use of till Februarj^ 1st, without diminution in the severity or frequency of the attacks ; when bromide of potassium was prescribed in half- grain doses every six hours. From February 1st to 3d there were two convulsions daily. On the 3d the medicine w^as given every .three hours, after which there was no further eclampsiji. The medicine was discontinued on the 7th. The infant nursed as usual, and its health seemed to be re-established, wath the excep- tion of those symptoms which indicated the presence of a calculus. Examination of the bladder for stone was deferred for a few days, when, about two weeks subsequently to the last convulsion, the infant died suddenly and unexpectedly. Though the result of this case was unfavorable, the controlling power of the bromide over the eclampsia was apparent. Those children who are subject to eclampsia from trifling causes, and sometimes w^ithout apparent cause, while their general health is good, are more benefited by bromide of potassium than by any other medicine. The etficacy of the bromide in epileps}- is well known, and in all those cases of eclampsia which aj)proximate epilepsy, and in which it is feared that the child will become ejii- leptic, this agent is preferable to all others. It may be given in doses of one grain to a child one year old, every three to six hours, and an additional half grain or grain for every subsequent year. R. Potass, bromid. gr. xvj ; Saccli. alb. 5ss ; Aq. anisi §ij. Dose, one teaspoonfiil every three to six hours, to a child of one year. The treatment of eclampsia obviously should vary in different cases, according to the cause. If it occur in an eruptive fever, as scarlatina, and the eruption has receded, active revulsive mea- sures, as hot mustard-baths, are required ; if in dysentery, or other internal inflammation, sinapisms should be applied over the affected part; if the gums are swollen, and the eclampsia is not readily controlled by the ordiuary measures, they should be scarified. In those dangerous cases in which symptoms of cerebral 382 TETANUS INFANTIUM. congestion continue after tHe eclampsia ceases, additional treat- ment is required. The child remains drowsy, does not speak, or apparently suiter in any way, and the pupils act less readily than in health. If this condition remains after the lapse of a few hours, there is probably serous eftusion. All attacks of eclampsia, unless the mildest, are followed by a period of drowsi- ness, but the persistence of it, with symptoms which indicate hyperemia, with perhaps eifusion within the cranium, calls for the employment of additional measures. Vesication should then be produced behind the ears, mild revulsives be applied to the extre- mities, the head kept cool, the bowels ojaen, and, in certain cases, a diuretic like iodide of potassium may be advantageously employed. The utmost care should be enjoined in reference to the hygienic management of those who are subject to eclampsia. The diet should be nutritious, but bland, and all causes of excitement be studiously avoided. CHAPTER XTI. TETANUS INFANTIUM. Tetanus or trismus is one of the most interesting diseases of infancy. It is lirst, in point of time, in the long catalogue of fatal maladies. It occurs suddenly and unexpectedly in the robust as well as feeble, almost certainly destroying life within a few hours under modes of treatment heretofore employed. It is more frequent in some localities and conditions of life than in others. In New York it is more common than tetanus at any other age, or, indeed, in all other ages, since the mortuary statistics of this city exhibit a larger number of deaths from this disease in the first year of life than subsequently. Infantile tetanus occurs, with very few exceptions, in the new-born. Interesting and important as is tetanus infantium, it must be confessed that our knowledge of it is much more limited and imperfect than it should be, when we consider what great advance- ment has been made in pathological inquiries during the present century. Our information in reference to its causation, symptoais, and proper treatment is not much in advance of that of M. Dazille, or Dr. Joseph Clarke, who lived in the latter part of the last century. Did we better understand the pathology of diseases in the new- born, or could we more accurately ascertain the condition of CASES. 383 organs ut this age, doul)tlcss we should occasionally consider those })henonKMia which we now designate as a disease per 6'c, under the title tetanus, as symptoms of some other aftection. But as tetanic rigidity and spasms in the now-born occur so abruptly, masking all other symptoms, and ordinarily ending in death without our knowing certainly whether or not there is any antecedent disease, it seems eminently proper that we should recognize the state in which such muscular rigidity occurs with such a rapid result as an independent affection. This explanation is required from the fact that I have added to the accompanying table one case from Billard, which this observer relates under the head of spinal meningitis. In this case, an infant three days old was attacked with convulsions. "His limbs were rigid and violently bent; the muscles of the face were in a continual state of contraction." On the following day " the convulsions continued ; . . . 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 immovable whenever the child was raised." At the autops}', in addition to meningeal apoplexy, which is often present in those who die of tetanus infantium a thick pellicular exudation was found upon the spinal arachnoid. There is, there- fore, a strict accordance of the symptoms and history of this case with those which other observers describe as examples of tetanus infantium ; moreover, as a satisfactory reason for including this case in our statistics, certain eminent observers, as we will see, have reported epidemics of tetanus in which meningitis was the princi- pal lesion. Fatal Cases. Case 1. Male; taken when three days old; lived sixt}^ hours. Labatt, Edin. Med. and Surg. Jourri., April, 1819. Female; taken when three days old; lived forty hours. Ibid. Taken when five days old; lived fifty hours. Ibid. Taken when three days old ; lived one da3\ Ibid. Male; taken when two days old; lived two daj's. Billard, Treatise on Diseases of Children, Stewart's trans., p. 471. Male; taken when three days old; lived two days. Romberg. Male; taken when six days old; lived ninety-three hours. Dr. Imlach, Month. Journ. of Med. Sci., Aug. 1850. " 8. Female; taken at five days; lived four days. Caleb Woodworth, M.D., Boston Med. and Surg. Journ., Dee. 13, 1831. " 9. Negro; taken at seven days; lived twenty-four hours. P. C. Gaillard, M.D., South. Journ. of Med. and Fhar., Sept. 1846. " 10. Male; taken when seven days old; lived one day. Augustus Eberle, M.D., Missouri Med. and Surg. Journ., 1847. (( 2. (I 3. (( 4. u 5. u 6. u 7. 384 TETANUS INFANTIUM. Case 11. Taken when seven days old. D. B. Nailer, N. 0. Med. Journ.^ Nov. 1846. " 12. Male; taken when three days old; lived one day. N. 0. Med. and Surg. Joiirn., Maj', 1853. " 13. Negro ; taken when three days old; lived three days. Robert H. Chinn, M.D., N. 0. Med. and Surg. Journ. " 14. Taken when two days old ; died in four hours after the doctor's visit. Ibid. " 15. Taken when seven days old; lived one day. C. 11. Cleaveland, Neio Jersey Med. Rep.., April, 1852. " 16. Negro; taken when seven days old; death finall}'. Greenville Dowell, Amer. Journ. of Med. Sci., Jan. 1863. " 17. Taken when twelve days old; lived one day. Thomas C. Boswell communicated to Dr. Sims, Amer. Journ. of Med. Sci., 1846. " 18. Taken when about five days old; died at about the age of nine days. B. R. Jones. Ibid. " 19. Taken at or soon after birth ; lived two days. Dr. Hims, Amer. Journ. of Med. ScL. April, 1846. 20. Taken at the age of six days ; lived one day. Ibid. 21. Taken when three days old; lived two days. Ibid. 22. Male; taken at the age of eight daj's; died in three hours. Communicated to the writer. 23. Talven at the age of twelve hours ; lived two days. Communi- cated to the wa-iter. 24. Female; taken when seven days old; lived forty-five hours. The writer. " 25. Male; taken at the age of seven days; lived about fortj'-eight hours. Ibid. " 26. Female ; taken at the age of eight days ; lived three days. Ibid. " 21. Female; taken at the age of five days; lived three daj^s. Ibid. " 28. Female ; taken when four da3^s old ; lived tw^o days. Ibid. " 29. Taken when six days old ; died next da}'. Ibid. " 30. Taken when five days old ; lived twenty-four hours. Ibid. " 31. Taken when eight days old ; lived two days. Ibid. " 32. Male; taken when five daj's old; lived one day. Ibid. Favorable Cases. Case 1. Negro; female; taken when three days old; recovered in a few days. Robert S. Baily, Charleston Med. Journ. and Rev.., Nov. 1848. " 2. Negro ; taken at eleven days ; recovered in fifteen days. W. B. Lindsay, N. 0. Med. Journ.., Sept. 1846. " 8. Negro; taken when ten days old; recovered in thirty-one days. P. C. Gaillard, Charleston Med. Journ. and Rev.., Nov. 1853. " 4. Male ; taken at the age of eight days ; recovered in twenty-eight days. Ibid. " 5. Negro; taken at seven days; recovered in fifteen days. Au- gustus Eberle, Missouri 3Ied. and Surg. Journ., 184Y. " 6. Taken when eight days old; recovered in four weeks; Furlong, Edin. Med. and Surg. Journ., Jan. 1830. a ^-u FREQUENCY IN CERTAIN LOCALITIES. 385 Case T. Taken at the age of one week; recovered in two days. Dr. Sims, Amer. Journ. of Med. Sci., April, 1846. " 8. Female ; taken at the age of three days; recovered in five weeks. The writer. Period of Commencement. — Finckh, who saw cases of tetanus of the new-born in the Stuttgart Hospital, states {Hecker's Annalen, vol. ill. No. 3, p. 304) that it began in one case on the second day after birth, in eight on the fifth, and in seven on the seventh. Professor Cederschjold, of Stockholm, treated forty-two cases in hospital practice in 1834, and in these cases it usually com- menced between the ages of four and six days. Copland says [3Iedi- cal Dictionary) that it generally commences in the first seven or nine days after birth, and rarely later than the fourteenth. Rom- berg states that it commences between the fifth and ninth days. In two hundred cases observed by Reicke, in Stuttgart, in the course of forty -two years, it was never found to commence before the fifth, rarely after the ninth, and never after the eleventh day. Schneider says that the disease occurs oftenest between the second and seventh, and rarely after the ninth day. In six cases reported by Dr. C. Levy, of Copenhagen, it began in two on the third day, in two on the fifth, and in two on the sixth. Dr. Greenville Dowell {Amer. Journ. of Med. Sci.., Jan. 1863), who has seen much of tetanus infantum among the negroes in Mississippi and Texas, says it is almost sure to come on between the fifth and twelfth days after birth. In the forty cases embraced in the above table, the disease began as follows : — Age. Cases. Age. Cases One day or imder . . 3 Seven days . 8 Two days . 1 Eight " . 6 Three " . 9 Ten . 1 Four " . . . 2 Eleven " . 1 Five " . 6 Twelve " . 1 Six " . 3 Very rarely, as will be seen hereafter, tetanus begins at or soon after birth, that it may be properly called congenital. Frequency in Certain Localities. — Tetanus infantum occurs probably in all countries, but it does not greatly increase the mor- tality except in certain localities. Some of the British and conti- nental physicians whose observations of disease have been ample, confess that they have seen so few cases that they have almost no personal knowledge of this aftection. On the other hand, there are, or have been, places in every zone where it is or has been so 25 386 TETANUS INFANTUM. prevalent as to sensibly check the increase of population. The attention of the profession, more than half a century since, was directed to the prevalence of tetanus in the Island of Heimacy, off the coast of Iceland. On this island scarcely an infant escaped, while on the mainland scarcely one was affected. Heimacy, the product of volcanic action, of small extent and almost destitute of vegetation, supports a scanty pojDulation. The inhabitants live chiefly on the flesh and eggs of the sea-fowl, and are filthy and degraded in their habits. About the year 1810, the Danish government deputed the landphysicus of Iceland to visit Heimacy, and ascertain the nature of the disease which was so destructive to the infants. Although this gentleman, from his brief stay, saw no case himself, he obtained interesting particulars in reference to the disease from the priests and parents. At this time scarcely an infant escaped. Again, according to Dr. Schleisner, whose report in reference to the same locality was published forty years later, this disease was still the most fatal of all infantile affections. Tetanus infantum is also represented as very fatal in the Island of St. Kilda, off the coast of Scotland. In the temperate regions of America and Europe cases are not frequent, except occasionally in the poor quarters of the cities, in foundling hospitals, and rarely in country towns where the conditions are favorable for its occurrence. The records of the Dublin, Stuttgart, and Stock- holm lying-in asylums furnish many cases. In the town of Fulda, Germany, in 1802, Dr. Schneider saw six cases in fourteen days, while a midwife in the same place stated that she had seen more than sixty in nine years. But the greatest mortality from tetanus infantum is in the warm climates, both of the Eastern and Western Hemispheres. In the AVest Indies, the southern portion of the United States, the equa- torial regions of South America, and in the islands of Minorca and Bourbon, it has, in many localities, been the most frequent and fatal of infantile maladies. It is an interesting fact that in the warm regions of the United States the victims are chiefly negro infants. L. S. Grier, M.D., of Mississippi, says, in the N. 0. Med. and Surg. Journ.^ May, 1854 : "The first form of disease which assails the negro among us is trismus. The mortality from this disease alone is very great, l^o statistical record, we suppose, has even been attempted, but from our individual experience we are almost willing to affirm that it decimates the African race upon our plantations within the first week of independent existence. We have known more than one CAUSES. 387 instance in which, of the births for one year, one-half became the victims of this disease, and that, too, in spite of the utmost watcli- fuhicss and care on the part of both planter and physician. Other places are more fortunate, but all suffer more or less ; and the planter who escapes a year without having to record a case of tris- mus nascentium may congratulate himself on ])eing more favored than his neighbors, and prepare himself for his own allotment, which is surely and speedily to arrive." Dr. Wooten (iV. 0. Med. and Surg. Journ., May, 1846) says: "It is a disease of fatal fre- quency on the cotton plantations in this section of Alabama." He has, however, never seen a white child affected with it. In I^ew Orleans, according to the death statistics in our posses- sion, which, however, relate to only one year, tetanus infantum is the most fatal of all diseases except phthisis. Mr. Maxwell says, in the Jamaica Physical Journal (copied in the Lo7idon Lancet., April 11th, 1835): "From observations, that I have made for a series of years, ... I found that the depopulating influence of trismus neonatorum was not less than twenty-five per cent. It scarcely has a parallel within the bills of mortality." This gentle- man's observations relate to the "West Indies. Similar statements are made in reference to this disease as it occurs in Cayenne and Demerara in South America. While tetanus infantum prevails in regions wide apart, and presenting very diverse climatic conditions, there is a similarity as regards the personal and domiciliary habits of the people who suffer most from its occurrence. It occurs chiefly among those who are filthy and degraded in their habits, who live, either from choice or necessity, in neglect of sanitary requirements. This fact aids us in an understanding of the Causes. — That uncleanliness and impure air are a cause of tetanus is as fully demonstrated as most facts in the etiology of diseases. The attention of the profession was forcibly directed to this cause by Dr. Joseph Clarke in a paper read before the Royal Irish Academy in 1789. This physician was in charge of the Dublin Lying-in Asylum, and had rightly concluded that the mortality among the new-born infants was due to imperfect venti- lation. Through his advice, apertures, twenty-four inches by six, were made in the ceiling of each ward; three holes, an inch in diameter, were bored in each window-frame; the upper part of the doors leading into the gallery were also perforated with sixteen one-inch apertures, and the number of beds was reduced. The result of these simple sanitary regulations may be seen from Dr. 888 TETANUS INFANTUM. Clarke's own statement. He says: "At the conclusion of the year 1782, of 17,650 infants born alive in the Lying-in Hospital of this city, 2944 had died within the first fortnight, that is, nearly every sixth child." The disease in nineteen cases out of twenty was tetanus. After the wards were better ventilated, namely, from 1782 till the time of the preparation of Dr. Clarke's paper, 8033 children Avere born in the hospital, and only 419 in all had died, or about one in nineteen. So impressed was Dr. Evory Kennedy, who at a later period had charge of the same asylum, with the belief that Dr. Clarke had discovered the true cause, and had been able in a great measure to jirevent it, that he writes in his enthu- siastic way : " If we except Dr. Jenner, I know of no physician who has so far benefited his species, making the actual calculation of human life saved the criterion of his improvements." The cases occurring in my own practice were all met in tenement- houses or shanties, where habits of cleanliness are impossible, and I have not yet seen, in the practice of others, nor heard of a case which occurred in the better class of domicils. The statements of physicians in the southern States, who speak from extensive observation among the negroes, are strongly corroborative of the idea that the disease is in great measure due to uncleanliness and impure air. Dr. Greenville Dowell, of Texas, states that he has been able to trace the disease to the old bedclothes, saturated with excrementi- tious matters, which are found in the negro cabins. In a paper published in the Nashville Journ. of Med. and Surg., June, 1851, by Prof. John M. Watson, the frequency of this disease among the negroes is accounted for as follows: — "When called to see their children, we find their clothes wet around their hips, and often up to their armpits, with urine The child is thus presented to us, when, on examination, we find the umbilical dressings not only wet with urine, but soiled, like- wise, with fpeces, freely giving oft' an ofliensive urinous and frecal odor, combined at times with a gangrenous fetor arising from the decomposition, not desiccation, of the cord." Another cause is believed to be some irritation in the bowels, iis from retained meconium. Observers in the southern States and elsewhere occasionally mention this as a cause. In one case treated by myself, there was obstinate constipation immediately before the attack, and in another diarrhoea preceded, and was the only apparent cause. In certain cases the assignable cause is exposure to wet or cold, or CAUSES. 389 to a variable temperature, which, it is known, occasionally, causes tetanus in the adult. Prof. Ceclerschjold attributed the epidemic which he observed in Stockholm to a sudden change of temperature, from hot weather in May, to frosty in June. In a case related by Dr. P. C. Gaillard, in the Southern Journ. of Med. and Pharmacy^ Sept. 1846, the disease commenced as follows: The nurse came in with wet apron and clothes, in the evening; a short time after she had taken the child into her lap, it sneezed violently two or three times. At 10 P. M. tetanus began. In certain localities on the continent, where there are no parish churches, the frequent occur- rence of tetanus has been attributed by the physicians to the practice of carrying the infants to a distance to be christened, thus exposing them to the wind and often rain. Even in this city I have observed the same cause. The influence of the weather in the production of tetanus of the new-born is also shown by facts observed in the Stuttgart Hospital. In an aggregate of twenty- five cases treated in that institution, all but three occurred in the cold months. In the island of Cayenne, at a hamlet surrounded by mountains and dense forests, tetanus attacked only one in everj^ twelve or fifteen of the infants. After a great part of the forests had been cut down, so as to allow access to the cold sea winds, almost all the new-born infants fell victims to tetanus. (Insel, Cayenne.) Hein relates that a citizen of Berlin lost, successively, two children with tetanus soon after birth. When the second child fell ill, he observed that its cradle was exposed to a current of air. At the third accouchement the position of the cradle was changed, and the infant escaped. Exposure to wet and cold has been long recognized as a cause of the disease. According to Sauvages, "Hie morbus hieme et cum aura humida ssepius advenit quam sicca restate." (Nosol. Method, vol. i. p. 531.) The causes of infantile tetanus, enumerated above, may be proxi- mate or remote, may produce the disease by their direct effect on the system or by producing a pathological state which in turn leads to the development of the disease. There are other direct causes, namely, organic affections. In the bodies of those who die of this disease lesions are observed which doubtless result from the spasms. Again, others are found, which, from their nature, could not be a result, and which, being observed in different cases, are to be regarded as direct causes. The most frequent of such lesions is inflammation of the umbilicus or umbilical vessels. Moschion, who lived in the first century of the Christian era, 390 TETANUS INFANTUM. stated in writinojs still extant that stagnant blood in the umbilical vessels sometimes produced dangerous disease in the new-born infant, and it is supposed, though this is doubtful, that he referred to tetanus. In modern times the attention of the profession was more particularly directed to this cause by a paper j^ublished by Dr. Colles, in the first volume of the Dublin Hospital Re-ports^ in 1818. The observations published in this paper were made in the Dublin Lying-in Hospital during the period of five years. In each of these years he had witnessed from three to five post-mortem examinations in cases of infantile tetanus, and the lesions, he states, were in all much alike as follows : The floor of the umbilical fossa was lined by a membrane apparently formed by suppurative inflammation, and in the centre of this fossa was a large papilla. This papilla consisted of a soft yellow substance, apparently the product of inflammation, and in all the cases the umbilical vessels were in contact with this substance and were pervious. In a few instances superficial ulcerations were found near the mouth of the umbilical vein, and occasionally the skin surrounding the umbilicus was raised. The peritoneum covering the vein was highly vascular, often not to a greater distance than an inch above the umbilicus, but sometimes as far as the fissure of the liver. The peritoneum in the course of the umbilical arteries presented the inflammatory appearance in still greater degree sometimes as far as the sides of the bladder. The connective tissue lying along the arteries and urachus anteriorly was loaded with a yellow watery fluid. The inner surface of the umbilical vein was not inflamed, but its coats, in general, were thickened. On slitting open the arteries, a thick yellow fluid, resembling coagulable lymph, was found within their coats, and in all cases these vessels were thickened and hardened as far as the fundus of the bladder. Dr. Finckh, who observed twenty-five cases in the Stuttgart Hospital, believes that the most frequent cause was suppuration or ulceration of the umbilical cord. In ten of the twenty-five cases the navel was dry and cicatrized; in the remainder it was either wet or swollen, with a bluish-red inflamed edge at the margin of the navel; a dirty viscid pus covered the umbilical depression. Dr. Levy, physician of the Foundling Hospital in Copenhagen, attended twenty-two cases in that institution in 1838 and '39. Of these, twenty died, and fifteen were examined carefully after death. In fourteen there were decided marks of inflammation in the umbilical arteries, especially those portions lying along the CAUSES. 391 urinary bladder; in several cases the peritoneum over the arteries was much injected, and in three adherent either to the omentum or intestine by coagulable lymph ; the coats of the arteries were thickened, their cavities dilated and containing dark reddish-brown or greenish puriform matter, always fetid. Sometimes the arterial tunica interna was found ulcerated and absent in places, and there was spongy thickening of the subjacent connective tissue. In two cases the ulcerative process had extended from the tunica interna to the peritoneum, and there was a deposit of thick ichorous matter around the ulcer ; in one case both arteries were so softened that their coats were scarcely distinguishable, and in another these vessels had become gangrenous. The appearance of the umbilicus was unchanged in four cases ; in ten the fundus was red and filled with puriform fluid, which quickly reappeared when removed, and, in general, shortl}^ before death the navel presented a greenish color. According to Romberg, Dr. Scholler made post-mortem examina- tions in eighteen cases of tetanus infantum, and in fifteen found inflammation of the umbilical arteries. These vessels were swollen near the bladder, in one case to the diameter of four lines, and were found to contain pus. The lining membrane was eroded or covered with an albuminous exudation. Both arteries were not always equally inflamed, and in three cases only one was aflfected. Schneeman found minute points of suppuration in the umbilical vein in eight cases {Holscher''s Annalen^ vol. v. p. 484, 1840), and pus throughout the course of this vessel in one. The observations mentioned above were made, for the most part, in hospitals on the Continent ; but similar observations have been made in private practice. M Boiran, of the Isle of Bourbon, says that he has found in every case inflammation around the umbilicus {Gazette Medicate, Paris, July 11, 1841). Dr. John Furlonge {Edin. Med. and Surg. Jourji., Jan. 1830), who resided at St. John's, Antigua, attributes the disease to improper dressing of the umbilicus. The same opinion is expressed by Mr. Maxwell, who also saw the disease in the West Indies (Jamaica Phys. Joiirn., copied into the London Lancet., April 11, 1855). Dr. Ransom states, in a communication to Prof. John M. Watson {Nashville Journ. of Med. and Surg., June, 1851) that he has never seen a case of tetanus of the new-born in which the umbilicus was healthy. In a case related by Robert S. Baily, in the Charleston Med. Journ. and Rev., l^ov. 1848, there was a hard scab on one side of the umbilicus, and this part was much distended. A discharge fol- 292 TETANUS INFANTUM, lowed the removal of the scah, and the child recovered. In a favorable case, related by W. B. Lindsay, in the N. 0. Med. and Surg. Joiirn., Sept. 1846, the umbilicus was tumid, and not disposed to heal. Dr. II. 0. Wooten (same journal. May, 1846) attributes the disease to the condition of the umbilicus and umbilical vessels, and states that he has found the umbilicus gangrenous. In a case related in the N. 0. Med. and Surg. Jour7i., May 1, 1853, the um- bilical vessels were blocked up by purulent matter. Robert A. Chime, M.D., Brazoria, Texas {N. 0. Med. and Surg. Jouni., Sept. 1854), believes one cause of the disease to be improper tying and management of the umbilical cord, by which a diseased state is produced, which extends to the umbilicus, and thence to the vis- cera. At a meeting of the Obstetrical Society of Edinburgh, held April 24, 1850, Dr. Imlach related a case in which there was a dark and gangrenous appearance of the integument around the um- bilicus, and the peritoneum underneath was also dark, but not inflamed ; umbilical vein healthy ; a little fibrin in the left um- bilical artery; right umbilical artery much diseased; its two inner coats apparently destroyed, and in their place a yellow pultaceous slough, in which pus-globules were discovered with the micro- scope. It is evident that the pathological state of the umbilicus and umbilical vessels described above, and which has been noticed by so many observers in difterent countries, cannot result from the tetanus. It is possible that the puriform substance noticed in the umbilical vessels was disintegrated fibrin, which had coagulated at the time of ligation of the cord, and the cells seen by Dr. Imlach and others may sometimes have been white corpuscles still remaining from the stagnated blood. {Virchow's Cellul. Pathol.) Still, the evidences of inflammation, in at least a part of the cases related above, were of a positive character. The belief that umbilical lesions sometimes cause tetanus in- fantum comports with the well-known traumatic causation of teta- nus in the adult. This belief is strengthened by the fact, which will appear further on in our remarks, that this disease of the new- born, from being frequent in certain localities, has become infre- quent through greater care in dressing and managing the umbilical cord. But there are cases of tetanus infantum in which there is no disease in or about the umbilicus. Dr. Pinckh, of Stuttgart, examined the umbilical vessels in eleven cases without discovering any pathological change. Dr. Samuel B. Labatt, master of the CAUSES. 39 Q DulJliii Lying-in Hospital, i^nblished in the Edin. 3Ied. and Surg. Joujii., April, 1819, a ])[iper entitled "An Inquiry into an Alleged Connection between Trismus JSTascentium and certain Diseased Appearances in the Umbilicus." This paper was designed as a reply to the essay of Dr. Colles. Dr. Labatt relates several cases in which there was no disease of the umbilicus and umbilical vessels, and others in which the disease was so slight that it probably pro- duced no injurious eftect on the health of the child. Dr. James Thompson, who spent considerable time in the tropical regions, says [Edin. 3Ied. and Surg. Journ., Jan. 1822) : " I have myself examined nearlj^ forty cases of infants that have sunk under this complaint. In many I have looked at no other part but the navel, and have found it in all states ; sometimes perfectly healed, espe- cially if the infants had lived several days ; at other times a simple clean wound. When death occurred on the fifth or sixth day, the \vound was frequently in a raw state. I never yet saw" it in a sphacelated condition." This writer concludes from his observa- tions that there are cases in which the cause is located elsewhere than in the umbilicus or umbilical vessels. In the Eub. Joiirn. of Med. and Chem Sci., Jan. 1836, Dr. John Breen remarks: " From dissections . . . we have never been able to discover any peculiar morbid appearance which would justify us in offering any explana- tion of the pathology of the disease." In my own cases there was no evidence of disease of the umbilicus or umbilical vessels so far as could be ascertained by external examination, and in one (I^o. 32) a careful post-mortem examination disclosed no lesion of these parts. The inference from the above observations is that, although umbilical disease may be an occasional, probably not infrequent, cause of tetanus infantum, cases occur in which such disease is not present, and we must look for the cause elsewhere. From the nature of tetanus infantum, the cerebro-spinal axis has been from time to time examined in those who have died of this disease, and occasionally sufficient cause has been found in this part of the system. I have alluded in another connection to a case from Billard, in which tetanic rigidity occurred in an infant three days old, as the result of spinal meningitis. That tonic spasms not infrequently occur in older children in consequence of meningeal inflammation is well known, and in some of the reported epidemics of infan- tile tetanus meningitis was really present, and was doubtless the cause of the tonic spasms. Such an epidemic was observed by 394: TETANUS INFANTUM. Professor Cederschjold in Stockholm, in 1834. "Within a few months he treated forty-two cases, and, in addition to the lesions which are known to result from tetanus, there was found in the bodies examined a plastic exudation at the base of the brain. Finckh, of Stuttgart, made twenty post-mortem examinations of those who had died of this disease, and in nine found spinal menin- geal inflammation. Meningitis in the new-born infant is, however, rare, and we must regard it as an exceptional cause of tetanus. In 1846 there appeared from the pen of Dr. Sims, then practis- ing at Montgomery, Alabama, a paper designed to show that tetanus of the new-born is produced by pressure exerted on the ner- vous centre, through depression of the occipital bone. In 1848 the same writer published a second paper, also in the Amer. Journ. of Med. Sci., fully enunciating his theory as follows: "That trismus neonatorum is a disease of centric origin depending on a mechani- cal pressure exerted on the medulla oblongata and its nerves; that this pressure is the result, most generally, of an inward displace- ment of the occipital bone, often very perceptible, but sometimes so slight as to be detected with difficulty ; that this displaced con- dition of the occiput is one of the fixed physiological laws of the parturient state ; that when it persists for any length of time after birth it becomes a pathological condition, capable of producing all the symptoms characterizing trismus neonatorum, which are in- stantly relieved simply by rectifying this abnormal displacement, and thereby removing pressure from the base of the brain." In both papers cases are narrated in support of this theory, but there are serious objections to this mode of explaining the occurrence of the disease. In the first place, if this explanation were correct, tetanus ought ordinarily to occur sooner, for the occiput is as much depressed previously, and in the majority of cases more depressed than at the period when it does actually commence. Pressure on the medulla would certainly be followed by immediate and marked symptoms, instead of an immunity for four or five days. Again, well-known facts in reference to the causation of teta- nus infantum conflict with Dr. Sims's theory, as, for example, epi- demics of the disease, its prevalence in one locality and absence in another, although no particular attention is given to the position of the infant, the diminution of the number of cases by greater attention to cleanliness, of which there is abundant proof. More- over, there are many reported cases of this disease at the commence- CAUSES. 395 ment of which there was no perceptible displacement of the occipital bone. The inequality of the cranial bones often observed in tetanus infantum should, in my opinion, be explained as follows: When the new-born infant becomes emaciated, the volume of the brain is diminished, like that of the trunk or limbs, and the sinking of the occipital bone simply corresponds with the amount of waste in the cerebral substance. Whatever the disease in the young infant, if there is much emaciation, the parietal bones will usually be found more prominent than the occipital. Now, in fatal tetanus infantum, emaciation is very rapid; those fleshy and plump, if the disease do not speedily end, become pinched and wrinkled. Viewed in this light, the occipital depression should be regarded as a result, and not cause, of the tetanus. Although we do not accept the theory which attributes tetanus infantum to occipital depression, there are a few cases on record in which it was apparently due to injury of the head received at birth. Dr. Sims has related one such case, that of a negro infant. The mistress, an observing lady, gave to Dr. Sims the following account of it: Its head was "mightily mashed The bones seemed to be loose. I got it to take a little boiled milk on the first day; but it swallowed very little and very badly, for its jaws seemed to be locked. On the next day it took spasms and got stiff all over ; its hands were shut up tight, and its arms were bent up so (she placed her forearms at right angles). Every time I touched it the spasm would get worse all over, screwing up its face till it was the ugliest thing in the world; and when the spasms wore off it looked as well as any other new-born baby. But then the stiffness never left it, and the spasms kept coming and going- till it died." It lived two days. It is evident, from the description given by the mistress, that this was a case of tetanus commencing at or so soon after birth that it seemed almost congenital. The apparent cause was injury of the head, occurring in consequence of protracted birth, the infant being resuscitated with difiiculty after several minutes. Dr. W. C. Sutton published a similar case in the Nashville Journ. of Med. and Surg., April, 1853. The infant at birth was apparently dead, but was resuscitated so as to live eighteen hours in a state of tetanic rigidity. In cases in which tetanus begins at birth, doubt- less, the cerebro-spinal axis is in some Avay affected ; but in the ab- sence of post-mortem examinations, the exact nature of the lesion is uncertain. 896 TETANUS INFANTUM. It IS evident, therefore, that in this disease, as in eclampsia, the cause in different cases may be entirely distinct. Dr. James John- son, many years aojo, expressed his belief in the multiplicity of causes, and he had been a careful and intelligent observer in the West Indies. The causes may be arranged in two groups, one external, the other internal. In the first group should be placed imperfect ventilation, personal and domiciliary uncleanliness, and atmospheric vicissitudes ; in the second group, so far as ascertained, inflamma- tion of the umbilicus and umbilical vessels, meningitis, and, rarely, injury of the cerebro-spinal axis during birth. The lesions resulting from tetanus infantum pertain chiefly to the circulatory system. In the cases examined by Prof. Ceder- schjold, of Stockholm, already alluded to, the meningeal and cerebral vessels, and those of the spinal cord, the cavities of the heart, and the large vessels connected with the heart, were dis- tended with blood. Finckh made post-mortem inspection of twenty cases in the Stuttgart Hospital, the bodies, at death, having been placed on their faces, in order to prevent any deceptive apjjearance from the gravitation of blood. In four there was no appreciable altera- tion in the spinal cord or its membranes. In the remaining six- teen there was eff'usion of blood, in considerable quantity, the wnole length of the spinal cord, between the bony walls and the dura mater. It should be stated, however, that there was spinal meningeal inflammation in nine of the sixteen, though the extra- vasation did not, probably, result from the inflammation, but from the tetanus. The blood in Finckh's cases was very dark, some- times fluid, at other times coagulated. In one case there was no change in the appearance of the brain or its membranes. In the remaining nineteen, more or less extravasated blood was found on the surface of the brain, or in its interior. The substance of the brain was healthy, as also its membranes, except the congestion. The only abnormal appearance observed in the thoracic and abdominal viscera was strong contraction of some portion of the intestinal tube in five cases. Dr. West says: "The most frequent post-mortem appearance in these cases" — referring to tetanus infantum — "and that which I found in the bodies of all the four children whom I observed, consists of eft'usion of blood, either fluid or coagulated, into the cellular tissue surrounding the theca of the cord. Conjoined with this there is generally a congested state of the vessels of the spinal arachnoid, and sometimes an eflu- CAUSES. 397 sion of blood or scrnni into its cavity. The signs of congestion about the head are less constant, though much oftener present than absent, and sometimes existing in an extreme degree; while in one instance I found not merely a highly congested state of the cerebral vessels, but also an effusion of blood, in considerable quantity, between the skull and dura mater, and also a slighter effusion into the arachnoid cavity." Dr. Weber, of Kiel, also placed infants who had died of tetanus on their faces, and, with- out exception, found injection of the capillaries of the cord and spinal meninges, and extravasation of blood. M. Matuszynski, according to Bouchut, "has observed effusions of blood, of variable quantity, in the cerebral pia mater, in the ventricles, and in the choroid plexuses, with considerable injection of the membranes of the brain. He has also seen serous infiltration beneath the arach- noid, and serous efllision into the ventricles, accompanied by a diminution of the consistence of the cerebral substance." In two cases examined by myself, there was intense injection of the cere- bral meninges, and of the meninges of the upper part of the spine, but no extravasation was noticed. The spinal canal was not opened. In a third case, in which the spinal canal was opened, there was extravasation in achlition to the congestion ; this was especially observed along the spinal theca. Dr. II. 0. Wooten {N. 0. Med. and Surg. Journ.^ May, 1846) states that he has made several post-mortem examinations, and has found the pathological appearances as uniform as in any other disease, as follows : " Engorgement of the substance of the brain, and of the meninges lining the base of the brain, the medulla oblongata, and spinal marrow; liver congested." In a case related by Dr. Imlach before the Edin. Obst. Soc, April 24, 1850, the upper part of the lungs was healthy, the poste- rior portion congested, and containing many dark points ; heart and liver healthy ; small intestines of a light-brown color; stomach and large intestines pale; there had been umbilical hemorrhage. Romberg states that he found in a child, whose death occurred from this disease, such intense congestion of the veins and sinuses of the brain, that a slight touch, and the removal of the cranial bones, produced extravasation of the partly coagulated and partly fluid blood. Dr. Scholler, on the other hand, found actual extrava- sation of blood in the spinal canal in only one case in eighteen. It is seen from the above observation, that tetanus of the infant is ordinarily accompanied by great passive congestion, which is 398 TETANUS INFANTUM. especially marked in the cerebro-spinal axis, and that frequently extravasations occur from the distended capillaries. The embar- rassment of respiration and the retarded circulation of blood con- sequent on the tetanic rigidity aitbrd sufficient explanation of this state of the vessels. Symptoms. — In many cases premonitory symptoms are absent, or are so slight as to escape notice. Sometimes there is a degree of fretfulness previously, but no more than is often observed in those who continue in good health. The fi.rst symptom which alarms the parents, and shows the grave nature of the commenc- ing disease, is inability to nurse, or evident pain and hesitation in nursing. Commencing with rigidity of the masseters, the dis- ease gradually extends to the other voluntary muscles, and in the course of a few hours the muscles of the limbs, as well as of the trunk, are involved. Persistent muscular contraction, which is the pathognomonic feature of infantile tetanus, is developed not fully in the beginning, but by degrees in each affected muscle, so tliat it is not till after the lapse of several hours, perhaps even a day, that the greatest amount of rigidity is attained. Therefore, in the commencement of the disease, the limbs can be bent, and the jaws pressed open, more readily than at a subsequent stage, though with manifest pain to the infant. During the period of maximum rigidity, the jaws are fixed almost immovably, often with a little interspace between them, against which the tongue presses, and in which frothy saliva col- lects. The head is thrown backward and held in a fixed position by the stiffness of the cervical muscles. The forearms are flexed ; the thumbs are thrown across the palms of the hands, and are firmly clenched by the fingers ; the thighs are drawn towards the trunk ; the great toes are adducted, and the other toes flexed. Oc- casionally opisthotonos results from the extreme contraction of the dorsal and posterior cervical muscles. The infant can sometimes be raised without any yielding of the muscles, by one hand under the occiput and the other under the heels. The rigidity is liable to variation in its intensity, even after the full development of the disease. If the infant is quiet, especially if asleep, the muscles are partially relaxed to such an extent, some- times in the first stages of the complaint, that the features have a placid and natural expression, though only for a short time. There are frequent exacerbations in the muscular contraction, sometimes occurring without any apparent cause, and sometimes produced by anything which excites or disturbs the child. Attempts to open SYMPTOMS. 899 the lips or jaws, or eyelids, or to bend the limbs, blowing on the face, or even the crawling of a fly upon it, occasions the paroxysm. During the paroxysm the eyelids are forcibly compressed, as well as the lij)s, which are either drawn in or are pouting; the forehead and cheeks are thrown into wrinkles, and the physiognomy is indicative of great suffering. The unnatural positions of the trunk and limbs, which result IVom the muscular contraction, are increased for the moment ; the head is more forcibly thrown back, and the limbs more strongly flexed. The muscular movements which occur during the paroxysms are sometimes described as clonic spasms. There is indeed occasionally some quivering of the limbs, and yet, as I have on different occasions noticed, so far from the muscular action being a clonic spasm, it possesses a tonic cha- racter, which is at times intensified. In fatal cases the paroxysms occur more and more frequently until the period of collapse. The crying of the child affected by tetanus is never loud, how- ever great the suffering. It is variously described by writers as "whimpering" or "whining." It is of this suppressed character in consequence of the rigid state of the respiratory muscles and their imperfect movement. During the exacerbation respiration is suspended, or so imper- fect, and the circulation so retarded, that the surface becomes of a deep red, almost livid, color. Sometimes epistaxis occurs, affording partial relief to the congestion, and sometimes, though less fre- quently, the blood forces itself from the congested liver along the umbilical vein, and escapes from the umbilicus. I have already alluded to the occurrence of meningeal apoplexy. The frequency of the pulse and respiration varies in different cases, and at different stages of the same case. They are often somewhat accelerated, but at other times are natural, or are even slower than in health. "While the appetite of the infant, to appearance, is not dimin- ished, the pain which it experiences in nursing is such that alimentation is necessarily deficient. It can be fed with a spoon for a time after it ceases to take food in the natural way, but arti- ficial feeding soon fails. The milk placed in its mouth is in great part pressed back through the violence of the spasm which is induced by the attempt to feed it. In consequence of imperfect nutrition, the infant rapidly wastes away. There is no other disease except the diarrhoeal affections in which emaciation is so rapid. In a case related by Dr. W. B. Lindsay in the N. 0. Med. Journ., Sept. 1846, the record states 400 TETANUS INFANTUM. that "the infont was fat three clays before, but was now emaci- ated." Romljerg, who saw tetanus infantum in European hospi- tals, and Dr. Robert H. Chinn, of Texas {N. 0. Med. and Surg. Journ.^ Sept. 1854), both speak of the rapid emaciation. The trunk and extremities lose their fulness, and the features become pinched. Several observers have noticed the appearance of miliaria in this reduced state of system, especially around the shoulders, and some- times a decidedly icteric hue appears on the skin. The condition of the bowels is not uniform. They may be relaxed, particularly if the disease is due to some irritation in them ; in other cases the stools are natural or constipated. It is often difficult to ascertain the state of the eyes, since attempts to open the eyelids bring on spasms and cause firm compression of the lids against each other. According to Sir Henry Holland, one of the first symptoms w^hich occurred in cases on the island of Heimacy, was strabismus, with rolling of the eyes. But this statement must be received with caution, since these cases were not seen by any physician, and the information was obtained from the parents and priests. If true, the proximate cause of the disease in Heimacy would seem to be located in the cerebro-spinal axis. Contraction of the pupils commonlj^ occurs in the stage of collapse. Mode of Death. — Death in infantile tetanus may occur from apnoea in the paroxysms, from extreme congestion of the cerebral vessels, or apoplexy ; and, lastly, it may occur from exhaustion. The last mode is, probably, the most frequent. Prognosis. — All waiters till recently agree that tetanus of the infant rarely terminates favorably. Cullen attributes the ignorance of physicians in regard to this disease to the fact that it is so little amenable to treatment, that they are not usually summoned to attend those affected w^ith it. In the island of Heimacy, of one hundred and eighty-five cases, occurring during a series of years about the commencement of the present century, not one survived ; and in the same locality, at a more recent period, according to the report of Dr. Schleisner already alluded to, sixty-four per cent, died. Similar statements in regard to the mortality of tetanus infantum are given by physicians in the southern States. Dr. H. 0. Wooten, of Alabama, says {N. 0. 3Ied. .louni., May, 1846) that he has " never seen a decided case of tetanus nasccntium that did not prove fatal ; . . . and that it is very generally deemed useless to call in medical aid after the initiatory symptoms are well declared." Mr. Maxw^ell, speaking in reference to the West Indies, DURATION IN FATAL CASES. 401 says {Jamaica Phys. Joiam., copied into the London Lancet, April 11th, 1885): "From observations which I have made for a series of years, ... I found tliat the depopulating influence of trismus nascentium was not less than twenty-five per cent. It scarcely has a parallel within the bills of mortality." Dr. D. B. Nailer (iV. 0. Med. Joiirn., ]^ov. 1846) says: "About two-thirds of the deaths among the negro children are from this disease, and so uniformly fatal is it, that a physician is never sent for." Yet death does not always result. Eight of the forty cases in my collection recovered ; but a correct opinion cannot be formed from this of the actual ratio of favorable to unfavorable cases, since favorable cases are much more likely to be published. In the history of these eight cases, two interesting facts are noticed, which, when present, may serve as a ground for hope of a successful termination. These were, the age at which the disease began, and fluctuation in the symptoms. With two exceptions, the infants who recovered were about a week old when the initiatory symp- toms a]3peared, and there were fluctuations in the gravity of the symptoms ; whereas, fatal cases ordinarily grow progressively worse. Yet, in favorable cases, the symptoms are never so severe as they become in a few hours in those who succumb. Duration in Fatal Cases. — Of eighteen cases observed by Finckh in the Stuttgart Hospital, fifteen died in two days, two in five days, and one in seven days. During the epidemic in the Stock- holm hospitals, in 1834, where forty-two cases were treated, the disease seldom lasted more than two days. Romberg says: "It generally lasts from two to four days, but its duration is at times limited at from eight to twenty-four hours, and occasionally, though rarely, it extends from five to nine days." In thirty-one fatal cases in my collection, in which the duration is mentioned — One lived 3 hours. Eleven others lived 1 day or less. Twelve lived . . 3 days. Four " 3 " Three " 4 " Both Underwood, who published a little treatise on diseases of children, in 1789, and Dr. Elsasser at a more recent date, record fatal cases which were unusually protracted. The one described by Underwood was treated in the British Lying-in Hospital, and, although all the others treated in this institution died by the third day, this lived six weeks ; but it is suggested by the author, that 26 402 TETANUS INFANTUM. death was due in part to some other affection. The child treated hy Elsasser lived thirty-one days. DuKATiox IN Favorable Cases. — In the eight favorable cases in my collection, the duration of the disease, reckoned from the time when the infant ceased nursing till it began again, was as follows : In one case, two days ; in one, a few days ; in one, fourteen days ; in two, fifteen days ; in one, twenty-eight days ; in one, twenty-one days; and in the remaining case, about five weeks. Diagnosis. — To one who has seen this disease in the new-born, or is familiar with its symptoms, diagnosis is easy. The symptoms which possess diagnostic value are more manifest and reliable than in most other infantile aflections. Permanent rigidity of the voluntary muscles, with temporary exacerbations, such as have been described above, which are induced by any cause which disturbs the infant — as attempts to open the mouth or eyelids — is jjathognomonic. Preventive Treatment. — While tetanus infantum, if fully developed, is ordinarily fatal, in spite of any remedial measures heretofore used, there is no doubt of the efiicacy and value of preventive measures, when properly employed. This was shown by the great reduction in mortality in the Dublin Lying-in Hos- pital through the thorough ventilation introduced by Dr. Clarke. Dr. Meriwether, of Montgomery, Ala., says {Amer. Journ. of 3Ied. Sci., April, 1854): "When the disease appears endemically on a plantation, it may be arrested by having the negro houses white- washed with lime, inside and out ; by raising the floors above the ground ; by removing all filth from under and about the houses ; by particular attention to cleanliness in the bedding and clothes of the mother ; and in the dressing of the child, so as to prevent any of the matter from the umbilicus lying long in contact with the skin." Many physicians, especially in the Southern States, speak confidently of care in dressing the cord, and attention to the umbilicus, as a means of prevention. In the N. 0. Med. and Surg. Journ., July, 1853, Dr. Grafton says that he has "never known the disease to occur in any child whose navel had the turpentine dressing." lie uses turpentine as follows: "At the first time, a few drops of the undiluted turpentine are applied immediately to the umbilicus around the cord, and it is anointed at every suc- ceeding dressing, the turpentine being diluted one-half or two- thirds with olive oil, lard, or fresh butter." This use of turpentine has also been recommended by other practitioners in the warm regions. TREATMENT. 403 Dr. Jolm Furloiigc, of St. Jolin's, Antigua, believes {Edin. Med. and Surg. Journ., Jan. 1830) that no case would occur witli the following treatment : " The cord, when divided, should be wrapped in clean linen. Every night, for two weeks, one or two drops of tinct. opii and spts. vini, equal parts, should be given, and castor oil, with a little magnesia, every morning. The child must be washed in tepid water every morning, and the funis dressed." If this treatment is attended by the success which is claimed for it by Dr. Furlonge, so great care in dressing the cord is certainly well repaid in localities, as at Antigua, where a large proportion of the infants die of tetanus. Some experienced observers go so far as to assert that it is possible to ward off tetanus infantum after the occurrence of pre- monitory symptoms. Dr. Dowell says {AMe?\ Journ. of the Med. Sci., January, 1863): "Some with slight twitchings of the muscles, have recovered without any trouble by being put into a mustard- bath, washed clean, and put in a clean and well-ventilated cabin." Treatment. — In considering the effect of medicinal agents which have been employed in the treatment of infantile tetanus, the great difficulty which the child experiences in swallowing should be borne in mind. Without care, a considerable part of the dose is lost by the spasm of the muscles of deglutition, which ordinarily occurs when the spoon is placed in the mouth, so that, unless special attention is given to this matter, it is uncertain whether the prescribed dose is fully administered. The treatment employed by different physicians has been very diverse. Antiphlogistic remedies were prescribed by Finckh, but every case so treated was fatal. He states that whenever blood was abstracted, even in small quantities, the symptoms were aggravated. The same result has followed depletory measures in the practice of other physicians. The internal remedies which have been most frequently pre- scribed are opiates and antispasmodics. Furlonge, in a favorable case, gave laudanum, in doses of one drop every three hours, alternately with two grains of Dover's powder. Woodworth also gave one-drop doses of laudanum ; Eberle, one-sixth of a drop hourly. The opiate has generally been given in combination with an antispasmodic. The Dover's powder, given every three hours by Furlonge, was combined with five grains of sulphate of zinc. The hourly doses of laudanum, by Eberle, were combined with six drops of tincture of assafoetida. 404 TETANUS INFANTUM. When anresthetics began to "be employed in the treatment of diseases it was believed that they would be especially useful in cases of tetanus. Accordingly chloroform has been used in tetanus in the infant, with the effect of controlling the sj^asms during the time of its use, but without curing the disease. In Case 7 in our first table it was employed several times, but apparently without delaying the fatal result. The editor of the New Orleans Medical and Surgical Journal states, in the May issue of that periodical for 1853, that he has used chloroform in tetanus infantum, with the effect, he believes, of prolonging life. Anaesthetics certainly relieve the suffering of the infant, and on this account, even if they do not prolong life, their judicious employment seems proper. The remedy which, in my opinion, is far preferable to all others, is hydrate of chloral. Since the introduction of this agent into therapeutics, it has been employed by several physicians in the treatment of this disease with so good a result that it will prob- ably supersede all other medicines for this purpose. Dr. Wider- hofer, of Vienna, states that he has saved six out of ten or twelve by the use of chloral {London Lancet, March 18, 1871). He pre- scribes it in doses of one to two grains by the mouth, or, if there is great difficulty in swallowing, two to four grains by the rectum. Dr. F. Auchenthales relates a case [Jahrb.f. Kinderheil., 'N. S. IV.) in which he gave even six-grain doses, and in nine days the disease had entirely disappeared. I have employed hydrate of chloral in only one case of tetanus infantum, giving it in half-grain doses, every two hours, except when there was profound sleep. The disease was fully developed, and the symptoms severe when I was called. I did not believe that the infant with the old remedies would live more than two days, but by the chloral life was prolonged nearly one week. Moreover, by the use of chloral the suffering of the infant is greatly diminished. The administration of alcoholic stimulants is required at short intervals on account of the rapid emaciation and great prostration. Local treatment directed to the umbilicus in those cases in which there is evidence of inflammation of the umbilicus or umbilical vessels should not be neglected. Vesication of the umbilicus, and the application of poultices to it, have been followed by unques- tionable benefit, if we may believe the statement of some physicians who have made use of these measures. Dr. Merriwether, of Alabama, says, if there is no improvement from the medicine which he orders, he applies a blister, larger than a dollar, to the INTERNAL CONVULSIONS. 405 iinihiliciis, and with this trcatmoMt the child generally improves; a remarkable statement, since so few improve at all. A warm foot-bath repeated at intervals of a few hours, and stimulating embrocations along the spine, are proper adjuvants to the treatment. CHAPTER XIII. INTERNAL CONVULSIONS. Young children are liable to temporary suspension of respiration, induced by violent emotions, especially by anger. In the midst of their excitement, while they are crying or screaming, their breath is suddenly held, as if from tonic spasm of the respiratory muscles. In a few seconds respiration returns, and is natural. There is no stridulous inspiration or other unusual sound, and there is no apparent ill effect, unless occasionally a degree of languor. Ex- ternal convulsions, which seem to be threatening, seldom occur, and when they do, are ordinarily mild. Some writers consider dentition the predisposing cause of this arrest of respiration, by inducino- a sensitive state of the nervous svstem. Such an effect of dentition is possible, but certainly many infants are affected in this manner before the as-e of dentition. A much more serious state, and one which is recognized as a true disease, is that variously designated by writers as internal convulsions, spasm of the glottis, child-crowing, laryngismus stridulus, etc. Manifest difficulties attend the investigation of the pathological state in this disease. There can be little doubt that it is not precisely the same in all cases. That there is, during the paroxysms, tonic or clonic spasm of more or fewer of the respiratory muscles is inferred not only from the symptoms pertaining to the respiratory apparatus, but from the fact that in severe cases there are often spasms of the external muscles, as those of the limbs and face. Usually, also, the movements of the eyeballs indicate spasmodic contractions of the motor muscles of the eyes. The occurrence of these contractions in parts that are visible justifies the belief that they occur in other parts which are concealed from view, especially as the characteristic symptoms cannot be readily explained except on this supposition. Trousseau says: "Internal convulsions consist, then, principally in a spasm of the diaphragm 406 INTERNAL CONVULSIONS. and of the respiratory muscles of the abdomen and chest ; hut it occurs, also, that the muscles pertaining to the larynx are affected with spasm at the same time with these." Rilliet and Barthez conclude from the symptoms that the " heart is not always a stranger to this internal convulsion, which, perhaps, prolongs itself even to the intestines." The muscles of the pharynx appear to be involved, in some cases, as Avell as those of respiration, rendering deglutition difficult. In one form of internal convulsions, namely, that which is jDrincipally referred to by writers, there is not complete arrest of respiration, but the inspirations, during the paroxysm, are difficult and are attended by a stridulous noise. Again, the respiration may cease entirely, but when it commences it is stridulous, and difficult for a few inspirations. In still another form of the disease respiration ceases, but there is no symptom or sign indicative of glottic spasm or of an obstacle to the ingress of air ; the inspirations which succeed the paroxysm are easy and noiseless. It has been suggested that, in these cases, there is paralysis rather than spasmodic contraction of the respi- ratory muscles, but the symptoms may be explained in accordance with the commonly accepted opinion, namely, that there is spasm of the diaphragm and, perhaps, some of the muscles of the chest and abdomen, while the laryngeal muscles are not affected. M. Ilerard, indeed, who has written one of the best monographs on internal convulsions, describes three forms of the disease, according to the supposed location of the spasm, namely, laryngeal, dia- phragmatic, and another, which consists of a blending of the two. Internal convulsions are not frequent in this country ; they are rare in France, more frequent in Germany, and quite common in England. They occur, with few exceptions, before the age of two years. Dr. West observed thirty-one cases under the age of two years, and only six above that age. Causes. — The causes of internal convulsions are not fully ascer- tained. Most observers have remarked the relative frequencj^ of the disease during the period of dentition, and it is probable that dental evolution does operate as a cause, by rendering the nervous system more impressible. Spasm of the glottis has been attributed to enlargement of the thymus gland, and also to enlargement of the cervical and bron- chial glands. It is presumed that this effect is due to the pressure of these glands on the par vagum, or the recurrent laryngeal nerve. It is certain, however, that there is no such enlargement of the thymus gland which could possibly produce glottic spasm, or any CAUSES. 407 other form of internal convulsions at the age at which these con- vulsions commonly occur. Tliis gland is largest in the new-born, and having no function after birth, it gradually becomes atrophied. If enlarged thymus could produce glottic spasm, it would certainly occur most frequently in the new-born. Abnormal development of the thymus gland was the only assignable cause of atelectasis in two infants who died soon afterbirth, but I have never seen a case in which a convulsive attack was referable to this cause. M. He- rard examined the thymus gland in six children who died of inter- nal convulsions, and in sixty who died of other affections, and was not able to discover in its condition any causative relation to this disease. Indeed, cases have been reported in which the thymus had undergone more than its usual atrophy at the time when the convulsions occurred (Ilasse). Enlargements of the lymphatic glands in the vicinity of the pneumogastric or recurrent laryngeal nerve may possibly give rise to glottic spasm, but this is doubtless an infrequent cause, if it be a cause at all, since these glands are often greatly enlarged in strumous and tubercular diseases without such a result. According to Dr. Jacobi {N. Y. Journ. of Med., Jan. 1860): "In some cases described by Dr. Friedleben, a congenital hypertrophy of the thyroid gland has probably been the cause of laryngismus. The patients were new-born infants of normal de- velopment, and born by normal labors. There were no constitu- tional causes of the disease, but a remarkable vascular swelling of the thyroid gland. Whenever the swelling increased, the veins of the face and head increased in size also, the face grew livid, and the extremities and spinal column exhibited slight tonic convul- sions. The recurrent nerves were entirely surrounded by the glandular tissue, their neurilemma looked unusually red, and their functions were probably injured during the occasional swelling taking place during lifetime." The cause is occasionally located in the cerebro-spinal ^axis. Thus Dr. Coley relates a case in which an exostosis arising from the internal surface of the occipital bone pressed upon the cere- bellum, while nothing abnormal was discovered in other organs. There are also striking examples in which the cause was located in the spinal cord. Thus Marshall Hall relates the following case communicated to him. A child with spina bifida was attacked with croup-like convulsions, whenever it lay so as to press on the tumor. In some patients there is evidently an hereditary predisposition to this disease ; those affected belonging to families in which there 408 INTERNAL CONVULSIONS. is a tendency to convulsive affections. Thus Toogood relates that five infants of the same family were aft'ected with spasm of the glottis ; and Reid relates, on the authority of Powel, that of thir- teen infants of the same parents only one escaped internal convul- sions. The common predisposing cause is an excitable state of the ner- vous system, often associated with impaired general health. Hence the disease is more prevalent in cities, where anti-hygienic condi- tions abound, than in the country. Hence, too, the frequent im- provement when the patient is removed to the pure and bracing air of the country. The use of insufficient food, or food of a bad quality, must for the same reason be considered a cause, as it leads to impoverishment of the blood, and renders the nervous system more impressible. Facts mentioned by Reid and others show con- clusively the influence of premature weaning, and of indigestible or otherwise improper aliment, in the production of this disease. The causes enumerated above are for the most part predisposing ; occasionally they are the only apparent causes, since this disease sometimes occurs when the child is perfectly tranquil, even in the midst of quiet sleep, or when it is at rest in its mother's arms. In other cases, and more frequently, there is an exciting cause, often trivial. Anything that requires exertion on the part of the infant, or that excites strong emotions, may be a direct cause, as anger, or any of the violent passions ; so may even coughing, or, in rare instances, attempts to swallow. One author has known it to occur from excitement produced by examining the throat with a spoon. In a case in my practice, hereafter related, it occurred whenever the infant cried violently. It appears from the above facts that the etiology of internal convulsions is very similar to that of eclamp- sia. The same spasmodic muscular contraction may occur from a variety of causes. Anatomical Characters. — While, therefore, structural changes in various parts of the system may give rise to internal convulsions, this disease, so far as ascertained, presents no anatomical charac- ters, and must consequently be considered one of the neuroses. The lesions of the respiratory apparatus, observed at pott-mortem exami- nations, are either due to the convulsions or are coincidences. Em- physema has sometimes been observed as a result, it is believed, of the spasmodic and irregular respiration. It was present in all of Herard's cases, and Rilliet and Barthez consider it common in those who die of this affection, although they did not observe it in any of their cases. Slight emphysema occurring in the upper lobes is, SYMPTOMS. 409 however, a common lesion in feeble infants, whatever the disease of which they die. Therefore its occurrence in internal convul- sions is probably more due to molecular change in the lungs, since these patients are cachectic, than to the irregular breathing, which is only momentary. In fatal cases of internal convulsions the blood is darker than usual, from an excess of carbonic acid ; the cavities of the heart and large vessels are sometimes engorged with blood, but in other cases they contain no more than the normal amount. More or less passive congestion occurs in the internal organs ; and congestion of the cerebral vessels is sometimes such that transudation of serum occurs. Symptoms. — I have said that the symptoms vary according to the seat and function of the muscles which are affected. There is generally previous ill health. The child is drooping, and is some- times restless for days before the disease appears. Finally, if the muscles of the glottis become affected, the peculiar crowing sound is heard now and then during inspiration. It is observed espe- cially when the child is crying or is agitated. It may be loud and well defined from the first, but in most patients it comes on gradually, so that several days elapse before its full stridulous character is developed. The attacks are more frequent and severe at night, in or after the first sleep, than in daytime. Under favorable hygienic conditions, the disease may pass oS without becoming more serious. In other cases the paroxysms gradually increase in frequency and severity. The dyspnoea in the attack is such that the features are livid, the head forcibly retracted, and death seems imminent from apnoea. In these severe paroxysms respiration often ceases entirely for a moment. When the spasm ends, a deep stridulous inspiration occurs, after which the breathing is natural. It has been stated that internal convul- sions are often associated with those, usually tonic, but sometimes clonic, of the external muscles. In the tonic form, the thumbs are flexed across the palms of the hands, and sometimes are grasped by the fingers; the great toes are adducted, and the other toes flexed. In severe cases, the hands, forearms, feet, and legs are also somewhat flexed and rigid. At first, the contraction of the external muscles is temporary, either corresponding with the internal spasm, or it is most intense at the time of the spasm, though commencing sooner and subsiding later. After a while, however, if the dis- ease continues, the external contraction becomes more persistent. In severe cases, nearly every inspiration is accompanied by the 410 INTERNAL CONVULSIONS. wheezing sound, and the paroxysms of dyspnoea are excited by trifling causes. Anything that suddenly disturbs the mind or body may bring on the attack, as anger, the impression of cold, or currents of air. Dr. West calls attention to the fact that an anasarcous condition is sometimes present, accompanied by albu- minuria. If the convulsions affect other muscles, as the diaphragm or the pectoral and abdominal muscles, which are concerned in the respiratory function, while those of the larynx escape, respiration is irregular, or even suspended for a moment, but the stridulous laryngeal sound is absent, as there is no obstacle in the larynx to the entrance of air. In this form of the disease, the infra-mam- mary region ma}' be strongly retracted during the paroxysm from tonic conti-action of the diaphragm. In severe paroxysms, whether the spasm be laryngeal or diaphragmatic, consciousness is nearly or quite lost, the features may be pallid, or, if respiration be suspended, may be more or less livid. There is no fever in simple cases. In the paroxysm there is often relaxation of the sphincters of the bowels and bladder, with involuntary evacuations. The duration of the paroxysm may be a quarter, a half, or even a whole minute. Total suspension of respiration for even half a minute involves danger. In mild cases there may be but few paroxysms, and they slight. In other instances they occur in a severe form, almost daily for several weeks or even months. In the following case the muscles of the larynx were apparently not involved. Tlie patient was scrofulous, and has since had scrofulous periostitis, with necrosis and exfoliation of the surface of the tibia. At the time of the internal convulsions there was also a scorbutic or hemorrhagic cachexia. Case. — On the 28tli of August, 1858, a German female infant, four- teen months old, nursing, and having eight teeth, was suddenly seized with clonic convulsions. Uniformly delicate and pale, she had been in her usual health till the age of twelve months, when she had a single convulsive attack, and from that date had'remained well till August 27, when, witiiout any premonitory symptom, she had a stool consisting of almost pure blood, black and offensive. Ou the morning of the 28th a similar evacuation occurred, and another in the afternoon immediately preceding the convulsion. Pulse 128, after the convulsion; surface cool and pallid; flesh soft, but no emaciation. Turpentine was prescribed in two-drop doses every two hours, and laudanum in one and ahalf drop doses repeated sufficiently to insure quietude. On the 29th the pulse was 152. At 1 P.M. she had a general convulsion, lasting about five minutes; in the evening she had an evacuation similar to those passed on the preceding day. The record for August 30 states: "Pulse from 150 to 160; up to this time has been playful. DIAGNOSIS — PROGNOSIS. 411 but is now drows_y, and, when disturbed, fretful; manifests no desire for solid food, as before her sickness, but still nurses; has taken up to this tiuie tliirty-two drops of turpentine. "When she cries or frets, she has a spasmodic attack." This was the commencement of internal convulsions, with which this child was affected for several months. An opportunit}^ was afforded of observing their character, for her excite- ment, when she was examined, was usually sufficient to produce them. After a succession of short expirations, respiration ceased ; for a moment she was apparently insensible; eyes closed; face pale; no frothing at the mouth. The return of consciousness and respiration was without any laryngeal rale ; and after the attack she seemed as well as before. No external convulsion and no evacuation of blood occurred after August 31. There was gradual improvement in her health, but she continued for many months pallid and irritable, and subject to attacks of internal convulsions. On the 11th of April, 1859, when twenty-two months old, she had another attack of general convulsions. The record made on that da}^ is: "Has had internal convulsions (one or more paroxj'sms) almost every day since last August, brought on usually by cr3'^ing when she is corrected in any way, or her wishes are refused." Again, on Dec. 1, 1859, it is stated : " lias grown considerably since the last record, and appears to have recovered, except that at long intervals the spasms still occur." She took a preparation of iron, but her recovery seemed to be due more to the growth and development of the body, and to hygienic than therapeutic measures. The general healtli in internal convulsions is more or less im- paired, except in mild, forms of the disease, in which the convul- sive attacks soon cease. Pallor, or a sickly and cachectic aspect, irregular, usually constipated bowels, poor appetite, and morose- ness or irritability of temper, are common symptoms of severe and protracted cases. Diagnosis. — This disease is easily diagnosticated, unless when its symptoms are masked by those of external convulsions ; it may then escape notice. Spasm of the glottis may be mistaken for spasmodic laryngitis, and vice versa. In some of the published cases this mistake appears to have been made. Spasmodic laryngitis is, however, so difterent not only in its nature, but in its clinical history, that a diflerential diagnosis is not difficult. It is an inflammatory disease, and is attended with febrile reaction and a sonorous cough ; it commences at night after the first sleep, and from exposure to cold — particulars in regard to which it contrasts with true spasm of the glottis. Prognosis. Modes op Death. — Statistics show great mortality in this disease. Dr. Reid, in a monograph on "Infantile Laryn- gismus," states that of 289 cases which he collated, 115 died. Rilliet and Barthez met with one favorable case in nine unfavorable ; and Ilerard, one in seven. If the paroxysms are mild, infrequent, 412 INTERNAL CONVULSIONS. and dependent on a cause which can be easily removed, recovery- is probable with proper treatment. The cause may, however, be such, even when the spasm is mild, that the case is necessarily unfavorable; as when it is due to disease of the cerebro-spinal axis. We should not, however, in any case consider the patient entirely safe, since grave symptoms may suddenly arise, so as to change entirely the prognosis. Long and severe paroxysms, with lividity of the face, and symptoms of suffocation, indicate an unfavorable result. The same should be predicted also if the infant gradually waste away, losing appetite and strength, especially if the face is pale and the pulse feeble. There are three modes of death in internal convulsions. The first is apnoea. The infant dies suffocated in the attack. Respiration is first arrested, and then the pulse ceases, and at the autopsy the lungs and the cavities of the heart are found engorged with dark blood. Death may also occur from the state of the brain. In such cases, passive congestion of the brain occurs from obstruction to the return of blood from this organ to the heart and lungs ; and if this congestion is not soon relieved, serous effusion also occurs. Death results from the congestion, and consequent oedema or dropsy. Tlie third mode of death is from exhaustion. Repeated and severe attacks undermine the constitution ; the infant grows pale and thin gradually, and dies of inanition, or of some disease which this state induces. Treatment. — The treatment of internal convulsions has varied according to the theories which physicians have held in reference to its cause. Glandular enlargement is no longer regarded as a common cause, and therefore treatment directed to its removal is less frequently employed than formerly. The causes of internal convulsions are in part very similar to those of eclampsia, and the remedies employed in the one affection are, in a measure, appro- priate in the other. That dentition is sometimes a cause, is usually admitted; and two cases, one of which occurred in my practice, and the other was reported to me, clearlj^ show the truth of this belief. The effect of dentition is especially observed in weakly infants, when several dental follicles are undergoing active evolu- tion. Thus, in one of the cases to which I refer, five teeth pierced the gums in the course of two weeks ; after which no convulsive attack occurred. If, therefore, the gums are swollen, scarification is proper. In all cases of internal convulsions a careful examination should be made, in order to detect any appreciable cause of nervous exci- TREATMENT. 413 tation. Tlic condition of the digestive ore;ans should be aBcertaincd, and evacuants or other remedies prescribed if there is evidence of their derangement. Sometimes the alimentation of the infant is in fault. It is, perhaps, bottle-fed, and the stools have an unhealthy appearance. Attention should be given to the preparation of its food and the times of its feeding; or, if it nurse, the mother or wet-nurse who suckles" it should have j)lain but nutritious diet, live with regu- larity, and give the breast to the infant at regular intervals. If there is a torpid state of the bowels, Dr. Meigs recommends "castor oil and aromatic syrup of rhubarb rubbed up together, three parts of the former and five of the latter." A simple enema answers well in such cases, and, in debilitated infants, this is preferable to medicine administered by the mouth. If there be diarrhoea, and it persist after the requisite changes are made in regard to the diet, remedies calculated to relieve it, and which are detailed elsewhere, should be employed. Marshall Hall states that he has ordinarily succeeded in curing the disease by attending to the condition of the gums and digestive organs. In pallid and cachectic infants, tonics are required. The elixir of Calisaya bark in half-teaspoonful doses, three or four times daily, to an infant of one year, is an eligible preparation. The compound tincture of bark, or of gentian, or the two mixed, may be given instead of the Calisaya bark. The preparations of iron are sometimes to be preferred. The best of these are the sj-rup of iodide of iron, tincture of iron, or the wine of iron. To an infant of one year the syrup may be given in doses of four drops, the tincture of two drops, and the wine in doses of one teaspoonful, three times daily. If the child is old enough, it may take iron in lozenges, as those of chocolate and iron. Antispasmodics, as assafoetida, valerian, and oxide of zinc, are often prescribed in this disease, but they are less efficacious than the general tonic measures which I have indicated. The salutary effect of bromide of potassium in eclampsia, and certain epilepti- formx attacks, certainly justifies the trial of this agent in internal convulsions, if they persist after the employment of invigorating measures. Hygienic measures are of the utmost importance. The infant should reside in dry and airy apartments, and should be kept much of the time through the day in the open air. Remarkable success sometimes attends this simple expedient, when medicines have entirely failed. In the London Med. Gazette, Jan. 14, 1865, Mr. 414 INTERNAL CONVULSIONS. Hobertson, of Manchester, relates five severe cases in which this disease was cured by exposure of the infants several hours daily to a cool atmosphere. These cases were treated in the winter months, and were kept out-door, even during strong winds. Mr. Robertson has records of forty cases, all occurring betw^een Decem- ber and April, while he has seen no case in the summer months. As the result of such extensive experience, this writer recommends "the free exposure of the infant out of doors, for many hours daily, to a dry, cold atmosphere, and if the air be dry, the colder the better." Dr. Marshall Hall's experience was similar. Says he : " The curative influence of change of air, and especially of the sea-breezes, is not less marked in this aflection than in hooping- cough." Mr. Robertson recommends also, as part of the tonic treatment, "free sponging of the body every morning with cold w^ater." In February, 1867, I attended a nursing infant, five months old, wath internal convulsions, the paroxysms being attended wdth lividity of the face, and, at times, tonic convulsions of the limbs. Among the remedies employed was bromide of potassium, but more benefit obviously accrued from keeping the infant much of the time in the open air, than from the medicines employed. The disease passed off in six or eight weeks. Unless the cause is of such nature that it cannot be removed, the above hygienic and therapeutic measures will, in a large pro- portion of cases, be followed by a satisfactory result. The mother or nurse may abridge the paroxysm by raising the infant, blowing upon it, sprinkling water in the face, or gently stroking it. Dr. Hall recommends tickling the nostrils with a feather, to produce respiration, or the fauces, to occasion vomiting, and thereby interrupt the paroxysm. Anything which produces a sudden and j)rofound eflect upon the system may abridge the attack. This was effected in one case, in the practice of Dr. C. D. Meigs, by applying a cloth wrapped around ice over the epigastrium and the lower part of the sternum. The chief danger during the attack is from congestion of the brain, with eftusion of serum or extravasation of blood. If the attack is severe, and the features congested, so that there is evident danger of such a result, cold applications should be made to the head, derivatives used for the extremities — as sinapisms, or mustard foot-baths — and the bowels should be speedily opened by enemata. CHOREA. 415 CHAPTER XIV. CHOKEA. Chorea, or St. Vitus' or St. Guy's dance, is a nervous affection, which is characterized by irregular and involuntary muscular movements, without loss of consciousness. The movements occur in the muscles of volition, and there is probably no one of them that may not be engaged, though some are more frequently affected than others. It is not known that any involuntary muscle is ever involved, though Sir William Jenner has expressed the opinion that occasionally the papillary muscles of the heart are, so that, by their spasmodic contractions, they produce insufficiency of the mitral valve. This, according to him, affords explanation of the fact that, in certain instances, a mitral regurgitant murmur is heard, which disappears about the time that the external movements cease. It is rare, however, that a mitral regurgitant murmur, heard during chorea, ceases when the latter terminates, and it is not improbable that in such cases there is, after all, a lesion of the valve, due to recent endocarditis, whether of a rheumatic or other origin. For a valve may be so thickened by recent inflammation as to cause a murmur, and after a few weeks or months the infil- trating substance be so absorbed that the murmur is no longer audible. If we admit the fact that cardiac bruits occasionally appear and disappear with chorea, this explanation seems to me more plausible than that of Jenner. Hillier says, in reference to this subject : " My own experience leads me to doubt the existence of dynamic apex murmurs in chorea, that is to say, murmurs pro- duced in hearts entirely free from organic change. If such murmurs ever occur, they are certainly rare. Organic murmurs of the heart, on the other hand, are common in chorea, and I am inclined to believe that organic disease of the heart often exists in chorea when there is no murmur." Ilillier also calls attention to the fact that choreic movements are irregular ; but a cardiac bruit occur- ring regularly and uniformly, if not due to organic disease, would require rhythmical contractions of the papillary muscles to pro- duce it. 6 years 6 to 10 10 to 15 and iiuder. years. years. . 81 237 1041 , 10 61 118 . 2 26 16 416 CHOREA. Age. — Chorea may occur at any period of life ; but while it is comparatively rare at other ages, it is not infrequent in childhood. A large majority of cases are between the fifth year and puberty. Under the age of five years, the proportionate number diminishes as we approach the time of birth, and it is rarely observed in in- fants under one year. The j^oungest in the statistics of Hillier was three months. In 1870, at the Out-door Department of Bellevue, a child was presented for treatment, who, the mother stated, had had chorea from birth. The choreic movements were no doubt observed very early in infancy, though the disease probably was not congenital. The following table exhibits the relative frequency of chorea at difi:erent ages during infancy and childhood : — Children's Hospital, London, Hillier M. Rufz Out-door Department, Bellevue . M. See collected the statistics of 631 cases occurrino; in the Children's Hospital, Paris, and from them concludes that the maxi- mum frequency of chorea is between the sixth and tenth years. Only twenty-eight of his cases were under six years, the remainder, 503, occurring between the sixth year and puberty. Causes. — The profession are nearly agreed in regard to certain causes of chorea, while there is a diversity of opinion in reference to others. It is admitted that in a large proportion of cases there is a neuropathic state, which antedates and predisposes to chorea. This state is often manifested in the family history by a proneness to aflt'ections of the nervous system, and in the individual by a highly excitable state of the emotions, so that he evinces joy, grief, or anger, from slight causes. All writers admit that there is often an inherited predisposition to chorea. In 27 of 48 cases of chorea, E.adclifl:e found that father, mother, brother, or sister had been or was the subject of one or other of the following, disorders : paralysis, epilepsy, apoplexy, h^'s- teria, or insanity. The children of parents who when young had chorea, or who exhibit proneness to ailments of the nervous system, arc more liable to chorea than other children. Hence the fact sometimes observed, of different children in the same family be- coming affected with chorea when they attain the age at which this disease ordinarily occurs. In one family, in my practice, three girls at different times were affected. ' None over 12 years admitted. SEX — ANEMIA. 417 Sex. — Tlie emotions are strong in girls, since in them the nervous system predominates, while the muscular power is weaker than in boys. Hence a partial explanation of the fact which statistics fully establish, that the proportion of choreic boys to girls is about in the ratio of one to two and a fraction. I have remarked, in this city, the large proportion of cases in school-girls between the ages of six and twelve years; the severe discipline and confinement of the public schools no doubt increasing the strength of the emotions, and weakening the control of the will over the muscles. Proportion of Males to Females. 27 to 73. Hughes' Digest of Cases in Guy's Hosp., 1846. 138 to 393. M. See. 25 to 40. Out-door Department, Bellevue. 276 to 499. Children's Hosp., Lond. West (Lumleian Lect.). 466 to 1005 =1 to 2.15. Uterine Irritation. — The peculiar changes occurring in the female at puberty constitute an important cause. Hence another reason of the excess of female cases. Dysmenorrha?a and preg- nancy are causes of a large proportion of cases in the first years of puberty. In the male, on the other hand, the changes of puberty do not appear to increase the liability to the disease, directlj' or indirectly, and male cases, after the age of twelve years, are com- paratively rare. Radcliffe states {Reynolds'' Systoii of 3Ied.) that after the ninth year, females are more liable to chorea than males, in the proportion of 5 to 2; while before the ninth year, the two sexes are equally liable to it. Carefully prepared statistics, how- ever, notwithstanding the high authority of RadcliflJe, show a preponderance of girls under the age of nine years, though not as great as over that age. In the Out-door Department at Bellevue, of 35 patients under the age of ten years, 22 were girls, while of 20 from the age of ten years to sixteen, 15 were girls. According to West (Lumleian Lect.), in 775 children with chorea, under the age of ten years, treated in the Lond. Children's Hosp., 64 per cent, were girls. Anemia. — Among the most common predisposing causes of chorea is anaemia. It is present in so large a proportion of cases, exhibiting itself by pallor of the countenance and other character- istic sigDs, that medicines designed to improve the quality of the blood are among the vaost valued remedies. The peculiar neuro- pathic state already alladed to, which needs only a slight additional 27 418 CHOREA. cause for the development of chorea, is, no doubt, largely depen- dent on impoverishment of the blood, if it is not sometimes due entirely to it. Among the poor of a large city like 'New York, or in hospital practice, the proportion of anaemic cases of chorea is, for obvious reasons, much larger than would appear from general statistics. Rheumatism. — Dr. Copland, M. Bouteille, and afterwards M. Germain See, in a more extended monograph, directed the atten- tion of the profession to rheumatism as a cause of chorea. Subse- quent observations have established the fact that rheumatism, or the rheumatic diathesis, is so frequently present that it obviously sustains an important relation to chorea, though in what manner is not fully ascertained. This relation betAveen the two is more fre- quently observed in some countries than in others. In England and France, so large a proportion of choreic patients present the history of rheumatism either in themselves or family, that certain phy- sicians of these countries believe that rheumatism is the most common cause of the disease. In Germany, on the other hand, according to Romberg, in the majority of cases no relation can be traced between chorea and rheumatism, and the statistics of this city, and I think of this country, correspond with those in Ger- many. Various theories have been promulgated in explanation of the relationship of the rheumatic and choreic diseases. It has been suggested that chorea is due to rheumatism of the brain or spinal cord. This is simply an hypothesis, the truth or falsity of which can only be ascertained by carefully conducted necropsies ; but the theory appears improbable in view of all the facts. Another theory attributes chorea to the state of the blood which is present in those having rheumatism or the rheumatic diathesis, as well as in cer- tain other conditions. This theory is enunciated by Dr. Ogle, as follows: "Recognizing the frequent existence of these fibrinous deposits or granulations on the heart's valves in chorea, I should be much inclined to look upon these post-mortem appearances leather as results of some antecedent general condition of the blood, common also to the choreic condition. It is very freely recognized that this affection is frequently, in some way or other, connected with that condition of blood which obtains in what we call anaemia, or that existing in rheumatic constitutions. In both of these states we know that the fibrin of the blood is much in excess (as also it is in pregnane^', another condition looked upon as obnoxious to chorea) ; and in these states we know that the fibrin with which RHEUMATISM. 419 the blood is surcharged is verj prone to be readily precipitated, either owing to its superalnmdance, or from other obscure and acquired properties . . . upon the heart's walls or valves. May not this hyperinosis be the explanation of the coincidence alluded to?" {British and Foreign Mal.-Chir. licv., January, 1868) — namely, the occurrence of chorea in those affected with rheumatism. Others still hold that chorea is the result of the heart disease, and not directly of rheumatism, occurring when the heart is aftected from other causes, as well as when the lesion has a rheumatic origin. This theory is plausible, and probably to a certain extent correct. Heart lesions, observed in children, result from scarlet fever in a considerable proportion of cases, though, it is true, the endocarditis and pericarditis of scarlet fever are believed often to have a rheu- matic origin, occurring, in some instances, from scarlatinous rheu- matism, but in other cases from scarlatinous uraemia. Occasionally also the heart disease appears to have occurred independently of both rheumatism and scarlet fever. Thus in a fatal case of chorea with valvular disease, related to the Lond. Path. Soc, April 6, 1869, the child was always healthy up to the present illness (chorea), and tliere was no history of rheumatism in the family. The more observations accumulate, the more important does heart disease in itself appear as a cause of chorea. In nearly all recorded cases of fatal chorea, which were supposed to be due to rheumatism, and in which post-mortem examinations were made, vegetations have been discovered upon the valves — aortic or mitral. We shall see that certain eccentric causes of irritation aid in producing chorea, and may not the valvular disease, or the endocarditis which causes the valvular lesion, operate in a similar manner as a cause ? We know that in the adult severe cardiac disease often profoundly aifects the nervous system, perhaps in consequence of the irregular and embarrassed circulation ; and certainly in the child a similar cause would be likely to produce a more decided eifect. But there is an ingenious theory which attributes chorea to minute emboli detached from vegetations on the valves, and arrested by capillaries in the corpora striata, or other portion of the cerebro-spinal axis. Since attention was directed to this matter, emboli have been found in one case in the medulla oblon- gata, although this portion of the spinal axis appeared healthy to the naked eye. Further observations are necessary in order to determine how much truth there is in this theory ; but it seems probable, for reasons to be stated, that if capillary embolism does cause chorea, it is only in a limited number of cases, and that 420 ■ CHOREA. therefore those British observers who regard it as the common cause, have been led into error by the large proportion of choreic cases which are complicated by valvular lesions in their climate. That embolism is not a common cause, if indeed a cause at all, appears probable from the following facts: First. In many cases of chorea there are no vegetations, or other appreciable lesion, which could give rise to emboli. Secondly. Most patients recover, and some speedily, by treatment, which we would not expect if the cause were embolism. Thirdly. Embolism is not infrequent in the cerebral vessels of the adult, without the occurrence of chorea. Indeed, the conditions which produce embolism are much more common in adults than in children, while the reverse is true as regards the liability to chorea. Fourthly. Dogs sometimes have chorea, but the injection of minutely divided fibrin or other substance in the veins of the dogs is not followed by chorea as one of the phenomena. Fifthly. Were capillary emboli the cause, we would expect to find an occasional embolus in the larger vessels of the brain, so as to be appreciable to the naked eye ; but I find no examples of this in all the recorded autopsies which I have been able to consult. Moreover, it seems improbable that capillary embolism, when producing no lesion appreciable to the naked eye, would so arrest the circulation, and disturb the function of the brain or spinal cord, as to cause chorea, for the ill eft'ects of such • an obstruction would be likely to be obviated by the numerous anastomoses. It is obviously better, in the present state of uncertainty regard- ing the exact relation of rheumatism and valvular disease to chorea, to postpone the acceptance of any theory till the minute anatomy of chorea has been as fully investigated as has its clinical history. Fright. — A not infrequent exciting cause of chorea is sudden and profound emotion, especially fright. All statistics give fright as the cause of a certain proportion of cases, though there are usually other potential co-operating causes, as anajmia or valvular disease. Fright was stated as the cause of chorea in 31 of the 100 cases occurring in Guy's Hospital, reported by Hughes, or in nearly one in three. Eut the statistics of other observers do not give 60 large a proportion of cases originating in this way. Chorea may commence within a few hours after the fright, or not till the lapse of several days (eight or ten). If several weeks have passed since the fright, as in some reported cases, the chorea is probably due to other causes. In rare instances, chorea is said to have been caused by sudden and excessive joy. INTESTINAL IRRITATION, 421 Imitation. — Under nnusual circumstances, especially in a state of sreat mental excitement, imitation has been known to cause a form of chorea, llccker describes an epidemic of it, occurring in the middle ages, and spreading through villages. In modern times it is rare that chorea originates from this cause, nevertheless occasional examples have been recorded. Hut the disease which occurs from imitation differs from the ordinary form, and lias been termed chorea major; while chorea proper, which is the subject of this article, is sometimes designated, in contradistinction, chorea minor. In chorea major, the patient leaps, dances, or whirls like a top. It has its origin commonly in religious excitement, and spreads by imitation almost in the manner of an infectious disease. The epidemic of the middle ages was a chorea major. I have not been able to find any account of cases spreading by imitation, in modern times, which were not examples of the same form of chorea. Thus in the Edin. Journ. of Med. and Surg, for July, 1839, there is a clear description of chorea major, occurring successively in five children in the same family. Dr. Dewar, the attending physician, states that one of the children whom he was called to see was sitting near the fireplace, when her head dropped on her chest, and she aj^peared to doze some minutes. In the m(jantime the respiration became a little accelerated, the face altered and flushed, the eyes wild. In less than one minute she bounded from one extremity of the apartment to the other, leaping over chairs, a chest, and then throwing herself upon the floor; she attempted to stand upon her head, rolled upon the floor, and then, rising, ran with extreme swiftness in the room, till she finally fell again on the floor, where she remained motionless some minutes. Then, recovering, she noticed those who surrounded her, and asked of her sister a toy, which she had allowed to fall. The whole paroxysm lasted twenty minutes. Obviously, the symptoms of chorea major differ materially from those of chorea proper, and it is a question whether it should have the same generic name. It is a curious and interesting disease in its psychical and pathological aspects, but it is so rare in modern times that a knowledge of it is of little practical importance. Intestinal Irritation. — In rare instances intestinal worms cause chorea, though in these cases there have usually been some co- operating causes. The following is an example, related by Mr, Ogle {Land. 3Icdico-Chir. Rev.., Jan. 1868): Ellen L., 9 years old, had been under treatment about a month with chorea, rheumatisni, 422 CHOKEA. and worms. She had not slept in four days, and there was constant spasmodic movement of the body and face. Her general condition was very unpromising. As she had passed portions of a tapeworm at intervals during the last three months, one drachm of the oleum filicis maris was administered in mucilage, which caused the expulsion of the entire worm. From that time she fully and rapidly recovered from the chorea, though a mitral murmur remained. Lesions or Brain and Spinal Cord. — N'early all standard authors who reject embolism as a cause of chorea, believe there is no anatomical cause of the disease located in the cerebro-spinal axis. In other words, they regard chorea as one of the neuroses. This view is probably, in the main, correct ; but experiments, and also occasional cases, establish the fact that if not true chorea, at least choreiform movements, now and then result from a structural affection of the nervous centres. Experiments on certain of the lower animals demonstrate that irregular muscular movements may be produced by traumatic injury of certain portions of the cerebro-spinal axis, as the corpora quadrigemina, crura cerebri, pons Varolii, crura cerebelli, thalami optici, parts of the medulla oblongata, and the upper portion of the spinal cord. Pressure on the projecting part of the medulla oblon- gata of an acephalous monster also causes convulsive movements. At the meeting of the N". Y. Acad, of Medicine, April 20, 1871, Prof. Post related the case of a child who was struck with a billet of wood, over the occiput, and chorea followed, due, in all proba- bility, to the injury of the brain which resulted. If irregular muscular movements, choreic or choreiform, result from traumatic injury of certain portions of the nervous centres, may they not also occasionally occur from lesions of the same parts produced by disease? Sir Benj. Brodie relates the case of a choreic girl, dying in St. George's Hospital {London Lancet^ Dec. 19, 1840), in whom, after a careful post-mortem examination, the only morbid appearance observed was a tumor the size of a hazelnut, connected with the pineal gland. Dr. Broadbent described another case be- fore the London Pathological Society (vol. xiii., page 246, Trans- actions), in Mdiich a tumor was found arising from the centre of the spinal cord ; and Chambers one in which tubercles were imbedded in the cord. Romberg quotes from Frerichs a case in which the medulla oblongata was pressed upon by an enlarged odontoid pro- cess ; and Dr. Aitken {Glasgow Med. Journ., vol. i.) one in which the specific gravity of the thalamus opticus and corpus striatum ANATOMICAL CHARACTERS. 423 was greater on one side than on the other. Rilliet and Barthez relate other similar cases, and add: " We may conclude, from these diiFerent cases, that there exist two species of chorea : the one essentially a simple neurosis, while the other depends on an altera- tion of the encephalo-rachidian system. In a word, it is of chorea as of convulsions, that it is sometimes idiopathic, sometimes symp- tomatic." Still, the cases in which it is symptomatic are so few, that it is proper to consider chorea, as it ordinarily occurs, one of the neuroses until the microscope detects some anatomical cause in the cerebro-spinal system of which we are now ignorant. Anatomical Characters, — So far as ascertained, chorea has no certain anatomical characters. As we have seen, lesions are some- times present which probably sustain a causative relation to the disordered muscular action, and others are sometimes observed which are neither a cause nor result, their presence being a coinci- dence. But there are two lesions which, though often absent, have been observed in so large a proportion of fatal cases that they are justly regarded as an occasional result when chorea is severe. Dr. Hughes, of London, collected records of the post-mortem ap- pearances of 14 cases, with the following result as regards the cerebro-spinal axis : Brain, 14 cases : healthy, 4 cases ; only con- gested, 3 cases ; softened in part or entirely, 6 cases (some of these also congested). In some of these cases those occasional results of congestion, namely, transudation of serum and extravasation of blood, in greater or less quantity, were also observed. Spinal cord: healthy, 3 cases ; congested, 2 cases (one slightly, in the other the engorged vessels were large and numerous) ; softening in medulla oblongata, 1 case ; softening opposite fourth and fifth vertebrae, 12 cases. In one there was soft, in another firm adhesion of the spi- nal meninges, and in one it is stated that the rachidian fluid was opaque. Of sixteen fatal cases of chorea occurring in St. George's Hospital, " congestion (more or less complete) of the nervous cen- tres (brain or spinal cord, or both) was met with in six cases." There was softening of certain parts of the brain in one case, and of the spinal cord in another. (Ogle, Brit, and For. 3Iedico-Chir. Bev., Jan. 1868.) Other statistics of the anatomical character of fatal chorea correspond, in the main, with those of Hughes and Ogle. These lesions are probably not present in ordinary cases, occurring only when the choreic movements are so severe that the patient is deprived of needed repose, and the important functions of the economy, as the circulation and nutrition, are seriously disturbed. The post-mortem examination of other parts besides the cerebro- 424 CHOREA. spinal axis furnishes a negative result, if we except sucli affections as have heen ascertained to act as causes of chorea. What portion of the nervous centre is chiefly involved in chorea is uncertain. Some, as Sir Benj. C. Brodie {London Lancet^ Dec. 19,1840), con- sider chorea a disease of the nervous system generally, while others have attributed it to disease or disorder of a certain part, as the corpus striatum, cerebellum, etc. Finally, it is stated that, in late experiments on choreic dogs, the movements do not cease when the spinal cord is severed from the brain, nor also on division of the posterior roots of the spinal nerves. (Legros et Onimus, Rech. sur les mouvements choreiformes du chien,Acad. des Sci.,9 Mai, 1870', Lyons 3Ied. Journ., June 5, 1870.) In these cases, therefore, the part of the axis which is in fault would appear to be solely the spinal cord. Symptoms. — Chorea is partial or general. It is partial when it aflfects a few muscles, or groups of muscles, as those of one arm, the face or neck, or of one eye. It is designated general, when all the limbs, and certain of the muscles of the face and trunk, are involved. Statistics show that partial chorea occurs more fre- quently on the left than on the right side, and in general chorea the movements on the left side are apt to predominate. The com- mencement is usuall}^ gradual. Even when finally chorea becomes general, certain muscles only are aflJected in the commencement in ordinary cases. The child in whom this disease is about to begin is observed to be fretful and impatient from slight causes, and the irregular muscular action at first is apt to be misunderstood by the parents, who reprimand him for his supposed fidgety habit. In exceptional instances, especially when the cause is a sudden and profound emotion, the commencement is abrupt, and the disease is severe and general from the first. In a majority of cases the muscles which are primarily affected are those of the face, neck, fingers, or hand on the left side. Sydenham erred, unless the clinical history of chorea has changed during the last two centuries, when he stated as the common fact that a tottering gait is its first manifestation ; but now and then such a case does occur. "Wherever the choreic movements first appear, other muscles are soon involved, so that in the course of a few weeks, sometimes of a few days, all the muscles that particir pate are engaged. A muscle aft'ected by chorea alternately contracts and relaxes, but less forcibly and rapidly than in eclampsia, and the movement is partly controlled by volition. This produces an unsteady and SYMPTOMS. 425 tremulous action of the part, wliethor a limh, the neck, or face ; which at once arrests attention, and indicates the nature of the disease. The result is similar, as regards the muscular action, whether the jDatient wills a movement, or attempts to control those which chorea produces. If the case is of ordinary severity, the movements continue with but momentary intermissions, except during sleep, when they ordinarily cease. In grave cases patients are often deprived of the proper amount of sleep in consequence of the severity and per- sistence of the muscular action, and in exceptional instances, especially when the result is fatal, the movements continue in sleep, but the sleep is not sound, and is frequently interrupted. In profound sleep, the muscles are probably always in repose. The older writers have left us graphic descriptions of those diseases which have striking external manifestations, though often with somewhat of exaggeration. Sydenham says of chorea : " The patient cannot keep it (his hand) a moment in the same place; whether he lay it upon his breast, or any other part of the body, do what he may, it will be jerked elsewhere convulsively. If any vessel filled with drink be put into his hand, before it reaches his mouth, he will exhibit a thousand gesticulations, like a mounte- bank. He holds the cup out straight, as if to move it to his mouth, but has his hand carried elsewhere by sudden jerks. Then perhaps he contrives to bring it to his mouth, and if so, he will drink the liquid off at a gulp, just as if he were trying to amuse the spectators by his antics !" In severe general chorea a similar description is applicable to the movements of the legs and features. Grimaces and distortions of the features occur, while the gait is halting and unsteady, or it is impossible to walk, and the patient lies or sits. The speech is slow, thick, and indistinct, in consequence of the muscles of the tongue and larynx becoming engaged, and even mastication and deglutition are rendered difficult. The imperfect speech in chorea is attributed partly, however, to the impairment of the mental faculties. Chorea, except in mild cases, is accompanied by other symptoms referable to the nervous system. More or less impair- ment of the mental faculties occurs in severe and protracted chorea, exhibiting itself in dulness or aimthy. The countenance sometimes presents in aggravated cases almost the appearance of idiocy. The muscles, instead of becoming hypertrophied, and more powerful by their frequent contraction, grow softer, more flabby, and weaker. Indeed, a partial paralysis sometimes results, so that a degree of 426 CHOREA. numbness is experienced in the affected part, and the limb when raised cannot be sustained. Pain is not a symptom of chorea, bnt fugitive rheumatic or neuralgic pains are sometimes experienced. Derangement of the digestive function, exhibited by a poor or capricious appetite, constipation, etc., are common. The urine of choreic patients has been examined by Drs, "Walsh, Ford, Bence Jones, Handfield Jones, Radcliffe, and others, and its elements have been found in most cases to vary from their normal quantity. Dr. Handfield Jones read a paper before the Clinical Society of London, in 1871 {London Lancet^ July, 1871), on two cases of chorea in which he had made careful chemical analysis of the urine, with the following result: During the height of the disease the amount of the urine was much in excess of what it was when the disease had ceased ; the amount of urea excreted during the choreic period was enormous ; the amount of phosphoric acid excreted when the choreic symptoms were at their maximum was excessive, but the quantity was less than the average during con- valescence ; a moderate amount of uric acid during the disease, but none upon recovery. Prognosis ; Course. — Chorea, though obstinate and often incura- ble in adults, usually terminates favorably in children in three or four months. Bouchut considers its ordinary duration at from thirty to fifty days, which is certainly shorter than the average duration in this country, except as the disease is materially abridged by treatment. The same author states that it may con- tinue only twenty-four hours, or some days, as he has observed in the convalescence from scarlet fever. But tremulousness of the muscles occurring in the state of weakness following a grave disease, and abating as the general health is restored, I should not consider as properly choreic, any more than that occurring from over-fatigue. As the choreic movements gradually increase in the initial period till a certain maximum is reached, so their decline is gradual. There are temporary variations also throughout the disease as regards the extent of the movement, which are aggra- vated by mental excitement, bodily fatigue, certain functional derangements, especially of digestion, and sometimes from causes which are not apparent. Though, as a rule, chorea in children ordinarily terminates favorably under different, and even injurious, modes of treatment, there, are exceptional cases. Romberg relates the history of a patient who died at the age of seventy-six years, having had chorea since the age of six years. In chorea limited to a few muscles, or DIAGNOSIS. 427 a group of muscles, the prognosis is more doubtful than when it affects a large number, since in the former case the cause is more apt to be some lesion of the cerebro-spinal axis. Thus chorea involving only certain muscles of the neck or of the eyes is some- times due to this cause, and is then very obstinate. Again, observations demonstrate that chorea, when at first in all probability strictly a neurosis, but of a protracted and grave character, may give rise to a central organic disease. This is the course of most of the fatal cases, congestion, softening, or other lesion occurring over a greater or less extent of the nervous centres. Radcliffe has known cerebral meningitis to supervene in two instances. With the occurrence of a lesion of the cerebro-spinal axis, new symptoms arise, such as headache, convulsions, delirium, and paralysis, and the choreic movements cease or continue, accord- ing to the nature of the lesion. Chorea, like certain other diseases, either of a nervous character, or having a nervous element, is more or less modified by intercur- rent inflammatory and febrile affections. The oft-quoted expres- sion from Hippocrates, fehris accedens solvit spasmos, observations show to be founded in fact, the most frequent example of which occurs in pertussis. In chorea the movements, as a rule, are either rendered milder or they cease as long as the febrile excitement continues ; but there are exceptions, and the subsequent course of the disease is not modified. Diagnosis. — This is not difficult in ordinary cases. The irregular movements, with consciousness preserved, enable us to make a diagnosis at sight. In its commencement, and when it continues in an unusually mild form, chorea might be overlooked by the physician, as it often is by the parents, the movements being at- tributed to a fidgety habit ; but medical advice is seldom sought till the movements are so pronounced that it is impossible to err, except through gross ignorance or carelessness. It is important to determine when chorea merges in an organic disease, and also whether there is a local cause of the chorea. A careful and intelligent study of the symptoms and history of the case is requisite in order to a correct diagnosis in these particulars. Treatment. Begimenal. — As chorea in a large proportion of cases occurs in a state of anaemia, and the vital forces are ordi- narily more or less reduced, obviously the regimen should be such as invigorates the system. Fresh air and out-door exercise, active or passive, according to circumstances, with the avoidance of undue excitement, are requisite ; and the diet should be nutritious, but 428 CHOREA. plain and unirritating. The various functions should be preserved so far as possible iu their normal state. In exceptional instances, when the choreic movements are violent, the patient should lie in bed, and the muscular action, if so constant and excessive as to deprive him of the requisite sleep, should be restrained by light and well-padded splints. JfedicinaL — Sometimes among the co-operating causes is one of a local nature, which is susceptible of removal, as a carious and painful tooth, intestinal worms, etc., and measures calculated to effect this are obviously required. Allusion has alread}- been made to a case iu which the employment of the oleum filicis maris, and expulsion of a tapeworm, effected a speedy cure. The remedy which has been most employed in chorea, and wliieli in consequence of the antemia is plainly indicated in a large pro- portion of cases, is iron. It does not interfere with the employ- ment of other remedies wbich have a more specific effect. Xcarly all the ferruginous preparations have been prescribed in different cases with benefit. Radcliffe, who justly ranks as one of the firet authorities in nervous diseases, gives the preference to the iodide of iron, believing that iodine, as well as iron, exerts a curative influence. I have of late inclined to the use of the ammonio- citrate, as it is easy of administration in simple syrup, and is well tolerated. Arsenic, highly extolled by Romberg and others, is a remedy of undoubted value. It is convenientlv o-iven in Fowler's solution. It should be administered in doses of three to five drops three times daily, after the meals, as in the treatment of cutaneous or other aftcctions. Eadclifle has administered by subcutaneous injection Fowler's solution, diluted with an equal quantity of water, in a few cases of obstinate local chorea, with a satisfactorv result. An adult with choreic movements in one side of the neck of nine years' duration was nearly cured by fourteen injections, employed at intervals of a few days, the quantity employed being increased gradually from three to fourteen minims of the solution. Another remedj- of undoubted value is strychnia. Trousseau, who prescribed it iu most cases, and highly extolled it, employed the following formula: — R. Strychnise sxilphat. gr. j. Syr. simplic. oU^s. Misce. A child of the ordinary age, say ten years, takes at first a tea- spoonful twice or three times daily, at uniform intervals, and the dose is gradually and cautiously increased until it begins to pro- MEDICINAL. 429 duce physiological effects. Strychnia, when employed to the extent of causing some rigidity, is more efficient as a remedy, hut smaller doses have been found useful. Prof. Hammond {Diseases of the Nervous System^ p^g^ ^l^J says: "My main reliance is on strychnia, which, I think should be given in gradually increasing doses, somewhat after the manner recom- mended by Trousseau. . . . This plan of treatment certainly shortens the duration of the disease very materially, and causes great im- provement in the general health of the patient. Sometimes the effect is so well marked, and is so immediate, that it is not neces- sary to increase the doses to the extent of causing muscular cramps, but generally the full therapeutical effect of the drug is not obtained till the calf of the leg or the nucha has slicfht tonic spasm. I have never seen the slightest ill-consequence follow this mode of treatment, and the doses are increased so gradually that, with careful watching, danger need not be apprehended." Dr. Hammond has treated thirtv-two children with this agent without a single failure. But as chorea terminates favorably with smaller and safe doses, even if the time required is longer, it does not seem proper to re- commend its employment to the exter.,^ of producing pjhysiological effects for general practice. Bouchut, speaking upon this point, says : " But, with these precautions, strychnia is extremely danger- ous, for I have seen, at the Ilopital des Enfants Malades, a young girl of thirteen years die in tetanus," produced by an increased dose of this drug (article on Chorea). Dr. West, in his Lumleian Lectures, also says : "I have seen one instance in which its employ- ment, while it failed to benefit a somewhat severe case of chorea, was followed by two attacks of violent tetanic convulsions, which nearly proved fatal ; " and he adds, " the twitching of the limbs of itself prevents our becoming aware of the dose being excessive, and a child's inability to describe its sensations deprives us of another." For such reasons, Dr. West does not favor the employment of this agent. Still, any agent may be given in an overdose, and it is not difficult to prescribe strychnia in a dose which will be efficient and yet safe for children at the age at which chorea ordinarily occurs. I have employed bromide of potassium in a few cases, but with so little benefit that I am not inclined to continue its use for this disease. Others have not been more successful. However effica- cious the bromide may be in ejjilepsy, it does not apptear to be a remedy for chorea. Cimicifuga, first employed by Jesse Young of this country, is 430 CHOREA. highly esteemed by Philadelphia physicians in the treatment of chorea. I have employed the fluid extract in doses of half a drachm, increased to one drachm, for a child from six to ten years of age, and though it benefits some cases, it has no appreciable effect either in moderating the movements or abridging the duration of others. Ether, assafoetida, valerian, musk, the oxide and sulphide of zinc, turpentine, tartar emetic, opium, and numerous other reme- dies, have been recommended, and some of them have seemed use- ful in certain cases. In this city sulphate of zinc has been frequently employed as a remedy for chorea, and in gradually increasing doses till more than twenty grains were administered three times daily, but it has not appeared, so far as I have been able to ascertain, to exert any marked influence either on the severity or duration of the choreic movements. Justice, however, requires us to state that Dr. West, who has written most recently on the nervous dis- orders of children, thinks that it has been beneficial in certain cases in which he has employed it, and regards it on the whole as the best remedy. Radcliffe, who has had ample experience in the treatment of nervous affections, writes : " L: an ordinary case of chorea the plan of treatment which I have now adopted as a rule for some time is to give cod-liver oil, in conjunction with hypophosphite of soda, making the draught containing the latter salt the vehicle for the administration of the cod-liver oil." Sometimes camphor or the sesquicarbonate of ammonia is added. Of more than thirty cases treated in this way, the average duration was under three weeks. Radcliffe began to prescribe these remedies on theoretical grounds, believing that phosphorus and cod-liver oil were re- quired to restore " nerve tone," and the result of this treatment has certainly been such as to commend it to the profession. To children he gives from five to eight grains of the hypophosphite of soda three times daily. In those severe cases in which the choreic movements prevent the proper amount of sleep, a moderate dose of hydrate of chloral may occasionally be advantageously administered. Electricity has been many times employed in the treatment of chorea, and though some, cliiefl}' electricians, believe that it has a curative effect, others, and the majority, fail to see any material benefit from its use. Cold general baths, the shower-bath, frictions along the spine, etc., have been employed ; but the local treatment, which has so INFANTILE PARALYSIS. 431 far been most successful, and which promises to supersede all others, consists in the application of ether spray over the spine. About two ounces of ether are employed at each sitting, the spray being applied from an atomizer up and down the whole length of the spine if the chorea is general. The operation, which occupies from ten to fifteen minutes, should be repeated daily or every second day. Although this mode of treatment is quite recent, a considerable number of cases have already been reported, in which the spray has apparently had a very decided efiect in controlling the disease. CHAPTER XV. INFANTILE PARALYSIS. Paralysis m young children, especially infants, is in most instances due to causes which seldom produce it in adults. The principal cause of it in the adult, namely, cerebral apoplexy, is indeed rare in children. Paralysis in children has the following recognized causes: 1st. A change in the blood, not fully under- stood, induced by certain grave diseases, as diphtheria, typhoid fever, measles, scarlet fever, etc. 2d. Reiiex influence. The func- tion of some part of the system is in some way disturbed, and paralysis occurs in certain muscles, may be at a distance from the cause, and it disappears when that cause is removed, unless it has continued too long. The only rational explanation is found in the fact of a continuous connection between the local causes and the paralyzed muscles through the aiierent and efferent nerves, and the nervous centres. 3d. An anatomical alteration in the muscular fibres, the nerves and nervous centres remaining unafiected. This has been designated myogenic paralysis. This form of paralysis is probably often of a rheumatic nature. We see a similar disease in that form of facial paralysis of the adult which results from long exposure of the face to a cold wind. 4th. A cause seated in the nervous system, either congestion, hemorrhage, softening, or com- pression, whether from inflammatory products or other cause. Paralysis occurring as a symptom, or sequel of some obvious local or general disease, as diphtheria, lesion of the nervous centres, etc., and which may occur at any age, need not detain us. It is described in connection with the primary diseases on which it 432 INFANTILE PARALYSIS. depends. But there is a form of paralysis which in the present state of our knowledge we must consider an idiopathic disease, and which is peculiar to the first years of life, or is so rare at other periods that it is proper to regard it as strictly a disease of infancy and early childhood. It occurs between the ages of six months and three years. Symptoms. — The previous health of the patient is usually good. The paralysis does not always commence in the same manner. In some it begins abruptly, after sound sleep. The child goes to bed well, sleeps through the night, and awakens in the morning paralyzed. I have known it to occur in one instance after sleep in the middle of the day. In these cases there has sometimes been an exposure, before the sleep, to wind or rain, or from sitting upon a cold stone. In other and the majority of cases the paralysis is preceded by a very decided febrile movement, which comes on suddenly, without appreciable cause, and after a few days the power of motion is found to be lost in one or more of the limbs. There is no symptom during the febrile movement to indicate any affection of the brain: consciousness is retained, and there is no more headache or apparent liability to convulsions than occurs in other pathological states accompanied by an equal amount of fever. In whatever way the paralysis begins, it is at its maximum in the commencement. Occurring as by a stroke, the full extent of the paralytic state is exhibited at once, and so far as there is any sub- sequent change, it is an improvement, as regards the number of muscles affected, and the degree of the paralysis. Most frequently the paralysis affects one or both lower extremities. Occasionally one of the upper extremities is also paralyzed in addition to the lower, but paralysis of an upper extremity is less in degree, and disappears sooner, than that of the lower. The bladder and lower bowels remain unafiected, since only the muscles of volition are involved. Sensation is unimpaired in the affected limbs, and' in the commencement there is even in some cases a state of hyper?es- thesia (West). The febrile movement, which precedes and accom- panies the paralysis in certain cases, gradually abates, and in a few days nothing abnormal remains except the loss of power in the affected muscles. These muscles are in a flaccid and relaxed state, so that the limb falls by its weight when unsupported, and they are usually free from pain. The number of muscles paralyzed varies greatly in different cases. Only one muscle or a single group of muscles may be affected, or, on the other hand, both the extensor and flexor muscles of two or more limbs. In the opinion of Mr. PROGNOSIS — PROGRESS. 433 Adams, the following table exhibits the groups of muscles and single muscles most fre(iuciitl3^ involved, and in the order stated. Groups. 1. Extensors of toes, and flexors of the foot. 2. Extensors and supinators of the hand. 3. Extensors of leg, and with them usually the first group. Single Muscles. 1. Extensor longus digitorum of toes. 2. Tibialis anticus. 3. Deltoid. 4. Sterno-mastoid. Prognosis — Progress. — The paralysis in nearly all cases soon begins to abate. The power of motion returns little by little, and whatever improvement occurs is permanent. There is no retro- gression in the convalescence. The sooner improvement com- mences, the more favorable is the prognosis. In the most favorable cases there is complete restoration in from three to four weeks. In other patients, while certain of the muscles regain the power of motion, other muscles, oftener those of the lower extremity than upper, do not recover their function, and, unless proper reme- dial measures are employed, and even with them in certain instances, atrophy soon commences. The temperature of the paralyzed limb falls three, five, or even eight degrees, and the amount of blood which circulates in it is diminished so that the pulse of the limb is feebler and its vessels smaller than in health. With the atrophy the contractility of the muscular fibres by the electric current diminishes, and in unfavorable cases after a time powerful induced and even primary currents have no appreciable effect. The nutri- tion of a paralyzed limb is always imperfect, and if the paralysis occur in a child, its growth is retarded. Therefore in cases of pro- tracted or permanent infantile paralj^sis of one limb a disproportion occurs both in diameter and length between it and that on the- opposite side. If the paralysis continue, the ligaments of the paralyzed limb become relaxed and lengthened. West mentions a case of paralysis of the deltoid in which the humero-scapular ligaments were so extended that the humerus droj^ped from the glenoid cavity, so as to increase the length of the limb three- fourths of an inch. In the paralysis of certain muscles of the lower extremity, and continuance of the contractile ]30wer in 28 434 INFANTILE PARALYSIS. others, we have the conditions which give rise to club-feet, and accordingly this deformity is the common result of the paralysis when it is not cured. Etiology. — Opportunity for post-mortem examinations seldom occurs, and what the exact pathological state is which causes the paralysis has not been fully ascertained. As most of the cases occur during the time of first dentition, it was long believed that this physiological process was the chief cause, and hence the term dental paralysis by which this disease was designated. It is now, however, generally admitted that the evolution of the teeth is not a direct cause, and can only operate as a cause by increasing the susceptibility of the nervous system. The brain and cerebral meninges may also be excluded as sustaining any causative rela- tion to the paralysis. There is no symptom indicating that they are involved. The mind remains clear, and convulsions are no more frequent than in any other disease attended by an equal degree of febrile reaction. Most of the highest authorities as regards diseases of the nervous system, attribute infantile paralysis to disease of the spine. If we accept this theory, certainly the cause of infantile paralysis must in many instances be one of the mildest of the pathological states of the nervous centres, since there are so many cases of speedy recov.ery. Spinal congestion is held by Radclift'e and others to be this pathological state. Still there are certain dififerences in the symptoms of spinal congestion as it ordinarily occurs, and those present in many cases of infantile paralysis. (See *S'^. Thomas's IIosp. Bep., 1870, Barwell.) Another theory regards infantile paral3\sis as entirely a peripheral ■disease, resembling in many instances, both as regards origin and nature, facial paralj^sis as it occurs in adults from protracted ex- posure to cold. This theory is thus advocated and enunciated by Mr. Barwell:' "I do not see how at all we can escape the conclu- sion that this paralysis is purely peripheral ; a malady affecting the ultimate fibrillse of distribution of the nerves among the muscular elements." .... "Its essence lies probably in some subtile de- rangement in relationship between the ultimate muscular and terminal nerve-fi^bres, perhaps from some inflammatory, perhaps from some chemical or nutrient charge." {Ibid.) This theory may not be broad enough to cover those cases in which the paralysis is extensive, as when both lower and upper extremities are involved, but the facts observed in certain cases do harmonize better with this theory than with that of a central origin, and I would ask ANATOMICAL CnARACTERS. 435 whether in some instances, at least, the supposed hypersesthesia which attends certain cases may not he a tenderness due to the anatomical chano-e affectino; the terminal nerve-fibres alluded to by Barwell. The following is an example of the class of cases which the symptoms indicate have a peripheral rather than central origin. A. K., German, female, aged three years four months, fleshy; had been in the habit of sitting on the ground near the house and on the door-sill. On July 2d, 1871, she had a sound sleep in the afternoon, having been entirely well previously, and awoke trembling and with a high fever at 3| P.M. At 8 P.M., the febrile excitement continuing, general clonic convulsions occurred, lasting about ten minutes. At this time I was called to see her, and found the face flushed, surface hot, and pulse about one hun- • dred and thirty. Consciousness returned after the convulsion. The intelligence was good, tongue moist and slightly furred, bowels rather constipated, and the urine was freely passed. The febrile excitement continued two days, when it gradually and en- tirely abated, but before it ceased paralysis of the left lower ex- tremity was observed. ISTo weight at first could be sustained upon this limb, and it hung powerless when we endeavored to make her walk. The attempt caused her to cry, as if in pain, and pressing upon the thigh, or moving it, had the same eflect. The thigh of this limb did appear slightly swollen on inspection, but measurement did not indicate any notable enlargement. The dif- ference in circumference was certainly not more than one-eighth to one-fourth of an inch. There was no appreciable increase of heat in the thigh over the general temperature of the body. Sensibility remained in every part of the limb, and the loss of power was not complete, for on the first day, as soon as the paralysis was ob- served, slight and imperfect movements could be produced by pinch- ing the limb. In three weeks the use of the limb was fully restored, by mildly stimulating liniments, and simple medicines to regulate the bowels. It does not seem improbable that in the future, when the true pathology of this disease is revealed, we shall find that there are two forms of it, one having a centric origin, and the other an eccentric,'cases like that described above being examples of the latter. Anatomical Characters. — All muscular fibres which are in a state of disuse, begin in a few weeks to atrophy,* and undergo fatty degeneration. The transverse striae in the primitive muscu- lar fasciculus gradually disappear and are replaced by granules of fat, and later still by small oil globules. If we examine with the 436 INFANTILE PARALYSIS. microscope the fibres from a muscle wliicli has been a considerable time paralyzed, but which has still some electric contractility, we will find in places the striae remaining, but numerous opaque granules of a fatty nature within the sarcolemma wherever the strise are absent, and in other places, where the degeneration is most advanced, oil globules occur, always small. If the paralysis is more profound, the striae have all disappeared. At a later stage, usually after some years in cases of complete and incurable paraly- sis, the fatty matter may be to a considerable extent absorbed, and the fibrous network of the muscle which remains presents a ten- donous appearance. There is a great difference, however, in differ- ent cases, as regards the rapidity with which these changes occur. Hammond states that he found the striae remaining in two cases after the lapse of more than four years of decided paralysis. The nerves of the paralyzed part also undergo atrophy. Little can be said that is positive and satisfactory in reference to those anatomical changes, whether peripheral or centric, which are believed to cause the paralysis. As to the peripheral cause, nothing is known beyond conjecture. As to the spinal cause, several autopsies have been made of those, dying of various ages, who were paralyzed from infancy or childhood, but there has been no uniformity as regards the condition of the spinal cord or its meninges, and an examination of the records of these cases con- vinces me that most of them were examples of spinal disease, which may occur at any age, and not of the true infantile paralysis. Certain diseases of the spine in the child will give rise to paralysis as they do in the adult, but we should not regard a case as one of infantile paralysis unless it has the clinical history of that disease. Thus, writers have included in their descrij^tion of the lesions of infantile paralysis a case reported by Berend, in which the cele- brated Recklinghausen found tubercles in the spine. Another case, reported by Hutin, presented atrophy of the lower part of the spinal cord, but the paralysis, unlike that which we are describing, began at the age of seven years. The following are the chief lesions which have been found in reported cases : sclerosis of spinal cord (increase of its connective tissue, and more or less atrophy of the nervous substance by compression) (Laborde and others), cica- trix and clot (Hammond), spinal arachnitis, with thickening of meninges (Jaccoud), atrophy of anterior roots of spinal nerves (Longet), atrophy of lower part of spinal cord (Hutin), tubercles (Berend). Finally, Fleiss, Adams, and Rilliet and Barthez ex- amined cases and found no lesions of the spine or spinal meninges. DIAGNOSIS — PROGNOSIS. 437 It is obvions that the discovery of such varied lesions in the spi- nal cords of those who have been paralytic from childhood aids 1)iit little in elucidating the pathology of infantile j^aralysis. These observers have seen the lesions in spinal, whether they have or not in cases of true infantile paralysis, but it is to be observed that, tubercles excepted, these lesions have been such as would be likely to result from intense and continued congestion of the cord. Intense congestion may cause apoplexy, and congestion long con- tinued often causes a subacute and chronic inflammation, among the results of which, in case of the spine, would probably be sclerosis and atrophy with thickening and opacity of the meninges. Or may not the atrophy be a result of the paralysis just as atrophy of the nerves occurs? But in order to determine the exact relation which the state of the spine sustains to infantile paralysis, accu- rate and minute examination of the spinal cord is required in those who have died of intercurrent diseases at an early period of the paralysis. The researches of J. Lockhart Clarke have demonstrated that the microscope may aid greatly in elucidating the cause and nature of obscure diseases of the nervous system. It has already, in his hands, revealed structural changes of the cerebro-spinal axis in certain affections, which without its aid would be considered neuroses. It cannot be doubted that it will yet contribute much to a better understanding of this disease. Diagnosis. — This is easy as soon as the attention of the j^hysi- cian is directed to the state of the limbs. In a large proportion of cases the mother or nurse first observes the paralysis, and calls the attention of the physician to it. A knowledge and recollection of the facts in relation to infantile paralysis should lead the physician to examine the state of the limbs in all cases of 2:reat febrile excitement in young children, occurring without apparent cause. Prognosis. — It may be confidently predicted, if the child is seen early, and correctly treated, that the paralysis will diminish, if it cannot be entirely cured. .If the paralysis has continued a con- siderable time, and there is no electric contractility of the muscles, there is poor prospect of any improvement. The induced current will fail, sometimes, to cause muscular contraction, when the direct current may produce it ; but if there is no response to the direct current, there is no therapeutic agent which can restore the use of the limb. In cases seen soon after the paralysis commences, and before the stage of atrophy, the prognosis is most favorable, when there is still slight voluntary motion, and improvement commences early. 438 INFANTILE PARALYSIS. In most instances, even when the paralysis has been mild, and of comparatively short dnration, the limb, although its motion is full}" restored, is for a long time weaker than the limb on the opposite side. Treatment. — A physician called at the commencement of the paralysis should endeavor to remove every cause which might increase the irritability of the nervous system. It is proper to scarify the gums, if much swollen and tender from dentition, the bowels should be kept regular, worms, if present, expelled by appropriate medicines, and the diet be plain and unirritating. As the cause of the paralysis is in the commencement still opera- tive, measures are appropriate which are calculated to remove it. Local treatment is very important at all periods of the paralysis. In the first days a tepid hip-bath employed daily, with brisk fric- tion of the surface, has a salutary effect. Stimulating embrocations along the spine, and upon the paralyzed limb, are appropriate also at an early date. Possibly, if there is a strong ^jrobability of spinal congestion, cold -applied along the spine, by ether spray or otherwise, might be useful, but I am not aware that it has been employed in this disease. If the paralysis appear to have a central origin, ergot, the bromide and iodide of potassium, which may be administered variously combined, or singly, are the appropriate remedies for the first twelve or fourteen days. Administered every three or four hours in proper dose, they are the most eiiectual of all internal remedies for diminishing spinal congestion, and pre- venting efiJ'usion, and permanent structural change in the cord. If the paralysis continue, or is not progressively diminishing, we should not delay more than two Aveeks from the commencement of the disease before employing appropriate measures to restore the use of the limbs, and prevent atrophy of the muscles. The expectant plan of treatment which is proper in many diseases of children is unsuited to this. Muscular atrophy may commence in three weeks, and the further it has advanced, the more difiicult and tedious will be the cure. Therefore, by the close of the second week if the paralysis continue, or is not rapidly disappearing, iron as a tonic with strychnia should be prescribed. There is j^robably no better formula for the exhibition of these agents than the fol- lowing from Prof. Hammond: — ^. Strycli. sulpliat. gr. j ; Fcrri pyropbosphat. .^ss ; Acidi phosphorici dilut. §ss; Syr. zingib. §iijss. Misce. TREATMENT. 439 One-third of a teaspoonful, or one-ninetieth of a grain of strychnia, is sufficient for a cliild of two years, administered three times daily. Ilillier, Barwell, and otliers have employed subcutaneous injections of stryclmia, with, it is stated, a good result. While in the first and second weeks the child has been allowed to remain quiet, he should now be encouraged to use his limbs. Frequent muscular contraction must, if possible, be produced, and the voluntary movements, when not totally lost, aid greatly in pro- moting the nutrition of the muscles and restoring their function. Immersing the limb for half an hour in water at a temperature of 110 or 115 degrees, rubbing the limb with a coarse towel, and kneading the muscles, aid also in restoring nutrition and tone to them. But, fortunately, w^e have an invaluable agent in the subtle electrical fluid, which can be made to penetrate the muscles and cause their contraction when every other measure has failed. The induced current should be employed upon the limb every day, or second day, if it cause the muscles to act, but if the loss of power is of long standing, or complete, so that the induced current is not sufficiently powerful, the direct current should be used instead. It is not regarded as important which way the current p)asses, pro- vided the muscles contract. In a large proportion of cases a cure cannot be effected until the lapse of several months, so that the patience of the physician and friends may be put to the test; but if muscular atrophy can be prevented, and the limb kept at near the normal temperature, this mode of treatment will ordinarily in the end be successful. The primary affection which caused the paralysis will, with some exceptions, abate of itself, so that the state of the muscles and their nervous supply demand the whole attention. Observations show that by treatment perseveringly employed, fatty degeneration of the muscular fibres can not only be arrested, but the fat which has already been deposited within the sarcolemma may be absorbed, and the muscular strise restored. In those cases in which it has been necessary to employ the direct current, the induced should be employed, whenever by the improvement of the case it is found sufficiently powerful. 440 FACIAL PAEALYSIS. CHAPTER XYI. FACIAL PAEALYSIS. Causes. — Facial paralysis, in the new-born, commonly occurs from pressure of the blade of the forceps upon the portio dura, at a point external to the stvlo-mastoid foramen. It mav also occur in children of any age, as it is known to in the adult, from exposure of the face to a cold wind. The pressure of a tumor upon some part of the portio dura, or even of the fist of the child placed under the face during sleep, may cause it. It may also result from disease of the temporal bone, producing pressure on the nerve, as caries, periostitis, suppuration, or hemorrhage into the aquteductus Fallopii, and also from intra-cranial disease afiecting the pons Varolii or the medulla oblongata. Symptoms. — The portio dura, which is a nerve of motion, supplies the muscles of the face, and therefore its loss of function is at once manifest in distortion of the features. The eye of the affected side remains open in consequence of paralysis of the orbicularis palpe- brarum, the upper lid being raised by the levator muscle, which is not paralyzed, as its nerve is derived from the third pair. From the inability to wink, the eye becomes irritated by dust and con- stant exposure, and, in children old enough to have an abundant lachrymal secretion, the tears are apt to flow over the cheek. On account of the paralyzed and relaxed state of the facial muscles the mouth is drawn towards the healthy side, while the affected side presents a swollen appearance. Movement of the eyebrow and of the anterior portion of the scalp on the paralyzed side is also impossible, since the occipito-frontalis and corrugator supercilii are supplied by the portio dura. If the cause of the disease is located above the origin of the chorda tympani, the flow of saliva, and consequently the taste, on the affected side are impaired. If the injury is posterior to the gangliform enlargement, those symptoms are superadded which are due to paralysis of the petrosal nerves. Prognosis. — This depends on the cause. K the cause is peri- pheral, as from the pressure of the forceps or from cold, the prog- nosis is favorable. In cases of deep-seated lesion, unless syphilitic, PARALYSIS WITH APPARENT HYPERTROPHY. 441 the prognosis is usually unfavorable. A sjj»liilitic lesion can often be removed by appropriate remedies and the paralysis cured. Treatment. — In the paralysis of the new-born, from pressure of the forceps, all that is required is occasional rubbing or gentle kneading over the affected muscles. In those who are older, the nature of the cause, so far as ascertained, must determine the treatment. If there are glandular swellings, and discharge from the ear from scrofula, cod-liver oil and the syrup of the iodide of iron are required internally, with appropriate external treatment of the glands and ear. If sy^jhilis is the cause, mercurials and the iodide of potassium should be employed. If the patient does not begin soon to improve, the treatment recommended for infan- tile paralysis, modified somewhat on account of the difference in location, is appropriate. Iron and strychnia may be administered internally; friction, kneading, hot applications, and the electric current employed. The current should have only moderate inten- sity, for a high degree of it might injure the vision. It should be applied every second day, with one pole over the mastoid foramen, and the other moved slowly over the muscles. PARALYSIS WITH APPARENT HYPERTROPHY. This is a rare disease. It was first described by Duchenne in 1861, and since the attention of the profession was directed to it, cases have been observed on the continent, in Great Britain, and this country. Though our acquaintance with this disease is so recent, it has been fullv and accuratelv described bv various writers in our language. The Transactions of the Load. Path. Soc. for 1868 contain a translated pa]:>er relating to this disease, communicated by M. Duchenne, with photographic views, remarks by Lockhart Clarke, and also the histories of two cases occurring: in London, and ex- hibited to the society by Adams and Hillier. In this country an elaborate paper has appeared on this form of paralysis, from the pen of Dr. Webber, of Boston, who succeeded in collecting the records of forty-one cases. {Bost. Jled. and Surg. Journ., Xov. 17, 1870.) Meigs, and Pepper, and Prof. Hammond have described this dis- ease in their treatises, and the following wood-cut represents a case which occurred in the practice of the last gentleman, and which conveys a good idea of the appearance of one affected with this paralysis. In certain cases, however, as in one figured by Duchenne, there are still greater curvatures and enlargement than are repre- sented in this wood-cut. 442 PARALYSIS WITH APPARENT HYPERTROPHY. Symptoms. — This disease in a considerable proportion of cases begins in infancy, and attention is first directed to it when the patient attains the age at which it begins to stand and walk, which is not ordinarily till some months later than the usual time. In eleven of the cases tabulated by Webber in which the disease had an early commencement, walking was impossible till between the ages of seventeen months and three years, and then it was in a clumsy manner. The gait, which is unsteady and waddling, has been compared to that of a duck. The child stands with the legs wide apart, and, from the unsteadiness of the gait, frequently stumbles and falls. It is admitted by those who have had the best oppor- tunities to study the disease, that the muscular weakness com- mences before there is any appreciable enlargement. Therefore, if the disease begin after the child has walked, the peculiar clumsy gait attracts attention before there is anything in the appearance to indicate the nature of the disease. The enlargement ordinarily occurs first in the calf of one leg, then in the opposite calf, and later in the thighs and hips. In l^ie- meyer's case, the muscles of the gluteal re- gion were first afl'ected. When the disease is fully developed, the spine is so incurvated that a perpendicular line from the most poste- rior of the spinous processes falls behind the sacrum. Duchenne attributes the curvatures to weakness of the erector muscles of the spine. As the disease advances, the muscles of the trunk and upper extremities become in- volved, though the enlargement is less rapid and less in degree in these muscles than in those of the lower extremities. Finally, in advanced and severe cases walking is impos- sible, and the patient is obliged to remain in a reclining posture. Movements are now often painful, and distortions may occur on account of the loss of antagonism in the muscles. Experiments show that in some cases the electric contractility of the muscles remains nearly normal, while in other cases it is impaired. The skin retains its normal sensibility. The intellectual faculties are usually more or ANATOMICAL CHARACTERS. 443 less impaired, cspcciall}^ in tliose cases which begin in early infancy. This disense is chronic, rarely terminating till after five or six years, and in many not till a considei'ably longer time. Anatomical Characters. — There have been so few post-mortem examinations of those who died having this disease, that it is still uncertain whether there is any centric lesion. Cohnheim examined the spinal cord in one case, and could find nothing ab- normal. Recently, Mr. Kesteven has examined the brain and spinal cord from a case, and found dilatation of the perivascular canals, both in the brain and spinal cord, and also spots of granular degeneration chiefly in the white substance, "caused by loss of cerebral tissue replaced by morbid matter." (Journ. of- Mental Sci., Jan. 1871). As this child was imbecile, it is not improbable that these lesions were connected with the mental state, and not the muscular disease. It is probable, from the facts which have been observed, that the lesions of this paralysis are eccentric, or if central lesions occur, that they are consecutive and subordinate. As the disease consists in a sclerosis, or hyperplasia of the connective tissue surrounding the muscles, there is sufficient explanation of the paralysis in the impairment of function, and atrophy of muscular fibres, which such a hyperplasia would be likely to produce by its mechanical effect. Analogous examples will occur to the reader, of impairment or loss of function of internal organs, from hyperplasia of their connective tissue. Still, in those cases of this disease which have been observed from their commencement, weakness of the muscles has appeared before there was that degree of hyperplasia which produced any decided enlargement of the affected part. The disuse of the muscles increases their atrophy, consequently in cases of this disease which have continued a considerable time, and are fully developed, the microscope shows not only atrophy of those muscles whose connective tissue have undergone hyperplasia, but also to a certain extent of those which are adjacent, and have a similar function, but are not the seat of the disease. The aiFected muscles present a pale yellowish hue, resembling, says ISTiemeyer, the appearance of lipoma. Examining by the microscope, we find in addition to a large increase in the fibrous tissue, and atrophy and in some places disappearance of the muscular element, more or less fatty matter, granular and globular, occu23ying the interstices. Mr. Kesteven describes as follows the appearance of the muscles in the case which he examined : " The muscular substance is pale, almost white, and very greasy. The superabundance of fat is 41-i PARALYSIS WITH APPARENT HYPERTROPHY. evident to the naked eye. The muscular fibres present the ordi- nary striation, but less distinctly than usual. The ultimate fibres are pale, and separated by a large increase of areolar and fibrous tissue. Causes. — These are obscure. Duchenne, in cases which he ex- amined, could find no evidence of inherited taint or predisposition. ^Nevertheless, in several of the recorded cases one or more brothers or sisters were similarly affected, showing some latent cause in the family. In one case observed by Duchenne the disease appeared to be congenital, for at birth the limbs were unusually large, and the patient when he came under observation had never been able to walk. 'No relation has been observed between syphilis, scrofula, or other diathetic diseases, and this form of paralysis. Boys are more apt to be affected than girls. Of the cases embraced in the statistics of Dr. "Webber, thirty-eight were boys and seven girls. Prognosis. — This disease is in most instances progressive, termi- nating fatally after a variable period. It is in its nature chronic, rarely ending in less than five or six years, and a considerable proportion living longer, some even attaining adult age. The paralj^sis may be stationary for a time, but afterwards continue to increase. Duchenne has reported one case of recovery. In two or three other instances patients appeared to improve somewhat under treatment, but the writers admit they may have become worse afterwards. Death is apt to occur, not directly from the paralysis, but from some intercurrent disease, especially of the lungs. Treatment. — The treatment thus far employed* has been chiefly local, consisting in the use of electricity, and kneading or sham- pooing over the affected muscles. Both the primary and induced electrical currents have been employed, but, unfortunately, with- out any appreciable benefit in most cases. Benedikt, who claims a better result from electrization than any other observer, applied the copper pole over the lower cervical ganglion and the zinc jDole along the side of the lumbar vertebrae by means of a broad metallic plate. SECTION" 11. DISEASES OF THE RESPIRATORY SYSTEM. CHAP TEH I. CORYZA, The term coryza is a2:)plied to inflammation of the Sclnieiderian membrane. It is acnte or chronic. The acute form is primary or secondary. Acute primary coryza is common in infancy and child- hood. Its usual cause is exposure to currents of air, to cold, and especially to sudden changes of temperature from warm to cold. The cause is the same as that in the ordinary forms of bronchitis. These two diseases frequently indeed coexist, occurring from the same exposure. The inflammation in such cases commences upon the Schneiderian membrane, immediately upon the operation of the cause, and soon after extends to the bronchial tubes. Acute coryza may also be produced by the inhalation of irritating vapors, hot air, or dust, and also by the presence of a foreign body, as a button or bean, in the nostril. Secondary coryza is commonly due to a specific cause. The diseases in connection with which it occurs are hooping-cough, measles, scarlet fever, diphtheria, and constitutional syphilis. In the infant, coryza is one of the first manifestations of hereditary syphilitic taint. Acute primary coryza ordinarily abates in from one to two weeks. The secondary form gradually declines, in most cases, when the primary affection on which it depends is cured. Syphi- litic coryza is more protracted than the primary form, or than that accompanying the eruptive fevers. Some children are so liable to coryza that it occurs whenever they take cold. Occasionally it is so frequently renewed in the winter months, that it resembles the chronic form of the disease. Chronic coryza is commonly dependent on a dyscrasia. It cor- 446 CORYZA. responds with chronic inflammation of the external ear, and otor- rhoea is not infrequent in connection with it. The dyscrasia is indicated hy pallor, flabbiness of the flesh, and liability to glandu- lar swellings. Chronic coryza may also occur in those who have good general health, as the result of an acute attack. Many a case dates back to one of the exanthematic fevers, the local affection continuing after the general health is restored. Rarely chronic coryza comes on gradually and without appreciable cause. Anatomical Characters. — The alterations which the nasal mucous membrane undergoes when inflamed, vary considerably in different cases. In the simplest and most common form of coryza, this membrane is sometimes in patches, sometimes generally red- dened, thickened, and softened. Its papillse are prominent, produc- ing an inequality of the surface. Ulcerations are not common in simple acute coryza, but they sometimes occur in the chronic form. In diphtheria, and not infrequently in scarlet fever and variola, the corj'Za is pseudo-membranous, and when it presents this form it is associated with pseudo-membranous angina or laryngitis. A case of pseudo-membranous coryza occurring in measles is related by M. Guibert. The patient was a rachitic boy, three and a half years old. The pseudo-membrane, in severe cases, may cover almost the entire surface of the nostrils, but ordinarily it occurs in patches. Symptoms. — The constitutional symptoms are mild or severe, according to the gravity of the inflammation. If the coryza is acute and pretty general, there is febrile movement, with thirst and loss of appetite. Frontal headache is common, from the proximity of the inflammation to the head, or its extension to the frontal sinuses. Sneezing is the first symptom in many cases of acute corj'za. As the inflamed membrane swells, more or less ob- struction occurs to respiration. The breathing is noisy, especially during sleep, and, in severe cases, the patient is compelled to breathe mostly through the mouth. If there is much obstruction to respiration, the suffering of the patient is considerable, from the sensation of fulness in the nostrils, the headache, and the muscular effort required in each respiratory act. In the conmicncement of coryza the patient experiences a sensa- tion of dryness in the nostrils, which is soon succeeded by a thin dis- charge of a serous appearance. In the course of a few hours the secretion becomes thicker. It is muco-purulent, and remains such till the disease begins to decline. Inspissated mucus and crusts PROGNOSIS — TREATMENT. 447 are apt to collect within tlie nostrils and around tlicir orifice in chronic coryza, and sometimes also in the acute disease, if the dis- charge is not abundant. These crusts increase the difticulty of breathing. Often the acridity of the discharge is such that the skin of the upper lip, and around the nostrils, is excoriated. Prognosis, — Simple, uncomplicated coryza rarely terminates fa- tally. It is only dangerous in young nursing infants, in whom it may seriously interfere with lactation. Coryza, accompanying the eruptive fevers, although it may increase the suffering, does not materially increase the danger. ' Syphilitic coryza subsides when the system is sufficiently affected by anti-syphilitic remedies. Chronic coryza is sometimes very obstinate. It may continue for months or years, giving rise to a constant, but often not abundant, discharge. Treatment. — Common mild attacks of coryza require little treatment. The bowels should be kept open, the feet soaked in mustard-water, and the body should be warmly clothed. Some benefit may be derived from friction with camphorated oil over the nose. If coryza commence with symptoms which indicate a pretty severe attack, and there are evidences of extension of the disease towards the bronchial tubes, an emetic of syrup of ipeca- cuanha, given at an early period, moderates the severity of the inflammation and may prevent the occurrence of bronchitis. Afterwards a simjjle diaphoretic mixture, as the following, should be given : — R. Syrupi ipecacnanhfe ,"ij ; Spirit, fpthei-. nitr. 5j ; Syrupi simplicis gij. Misce. One teaspoonful every three hours to a child of six months. In place of sweet spirits of nitre, acetatt^ of potash may be employed in the dose of one to two grains for infants ; and if there is decided febrile reaction, from half a minim to two minims, according to the age, of tincture of digitalis, should be added to each dose. In pseudo-membranous coryza the main treatment must be di- rected to the accompanying laryngitis, if, as is usual, the latter affection is present, since the coryza is much less dangerous than the other inflammation. Still, if it cause any obstruction to the respiration and increase the suffering of the patient, it requires attention. The frequent injection into the nostrils of a solution of chlorat'e of potash in water, with five or six drops of carbolic acid to each ounce, exerts a beneficial effect upon the inflammation, and aids in removing the accumulation of fibrin, mucus, and pus. It 44:8 CORYZA. slioiild be employed several times in tlie course of tlie day. Alum injections, four or five grains to the ounce of water, are also useful in a certain proportion of cases ; or a solution of one of the mineral astringents may be employed, as liquor ferri subsulphatis, acetate of lead, sulphate of copper, or nitrate of silver. The bromine solu- tion described in our remarks on the treatment of croup will also be found useful, injected into the nostrils. In most cases of pseudo-membranous coryza constitutional mea-' sures are required, on account of the disease with which it is associated. In cases of acute simple coryza, and in the pseudo- membranous, inhalation, through the nostrils, of the vapor of hot water or of steam from hops often gives relief ; occasionally it is an important part of the treatment. Syphilitic coryza requires those measures which are appropriate for constitutional syphilis. Chronic coryza, dependent on a dyscrasia, is best treated by tonic and alterative remedies. The various ferruginous prepara- tions, as wine of iron, tincture of the chloride of iron, iron lozenges, may be advantageously employed, or the vegetable tonics. If there are pallor, softness of flesh, and especially glandular swellings, indicating a scrofulous state of system, the syrup of the iodide of iron is useful, with or without cod-liver oil. The diet should be nutritious, and the hygienic measures such as invigorate the gene- ral health. Injections into the nostrils of a solution of alum, five grains to the ounce, of nitrate of silver, three to five grains to the ounce, or of one of the other mineral astringents, are sometimes useful in connection with constitutional measures. An excellent formula in chronic coryza, for application to parts which can be reached by a camel's-hair pencil, is the following : — I^. Ung. hydrarg. ammoniat., Axungife, equal parts. Misce. At the Out-door Department of Bellevue, this ointment, or the citrine diluted in the same proportion, has proved more eflectual in this disease than any other local remedy. It should be applied three times daily, as far within the nostrils as possible. Dr. J. F. Meigs, of Philadelphia, recommends the following ointment in chronic coryza, to be applied at night, after the use of injections through the day: — I^. Unguenti liydrargyri nitratis 3s3 ; Extract! belladonua? gr. x ; Axungiae §ss. Misce. "It should be applied," says Dr. Meigs, "after being completely SIMPLE LARYNGITIS. 449 Boftened by a gentle licat, on a camel's-hair pencil, care being taken to ap[ily it tlioronglily to the surface of the mucous membrane itself, and not merely to the outside of tlic hardened scabs." C HATTER II. SIMPLE LARYNGITIS. Simple acute laryngitis occurs at all ages, but it is so common in infancy and childhood that it is proper to treat of it in a work relating to the diseases of these periods. Like other inflammatory affections of the air-passage, it is most common in the cold months or when the weather is changeable. Its usual cause is, therefore, exposure to cold. Crying, protracted and violent, and the inhalation of acrid vapors, are occasionally causes. Simple or erythematous laryngitis also occurs in connection with certain other diseases, among which may be mentioned measles, scarlatina, and variola. In most cases of bronchitis, also, and in many of pneumonia, there is laryngitis, though its symptoms are, in great measure, obscured by those of the graver affection. More or less laryngitis is com- mon in pharyngitis, due to extension of the inflammation. Symptoms. — Ordinarily, in cases of simple or erythematous laryn- gitis, produced by the impression of cold, coryza precedes and ac- companies the attack. The first symptom is chilliness, followed by sneezing, and a discharge from the nostrils due to the coryza. The commencement of laryngitis is indicated by hoarseness, which is apparent when the child cries, or, if old enough, when he attempts to speak. There is, in severe cases, often complete loss of voice, so that the child cannot speak above a whisper. I have noticed this most frequently in the laryngitis which accompanies measles. Cough is also a common symptom of this disease. It is at first dry and husky, becoming loose in the course of a few days. But expectoration is scanty, except when the inflammation has extended to the trachea and bronchial tubes. This disease is often accompanied by soreness of the throat, no- ticed in the act of coughing or when the larynx is pressed with the finger. In simple laryngitis, when uncomplicated, the respiration remains nearly natural and the pulse is but little accelerated. In mild cases the nature of the disease is often not apparent as long 29 '0 450 SIMPLE LARYNGITIS. as the cliild remains quiet, in consequence of the absence of symp- toms, but the character of the voice, when he cries or speaks, or of the cough, reveals at once the nature of the affection. Simple acute laryngitis subsides in from one to two weeks. Oc- casionally it lasts three or four weeks before the symptoms entirely disappear. Death, which is rare, is due to some complication. Chronic laryngitis is much less frequent than the acute form. Its anatomical characters are similar to those in other chronic inflammations affecting mucous surfaces, namely, thickening and more or less infiltration of the mucous membrane, increased pro- liferation and exfoliation of the epithelial cells, and increased functional activity of the muciparous follicles. In the adult chronic laryngitis is common as one of the lesions of the syphilitic or tubercular disease. In the child this disease is more rare, but it sometimes occurs in connection with pulmonar}^ or bronchial tubercles. Such patients are emaciated, and have the ordinary symptoms of tuberculosis. Chronic laryngitis also occurs in young children, usually infants, as one of the manifestations of the strumous diathesis. I have records of about twelve such cases, mostly nursing infants. Some of these patients had mild bronchitis, but it was obviously subordinate to the laryngitis. Their respira- tion was noisy and harsh, continuing of this character for several weeks and even months. The cough was also harsh and loud, conveying the idea of thickening and relaxation of the mucous membrane covering the vocal cords. Their respiration was not notably accelerated, and the blood was apparently fully oxygenated, though the friends were often alarmed by the noisy breathing and cough. In this form of chronic laryngitis there is little expectoration, the fever is slight or absent, the appetite remains unimpaired, and the general condition of the child is good. There are from time to time exacerbations, and occasionally improvement is such as to encourage the hope of speedy cure, but in the cases which I have seen there has not been complete intermission in the disease till the final recovery. Those patients whom I have been able to follow through the disease have recovered in from three or four months to one year. This chronic laryngitis is to be distinguished from frequent attacks of acute laryngitis, which are due to fresh exposures, and are accompanied by the ordinary symptoms of the acute disease. It is to be distinguished from protracted acute laryngitis, which sometimes does not entirely subside in less than a month or six , TREATMENT. 451 weeks, by its lono'cr duration, the greater tliickening of the iii- tiamed lucnibrane, and more noisy respiration. (Certain cases of chronic hiryngitis result from tlie acute disease, the inflammation lieing perpetuated by the struma or dyscrasia of the patients. Anatomical Ciiaragters. — In simple acute laryngitis the mucous membrane of the larynx presents the usual appearance of mucous surfaces when inflamed, namely, redness and thickening. It is also somewhat softened. Ulcerations rarely, perhaps never, occur in primary acute laryngitis. When present in chronic laryngitis, the ulcers are small and situated upon or near the vocal cords. Tu- bercular and syphilitic ulcers of the larynx are much more rare in children than adults. The inflammation in simple acute laryngitis usually extends over the whole surface of the larynx, and also to the upper part of the trachea. It may be pretty uniform, or more intense in one place than another, and, like other mucous inflam- mations, it is accompanied by more or less rapid proliferation and exfoliation of epithelial cells. In most cases of simple laryngitis, whether acute or chronic, the inflammation extends to the pharynx, producing redness and thickening, though generally moderate, of the mucous membrane which covers it. Examination of the fauces therefore aids in diagnosis. In the adult cedema glottidis occasionally results from laryn- gitis. In the child there is little danger that this will occur, in consequence of the anatomical character of the larynx. In early life there is but little submucous connective tissue in the larynx, and therefore less submucous infiltration or eftusion during the inflam- mation. The structural changes occurring in simple laryngitis of infancy and childhood relate almost exclusively to the mucous, membrane. Treatment. — Simple primary and uncomplicated laryngitis re- (piires little treatment. Most cases would do well by the employ- ment of suitable hygienic measures, without medicines. Benefi.t is, however, derived from the use of demulcent drinks and an occasional laxative. A mixture of paregoric and syrup of ipecacu- anha, or a small Dover's powder, will relieve the cough if it is troublesome. If there is restlessness, a warm mustard foot-bath is useful. An important part of the treatment is the application of some mild counter-irritant over the larynx. In most instances camphorated oil, preceded perhaps by mustard, produces sufiicient irritation. It should be rubbed several times daily over the throat, or a strip of flannel soaked with it may be applied around the^ neck. Chronic laryngitis dependent on syphilis or tuberculosis. •i52 SPASMODIC LARYNGITIS. requires the constitutional treatment which is approi:^nate for that disease. Local measures have hut little effect upon this form of inflammation. The chronic laryngitis which I have described as occurring chiefly in infancy, and which appears to be of a strumous character, is apt to be obstinate. The patient should be warmly clothed, and constant care should be taken that there be no exposure which would endanger taking cold, as this would inevi- tably produce an exacerbation of the disease, and counteract all that had been gained by remedial measures. This form of chronic laryngitis is most satisfactorily treated b}' the application of tincture of iodine upon the neck, directly over the larynx, and the internal use of cod-liver oil and the syrup of the iodide of iron. Little benefit results in this form of laryngitis from the usual ex- pectorant remedies, as squills or senega. Spasmodic Laryngitis. This is a common disease. It is also called false croup, in con- tradistinction to true or pseudo-membranous croup, and, by some of the continental writers, stridulous angina or stridulous larjai- gitis. It should not be confounded with spasm of the glottis, which is a form of internal convulsions, and is not inflammatory. It occurs ordinarily between the ages of two and five years. It is commonly a sporadic affection, but Eilliet and Barthez state that "it is incontestable that it may prevail epidemical!}'." They express this opinion, not from their own observations, but chiefly from those of Jurine, made in the commencement of the present centurv. Causes. — Children in some families are more liable to false croup than in others, so that an hereditary tendency to it must be admitted. The exciting cause in most cases is exposure to cold. False croup is not uncommon in the commencement of measles. iSTarrowness of the rima glottidis, and an excitable state of the nervous system, both of which are common in early childhood, are predisposing causes. Symptoms. — Spasmodic laryngitis is ordinarily preceded for a day or two by a slight cough and fever, by symptoms of mild coryza or catarrh, such as all children are liable to on taking cold. In exceptional cases these sjmiptoms are absent, and the disease begins abruptly. Singularly, it commences nearly always at night, after the first sleep, between ten and twelve o'clock. The sleep is usually quiet and natural, but the child awakens with a SYMPTOMS, 453 loud, barking cough. There is great dyspnoia, and the rcsj/iration is harsh or wliistling, on account of the narrowing of tlie cliink of the glottis from the swelling and tension of the vocal cords. The face is flushed and indicative of suffering. The child cries, moves from one position to another, wishes to be held or carried, seeking in vain for relief. The skin is hot, pulse accelerated, the voice hoarse or even whispering. After a variable period, usually from half an hour to two or three — not more than half an hour with proper treatment — these symptoms abate. The patient is then somewhat exhausted, and falls asleep. The face is less flushed or even pallid, the heat abates, and the pulse is less accelerated. The cough, though less frequent, remains for a time barking or sonorous, and the respiration, though greatly relieved, is not at once entirely natural, but it gradually becomes so. Often there is no return of the spasmodic respiration and cough, but sometimes the attack is repeated once or more, especially during the subse- quent nights. The symptoms vary greatly in intensity in different patients. As the attack declines, the disease, losing its spasmodic character, becomes a simple inflammation. In some there is immediate return to perfect health, but oftener the inflammation extends not only into the trachea, but also into the larger bronchial tubes, and the disease is then a laryngo-bronchitis, which gradually subsides. The termination is not always so favorable. Spasmodic laryn- gitis is, in exceptional instances, the precursor of other serious aftections, which may prove fatal. It has been stated that measles often begins with spasmodic laryngitis. Bronchitis becoming capillary, may occur in connection with it, as may also pneumonia, and by either of these severe inflammations the prognosis may be rendered doubtful. There are a few cases on record in which it is believed that spasmodic laryngitis was of itself fatal. In some of these cases the dyspnoea was extreme and persistent, and was the cause of death. In a case reported by Rogery, on the other hand, the respiration became easy before death, and the pulse more and more frequent and feeble. Death apparently occurred from exhaustion. It is not improbable that, had careful post-mortem examinations been made, in those cases of spasmodic laryngitis which have ended fatally, other lesions would have been discovered besides those located in the larynx, perhaps tracheo-bronchitis, with an accumulation of mucus in the larynx, producing suffoca- tion, or perhaps sometimes congestion of the brain or lungs and serous eftusion. 454 SPASMODIC LARYNGITIS. AxATOMiCAL Character; Pathology. — The opportunity does not often occur of determining the anatomical characters of spasmodic larvno:itis. I have witnessed but one post-mortem examination. A little girl, nine years old, was taken on Friday night with cough and dyspnoea, indicating a pretty severe attack. The mother, actino- throu<2;h the advice of a friend, gave kerosene oil to her in considerable quantity. This was succeeded by obstinate vomiting and purging, which continued during Saturday and Sunday. Death occurred on Monday. At the autopsy we found uniform and intense injection throughout the whole extent of the larynx and trachea, and extending into the bronchial tubes. There was no pseudo-membrane on the inflamed surface, and but little mucus and pus. The solitary follicles of the intestines and Peyer's patches were tumefied. There was injection, in places, of the gastro-intestinal mucous membrane. The cause of death was obviously the diarrhoea, apparently of an inflammatory character, and probably produced by the kerosene oil. The condition of the mucous membrane of the larynx w^as that which is ordinarily present in spasmodic laryngitis, though in some cases in which post-mortem examinations have been made the evidences of laryn- ofcal inflammation were slig-ht. Guersant relates a case in which the surface of the larynx seemed to be nearly in its normal state. Death in cases of slio'ht laryngitis is due to causes which are independent of the larynx. In Guersant's case there was tuber- culosis. There is, as has already been intimated, another and an impor- tant element besides the inflammation, in the pathology of spas- modic laryngitis — an element producing those phenomena which render it a disease distinct from simple laryngitis. I refer to spasm of the laryngeal muscles. This element pertains to the nervous system, so that spasmodic laryngitis is allied both to the neuroses and to the inflammations. ^ Diagnosis. — The disease for which sj)asmodic laryngitis is most frequently mistaken is pseudo-membranous croup. The friends, indeed, usually make this mistake in forming their opinion of the case before the physician arrives ; and there can be no doubt that many of the cases which physicians have pvdjlished in medical journals as true croup were examples of this aftcction. The points of difl'erential diagnosis are the following : True croup begins with symptoms which at first are slight, so as scarcely to arrest attention, but which gradually increase in intensity. The cough becomes more harsh, and the respiration more diflicult, by degrees. PROGNOSIS — TJIEATMENT. 455 This increase in the gravity of the symptoms occurs by day as well us by night. On the other hand, false croup, though preceded by symi)toms of coryza, or catarrh, begins al)ru})tly. The symp- toms have from the first their maximum intensity, and the time at which it commences is the night. Again, the cough in spas- modic laryngitis possesses a loud, sonorous character; while in true croup it is harsh or rough, from the presence of the membrane, and having, therefore, less fulness. The voice in spasmodic laryn- gitis may be hoarse, but it is not lost, or is lost only for a short time. It afterwards becomes natural, or is slightly hoarse. On the other hand, in true croup, the voice, from being natural at first, is gradually extinguished. In fatal cases it soon becomes whispering, and continues such till the close of life ; in those that recover, the voice remains hoarse for several days. These differ- ences are important, and, if fully appreciated, are in most instances sufficient to establish the diagnosis. Besides, in a large proportion of cases of true croup, portions of the pseudo-membrane may be discovered on inspecting the fauces, and the faucial surface is deeply injected, while in spasmodic laryngitis there is, with rare exceptions, no false membrane upon the surface of the fauces, and but a moderate amount of congestion. Laryngismus stridulus, or internal convulsions, must not be confounded with this disease. It is not inflammatory, but purely spasmodic, suddenly commencing and abating — identical, it is believed, in character, with tonic convulsions of the external mus- cles, but affecting the internal muscles of respiration. This disease has already been fully described. Prognosis. — Little need be added, as regards the prognosis, to what has alreadj^ been stated. While a favorable opinion in reference to the result may ordinarily be expressed, the physician should not forget the fact that death may occur. Symptoms indi- cating an unfavorable termination are : great and continued dysp- noea, not diminished by the proper remedial measures ; stridulous expiration as well as inspiration ; lividity of the prolabia and fin- gers ; pallor and coldness of surface ; pulse progressivel}^ more frequent and feeble. Convulsions and coma may also occur near the close of life. Treatment. — The indications of treatment are twofold : first, to relieve the spasmodic action of the laryngeal muscles ; secondly, to cure the laryngitis. To meet the first indication, a warm bath of the temperature of about 100° should be employed as soon as possi- ble after the commencement of the attack. The patient should be 456 SPASMODIC LARYNGITIS. kept ill it ten or fifteen minutes, in order to obtain its full relaxing eftect. In mild cases a warm foot-batli may be sufficient. A second means is the use of an emetic, which should be simultaneous with the bath. To children under the age of three years, syrui3 of ipecacuanha should be given, in doses of one teaspoonful, repeated in twentj'' minutes, till vomiting occurs; or alum and syrup of ipecacuanha, two drachms of the former to one ounce of the latter, may be given in the same dose. The alum and the syrup produce more prompt emesis than the syrup alone. Children over the age of three years, unless of feeble constitutions, are best treated by the compound syrup of squills in teaspoonful doses, or a mixture of this with sj'rup of ipecacuanha. It is not often necessary to give more than three or four doses, and sometimes one or two are suffi- cient to produce vomiting. In most cases, by the use of the warm bath and the emetic, the symptoms are rendered milder, and convalescence soon commences. In the American Journal of the 3Iedical Sciences^ April, 1867, Dr. R. R. Livingston reports a case of laryngitis treated by Squibb's ether. It is stated that portions of pseudo-membrane, from one- eighth to three-fourths of an inch in length, were expectorated; but the symptoms certainly indicated a spasmodic element as decided as in spasmodic croup, and the benefit from the ether was apparently due to the relaxation of tlie laryngeal muscles which it produced. The treatment of the patient, who Avas two years old, was commenced by the administration by the mouth of half a teaspoonful of the ether, and followed by its inhalation. "In precisely eight minutes from the time the patient commenced the inhalation, the abnormal muscular exertion ceased ; a general relaxation took place; the pulse (which had numbered 150) fell to 100." Ether, judiciously employed, will probably prove to be a useful remedial agent in spasmodic forms of laryngitis, wliether or not it has any effect on pseudo-membranous formations. The same may be said of chloroform. A large majority of cases, however, recover speedily without its employment, by the other measures recommended. To fulfil the second indication, namely, the cure of the inflam- mation, as well as to control the spasm of the laryngeal muscles, bloodletting has sometimes been resorted to. It is, however, so seldom required, that it may be almost discarded as a part of the treatment. In those of full habit, with strong pulse, if the mea- sures already recommended should not give relief, one or two leeches might be advantageously applied to the top of the stcr- TREATMENT. ioi niim ; but, except in such cases, local bloodletting, and much less general, should not be resorted to. Attention should always be given to the state of the bowels in spasmodic laryngitis. If they are not well open, a purgative should be administered. For those that are robust, and with considerable febrile movement, the saline cathartics are ordinarily preferable, as Rochelle salts, or a purgative dose of calomel may be administered. The cathartic should not be prescribed till the nausea from the emetic has subsided. By its derivative eifect, it tends to diminish the laryngitis, and, in severe cases, it may ob- viate the need of depletion by leeches. Inhalation of the vapor of hot water, and the application of a sinapism over the neck and upper part of the sternum, followed by an emollient poultice, are useful adj u vants to the treatment. "When the spasmodic element in the disease is relieved, the case becomes one of simple laryngitis, and the general plan of treat- ment recommended for that disease is proper for this. Small doses of ipecacuanha, or of one of the antimonial preparations, as the compound syrup of squills, not sufficient to cause nausea, should now be given at regular intervals. I have sometimes added to the expectorant one drop of tincture of veratrum viride, for robust children over the age of three or four years, having a full and rapid pulse, flushed face, and other evidences of active febrile movement. Its eft'ect should be watched, and it should be discontinued when its sedative influence on the circulation begins to be apparent. It should not be given in the spasmodic laryngitis which occurs in the commencement of measles. If, however, there is not a speedy termination of the disease by recover}^, or, more rarely, by death, there is nearly always tracheo- bronchitis, or a more serious affection, coexisting with the laryn- gitis, or following it; therefore, depressing measures should not be long continued. Expectorants of a stimulating character, as carbonate of ammonia, or syrup of senega, are required in the course of a few days, and in young and feeble children they should be given at an early period. The mode of treatment recommended above is appropriate for that large class in whom the inflammatory element predominates. In a smaller number of cases the nervous element predominates over the inflammatory, and the treatment should be in some re- spects different. Such children are usually pallid and of spare habit, having, indeed, the nervous temperament. They are liable to attacks of this disease, though generally of a mild form, on 458 PSEUDO-MEMBRANOUS LARYNGITIS. slight exposure to cold, and with a very moderate amount of in- Hammatioii. The treatment in these cases should be directed more to the nervous system. My plan has been, in the treatment of such cases, after perhaps the use of a mild emetic, to give quinine, one strain three or four times daily, to a child from three to five years old, prescribing at the same time a simple expectorant, as syrup of squills, and a mildly irritating application to the throat. The symptoms in these cases are not severe, and active measures are not required, though the peculiar cough continues longer than in the more inflammatory forms of the disease. The patient with spasmodic laryngitis should be kept in a warm room during tlie paroxysms, and should inhale an atmosphere loaded with moisture. Trousseau recommends a mode of treatment of spasmodic laryn- critis which was first suggested by Graves, of Dublin. It consists in the application underneath the chin, so as to cover the larynx, of a sponge soaked in water as hot as can be borne ; in ten or fifteen minutes it is repeated. This reddens the skin, producing revulsion from the larynx. The hoarseness, dyspnoea, and cough diminish with this treatment, and some recover without other measures. Guersant and others speak of the importance of prophylactic manao-ement of children who are liable to this disease. Attention should be given to the dress, so that there may be sufficient protection from changes of temperature, and there should be an equable temperature of the apartments in which the}^ reside. Children of a decidedly nervous temperament, in whom the slightest laryngitis is ajtt to be spasmodic, require additional jtrophylactic measures. They are pallid, and in a more or less cachectic state. Such children are benefited by chalybeate and vegetable tonics, and by exercise in suitable weather in the open air. CHAPTER III. PSEUDO-MEMBEANOUS LARYNGITIS. The term pseudo-membranous laryngitis, or true croup, is applied to a common and fatal disease, the essential anatomical character of which is inflammation of the mucous membrane of the larynx, with the formation upon its surface of a pseudo-membrane. It ANATOMICAL CnARACTERS. 459 occurs most frequently between the ages of two and seven years. It is rare in adult life, and also under the age of six months. Causes. — There is greater liability to this disease in some chil- dren than in others, and occasionally the predisposition to it appears to be inherited. The common exciting cause is exposure to cold. Those children, especially, are liable to croup, who live in heated apartments, and are taken into the open air without proper covering, and those who a part of the time are warmly and a part of the time thinly clothed, especially as regards the covering of the neck. This disease is common among the poor of New York, who live in close rooms, overheated through the day and cool at night. Another less common cause is the inhalation of irritating vapors, or swallowing irritating or corrosive liquids. I have known a child to die from swallowing acetic acid, and another from scalding water, both having the dyspnoea and cough of true croup. This disease is ordinarily primary, but occasionally it is second- ary. The secondary form is not unusual in the declining period of measles, and it is an occasional complication of scarlet fever. Croup is most common in the winter months, and in times of changeable weather. It is said, also, that it sometimes occurs as an epidemic, but it is a question whether the supposed epidemics may not have been diphtheritic. Anatomical Characters. — The inflammatory action in this dis- ease affects not only the mucous membrane, but, in a certain pro- portion of cases, extends to the submucous connective tissue, caus- ing infiltration or cedema. The mucous membrane itself undergoes similar alteration to that in simple or spasmodic laryngitis, con- sisting of hypersemia and thickening, proliferation, and rapid desquamation of its epithelial cells, and an abundant production of muco-pus. Sometimes the redness is found only in patches at the autopsy ; in other cases it extends over the Avhole surface of the larynx, while occasionally it has disappeared so that the laryngeal mucous membrane, though thickened and softened, presents nearly its normal color. In all except the mildest cases the inflammation extends further than the larynx, involving not only the surface of the pharynx, but also in greater or less degree that of the trachea and bronchial tubes. The distinguishino; feature as re2:ards the anatomical character of this disease remains to be noticed, namely, the false membrane which covers the laryngeal and often contiguous surfaces. This has long been considered as consisting of fibrin, which, exuding 460 PSEUDO-MEMBRANOUS LARYNGITIS. in its liquid state from the submucous vessels, became fibrillatecl when exposed to the air, its interstices being filled with a greater or less amount of pus, epithelial cells, and amorphous matter. At a recent date Wagner has surprised pathologists by the statement that these pseudo-membranes contain no fibrin, but that they consist of epithelial cells, which, undergoing some form of degenera- tion as they are pushed forward from the mucous surface, enlarge, and appear under the microscope as irregular blocks interlacing with each other. By employing the picro-carminate of ammonia, or a weak ammoniacal solution of carmine, "Weber and other micro scopists have been able to trace the boundaries of these irregular and interlacing blocks, which have prolongations like the shape of a stag's horns, and they have observed the intermediate forms of transition between these and the normal epithelial cells. The views of Wagner are now generally admitted to be in the main connect as regards the pseudo-membrane of croup, but some of the highest autliorities in pathological histology, as Rindfieisch, state that they find fibrin in the pseudo-membrane, in addition to the enlarged and degenerated epithelial cells of which it is chiefly composed. Rindfleisch says: "The pseudo-membrane is of a pecu- liarly stratified structure, since upon a layer of cells at tolerably equal distances there always follows a layer of fibrin, and this sequence is repeated from one to ten times, according to the thick- ness of the membrane." {Patholog. UistoL, translated, page 351.) As lending support to the views that the pseudo-membrane does contain fibrin, the fact may be stated, that while in the ordinary pneumonia of young children there is no fibrinous exudation in the air-cells, this exudation does occur, at least in a certain proportion of cases, in pneumonia occurring as a complication of croup. Thus, recently in this city, in a pneumonic lung from a case of fatal croup, occurring at the age of about two years. Dr. Francis Delafield found fibrin in the exudat of the air-cells. The exact nature of the degeneration which the epithelial cells undergo is unknown. It is generally believed that they are infiltrated by an albuminate, but AVeber holds the opinion that the substance is fibrin. MAI. Cornil and Ranvier, on the other hand, state: "AVe have verified the correctness of the description given by AVagner ; we have separated and colored the cells by means of the picro- carminate of ammonia, and, in consequence of the facility which they present of fixing the carmine, we conclude that they are not filled with fibrin, Init rather by a matter resembling mucine. These exudats of true croup are pressed forward and detached in ANATOMICAL CHARACTERS. 461 proportion as the globules of pns or new epithelial cells are pro- duced underneath them," The pseudo-membrane varies greatly in amount in difierent cases. It may occur only in points or small patches, which are generally found in the vicinity of the vocal cords, while in other cases it extends an almost continuous mem- brane from the epiglottis into the bronchial tubes, and there is every gradation between these two extremes. It fills the orifices of the muciparous follicles, and the minute depressions upon the mucous surface, being closely adherent, so as not to be detached by eltbrts of coughing or vomiting, except in small portions. As the inflammation commonly extends beyond the larynx, so the pseudo-membrane, in a large proportion of cases, is formed not only upon the laryngeal, but also upon contiguous surfaces. In thirty-three cases of true croup, comprised in the statistics of Dr. Ware, of Boston, pseudo-membranous pharyngitis was also present in all but one ; and in nineteen cases observed by Dr. Meigs, of Philadelphia, in all but three. The formation of a pseudo-mem- brane in the trachea in connection with that in the larynx is also common, and it is not infrequent in the bronchial tubes. M. Guer- sant has, so far as I am aware, collected the largest number of records relating to the extent of the pseudo-membrane in true croup. In an aggregate of 120 cases it was confined to the larynx and trachea in 78, or about two-thirds, while in the remainder, namely, 42, it extended into the bronchial tubes. In those whose systems are robust, the false membrane is usually firmer than in those whose systems are reduced. In a state of decided cachexia it is sometimes friable and easily detached. If the case continues from four to six days, it begins to soften from commencing decomposition, the minute fibres which attach it to the mucous membrane give way, and, in favorable cases, by the effort of coughing or vomiting it is thrown off". Separation is aided by muco-pus, which collects underneath. In fatal cases the false membrane, if detached by the efforts of the child, is rapidly reproduced, so that in twelve to eighteen hours the dyspnoea re- turns. Pneumonia not infrequently complicates croup. In extrejne cases, in which inspiration is difficult in consequence of the obstruc- tion, the lungs are only partially inflated, and imperfect decarboni- zation of the blood and sometimes collapse of certain pulmonary lobules are the result. Occasionally there is that degree of thick- ening of the mucous membrane, and submucous infiltration, that the dyspnoea and danger occur more from these than from the presence of the pseudo-membrane. 462 PSEUDO-MEMBRANOUS LARYNGITIS. Symptoms. — In some cases, pseudo-membranous, like simple laryn- gitis, is preceded by coryza and pharyngitis, while in others laryn- gitis is present from the first. The commencement of croup is indicated not only by fever, diminished appetite, thirst, and such symptoms as accompany all acute inflammations, but by certain other symptoms which serve to distinguish this from all other diseases. The cough is one of the earliest symptoms which distinguish true croup from other laryngeal inflammations. It is hoarse or harsh ; its character may be expressed by the term dry or suppressed. It difters from the cough of spasmodic laryngitis, which is less hoarse and more sonorous. It is much more frequent in some cases than in others ; in many patients, towards the close of life, it nearly or quite ceases. Hoarseness of the voice is also one of the first and most constant symptoms, and it continues throughout. Towards the close of life the voice is usually lost, and the child expresses its thoughts in an indistinct whisper. The amount of expectoration varies considerably in difterent patients, according to the presence or absence of bronchial inflam- mation. If the inflammation extends no lower than the upper part of the trachea, the sputum is scanty during the whole course of the disease. In ordinary cases it is scanty at first, then more abundant, and again more scanty if the case is fatal. The scanti- ness of the sputum towards the close of life is due not entirely to exhaustion of the patient, but in part to obstruction in the larynx above the mucus and pus. By vomiting a much larger quantity is expectorated than by the cough. Frequently small portions of pseudo-membrane are expectorated with the mucus and pus, and occasionally also larger masses, complete moulds, indeed, of the larynx, trachea, or even of the bronchial tubes. The respiration is accelerated, but not so much as in pneumonia or capillary bronchitis. In the advanced stage it commonly becomes slower than at first. As the obstruction in the larynx increases, the respiration assumes more and more the character which has been designated abdominal ; the infra-mammary region is depressed in each inspiratory act, while the larynx approaches the sternum, and the alse nasi are dilated. Patients sometimes have painful attacks of dyspnoea, due to detachment of an edge of the pseudo-membrane, and its doubling upon itself. In the paroxysm, the sufterer throws himself from side to side in the bed, or reaches his arms to his mother or nurse for relief; his eyes are wild, features anxious, and, in severe paroxysms, fingers SYMPTOMS. 463 and prolabia livid. In the interval there is comparative quietude, though the respiration is constantly embarrassed. Tiie frequency of the pulse varies according to the extent of the inflammation and the stage of the disease. In the commencement of primary croup it ordinarily varies from about one hundred and ten to one hundred and twenty beats per minute. In the course of the disease it becomes more frequent, and towards the close of life feeble. Now and then a patient presents a decided remission in symp- toms, due to detachment of the adventitious layer, and the friends are apt to think that the danger is passed. Unfortunately the lull in symptoms is in most cases deceitful, as the cause of the dyspnoea is rapidly reproduced. I once attended a case in which there had been such dyspnoea that an unfavorable prognosis was given. An almost complete intermission, however, occurred in the symp- toms, with the exception of the febrile movement, so that a physi- cian who visited the patient at this time diagnosticated an essential fever. In a few hours, the pseudo-membrane being reproduced, the symptoms returned with greater violence than ever, and the child died. So complete an intermission seldom occurs in a fatal case ; and in most patients, during the times of temporary im- provement, there is still such dyspnoea, with the characteristic cough, that the nature of the disease is apparent. If the stethoscope is applied over the larynx in true croup, the loud expiratory as well as inspiratory sound is heard as the air passes by the obstruction. This sound is often transmitted to every part of the chest, so as to obscure the rales which may be produced there. Auscultation over the chest reveals either the vesicular murmur, perhaps somewhat diminished in intensity, or more frequently the sonorous and afterwards moist rales due to coexisting bronchitis. In a limited number of cases, dulness on percussion is observed at some part of the chest, with bronchial respiration, indicating pneumonia. Recovery from croup is in most patients gradual ; the voice becomes less hoarse, the cough looser, and the dyspnoea ceases by degrees. The structural changes which have occurred in the mucous membrane of the larynx do not disappear till several days after the last pseudo-membrane is detached. Fatal cases may terminate in two or three days, but their ordi- nary duration is from five to fourteen days. Death may result directly from the thickness and firmness of the pseudo-membrane, which obstructs the entrance of air. Sudden death in a paroxysm 464 PSEUDO-MEMBRANOUS LARYNGITIS. of dyspnoea may occur from the detachment of one end of the i:)seudo-membrane, and its folding ujDon itself. In many patients, death is not due so much to obstruction to the entrance of air from the presence of the pseudo-membrane, as to the mucus and pus which collect in the trachea and bronchial tubes, and which are not expectorated on account of the presence of the pseudo-mem- brane and the feeble expiratory efforts of the child. In a case which was examined after death in the Nursery and Child's Hos- pital of this city, the false membrane was apparently not sufficient to produce a fatal result, but the air-passages below it were nearlj'^ filled with muco-purulent matter, which obstructed the entrance of air. Pathological Characters. — This disease is then essentially a laryngitis presenting the lesions of a simple though usually severe mucous inflammation, but with a superadded element, namely, the false membrane. The coexistence of simple or pseudo-membranous pharyngitis, tracheitis, and bronchitis is also, as we have seen, common. The impediment to respiration, which renders croup so dangerous and fatal, is due not only to the presence of the false membrane, but to the mucus and pus which collect below it, and also to the inflammatory swelling of the mucous membrane and submucous oedema. In addition, there is a neuropathic element which increases the dyspnoea, and which most observers consider a spasmodic contraction of the laryngeal muscles induced by the in- flammation, and hence the easier breathing in sleep, and in the general muscular relaxation, which precedes death. Prof. Jacobi {Amer. Journ. of Obstet.jetc.,!^. Y., May, 1868), however, holds that the state of these muscles is one of paralysis rather than S2:)asmodic contraction. In his opinion, this paralysis " is secondary. It de- pends on the oedematous soaking of the posterior crico-arytenoid muscles following the oedema of the mucous membrane of the crico-arytenoid folds." In several fatal cases which I have had an opportunity to exam- ine after death, I have found the ajipearance of the lungs quite uniform. They were reduced in volume (semi-collapsed) and more or less congested. Certain parts distant from the bronchi, espe- cially the edges and thin portions, were collapsed completely, and certain lobules also hepatized. I have also observed, though in some of the cases my attention was not directed to it, distension of the right cavities of the heart with blood, and large thrombi. From the nature of the disease, the blood is less oxygenated, and I DIAGNOSIS — PROGNOSIS. 465 somewhat darker than in those who die of diseases not involving the respiratory apparatns. Diagnosis. — The diagnosis of true croup is ordinarily easy. It might be mistaken for spasmodic laryngitis, but more frequently spasmodic laryngitis is mistaken for it. The differences whicli will aid in differential diagnosis are the following : commencement abrupt and at night in one, gradual in the other ; presence in one, absence in the other, of a pseudo-membrane upon the surface of the fauces ; fragments of this membrane in the sputum in one ; charac- ter of the cough ; course of the disease growing gradually worse in one, in the other, with few exceptions, rapidly improving. Trous- seau speaks of the liability to error of diagnosis in those cases in which spasmodic laryngitis is associated with pseudo-membranous pharyngitis. Few physicians hesitate to designate as true croup those cases in which there is a croupal cough in connection with false membrane upon the surface of the fauces, and yet the laryn- gitis under such circumstances may be merely spasmodic. This coexistence of pseudo-membranous pharyngeal and of spasmodic laryngeal inflammation is, however, probably rare, but its occa- sional occurrence should be borne in mind. True croup is readily distinguished from laryngismus stridulus, or internal convulsions. Laryngismus stridulus is a purely nerv- ous affection ; it occurs suddenly, causing great dyspnoea, or momen- tary suspension of respiration, without the fever and without the hoarse voice and cough of croup. When muscular relaxation oc- curs, the attack ceases. The difference between the two diseases is therefore obvious. Prognosis. — The great mortality from true croup is universally known, and those physicians who report a large number of favor- able cases have probably mistaken spasmodic croup for this disease. According to the statistics of Dr. "Ware, nineteen out of twenty die; but with judicious treatment, commenced early, the mortality is probably less than this, though still great. Increase of dyspnoea, the voice and cough becoming more hoarse, and the pulse more accelerated, indicate a fatal form of the disease. Attention has already been called to temporary improvements which are apt to occur in croup, and lead to an error in prognosis. However, im- provement continuing more than twelve hours is evidence of the decline of the disease. The near approach of death is shown by lividity with great rest- lessness, or by pallor and somnolence. If the patient recover from croup, there often remains more or less bronchitis or broncho-pneu- 80 466 PSEUDO-MEMBEANOUS LARYNGITIS. monia, which requires treatment, and the laryngitis when its pseudo-memhranoiis character is lost, persists for a time, causing more or less hoarseness and acceleration of pulse. Treatment. — The importance of early treatment in this disease has been sufficiently alluded to. If it has continued two or three days when first recognized, the chance of recovery is greatly dimin- ished. As the danger in true croup arises from the presence of the pseudo-membrane, the indication is to prevent its formation, so far as possible, and to aid in its removal when formed. Emetics have been and are still much prescribed in the treatment of this disease. Properly employed, they produce a good effect, but much harm has been done by their injudicious administration. As a rule, the depressing emetics should not be given except at the comlhencement of the disease, not later, indeed, than the second day, and not given at all if the patient is feeble or cachectic, or if the croup is secondary, as when it occurs in connection with measles or diphtheria. I have known death occur almost imme- diately after the administration of an antimonial emetic in the pseudo-membranous larjmgitis accompanying diphtheria, when there was no urgent dyspnoea. At the commencement of croup, ipecacuanha or tartrate of antimony and potassa may then be prescribed if the disease is primary, and the patient in good general condition ; but if it is secondary, or the vital powers at all reduced, an emetic which is less depressing is preferable, as turpeth mineral or sulphate of copper. The emetic promotes the secretion of mucus, and a considerable quantity of this substance is usually found in the vomited matter, and it may also cause the detachment and expulsion of the softer portions of the pseudo-membrane. If the child in the initial stage of croup is under the age of three years, the syrup of ipecacuanha, with or without alum, may be administered in teasiwonful doses at intervals of ten or fifteen minutes till the emetic effect is pro- duced, or if the age is above three years, the compound syrup of squills may be emploj-ed instead. But when assured that a pseudo- membrane is forming, I prefer in most cases the sulphate of copper in one or two grain doses given in powder with an equal quantity of ipecacuanha, and repeated in ten minutes if the first dose does not produce the desired emetic effect. There is in most cases more or less relief of the symptoms after the emesis, though it may be but temporar}'. In one case recently in my practice, in which there was at the first visit considerable dyspnoea, distinct croupy cough, and a pseudo-membrane on both sides of the fauces, and in wliieh TREATMENT. 467 I liad made an unfavorable prognosis, the parents observing the good effect of the first powder, repeated the medicine, contrary to directions, at intervals of about two hours, till my visit on tlie following day, and the patient recovered. Two or three powders are, however, ordinarily sufficient for this preliminary treatment. Turpcth mineral is not inferior in its effects to sulphate of copper, and many physicians of ample experience prefer it, given in doses of two or three grains. Prof. Fordyce Barker, of this city, who prescribes an emetic of turpcth mineral immediately on being summoned to a case, states that he has not lost a patient thus treated for many years. After prompt and efficient emesis is pro- duced, other measures are required. We will speak hereafter of the further employment of emetics during the progress of croup. Loss of blood is not required in the treatment of croup. The stronger cardiac sedatives, as aconite and veratrum viride, may occasionally be advantageously employed on the first and second days of primary croup. They should only be administered to those that are robust. They should not be prescribed after the pseudo-membrane is fully formed, nor in cases of secondary croup. Unfortunately the emetic treatment recommended above, and which must be considered preliminary, fails to arrest the disease in a large proportion of cases. It does seem to diminish the amount of false membrane in certain cases, and there is reason to think that it may even in some instances prevent its formation, so that the inflammation remains a simple laryngitis, though pre- senting in its commencement the characteristic symptoms of croup; but in other and a large proportion of cases the pseudo-membrane becomes fully formed, and continues to increase. The profession have been long looking for a remedy wdiich, taken internally, ma}^ by its effect upon the blood or the inflamed surface, prevent or diminish the membranous formation, and also for a remedy which, employed topically, may liquefy and remove it. The remedy which has been and still is most frequently prescribed for the first of these purposes is calomel. The ordinary ill-effects of this agent, namely, stomatitis and ptyalism, should not deter from its employment if it exerts any controlling influence over a disease so rapid and fatal as true croup. I am of opinion that it is useful unless there is that degree of impoverishment of the blood and cachexia which would contra- indicate the continued use of any depressing agent. Calomel probably has no effect upon the false membrane ; but it is to be recol- lected that there are other factors in the production of the dyspnoea which it is probable that calomel does aid in removing, whether 468 PSEUDO-MEMBRAXOTJS LARYNGITIS. by its derivative effect on the intestinal surface, or by some other mode of action not fully understood. Calomel is believed to be one of the most efficient agents, administered internally, for removing the thickening and infiltration of the laryngeal mucous membrane and the submucous oedema. I think that I have observed benefit from its employment, whether in a single dose of six to ten grains, or in small doses of one-fourth to one grain repeated several times in twenty -four hours. The calomel may be administered alone, or with ipecacuanha not in sufficient quantity to cause emesis, or in certain cases with Dover's powder. It may be given from two to four days, perhaps sometimes longer, when it should be followed by a mixture of chlorate of potassa or soda and muriate of ammonia given frequently. In cases in which the vital powers are reduced, especially in secondary croup, this mixture should be given from the first, in place of calomel. The chlorate has a solvent effect, though feeble, on pseudo-membranes, and as when taken into the system it is known to be eliminated in most of the secretions and excretions, it is not improbable that it escapes also from the surface of the larynx in the mucus, and therefore comes in contact with the mem- branous formation. The chlorates in frequent large doses some- times cause salivation. Probably the eflect of the muriate is subordinate, but it is believed by therapeutists to increase the muco- purulent secretion, and therefore diminish in some degree the turgescence of the mucous membrane. Cases in which there is marked and protracted dyspnoea and croupal cough do now and then recover with the use of chlorate of potassa or soda and mu- riate of ammonia, either employed after calomel, or without it as the main remedy from the commencement of the disease — so many, indeed, that it cannot be doubted that they do have some curative effect. The following formula may be employed for a child from three to five years of age : — R. Potas. chlorat. 3j ; Amnion, muriat. ^ij ; Syr. simplic. 5J ; Aquae §ij. Misce. Dose, one to two teaspoonfuls every half hour or hourly, accord- ing to the urgency of the symptoms. This should be continued regularly night and day until the cough becomes looser, or until it is evident from the unfavorable nature of the case that it can be of no further service. A very important part of the treatment is the inhalation of steam. Some of our most experienced physicians consider this TREATMENT. 469 more useful than all otlier measures combined. In one of the most severe cases which I have met, which terminated favorably, the room was so filled with steam that water hung in drops from the ceiling. The atmosphere which the child breathes should be con- stantly loaded with moisture, without, however, that degree of heat which would add materially to the discomfort of the patient or attendants. Moist warm air coming in contact with the in- flamed surface promotes expectoration and renders the cough looser. Steam may be readily produced by placing heated irons or bricks in a shallow pan or pail containing a little water, by pouring water upon a heated surface, or by a spirit-lamp or gas- jet under a pan of water. In order to avoid heating the entire room and to concentrate the vapor, the nurse may sit with the child under a frame covered with a blanket, and the steam be pro- duced underneath. A temperature of 75° or 80°, if the atmosphere is loaded with moisture, is more readily tolerated than a lower temperature with a dry atmosphere, and a temperature at least as high as 75° is required, or too much of the vapor is deposited. Of late, the in- halation of the spray of lime-water has been recommended, in the belief that it exerts a solvent effect upon the false membrane. The atomizer has been employed in order to produce the spray, but difficulty attends its use for children. It has been still more recently recommended to add to the water which is employed for the purpose of producing steam one or two lumps of quicklime, and allowing them to slake. The vapor by this means becomes impregnated with particles of lime. This last mode of employing lime may partially obviate the principal objection which has been raised against the use of steam in the treatment of croup, namely, that it necessitates confining the air, which soon becomes loaded with carbonic acid, since slaked lime, when moistened, rapidly absorbs this gas. The employment of lime by inhalation in this disease certainly merits further trial, although, in the few cases in which I have employed it in both the ways stated above, I have observed no decided benefit from its use. It has already been stated that depressing emetics should not be employed after the second day, but a period arrives in most cases when another class of emetics are required. They are required when the dyspnoea is urgent, as a means of removing from the air- passages the collection of mucus and pus and portions of false membrane which may be detached. Those emetics should now be 470 PSEUDO-MEMBRANOUS LARYNGITIS. prescribed which operate promptly with the least depression. Sulphate of copper is one of the best, if not the best, for this stage of croup, and it is usually employed by physicians. A child of five years may take one grain dissolved in a little water, and the dose be repeated if required in ten minutes. Sulphate of zinc or turpeth mineral may be used in the place of the copper. Dr. J, F. Meigs, of Philadelphia, prefers pulverized alum given in tea- spoonful doses, but it is less efiicient, and I am not aware that it possesses any advantages over the sulphate of copper. "Whatever emetic is employed, its operation may be promoted by draughts of warm water. It is to be recollected in the treatment of croup that the pseudo- membrane, by commencing decomposition, and by the pus and mucus which collect underneath, is more easily detached after a few days, if the patient lives, than at first. Therefore the phy- sician should endeavor to sustain the vital powers, in order that the cough may have sufiicient force to separate this substance as soon as its fibres of attachment begin to loosen. A patient with croup rarely takes solid food, but he should be allowed beef-tea, milk, and farinaceous drinks at short intervals. If there are signs of exhaustion, alcoholic stimulants are proper, and fresh air should also be allowed so far as is compatible with the inhalation of steam. "While these general measures are employed, local treatment should not be neglected. The profession are not agreed as to the treatment either external or internal of the throat. As to external treatment, some recommend poultices, others cold applications, and others still, irritants. Professor Peaslee, of this city, in a series of • papers on the pathology of croup, published in the American Medical Ifonthli/, 1854, says of cold applied externally: "We con- sider this of the greatest value and importance. If cold applications are efiicacious in all cases of external inflammation, they are scarcely less so here, where the inflamed surface is so nearly super- ficial. Cold must, however, be continuously applied to produce the desired effect. Applied at intervals, indeed, it rather promotes than retards the inflammatory process ; since during the intervals the temperature rises above the norrnal standard, in consequence of the reaction of the chill on the surface. Cold water may be constantly dropped from a sponge upon a compress laid over the throat of the child; and the latter should be of only one or two thicknesses of linen, that evaporation may go on as rapidly as possible." In ordinary cases cold applied over the larynx is preferable to poultices or warm applications. The sides of the neck should be TREATMENT. 471 kept warm by pieces of pork, or one or two tliickiiesses of ilanucl, while in the interspace in front, over the larynx, a compress of muslin or linen squeezed from ice-water should be applied every five or ten minutes. These may be retained in place by a single thickness of muslin passing around the neck, and cut narrow in front, in order to facilitate the applications of the compress. In place of the compress, a small quantity of crushed ice may be em- ployed, surrounded by oil-silk to prevent dripping. This mode of applying cold I have found to be more convenient, on account of the frequent restlessness of the child, than that recommended by Prof. Peaslee. Cold is especially serviceable if the child is robust, with flushed cheeks and full and rapid pulse. In secondary croup, or croup occurring in feeble states of system, or presenting a sub- acute character, poultices or fomentations to the neck, with mode- rate irritation, may sometimes give most relief. Topical treatment of the fauces and larynx has long been re- commended in croup, and the agent Avhicli has been most fre- quently applied is nitrate of silver in solutions varying in strength from ten to forty grains to the ounce. It is applied once, twice, or several times daily. JSTitrate of silver does not dissolve the pseudo-membranes, but it contracts those with which it comes in contact, and by the contraction aids in their detachment. Great difficulty, however, attends the application of the probang to the larynx of the child, on account of his struggles and resist- ance, and it may well be doubted whether the most skilful opera- tors usually succeed in applying it to the interior of this organ. But if the instrument is pressed against the aperture of the glottis, some of the liquid trickles from the sponge into the larynx, as is indicated by the severe coughing which it produces. Of late years three other substances have been used for topical treatment of the throat, which appear to be more effectual in removing the pseudo- membrane and controlling the inflammation. One is liquor ferri subsulphatis, another carbolic acid, and the third bromine. The liquor ferri subsulphatis is best employed with glycerine in the proportion of one part to four. B, Liq. ferri subsulphatis 5j ; Glycerinse ^ss. Misce. Carbolic acid, in its crystalline or undiluted state, is an active caustic, with a tendency to spread. It should be used considerably diluted with water. R. Acid, carbolic. f5ss; Aquae gv. Misce. 472 PSEITDO-MEMBEAKOUS LARYNGITIS. Bromine has only recently been employed for topical treatment of pseudo-membranous inflammations. It is used in conjunction with bromide of potassium. IJ;. Bromiuii gij ; Potass, bromid. gr. xiv; Aqufe 3j. Misce. This is called the bromine solution, but it must be considerably diluted for use. Twenty-four to forty drops should be added to an ounce of water for application to the fauces or larynx. There are physicians who highly extol each of these three agents in the treatment of croup as well as diphtheria. They are probably all useful, though I cannot speak from personal observation in refer- ence to the efl:ect of bromine. They should be applied in the same manner as nitrate of silver, to which either one is probably prefer- able. Of the three agents, the one which I can highly recommend from personal experience for those cases which require this mode of treatment, is the subsulphate of iron. Local treatment, as re- commended above, is obviously most useful in those cases in which there is decided inflammation of the faucial surface attended with patches of false membrane, or those cases in which the inflamma- tion is first pharyngeal and becomes laryngeal by extension. Unfortunately, as I have already stated, true croup, whatever the therapeutic treatment, is, in a large proportion of cases, a pro- gressive disease. The hoarseness of the cough and voice and the dyspnoea gradually increase. The pulse, becoming more frequent and feeble, indicates the need of the most nutritious food, as the animal broths, and of alcoholic stimulants. The danger is, how- ever, from the dyspnoea rather than asthenia. Medicine has failed to check the disease, and shall now the expedients of surgery be tried — shall tracheotomy be performed ? The published statistics relating to tracheotomy in croup are to a considerable extent unsatisfactory, since we are not informed, as regards most of them, at what stage of the disease the operation was performed, and what were the evidences of a fibrinous exuda- tion. The most valuable and reliable statistics bearing upon this subject, so far as I am aware, are those published by Prof. Jacobi, of this city, in the American Journal of Obstetrics, etc., for May, 1868, and containing the results of the cases which were operated on by himself and Drs. Krackowizer and Voss. These gentlemen are known to the profession of Xew York as careful and judicious practitioners, not likely to operate when there was probability of success by therapeutic measures, and not likely to mistake simple TREATMENT. 473 or spasmodic laryngitis for true croup, tistics of their operations : — I have tabulated the sta- Age. Under 2 years From 2 to 3 years " 3 to 4 " " 4 to 5 " " 5 to G " " Gto7 " " 7 to 8 " 10 " Not given Number. Recovered. Died 8 1 7 29 5 24 26 4 23 34 11 23 9 2 7 1 1 3 8 1 1 55 15 40 1G6 39 127 Time of death after operatiou. Within 24 hours On 2d day " 3d " " 4th " Total Number of Time of Death after cases. operation. 19 On 5th day 7 " Gth " 16 " 7th " 15 " 9th " From 10th to 31st day Number of cases. 9 4 2 1 5 78 The following were the causes of death, as given in the records of 73 cases : — In operation Apnoea from too late operation Apnoja .... Anfemia and exhaustion . Diphtheria . . . Bronchitis Broncho-pneumonia . 1 6 3 4 8 6 15 Pneumonia .... 5 Broncho-pneumo, & pulm. gangrene 1 Pulmonary oedema ... 1 Pseudo-membranous bronchitis 18 Tuberculosis .... 1 Convulsions .... 2 Emphysema .... 2 Total 73 The following table gives the result of tracheotomy in one hun- dred cases. It is prepared from the statistics of Giiterbach, lately published : — Age. Under 1 year. Between 1 and 2 years " 2 and 3 " " 3 and 4 " 4 and 5 " 5 and 6 " 6 and 8 " 8 and 9 From conversations whic Result. 1 case fatal 33| per cent, recovered. 40 38^3 44| 14f 25 1 I have had with surgeons of ISTew York, I am persuaded that the above tables present a more favor- 474 PSEUDO-MEMBRANOUS LARYNGITIS. able result than could be furnished by the general surgical practice of this city. Most I^ew York surgeons, however, seem to shun the operation and regard it with ill-favor, and did they operate as fre- quently as those whose names I have mentioned, possibly the re- sult would be better. Statistics in Paris probably give nearly the true proportion of successful and unsuccessful operations of tra- cheotomy for croup, as it is performed by skilful and careful sur- geons. Of 388 cases occurring in the practice of several Parisian surgeons, 346 died and 42 recovered; while in the Hopital Sainte Eugenie, of 374 operated on, 310 died. (Bouchut.) The facts in reference to tracheotomy in croup are the following : The majority of those operated on do not recover, but some live who without the operation would die. The operation is now more successfully performed than formerly, as the conditions of success- ful operation are better understood. Those who have operated several times, confess that their last cases did better than their first. Trousseau's experience was striking and instructive in this respect. 'No one, probably, ever performed this operation for croup more times than he, and, from constantly greater success, he be- came more and more an advocate of the operation. Tracheotomy, if proi^erly performed, does not in any case shorten life, but it frequently prolongs it several days. It diminishes greatly the dyspnoea, and renders death easy. The objections to the operation are partly of a moral nature. The parents, already in the extreme of grief on account of the suiiering and probable death of the child, consent with reluctance to an operation which promises not cure, but a prolongation of life. Common sympathy with the child and regard for the emotions of the parents should certainly have an influence in deciding for or against the operation. The first case of tracheotomy which I witnessed was such as, if common, would condemn this operative measure entirely. No anaesthetic was given, and, in the midst of the struggles of the child, large veins were severed, from which an abun- dant hemorrhage occurred. The trachea was opened, but this was no sooner done than death occurred, partly from the loss of blood, and partly from the obstruction to respiration caused by its entrance into the bronchial tubes. Such cases are, however, quite exceptional. Death rarely occurs during the operation, unless the patient is al- ready moribund, and the possibility of such a result should have little weight in our decision for or against the operation. Few will deny, in the light of statistics, that tracheotomy is, in certain cases, proper, and that a physician at times would be TREATMENT. 475 culpiil)lc if lie (lid not strongly urge its performance. There are certain supposed contraindications. One is age less than two years. It is true that those under the age of two years are less likely to recover after the operation than those above that age; still, trache- otomy has now and then saved the lives of the youngest infants who have croup. The possibility, therefore, of success justifies the performance of the oi)eration, however young the infant, when the only alternative is death. In the foregoing statistics it is seen that one of eight recovered who were under the age of two years. The presence of capillary bronchitis or pneumonia does not posi- tively contraindicate tracheotomy, though it diminishes greatly the chances of a favorable issue. N"or is tracheotomy forbidden by the extension of the false membrane into the bronchial tubes, since it diminishes the amount of obstruction along which the air passes in or^er to reach the lungs, and the muco-pus as well as pseudo-membrane, lying below the point of operation, may be expectorated through the aperture. A decidedly asthenic state, as after measles or scarlet fever, indicated by feeble pulse and other symptoms of exhaustion, may or may not contraindicate the ope- ration, whether the pseudo-membrane is limited to the larynx and trachea or is more extensive. The manner of performing tracheotomy and the subsequent treatment pertain to surgery, and are described in surgical works. A skilful surgeon should, indeed, be employed to perform the operation when it is practicable. At what time in the course of the disease tracheotomy should be resorted to is an important practical question. Trousseau at one time recommended it as soon as there were certain evidences of the presence of a pseudo- membrane, but in the latter part of his life he did not operate so early. The correct rule, in my opinion, is not to operate till there are signs that the blood is not sufficiently oxygenated, such as lividity of the prolabia and tips of fingers. "When these signs occur, it is unsafe to delay long. The arrangements should be pre- viously made, that no time be lost. It is an interesting fact that a large proportion of those who die after tracheotomy die of bronchitis, usually capillary, or of pneumonia developed after the operation. These diseases seem to be partly attributable to the operation, or, if previously existing, to be aggravated by it. It is believed that the introduction into the bronchial tubes and the lungs of cool air, of air not warmed by the natural circuit through the nostrils and larynx, may be a cause of these inflammatory complications. Sometimes, also, the canula 476 BRONCHITIS. by pressure increases the inflammation of the surface on which it lies. Therefore, not only does the operation require skill in its performance, but much of its success depends on the subsequent management. After the operation, the temperature of the apart- ment should be kept constantly at from 85° to 90°, and loaded with m.oisture. This obviates in part, but only in part, the tendency to bronchitis and pneumonia. Constant attention should be given to the canula, to prevent its filling with mucus and pus. Trousseau employed a double canula, which can be readily cleaned by removing the internal cylinder. The nurse, when properly instructed, can remove this cylinder as often as may be necessary in order to clean it. Mr. Lawrence, of London, and, following him, some other surgeons, prefer not to use the canula. The edges of the wound are kei:»t apart by a wire which passes around the neck, or a little of the trachea is removed so as to produce a sufiicient aperture. The reader is referred for particulars regarding this mode of ope- rating to recent treatises on operative surgery. After the operation no more medication is required. The patient should be kept quiet and free from excitement. His diet should be mainly liquid, and of the most nourishing character. In a few days, if the symptoms abate, the aperture may from time to time be closed with the finger after the withdrawal of the canula, in order to ascertain if the larynx is free from obstruction. If bron- chitis or broncho-pneumonia arise, the oil-silk jacket, with counter- irritation to the chest, is required, and stimulating expectorants, as carbonate of ammonia and syrup of senega, should be ordered. CHAPTER IV. BRONCHITIS. Inflammation of the bronchial tubes, or bronchitis, is probably the most frequent disease of early life. It is usually associated with more or less inflammation of the mucous membrane of the nostrils, larynx, and trachea. We designate the disease coryza, laryngitis, or bronchitis, according as one or the other inflamma- tion predominates. Sometimes bronchitis occurs with but slight inflammation elsewhere, and often the coryza and laryngitis abate while the bronchitis is still active. BRONCHITIS. 477 Bronchitis occurs both as a primary and secondary disease. The secondary form is common in connection with measles, hooping- cough, pneumonia, and pulmonary j^hthisis, and it is not uncom- mon in scarlet fever, variola, remittent and continued fevers. Bronchitis is mild or severe, and acute, subacute, or chronic. If the inflammation atfccts the bronchules, the bronchitis is called capillary. Bronchitis is usually bilateral, afiecting the tubes on the two sides with about equal intensity. The exceptions are when it is dependent on pneumonia or pulmonary phthisis. In these cases it is confined to those tubes, or nearly to those, which are surrounded by the tubercular or inflammatory product. Causes. — The causes of secondary bronchitis are obviously the diseases in connection with which it occurs. The cause of primary bronchitis is the same as that of simple acute laryngitis or coryza, namely, sudden change of temperature from warm to cold, exposure to currents of air, the practice of sending children without sufii- cient clothing from heated rooms into the open air, the throwing off of bedclothes at night, etc. Dentition is also an occasional cause, since some children have attacks which coincide with the eruption of the teeth. The cough of dentition is usually purely a nervous afilection ; but in other instances it is accompanied by more or less mucous secretion, and is evidently dependent on a mild inflammation. Anatomical Characters. — In the most common form of bron- chitis, the larger bronchial tubes only are afliected. They are the seat of the inflammation in most of those cases which are desig- nated " colds" by families, and which are often treated without the aid of the physician. The lining membrane of the bronchial tubes presents the ordinary anatomical characters of mucous in- flammations. It is reddened uniformly or in patches, intensely, or in that milder degree known as arborescence, according to the severity of the inflammation. The secretion of the muciparous follicles is at first arrested, and the surface of the membrane is drv. In the course of a dav or two the secretor}' function is re-established, and the surface is covered with thin and transparent mucus. A day or two later, the secretion becomes thicker, consisting of mucus and pus. Mixed with these substances are epithelial cells, which are exfoliated in abundance from the inflamed surface. At the same time the mucous membrane becomes thickened and more or less softened. If the inflammation is severe, the vessels of the submucous cellular tissue are also injected. 478 BRONCHITIS. Usually, in about a week in the young child, in from one to two weeks in older children, the inflammation begins to abate. Gradu- ally the inflamed membrane returns to its normal consistence, thickness, and vascularity, and with this return to the healthy state the muco-purulent secretion abates. In this, which is the simplest form of bronchitis, and most com- mon, there is no uk-eration, and rarely any pseudo-membranous formation, if the disease is idiopathic. Pseudo-membranous bron- chitis is not unusual as an accompaniment of pseudo-membranous laryngo-tracheitis. Were bronchitis limited to the larger bronchial tubes, it would indeed be a simple aflfection, but unfortunatel}^ it has a tendency to extend downwards. Commencing in the larger, it gradually invades the smaller tubes in a similar manner to the extension of erj'sipelas upon the skin. More rarely the inflammation com- mences simultaneously in the larger and smaller tubes. I^ow the gravity of bronchitis is proportionate to the degree of its exten- sion downwards. It may stop at any point in its progress, but if it reach the smaller tubes it is one of the most serious afliections of early life, that already alluded to, namely, capillary bronchitis. The mucous membrane of the minute tubes, those next to the air-cells, is delicate, with but little submucous connective tissue, and it frequently, at post-mortem examinations, does not present to the eye those distinct inflammatory changes which are observed in tubes of large diameter. It is sometimes not notably thickened, nor its vascularity much increased, even when there is reason to believe from the symptoms that it was the seat of active phlegmasia. As we pass from these minute tubes to those of larger calibre, the inflammatory lesions become more distinct. The inflammation produces minute and abundant points of redness, and the membrane is evidently thickened ; often it is rough or granular. The minute bronchial tubes are very small, especially under the age of three years, and since in capillary bronchitis a large proportion of them are inflamed, the source of the danger is apparent. It is with difiiculty that the patient with capillary bronchitis can, by the efibrt of coughing, free the tubes from the secretions which are constantly collecting in them. In weakly children, under the age of two years, expectoration is most difficult, and hence the great and increasing dyspnoea from which such patients suflfer. In unfavorable cases of capillary bronchitis, the following changes are apt to occur. The small tubes, usually those in the posterior por- ANATOMICAL CHARACTERS. 479 tion of the lungs, become more and more loaded with mucus and pus, obstructing the entrance of air till, finally, one after another of the lobules cease to be inflated. As the air passes out of the air-cells of a lobule more readily than it enters them, partial lobular collapse occurs. Doubtless, also, some of the mucus and pus, no longer expectorated, is forced backward into the air-cells. JSTow, a. portion of lung from which air is excluded while the circulation continues, becomes congested. If the lungs of a patient who has died at this stage of capillary bronchitis are examined, the ante- rior portions will be found to present nearly their normal appear- ance, while the lobular changes which have been described will be found mainly in the posterior part. Certain of the lobules will be observed depressed below the common level, of a dark red color from passive congestion, firm to the touch, and non-crepitant or feebly crepitant. Sometimes only a few of the lobules have under- • gone this change of colkpse and congestion, but more frequently a considerable number on both sides are affected. Up to this time there is often no pneumonia, but this is the state of Inngs and bronchial tubes which has sometimes been mistaken for and designated broncho-pneumonia. It has also been called lobular pneumonia. The substance which fills the bronchial tubes is usually muco-purulent,but in exceptional cases, in addition to mucus and pus, there is more or less fibrin. This ordinarily occurs as a delicate film of small extent, observed here and there, and readily detached from the surface underneath. In rare instances it occurs as a firm and continuous membrane, forming a mould of the tubes, increasing greatly the dyspnoea, and constituting a true bronchial croup. If the patient survive the immediate effects of capillary bron- chitis, the inflammation of the mucous membrane soon begins to abate. The collapsed and congested lobules, and the terminal portions of the bronchial tubes leading to them, which are ob- structed by inflammatory products, ordinarily return to their nor- mal state as the inflammation declines, but in other instances they undergo changes which are interesting, but which are not fully un- derstood. When the function of a portion of lung ceases, as it does when the air is excluded from it, the cells and nuclei which it con- tains, and probably other parts, begin to undergo fatty degeneration. These elements become granular, somewhat enlarged and opaque, and here and there mixed with them are other large cells filled with oil globules. These are the compound granular cells of patho- logists, and, occurring in this situation, are produced by metamor- 480 BRONCHITIS. pilosis of the epitlielicil cells. They are epithelial cells which have progressed more rapidly than others in fatty degeneration, having reached that stage of it which immediately precedes liquefac- tion. "\Ye often with the microscope observe not only these cor- puscles, but their fragments as they are dissolving. These changes are common in lobules which are for a certain time collapsed and congested, whether or not pneumonia has supervened. If the lobules remain collapsed for a considerable period on account of the feeble inspiratory efforts of the child, and the pre- sence of mucus and pus which obstruct the tubes, they may undergo such change that they are not inflated, even when the tubes be- come freed from obstruction. If an opportunity is presented of examining the lungs at this time, it will be found difficult, if not impossible, to expand, even by strong insufflation, the lobules which have been for a considerable period collapsed and more or less congested. These lobules have a greater specific gravity than water, and closely resemble lobules which are solidified by inflam- mation; but when the changes occur which have been detailed above, there is obviously no true pneumonia at first. Pneumonia is, however, a not infrequent complication and result of capillary bronchitis. While in certain lobules collapse and simple congestion occur, others may be afffected by a true inflam- mation extending from the adjacent inflamed tubules. Therefore in fatal cases it is not unusual to find in the same lung lobules collapsed and congested, and others hepatized. In the former there is diminution in the size of the alveoli, with sim]3le conges- tion, while in the latter the alveoli are of full size, or distended in consequence of the abundant proliferation of cells within them. Pneumonia may also occur as a sequel of capillary bronchitis in lobules, which in -consequence of the feebleness of the infant, or other cause, remain collapsed and congested, since tissues remain- ing in a state of passive congestion are very prone to inflammation. That pneumonia, subacute and catarrhal, does occur in the collapsed lobules, is demonstrated by the fact of a proliferation of cells with- in the alveoli. Minute abscesses, usually directly under the pleura, have occa- sionally been observed at the autopsies of those who have recently had capillary bronchitis, and pathologists are not agreed as to the mode in which they are produced. Some of them, if not all, are evidently connected with the minute bronchial tubes, and the quantity of pus contained in each is not usually more than one or \ SYMPTOMS. 481 two drops. The most reasonable view of their causation is that they are produced in the terminal tubes where the mucus and pus collect. The pus acts as an irritant and causes inflammation, and the inflammation increases the quantity of pus. The walls of the tube which is now the seat of an abscess are destroyed by ulcera- tion, and probably, also, some of the contiguous air cells. The little cavity is soon surrounded by a delicate membrane, the same in character, though less thick and firm, with that which consti- tutes the walls of larger abscesses. The pus presents the usual appearance of this liquid, or it may be tinged by the presence of blood cells, or again it may be thick from partial absorption of the liquor puris so as to resemble softened tubercle. The abscess is ordinarily located in the centre of a collapsed lobule. In certain cases it approaches the surface of the lungs, so as to produce circumscribed pleurisy, with adhesion, of the costal and visceral pleura. At the autopsy of such a case, on separating the adhesions and attempting insufliation, the air passes through the aperture, so that the lung on that side cannot be inflated unless the aperture is closed. Occasionally pneumothorax results from opening of the abscess into the pleural cavity. Dilatation of the bronchial tubes is an occasional result of bron- chitis, especially when severe and protracted. Emphysema is a common lesion observed in young children, whether death has occurred from disease of the respiratory or some other system. It is observed most frequently in the upper lobes, and oftener in their anterior than posterior portions. If it is vesicular, the sacs of air are numerous and minute, but if interstitial, they are large and irregular. If they are upon or near the surface of the lung so as to distend the pleura, they may attain considerable size. I have seen them of the size of a filbert in infants under the ' age of one year. In exceptional cases there are many of these air bladders situated between the root of the lung and its anterior border, and percep- tibly augmenting its volume. Severe bronchitis attended by labored respiration and a large collection of muco-pus in the tubes, while it produces collapse of certain lobules, is recognized as a common cause of these emphysematous lesions. Symptoms. — It is evident, from the description which has been given of the anatomical characters of bronchitis, that its symptoms vary greatly in severity in difterent patients. It usually com- mences with more or less coryza. The symptoms are headache, flushed face, elevation of temperature, acceleration and fulness of pulse. In the mildest cases these symptoms are scarcely appreciable. 31 482 BEONCHITIS. The child is observed to sneeze and have some defluxion from the nostrils, and this is followed by an occasional mild, almost painless, cough, which declines in the course of a few days. The respira- tion and pulse are scarcely accelerated, and the appetite is but slightly impaired. There may be a little fretfulness, but the child is not confined to his bed or room, and usually amuses him- self with his playthings. Auscultation in these mild cases reveals coarse mucous rales in the larger bronchial tubes, while the smaller tubes are free from mucus. Sibilant and sonorous rales are also observed, especially in the commencement of the bronchitis, at which time the secretion of mucus is suppressed or scanty. The cough in the commencement is for the same reason dry. It be- comes looser by the second or third day, the sputum consisting of frothy mucus, with the admixture of pus and epithelial cells. The pus becomes more abundant as the disease continues. Expectora- tion does not usually occur till after the age of four or five years ; under this age the sputum is ordinarily swallowed. The mild form of bronchitis described above, that in which only the larger bronchial tubes are affected, is common at all periods of infancy and childhood, but a severer grade of the dis- ease is also of common occurrence, exclusive of those cases in which the minute branches of the bronchial-tree are affected. It has already been stated that there is a tendency in bronchial in- flammation to extend downwards, and symptoms are proportionate in gravity to the degree of this extension. In severe bronchitis the pulse rises to 120 or 130 per minute, and the respiration is in a corresponding degree accelerated. The cough is frequent and painful, the pain being referred to the sternum, and often there is a steady dull pain in this region. The face is flushed and indica- tive of suffering, the temperature is considerably elevated, and the appetite is greatly impaired or lost. There is frequently an exacerbation of symptoms in the latter part of the da}^ Depres- sion of the infra-mammary region during inspiration, and dilatation of the alse nasi, accompany grave attacks of the inflammation. Auscultation in severe bronchitis reveals the presence of rales in all parts of the chest, sibilant and sonorous sparingly, coarse mucous and sub-crepitant more abundantly. Capillary bronchitis or suffocative catarrh, the most dangerous form of this inflammation, is less frequent than bronchitis, which is limited to the larger tubes, or to the larger tubes and those of medium size. It may commence quite abruptly, but ordinarily it results from the milder form of the disease. The symptoms at SYMPTOMS. 483 first, are such as occur in the common form of bronchial inflamma- tion, but instead of abating or remaining stationary, they gradu- ally increase in severity till, suddenly, marked dyspnoea super- venes. The inflammation has now reached the minute tubes, and what promised to be an ordinary attack of bronchitis becomes one of great severity and danger. The respiration in capillary bronchitis is short and hurried. Sixty to eighty inspirations per minute are not infrequent, while the pulse also is greatly accelerated, attaining as high a number as 140 to 160 or 180 beats per minute. The cough is fre(][uent, and the sputum, which collects in abundance, is expectorated with difiiculty. If expectorated so as to be examined, it is found to consist largely of frothy mueus with epithelial cells. After a few days, if the patient live, it becomes more purulent. Sometimes, as in bronchitis of the adult, streaks of blood appear upon the mucus. In the first days of capillary bronchitis, the temperature is considerably elevated, the face flushed and indicative of sufter- ing. The patient is restless, moving from one part of the bed to another, seeking in vain for relief. The digestive function is impaired, as in all severe inflammations ; the tongue is moist and covered with a light fur; the appetite is nearly or quite lost. The nursing infant nurses with difiiculty, frequently relinquishing the breast on account of the dyspnoea ; older children take no solid food in consequence of the anorexia and the dyspnoea, and even drinks are swallowed hastily and apparently without relish, since deglutition interferes with respiration. On auscultation in capillary bronchitis, at first sibilant, and after a day or two sub-crepitant, rales are observed in every part of the chest. Percussion elicits a good resonance, unless the substance of the lung has become involved. As the disease approaches a fatal termination, the pulse becomes greatly accelerated, the respiration is also in a corres- ponding degree frequent and panting, the inspiration being accom- panied by marked infra-mammary depression and dilatation of the alse nasi. The face becomes pallid, the prolabia livid, and the tips of the fingers livid and cool. The mucus and pus, accumulating in the air passages, increase more and more the obstruction to the en- trance of air, and, finally, death occurs from ajDuoea. The nursing infant usually ceases to nurse for several hours before death, and a state of stupor commonly precedes the fatal event, in consequence of the carbonaceous state of the blood. In young infants, espe- cially those under the age of six months, not only in capillary bronchitis, but in severe ordinary bronchitis, I have often observed 484 BRONCHITIS. toward the close of life, intermissions in the respiration. It occurs after every six or eight or ten respirations, and equals in duration the time occupied in, jDcrhaps, half a dozen respiratory movements. It is, therefore, an unfavorable prognostic, but some recover by stimulation in whom it occurs. The duration of acute bronchitis varies accordino- to the extent of the inflammation. In the mildest form, the patient is con- valescent after three or four days, and, in severer forms that terminate favorably, the disease begins, ordinarily, to decline by the close of the first week or in the second. The progress of bronchitis is somewhat more rapid in young children than in those of a more advanced age. When convalescence is fully established, it is not unusual for the cough to continue three or four weeks, though gradually declining. It is loose and painless, and is scarcely regarded by the patient. Death sometimes occurs as early as the second or third day in capillary bronchitis. The younger the infant, with the same extent and intensity of inflammation, of course the sooner the fatal result. The ordinary duration of fatal bronchitis is from six to eight days. If the patient pass beyond the tenth day, decline of the inflammation may be confidently expected, and recovery, unless there is a complication. Occasionally bronchitis becomes chronic, lasting several months before it entirely ceases. The chronic form may result from mild, as well as severe, bronchitis. The active fever and accelerated respiration which characterize the acute affection abate, and the general health is nearly or quite restored ; but an occasional cough continues, and the respiration is often audible, from the mucus which collects in the tubes, or from thickening of the mucous membrane. Sometimes there is moderate febrile movement, espe- cially in the latter part of the day. On auscultation, coarse mucous, with perhaps sibilant and sonorous, rales are observed in the chest. There is great liability in chronic bronchitis to exacerbations. The disease often seems to be abating, and there is prospect of its speedy cure, when all the symptoms are intensified. The exacerba- tions are due to the fact that the bronchial surface, when it has been a considerable time inflamed, is very sensitive to the im- pression of cold. Even when the disease is entirely relieved, it is very apt to return by exposure to currents of air or changes of temperature. Chronic bronchitis occurs most frequently in the winter and in the spring and fall, when the Aveather is changeable, DIAGNOSIS — PROGNOSIS, 485 and is most intractable in these periods of the year. Many cases of chronic bronchitis are associated with dilatatipn of the bronchial tubes or with emphysema. The general health in chronic bron- chitis, when not dependent on a tubercular deposit, ordinarily remains good. Tubercular bronchitis, which is the result of a grave disease, does not require a separate consideration. It is attended with emaciation, and is obstinate on account of the nature of the primary aficction. It is due to the irritating effect of tubercular matter lying against the bronchial tubes. Diagnosis. — Bronchitis can ordinarily be diagnosticated by the character of the respiration and cough. The absence of hoarseness, stridulous inspiration, and croupy cough, excludes laryngitis ; and the absence of the expiratory moan and of the stitch -like pain on coughing, which characterize pneumonia and pleurisy, excludes those diseases. Accurate diagnosis, however, can be most readily made by percussion and auscultation. Examination of the chest enables us to state with positiveness, not only the nature, but the extent of the atfection. If the inflammation is confined to the larger bronchial tubes, coarse rales are discovered in them, while finer mucous rales are absent. If the bronchitis is capillary, sub- crepitant rales are discovered in the smaller tubes. Percussion gives clear resonance on both sides, except in those instances in which collapse or pneumonia has supervened. Prognosis. — Bronchitis, limited to the larger bronchial tubes, or to these and those of medium size, terminates favorably in a large majority of cases. Occasionally, severe inflammation, not extending to the smaller tubes, proves fatal in young infants, or those of feeble constitution. True capillary bronchitis is, on the other hand, a disease of great danger. It may be fatal at any period of childhood, but the younger the patients and more feeble, the greater the proportion of deaths. Under the age of one year, it is one of the most fatal diseases of early life. The prognosis, in the commencement of all cases of bronchitis of average severity in the young child, should be guarded, on account of the tendency of the inflammation to extend, since ordinary bronchitis may become capillary. After five or six days, extension ceases, and, if during that time there is no increase in the severity of symptoms, the prognosis is favorable. Signs which indicate an unfavorable result are increasing frequency of pulse and respiration, difiicult and scanty expectoration, restlessness, -a countenance indicative of suftering, and a progressively greater accumulation of mucus in the bronchial tubes, as determined by 486 BEONCHITIS. auscultation. Pallor and coldness of tlie face and extremities, lividity of the tips of the fingers, rapid and feeble pulse, drowsi- ness, diminution of cough, while the mucus and pus accumulate in the bronchial tubes, and, in young children, intermissions in the respiration, indicate the near approach of death. Cases may, how- ever, recover by proper treatment, although the symptoms are most unfavorable. It is unnecessary to mention the favorable prognostic signs of bronchitis. This disease, when fully established, continues a cer- tain number of days, whatever remedial measures are employed, and if the symptoms do not increase in severity during the first five or six days, a favorable result is highly probable. The prognosis in chronic bronchitis is ordinarily favorable, so far as life is con- cerned, provided there is no emaciation. If there is emaciation, the bronchial inflammation may be due to tubercles in the bronchial glands or lungs, and, of course, the prognosis is unfavorable. Treatment. — Bronchitis may be rendered much milder, and perhaps even prevented, by an emetic employed in the first twelve or twenty-four hours, in conjunction with a warm bath. The physician is not, however, ordinarily called sufliciently early to render this treatment efiectual. The remedial measures proper for this disease vary greatly, according to the stage and intensity or extent of the inflammation and the age of the patient. Bronchitis, limited to the larger tubes, requires simple measures. A laxative may be employed, with a mild expectorant, and moderate counter- irritation should be produced by camphorated oil, or the occasional employment of a sinapism. I have sometimes ordered for these cases a mixture recommended by Dr. James Jackson, of Boston, in his letters to a young physician. " For young children," .... says he, " I employ the following : Take of either almond or olive oil, of syrup of squills, of any agreeable syrup, and of mucilage of gum acacia, equal parts, and mix them. Of this mixture, a tea- spoonful may be given to a child at two years of age ; a little less if younger, and increased if older, so as to double the dose to one in the sixth year. This may be given from three to six times in the twenty-four hours. Sometimes a little opiate must be added at night to appease an urgent cough." These cases also do well with simple mucilaginous drinks in conjunction with gentle ape- rients. Bronchitis, extending beyond the primary or secondary bronchial divisions, requires more careful watching and more decided mea- sures. The abstraction of blood by leeches, or otherwise, is seldom TREATMENT. 487 required in the treatment of bronchitis. Occasionally, it the in- flammation is intense and the symptoms urgent, moderate abstrac- tion of blood at an early period may be useful, but the employment of cardiac sedatives under such circumstances is generally prefer- able. As a rule, actively depressing agents should be avoided in the treatment of bronchitis in patients under the age of two years ; and, on the other hand, sustaining remedies are in a large propor- tion of cases required after the first two or three days. Many infants with bronchitis are sacrificed in consequence of the old theory, which still influences medical practice, that, an inflamma- tion, with its increased force of circulation, is necessarily Ijest controlled by depletory and sedative measures. Remedies too de- pressing are prescribed, and with a less favorable result than would follow a strictly expectant course of treatment. What is, therefore, the proper mode of treating bronchitis, severe or of ordinary gravity, occurring in infancy and childhood ? It is supposed that the physician is called when the inflammation is fully established, or that, if he has seen the patient at the com- mencement, and has prescribed an emetic, it has failed to throw off the disease. A large emollient poultice, not thicker than the cover of a book, so wet as to produce constant moisture of the surface, and sufliciently irritating to produce constant redness without necessitating its removal, should be applied to the front and sides of the chest, and over it an oil-silk jacket placed. I pre- fer a poultice of the following: — R. Pnlv. sinapis §ss ; Pulv. sernin. lini §viij. Misce. Local treatment in bronchitis is very important. The exact mode of applying it, or the substances used, matters little, provided it meets the indication, which is twofold — namely, derivation to the surface, and the application to it of warmth and moisture. Such applications are found, by experience, to give most relief. Warmth and moisture are furnished by cataplasms most con- veniently, or by warm water applications under oil-silk. Derivation to the surface, early made and repeated, tends to check the downward extension of bronchitis ; but it is not advisable to vesicate, or to produce anything more than moderate and con- tinued redness. Often improvement in symptoms is observed, especially less dyspnoea and restlessness, immediately on the em- ployment of the local measures recommended above. 488 BRONCHITIS. The general or internal treatment appropriate for bronchitis varies according to the age and the character of the inflammation, whether primary or secondarj^ The following formula will be found useful for infants affected with primary bronchitis: — H. Spts. aether nitr. 3j ; Syr. ipecacuanhag, 01. ricini, aa 3ij ; Syr. bal. tolut. 3vij. Misce. One teaspoonful for an infant one year old every two to four hours. Another eligible formula is the following : — R. Syr. ipecacuanhas gij ; Potas. acetat. gr. xvj-^ss ; Aq. anisi 3xiv. Misoe. Dose, one teaspoonful for an infant of six months. If there is decided febrile reaction, tincture of digitalis, one or two drops, according to the age, may be added to each teaspoonful. In a majority of cases of infantile bronchitis, this mode of treat- ment is appropriate only for the first few days, after which, if farther medication is required, more sustaining, or even stimulating, medicines are proper. For children over the age of three years, if the previous health has been good, and the bronchitis is primary, aconite or veratrum viride is often useful in the first stage of the inflammation. The following is a recipe for a child of five years : — R. Tinct. rad. aconit. gtt. xij ; Syr. scillae comp. 3ij ; Syr. bal. tolut. gxiv. Misce. One teaspoonful every two to four hours ; the medicine to be omitted, or given at a longer interval, if the frequency of the pulse is reduced. The tincture of veratrum viride is more powerful than that of aconite, and may be employed in the same dose for those who are more robust. The effect of cardiac sedatives should be carefully watched. In general they should be administered only during the first three to five days ; but if the child is robust, with full and strong pulse, they may be continued longer. As the active inflammation begins to abate, simple expectorant mixtures may be given, as syrup of squills, or ipecacuanha in spiritus Mindereri! At this stage of bronchitis, it is often best to commence the use of stimulating ex- pectorants, and they are required in nearly all cases of advanced bronchitis. In secondary forms of the disease, as when it occurs in connection with hooping-cough or measles, such expectorants TREATMENT. 489 should be employed from the first; and also if there is a state of feebleness or cachexia, although the bronchitis is primary. It is important for successful practice to be able to determine at what period in the disease this class of medicinal agents should be pre- scribed. In doubtful cases, it is safer to prescribe them than those of a depressing character; but it is better to employ, for a day or two, a simple mucilaginous or other soothing mixture, after which a stimulating expectorant can be given. A favorite prescription with me is the following : — R. Ammon. carbonat. gr. xvj-xxiv ; Tinct. sanguinar. gtt. xxiv ; Syr. senega; ^ij ; Ext. glycyr. 3ss ; Aquae 3xiv. Misce. Dose, ote teaspoonful every two or three hours to a child of two years. If there is restlessness, Dover's powder, paregoric, or syrup ot poppies should be given with this mixture, or separately. As convalescence approaches, the medicine should be administered less and less frequently or in smaller doses. Emetics in ordinary cases of bronchitis are not required, except in the commencement. In severe bronchitis, however, especially when the smaller tubes are inflamed, they are sometimes of great service. The cases which require their administration are those in which mucus and pus collect in the tubes more rapidly than they are expectorated, so as to give rise to urgent dyspnoea. ITothing gives such decided and immediate relief under these circumstances as an emetic. The object to be gained is obviously very different from that in the commencement of bronchitis, and such agents should be employed as act promptly, with the least possible depression. Sulphate of zinc or of copper is, therefore, an appropriate medicine. The former may be given in a dose of live grains ; the latter, of one or two grains to a child five years old. If there is considerable strength of pulse and heat and dryness of surface, ipecacuanha may be administered. If there are evidences of exhaustion, stimulants may be administered immediately before and after emesis. Infants oppressed by the accumulation of mucus and pus may sometimes be relieved by tickling the fauces with the finger. This provokes vomiting, and the viscid mucus which collects at the entrance of the glottis is removed by the finger. In secondary bronchitis whatever the age, in primary or second- ary occurring in infants or feeble children, the diet should, as a rule, be nutritious through the entire disease. Robust patients, 490 PNEUMONITIS. or those who have had ordinary health, if over the age of two years and aftected with primary bronchitis, should have light diet, chiefly farinaceous in the first days of the attack, after which animal broths are proper. Whatever food is given in severe bron- chitis must be in the form of drinks, since the appetite is lost, while the thirst is such that liquids are less likely to be refused. In primary bronchitis, if mild or of ordinary severity, alcoholic stimulants are not required. In secondary bronchitis they are often needed, and also in capillary or severe ordinary bronchitis if there is dyspncea with evidences of prostration. The occasional loose cough which is often present during the period of conva- lescence requires but little treatment; either no medicine or a gently stimulating expectorant may be given. CHAPTER y. PNEUMONITIS. In children over the age of five or six years, pneumonitis differs but little in form or phenomena from that of the adult, being ordinarily primary except as it depends on an irritant, as tubercles, and extending rapidly over one or more entire lobes. In those under the age of five years it is, on the other hand, as a rule, a secondary affection, and limited to a part of a lobe. Most writers, until recently, have classified cases according to their origin as primary and secondary, or their extent as lobar and lobular, or their duration as acute or chronic. A better classification, having an anatomical basis, is that into catarrhal, croupous, and inter- stitial. Catarrhal pneumonitis consists in an inflammation of the air- cells, with an abundant proliferation of epithelial cells within them, and the exudation of serum but not of fibrin. The secondary and lobular pneumonitis of young children, alluded to above, is usually of this character. Croupous pneumonitis consists also in an inflam- mation of the alveoli, but with an abundant formation of pus-cells within them, and the exudation of fibrin and serum. The lobar and primar}^ pneumonitis of advanced children and adults is com- monly of this character. In both catarrhal and croupous pneumo- nitis, therefore, the solidification of the lung and exclusion of air are CAUSES. 491 due mainly to the newlj^-formed cellular elements with which the alveoli arc filled, though the source and nature of these cells differ in the two diseases. Interstitial pneumonitis consists in an in- flammation and hyperplasia of the connective tissue of the lungs. It is the chronic pneumonia of authors, resembling in many respects, in its anatomical and clinical characters, cirrhosis of the liver. The inflammation which produces this result is subacute, and in nearly all cases is dependent on some persistent local disease in the minute bronchial tubes or lungs, as softened or cheesy tubercles, cancer, abscesses, protracted inflammation of the alveoli or bron- chioles, whether produced by the inhalation of dust of an irritating nature or other cause. Interstitial pneumonia is much more rare in children than adults, and, as it presents no peculiar features in them, it need only be alluded to in this connection. Causes. — Croupous pneumonitis in most cases results from that common cause of inflammations — namely, taking cold. It com- mences as a primary disease within a few hours after exposure. Catarrhal pneumonitis, in exceptional instances, also commences abruptly as a primary disease from the same cause, but being, probably in nine cases out of ten, secondary, it commonly results from antecedent pathological states, which we will enumerate. First. Many cases result from bronchitis. The inflammation extending downward engages the minute bronchial tubes, and from them traverses the alveoli of one or more lobules. This is the broncho-pneumonia of children described by authors ; it occurs most frequently between the ages of six and eighteen months. ^.--Secondly. Hypostasis, or passive congestion, is an important factor in the causation of many cases, and in feeble infants it is not infrequently the sole cause. Infants with feeble health and languid circulation, lying in their cribs day after day with little movement of the body, are very liable to passive congestion of the depending portions of their lungs, and this by and by eventuates in a cell proliferation within the alveoli — in other words, a pneumo- nia presenting some peculiarities, but of the catarrhal form. In foundling hospitals, where feeble infants are received and treated, this is one of the most frequent pathological states, and is the pre" vailing form of j)ulnionary inflammation-.- It is sometimes de- scribed as hypostatic pneumonia. Hence physicians, whose obser- vations have been largely in such institutions, have almost ignored any other form of pneumonia in infants. Billard, a close and accurate observer, wrote nearly half a century ago : " Pneumonia of infancy presents peculiar characters, in which it differs from the 492 PNEUMONITIS. same aiFection in adults. Instead of being an idiopathic affection arising from irritation developed in the pulmonary tissue under the influence of atmospheric causes, which often excite the disease, the pneumonia of young infants is evidently the result of a stagna- tion of blood in their lungs. Under these circumstances this blood may be regarded as a kind of foreign body .... It would, therefore, appear that inflammation of the lungs, which produces hepatization, arises in infants, in general, from some mechanical or l^hysical cause." Valleix also states that he found the lesions of pneumonia in a majority of the infants who died in the Hopital des Enfants Trouves. The statements of Valleix are applicable also to the Infants' Hospital, and ]N'ursery and Child's Hospital, of this city, as regards those cases in which death results from chronic disease. We shall see hereafter that hypostatic pneumonia is one of the most common complications of chronic infantile entero- colitis, the summer complaint of the cities. Thirdly. Catarrhal pneumonia of infants sometimes results from collapse. It is not unusual to find, at the autopsies of infants who have died in a state of emaciation and feebleness, portions of the lungs remote from the bronchi collapsed, as, for example, the thin edges of the inferior lobes, and the tongue-like process of the left upper lobe, the process which lies over the heart. The immediate cause of the collapse has been a bronchitis, or it has resulted di- rectly from the general weakness of the infant, and its feeble res- pirations. N'ow, a collapsed lung soon becomes affected by passive congestion. The functional activity of an organ favors circulation through it, and if the function is abolished the flow of blood in the part is retarded, and stasis more or less complete results. The hyperffimic state of collapsed pulmonary lobules presents the same anatomical condition for the supervention of pneumonia, as occurs in cases of hypostatic congestion. Consequently, cell proliferation soon begins in the collapsed alveoli, the volume of the affected lung increases, and it becomes firmer and more resisting to the touch, and the microscope reveals the characters of a subacute but genuine catarrhal pneumonitis. I have made or have procured microscopic examinations of a considerable number of such speci- mens, and have found the alveoli more or less filled with cells of the epithelial character. In rare instances in infancy and childhood pneumonitis results, as it more frequently does in the adult, from an embolus detached from a clot, which had formed in some remote vein, in consequence of arrest of circulation in it, by inflammation of the contiguous ANATOMICAL CHARACTERS. 493 tissues. This is described by writers as a distinct form of pneumo- nitis designated embolic or cmbolismal. A specimen showing this mode of causation was exhibited by me at the New York Patho- logical Society, in February, 1868. An infant born January 22d, 1868, of strumous parents, had been fretful, but without appreciable ailment till February 3d, when inflammation of the connective tissue occurred on the anterior aspect of the left leg, a little below the knee. This extended downwards, suppurated, and the pus was evacuated February 5th. In the mean time, three other similar inflammations occurred, two on the right foot and leg, and the other over the parietes of the chest in the right infra-mammary region. Suppuration occurred in all of these. On February 8th this infant was suddenly seized with extreme dyspnoea, and died in a few hours. l!^umerous minute puriform collections (formerly called metastatic abscesses) were discovered in each lung, most of them scarcely larger than a pin's head. One of them p\ ~, f^,?, on the right side in the middle lobe '"^M Vi^if^^l^} connecting with a bronchial tube had jWif %'-MM,'B0 ruptured into the pleural cavity, cans- w^'^^^i^h^ '^^"'^^^ ing pneumothorax, collapse, and incipi- |4, mMM}. t^v?^-. ent pleuritis. ^ ^^^''Wjil -^#^ The annexed figure exhibits the i^li^ f ^\l5Mil>^> \1 '':*'1 / microscopic appearance of this softened "^^^ "fMm^^^m^ ' '^*"* ^"^^ fibrin, which, to the naked eye, so " '''''^^^^m^ ^ closely resembled pus. On account of the speedy death, the emboli had produced, in the lobules where they had lodged, little more than congestion or the first stage of pneumonitis around them. Had the infant lived longer, doubtless the ferments or the vibriones, which some con- sider the irritating element of emboli, would have produced sup- purative inflammation. Anatomical Characters. — Nothing need be added in this con- nection to what has already been said, in reference to interstitial and embolismal pneumonias. Being comparatively rare in children, they present the same anatomical characters as in the adult. That unimportant form of pneumonia called pleurogenous, and which consists in a croupous inflammation of the superficial infundibula of the lung underneath an inflamed pleura, occurs in children as well as adults. Being secondary to the pleuritis produced by extension of the inflammation of the pleura, it gives rise to no physical signs, or appreciable symptoms, on account of its slight extent, and as it presents no peculiar features in the child, it need only be alluded to. 494 PNEUMONITIS. Croupous pneumonitis, •winch we have stated is the ordinary form of puhiiouarj inflammation in children over the age of five years, has the same anatomical characters as in the adult. It ordinarily in- volves an entire lobe. It is more frequent in the right than left lung, and in whichever lung it occurs its most frequent seat is the lower lobe. The inflammation may, however, be limited to an upper lobe, especially on the right side. It ordinarily commences near the root of the luns; and extends forward. Croupous pneumonitis presents three stages, that of congestion, red hepatization, and gray hepatization. In the stage of conges- tion the capillaries in the walls of the alveoli are greatl}^ distended, bulging forward in loops within the alveolar spaces so as to diminish them, and a viscid albuminous fluid begins to exude, in which points of extra vasated blood appear. The afifected lung in this stage has a deep red color, its elasticity is greatly diminished, and its density and weight increased. On account of the reduced size of the alveoli from the bulging of the alveolar walls, and the viscid fluid within the alveoli and terminal bronchial tubes, the function of the alFected lobe is nearly lost, and hence the dyspnoea which patients experience in the first stage of the inflammation. The second stage is characterized by the continued and increased escape of the liquor sanguinis, and red and white corpuscles, through the stigmata or little apertures which exist normally in the walls of the capillaries. The inflamed alveoli, and the minute bronchial tubes which terminate in them, are filled with this pneumonic exudation. The relative proportion of the elements of the blood in the exudate varies in different cases. Fibrin is always present, immediately coagulating in delicate filaments within the interstices of which the corpuscles are lodged. The white corpuscles in some cases are much in excess of the red, while in others the red predominate. The lung in the second stage con- tains no air, has a greater specific gravity than water, is friable so as to be readily torn and penetrated by the finger. The torn surface in the adult presents a granular appearance, each granule being the contents of an air-cell. In the child the granules are not distinct on account of the small size of the air-cells, but the volume of the inflamed lobe is somewhat increased as in the adult. The stage of gray hepatization succeeds, in which the volume of the lung is still greater. The change of color is due partly to the compression of the capillaries by the inflammatorj'- material, partly to the destruction of the red corpuscles, and disappearance to a greater or less extent of their coloring matter, while the white ANATOMICAL CHARACTERS. 495 corpuscles (pus-cells) rem:un, but more to commencing fatty degene- ration in the exudate prior to its liquefaction. In favorable cases the lung soon returns to its normal state, the liquefied substance which tilled the alveoli being in part absorbed, in part expectorated. Croupous pneumonitis often causes inflammation of the portion of the pleura which covers it. Pleuritis developed in this way is circumscribed, but it frequently extends beyond the inflamed parenchyma to the distance of one or two inches. Bronchitis is also a common accompaniment. It may be general, in which case it occurs independently, or be limited to the tubes lying within the inflamed lung, in which case it results like the pleuritis from the pneumonitis. It is seen from this description that the pus-cells which are produced so abundantly in the alveoli are believed to be chiefly exuded white corpuscles of the blood. Possibly some of them may be produced by jjroliferation of the epithelial cells, which line the alveoli, in the same manner as they are believed to be produced in the bronchial tubes. Catarrhal pneumonitis, which is, as we have stated, for the most part the lobular pneumonitis of writers, and which, with an occa- sional exception, is the form of inflammation in children under the age of five years, presents not only clinical but anatomical features, which distinguish it from the croupous form of the disease. Those who have witnessed few post-mortem examinations of young- children, and whose views of the lesion are influenced by the ex- pression lobular, are ajjt to suppose that there is an alternation of inflamed and healthy lobules, so that the surface of the lung pre- sents an appearance not unlike mosaic work. This is a mistake. Although an entire lobe is seldom inflamed as in croupous pneu- monitis, the inflammation commonly extends over more or fewer contiguous lobules, but we find certain lobules in the midst of the inflamed area, which are but slightly afiiected or have escaped entirely. The extent of the inflammation is ordinarily from one to three inches, but I have seen a nodule of true catarrhal pneu- monia not larger than a pea, while every other portion of the lung- was healthy. On the other hand, almost an entire lobe may appear hepatized to the naked eye as in the croupous inflammation, but by a careful examination certain lobules will be found unafiected. Thus, in a case in the JSTursery and Child's Hospital, in which death occurred at the age of one year from pneumonitis supervening upon pertussis, an entire lower lobe, with the exception of a little of its anterior border, presented the appearance and feel of red hepa- tization, but a careful microscopic examination revealed not only 496 PNEUMONITIS. the absence of fibrin in the exudate, showing the catarrhal nature of the inflammation, but also certain lobules in the midst of the inflamed lunor which were not involved. The first change occurring in a lung invaded by catarrhal pneumonitis is congestion, whether active, as in the common form of the disease, in which the inflammation has extended into the lung from the bronchioles, or passive, as when the inflammation results from hypostasis or collapse. An exudation of serum, but not of fibrin, follows, and soon the epithelial layer which lines the alveoli begins to swell. The nuclei of the epithelial cells divide, the cells themselves forming large round cells with vesicular nuclei. These cells, to which the solidification of the lung is mainly due, are, therefore, on account of their origin and appear- ance, regarded as epithelial. The alveoli in catarrhal pneumonitis, it is seen, are filled with an inflammatory product quite diflferent from that in the croupous inflammation. Inflammation of the pleura over the inflamed lung, so common in croupous pneumonia, and which gives it the name pleuro- pneumonia, by which it is sometimes designated, rarely occurs in this disease. The seat of this inflammation is ordinarily the posterior part of the lungs, even when it results from extension of the inflammation from the bronchial tubes. TVhen resulting from collapse, it aifects chiefly those lobules which are remote from the bronchi, and which the air enters only by a long circuit. Catarrhal pneumonitis, when it arises from extension of acute inflammation of the bronchioles, is acute, but in those forms of the disease which supervene upon passive congestion it is subacute. The alveoli are less distended by inflammatory products than in croupous pneumonia, not only from the absence of fibrin, but from a less amount of cells. Hence the volume of the inflamed lung is not so great as in that disease, and the torn surface, even in the adult, does not present a granular appearance. Hence, also, the stage of gray hepatization does not supervene so uniformly and regularly, since there is less compression of the capillaries in the alveolar walls, and the mutual pressure of the inflammatory pro- ducts is less. In infants who have died with this form of pneu- monitis, of six or eight weeks' duration, it is not unusual to find the afi'ected lobules still in the stage of red hepatization. Cell proliferation occurs in the bronchioles of the inflamed lung as in the alveoli, producing within them numerous plugs, which, though they obstruct the entrance of air, are not so firm as in croupous pneumonitis, as they are destitute of fibrin. CHEESY PNEUMONITIS. 497 In favorable cases the lung aftected by catarrhal inflammation returns to its normal estate, probably by the same process as in croupous pneumonitis. In other cases, especially in scrofulous and feeble children, the inflammation instead of resolving passes into what is now designated cheesy, or by certain writers scrofulous, pneumonitis. CnEESY Pneumonitis. — Cheesy degeneration of the inflammatory product occasionally occurs in the croupous form of inflamniation, but it is more common in the catarrhal. I have most frequently observed it in ISTew York during epidemics of measles, when this form of pneumonitis supervened upon the catarrhal bronchitis of that disease. Cheesy pneumonitis is in its nature 'chronic, and attended with great reduction of the vital powers. Cheesy degeneration of the exudate or infiltrate consists essen- tially in the absorption of the liquid portion, and fatty degenera- tion of the solid. The obstruction of the circulation in the capillaries and the accumulation of cells in the alveoli and bron- chioles which cannot be expectorated, are conditions which favor the cheesy metamorphosis. The appearance and consistence of the lung when it has undergone this change are well expressed by the term which is employed to designate it. The cheesy mass consists of fatty, shrivelled, and fragmentary cells, and amorphous matter, in which can be traced the elastic fibres and larger vessels of the parenchyma, the other histological elements having disappeared. The caseous mass after a time softens, attracting moisture from the surrounding tissues. The molecular detritus and the shrivelled cells are now suspended in a liquid, and, like any dead matter, they are irritants to the surrounding lung substance. The bronchial tube which supplies the diseased lobule, and which in many in- stances was the starting-point of the disease, again becomes per- vious, either by softening of the plug or by ulceration at a higher point upon its walls, and air is admitted, which promotes the putrefactive process and chemical changes of the caseous substance. The lesion now described is that of pulmonary consumption, a disease not infrequent in children of two or three years. There are as yet no tubercles, but the presence of softening caseous material in the lungs very frequently leads to their development (see Art. Tuberculosis), and accordingly, before the case ends, clusters of tubercles may appear in the connective tissue and walls of the vessels of the lungs and in other organs. In the subsequent progress of cheesy pneumonitis, if the patient live sufiiciently long, there occurs more or less expectoration of 32 498 pneumo:n"itis. the offending substance, producing a cavity. Around the cavity a vascular pyogenic membrane forms, upon which granulations arise. These granulations, which produce pus abundantly, and from which small extravasations of blood are frequent, are gradu- ally transformed into connective tissue. If the dead portion is expectorated, and there is a single small cavity, the child may recover, the empty space being finally filled up by the extension of the granulations, and the production of a cicatrix, which contracts, producing a puckered appearance. Ordinarily, however, there are several depots of cheesy matter, and several cavities resulting, which continue to enlarge by the continued softening of cheesy matter in therir walls. Often, also, certain of the cavities intercom- municate. The bronchial glands undergo hyperj^lasia, and certain of them are apt, also, to become cheesy. As the disease advances, the suppuration and expectoration increase. The fatal result occurs sooner in children than in adults, and, therefore, the lesions, destructive and inflammatory, observed at autopsies, are ordinarily not so far advanced in the former as in the latter. Other unfavor- able changes may occur in the hepatized lung, but cheesy degene- ration is the most common and noteworthy. Whether it is possible to inflate a lung which presents to the naked eye the appearance of pneumonitis, has long been regarded as a reliable sign of the presence or absence of inflammatory consoli- dation. The facts as regards the possibility of insufliation are these: In croupous pneumonitis, when it has passed beyond the first stage, insufflation is impossible in the lung of the child as well as adult, with the utmost force of the breath. "We produce emphy- sema in healthy portions of the lungs, while the inflamed area is not encroached upon. On the other hand, in catarrhal pneumonitis, which we have seen is the common form of pulmonary inflammation in children under the age of five or six years, and in which there is less distension of the air cells by inflammatory products, the lung can be inflated, ex- cept in protracted cases, but when fully inflated the solidified lobules can still be felt between the thumb and fingers. In protracted catarrhal pneumonitis, as well as in protracted collapse, which, in- deed, may and often does become a pneumonitis, full inflation is impossible. Central portions still remain impervious to air. While, therefore, the possibility or impossibility of inflating a lung re- moved from an adult, and which presents to the naked eye the appearance of pneumonic solidification, is a valuable sign as in- SYMPTOMS. 499 dicatiiif^ wlietlier or not the disease was pneumonitis, in tlic child little importance can be attached to it. Symptoms. — Croupous pneumonitis commonly begins abruptly, or it is preceded for a brief period by symptoms of a cold. In the adult, the abrupt commencement is ordinarily with a chill. In the child, there is often a sensation of chilliness, but a distinct chill is not common. Convulsions sometimes occur in place of a chill. Catarrhal pneumonitis, being ordinarily a secondary disease, begins in a more gradual way, its symptoms being preceded by, and associated with, those of the primary affection. The symptoms of acute pneumonitis, whether catarrhal or croupous, are the following: Anorexia, thirst, restlessness, elevation of temperature, acceleration of pulse according to the intensity of the inflanmiation and the feebleness of the patient, flushed face, a countenance indicative of suffering, accelerated respiration, with an expiratory moan. These symptoms are constant in the acute inflammation unless of the mildest form. Those which are im- portant I shall describe more fully. The expiratory moan is described by writers as a pathognomonic symptom of this disease, or of pleurisy. It is evidently due to the pain experienced by the friction of the inflamed pleura. As a rule, the expiratory moan does indicate either pneumonitis or simple pleuritis ; but there are exceptions. It may occur, for example, from indigestible substances in the stomach and intestines, giving rise to acute dyspepsia; or from certain forms of abdominal inflam- mation, w^iicli render movements of the diaphragm painful. The cough in the first days of pneumonitis is often dry or hacking and painful. It afterwards, if the case is fsxvorable, becomes looser, and is painless. We very seldom observe -in the child the bloody sputum which characterizes pneumonitis in the adult, since in catarrhal inflammation there is little or no exudation of blood corpuscles. The sputum, which in this form of the disease is the product of secretion and cell proliferation, is at first thin and frothy, but afterwards thicker and less tenacious from the greater number of cells. There is often, in the first period of the inflammation, pretty severe and constant headache, the patient complaining of the head, if old enough to speak, before he does of the chest. In a severe attack the child at this period lies with the eyes shut, ap- parently in a half-conscious state, fretful if spoken to or aroused, so that the physician might be led to suspect the presence of cere- bral disease. If there is vomiting, accompanied with sudden twitching of the muscles, and convulsions — symptoms which some- 500 PNEUMONITIS. times occur — the liability to error in diagnosis is greatly increased. Cerebral symptoms are more prominent in the commencement of pneumonitis than subsequently. As the disease advances they subside, and symptoms referable to the chest become more con- spicuous. The breathing is, as I have said, accelerated. Thirty or forty respirations per minute are common, and, in severe cases, the num- ber reaches sixty or even eighty. In infants there is greater fre- quency of resi^iration than in children. In those at the breast, if the dyspncea is urgent, nutrition is sometimes seriously interfered with, since in these severe cases respiration is performed more through the mouth than nostrils, so that if the infant seizes the nipple, it is forced to relinquish it in order to breathe. Dilatation of the alse nasi, and depression of the infra-mammary region, accom- pany inspiration. The dyspnoea in catarrhal pneumonitis is often due in great part to accompanying bronchitis. The temperature in mild cases of pneumonitis is elevated to about 101° to 103° ; in severe cases it may reach 105° or even 107°, the former being the highest observed by Mr. Squire. In ninety- seven observations made by M. Roger, the average temperature was 104° during the active period of the inflammation. The face is therefore flushed, and the heat of surface pungent, except in weakly children, in whom, even in severe and active inflammation, the face is sometimes pale, and the extremities of natural or less than natural temperature. The tongue is moist, and covered with a light fur ; the thirst is such that nutriment may be given in the form of drinks, when the loss of appetite prevents the use of solid food. The bowels are usually constipated. The secretions, in the first and second stages, are diminished. The urine is more deeply colored than in health, and in vigorous patients it deposits ]jrates on cooling. The chlo- rides are also deficient, or absent;^ from the urine, as long as the inflammation is extending. In favorable cases, in from seven to ten days the heat and thirst decline ; the pulse and respiration gradually become less frequent ; the cough looser ; the features have a more placid or contented expression ; the appetite returns, and the patient is again amused ^y playthings. The improvement is progressive, but gradual. A slight cough is occasionally observed for two or three weeks after convalescence is fully established. Death in the acute stage of the inflammation commonly occurs from asthenia. The pulse gradually becomes more frequent and PHYSICAL SIGNS. 501 feeble, the respiration more oppressed, and finally, as death ap- proaches, the face and extremities become cool. Occasionally death results from apncca, due in great part to coexisting bronchitis. In exceptional instances it occurs from convulsions, followed by coma, especially in the first week. Death, in those protracted cases in which the inflammatory products have undergone cheesy degene- ration, is usually from asthenia. Such are the symptoms and progress of ordinary acute pneumo- nitis in children. When the inflammation is subacute, as in those forms of the disease which result from collapse or hypostasis, the symptoms are less pronounced. The respiration in such cases is but moderately accelerated, is attended by little pain, and therefore the expiratory moan is often absent. An occasional short, dry cough occurs, with so little increase of temperature and quicken- ing of the pulse that the pneumonitis is apt to be overlooked by the physician, the symptoms being referred to bronchitis. Pleuri- tis does not occur in connection with this form of pneumonitis, ex- cept when a small abscess or gangrene occurs in an aflected lobule directly under the pleura. A few such cases I have observed. Tubercular pneumonitis extends over much or little of the lung according to the amount of tubercles. The symptoms are like those of severe primary pneumonitis, superadded to such as pertain to tuberculosis. This inflammation, when once established in the consumptive child, commonly continues till the close of life. I have sometimes had these cases under observation for several consecutive weeks, even months, and during the whole time there was not only acceleration of pulse and respiration, but the expira- tory moan. As regards pneumonitis occurring in hooping-cough, it is an interesting fact that its symptoms modify those of the primary disease, so that, during the active period of the inflamma- tion, the paroxysmal cough diminishes, and a short, hacking cough and expiratory moan occur in place. As the inflammation abates, the spasmodic cough returns. Pneumonitis, occurring in measles, is more obstinate, protracted, and dangerous than the primary form. It usually commences about the period of the decline of the eruption, and, in favorable cases, continues two or three weeks. It is then a sequel, rather than complication. Physical Signs. — The physical signs of pneumonitis in infancy and ctiildhood are the same as in the adult, but in a large propor- tion of cases they are less distinct. In a majority of patients under the age of three years the crepitant rule is not observed. This is due to the small size of the air vesicles at this age. I have 502 PNEUMONITIS. now and then detected it in quite young children, in whom it is a finer rale than in the adult. If observed, it is, of course, positive proof of the existence of pneumonitis. The physical signs, there- fore, in the first stao-e of the inflammation are often obscure in consequence of the absence of the pathognomonic rale. The vesicu- lar murmur is somewhat intensified through the chest, and there is in this stage slight dulness on percussion over the seat of the inflammation due to engorgement of the vessels, but it is difiicult to appreciate this. In the second stage, which supervenes more or less rapidly, the physical signs are more distinct. Bronchial respiration is in most cases detected, higher in pitch than the vesicular murmur, with the sound of expiration higher than that of inspiration. The voice of the patient is transmitted to the ear applied over the seat of the disease, and often a peculiar vibratory sensation is communicated to the hand applied over the part, so that it is possible to locate the disease by palpation alone. There are frequently, in the second stage, and sometimes in the first, coarse mucous rales in various parts of the chest from coexisting bronchitis. Percussion, in the second stage, elicits a dull sound as compared with that produced on the opposite side of the chest. The dulness corresponds in extent with the solidification, and with the bronchial respiration. As the inflammation abates, the dulness on percussion gradually diminishes, and the bronchial respiration is succeeded by the subcrepitant rale. Often, for a considerable period after convales- cence is established, moist rales are observed in the chest, and sometimes the dulness on percussion does not entirely disappear till after the health is fully restored. In catarrhal pneumonitis the physical signs are not so distinct. This is due in part to the limited extent of the inflammation, in part, in many cases, to its subacute character, and in part to the fact that this inflammation is apt to be double, especially in those frequent cases in which the cause of the disease is hypostatic congestion. Diagnosis. — In the adult, pneumonitis is a diseaseof easy diagnosis. In infancy and childhood, on the other hand, diagnosis is often difficult. Acute primary pneumonitis in young children is apt to be confounded with mening-itis or one of the essential fevers if the examination be made within the first or second day. In children over the age of three or four years, it is most frequently mistaken for remittent fever. The two diseases do, as regards symptoms. DIAGNOSIS. 503 resemble each other. Both are characterized by great elevation of temperature, rapid pulse, languor, and drowsiness, and in both there is apt to be a cough even from the first day. But remittent fever (I include for the present under this term also typhoid fever) usually begins more gradually than pneumonitis. It is preceded for a few days by sym[)tom8 of mild indisposition, though there are exceptions, and it may commence quite abruptly. The expira- tory moan occurring in pneumonitis in most cases by the second or third day is a symptom of great diagnostic value. But positive proof of the nature of the disease is afforded only by auscultation and percussion. Scarlet fever, in its commencement, bears some resemblance to acute primary pneumonitis. The points of diffier- ential diagnosis are the redness of the buccal membrane and the fauces, and the efflorescence upon the skin in scarlet fever on the one hand, and on the other the rational and physical signs of pneumonitis, which have been described. Greater difficulty attends the diagnosis of acute pneumonitis from bronchitis and pleuritis. The presence of the expiratory moan, if it is pretty constant and marked, is sufficient to exclude bronchitis, unless as a complication, but the physical signs con- stitute the only reliable means of exact diagnosis. The presence or absence of bronchitis is readily determined hy auscultation. The physical signs should be carefully noted, in order to deter- mine if there is some point of solidification. Solidification gives rise to dulness on percussion, bronchial respiration, and bronchophony. These three signs coexisting afford sufficient proof of pneumonitis, unless there is tubercular consolidation or possibly collapse supervening on suffocative bron- chitis. The history of the case aids in determining whether there is either of these diseases. Moreover, collapse occurs later after the attack commences than hepatization, and does not produce so distinct bronchophony or bronchial respiration as are observed in the common form of pneumonitis. Pleuritis with eff"usion may present physical signs which bear considerable resemblance to those in pneumonia ; but in pneumonia, except when associated with tubercular deposit, the dulness on percussion is not so great as that from pleuritic eff'usion, nor does the line of dulness vary according to the j)osition of the child. In pleuritic eff'usion in a young child, the respiratory murmur can often be heard with the ear applied over the liquid, but it is indistinct, and transmitted through the liquid from a distance. The practised ear is able to discover the difference between it and 504 PNEUMONITIS. the bronchial respiration of pneumonitis. Attention to these facts enables us to make a positive differential diagnosis in most cases. Occasionally the physical signs indicate the coexistence of pneu- monitis and pleuritis. In catarrhal pneumonitis, it is often difiicult to determine cer- tainly the nature of the disease, since the physical signs, if there is but little extent of inflammation, are absent or indistinct. I have often, in post-mortem examinations, found so small a part of the lung hepatized that it could not possibly have produced any appreciable dulness on percussion, bronchial respiration, or bron- chophony. Such cases are apt to pass for bronchitis, and, practi- cally, this matters little, since the treatment required by the two is not dissimilar. Prognosis. — Primary pneumonitis, aflfecting only one lung, if properly treated, in most instances terminates favorably in children , and even in infants. If double, it is, as in the adult, much more serious, and, in a large proportion of cases, fatal. Secondary pneumonitis, pneumonitis occurring in measles, hooping-cough, tuberculosis, or resulting from hypostatic congestion in the course of some exhausting disease, is, on the other hand, more frequently fatal. As death usually occurs from asthenia, the younger the child, and more feeble the constitution, the greater the danger. Unfavorable symptoms are a pulse becoming more and more frequent and feeble, pallor of countenance, inability of the patient to support the head, total loss of appetite, refusal to notice or be amused by playthings, absence of tears when crying — a symptom which the French writers have pointed out — and the appearance of pemphigus on the face or elsewhere. Indications on which a favorable prognosis may be based are moderate acceleration of pulse, pneumonitis primary and limited to one side, ability to support the head or sit erect, being amused by playthings, etc. Treatment. — The treatment of the two forms of pneumonitis, croupous and catarrhal, the former for the most part primary and acute, and the latter secondary and often subacute, requires to be considered separately, as much as do their symptoms and anatomical characters. In croupous pneumonitis, if seen at the commencement or within a few hours of the commencement, an emetic of ipecacuanha may be given, as recommended by Trousseau. This acts promptly as a cardiac sedative, diminishing somewhat the afflux of blood towards the lungs, and moderating the inflam- TREATMENT. 505 niation. It should never be employed except at the period mentioned. If the previous health of the patient has been good, his age above three years, and if the inflammation is, in part at least, in the first stage, aconite or veratrum viride, properly employed, is serviceable. Either one is an eflicient substitute for bloodletting. Some prefer aconite as less depressing than veratrum, and it is known to be a favorite remedy of homoeopath ists. I have ordinarily employed the veratrum, prescribing the tincture in doses of one drop every three hours to a child of five years. It can be given dropped in sweetened water or in the syrup of tolu. Its effect should be care- fully watched, and it should be omitted, or given less frequently, when the pulse is reduced to near the natural frequency. The pulse should be maintained two or three days, dating from the commencement of the attack, at about its natural frequency, but never below it. If bronchial respiration, bronchophony, and dulness on percus- sion are present, indicating the second stage ; in other words, if it appear from the signs that the inflamed lobe or lobes are hepatized, little benefit accrues from the use of so powerful a sedative, and much harm may be done. "When this medicine is discontinued, or without its use, if the physicitin is not called till the stage of hepatization, a minute dose of tartrate of antimony and potassa should be prescribed in the class of cases to which I allude. It may be advantageously combined with sulphate of morphia, if the respiration is painful or cough troublesome. The following formula I have sometimes employed with a satisfactory result, for a child of five years : — R. Morph. sulpli., Antim. et potas. tart, aa gr. j ; Syr. bal. tolut. ^^iv. Misce. Dose, one teaspoonful from two to four hours. In place of this, Dover's powder may be administered in combination with nitrate of potash. There soon arrives a period when depressing remedies should be omitted. Many now recover with simple mucilaginous drinks or mild expectorants, like syrup of squills or ipecacuanha in small doses. Others require more sustaining measures, and for such carbonate of ammonia with the syrup or decoction of senega is preferable. The treatment described above is proper only for robust children with primary pneumonitis. In no other cases are measures so depressing required. There can be no doubt that the great error, 506 PNEUMONITIS. in the therapeutic management of children with this disease, has been the employment of medicines which reduced the strength, when gentler measures, or those of a sustaining nature, were required. In secondary pneumonitis or primary if the patient is pallid, scrofulous, or at all wasted, or under the age of three years, neither aconite, veratrum viride, nor antimony should be given. Such cases require milder therapeutic agents, as syrup of squills or ipecacuanha in the first stages, and, subsequently, carbonate of ammonia with senega. Some are best treated with ammonia and senega from the commencement. The bowels should be kept open, as an important part of the treatment of croupous pneumonitis in its first stages. A small dose of castor oil, Rochelle salts, or citrate of magnesia should be given if there is any tendency to constipation, and repeated from time to time if required. A saline aperient by its derivative and refrigerant effect in some cases obviates the necessity of employing cardiac sedatives. Local treatment is required in all cases; counter-irritation should be produced as soon as possible over the inflamed lobe, by mustard, iodine, or some stimulating liniment, and, except at the time of this application, the chest should be constantly covered with an emollient poultice, or with a cloth wrung out of warm water and covered with oil-silk. I prefer, however, the constant application, under the oil-silk, of the following poultice, made large but thin as the cover of a book and therefore light. ^. Pulv. sinapis. .fss; Pulv. semin. lini §viij. Misce. In a large proportion of cases, vesication is not required. If the inflammation is extensive, and the symptoms urgent, it is occa- sionally advisable to blister, and the cantharidal collodion should be used for this purpose. A safe, almost painless, and at the same time efiScient, mode of applying this is in spots as large as a ten cent piece, half a dozen, more or fewer according to the extent of the inflammation, the skin of course remaining sound between them. This mode of application obviates the danger of producing a troublesome sore, which sometimes occurs in children from the ordinary mode of vesication. The diet should be nutritious, consisting of animal broths and the like, unless during the first three or four days, in robust chil- dren. In those few cases of croupous pneumonitis which occur in young children, no remedy should be employed more depressing PLEURITIS. 507 than ipccacuaiilia, perhaps combined with some aperient like castor oil, as in the formula recommended in the treatment of bronchitis. Before leaving the subject of the therapeutics of pneumonitis, I desire to impress u])on the reader the paramount importance of ascertaining fully, before he prescribes, not only the extent and stage of the inflammation, but especially the condition of the patient's constitution. For many cases require sustaining measures from the first, and, without a proper appreciation of the patient's state, the medicines ordered may be highly injurious instead of useful. Catarrhal pneumonitis requires somewhat different treatment, not only because it occurs chiefly in infancy and early childhood when there is little vigor of constitution, but because it is as a rule secondary. In acute catarrhal pneumonitis, which, as we have seen, in most instances results from an active bronchial inflamma- tion, the treatment already employed for the primary disease should be continued. (See Art. Bronchitis.) If there is pain or restless- ness, a little opiate should be added. In subacute forms of the disease, and in the acute when it has continued a few days, sus- taining and even stimulating measures are indicated; carbonate of ammonia with some tonic is useful in such cases. In cheesy pneumonitis, or in protracted catarrhal pneumonitis which may or may not have become cheesy, carbonate of ammo- nia in combination with citrate of iron and ammonia, equal parts, or cod-liver oil to which two or three drops of syrup, ferri iodidi are added, will be found useful, as are also alcoholic stimulants. ISTutritious diet is required in all cases of catarrhal pneumonitis. The local treatment should consist of an oil-silk jacket and coun- ter-irritation, as recommended in the treatment of croupous pneu- monitis, without vesication. In case of hypostatic pneumonia the position of the patient should be frequently changed. CHAPTER VI. PLEURITIS. Pleuritis occurs both as a primary and secondary disease. If we except such cases as are due to pneumonitis and tubercles, secon- dary pleurisies are more common in children than in adults. 508 PLEUKITIS. Causes. — The ordinary cause of primary pleuritis is the same as that of most primary inflammations, namely, the impression of cold. It is therefore most commoa in the cold months, and in times of changeable temperature. Cachexia is a predisposing cause. There- fore, children whose blood is impoverished by the anti-hygienic conditions in which' they reside, or by previous disease, are more liable to it than those who have robust constitutions. Hence, also, its frequency among foundlings and the cT:iildren of the city poor. The causes of secondary pleuritis are quite numerous. The most common, after the age of three years, are tubercles, pneumonitis, and scarlet fever. Tubercles cause pleuritis by their irritating effect upon the pleura, and of course only those tubercles can produce this result which are seated directly underneath this membrane. Pneumonitis causes pleurisy by extension of the in- flammation. Scarlet fever gives rise to it indirectly as a sequel. In a certain proportion of cases of this exanthem, during the period of desquamation or convalescence, active congestion or inflamma- tion of the kidneys occurs, giving rise to ursemia. Urea in the blood is an irritant to serous structures, and hence is a not infre- quent cause of pleuritis. In the infant many cases of pleuritis are due to the escape or discharge into the pleural cavity of some pathological product, usually pus, softened tubercle, or decomposed lung tissue. This substance is an irritant, and it produces acute and often general pleuritis. A very small amount of pus or softened tubercle, or of decomposed lung escaping into the pleural cavity, gives rise to violent and fatal pleurisy. I have made post-mortem examinations of several such cases. A retro-pharyngeal abscess in rare instances descends behind the pharynx and oesophagus, and opens into one of the pleural cavities, causing fatal pleuritis. A suppurated bronchial gland, or an abscess in the walls of the chest, occasionally produces the same result. In January, 1864, I presented to the 'New York Pathological Society the lungs of an infant with the following history: R., nine months old, of German parentage, family scro- fulous. Its own health was good prior to the sickness of which it died, and it was fleshy. The only other child in the family, a girl, had suffered from strumous ophthalmia and strumous peri- ostitis of the tibia. This infant was taken sick about December 19th, 1863, with moderate febrile movement and restlessness, but apparently without any serious indisposition. On the 22d of December, the mother called my attention to a prominence just CAUSES. 509 below the right clavicle. This proved to be an abscess. A poultice was applied, in the expectation that it would discharge externall}''. On the 24th of December, however, the prominence subsided, and immediately the symptoms were greatly aggravated. The pulse rose to 160 per minute, the respiration to 60 or 80, and expiration was accompanied by a moan, so common in acute inflammation of the pleura or lung. Within a day or two after the disappearance of the tumor, and the exacerbation of the symptoms, dulness on percussion was observed on this side, and this increased till there was perfect flatness. The right pleural cavity had evidently filled with liquid, the acceleration of pulse and respiration continued, the patient grew more and more feeble, and death occurred De- cember 31st. At the autopsy, on dissecting away the integument from the right side of the chest, an abscess was opened, containing nearly an ounce of pus, located at the point where the tumor had been observed. There was a small round opening from this abscess directly into the cavity of the chest, so that, on depressing the ribs, liquid escaped from the cavity. On removing the sternum, the liquid was found to consist mainly of serum with lymph, and at the bottom of the liquid was considerable pus. I have met one other case, apparently almost identical with this, the infant being seven months old, but I did not attend it in the latter part of its sickness. The abscess in the case which I have detailed was ob- viously strumous, probably occurring from glandular inflammation. This mode of production of pleuritis, namely, by the discharge of an abscess located in the thoracic walls, is no doubt rare. It was so considered by the members of the Pathological Society. Pleu- ritis, which is a common accompaniment of croupous pneumonitis, is not common in the catarrhal form of the disease, and therefore cases due to pulmonary inflammation are less frequent in children than in adults. But inflammation of the pleura occasionally occurs in catarrhal pneumonitis in the following manner: Little abscesses are produced in the solidifled lung, containing from one or two to as many as fifteen or twenty drops of pus, as has been stated in our remarks on pneumonitis. The pus, approaching the pleural surface, produces circumscribed pleuritis at that point, or, opening into the pleural cavity, it gives rise to general pleuritis, with or without pneumothorax. The following cases, among others which I could present, established this point. These cases are also interesting, as showing the occasional latency of pneumonitis. 510 PLEURITIS. Case 1. — I. M , male infant, was admitted into the Nursery and Child's Hospital, May 19th, 1859, at the age of two months. He was very delicate at the time of admission, and had slight bronchitis, but, being placed with a wet-nurse, he gradually improved. About the middle of July, attacks of diarrhoea occurred, each lasting from one to two days, and from this time his health declined. Furnncular eruptions appeared on the head and neck, and, though sustaining measures were emplo3'ed with medicines to control the diarrhrea, there was progressively more emaciation and feebleness. The records on August 1st state, "Continues to fail, apparently from the attacks of diarrhoea; the furnncular eruption continues." On the 3d of August, he died suddenly of apnoea, though there had been no s^'mptoms to direct attention to the chest. Possibly he had a slight cough, which had escaped detection. Autopsy eight hours after death. — Stomach and jejunum healthy ; mucous membrane lining the lower part of the ileum and the entire colon vascular, and that of the colon considerably thickened ; mesenteric glands enlarged, and of a lighter color than in health ; right lung com- pressed by a sero-fibrinous exudation, so as to occup}^ a small space, though the amount of liquid was not more than two ounces ; nearly the entire pleura, visceral and parietal, on this side was covered with a fibri- nous deposit of a creamy appearance. Some of this had settled in the depending portion of the cavity. This lung could be inflated, except a little of the lower lobe, winch was hepatized. On the left side, the lung also occupied a very small space, being col- lapsed; the upper lobe could be readily inflated when it had the elasticity of healthy lung; the lower lobe had a healthy appearance, and could be inflated, except a portion in the posterior aspect measuring, perhaps, an inch in diameter; this was partially coated with lymph, and was found to contain two small abscesses, one closed, the other opening externally on the surface of the lung and internally into a bronchial tube. On attempting inflation, the air passed directly through this opening. The closed abscess contained from one-third to half a drachm of pus cor- puscles, and disintegrated lung tissue, as shown by the microscope. The child was much emaciated. Case 2. — M. I , female, was admitted into the Child's Hospital October 7th, 1859, at the age of about four months; at the time of admis- sion, was somewhat wasted with diarrhoea; her health improved [jartiall}', but she remained feeble, and was at times much troubled with meteorism which occasioned pain. On the 2d of November, she was suddenly seized with great dyspnoea, which terminated fatally in about a quarter of an hour. Previously' to the dyspnoea, no cough had been noticed, or other symptoms referable to the chest. Aufoj)f^;/. — Body considerably emaciated ; left lung healthy, with the exception of slight hypostatic congestion; right lung adherent to the diaphragm, and to a considerable part of the costal i)leura, by fibrinous exudation; this lung was somewhat compressed and non-crei)itant; the upper lobe floated in water; the middle and lower sank and could not be inflated, or but slightly; this portion of the lung contained a few small abscesses, filled with purulent matter, each holding scarcely more than one drop; two of these seemed to have discharged into the pleural cavit}', as the air passed through them in attempting to inflate, l)ut possibly they may have been opened in separating the adhesions which ANATOI^IICAL CnARACTERS. 511 united the two pleural surfaces at this point; two or three ounces of thiid wore contained in tlie pleural cavity, consisting, in addition to serum, of fibrinous tlocculi, epithelial cells from the i)leura, pus cells, and compound granular cells: the lower portion of this fluid, on stand- ing-, contained so much i)us that it presented the characteristic gelatinous ai)pearance on the addition of liquor potassiu; the other organs generally were normal in appearance, but the liver was somewhat congested, and there was also decided hypernjraia of the mucous membrane of the colon near the ileo-ccecal valve, and in the descending portion. In cases like the above, the pleuritis is obviously due either to the escape of pus from the lung into the pleural cavity, or to its near approach to the pleura. In the former case the inflamma-' tion is apt to be general; in the latter circumscribed. The above cases are interesting, as sliowing an occasional result of circum- scribed pneumonitis in the infant, namely, hydrothorax in addition to pleuritis. Sometimes, especially in young children, the cause of the pleuritis is apparently general, or constitutional, but is obscure. Thus, at the autopsy of an infant who died at the age of about one month in the Infant's Service of Charity Hospital, in 1867, a small amount of pus, not more than a drachm, was found in one pleural cavity, and less than this quantity in the other. On both sides there was nearly general injection of both the visceral and costal pleurae, but without exudation of serum or fibrin. There was pus also at the roots of the lungs, extending somewhat over the lungs but under the pleura. The fact of a double pleurisy appeared to indicate a constitutional cause, but there was no apparent cause of this nature except cachexia, to which allusion has already been made, as predis- posing to this form of inflammation. Anatomical Characters. — The first appreciable structural change which occurs in pleuritis is engorgement of the vessels lying underneath the pleura. Tliere can be seen, if an opportunity is presented, as in the case detailed above, a network of engorged capillaries. Immediately exudation commences into the connec- tive tissue surrounding the capillaries, the pleura becomes ojDaque, and liquor sanguinis escapes on its free surface. The amount of serum and fibrin which is exuded into the pleural cavity varies greatly in dift'erent cases, as does their relative projiortion. In pleuritis due to the irritation of tubercles, or to extension of inflammation from an inflamed lung to the pleura wMch covers it, the amount of serum is ordinarily small, and occasionally almost entirely absent, so that the visceral and costal surfaces remain in contact. In other cases, namely, wlien the pleuritis is idiopathic. 512 PLEURITIS. or due to uraemia, or to a foreign substance in the pleural cavity, the amount of serous eft'usion is considerable, producing more or less compression of the lung. The most frequent exceptions to these general statements I have observed in the pleurisy of tuber- culosis in infants, in which form of the disease the lung is not infrequently somewhat compressed by the liquid. Ordinarily the fibrin forms a layer over the inflamed pleura, at first soft and readily detached, but gradually becoming firmer, and shreds or flocculi of fibrin, becoming separated, float in the exuded serum. When the inflammation has continued a short time, granulations appear on the inflamed surface, receiving their supply of bloqd from the sub-pleural capillaries, which have been pro- longed. These granulations, when the serum is absorbed, uniting with those on the opposite side, form permanent adhesions, Pleuritis, except when due to a local cause seated beneath the j^leura, as tubercle or pneumonitis, extends rapidly, soon becoming general. In a certain proportion of cases empyema occurs. The propor- tion of pleurisies in feeble and ill-conditioned infants which are or become suppurative is very large. Hence empyema, as I have often noticed, is not infrequent in the institutions of this city where such infants are treated. As, in recent fatal cases, we find the exuda- tion mainly sero-fibrinous, and empyema in those who have lived a month or more, it has seemed to me that the suppuration is probably referable to -the irritating eftect of the fibrin, which, liquefying, and not absorbed on account of the general feebleness, acts as an irritant, and provokes a suppurative inflammation. Pleuritis has, for convenience of description, been divided into three stages: the first, extending from the commencement of the inflammation to the time when there is an appreciable amount of exudation; the second, from the time that the exudation is appre- ciable to the commencement of absorption; the third stage is that of absorption or convalescence. Absorption commences when the inflammation abates, and the rapidity with which the fluid dis- appears varies greatly in difierent cases. As absorption occurs, the compressed lung gradually expands to occupy the place of the fluid. Sometimes absorption occurs more rapidly than the expan- sion, so that there is depression for a time of the thorax on the aflected side, which gradually disappears. The serum is first absorbed, and then the fibrin, undergoing fatty degeneration and liquefaction, is also absorbed. Occasionally portions of the fibrin instead of being absorbed undergo calcification, after which tliere SYMPTOMS. 513 is no fartlier change. Commonly, as the serum is removed the two pleural surfaces become permanently adherent, and the lobes are likewise united to each other. In rare instances, in which there is a large amount of serous exudation, producing complete carnification of the lung, and absorption is slow, inflation never occurs, and the ribs of the affected side are permanently depressed. Eespiration henceforth is performed entirely by the other lung, which increases somewhat in volume by hypertrophy of the air cells. The compressed lung remains non-crepitant and firm, and its color somewhat lighter than the natural hue, from defective supply of blood and granular change in its anatomical elements. In empyema, absorption obviously cannot occur unless the quantity of pus is small. Empj-ema, therefore, except when re- lieved by paracentesis, is a lingering disease, attended by many of the symptoms of tuberculosis. Spontaneous cure occasionally occurs", by discharge of pus into a bronchial tube, or externally through the walls of the chest. I have witnessed both these modes of termination. In certain instances, pleuritis on the left side becomes complicated with pericarditis, and, more rarely, pleu- ritis in the lower jmrt of the right pleural cavity, with perihepatitis, the inflammation extending in the one case through the pericar- dium, in the other through the diaphragm. I have met four cases of the former complication, and one of the latter in infants. Symptoms. — Occasionally pleuritis is latent. This may be its character, both in the primary and secondary form, latency being more frequent in infancy than in childhood. The following is an example. A feeble infant, 5 months 28 days old, died suddenly at the l^ursery and Child's Hospital, December 29th, 1870. The attention of the resident physician had not been called to it, as it was not supposed to be sick, although its general condition was bad, and the attendant nurse who had charge of the ward denied that there was any symptom, unless possibly an occasional slight cough in the last three or four days. Percussion over the right side of the chest of the corpse gave a flat resonance, and the rio-bt lung was found at the autopsy carnified and covered with a loose fibrinous layer, in places three-fourths of an inch thick. As circumscribed pleurisy is for the most part a secondary dis- ease, the symptoms which are present are due partly to it and partly to the primary aflfection. Obviously the symptoms vary in diflerent cases, according to the presence or absence of other dis- eases, the age and robustness of the patient, and the extent of the 83 614 PLEURITIS. inflammation. In most cases the commencement of plenritis is in- dicated by increase in the frequency of the pulse and respiration, the expiratory moan, and sometimes by tenderness on percussion over the seat of the inflammation. There is a short cough, dry or hacking, unless bronchitis coexists, in which case there is more or less expectoration; at the same time, those symptoms are present which are common in all inflammatory afiections, such as anorexia, thirst, and increase of temperature. The symptoms enumerated, though commonly so severe as to draw attention at once to the chest, are in other cases so mild, even when the inflammation is not latent, that they may be at first overlooked. There is, indeed, every gradation between severe symptoms and latency. In acute general pleuritis the symptoms are commonly severe. The pulse rises to 130 or 140 beats per minute, and in young children it may be more frequent ; the respiration is increased in a corresponding degree ; the face is flushed and indicative of suf- fering; the patient is restless, complaining, if old enough to speak, of the stitch-like pain in the chest, which is most intense on in- spiration and in coughing. The mean temperature, according to the observations of Mr. Squire, is 101° Fahr. When exudation occurs the symptoms abate partially. The pulse and respiration are less frequent, though still accelerated, and the latter is less painful. Convalescence is more protracted in pleuritis than in pneumonitis. Several weeks frequently elapse before the liquid is fully absorbed, during which time there is more or less acceleration of pulse. The appetite and strength return gradually. In suppurative pleuritis or empyema, the symptoms may not dift'er materially at first from those in the ordinary form of inflam- mation, but absorption does not occur, or there is but a slight de- gree of it, limited to a portion of the liquor puris. The pus produces the ordinary eftects of purulent collections in the system, namely, loss of appetite, hectic fever, emaciation, loss of strength. No im- provement occurs except by discharge of pus, when restoration to health is often rapid. In fatal cases of empyema the vital powers gradually yield, the pulse becomes more frequent and feeble, the face and limbs pale and cool, and death occurs from asthenia. Physical Signs. — The physical signs vary according to the ex- tent of the inflammation, and the amount of exudation. The fric- tion sound is seldom observed in the infant, and it is less frequently heard in the child than in the adult. Percussion, in the commencement of pleuritis, before there is any PnYSICAL SIGNS. 515 appreciable exudation, gives a negative result. If dulness is ob- served, it is due to coexisting disease, commonly pneumonitis or tuberculosis. In tbose cases in which no effusion of serum occurs, or in dry pleurisy, as it is termed, percussion at all periods of tlie disease gives only negative information, impaired resonance if present being due to the pulmonary disease, pneumonitis or tuber- cles, to which this form of pleurisy is commonly due. In a large proportion of circumscribed pleurisies the percussion sound is not materially affected. If there is serous effusion, and this occurs in most pleuritic attacks which are not dependent on pulmonary disease, and some in which there is this dependence, percussion over the liquid elicits a flat sound, while the resonance above the level of the liquid is good, and occasionally even tympanitic. Flatness on per- cussion distinguishes pleuritic effusion from simple pneumonitis, since in pneumonitis percussion produces a dull, but not fiat, sound. In young children in whom pneumonitis is catarrhal and limited to a part of a lobe, the difference is very marked. Change in the height of the flatness, according to the position of the patient, is observed in infancy and childhood, not less than in adult life. • "When the second stage commences, and the pleural cavity con- tains more or less liquid, the respiratory sound often disappears from the part of the chest which is occupied by the liquid in chil- dren over the age of five or six years, but in a large proportion of cases in the first years of childhood, and usually in infancy, in which period the pleural cavity is small, respiration is heard with the ear applied over the liquid. It is transmitted from a distance. Its character is bronchial, broncho-vesicular, or even sometimes vesicular. It appears in certain cases, especially when vesicular, to be transmitted from the opposite side of the chest. It varies in its intensity, according to the amount of the licjuid and the strength and rapidity of the respiration. It sometimes, according to Rilliet and Barthez, partakes of the cavernous respi- ratory sound, so that, in the first case in which they observed this modification, their diagnosis was erroneous. There was complete restoration to health, with absorption of the fluid, although they had diagnosticated a cavity. If there is a large amount of fluid and the lung is compressed at the top of the pleural cavity, bronchial respiration may be heard above the level of the fluid, in the infra-clavicular region. In the adult this is a common physical sign. -<^gophony is occasionally observed in acute cases, in which there is a rapid and large eflusion. 516 PLEURITIS. It is heard in the infra- and inter-scapular spaces. Its duration is commonly brief, disappearing in three or four days or even in less time. Bulging of the intercostal spaces and distension of the thoracic walls from the fluid are less frequent in young children, and especially infants, than in adults. In the infant, so readily are the lungs compressed, complete carnification is apt to occur, before the shape of the chest is materially altered. On account of these peculiarities as regards the physical signs and the mechanical effect of a liquid in the pleural cavity of a young child, physicians whose knowledge of pleuritic effusions is derived chiefly from the exami- nation of adult cases are apt to err in diagnosis. Thus, in 1870 a carnified lung, covered with a thick pyogenic membrane from which granulations had arisen, was presented by myself to the IS^ew York Pathological Society, with the following history of the case. W., twelve months old at the time of death, was taken sick at the age of six months, with fever, and a cough, which was slight and not frequent. At about eight months he first came under ob- servation. The infant was then small for its age, pallid and thin. The two sides of the chest measured the same, and on both sides the intercostal spaces were somewhat depressed, but percussion over the right side produced a flat sound, showing that the air was wholly excluded from the right lung. The respiration upon the affected side was bronchial and distinct. Two well-known physi- cians of this city, thorough in their examinations, and usually accurate in diagnosis, examined this case in reference to the pro- priety of thoracentesis, and both expressed a decided opinion that the pathological state was not a pleuritis, but either collapse or interstitial pneumonitis, one of them observing, as he thought, in addition to the physical signs already stated, bronchophony. The febrile movement was moderate, and no decided hectic was observed. Death occurred from exhaustion. At the autopsy about half a pint of thick pus w^as found in the right pleural cavity, producing complete carnification of the lung. The pus, which, considering the stunted growth of the child and small size of the pleural cavity, was considerable, had evidently lost part of the liquor puris by ab- sorption. The following case, which shows how deceptive the physical signs may be in young children in cases of suppurative pleuritis, will repay perusal, since the life of the patient depends in great part on a correct understanding of his condition, so that appropriate measures will be employed: — DIAGNOSIS. 517 Case. — IT — , boy four years four months old, was taken with scarlet fever in the latter part of May, 1868. It was severe, and was attended witli inflammation of the "lands and connective tissue of the neck, with suppui'ation on both sides. Purulent discharges from the al)scesse8 continued through the month of June. The patient was gradually con- valescing, when, about July 4tli, pleuritis commenced on the left side, attended by the ordinary symptoms of acute forms of this inflammation. A few days subsecpiently, the pleural cavity was ascertained by physical examination to be about half full of liquid. Towards the close of July, anasarca commenced about the ankles and gradually extended upwards. It was limited to the lower extremities, and to the abdominal walls, and by the middle of August became excessive. The thoracic walls and the upper extremities were somewhat emaciated, and the face was pallid and anxious. On the 7th of August, a careful examination of the chest was made in reference to the propriety of thoracentesis. The intercostal spaces on tlie left side were not prominent, but rather depressed. Percussion over the lower third of the left pleural cavity elicited a flat sound, while above this the resonance was tympanitic. On account of the great rest- lessness of the patient, no useful information was derived from change of position. On auscultation distinct bronchial respiration was heard over nearly or quite the entire left side of the chest. The apex beat of tlie heart was on the right of the sternum. It was my opinion, as well as that of two other physicians, that the liquid was in process of absorp- tion, and that the quantity present was not large. Thoracentesis did not, therefore, seem a proper measure. The anasarca still limited to the lower extremities, and the abdominal walls continued to increase, and on the 25th of August, so great was the distension, that the skin broke in one or two places above the ankles. The mind remained clear, and the appetite was prett3' good. Death occurred August 21th. Secdo Cadaver. — Head not examined ; abdominal and right pleural cavities contained no eft'usion, and were in their normal state, except that the latter cavity was somewhat encroached upon by the heart and mediastinum; a great amount of oedema in the lower extremities and in the abdominal walls; abdominal walls towards the spine about three inches tliick, in consequence of oedema; right lung of good size, and pre- senting the ordinary appearance except a greater amount than usual of hypostatic congestion; about three pints of pus (laudable) in the left pleural cavity; left lung completely carnified and lying against the vertebral column, its size about that of an orange, and its surface covered with a dense layer of fibrin ; heart displaced, as alread}' stated, to the right, and a little downward, so as to compress and partially obstruct the circulation in the ascending vena cava; this vessel con- tained a continuous, firm and yellow fibrinous clot, nearly filling its calibre; the femoral vein, examined on one side, was found to contain soft and dark clots. Compression of the cava opposite the heart and the formation of clots had evidently given rise to the anasarca. Diagnosis. — This is in certain cases readily made, but in others, as we have seen, is attended with difficulty. It is more difficult in those under than over four or five years. Partial or circum- scribed pleuritis, attended by little or no serous exudation, is more 518 PLEUKITIS. apt to be overlooked than other forms of the inflammation, but, as it is ordinarily due to graver disease of the lungs, its detection is not very important. The points involved in its diagnosis are acceleration of pulse and respiration, increase of temperature, expiratory moan, friction sound, and tenderness on percussion. The diagnosis of acute general pleuritis in its commencement, before the stage of effusion, is attended with some difficulty. It is most likely to be mistaken for ^pneumonitis, since the prominent symptoms in the commencement of the two diseases are similar. There is, however, in pleuritis ordinarily greater acceleration of pulse and respiration, greater elevation of temperature, greater suffering, as indicated by the features, and a more decided expira- tory moan. It will aid in the differential diagnosis, in children under the age of five years, to recollect that acute pneumonitis is in most instances preceded by bronchitis, which is not the case with acute pleuritis, except as a coincidence. Pleuritis with effusion could only be mistaken for pneumonitis or hydrothorax. But the loss of resonance on percussion in cases of pleuritic effusion is much greater than when the lung is solidified from pneumonitis. The physical signs, which are involved in the differential diagnosis of these diseases in the adult, are important, also, for diagnosis in children, though, as we have seen, they are less constant and less reliable in young children than in adults. In children over the age of five years they are pretty uniformly present. The signs alluded to are bulging of the intercostal spaces, expansion and subsequently retraction of the chest, evidence of change in the height of the fluid, by change in the position of the body, no bronchophony and fremitus as in pneumonitis, etc. Hy- drothorax in the child commonly results from one of the eruptive fevers, especially scarlatina, and its immediate cause is nephritic congestion or inflammation, or heart disease. Rarely it is due to obstruction in the pulmonary circulation, in consequence of enlarged bronchial glands. It is not, therefore, preceded nor accompanied by symptoms of inflammation referable to the chest, as in cases of pleuritic etiusion. Empyema may be diagnosticated from the fact that there is little or no diminution in the amount of liquid after several weeks have elapsed, and from the febrile movement, loss of appetite, flesh, and strength, which attend all large purulent collections. Prognosis. — Primary pleuritis, occurring in patients previously healthy, commonly ends favorably ; but it is a serious disease if the general health has been much impaired. The prognosis is TREATMENT. 519 more favorable if, as is commonly the case with this form of pleurisy, the patient is over the age of three or four years. Secondary pleuritis is, on the other hand, a grave affection, but the prognosis depends greatly on the character of the primary dis- ease, and also on the age. Pleurisy resulting from and coexisting with pneumonitis commonly ends favorably even in quite young patients. Pleuritis arising from scarlet fever is apt to be suppura- tive, and is, therefore, a serious complication or sequel, but a considerable proportion affected with it recover under judicious treatment. The prognosis in tubercular pleuritis and pleuritis occurring from the escape of pus into the pleural cavity is obviously unfavorable. Tubercular pleuritis may be temporarily relieved, but it is apt to return. Suppurative pleuritis, or empyema, is also an unfavora- ble form of inflammation, characterized by the chronicity and many of the symptoms of tuberculosis. It is in time fatal unless the pus is evacuated. On the escape of the pus, whether spontane- ously or by thoracentesis, there is usually progressive and complete restoration to health. In case the pus is evacuated, the prognosis is better in children than in adults. Treatment.^ — ^The indications of treatment are, in the commence- ment of the inflammation, to diminish its intensity, and relieve pain ; at a later period, to promote absorption and sustain the vital powers. Pleuritis is one of the few inflammations in early life in which the abstraction of blood may be proper. It may be stated as a rule, that loss of blood is not onl}^ not required, but is an injudi- cious measure in all secondary pleurisies, and in the primary form after exudation into the pleural cavity has occurred. It is a useful measure at the commencement of acute primary pleuritis occurring in a robust state of system. One or two leeches should be applied directly over the seat of the inflammation, and bleeding may be encouraged for two or three hours subsequently by the application of cloths wrung out of warm water. Unfortunately the physician is, in many cases, not called at this early period ; or, if called, he fails to make the dias^nosis till there are evidences of exudation. After bleeding has ceased, or in subacute and secondary pleurisies without the employment of leeches, rubefacient applications should be made over the affected side of the chest, followed by a poultice, or flannel wrung out of warm water and covered with oil-silk. Moderate counter-irritation diminishes the pain, but vesication at this early period is injurious. A blister applied so near the seat of 520 PLEURITIS. the inflammation may increase the aiflux of blood towards it, and aggravate the disease. Robust patients over the age of three or four years are benefited by the use of cardiac sedatives in the commencement of acute pleuritis. The tincture of aconite or of veratrum viride may be given, but its effects shoukl be carefully watched, and it should be discontinued when the pulse is reduced to near the natural fre- quency, or when sufficient exudation has occurred to produce the ordinary physical signs of liquid in the chest. They should not be given in secondary pleuritis. Opiates are required, as in other serous inflammations, accord- ing to the pain. Dover's powder, in doses of one to three grains, according to the age, may be given every three hours, or less fre- quently if the patient is inclined to sleep. Such is the treatment required in the first stage of. acute primary pleuritis, or that preceding the effusion. Secondary pleuritis requires fewer and less depressing measures. The appro- priate treatment, in a large proportion of the cases of this form of the disease, consists in the use of an opiate, with rubefacient and emollient applications to the chest. Abstraction of blood, and powerful cardiac sedatives, as aconite and veratrum viride, are dangerous remedies in secondary pleurisies, and are almost never used. Pleurisies dependent on pulmonary disease, which are circum- scribed and attended with little serous eiiusion, require no other therapeutic measures than those already mentioned. The judi- cious use of opiates, and rubefacient and emollient applications, suffice for their treatment. In the treatment of other forms of pleurisy, which are attended by more or less effusion of liquid into the pleural cavity, measures designed to remove this liquid are required when the inflammation has abated, and antiphlogistics are no longer appropriate. Liquids in the great cavities are best eliminated by hydragogue cathartics and by diuretics. For children, however, already weak- ened by pleuritic inflammation, cathartics are usually too depress- ing unless for one or two days. Now and then a robust patient, over the age of five or six years, with pleuritic eff'usion, may be benefited by an occasional purgative dose of bitrate of potassa, or by from one-twelfth to one-sixth of a grain of podophyllin. But such cases are exceptional. In a majority of children the loss of strength resulting from cathartics more than counterbalances the good result from the liquid evacuations which they produce. TREATMENT. 521 Diuretics, on the other hand, arc efficient remedies, and upon them our chief reliance must be placed. Tlie diuretic from which I have seen better effects than froni any other is iodide of potassium, but it should be given in large doses. In the adult I have observed rapid absorption of the liquid by the administration of from one to two drachms daily of this agent, given in doses of ten grains, and a child can take a proportionate dose. Two to five grains, according to the age, may be given every three hours. At the same time it is advisable to restrict the drinks. At this stage of the disease counter-irritation is appropriate, either by rubefacients or vesicants. The preferable mode of blistering the child is, in my opinion, by cantharidal collodion applied as recommended in the treatment of pneumonitis. In secondary pleuritis the diet should be nutritious, consisting largely of animal broths, through the whole period of the disease. In primary pleuritis nutritious diet should be allowed after exu- dation has occurred. In some cases, more frequently in secondary than primary pleuritis, stimulants are required. In protracted pleurisy, or pleurisy occurring in a debilitated patient, tonics, both vegetable and chalybeate, are often serviceable, sustaining the strength while the process of absorption is going on. Occasionally the measures which have been recommended above to promote absorption of the liquid in the pleural cavity do not have the effect which is desired. If there is no sensible diminu- tion in its amount, and if the general health of the patient begins to fail, the performance of thoracentesis should be considered. "We may accomplish by surgery what we fail to effect by therapeutic means. The following are the remarks by Prof. Flint, on this subject. They apply to thoracentesis in children as well as adults. (Flint's Practice of Medicine^ 2d ed.,p. 155.) "Heretofore this operation was performed only as a dernier resort^ under circumstances when little was to be expected from any measure. It was deferred as long as possible, sometimes on account of doubt as to the diagnosis, and because the perforation and introduction of air were supposed to involve danger of an increase of the inflammation. A considerable opening was necessary in order to give free exit to the liquid, and it was not easy to prevent the air from entering the pleural cavity. Objection to the opera- tion on the score of diagnosis is now removed by our present knowledge of physical signs. Moreover, the operation has been divested of all severity, and the liability to the introduction of air 522 PLEURITIS. has been provided against "by the application of the suction pump, first suggested by Dr. Morill Wyman, in 1850, and since employed in a large number of cases by Dr. Bowditch. The introduction of air is not attended by the injurious eftects formerly apprehended, but it is objectionable because the presence of air is an obstacle to the full expansion of the lung after the liquid is removed. Its introduction is prevented by the use of the pump in withdrawing the liquid. The operation is rendered trivial, because with the suction force of the pump a small exploring trocar suffices to make the puncture, which causes very little pain, and closes directly the canula is removed." Dr. Bowditch had performed the operation one hundred and fifty times on seventy-five individuals prior to 1863, in the manner described above, and in twenty-nine of the patients recovery was apparently 'due to it. Prof. Flint has several times successfully performed the operation, using a small trocar and canula made to screw on the flexible suction tube of Davidson's syringe. M. Gruersant describes his mode of performing thoracentesis, in the Ball. Gener. de Therap., Oct. 15,1866. He generally "plunges in the instrument above the superior border of the tenth rib on the left side, and the eighth rib on the right, and at the junction of the posterior one-third with the anterior two-thirds of the inter- costal space. He employs a trocar about two lines in diameter, and nearly two inches in length, curved like a tracheotomy canula and furnished with a flap of membrane over its external orifice. The child is placed upon its back, and firmly held, while the operator with his left hand draws_ upon the skin, and with his right inserts the trocar, with its concavity looking downwards so as to avoid injuring the lung. The membrane at the external orifice of the canula, being previously moistened, excludes the en- trance of air. On withdrawing the instrument, the skin passes over the wound, and the parts unite by first intention, provided that the liquid is sero-fibrinous." The following are my experience and views in reference to this operation. Thoracentesis is rarely required in the child except for eiiipyema, and it should not as a rule be performed in less time than eight weeks after the commencement of the inflammation, so as to allow as much as possible of the liquid to be absorbed. If the health of the patient is but little impaired, it is proper to wait longer, for, if the efiVision is largely sero-fibrinous, and the amount of pus small, recovery is possible by absorption, for a small amount of pus may be absorbed, the pus cells undergoing fatty TREATMENT. 523 degeneration and liquefaction. The operation can be best per- formed with the patient etherized, the point selected being a little below the lower angle of the scapula. The operation is no more difficult than the opening of any deep abscess, and it is not dangerous to the patient. The skin being drawn up a little, so that after the operation it will close the ojtening like a valve, an incision should be made through the integument, and then a medium-size trocar pushed through the walls of the chest into the cavity at the upper border of the rib. A trocar of medium size is preferable to one that is smaller, as the pus is often thick and would flow with difficulty. Or, without the trocar, the operation may be performed by the bistoury alone. The admission of a moderate amount of air into the pleural cavity in tapping for empyema does no harm, except so far as it prevents inflation, since the pleural surface with which it comes in contact is already a pyogenic membrane. "When the pus ceases to flow, the curved end of a pocket male catheter may be introduced, and with the India- rubber syringe attached more pus can be removecL I prefer, how- ever, to make the aperture sufficiently large, enlarging it a little if necessary with a bistoury, that it may remain as a fistulous open- ing from which pus continues to flow. The skin acting as a valve prevents the admission of air after the canula is withdrawn. If the discharge ceases after a day or two, the small quantity of pus remaining will commonly be absorbed. The injection daily into the pleural cavity, as long as the aperture remains, of a weak solution of carbolic acid, of the temperature of the blood, expedites recovery, but without this there is a gradual, though sometimes slow, convalescence. Since the publication of the first edition of this book, thoracen- tesis has been performed in four children in my own practice, and in one at the Out-door Department at Bellevue. In four the apertures was left open, being covered with oakum, and allowed to drain, but in three of these pus soon ceased to flow. The five children operated on recovered gradually, though four of them were in a reduced state which involved immediate danger. In about the same period death occurred in nearly an equal number, in whom the operation was not performed, in consequence of uncertain diagnosis or for other reasons. The one of those operated on, in whom thoracentesis was longest deferred, was taken with pleuritis of the right side in April, 1871, and the pus was evacuated by the knife in September following, the trocar, which 524 PLEURITIS. was introduced immediately afterwards, being of little use, as the pus escaped by its side. Although the general health of the child, which remained for a time precarious, is fully restored, there are evidences of incomplete inflation of the lung. These few cases, if they correspond, as I believe they do, with more ample statistics, show the urgent need of thoracentesis in the empyema of children, and the probability of a favorable result, even when it is performed under discouraging circumstances. If the liquid removed by the operation prove to be sero-fibrinous, it is very important that no air enter the pleural cavity, as it would be likely to produce a suppurative inflammation. Therefore, the puncture of the walls of the chest should always be made with the trocar in those cases in which there is doubt as to the nature of the liquid, since the entrance of air can be most readily pre- vented when this instrument is employed. Tn certain cases, in which absorption is slow, and empyema is suspected from the symptoms, it is proper to ascertain the nature of the liquid by the exploring needle before instituting any operative procedure. SECTIO]^ III. DISEASES OF THE DIGESTIVE APPARATUS. CnATTER I. SIMPLE STOMATITIS ; ULCEROUS STOMATITIS ; FOLLICULAR STOMATITIS. Diseases of the digestive system in infancy and childhood are of frequent occurrence. They are for the most part readily recog- nized, and are more easily and quickly controlled by therapeutic agents, if rightly applied, than are the diseases of any other system. If misunderstood and improperly treated, they may, even when mild and very manageable in their commencement, become chronic and obstinate, or even fatal, or they may lead to other and more dangerous diseases. It is necessary, then, that the physician should understand thoroughly the pathology as well as therapeutics of the digestive system, that he may make timely and correct use of the required remedies. The diseases of the buccal cavity in early life are for the most part inflammatory. The mildest is that known as Simple or Erythematic Stomatitis. This form of inflammation occurs usually before the completion of first dentition, and it is most frequent under the age of one year. Giving rise in itself to no severe symptoms, and often being connected with other grave and dangerous aflfections, it is, doubt- less, in many cases overlooked. It is sometimes confined to a por- tion of the buccal surface, or is more intense in one part than in another. In other cases the stomatitis is uniform, or nearly so, aflecting the entire cavity of the mouth. Causes. — The common cause of simple stomatitis in infants is the same as that of most cases of gastro-intestinal inflammation at that age. This is the use of indigestible and therefore irritating food, uncleanliness, personal and domiciliary; in fine, all those 526 SIMPLE OR ERYTHEMATIC STOMATITIS. agencies which impair the general health, and enfeeble the diges- tive organs. Therefore, stomatitis, like entero-colitis, is more common in the city than in the country, and among the city poor than those in the better walks of life. Infants deprived of the mother's milk and given a diet which, with all care of preparation, is a poor substitute for the natural aliment, are very liable to this disease. Beaumont ascertained from his experiments on St. Martin that irritative changes produced in the stomach by indigestible substances were soon followed by similar changes in the buccal mucous membrane. Since in young infants any kind of artificial food is less digestible than the breast milk, it is evident why those who are prematurely weaned or are carelessly fed are so liable to stomatitis. This inflammation is also sometimes due to irritating substances taken in the mouth, as drinks habitually too hot or too cold. Stomatitis is also present in measles and scarlet fever. It then corresponds with the cutaneous eruption, and disappears when that subsides. Another cause is dentition. The gum over the advancing tooth first becomes inflamed, and, other causes perhaps conspiring, the inflammation extends over more or less of the buccal surface. When due to dentition the stomatitis is more apt to be partial than when it arises from a constitutional cause. Mercury, in whatever form introduced into the system, excreted from the salivary glands, and flowing over the buccal surface, is an occa- sional though now-a-days rare cause. Symptoms, Appearances. — Stomatitis, like other mucous inflam- mations, is characterized by increased redness and more or less thickening of the inflamed buccal membrane, by rapid proliferation and exfoliation of epithelial cells, and by an increased functional activity of the muciparous follicles. The heat of the mouth is sometimes augmented in an appreciable degree. The gums in severe cases are swollen and spongy, and bleed easily if rubbed or pressed. The tongue is usually covered with a light fur, and the salivary secretion is augmented to such an extent sometimes as to dribble from the corners of the mouth. Often there is little sufter- ing, but in other cases the child is fretful, experiences pain from the contact of solid food, and if nursing may even wean itself, from dread of pressure of the nipple. Simple stomatitis is not difficult of detection, provided atten- tion is directed to the mouth. Inspection informs us of its pre- sence and extent. A favorable termination may be confidently predicted, unless there is a state of marked cachexia, or a grave ULCEROUS STOMATITIS. 527 coexisting disease. If circumstances are unfavoral)lc, simple stomatitis may terminate in a more severe form, as tlie ulcerous or diphtheritic. Treatment. — The physician should endeavor to ascertain the cause, and, if possible, should remove it by appropriate medicinal or hygienic measures. Sometimes no special treatment is required, as in measles or scarlet fever. When the j)rimary aftection termi- nates, the stomatitis disappears of itself. If dentition is the cause, and there is much fever and frctfulness, it may be advisable to scarify over the advancing tooth, and employ such soothing and derivative measures as are required in painful dentition. In these cases mucilaginous and mild astringent lotions may be employed. Borax is a good remedy used either with honey or water ; one part of borax to three of honev, or a drachm of borax to an ounce of water. A weak solution of alum is also a good topical remedy. With either of these remedies in a favorable condition of system, and without any serious coexisting disease, the stomatitis is relieved. Ulcerous Stomatitis. In ulcerous, or, as designated by Eilliet and Barthez, ulcero- membranous, stomatitis, the anatomical characters are those of severe simple stomatitis, with the additional element which gives it the name by which it is designated. The inflammation usually begins upon the gums and extends along the buccal surface. Wherever it commences, there soon appear little white points underneath the mucous membrane, pro- ducing slight prominence of it. These points, which are inflam- matory exudations mainly fibrinous, gradually enlarge. Some unite and give rise to large irregular ulcerations ; others remain isolated, producing ulcers which are smaller and of more regular shape. There is, indeed, no uniformity as regards the size and form of the ulcers. In the folds of the buccal membrane they are apt to be elongated, while inside the lips, or where the surface is smooth, the circular or oval form predominates. Ulcerous stomatitis is usually confined to that part of the buccal surface which covers the gums, or is in their immediate vicinity, but in some instances it aftects nearly every part of the cavity of the mouth. If the disease is severe, there is considerable swelling around the ulcers, but the swollen part is soft and cushiony, and not veiy tender on pressure. The soft and yielding nature of the swelling 528 ULCEROUS STOMATITIS. serves as a means of diagnosis between tins disease and the pre- monitory stage of gangrene, since in the hitter affection the swollen part is more indurated. If the disease grows worse, more ulcers appear; the fibrinous exudation if detached is renewed or it becomes thicker by the formation of new layers. The ulcers grow deeper and wider, and their edges more vascular. If, on the other hand, there is improvement, the swelling sub- sides, the ulcers become more clean, their bases approach the level of the mucous membrane and present a granulating appearance. Finally the mucous membrane is reproduced. A considerable time after the ulcers are healed, the new membrane which occupies their site has a redder hue than the adjacent surface. Causes. — Ulcerous, like simple, stomatitis, is most frequent in the families of the poor. Personal uncleanliness, poor food, a residence in apartments dirty, humid, or in other respects insalu- brious, favor its development. In fine, a cachectic condition, how- ever produced, is a common predisjDosing cause. It frequently occurs when the system is reduced or enfeebled by acute diseases, as after the essential fevers and thoracic and intestinal inflamma- tions. In protracted entero-colitis of infants, it is sometimes severe and obstinate, and a case in which this comjDlication arises usually ends unfavorably. Occasionally several cases occur together or consecutively in the wards of a hospital, and this has led some observers to be- lieve that ulcerous stomatitis is contagious. But its prevalence under such circumstances is attributable to the fact that there is a common exposure to the influences which give rise to the disease, just as a whole household exposed to malaria may be seized with intermittent fever. Diflicult dentition is also an occasional cause. Symptoms. — The symptoms in ulcerous stomatitis are more severe than in the simple form. There is more fever, more salivation, and more fretfulness. The ulcerated surface is sometimes very tender, so that there is but little sleep. Drinks, unless bland and lukewarm, are painful, and, if the ulcers are on the lips or the front of the mouth, the infant nurses less eagerly than usual, and even with reluctance, sometimes weaning itself. Occasionally the sub- maxillary glands are tumefied, hard, and tender. The breath has an oflensive odor. In mild cases in which the stomatitis is of limited extent, this odor may scarcely be noticed, but in severe cases it is almost like that exhaled from putrid substances. PROGNOSIS — TREATMENT. 529 Prognosis. — A ftivorablc prognosis may be given unless the patient is in a decidedly cachectic condition, or there is a serious coexisting disease, under which circumstances the case may Ijc protracted. If death occur, it is due to the cachexia or to some pathological state quite distinct from the stomatitis, most fre- quently entero-colitis. Ulcerous stomatitis, when the ulcers are small and the inflammation of limited extent, is of course more easily cured than when it is extensive and the ulcers are large. This disease is very liable to return, unless the general health is good. Treatment. — The physician should endeavor to ascertain the cause of the stomatitis, and so far as possible should remove the patient from its influence. It is often necessary, in order to insure a speedy recovery, to recommend a change in regimen, especially as regards diet and cleanliness. If the patient live in damp, dark, and dirty apartments, the family should seek a better residence, and he should be taken daily in the open air. Tonic remedies are generally required. The ferruginous pre- parations may be advantageously given, or the vegetable tonics, or the two in combination. In selectino- the internal remedies we O must regard the antecedent disease, if there be any, which the buccal inflammation complicates, and on which it depends. For that large proportion of cases in which there is chronic intestinal inflammation, the liquor ferri nitratis with tincture of coluiubo administered in simple syrup will be found useful. For local treatment Trousseau recommends occasional applications of nitrate of silver or muriatic acid as a caustic, and in the intervals a wash of equal parts of borax and honey. The chloride of lime is also considerably used in Paris. It is re- commended by Rilliet and Barthez. It is applied dry to the ulce- rated surface twice daily, and in the interval the mouth is washed with simple water. This treatment is continued till the ulcers present a healthy appearance and begin to cicatrize. Then a weak solution of chloride of lime is employed, one grain to forty-five of the vehicle. By this treatment a cure is usually efl'ected. Bouchut prefers using chloride of lime with honey, one drachm to the ounce. But painful applications are not required. The remedy which is most employed in this country and in Great Britain is chlorate of potash. It often acts like a specific for this as well as other forms of stomatitis. It may be given dissolved in water with sugar, or with one of the syrups to render it more palatable. The U 5'60 FOLLICULAR STOMATITIS. dose is from two to five grains every two hours. It should be allowed to run over the aiiected part, as it is believed to have a local action. :^. Potass. Chlorat. 5j ; Mellis 5SS ; Aquog 5ij. One teaspoonful every two or three hours. Of all topical remedies in common use, chlorate of potash is the most safe, most easily administered, least painful, and probably the most efficacious. Some physicians prefer the chlorate of soda, on account of its greater solubility. Follicular Stomatitis. In this form of stomatitis the inflammation is confined to the muciparous follicles of the mouth, or to them and the mucous membrane in their immediate neighborhood. Anatomical Characters. — At first there appear in the mouth minute papular elevations, red, hard, and tender, which continue to enlarge and soon become vesicular. They may now break, leaving an ulcerated surface ; but if they continue entire they be- come purulent, and then their contents are discharged. From the commencement of the papule to the purulent transformation the period is perhaps three or four days. The ulcer which occupies the site of the eruption is round, hard, painful, and with a vascular margin. The base has a white or grayish appearance. The reparative process soon commences, the ulcer presents a healthy appearance, its size is graduall}^ dimin- ished, and finally cicatrization occurs. The liquid with which the follicles are distended in the first stages of the disease is believed to be the natural secretion some- what modified by the inflammation. The number of ulcers is various. There are in most cases from six or eight to as many as twenty. They are ordinarily discrete, and one or two lines in diameter. The stages of the disease rapidly succeed each other, and the patient fully recovers in from six to eight days, but not always. In exceptional instances the ulcers enlarge and become confluent, or one or more of them assume a gangrenous appearance. This indicates a faulty condition of the system, a vitiated state of the blood, due perhaps to some antece- dent or concomitant disease. In these cases the ulcerative stage is apt to be protracted, and recovery doubtful. CAUSES— SYMPTOMS. 531 The seat of follicular stomatitis is usually the internal surface of the lips and cheeks, the gums, tongue, and occasionally the roof of the mouth. It rarely affects the fauces. Occasionally this form of stomatitis is associated with more general inflammation of the buccal cavity. The gums may then be swollen and tender, bleed- ing if rubbed or pressed. Causes, — The causes are not fully ascertained. Follicular stomatitis has not usually in my practice occurred in so feeble a state of system as has been present in ulcerous stomatitis. Billard, speaking of the aphthce, or ulcers of this disease, says : " They are particularly to be seen in children who are very feeble, pale, and of a lymphatic temperament. "We do not look for the causes of aphthse in the retention of the meconium, acidity of the milk, or in the predominance of acidity in the fluids of the child; we attach 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 ventilated places in those who are crowded together with a number of sick children." Barrier considers follicular stomatitis to be allied to those gas- tro-intestinal diseases which are attended by turgescence of the mucous follicles, and he mentions among the causes habitual con- gestion of the buccal mucous membrane, and diflicult dentition. In most cases probably the exciting cause is some derangement of the digestive organs which may not be appreciable. While simple stomatitis, and stomatitis with thrush, are most common under the age of six months, follicular stomatitis is rare at this age. It is most frequent during the time which corresponds with dentition, when there is also the most rapid development and greatest activity of the muciparous follicles. Symptoms. — The constitutional symptoms in a large proportion of cases of aphthfe are slight. In twelve children affected with this disease Billard found the pulse from sixty to eighty beats per minute. The ulcers are painful, as is indicated by the cries of the child when they are pressed, and its fretfulness. Solid food, and even drinks unless bland and unirritating, are badly tolerated. The salivary secretion is also augmented. In those rare cases in which the ulcer becomes confluent or gangrenous, the state of the patient is really serious. There is then often gastro-intestinal disease. The symptoms indicate pros- 532 FOLLICULAR STOMATITIS. tratioii. The pulse is feeble, the countenance pallid, and the body and limbs become wasted. Diagnosis. — This is easy. The only disease with which it is liable to be confounded is ulcerous stomatitis. In the ulcerous form there is antecedent and accompanying stomatitis affecting a considerable part, if not the entire buccal cavity, while in the follicular form the inflammation is ordinarily confined to the im- mediate vicinity of the ulcers. The character of the ulcers serves also as a means of distinction. In ulcerous stomatitis there is great variety as to size and form, while in follicular stomatitis there is great uniformity in both these respects. The small, cir- cular ulcers are characteristic of the follicular inflammation. Before the ulcerative stage the vesicular eruption serves to distin- guish this form of stomatitis from other local diseases affecting the cavity of the mouth. Prognosis. — Follicular stoijiatitis usually ends favorably ; but, if the ulcers become concrete or gangrenous, the health is seriously affected, and a more cautious prognosis should be expressed. The unhealthy appearance of the mouth, and the real danger, are often more due to the depressing effect of some concomitant disease than to the stomatitis. Treatment. — In ordinary follicular stomatitis, which is dis- crete and attended by little or no constitutional disturbance, local remedies sufiSce to cure the disease. Demulcent drinks, or appli- cations to the mouth, should be used, as the mucilage from gum acacia, marsh-mallow, or flaxseed. Mild astringent lotions with the demulcent are also beneficial. The mel boracis is one of the best and most agreeable applications. It may be placed in the mouth with a spoon, or applied with a camel-hair pencil. If there is much tenderness of the ulcers, with restlessness, a small quantity of some opiate should be added to the lotion, or it may be admin- istered separately. "With this simple treatment the ulcers generally soon heal, and the health of the patient is restored. If, however, the ulcers are quite painful, and not disposed to heal, or are healing tardily, they may be touched lightly with a pencil of nitrate of silver, or, as Barrier recommends, hydrochloric acid in honey of roses. This diminishes the tenderness and expedites the healing process. If, as may in rare cases occur, the ulcerations are numerous, and are accompanied by considerable fever, there may be symp- toms indicative of cerebral congestion, or even premonitory of convulsions. In such cases laxative and diaphoretic remedies are THRUSH — ANATOMICAL CHARACTERS. 533 required, and sinapisms or other revulsive applications to the ex- tremities. If there is an unhealthy appearance of the ulcers, if they gradu- ally enlarge, or become concrete, or gangrenous, indicating a cachectic state, tonics should he employed with nutritious and easily digested diet, and anti-hygienic influences should so far as possible be removed. CHAPTER II. THRUSH. The terms thrush, sprue, and muguet, the last from the French, are synonymous. They are used to designate a jiarticular form of inflammation of the digestive apparatus, the peculiar feature of which is the presence of points or patches of a curd-like appear- ance on the inflamed surface. The usual seat of thrush is the mucous membrane of the mouth, but occasionally it aft'ects the fauces, pharynx, and oesophagus. It is very rare in the sub-diaphragmatic portion of the digestive tube, but a few such cases have been reported by Billard and others. It never afi:ects the membrane of the nostrils, larynx, or bronchial tubes, and it very seldom occurs in any other part of the alimentary canal without also being present in the mouth. Thrush, then, is a stomatitis, pharyngitis, or cesophagitis, or a gastro-enteritis, with the additional element which I have described. Anatomical Characters. — The first stage of thrush is that of simple inflammation of the mucous surface. There next appear minute semi-transparent points or granules, which, increasing, soon become white and opaque. Some of them remain as points, while others, extending, and perhaps coalescing with those adjoin- ing, form patches of greater or less extent. The white points or patches are unequally elevated. Their central part, which was first formed, is most raised, while their circumference projects but little above the epithelium. Their highest elevation is not ordi- narily more than a line above the surface. They are smaller in the pharynx and oesophagus than when occurring upon the buccal surface. They resemble closely, in color and consistence, portions of curdled milk, and the nurse often mistakes them for such, and neglects to call attention to the state of the mouth. They are 534 '" THRUSH. readily detaclied by a little force, but are speedily reproduced. Their color in tlie first days of the complaint is white, and some- times this color continues. In other cases they assume, if the dis- ease is protracted, a yellow hue. Their true nature, long unknown, was finally revealed by microscopy. They consist in part of epithelial cells, and in part of a vegetable growth. This parasitic plant is in most cases the oidium albicans. Like other confervse, it consists of roots, branches, and sporules. The roots are transparent, and they penetrate the epithelial layer, sometimes even to the basement membrane. The branches divide and subdivide at an acute angle, and under the microscope they are seen to consist of elongated cells, with one or two nuclei. Around these branches are numerous sporules. In two or three instances I have examined the product of thrush removed from the oesophagus, and in both the parasitic plant was the penicillium glaucum, or a conferva closely resembling it. In the mildest form of thrush, this morbid product is in points or small patches. If the patches are of large extent, especially if, as rarely happens, a considerable part of the buccal surface is covered by them, there is generally a state of great prostration and danger, from some antecedent or concomitant disease. Thrush is, indeed, often the sequel of some grave affection, as pneumonitis or gastro-intestinal inflammation. Its complication with the last named disease is common in young, ill-fed infants, especially those deprived of the breast milk, and such cases are very apt to be fatal. Hence, some writers, who have studied infantile diseases in foundling hospitals, regard thrush as one of the most serious affec- tions of early life. Valleix, in a book of seven hundred pages re- lating to diseases of children, devotes more than one-third to the consideration of muguet. Of twenty-four cases, the records of which he publishes, twenty-two died, but their death was due to gastro-intestinal inflammation, which the author considered a part of the more general disease, muguet. Doubtless the same cause which produced the stomatitis, with the confervoid growth, in these infants, also produced the fatal gastritis or gastro-enteritis, occurring without this growth upon the gastric or intestinal sur- face. It seems to me much better to restrict the term sprue, thrush, or muguet to the inflammation of that portion of the mucous sur- face which is the seat of the parasitic growth. I reject, then, from my description of the anatomical characters of thrush, those sub- diaphragmatic inflammations which some writers consider an im- SYMPTOMS — CAUSES. 535 portantpart of tliis disease, and place them in the list of coexisting aftections. When the fatal gastric or intestinal inflammation is accompanied by the characteristic vegetable growth on the gastric or intestinal surface, it is i)roper in my opinion then, and only then, to say that death occurred from thrush. This explanation seems necessary in order to understand the dift'erent statements of writers in relation, not only to the anatomical characters of thrush, but also in reference to its mortality. The frequent coexistence of thrush with gastro-intestinal inflam- mation, has been remarked in the hospitals of Europe, and in the Infant Asylum and the Child's Hospital, in this city. In the post- mortem examinations of those who have died in these last institu- tions, having thrush at the time of death or immediately prior to it, and who for the most part have been infants under the age of three months, I have frequently found evidences of inflammation in every division of the alimentary canal. The confervoid growth was, however, seldom found below the fauces, and never below the oesophagus. Symptoms. — The symptoms in thrush are not different in most cases from those of simple inflammation. In the mildest cases they are chiefly of a local nature, such as have already been de- scribed in our remarks on simple stomatitis. If the inflammation is more extensive, especially if it affect the fauces and oesophagus, the infant becomes feverish and fretful, and the inflamed surface is hot, red, and tender. In the worst forms of thrush this surface not only presents the ordinary features of severe inflammation, namely heat, redness, and tenderness, but it is sometimes deficient in the natural secretion, so as to present a dry or parched appear- ance. It is in these cases that there is often a more extensive in- flammation than that of the buccal or oesophageal membrane. The sub-diaphragmatic portion of the digestive tube is inflamed. The infant in these severe cases has thirst, loss of appetite, restlessness, vomiting, and frequently diarrhoea. The countenance is anxious and pale ; there is rapid emaciation, and, if the disease is not ar- rested, a state of extreme prostration soon occurs. The twenty-four severe cases related by Valleix, already alluded to, twenty-two of which were fatal, were examples of this severe form. Causes. — Thrush is most apt to occur in those who are consti- tutionally feeble, or who are enfeebled by disease, or by unfavor- able hygienic conditions. Cachexia is a cause common to thrush and most other subacute inflammations of the alimentary canal. The most obvious and common of the unfavorable hygienic con- 536 THRUSH. (litions alluded to is the continued use of indigestible and im- proper food. It is, therefore, a common disease among foundlings, in institutions where these unfortunates are received, since they not only breathe an atmosphere which is often impure, but are deprived of the mother's milk, and are so frequently given a diet which is a poor substitute for it. Among the poor of the cities thrush is common, since with them, from necessity or choice, there is the greatest neglect of sanitary requirements. Exposure to hu- midity, to variations in temperature, increases the liability to the disease, though in less degree than defective alimentation. Billard and Valleix agree that thrush is more frequent in the warm months than in the cold, that its maximum frequency is in the months of July, August, and September. Cases in the Infant Asylum and Child's Hospital, of this city, have appeared to me to correspond in this respect with those related by Billard and Valleix. Various w^riters have mentioned the age at which thrush is most apt to occur, as one of the 2:)redisposing causes. Thrush is not common above the age of six months, and a majority of the cases occur under the age of three months. Infants of the age of one or two weeks, if in addition to lactation they are spoon-fed by nurses over- anxious that they should thrive, are ai:)t to take the disease. Diagnosis. — This is easy so far as thrush in the mouth is con- cerned, for simple inspection by one familiar with the disease is all that is required in order to discover it. The presence of thrush in portions of the alimentary canal hidden from view cannot be jwsitively ascertained. The vomiting, diarrhoea, pain or fretfulness, emaciation, and rapid sinking, which sometimes accompany severe forms of thrush, indicate gastro-intestinal inflammation, to which the attention of the practitioner should be chiefly directed. Prognosis. — The duration of thrush varies according to its intensity, and the favorable or unfavorable condition of the child. If it is slight and the health of the infant otherwise good, it may often be cured in two or three days. Under other circumstances it may continue as many weeks or even longer, before it is entirely removed. When thrush occurs in connection with gastro-enteritis, the mortality is very great. It has been already stated that in Val- leix's twenty-four cases twenty-two were fatal. M. Auvity esti- mates the mortality of such cases at nine in ten, and M. Godinat at two in three. Treatment. — As one of the most common causes of thrush is the use of indigestible or improper food, the physician should TREATMENT. 537 ascertain the nature of tlie infant's diet, and if it is faulty should direct a better. In many cases the infant is bottle-fed. It should be given only the mother's milk if practicable, or that of a healthy wet-nurse. This change of alimentation often removes the sole cause of thrush in the young infant, so that it rapidly recovers. If artificial feeding is necessary, such diet should be advised as is directed in our remarks on the treatment of the diarrhoeal maladies. There is often in thrush an excess of acidity in the digestive tube, and an alkali is required. Trousseau recommends the addition of saccharate of lime to the milk. Children with this disease should also be taken from filthy and damp apartments, to those in which the air is pure and dry. The remedy in common use in the treatment of thrush, and which is usually effectual, is borax. This, if api:)lied sufliciently often to the affected membrane, not only destroys the parasitic growth, but prevents its reproduction. It is commonly employed with honey, or in a powder with sugar or dissolved in water. The officinal mel boracis, consisting of one part of borax to eight of honey, is so much used in families that it may be considered almost a domestic remedy. There is, however, an objection to using any ai:)plication for the removal of thrush which contains either sugar or honey, since either substance remaining in the mouth would rather promote the growth of the parasite. Still, it is desirable to employ a wash of such consistence that it will remain a longer time in contact with the buccal surface than will a simple solution in water. I know no better vehicle for the borax than glycerine, which has the advantage of consistence, does not readily undergo any chemical change, and has no unpleasant flavor. The borax may be used dissolved in glycerine, with or without some flavoring ingredient : — I^, Sodre borat. 5j ; Glycerinse ^ij ; Aquae 5vj. Misce. Borax should be used four or five times daily, and continued for a time after the disease has disappeared from sight, since the roots of the plant must be destroyed or the branches are rapidly reproduced. It should be applied by a camel-hair pencil, or with a soft cloth upon the finger or a stick. It should be so freely used, in extensive and severe forms of the disease, that the infant will swallow some, as the entire oesophagus is apt to be afltected in such cases. In the intervals between the applications of borax, if the buccal surface is hot, dry, and tender, so as to increase the 538 GANGRENE OF THE MOUTH. fretfulness of the infant, it is well to use mucilaginous washes, as the mucilao-e of acacia or mallows. If the disease continue not- withstanding the use of these measures, the mouth should be occasionally washed with a weak solution of nitrate of silver or sulphate of zinc : — ^. Ziuci sulpli. gr. ii-iv ; Aq. Rosse gij. Misce. In many cases, however, the treatment of thrush is of less im- portance than that of the disease which the thrush complicates. The remedial measures which I have mentioned then become subordinate to those employed for the graver disease. When this disease is relieved and the general health improves, thrush is more easily and permanently cured than during the state of feebleness and ill-health. CHAPTER III. GANGRENE OF THE MOUTH. The diseases of the mouth which we have been considering are attended by little danger, but the one which we are next to con- sider is among the most fatal affections of early life. It is gan- grene of a portion of the cheek or gums, or of both. It is described by writers under various names, as cancrum oris, noma, necrosis infantilis, aqueous cancer of infants. Anatomical Characters. — Gangrene of the mouth is sometimes preceded by ulceration of the mucous meml)rane, at the point where it is about to commence, but in other cases this membrane is entire. The tissues at the point of attack, which is most fre- quently the inside of the cheek, become inflamed, thickened, and indurated. The induration extends, and soon the purple hue of gangrene appears and increases. The next stage in the progress of gangrene is sloughing of the portion the vitality of which is lost. The slough does not present the appearance of uniform decay. "While the color is generally dark, there are in the mass fibres of connective tissue or even bloodvessels, which remain unchanged or are but partially decomposed. After separation or sloughing of the part where the vitality is first lost, the surface of the AGE. 539 excavation, if the disease is not checked, has a dark, jagged, and unhealthy appearance. Commencing witli tlie mucous membrane and the tissue immediately underlying it, the disease extends on the one side towards the skin, and on the other towards the deeper seated structures of the jaw. According to Billard, the swelling which precedes and surrounds the gangrene is in great part oodematous. This disease is occasionally primary, but in a large proportion of cases it is secondary. Occurring secondarily, its symptoms are often masked by those of the antecedent and coexisting aiiection. Under such circumstances attention is sometimes first directed to the mouth, by the loosening of one or more of the teeth, or the appearance on the skin of a livid circular spot, which indicates the approach of the disease to the cutaneous surface. The mucous membrane presents a dark red appearance to the distance of a few lines beyond the point of gangrene. It covers tissues which are inflamed and indurated and about to become gangrenous. The tongue is usually more or less swollen, unless the disease is mild ; an offensive odor arises from the gangrene, due to the evolution of sulphuretted hydrogen and other gases. There is great difference in the extent of the destruction, and the gravity of the disease, in different cases. It may sometimes be arrested by proper applications and a favorable change in the general health of the child at an early period, when there is little loss of substance. In other cases it extends till it perforates the cheek, or even destroys a considerable part of the side of the face, and, extending inwards, attacks the periosteum of the maxillary bone, destroying the gum and teeth, and denuding the alveoli. Recovery, if it take place at all under such circumstances, is with the loss of a portion of the bone, and with deformity. The duct of Steno is sometimes included in the gangrenous por- tion, but it commonly resists the destructive process, and remains pervious. Age. — The age at which gangrene of the mouth occurs is usually between two and six years. In twenty-nine cases collated by Rilliet and Barthez, twenty -one were between the ages of two and six years, and the remaining eight were from six to twelve years old. Of the cases which have fallen under my observation, all were between the ages of two and six years. It is seen that the period of greatest frequency of gangrene of the mouth is different from that at which the ordinary forms of stomatitis occur. Gangrene of the mouth may, however, occur under the age of 5i0 GANGRENE OF THE MOUTH. one year. Billard reported three cases under the age of one month, but in two of these the disease does not appear to have been sufficiently marked to render it certain that they were genuine cases of this aflection. Causes, — Gangrene of the mouth usually occurs in those whose sj^stems are reduced or cachectic. It is, therefore, more frequent among the poor than those in comfortable circumstances ; in the city than in the country.' It is more frequently observed in asylums for children than in private practice. Half the cases which I have seen have been in these institutions. If the consti- tution is naturally good, it can only occur in those long deprived of pure air and wholesome nutriment, or those enfeebled by disease. Among the diseases which have been known to terminate in or be followed by gangrene of the mouth, are the pulmonary and intestinal inflammations, hooping-cough, and the fevers, both eruptive and the non-eruptive. Rilliet and Barthez have pub- lished a table of ninety-eight cases in which gangrene resulted from other diseases. In forty-one of these the antecedent disease was measles, in five scarlet fever, six hooping-cough, nine inter- mittent fever, nine typhoid fever, seven mercurial salivation, and five enteritis. It is seen that the essential fevers were the most frequent cause of the gangrene. Of forty-six cases collected by MM. Bouley and Caillault, the antecedent disease was measles in all but five. In this city, also, a larger number occur from measles than from any other disease. One reason why so many cases of gangrene occur as a sequel of measles is probably because this disease is accompanied by stomatitis. Simple or ulcerous stomatitis often precedes gangrene. Diseases sometimes terminate in gangrene of the mouth chiefly in consequence of injudicious treatment, which has lowered the vitality of the system. Rilliet and Barthez mention the case of a child four years old, in whom gangrene commenced at the twenty- ninth day of primitive pneumonia. This child had been reduced by the application of twelve leeches, three scarifications, a large blister, and by the use of absolute diet. The misuse of mercury was once a much more frequent cause of gangrene than at present, at least in this country, since this agent was formerly much more employed than now. In fact most of the aftections of infancv and childhood in which mercurials were formerly employed are now treated without it. Symptoms. — Gangrene of the mouth so often occurs in connec- tion with other disease, that its symptoms are in a large propor- SYilPTOMS. 41 tion of cases blended with those which arise from a distinct pathological state. There is usually prostration more and more pronounced as the gangrene extends. The features are ordinarily pallid, but occa- sionally their normal color is preserved for a time ; the expression of the face is melancholy but composed. Sometimes the child is fretful, if disturbed ; at other times it will quietly consent to an examination. The suliering is not proportionate to the gravity of the disease. There is less pain often than in some of the forms of stomatitis which are unattended with danger. As the disease advances, the body and limbs gradually waste, the eyes are hollow, or, if the gangrene is near the orbit, the eye- lids become cedematous, the lips are infiltrated, and both the lips and nostrils are often incrusted. If the cheek is perforated, alimentation is rendered more difficult, and the appearance of the child is melancholy in the extreme. The tongue is usually moist; it is occasionally swollen. The saliva flows from the mouth, either pure or mixed with offensive sanguinolent matter. Unless the disease is slight, there is the peculiar gangrenous odor. The appetite is sometimes poor, at other times it is preserved through the whole sickness. There is no vomiting or looseness of the bowels, unless from a complication. 542 GANGRENE OF THE MOUTH. The thirst is usually great, and the pulse is accelerated and feeble, except in mild cases. The skin in the commencement of gangrene is hot. "When the vital force is much reduced, and especially as the disease approaches a fatal termination, the face and limbs become cool, and the surface generally presents a waxen or ashy appearance. There is no derangement of the respiratory system. Those cases which are attended by a cough or accelerated respiration are really cases of bronchitis or pneumonitis, coexisting with the gan- grene. Diagnosis. — Gangrene of the mouth is easily diagnosticated. In those cases in which ulceration precedes the gangrene, it might be mistaken in its first stages for that form of ulcerous stomatitis in which the ulcers assume an unhealthy appearance. The follow- ing are the distinguishing features of the two affections: Around the ulcer where gangrene is about to commence, the tissues are greatly thickened and indurated, or oedematous, while ulcerous stomatitis begins with a submucous deposit of fibrin, and is attend- ed by little thickening of the surrounding parts, and little or no induration or oedema. In ulcerous stomatitis, the skin over the seat of the disease presents its normal appearance, whereas in gangrene it presents a distended and shining appearance. The destructive process in ulcerous stomatitis is also more limited than in gangrene. Deep ulcerations do not occur, or are rare. Ulcerous stomatitis is more readily healed, and it leaves no eschar, contrac- tion, or deformity. « The difterential diagnosis of gangrene of the mouth, from those cases of follicular stomatitis in which the ulcers occupying the seat of the follicles assume a gangrenous appearance, must be made by a consideration of the same facts or particulars which serve to dis- tinguish it from ulcerous stomatitis. Malignant pustule, of rare occurrence in the child, resembles this disease in some of its features. But the pustule always begins on the skin, while gangrene is a disease of the mucous surface primarily. In gangrene, therefore, the chief destruction is of the mucous membrane and of the submucous tissue, while in malignant pustule the chief destruction is of the skin and the subcutaneous tissue. Prognosis. — This depends, not only on the extent of the gangrene, but the nature of the disease, if there be one, which gave rise to it, and the degree of cachexia. If it occurs in connection with or as a sequel of one of the least debilitating diseases, and there is con- PROGNOSIS. 543 siderable vigor of system, it may often be arrested when it has destroyed only the mucous and subcutaneous tissues, so that no de- formity results. The friends may congratulate themselves if the case terminate so favorably. In the graver cases, when the gan- grene extends till it destroys the periosteum of the maxillary bone on the affected side, and perhaps perforates the cheek, if the child recovers it is with the permanent loss of teeth, tedious separation of the necrosed bone, and a cicatrix, which is aj)t to interfere with the free use of the jaw. Death is, however, the more common termination of severe cases. Occasionally the gangrene destroys the continuity of a bloodvessel, causing abundant hemorrhage, and accelerating the fatal result. In most cases, however, there is little or no hemorrhage, in consequence of coagulation in the vessels. Another serious complication occasionally arises, namely, gan- grene of other parts, as of the external genital organs. The English editor of Bouchut's treatise on diseases of children, relates the fol- lowing interesting case, from the Transactions of the Edin. Medico- Chir. Society : — An infant eiffht months old became affected with gano-rene of the face, head, and hands. " The right ear and the entire hairy scalp were of an intensely black color, and on both cheeks patches existed about the size of a half-crown piece. The right thumb and the backs of both hands were similarly affected. The child was noted to have been restless and feverish on May 22d, and on the 23d a slightly darkened ring was found to have formed round the thumb, about the middle of the first phalanx ; in a few hours the whole thumb was gangrenous, and the dorsum of the hand be- came involved. On the ear the gangrene commenced with the appearance of a fleabite, and subsequently extended rapidly to the scalp, assuming a remarkably regular form, and giving to the child the appearance of wearing a black skullcap. The pulse was ob- served to be very feeble. * * * Death took place in twelve hours from the first appearance of gangrene on the thumb, the child being sensible and continuing to suck well, vq) to a few minutes before death." Rilliet and Barthez state that pneumonitis is apt to arise in the course of gangrene of the mouth. Such a complication evidently diminishes materially the chance of recovery. "Whether the result be favorable or unfavorable, it is evident, from the nature of the disease, that the duration is very different in different cases. The physician's attendance may be required for a week or two or for several weeks. 5i-i GANGRENE OF THE MOUTH. Treatment. — As gangrene of the mouth is eminently a disease of debility, all anti-hygienic influences should be removed, and the most nourishing diet, together with tonics, be recommended. The ferruginous preparations or the bitter vegetables are required. As soon as the physician is called, he should endeavor to arrest the gangrene, accelerate the detachment of the slough, and pro- duce a healthy and granulating state of the surrounding tissues. This is best effected by applying a highly stimulating or even escharotic agent to the inflamed surface underneath and around the gangrene. For this purpose a great variety of substances have been used by difierent physicians, such as acetic, sulphuric, nitric, and hydrochloric acids, nitrate of silver, the acid nitrate of mercury, chloride of antimony, and even the actual cautery. M. Taupin recommends, after removing a considerable part of the gangrenous substance with scissors or some instrument, the application of strong muriatic acid, and, when the slough is de- tached, of dry chloride of lime. Eilliet and Barthez advised the use twice daily of muriatic acid or the acid nitrate of mercury, applied by a brush upon and around the slough, followed immediately by the application of dry chloride of lime, when the mouth is to be thoroughly washed with water from a syringe. They direct in the interval frequent ablution with water. After the slough has separated, the escharotic is to be discontinued, and the chloride of lime used alone. If o-ano-rene extends to the skin, a crucial incision is to be made and the escharotic applied, after which powdered cinchona is intro- duced and retained by a plaster. This treatment is to be continued till the gangrene is arrested and the decayed portion removed. Barrier, Valleix, and most French writers, recommend essentially the same treatment, namely, the application of undiluted escharotic assents. CD A safer, less painful, and, in my opinion, preferable, treatment, is that employed by many British and American physicians, namely, the use of escharotic agents diluted, or, if applied in their full strength, such as are least active and penetrating. Some employ from the first topical treatment which is astringent and stimulating rather than escharotic, and they report satisfactory results. Dr. Gerhard believes " the best local applications are the nitrate of silver, if the glough be small in extent ; if much larger, the best escharotic is the muriated tincture of iron, applied in the undiluted state. After the progress of the disease is arrested, the TREATMENT. 545 ulcer will improve rapidly under an astringent stimulant, siicli as the tincture of myrrh, or the aromatic wine of the French Phar- macopceia." The local treatment recommended by Evanson and Maunsell I believe to be preferable to that advised by any of the writers from whom I have quoted. I have seen it so successful, that I should employ it in all ordinary cases from the first visit. A knowledge of this treatment will be best imparted by quoting from the authors (Diseases of Children, 2d Amer. edit., page 188): "The lotion which we have found by far the most successful is a solu- tion of sulphate of copper as employed by Coates in the Children's Asylum. His formula is as follows: — "^. Cupri sulph. 3ij ; Pulv. cinchonae ^ss ; Aquae ^iv. M. "This is to be applied twice a day very carefullj^ to the full extent of the ulcerations and excoriations. The addition of the cinchonae is only useful by retaining the sulphate of copper longer in contact with the edges of the gums. A solution of the sulphate of zinc, 5j to an ounce of water, by itself or combined with tinc- ture of myrrh, Dr. Coates found to be also useful in some cases." A moment's reflection will show us that the above treatment is far preferable, provided it is equally efiectual in arresting the gan- grene, to the treatment by the strong escharotics which some of our best practitioners employ. Take, for example, the use of pure nitric or muriatic acid, which physicians of experience recommend. This agent causes such pain that it occasions restlessness of the child, and such stout resistance that the use of chloroform has been recommended to facilitate its application. The j)ain occurring from it and from the inflamma- tion which it excites doubtless reduces the strength which it is very necessary to preserve. If the acid comes in contact with the teeth, as it generally will, it injures them irreparably, and it some- times attacks the jaw-bone. Dr. West, who advocates the use of the acid (Diseases of Infancy and Childhood, 4th Amer. edit., page 467), says : " In one of the cases that I saw recover, the arrest of the disease appeared to be entirely owing to this agent, though the alveolar processes of the left side of the lower jaw from the first molar tooth backwards died and exfoliated, apparently from having been destroyed by the acid." ISTo such result follows the use of the solution of sulphate of copper, and of its efficacy I can speak con- 35 5-i6 DENTITION. fidently. In one of those severe cases in which the disease resulted from scarlet fever, and in which there was so much debility that an unfavorable prognosis was made, I succeeded in arresting the disease by the use of Dr. Coates' prescription. The child recovered with the loss of two teeth, and the corresponding portion of the maxillary bone. The application should be made twice a day till the gangrene is arrested, and healthy granulations appear. The gases arising from the gangrenous mass are not only highly oftensive to others, but they are doubtless injurious to the patient, who is constantly inhaling them. To remove the fetor chlorine or carbolic acid properly diluted should be occasionally used between the applications of the sulphate of copper. Labarraque's solution, one part to eight or ten parts of water, is an eligible form for its use. When the gangrene is removed, and the granulations present a healthy appearance, all danger is usually past, and convalescence is fully established. Then no energetic topical treatment is re- quired. A mild stimulating lotion, like the tincture of myrrh, as recommended by Dr. Gerhard, suffices with the aid of tonics and nutritious diet. CHAPTER IV. DENTITION. The part which dentition bears in the causation of disease is not fully ascertained. We know that the opinion formerly enter- tained in the profession, and now prevalent in the community, that a large proportion of the affections of infancy arise directly or indirectly from it, is erroneous. Still, many of the best authorities in infantile pathology concur in the belief that difficult and pain- ful evolution of the teeth frequently causes derangement in the functions of organs, even those remote from the mouth, and some- times produces in them a real pathological state. They, therefore, frequently speak of dentition as a cause of disease. On the other hand, there are physicians equally good observers, and the number is increasing, who almost wholly ignore the pathological results of dentition. They say that, as it is strictly a physiological process, it should, like other such processes, be excluded from the domain of pathology. Experience, they assert, corroborates this opinion, DENTITION. 547 and therefore dentition should seldom, if ever, be interfered with by the lancet or other means. A moment's reflection will show how important it is to under- stand the exact relation of dentition to infantile diseases. Every physician is called now and then to cases of serious disease, in- flammatory and others, which have been allowed to run on with- out treatment, in the belief that the symptoms were the result of dentition. I have known acute meningitis, pneumonitis, and entero- colitis, even with medical attendance, to be overlooked during the very time when appropriate treatment was most urgently demanded. Many lives are lost in this manner, especially from neglected en- tero-colitis, the friends and even physicians believing the diarrhoea to be symptomatic of dentition, a relief to it, and therefore not to be treated. Such mistakes are traceable to the erroneous doctrine, long inculcated in the schools, that dentition is directly or indi- rectly the cause of a large proportion of infantile diseases and de- rangements. May there not be an error in the opposite direction? May not some diseases be rendered milder, and their favorable termination more certain or probable, by measures calculated to relieve the turgescence of the gums ? If so, those who totally disregard the state of the gums are not less in error than those who use the gum lancet when it is not required. I shall endeavor to point out what is really ascertained in regard to the relation of dentition to disease. First dentition commences at the age of about six months and terminates at the age of two and a half years. The corresponding teeth of the two sides pierce the gum at about the same time. The two inferior central incisors first appear at about the age of six or seven months, followed, in the order in which they are mentioned, by the upper central incisors, upper lateral incisors, lower lateral incisors, the four anterior molars, the four canines, and, lastly, the four posterior molars. The incisors usually appear in rapid succession, so that all are in sight by the age of one year. From the age of one year to six- teen months the anterior molars penetrate the gum, from the age of sixteen to twenty-four months the canines, and from twenty- four to thirty months the posterior molars. This order is not always preserved. Sometimes the upper cen- tral incisors appear before the lower, and sometimes the lower lateral before the upper lateral. In rare cases there have been teeth at birth. I have seen but one or two infants with such pre- 5i8 DENTITION. mature dentition. Retarded dentition is much more common. Those who have rickets, or are feeble either constitutionally or by disease, often have no teeth till considerably after the usual period. In such the first incisors may not appear till the age of twelve months, or even later. Pathological Results of Dentition. — The evolution of the teeth is commonly attended by more or less turgescence around the dental bulbs. This is greater with some of the teeth than with others. Thus, the superior incisors cause more swelling than do their congeners of the inferior jaw. The turgescence, although it may be attended by more or less congestion, is so common that it is hardly proper to call it a disease. Turgescence, with redness and more or less tenderness of the swollen gum, may be considered the simplest pathological state. In other cases there is an unusual amount of swelling around the dental follicles, the afflux of blood to them is greatly aug- mented ; they are the seat of such a degree of tenderness and pain that the infant is fretful. It carries the finger often to the mouth, indicating the seat of its suffering. The surface over the folli- cles presents greater redness than in ordinary dentition, and the salivary secretion is considerably increased. There is now actual gengivitis. Sometimes the inflammation affects a greater extent of the buccal surface than that lying directly over the follicles, so that most writers speak of stomatitis as one of the results of dentition. In a few cases I have known such a degree of inflammation over the advancing tooth, that a small abscess formed, producing much pain and restlessness, till it was opened by the lancet. The pathological results of dentition which I have mentioned are unimportant in comparison with others not yet alluded to. They do not endanger the life of the child. They are easily detected. They result directly from the rapid growth and aug- mented sensibility of the dental follicles. There are other accidents of dentition occurring in distant parts of the system in consequence of that mysterious relation and interdependence of organs which exist through the system of nerves. These accidents are more serious, and their relation to dentition is obviously less readily ascertained, than are those located in the mouth. The most common of them occur in the stomach and intestines. Some children, previously to the eruption of the teeth, are PATHOLOGICAL RESULTS OF DENTITION. 549 affected with di.arrhoca, occasionally accompanied by irritability of stomach. Certain writers have supposed that gastro-intestinal inflammation is present in these cases ; others that there is simply a hyper-secretion, an increased activity of the intestinal follicular apparatus, that it is, in other words, one of the forms of non- inflammatory diarrhrea. Barrier believes that the diarrhoea of dentition depends usually on what he calls a " subinflammatory turgescence limited to the gastro-intestinal follicular apparatus." He believes that, in occasional cases, it is due to defective or altered innervation. It would then be analogous or similar to that form of diarrhoea which occurs in the adult from the emotions. Bouchut calls the diarrhoea of dentition nervous diarrhoea. It is certain, however, that in most cases of diarrhoea which are attributed to dentition there are other causes, such as unsuitable food, or residence in an insalubrious locality. It is certain, as regards city infants, that the chief causes of diarrhoea during the period of dentition are strictly anti-hygienic, dentition being quite subordi- nate as a cause, and probably often not operating at all as such. But when, as sometimes happens, at each period of dental evolu- tion, the infant is aflfected with diarrhoea, the influence of teething is apparent. Such cases enable us to see that teething may really sustain a causative relation to certain diseases not located in the buccal cavity. Among the most common pathological results of difficult den- tition, are certain aflfections referable to the cerebro-spinal system. Eclampsia is one of the admitted results. Barrier attributes con- vulsions in the teething infant to excitement of the nervous sj^stem arising from the pain which is felt in the gums, and to a determi- nation of blood to the dental apparatus, in which afflux the whole vascular system of the head participates. In most cases of convulsions occurring during the period of dental evolution, a careful examination discloses other causes in addition to the state of the gums. Difficult dentition must then be considered, not so frequently a direct as a co-operating or pre- disposing cause, producing a sensitive state of the nervous system, or possibly an afflux of blood to the head, of which Barrier speaks, and which, by an additional stimulus, perhaps trivial in itself, ends in convulsions. In exceptional instances eclampsia occurs mainly from dentition, or, if there are other causes, they are quite subordinate. This may happen when several teeth penetrate the gum at or about the same time. Infants who are burnt or scalded are very liable to clonic convulsions. This is, in fact, the chief 550 DENTITION. dano-er as res-ards life from such accidents. So, the swollen and tender gum, if several teeth are about emerging, may aifect the cerebro-spinal system like the burn or scald, and produce the same nervous phenomena. Thus, in a case already alluded to in the chapter on convulsions, five incisors pierced the gum within about two weeks, and in this period there were two attacks of eclampsia with an interval of a few days. The attacks were not severe, and the most careful examination could discover no other cause than the simultaneous development of so many dental follicles. Previously, and since, the infant has been well. Dentition sometimes, though rarely, occasions also tonic convul- sions. The following case occurred in the practice of Dr. A. S. Church, of this city, the history of which he has kindly commu- nicated, as follows : — "H., seven months old, was first visited April 3d, 1863. The patient had been fretful for several days, but about daylight on the morning of my first visit it commenced crying, and had not ceased for a moment at the time of my visit, 9 A.M. The bowels were somewhat constipated and tympanitic; abdominal muscles very tense. The pain was sup- posed to be in the abdomen, and a brisk catliartic, to be followed by an anodjaie, was ordered. Some relief followed, but, on the ensuing and for several consecutive mornings, the pain 'returned, each day lasting longer, until the child only ceased crying while under the in- fluence of a full anodj'ne. The gum over the upper incisors was con- siderably swollen, hot, and dry, but the parents would not consent to have it scarified. For the first week there was no fever, no vomiting, and not the least indication that the nervous system was suffering. About the 10th the thumbs were noticed to be flexed during the attack of pain, and about the 15th the flexors of the toes were contracted and the hands were turned backwards and outwards, but only while the child was awake. About the 20th there was constant contraction of the flexors of both extremities, with opisthotonos, and constant rolling of the head, loss of appetite, progressive emaciation, coated tongue, and highly in- flamed gums. Consent was, finally, obtained to relieve the inflamed gum, and free incisions were made, and the following night the child slept comfortably for three hours without opiates. In three days the gums were freely cut again, and the teeth soon made their appearance. AH symptoms of disease had now ceased, the child became playful, and on the 30th the patient was discharged." The opinion has been prevalent in the profession, that painful and difiicult dentition is one of the chief causes of infantile paralj^sis, but it is now commonly admitted that it is only a subordinate or remote cause if indeed it is proper to consider it as a cause at all (see Art. Paralysis). Some writers express the opinion that acute meningitis occa- sionally results from teething. The facts, however, that are relied DIAGNOSIS — TREATMENT. 551 upon to prove tliis arc iiiicertaiu. The occurrence of meningitis during dentition is probably in most instances a coincidence. Teething less frequently disturbs the respiratory system than either the digestive or cerebro-spinal. A cough occurs in some infants at each period of dental evolution. It is attended by little expectoration, but appears to be associated with, in at least cer- tain cases, an inflammatory turgescence of the bronchial mucous membrane. Acceleration of jmlse is often observed at the time of greatest swelling and tenderness of the gum. It subsides with the pro- trusion of the tooth. The febrile movement of dentition is ir- regular, sometimes presenting a remittent form, like remittent fever or the fever premonitory of meningitis. Eczema and certain other cutaneous diseases are common during dentition, but their dependence on it as a cause has not been demonstrated. Diagnosis. — The accidents of dentition which are located in the mouth are easily diagnosticated, except the odontalgia which writers describe, and which is not necessarily attended by any perceptible anatomical alteration of the gums. Those accidents which pertain to remote and concealed organs are usually detected with ease, though it is often difficult to determine with certainty their relation to dentition. When similar symptoms arise at each epoch of teething, and subside with the subsidence of the gengival turgescence, teething must be regarded as the cause. Or, if the disease is such as is known to be produced occasionally by difficult teething, and if, after a careful examination, we can discover no other cause, while the gums are swollen, especially over two or more advancing teeth, it is proper to refer the disease to dentition. It is evident that we must often be in doubt whether the disease which we are treating is due at all to the state of the gums, or, if so, whether directly or indirectly, or to what extent ; but, as a rule, if any other cause is apparent, we may properly regard the influ- ence of dentition as quite subordinate. Treatment. — It is obvious that remedial measures in cases of difficult dentition must be twofold, namely, those directed to the state of the gums, and those designed to relieve the derangements or diseases to which dentition has given rise. If there is diarrhoea, this should be controlled by proper remedies, so as to reduce the number of evacuations to two or three daily. It is well to state to the friends of the child, who believe that diarrhoea is salutary during the period of teething, that this number'is quite sufficient. 552 DENTITION. and that more frequent evacuations will endanger the safety of the child. The nervous affections, as convulsions, require such soothing and derivative measures as are recommended in our remarks on diseases of the nervous system. The bromide of potassium I have found especially useful and safe in cases of fretfulness and nervous excitement due to dentition. The rational employment of thera- peutic measures requires strict attention to be given to the causes of disease. Therefore, the physician called to treat an ailment, believed to be due to dentition, should not fail to examine the state of the gums, and adopt such measures as will mitigate the intensity of the cause — in other words, diminish the tenderness if not the swelling of the gum. Demulcent and soothing lotions are recommended by some. The infant should be allowed to hold in the mouth an India-rubber or ivory ring, which by pressure on the gum gives considerable relief. Mothers will often attempt to " rub through a tooth," as they term it, by means of a ring or thimble. This should be discour- aged. So great friction cannot fail to have an injurious effect, by increasing the swelling and inflammation, unless the tooth has already reached the mucous membrane. We come now to a subject which has engaged the attention of many of the ablest and most experienced physicians, and in refer- ence to which there is still a difference of opinion among the highest authorities in medicine. I refer to scarification of the gums. The gum lancet is now much less frequently employed than formerly. It is used more by the ignorant practitioner, who is deficient in the ability to diagnosticate obscure diseases, than by one of intelligence, who can discern more clearly the true patho- logical state. Its use is more frequent in some countries, as Eng- land, under the teaching of great names, than in others, as France, where the highest authorities, as Rilliet and Barthez, discounte- nance it. It is well to bear in mind, as aiding in the elucidation of this subject, the remark made by Trousseau, that the tooth is not re- leased by lancing the gum over the advancing crown. The gum is not rendered tense by pressure of the tooth, as many seem to think, for, if so, the incision would not remain linear, and the edges of the wound would not unite, as they ordinarily do by first inten- tion within a day or two. This speedy healing of the incision, unless the tooth is on the point of protruding, is an important fact, TREATMENT. 553 for it shows that the effect of the scariiication can only last one or two days. The early repair of the dental follicle is probably con- servative so far as the development of the tooth is concerned. It may help us to understand how active, how powerful, the process of absorption is, if we reflect that the roots of the deciduous teeth are more or less absorbed by the advancing second set, without much pain or suftering from the pressure. If the calcareous par- ticles of the teeth are so readily absorbed, what is the foundation for the belief that the fleshy substance of the gum is absorbed with such difliculty ? Too much importance has evidently been attached to the supposed tension and resistance of the gum in the process of dentition. Follicles in the period of development are especially liable to inflammation. We see this in the follicular stomatitis and enteri- tis, so common when the buccal and intestinal follicles are in the state of most rapid growth. Does not this law in reference to the follicles hold true of those by which the teeth are formed, so that the period of their enlargement and greatest activity, which corre- sponds with the growth and protrusion of the teeth, is also the period when they are most liable to congestion and inflammation ? This flict aifords a better explanation of the frequency of the so- called laborious or difficult dentition than that it is due to the resistance which dental evolution encounters from the gums. If there are no symptoms except such as occur directly from the swelling and congestion of the gum, the lancet should seldom be used. The pathological state of the gum which would, without doubt, require its use, is an abscess over the tooth. As to symp- toms which are general or referable to other organs, as fever and diarrhcea, the lancet should not be used if the symptoms can be controlled by other safe measures. All co-operating causes should first be removed, when in a large proportion of cases the patient will experience such reliSf that scarification can be deferred. If the state of the infant is such that life is in danger, as in convulsions, or there is danger that the infant will be permanently injured or disabled, as by paralysis, every measure which can possibly give relief should be employed without delay. In these dangerous nervous afl'ections, therefore, the gums if swollen should be lanced. I know no accidents of dentition which require prompt scarification except suppurative inflammation of the gums, convul- sions, and paralysis. In other cases the operation may be safely postponed till other measures have been employed. 55i DENTITION. Second Dentition. The fact is well established, though often overlooked in prac- tice, that second dentition occasionally deranges the functions of organs, and gives rise to pathological symptoms. Rilliet and Barthez mention particularly neuralgic pains, rebellious cough, and diarrhoea, as effects which they have observed. Rilliet re- lates the case of a girl eleven years old, who had a very obstinate and protracted cough, the paroxysms lasting often half an hour to an hour. This cough immediately and permanently disappeared when the molars pierced the gums. Dr. James Jackson, in his Letters to a Young Physician^ says: "I have seen persons between twenty and thirty years of age much affected by a ivisdom tooth not yet protruded, and distinctly relieved by cutting the gum. But I think the most common period of suffering from the second dentition is from the tenth to the thirteenth year. The most characteristic affections are wasting of flesh and nervous diseases. The boy loses his comeli- ness, and his complexion is less clear, while emaciation takes place in every part, though mostly, perhaps, in the face. The nervous symptoms are various, but the most common are a change in the temper and a loss of spirits. "With these there is some loss of strength. The patient is unwilling to engage in play, and soon becomes tired when he does do it. Among the distinct symptoms which are not uncommon, I may mention pain in the head and in the eyes. The headache is not commonly severe, but it is such as inclines the patient to keep still. The eyes are not only painful, but are often aft'ected with the morbid sensibility to which these organs are subject. I have known boys truly anxious to pursue their studies obliged to give them up on this account ; and these, not having the disposition to play, will of choice pass the day with their mothers, and increase their troubles by the want of air and exercise. Nervous affections of a more severe character are some- times manifested." Whether the symptoms which have been attributed to second dentition have always been due to this cause, is questionable. Practically, however, it matters little, whether we recognize dentition as the cause, or assign something else. Hygienic and medicinal measures to improve the general health will usually suffice to relieve the patient. I have known a boy, pallid and of nervous temperament, about seven years old, recover immediately from a cough which had lasted for several weeks, by taking three PHARYNGITIS — ANATOMICAL CHARACTERS. 555 times daily a mixture of iron and nitric acid. Many do well without medicine, simply by hygienic measures. Dr. Jackson says, " The remedies which I have found most useful are as follows : First, a relief from study or from regular tasks, yet using books so far as they afford agreeable occupation or amusement. Second, exercise in the open air, preferring the mode most agree- able to the patient, and in more grave cases the removal from town to country." CHAPTER V. SIMPLE PHARYNGITIS, PERI-PHARYNGEAL ABSCESS, OESOPHAGITIS. Children of all ages are liable to inflammation of the pharynx. In its mildest form it often, doubtless, escapes detection in the young infant. In older patients it is revealed by pain in swallow- ing solid food, and more or less tumefaction below the ears apparent to the sight. It is said to be less frequent in infancy than in childhood. In the adult, and in children over the age of four or five years, inflammation of the pharyngeal surface is often confined to the portion of membrane which covers or immediately surrounds the tonsils. It occurs in connection with inflammation of these glands. But in infancy and early childhood this limita- tion is comparatively rare. Inflammation of the throat at this age is ordinarily a general pharyngitis, the tonsils participating in the morbid state. Pharyngitis is primary or secondary. The secondary form occurs in measles, scarlet fever, bronchitis, croup, pneumonitis, and occasionally in other afifections. As these diseases are com- mon, physicians are oftener called to treat patients who have the secondary form than the primary. Rilliet and Barthez met eighty- three secondary to sixteen primary. Anatomical Characters. — The pathological anatomy of pha- ryngitis is ascertained by depressing the tongue and inspecting the fauces. The membrane lining the fauces is seen to be redder than in health, and presenting a more or less swollen appearance, according to the intensity of the inflammation. In idiopathic pharyngitis, the fauces commonly have a bright red hue, almost like that of arterial blood. If, on the other hand, the inflamma- 556 SIMPLE PHARYNGITIS. tion occurs in connection witli a constitutional afi'ection, the hue is apt to be darker. In grave cases of scarlet fever or measles, it IS sometimes even livid, indicating a vitiated state of the blood, a condition of real danger. The tonsils are tumefied so as to pro- ject, though not to the extent which we often observe in the adult. They are also less firm than in the normal state. The follicles of the throat are enlarged and active, pouring out a muco-purulent secretion. This is sometimes seen in a layer over the tonsil or the posterior portion of the fauces. In a case of primary pharyngitis examined after death by Rilliet and Barthcz, the tonsils were softened, infiltrated with pus, and sliglitly enlarged. A layer of bloody mucus lay on the pharynx, and the pharyngeal surface was dark red, thickened and granular. The submaxillary glands were also swollen and somewhat softened. If the inflammation is intense, the deep-seated portion of the tonsil becomes involved, and even sometimes the adjacent con- nective tissue. In most cases, by applying the finger in the hollow below the ears, the tonsil can be felt. In severe cases, also, the submaxillary glands are tumefied. Causes. — The usual cause of primary or idiopathic pharyngitis is exposure to cold. It also occasionally occurs from the use of drinks too hot or containing some irritating substance. I have met it in the most intense form caused by swallowing boiling water, and, in one case, from acetic acid taken through mistake. When it occurs from the eruptive fevers, it is part of a more extensive mucous phlegmasia, although the inflammation is often, as in scarlet fever, more intense in the pharynx than elsewhere. Symptoms. — Tenderness of the pharynx, and pain on swallowing, announce pharyngitis. These symptoms are not so readily detected in infancy as in childhood. They are not always proportionate to the intensity of the inflammation. The tongue is slightly furred ; there is thirst, and the appetite is more or less impaired. The breath is foul, but not fetid; the respiration is normal, or but slightly accelerated ; cough is sometimes present, sometimes absent. When present, it is due to extension of inflammation to the upper part of the larynx, or to the collection of mucus around the aper- ture of the glottis. When the tonsils are considerably enlarged, and the adjacent parts much swollen, the voice is sometimes much altered, present- ing a nasal character. The pulse in pharyngitis is accelerated, and the temperature of the surface elevated according to the severity of the inflammation. PROGNOSIS — DIAGNOSIS — TREATMENT. 557 Prognosis. — In mild cases of pharyngitis convalescence com- mences within a Aveek. If the inflammation is dependent on a constitutional affection, it may continue a much longer time, especially if the glands of the neck and the connective tissue are much involved. The prognosis of secondary pharyngitis is less favorable than that of the primary form. In fatal cases there is usually a vitiated state of the blood, either from the coexisting constitutional disease, or from previous cachexia. The younger the child, also, the less favorable the prognosis. Pharyngitis may, however, become dangerous from complica- tions to which it gives rise. The proximity of the inflammation to the brain, or its eflfect upon the cerebro-spinal axis through the medium of the nerves, sometimes gives rise to clonic convulsions. In a recent case of primary pharyngitis in my practice, repeated and violent convulsions occurred in an infant, about one year old, from this cause. They commenced at the inception of the inflam- mation, and constituted the only real danger. Pharyngitis may interfere materially with nutrition in consequence of the dysj)ha- gia, but in most cases of primary pharyngitis this symptom does not continue sufliciently long to endanger the life of the patient. In grave constitutional aftections, as scarlet fever, the difiiculty of swallowing, and the consequent innutrition, augment the danger. As regards, therefore, the prognosis in simple pharyngitis, whether primary or secondary, it may be stated as a rule, that it is not, jper se, a fatal disease, but is only so from complications, or from aggravating the primary affection with which it is associated. Diagnosis. — This is never difiicult provided attention is directed to the throat ; but the physician often fails to discover it at his first visit, from neglecting to examine this part. In many cases the local symptoms are not well-marked, and in the absence of these the febrile reaction may at first be referred to some other cause than the true one. Inspection not only reveals the presence of inflammation, but enables us to determine whether it is simple pharyngitis, or diphtheritic, or ulcerative. In some instances, simple pharyngitis resembles diphtheritic, from the presence of confervoid growths upon the inflamed surface, usually the lepothrix buccalis. The differential diagnosis is based on the easy removal and soft pultaceous character of the confervee, and the appearance under the microscope. Treatment. — Mild cases of simple pharyngitis require little treatment. With moderate counter-irritation over the throat, and the use of laxative medicines, the inflammation soon subsides. 558 SIMPLE PHARYNGITIS. The linimentum camphorse may be occasionally rubbed over the throat, and retained upon it by flannel. The effect is increased by the application, once or twice daily, of mustard or tincture of iodine, or by adding to the liniment a little volatile liniment or turpentine. Mucilaginous and refrigerant drinks, with a light diet, suffice to complete the cure. In the severe form of idiopathic pharyngitis more active mea- sures are required. The bowels should be freely opened, warm mustard pediluvia occasionally employed, and the head be kept cool. If the patient is robust, as in the first stages of the disease, and there is threatening of cerebral complication, it is proper to apply one or more leeches to the temples or neck ; but cases re- quiring such depletion are exceptional. Diaphoretics and sometimes cardiac sedatives are indicated, such as liquor ammonise acetati's, spiritus fetheris nitrosi, ipecacuanha, tartrate of antimony and potassa, aconite, and veratrum viride. Medicines of this kind may be variously combined according to the age and condition of the patient, and the severity of the dis- ease. Saline laxatives are also in some cases useful. As the symptoms abate, the intervals between the doses may be increased. In those cases of severe idiopathic pharyngitis attended by pain in deglutition, moderate but constant counter-irritation should be employed over the seat of inflammation. An excellent application, and one much used in families, is a slice of fat salt pork, cut as thin as possible, stitched on a single thickness of muslin, and applied from ear to ear. It is better, usually, to sprinkle more salt upon it, and sometimes powdered camphor. In cases of much tenderness and dysphagia great relief is often obtained by emollient poultices applied over the throat. Mustard or iodine may also be occasionally employed in addition if there is not already sufficient counter-irritation. Topical treatment of the pharynx is recommended by most authors. Rilliet and Barthez use for this purpose nitrate of silver or powdered alum. The former has been most employed by phy- sicians. It may be applied in the proportion of ten grains to the ounce, two or three times daily. I have commonly prescribed the liquor ferri subsulphatis mixed with three or four times its quantity of glycerine, for application to the inflamed part, and with a good result. Gargles, which we so often prescribe in the pharyngitis of adults, cannot be satisfactorily employed in infancy and early childhood. PERI-PnARYNGEAL ABSCESS. 559 The treatment of secondary pharyngitis will be described in connection with the treatment of the diseases which it complicates. Suffice it here to say that this form of inflammation must not be treated by those depressing remedies which are useful in certain cases of idiopathic pharyngitis. Pseudo-membranous pharyngitis, or diphtheria, being a constitu- tional disease, has been described elsewhere. Peri-Pharyngeal Abscess. Every practitioner should bear in mind the fact that an abscess occasionally forms between the pharynx and vertebral column (retro-pharyngeal), or upon the sides of the pharynx in the sub- mucous connective tissue. This constitutes a disease which is apt to be fatal, but which can ordinarily be promptly relieved by the surgeon. Yet, if we look over the records of peri-pharyngeal abscess, we shall see that in a large proportion of published cases, the disease was supposed to be something else, and so treated until its nature was revealed by post-mortem examination. The most complete monograph on this disease with which I am acquainted was pub- lished by Dr. Allin, of this city, in the N. Y. Journ. of Meek for 'Nov. 1851, under the title of retro-pharyngeal abscess. To this paper I am largely indebted for facts. Age — Cause. — This disease may occur at any age ; but it is most common in infancy and childhood. It is more frequent in the first year of life than at any other period. Of the cases collated by Dr. Allin, in which the age is stated, twenty were under ten years, while the number for all other ages was twenty-one. This disease arises in some patients from caries of the vertebral column, and, in others, from inflammation commencing with the mucous membrane of the pharynx, and extending to the submucous con- nective tissue. Whichever the cause, there is usually a scrofulous or reduced state of system. Writers describe two kinds of peri-pharyngeal abscess, the pri- mary and secondary. This distinction is based on the fact, whether or not the inflammation which leads to the abscess is de- pendent on an antecedent pathological state. In the primary form the cause is usually atmospheric, or it is some irritating substance which has been swallowed, and which, lodging in the pharnyx, produces pharyngitis. The cause is mentioned in twenty cases of the primary form, 560 PEKI-PHARYNGEAL ABSCESS. collated by Dr. Allin, as follows: exposure to cold, ten cases; lodgement of bone in pharynx, eight cases ; blow with a fencing foil, one case. In the last case, the button of a fencing foil passed through the right nostril into the pharynx. The secondary form occasionally occurs after measles and scarlet fever. The inflammation of the pharynx, common in those dis- eases, extends to the subjacent connective tissue, and, aided by the dyscrasia of the patient, becomes suppurative. Such cases have been observed by Rilliet and Barthez. The most common cause of the secondary form is, however, caries of the vertebral column. When thus occurring it is similar, both as regards cause and nature, to lumbar abscess. It would follow the same chronic course, and would properly be described in connection with it, were it not for its proximity to the air passages, which renders the disease so rapid and fatal. In a few recorded cases the abscess has been a sequel of erysipelas. It is believed by some that when it thus occurs there is retrocession of the erysipelatous eruption. In nineteen cases of secondary abscess in Dr. Allin's collection, the cause is assigned as follows : erysipelas of face, two ; inflamma- tion following a fall upon the inferior maxilla, one ; after cerebri- tis, one ; syphilis, four ; caries of the cervical vertebra, six ; scrofula, five; The proximate cause of peri-pharyngeal abscess is believed by Mr. Fleming {Dublin Journ. of lied. Sci. vol. xvii.) to be in some instances inflammation of small lymphatic glands lying in the con- nective tissue external to the pharynx. After remarking that two cases which he reports lend confirmation to this view, he con- tinues : " That those glands are only occasionally found in this situation, I admit, and hence, probably, the rare occurrence of this particular form of disease, but that they exist more frequently than is generally imagined, I am equally certain." Prof. Geo. T. Elliot relates a case {Obstet. Clinic, N. F., Appleton & Co., 1868) in which peri-pharyngeal abscess immediately followed and was appa- rently due to parotiditis. The patient was a boy seven months old. In rare instances the abscess, or the local disease which leads to it, appears to exist from birth. Thus, Dr. E. 0. Ilocken relates, in the Prov. Med. and Surg. Journ., 1842, the history of an infant who died at the age of nine weeks. It had always, when taking the breast, thrown back its head as if nearly suffocated. The walls of the abscess were thick and firm, described by the writer ANATOMICAL CHARACTERS — SYMPTOMS. 501 as cartilaginous. Occasionally there is no apparent cause of the abscess. We must then attribute it to some unknown dyscrasia. Anatomical Characters. — The seat of the abscess is not the same in all cases. The swelling can ordinarily be seen on exami- ning the fauces, but occasionally it is so low as to be really peri- ocsophageal, and therefore invisible. The size of the abscess varies ; sometimes it is large, pressing inward the wall of the pharynx even against the velum palati and into the posterior nares, if the abscess have a high location, or, if lower, against the larynx, so as to embarrass respiration. Sometimes the abscess is so large or has such lateral extension that there is external swelling along the side of the neck. In a few cases on record the pus, instead of being discharged into the pharynx, made its way down the neck between the muscles and the connective tissue to the pleural cavity, which it entered, producing fatal pleuritis. The walls of the abscess have been found in a different state in different cases. Sometimes the sac, at the projecting point, is so thin that it seems as if there might have been a spontaneous cure, could life have been preserved a few hours longer. In other cases the sac is so thick and firm that its rupture, for many days, would be impossible. Symptoms. — The precursory symptoms differ in different cases, according to the nature of the cause, whether it be pharyngitis, glandular inflammation, or vertebral caries. If the abscess proceed from caries, it is preceded by deep-seated and protracted pain, greatly increased by movements of the head. The patient with this disease is restless, his mouth hot and dry ; tongue furred; deglutition more or less diflicult. Sometimes after suppuration has occurred there are alternations of heat and chills. The -symptoms indicate approximately the seat of the inflamma- tion, but on examination we do not find that des-ree of redness 7 Cj and swelling of the mucous surface which we had been led to expect. The tissues which are chiefly involved in the inflamma- tion, being submucous, are hidden from view. We observe redness of the pharynx, but it is disproportionate to the intensity of the symptoms. Sometimes there is a sensation of chilliness through the entire period of the abscess, though greater at one time than at another, and occasionally convulsions occur, especially in young infants. In ordinary cases the embarrassment of respiration is one of the first and most conspicuous of the symptoms, and it is the cause of the chief dangeiv It becomes more and more marked as the abscess increases. It is noticed both during inspiration and 36 562 PERI-FHARYNGEAL ABSCESS. expiration. The dysphagia also increases, sometimes to such a degree that drinks are taken with difficulty, and solid food refused. The respiratory symptoms bear considerable resemblance to those in protracted laryngitis, for which this disease has been mistaken. While the respiration becomes impeded or whistling, the voice is also feeble or indistinct, from the pressure of the tumor. But the symptoms described above are not all present in every case. They vary according to the size and location of the abscess, whether it be high or low, posterior or lateral. I have met the dis- ease in a child old enough to express its subjective symptoms, in whom there was little or no dysphagia, and others report similar cases. "When the tumor has attained such a size as to produce well- marked symptoms and jeopardize the life of the patient, it, or a part of it, can ordinarily be seen on depressing the tongue, but usually its location and condition can be better ascertained by exploration with the linger. The dyspnoea increases as the abscess enlarges, and, after a time, unless it bursts spontaneously or is opened by the surgeon, imperfect oxygenation of the blood results. In some patients paroxysms of dyspnoea occur, so as to threaten immediate suffocation; coughing or attempts to swallow induce these paroxysms, and the patient is forced to remain in an erect or semi-erect posture. The tongue is protruded, the head thrown back, the pulse is frequent and rapid, the limbs become livid and cool, and linally death occurs from apncea. Occasionall}^, when death seems inevitable, the abscess gives way by the struggles of the child, and the patient is restored to health. In rare cases the result is different. The trachea and bronchial tubes are deluged by the purulent discharge, and immediate suffocation occurs. The following was an example: In May, 1871, a boy two years and five months old was brought to the Clinic at Bellevue, who had had the symptoms of an abscess for three months. The head was carried one side, its rotation caused pain, and a laryngeal rule accompanied respiration. The uj)per part of the tumor could be detected by the finger, but, on account of its low location, it was imix)ssible to open it with the bistoury. The temperature was 103°, pulse 156. The case was kept under observation, but in a few days the dyspnoea suddenly became so urgent that death was imminent, when the attending physician of the class, Dr. Swezey, broke the abscess with his finger, and pus was ejected on the floor; death, however, occurred almost immediately. A correct appreciation of the symptoms and the nature of peri- pharyngeal abscess will be best obtained by relating a case. I SYMPTOMS. 563 select the following from the Transactions of the London Patholor/ical Society, October 20th, 184G:— A female infiint died at the age of seven months, having had difficult breathing three weeks, and extreme dyspnoea during the last days of life. The dyspnoea was constant, and was aggravated by mental excitement, by movements of the body, and by exposure to cold. During the paroxj'sms, a peculiar, croupy sound accom- panied inspiration. There was no dysphagia through the entire sickness, and death occurred from apncea. The sac of the abscess was of the size of a pigeon's egg, and was situated between the upper cervical vertebrte and the back of the pharynx. The abscess was flattened in front, so as not to cause any material prominence of the wall of the pharynx. From the sac a second small cyst extended forward, forming a nipple- like swelling in the pharynx, which completely closed the orifice of the glottis. Its aperture of communication with the body of the abscess admitted the point of the little finger, and the whole swelling was freely movable and perfectly translucent at its ex- tremities and sides. The abscess might have been easily punctured, with probably the preservation of life. The duration of this disease is very different, according to the severity of the inflammation, the rapidity with which the abscess enlarges, and the direction which it points. A lateral or down- ward extension is not so immediately dangerous to life as the anterior. The time when the abscess begins to form cannot be precisely ascertained, and most writers, in determining the duration of the disease, compute from the first appearance of symptoms which are referable to the pharynx. Dr. J. Bryne relates, in the Amer. Journ. of Med. Sci., 1838, a fatal case in which the disease had apparently continued only about one week. The patient was an infant one year old, and died of apnoea. The abscess was large, extending from the base of the skull to the thorax, and pressing both on the larynx and trachea. M. Besserer [Archiv. Gen. de 3Ied., 1840) gives the history of an infant four months old, who died in the same way after thirteen days. An infant nine months old, whose case was published by Dr. W. C. "Worthington, in the Prov. Med. and Surg. Journ., 1842, lived nine days. The abscess occurred from exposure to cold ; the patient was treated for croup, and died from suffocation. The anterior wall of the abscess was very thin. Since the first edition of this book was published, I have met three patients with this disease in whom the pus was 564: PERI-PHARYNGEAL ABSCESS. evacuated when the dyspnoea had become urgent. In two the symptoms indicated a continuance of the disease from two to tour weeks, and in the third case four months. When the abscess grows slowly, and presses lightly on the air- passages, the case may continue for months. Such a one was observed by Prof. Willard Parker (Allin). This infant was one year old ; it suffered from pharyngeal symptoms nine months, was treated for tonsillitis, and death occurred as usual from apnoea. The abscess was two inches long, and there was no disease of the vertebrae. The same, surgeon saved the life of another patient four years old, in whom the disease was chronic, by puncturing the abscess; and Prof. Post, of this city, also treated successfully a case which had continued three months. (Allin.) Diagnosis. — The diagnosis of this disease is ordinarily not difficult, provided the physician examine carefully and bear in mind the occasional occurrence of such an abscess. In a large proportion, however, of the recorded fatal cases, the true nature of the disease was not recognized during life. Especially is the diagnosis difficult when the cerebro-sj^inal system is early impli- cated, and symptoms arise which divert attention from the throat to the brain. The diseases with which peri-pharyngeal abscess is most fre- quently confounded are laryngitis and simple but severe pharyn- gitis. From laryngitis, for which it has been most frequently mistaken, it may be distinguished by the dysphagia and by the character of the initial symptoms. In laryngitis there is usually the peculiar cough from the first or very early, while in abscess there is a period of several days or even weeks before respiration is materially affected. In abscess pressure of the larynx backward is badly tolerated, greatly increasing the dyspnoea, while in pharyngitis and croup this effect is not so marked. In abscess the horizontal position aggravates the dyspnoea, but not in pharyngitis and croup. The character of the voice will also aid in diao-nosticatino; abscess from laryngitis, since in the former it is apt to be nasal, and in the latter hoarse or whispering. The decisive test is afforded by inspection and digital exploration. The tumor is seen, or, if situated too low to be seen, is felt, upon the walls of the pharynx. If the symptoms of abscess are masked by those arising from the cerebro-spinal system, as by convulsions, the priority of the pharyngeal symptoms will serve to aid in determining the true disease. PROGNOSIS — TREATMENT. 565 In a case of suspected abscess the physician should not only carefully inspect the fauces, but should employ digital examination. The finger will sometimes detect fluctuation when no evidence of an abscess is presented to the eye. Two cases observed by Prof. Elliot {Obstet. Clinic, p. 420) were examples in point. Prognosis. — '"With proper treatment the result is usually favora- ble, but, if the disease is not recognized, the majority die. In Dr. Allin's cases, of those under the age of twelve years nine died, while ten recovered by the opening of the abscess by the lancet, trocar, or finger, and one by its spontaneous rupture. If the abscess is due to disease of the spinal column, death may occur immediately after the sac is opened, the caries of the inter- vertebral cartilages producing, according to Dr. Allin, dislocation of the vertebrffi. Death may also occur, though rarely, from pleu- ritis, in consequence of the bursting of the abscess into the pleural cavity. Even in caries, if the sac is properly opened, and if need be reopened, recovery is possible, as in a case treated by Prof. Post. Treatment. — The proper treatment of peri-pharyngeal abscess is simple, consisting in breaking or puncturing the sac by the fin- ger, the lancet, bistoury, or pharyngotome. Each method has been successfull}'" employed. In the majority of cases the proper way to open the abscess is by the ordinary curved scalpel or bis- toury, which should be covered by a strip of adhesive plaster to within a half inch of the point. If the abscess is post-pharyngeal, it should be opened in the median line. A single incision suflices to evacuate the pus. If the abscess points or is elastic, there is little danger of wounding any important vessel or producing dan- gerous hemorrhage if the operation is properly performed. It may be necessary to open the abscess more than once, as in a case re- ported by Dr. Post, and another which I saw with Dr. Livingston of this city. In certain cases, w^hen the knife can not be readily employed, the abscess may be opened by pressure with the finger nail or the edge of a teaspoon. Patients with this disease ordinarily require constitutional treat- ment, especially the use of tonics, ferruginous and vegetable. The citrate of iron and quinine, the citrate of iron and ammonia, and in strumous cases the syrup of the iodide of iron with cod-liver oil, are eligible preparations. Nutritious diet and often alcoholic stimulants are required. 566 (ESOFHAGITIS. Qjsophagitis. Disease of the cesopliagus in infancy and childhood is compara- tively rare, inflammation being the most frequent affection of this portion of the digestive tube in these periods, and, indeed, the only one which claims attention. It is most common in infants under the age of three or four months, who are deprived of the breast milk, and are given a diet which is with difficulty digested, and perhaps taken too hot or too cold. It is, therefore, most frequent in foundling hospitals. I have frequently observed it in the In- fant's Hospital, and the ISTursery and Child's Hospital, of this city, chiefly at the autopsies of bottle-fed infants, under the age of six months, whose symptoms had indicated disease or derangement of the digestive function. Many of them had diarrhoea, and died in a state of emaciation. CEsophagitis in these cases was associated with simple or gangrenous stomatitis, thrush, or with gastritis or entero-colitis. Sometimes all these inflammations coexisted. In a few cases the confervoid growth of thrush had extended from the mouth to the oesophagus. It occurred in small hemispherical masses, scarcely as large as a pin's head. Swallowing corrosive or strongly irritating substances, as the acids or alkalies, is an occa- sional cause of oesophagitis, the irritant at the same time producing stomatitis and gastritis. Anatomical Characters. — The inflamed surface sometimes presents a uniformly injected appearance. Usually, however, there is greater intensity of inflammation in streaks or patches than over the surface generally. I have frequently observed at autopsies a greater degree of inflammation in the lower than upper half of the oesophagus, even when the infant had stomatitis at the time of death. CEsophagitis occurring from faulty regimen or anti-hygienic con- ditions is not accompanied by as much thickening of the walls of the tube as often occurs in some other portions of the digestive canal, as, for example, in the colon. In diphtheritic inflammation of the oesophagus there are more submucous infiltration and thick- ening of the nmcous membrane than in simple oesophagitis. Occasionally ulcerations of the oesophageal mucous membrane are observed in the lower part of the tube, and Billard describes the ulcerative form of oesophagitis. At the first autopsies at which I observed these ulcers, I supposed that they were pathological, and indicated a severe grade of inflammation ; but a more extended observation has convinced me that they are usually post-mortem. INDIGESTION. 567 and are not at all dependent on inflammation of the ocsopliagus. The solvent power of the gastric juice not only causes ulceration in the stomach, but entering the oesophagus may and not infre- quently does produce a solvent action on the mucous tissue there. At the meeting of the London Pathological Society, March 4th, 1852, Dr. Graily Hewitt presented a specimen in wliich the gastric juice had not only eaten entirely through the coats of tlie oesopha- gus an inch above the stomach, but had even attacked the left lung. Over the age of six months inflammation of the oesophagus is rare. The symptoms of oesophagitis, in those young and emaciated infants in whom it ordinarily occurs, are not well pronounced. If they have pain in deglutition, or tenderness on pressure over the oesophagus, it is not apparent. ISTor have they seemed to me to vomit oftener than other infants of this class suffering from indi- gestion and gastro-enteritis, without oesophagitis. It is, therefore, difficult to diagnosticate oesophagitis. It is, according to my observation, oftener present than absent in spoon-fed infants of three months or under who have persistent stomatitis and entero- colitis. Treatment. — In the oesophagitis of foundlings and ill-nourished infants, which arises, as has been stated, from faulty regimen, no treatment is required apart from that designed to relieve the stomatitis or entero-colitis with which it exists. Attention must be directed mainly to the diet and hygienic management. The remedial measures are more fully detailed in our remarks on entero- colitis. CEsophagitis produced by swallowing corrosive or highly irritating substances requires the same treatment as in the adult, namely, poultices, demulcent drinks, perhaps leeches, etc. CHAPTER VI. INDIGESTION, CONGESTION OF STOMACH, GASTRITIS, FOLLICU- LAR GASTRITIS, DIPHTHERITIC GASTRITIS, POST-MORTEM DI- GESTION, SOFTENING. Indigestion is much more common during infancy than in any other period of life. While the digestive organs in the adult easily assimilate a great variety of food, it is necessary for the well-being of the infant that its diet be simple and carefully pre- 568 INDIGESTION. pared. Departure from this rule leads to indigestion and ulterior diseases. After the age of two years a mixed diet is readily assimilated, the digestive function less frequently disordered, and indigestion presents few peculiarities to distinguish it from that of the adult. Indigestion in some children is habitual; in others the digestive process is ordinarily well performed, but, from some temporary derangement of system or error of diet, an acute attack of indiges- tion occurs. Hence, two forms of this ailment may be described : first, acute, referring to temporary attacks; secondly, chronic, referrinij to the habitual state. Causes. — The causes of indigestion are twofold: first, the con- condition of the digestive function independently of the aliment ; secondly, the unwholesome or improper character of the ingesta. Anything which lowers the vital powers may be a predisposing cause of indigestion, by impairing the functions of some of the organs which assimilate the food. Impure air and personal uncleanliness, protracted hot weather, and previous disease, are among the common predisposing causes. The strong country child can thrive upon a diet which, given to the more feeble child of the city, would produce deleterious results. During the sum- mer months it often happens that an infant in the city cannot digest properly any food given to it except the mother's milk; and from this results much of the infantile sickness and mortality which make this season of the year so much dreaded by parents. There is a natural difference in children, as regards liability to disordered digestion. Some do well upon a diet which given to others similarly situated occasions vomiting, gastralgia, and flatu- lence. In the majority of cases of indigestion, however, the fault does not exist in the child. It is fed too often or irregularly, or upon a diet that is unwholesome or indigestible. It is well known that the milk of the mother or the wet-nurse is liable to changes which render it for the time unsuitable for the infant. Her food may be of such a quality, or her mind so excited, or some func- tion of her system so disordered, as to effect a temporary change in the constitution of the milk. The occurrence of the catamenia, or of gestation, in mothers who are suckling, not infrequently pro- duces this unfavorable result. Indigestion is most common in those infants who, deprived of the mother's milk, are intrusted to wet-nurses, or fed from the bottle. The milk of the wet-nurse, from not agreeing with the SYMPTOMS. 5t)9 age of the infant, from irregularity in her mode of life, from the acescent nature of her food, or from other causes which are not appreciable, may disagree with the infant, and be imperfectly digested. The most common cause of indigestion in the infant is artifi(^ial feeding. This, in the cities, is productive of a great amount of gastric and intestinal derangement and disease. The younger the infant, the less likely is it to thrive if brought up by hand. Whatever care may be bestowed in the preparation of its food, whether cow's or goat's milk or farinaceous substances be used, there is seldom that healthy nutrition which is observed in infants who receive the natural aliment. The "swill milk" in common use among the poor families of this city is totally unfit for children of any age, and is apt to produce flatulence, acidity, and indiges- tion. Acute indigestion occurs in children of any age from food unsuitable in quality or quantity, which produces gastralgia and other symptoms to be detailed hereafter. Those who suffer habitually from mal-assimilation are especially liable to such acute attacks. In the period of childhood, chronic indigestion is much less frequent than in infancy, but children are, perhaps, more subject than infants to the acute form. This is induced by ingesta taken in too large quantity, or of a kind which is with difiiculty digested. Cherries, currants, raisins, the parenchyma of oranges and lemons, dried fruits and confectionery, Avhich are so often heedlessly given to children, are common causes of acute attacks of indigestion. These substances, being but partially digested or not at all, and sometimes accumulating for days in the stomach or intestines, may lead to a very serious and dangerous condition. Symptoms. — The nursing infant, if the milk continually disagree with it, is fretful. It has a discontented aspect. It seldom §miles, and is not amused by playthings, or is only amused for a short time. Its features are pallid, and bear the appearance of faulty nutrition. Its body and limbs are more or less wasted, or are soft and flabby. Vomiting is frequently present, and sometimes a large mass or masses of caseum are ejected, which have evidently lain a considerable time in the stomach. The bowels may be constipated or loose, and the evacuations are unhealthy. This state of the infant continuing prevents the necessary rest of the mother, and may aflect unfavorably her health, so as to reduce the quantity of her milk, or render it still more unwholesome. In addition to the habitual indigestion, these infants sometimes 570 INDIGESTION. have acute attacks, similar to the acute dyspepsia of adults, and which have been described by writers as gastralgia or enteralgia. Their countenance indicates suffering; they utter sharp cries, and their thighs are drawn over the abdomen, indicating the seat of the suffering. Flatulence is common. By vomiting or an evacu- ation from the bowels, the offending substance is removed, and the pain subsides. Indigestion in the spoon-fed infant is similar to that in the in- fant who nurses, except that it is ordinarily accompanied by symptoms of greater gravity and persistence, and there is in the spoon-fed more liability to the acute attacks. In those who have advanced beyond the age of infancy, chronic indigestion is less frequent than in infants, but as the diet of such children is prepared with less care, and is less restricted, they are very liable to attacks of temporary indigestion. These come on suddenly, and sometimes are so severe as to endanger life. The child, previously well, is suddenly seized with languor; the pulse becomes accelerated, the face flushed, and surface hot. Drowsiness compels him to seek the bed, where he lies with his eyes shut. He sometimes has headache, and a sensation of oppres- sion in the epigastrium. The nervous system is not unfrequeutly affected, as shown by tenderness of a neuralgic character of the body and limbs, sudden twitching of the limbs premonitory of con- vulsions, and occasionally severe and repeated convulsions. These alarming and really dangerous symptoms speedily subside on the removal of the cause. One of the most severe attacks of eclamp- sia which I have seen occurred in a boy eight or ten years old, induced by swallowing the parenchymatous portions of oranges which he had been in the habit of eating, and which had accumu- lated in the stomach and intestines. The expulsion of the offend- ins: substance gave immediate relief. Sometimes, but not often, the symptoms of acute indigestion closely resemble those of pneumonitis. For example, an infant, whom I once treated, was seized at night with fever, hurried respiration, and the expiratory moan, which some writers consider pathognomonic of pneumonitis or pleuritis. These symptoms sub- sided when the bowels were freely opened, and currants, which had been eaten the previous day, were expelled. As the child advances in years and its general health improves, the digestive function is less frequently disturbed. After the age of three or four years the disease which we are considering becomes PROGNOSIS — TREATMENT, 571 one of much loss frequency and importance than in infancy and early chihlhood. Indigestion leads to some of the most common and serious affec- tions of early life. In the infant, if it continue a considerable time, inflammation of the buccal, oesophageal, or gastric mucous mem- brane, or of some part of the intestinal tract, ordinarily occurs. In the young infant thrush soon makes its appearance, and, whatever the age, the cachexia which results from continued indigestion in- creases the liability to organic affections. Eclampsia is the most serious, and at the same time a frequent, result of temporary or acute indigestion. Prognosis. — In simple indigestion this is good. It is doubtful 01' unfavorable when ulterior diseases occur, and in proportion to their gravity. Treatment. — The first indication in treatment is obviously the removal of the cause. In acute indigestion, when there is reason to believe that there is some offending substance in the stomach or intestines, if the symptoms occur soon after the substance is taken, an emetic may be administered, and ipecacuanha, in syrup or powder, is safe and usually efficient. If several hours have elapsed, a purgative should be given, as castor oil, or calomel, either alone or in combination with syrup of rhubarb. If the symptoms are urgent, especially if convulsions are threat- ened, we should not wait for the slow action of a purgative, but should resort to enemata to open the bowels. Sometimes the pain in acute indigestion is such as to require the use of opiates. In the infant there is often an excess of acid in the stomach and in- testines, which is best treated by alkaline remedies, as lime-water in combination with the opiate. The following mixture will be found useful in such cases : — R. Tinct. Dpii, or liq. opii compos, gtt. xij ; Magnes. calcinat. gr. xij ; Saccli. alb. gij ; Aq. anisi giss. Misce. Dose, the bottle being first shaken, one teaspoonful from two to four hours to a child a year old. If there is much pain, it is well to add a little chloroform or Hoffman's anodyne to the mixture. If in the acute indigestion of infants there is diarrhoea, the cam- phorated tincture of opium in combination with chalk mixture should be given instead of the above, fifteen drops of the one to a teaspoonful of the other. Infants whose diet properly consists largely of milk, digest with most difficulty the caseum, which is 572 INDIGESTION. apt to pass the bowels in an imperfectly digested state, or to collect in a large and firm mass in the stomach, causing gastralgia and renderino; the child fretful till it is vomited. I have elsewhere re- commended as important to prevent these attacks of acute dys- pepsia, the use of the upper third of the milk, which contains less than the average caseum, and the addition of an alkali to the milk, which retards the coagulation till it begins to be acted upon by the gastric juice, and tends to prevent the formation of large and firm caseous coasrula in the stomach. In chronic indigestion the means of relief are different. They are twofold : first, as regards change of diet ; secondly, measures to improve the digestive function. Spoon-fed infants, sufliering from habitual indigestion, require the utmost care as regards the character of their food, its preparation, and the times of feeding. Often it is best, if practicable, to procure a wet-nurse, and some- times removal to a more salubrious locality is followed at once by improvement in the digestive function. If the infant is already wet-nursed, the milk should be examined microscopically and otherwise, and inquiry should be instituted in reference to the health and diet of the wet-nurse. Sometimes a change of wet-nurse is advisable. For facts and considerations bearing on this point, the reader is referred to the chapters relating to regimen. Infants, as well as children, with chronic indigestion are occa- sionally much benefited by the moderate and judicious use of alcoholic stimulants. They should be given sparingly with their food, and should be discontinued as soon as the digestive function is fully restored. M. Donn^ and some other French writers recom- mend the habitual use of wine for infants even in a state of health, but there are reasons, moral as well as physical, why alcoholic stimulants should only be used as medicines, and never in a state of health. If the case is one of simple or uncomplicated indigestion, tonics, either the mineral or vegetable, may be employed. In many in- stances, however, especially in infancy, gastro-intestinal inflamma- tion has supervened, and in such cases those tonics should be em- ployed which exert a favorable, or, at least, not an unfavorable effect on the hypersemic and irritable surface over which they pass. When indigestion is simple, or accompanied by no serious com- plication, wine of iron, citrate of quinine and iron, and the elixir of calisaya bark, may be mentioned among the safe and efficient agents to improve the digestive function. The following is also a good formula for cases of simple indigestion: — TKEATMENT. 573 R. Ferri citrat. gr. xvj ; Bismuth, citrat. gr. xlviij ; A(iuai 5ij. Misce. Dose, one teaspoonful three or four limes daily to a cliild of two or three years. The ferruginous preparations are most efficacious in cases which are attended by signs of antcmia. Among the useful vegetable stomachics and tonics may be men- tioned the compound tincture of cinchona, compound tincture of gentian, infusion of columbo, fluid extract of columbo, and fluid extract of cinchona. If chronic indigestion is complicated with gastro-intestinal inflammation, subacute or chronic, for this is the form which is usually present, there are still certain tonics which may be advan- tageously administered. Columbo and the compound tincture of cinchona are often useful in these cases, and of the chalybeates wine of iron or the tincture ferri chloridi, in small doses, may be safely administered. But the remedy which I have found most serviceable, both as a tonic and for the inflammatory disease, is tincture of columbo in combination with the liquor ferri nitratis, given every four hours according to the formula contained in our remarks on the treatment of intestinal inflammation. I have not alluded to the use of pepsin as a remedial agent in indigestion. The theory of its employment in atonic states of the stomach is good, but physicians in this country have, in most in- stances, failed to observe that benefit from its use which they had been led to expect, and which seems to have followed its employ- ment in the practice of some of the European physicians. Perhaps the result would have been better had fresher and better prepara- tions of pepsin been prescribed. Boudault's pepsin from Paris has been most used in this country, but ordinarily I believe without appreciable benefit. I prescribed it in doses of two or three grains, several times daily, to foundlings from one to three months old in the Infant's Hospital, but the infants to whom it was given did not appear to do better than those from whom it was withheld. The American pepsin, prepared under the intelligent supervision of Dr. James S. Hawley, can be obtained in the shops in the form of a powder and wine. From its freshness and better taste it possesses advantages over the French preparations. Infants aflected with diarrhoea from indigestion I have often observed to improve under the use of powders consisting of equal parts of subnitrate of bismuth and the American pepsin, but the benefit was perhaps more due to the former than the latter agent. 574 CONGESTION OF THE STOMACH — GASTRITIS. An infant of three niontlis can take three grains of each every three hours, and one. of twelve months six or eight grains. Dyspepsia often rapidly disappears by hygienic measures with- out the use of medicines, as by removal from the city to the country, out-door exercise, or, if the patient is an infant, by being carried into the open air daily. In infants, also, marked improve- ment is often observed on the approach of the cool and bracing weather of autumn and winter. Congestion of the Stomach. Passive congestion of the stomach is described among the dis- eases of this organ by Billard ; but it is a pathological state of little importance in itself. It occurs in new-born infants, asphyxi- ated at birth and with difficulty resuscitated. In these cases there is generally intense capillary congestion throughout the system. The mucous membrane of the stomach is injected, but not more than that of the mouth or intestines. If circulation and respira- tion are fully established, this injection of the capillaries subsides. 1^0 treatment is required, except measures to promote the circula- tory and respiratory functions. In cyanosis and atelectasis there is often general congestion of the capillaries of the systemic circu- latory system, on account of the obstruction to the flow of blood through the heart in the one disease and through the lungs in the other. There is in these cases passive congestion of the stomach, but not more than of the other organs. Gastritis. Inflammation of the stomach, except when produced by the direct contact of some irritant, is rare in infancy and childhood, independently of disease in some other portion of the intestinal tract. Cases have, however, been reported in which it was not known that any irritating ingesta had been taken, and in which a careful examination revealed a healthy or nearly healthy state of other portions of the digestive tube. The subjects were, for the most part, young infants. The following is an example related by Eillard:— An infant, four days old, remarkable for the color of his face and firmness of flesh, refused the breast and vomited yellow, acid matter. On the following day the vomiting had increased, the legs were oedematous, face pale and pinched, respiration difficult, skin cold, pulse slow and irregular, and pressure on the epigastric region produced cries indicative of pain. CAUSES. 575 Tliird (lay: general sinking; face thin and expressive of great pain ; stools natural. Fourth and fifth days : condition the same. Death occurred on the sixth day, and the autopsy was made on the day following. With the exception of slight pneumonitis, no disease was dis- covered in any part of the system hesides the stomach. The mucous membrane of this organ was intensely vascular near the cardiac orifice and along the lesser curvature. It was also tume- fied, and could be easily raised with the nail. In the remainder of this organ there was strongly-marked capilliform injection. This case is interesting as showing what may happen, though rarely. A nursing infant is seized with gastritis without appa- rently having taken any irritating ingesta, and without other dis- ease of the digestive apparatus. It is probable, however, that, in cases like the above, the cause, if ascertained, would be found in the ingesta: perhaps drinks too hot, perhaps elements of colos- trum, or pathological elements in the milk, which might produce gastritis in young infants in whom the mucous membrane is deli- cate and sensitive. Gastritis is not uncommon in infancy in connection with inflam- mation of the intestines. The latter inflammation is sometimes apparently subordinate to the former, and, if such patients die, the fatal result is due mainly to the gastric disease. Causes. — Gastritis as I have observed it in infants has been in most cases due in great part to the continued use of improper food, of food not suitable to the age of the child, and which was, therefore, with difiiculty digested. Milk, acid or otherwise un- wholesome, farinaceous substances, stale or of an inferior quality and not properly prepared, drinks too hot or too cold, may be specified among the causes. Therefore, this disease is most com- mon in bottle-fed infants, and is comparatively rare in those who receive abundant and wholesome breast milk. Anti-hygienic agencies, apart from the diet, no doubt exert some influence in the production of gastritis, as they do of stomatitis. Uncleanliness, residence in damp and dark apartments, and in an atmosphere loaded with noxious gases, produce a condition of system which strongly predisposes to these inflammations, if, indeed, they may not be enumerated among the direct causes. Rilliet and Barthez have called attention to the fact that certain medicinal substances given to children occasionally cause gastritis. They have observed this eftect from the use of tartar emetic, Kermes mineral, and croton oil. Gastritis occurring in this way 576 GASTRITIS. may or may not be associated with inflammation in contiguous portions of the digestive tube. Elsewhere I have related a case in which gastro-enteritis occurred in a child nine years old, after having taken a considerable quantity of kerosene oil for spasmodic croup. Inflammation of the stomach is thought by some to accompany measles and scarlet fever during the eruptive period, though the proof of this is not decisive. If it occur, it corresponds wnth the , stomatitis and cutaneous inflammation of those diseases, and dis- appears as they subside. It is mild, and accompanied by few symptoms. I have, however, already stated, in the remarks on scarlet fever, that I have in a few^ instances examined the stomachs of those who had died during the eruptive period of these diseases, and found them free from any appreciable inflammatory lesion. Age. — From the records of about seventy cases of inflammatory disease of the digestive mucous membrane which I have preserved, it appears that gastritis is rare over the age of six months. On the other hand, it is not uncommon in infants under the age of three months who are deprived of the breast milk. I have met it chiefly in foundlings fed with the bottle, and having at the samfe time entero-colitis and often also stomatitis and oesophagitis. In these cases there is sometimes continuous or almost continuous injection and thickening of the mucous membrane, from the lips to near the pyloric orifice of the stomach and even beyond this orifice in the intestines. The following is an example of gastritis as it frequentl}' occurs in foundling institutions : — Case. — I\.W., female, two weeks old, was admitted into the New York Infant Asylum, August 24tli, 1865, anaemic and somewhat emaciated. It was in part Avet-nnrsed, and in part bottle-fed. The emaciation increased, and nearly the entire buccal cavitj' became covered witli the confervoid growth of thrush. On September 4th, diarrhwa commenced. Borax was used for the mouth, and alkalies and astringents to check the diar- rha'a, but witliout material improvement. The following was the record for September Ith : " Cries almost con- stantly, with feeble or whining voice ; still has thrush ; nurses and does not vomit ; dejections five or six daily, and green ; pulse 136, feeble." Death occurred September 8th. Autopsy September 9th. — Mouth and fauces not examined; mucous membrane of cesophagus vascular in its whole extent, with slight thicken- ing, but without ulceration ; mucous membrane of stomach injected like that of the a'sophagus, and somewhat thickened, except in its pyloric extrerait}^ where the appearance was natural, or nearly so ; the color in the central part of the inflamed gastric membrane Avas deep red ; no thrush was noticed, except on the buccal surface during life ; along the great curvature of the stomach Avere white flakes, resembling those of thrush, but which were found by the microscope to consist mainly of SYMPTOMS — ANATOMKJAL CHARACTERS. 577 oil glohules and epithelial cells, without the cryptogamic formation; mucous membrane of small intestines healthy in their whole extent, ex- cept slightly increased vasculaiity in a few places in the ileum ; mucous membrane of colon much injected throughout, except near the ileo-cyecal valve, where the vascularity was slight ; in the transverse and descend- ing colon, the redness was pretty uniform, and the membrane was thickened, but not ulcerated ; solitary glands and Peyer's patches some- what elevated. The observations of Vallcix show how frequently gastritis is associated wnth severe attacks of thrush. In twenty-three of his cases of the latter disease, in which tlie condition of the stomach was noted after death, this organ presented inflammatory lesions in seventeen, and in three others appearances w^hich may or may not have been due to inflammation. Symptoms. — A difficult}^ exists in isolating and defining the symptoms of gastritis from the fact that it commonly coexists with other inflammation of the digestive tube. Though we may never be able to diagnosticate this aflection as certainly as we can croup or pneumonitis, still, there are symptoms which arise directl}^ from the gastritis, and with care we may be able to distinguish them from those symptoms which are due to other pathological states. If gastritis is acute, pain is present. In the above case from Billarcl, as well as in a case observed by myself, and related under the head of gelatinous softening, there w^ere frequent cries, and the countenance indicated much suftering, until the stage of collapse. If there is less intensity of inflammation, and the disease is more protracted, as is ordinarily the case, the pain is not so severe, and it may be so slight as not to attract attention. Sometimes there is tenderness, so that pressure upon the epigastric region is badly tolerated. Vomiting is regarded as one of the most constant symptoms. The infant after nursing seems in distress till the milk is returned, but it nurses with avidity in consequence of the thirst, if it is not too exhausted or feeble. The dejections may be quite regular throughout the disease, as in the case from Billard. There is ordinarily, however, diarrhoea from the presence of enterc- colitis. The pulse is sometimes accelerated, and sometimes nearly natural. The emaciation in gastritis is rapid, since not only the milk is in great measure vomited, but the digestive function, so far as the stomach is concerned, is seriously impaired. The features become wrinkled and senile, the eyes hollow, the limbs attenuated, and the cranial bones uneven. Death occurs from exhaustion. Anatomical Characters. — Simple gastritis may afl:ect the 37 578 GASTEITIS. entire mucous surface of the stomach, or be limited to a certain part. The part which is most likely to escape is that towards the pyloric orifice. This portion of the organ is sometimes found in nearly or quite the normal state, while the cardiac half or two- thirds are inflamed. The vascularity of the diseased surface is not uniform. In one place there is simple arborescence ; in another intense continuous redness, and between these two extremes are different grades of vascularity. The mucous membrane is some- what thickened, softened, and the secretion of mucus increased. Extravasation of blood is not infrequent under the mucous mem- brane, usually in points, and the mucus may be mixed with more or less blood. Small shreds or portions of coagulated milk are often found with the mucus attached to the gastric surface. I have observed, though rarely, small superficial ulcers at the point where the inflammation had been most intense. Diagnosis.— In protracted cases, when entero-colitis is present, it is difficult to make a positive diagnosis. Our opinion must then be little more than a plausible conjecture. In the acute attacks we can diagnosticate the gastritis with more certainty. If a young infant affected with thrush is seized with pain, and it vomits often; if emaciation is rapid, and there is no diarrhcea, or diarrhcea not sufficient to account for the prostration ; if the buccal mucous membrane, dotted with the points of thrush, presents a dry appearance and the deep red color of severe stomatitis, there can be little doubt of the presence of gastritis. The diagnosis is rendered more certain by signs of tenderness, when pressure is made upon the epigastric region. Prognosis. — Like other inflammations, gastritis is probably sometimes so mild that it does not materially increase the suftering or danger of the child. This mild form of the disease under favorable circumstances soon subsides. In other cases, by the con- tinuance or increase of the cause, the inflammatory process becomes more severe and extensive, resulting even in disintegration of the mucous membrane. Those cases are especially severe and likely to terminate fatally, which are protracted and accompanied by severe thrush, with a desiccated appearance of the mouth, or with entero-colitis. Pain, vomiting, and rapid emaciation in such chil- dren indicate the speedy approach of death. Improvement in the stomatitis or entero-colitis is a favorable indication, but these in- flammations may improve without corresponding improvement in the gastritis. Treatment. — All food or drinks, except those of a bland and FOLLICULAR GASTRITIS. 579 niiirrltating nature, should be forbidden. If practical^le, the young infant shoukl take no nutriment except the mother's milk or that of a wet-nurse. As there is an excess of acid in inflam- mation of the mucous coat of the digestive tube, lime-water may be advantageously given in combination with the breast milk. Opium is required to relieve the pain and quiet the action of the stomach. The camphorated tincture of opium, in doses of four or five drops to a child a month old, or the syrup of poppy, tincture of opium, or liquor opii compositus, in proportionate doses, may be administered. If there is thirst, a little gum-water should be given frequently. If there is much emaciation and the vital powers are failing, it will be necessary to resort to the use of stimulants. Stimulating enemata are preferable to stimulants given by the mouth. Much benefit may be anticipated from local measures. Irritation should be produced upon the epigas- trium by mustard or other means, followed by fomentations. It is rarely, perhaps never, proper to use leeches, if the patient be a young infant. Death occurs from exhaustion, and it is, therefore, important that the vital powers should not be reduced. If the child is weaned, the diet at first should be restricted to arrowroot, rice-water, barley-water, or similar bland substances. In advanced stages of gastritis, animal broths and jellies may be required. Follicular Gastritis— Diphtheritic Gastritis. The pathological character of follicular gastritis is similar to that of follicular stomatitis. It is an inflammation aflectino- the gastric follicles and ending in their ulceration. It is not a fre- quent disease ; it occurs in young infants. Billard observed fifteen cases. The symptoms in these patients were similar to those in simple gastritis of a severe form. The emaciation and prostration were rapid, and death occurred early. We can only diagnosticate the gastritis without determining its follicular character. How many recover it is impossible to ascertain, but the disease is apt to be fatal on account of the intensity of the inflammation, not only of the follicles but of the intervening mucous membrane. The treatment is that of gastritis. DiPHTHEiiiTic gastritis is infrequent. It occasionally occurs during epidemics of diphtheria. Allusion is elsewhere made to a case treated in the Nursery and Child's Hospital of this city, in December, 1859. The patient, eighteen months old, previously had had protracted entero-colitis, and died exhausted after a brief attack of diphtheria. There were lesions referable to the eutero- 580 SOFTENING, colitis, and the body was much emaciated. The diphtheritic exu- dation was found covering the fauces, epiglottis, glottis, to the rima glottidis, the entire oesophagus, and almost the entire stomach. The mucous surface underneath was injected ; that of the oeso- phagus and stomach especially was very vascular, softened and thickened, and the submucous connective tissue was infiltrated. The pseudo-membrane, taken from the epiglottis and examined under the microscope, presented an amorphous appearance: no cells were noticed in it, and fibrillation was not distinct ; that from the stomach was found to consist almost entirely of cells, the plastic corpuscles of some writers, the pyoid of others. The digestive process, so far as the stomach was concerned, had evidently been almost if not entirely susj^ended, and hence in part the sudden prostration. Diphtheritic gastritis is but a local manifestation of a grave constitutional disease. Post-Mortem Digestion, Softening. It is now many years since the attention of the profession was directed to disorganization of the coats of the stomach, which is sometimes observed at post-mortem examinations. John Hunter first ascertained that the gastric juice begins to have a solvent effect on the tissues of the stomach soon after death. Thouo-h Hunter erred, when he stated that the coats of the stomach are more or less digested in all or nearly all cases, it is certain that post-mortem digestion does take place in many cadavers, so that a few hours after death the gastric mucous membrane is destroyed to a greater or less extent, and occasionally the stomach is perfo- rated or is even severed from its connection with the oesophagus. I have seen several examples of this post-mortem perforation in infants. Some of the cases of supposed pathological softening of the stomach reported by the older observers, seem to have been such as I have described, namely, cadaveric. Yet there are two other kinds of softening occurring in children, which are strictly patho- logical, the one designated white, the other, by Cruveilhier, gela- tinous. "White softening of the gastro-intestinal mucous membrane results from deficient alimentation. It has been observed only in anaemic and ill-nourished children. The mucous membrane in such loses its firmness, and is easily separated from the subjacent tissue. This disorganization has no connection with any inflam- matory process. It is simply a disintegration of the mucous ITS NATURE. 581 membrane in conseqnence of tlic low vitality of the patient, whether or not there are co-operating causes. I believe that, in a large proportion of infants whose systems have been reduced and blood impoverished for a considerable time, the gastro-intes- tinal mucous membrane will be found after death less firm and resisting than in those who have been habitually robust. A vague opinion exists in the minds of most physicians as to the nature and even appearance of the so-called gelatinous softening of the stomach, and the following observations will be cited in order to give a clearer idea of it. Billard has recorded two cases with his usual minuteness, and adds: "What inference shall be drawn from the preceding facts and considerations? JN^one other than that the g-elatinous softening; of the stomach consists in a disorganization of the mucous mem- brane of this viscus, caused by an acute or chronic phlegmasia; that this disorganization is characterized by an accumulation of serum in the walls of this organ ; the intumescence and gelatinous consistence of the mucous membrane in a part usually circum- scribed, situated more frequently in the greater curvature, and about which the membrane exhibits more or less evident traces of an acute or chronic phlegmasia. . . . The softening now under consideration must not be confounded with another kind of soften- ing" (white) " which does not usually succeed an acute phlegmasia." Billard believes that, while gelatinous softening results from inflammation of the mucous membrane, its proximate cause is an afflux of serum to the part in which the disorganization occurs. In one of the two cases which be reports, he thinks that the in- flammation was acute, but in the other chronic, and, therefore, presenting less vascularity. West, in speaking of gelatinous softening, says : " Softening of the stomach varies in degree from a slight diminution in the con- sistence of the mucous membrane, to a state of complete difilu- ence of all the tissues of the organ. . . . When the change is not far advanced, the exterior of the stomach presents a perfectly natural appearance, but on laying it open a colorless or slightly brownish tenacious mucus, like the mucilage of quince-seeds, is found closely adhering to its interior, over a more or less consider- able space at the great end of this organ." Cruveilhier says: "This softening often proceeds from the interior towards the exterior. There is at the beo-innino; simnle separation of the fibres by a gelatinous mucus, and in consequence the parietes are thickened and semi-transparent. ... If the trans- 582 SOFTENING. formation be complete, the disorganized portions are removed layer after layer, those which remain becoming gradually thinner. The peritoneum alone resists for some time, but at length it is attacked, worn, and gives way, and perforation of the stomach results. The parts thus transformed are colorless, transparent, apparently inor- ganic, completely deprived of vessels, and exhaling an odor re- sembling that of milk." Bouchut remarks : " Softening of the mucous membrane of the stomach in children at the breast is not a special disease which it is necessary to describe by itself This alteration is always con- nected with other diseases, and is especially with disease of the large intestine, the knowledge of which fact has been too long neglected. It is the consequence of the acidity of the liquids contained in the digestive tube of young children, liquids which are very acid in the disease we have above referred to." Dr. Carswell states that there is a pathological softening of the mucous membrane of the stomach, and that when it occurs the symptoms may be those of gastritis or enteritis. Rokitansky says of this form of softening : " If we consider, in addition to the above remarks, the uniform localization of the disease, that in none of its stages it presents, either at the point of the softening or in its vicinity, hypersemic injection or reddening, and that we are still less able to demonstrate upon the inner surface of the stomach or in the tissue of its coats the products of inflam- mation, we are constrained to infer the non-inflammatory nature of the affection." Without extending these extracts, it is seen that eminent au- thorities not only disagree in reference to the cause of gelatinous softening of the stomach, but that they also differ in their descrip- tion of its appearance. This diversity of opinion is most likely attributable to the fact that the two kinds of softening have been confounded. Rokitansky and Bouchut probably refer to cases of white softening, which occurs in atonic state of the tissues in feeble infants, and, therefore, have concluded that softening of the stomach is not inflammatory. I believe, from my observations, that the opinion of Billard is correct, and that true gelatinous softening is the result of gastric inflammation, sometimes chronic, sometimes acute. But I have seen appearances which led me to think that the immediate causes of the softening continue to operate after death, so that its amount is less at the time of death than a few hours subsequently. The following case, which was watched by myself with great CASE. 583 interest from beginning to end, is an example of inflammatory softening: — Case.— G. S., male, robust, was born July 10th, 1805, Tlie mother not being able to suckle the infant, and the danger of artificial feeding in the warm months being well understood, a wet-nurse was procured. Ahout the 14th of July, tliis wet-nurse liaving insufficient milk, anotlier was pro- cured temporarily, who suckled the infant till July 20th, when a tliird wet-nurse was engaged, whose chikl, healthy and tliriving, was six weeks old. Previously to this time the infant appeared well. It had uniformly nursed vigorously and seemed satisfied. On the 22d of July, thrush, apparently mild, was observed in the month, and a powder, supjjosed to be borax, and labelled such, was obtained at a drug store, to be used as a wash for the mouth. This powder was afterward ascertained to be alum. About five gi'ains were dissolved in as many teaspoon fuls of water, and the mouth of the child was swabbed occasionally with it. A piece of bnen, folded so as to resemble the tip of a nursing bottle, was occasionally dip[)ed into the solution, and the infant was allowed to suck it. The use of the alum was commenced about 6 P.M. In the first part of the evening the infant slept considerably, and of course did not nurse often, but about 8 P.M. it began to be very fretful, and it then nursed more frecjuently. It vomited once between 8 and 10 o'clock P.M. In order to quiet the infant, the tip soaked in the solution was often applied to the mouth, but there was scarcely any intermission in its crying. Through the night it vomited again once or twice, and about the middle of the night had one free liquid stool, which was passed with much tenesmus. The countenance of the infant was indicative of suffering, and its thighs were repeatedl}' flexed over the abdomen, as if that were the seat of its dis- tress. Paregoric in two-drop doses was several times given through the night, and flannel soaked with hot whiskey was applied to the abdomen. Jul}^ 23d. In ignorance of the cause of the child's sickness, another wet-nurse was obtained early in the morning, and one-sixth of a drop of liq. opii compos, was given every hour, with the effect of inducing a little sleep. The tongue was very red, desiccated, and studded with more numerous points of thrush than on the previous day. It now refused to nurse, apparently from soreness of the tongue. At each attempt of the nurse to induce it to take the nipple, it rubbed the mouth across the breast, crying either from pain or disappointment. The alum was not used in the latter part of the night of the 22d, but late in the morning of the 23d it was resumed, the mistake of the druggist not being discovered till midday, when it was estimated that about five grains had been used. Occasionally a little of the solution was placed in the mouth with a spoon so as to be swallowed, in the belief that the thrush aflected the oesophagus. The infant continued to suffer much during the day, sleeping at times a few minutes. Its strength was evi- dently failing; its respiration regular; pulse about 140; its alvine dis- charges yellow, of natural consistence and frequency. Evening, 23d. Surface hot; is very restless; pulse 150 to 160; tongue dry, intensely red, and dotted with points of thrush. Is treated with opiates, a little lime-water, and fomentations. 24th. In the first part of the day, nursed pretty well; in the latter part, could be induced to draw the breast only once or twice. The 584 SOFTENING. symptoms to-day were the same as yesterday, with the exception of greater emaciation and prostration; cranial bones nneven, and features pinched. 25th. Pulse 140 to 14S; strength rapidly failing, but it cries at times loudlv. The milk of the nurse, placed in the mouth with a spoon, is often held a consideraVtle time before it is swallowed, and deglutition seems difficult. Respiration in the first part of the day and previously, natural; in the latter part of the da^*, accelerated; dejections natural; no vomiting; appearance of tongue more natural than yesterday. 2Gth. Died to-day in a state of collapse at 12^ P.M. The hands were cold several hours before death, and the milk given it was regur- gitated. Julopsy tiventy-tico hours after death. — Much emaciation; no rigor mortis; cranial bones uneven; upper part of the pharynx injected to the extent of about half an inch; but from this point to the stomach membrane healthy; mucous membrane covering the cardiac two-thirds of the stomach disintegrated, alnlost diffluent, and in places detached from the subjacent tissue; mucous coat of the p\-loric third of the organ nearly healthy; along the edge of the softened portion the mucous membrane was vascular to the extent of a few lines ; the muscular and serous coats of the stomach underneath the softened portion were easily torn; the mucous membrane of the small intestine presented in places that degree of vascularity known as arborescence; there was no destruc- tion or softening of its mucous membrane; the colon was healthy 5 the stomach was nearly empty; the contents of the small and large intestines were natural in color and consistence; the other viscera were healthy; in the left pleural cavity was about an ounce of transparent serum, and a less quantit}^ in the right eavit}'. It cannot be doubted that the softening in the above case was pathological. The weather at the time was warm, but the infant was placed on ice, and a pan containing ice was kept upon the abdomen. This infant died evidently of gastritis, the accompany- ing inflammation being subordinate, and in fact insignificant. At fii-st it was a question with me, whether the alum might not have caused the gastritis, so that the case should be properly placed in the category of deaths from swallowing corrosive substances. In order to determine this point, I administered alum daily to two kittens, commencing when they were seven days old. The quantity given to each was ten grains daily in two doses for three consecu- tive days, and on the two following days five grains. The only uniform result noticed was an increased flow of saliva, which washed some of the alum from their mouths, and occasionally slight vomiting. There was not even any apparent inflammation of the buccal membrane from the alum. Post-mortem appearances as in the above case, and similar ones are recorded by Valleix and others, in which gelatinous softening coexisted with evident lesions of gastritis, render it highly probable, NON-IXFLAMMATORY DIARRHCEA. 585 if iiideefl they do not demonstrate, that the softening is a result of the inflammation at the point where it occurs. In Vallcix's twenty-four cases of what he terms fatal muguct, softenino; of the mucous membrane of the stomach was one of the most common lesions, and at the same time, which is the point of interest, there were signs which showed conclusively the presence of gastric inflammation. The common coexistence of the lesions of gastric inflammation, such as redness and thickening, with gelatinous softening of the stomach is certainly most reasonably explained on the supposition that the one results from the other. I am not prepared to accept nor reject the theory of Billard, that the immediate cause of the softening is the afflux of serum, nor that of Bouchut, that it is an excess of acid. It has been said that M. Baron was able to diagnosticate gela- tinous softening. The symptoms are those of the severer forms of gastritis. The vomiting, great pain, restlessness, sudden and pro- gressive emaciation, and, finally, collapse preceding the fatal result, are the symptoms on which the diagnosis is based. The treatment should be directed to the gastritis. CHAPTER YII. DIARRHCEA. DiARRHCEA is frequent during the whole j^eriod of infancy. The French writers describe several varieties according to the character of the evacuations, as acescent, mucous, and serous. M. Rostan even describes fourteen distinct kinds. But the tendency of medi- cal science in these modern times is to simplify the nomenclature of diseases — to describe under a single name those afl'ections which are essentially the same though differing somewhat in their features. jSTow, all the forms of diarrhoea in the infant may be so grouped as to reduce the number to not more than three or four. In this way repetition and prolixity are avoided, as well as an unnecessary refinement. Non-Inflammatory Diarrhoea. The most common and the simplest form of diarrhoea is that enunciated in our heading. Though attended often by an ana- 586 NON-INFLAMMATOEY DIAREHGEA. tomical alteration in the intestines, the inflammatoiy character is absent. This disease is described by some writers as simple, or catarrrhal, or spasmodic diarrhoea. Many cases of diarrhoea sup- posed to be non-inflammatory are really cases of entero-colitis, and very frequently diarrhoea not inflammatory in its commencement changes its character and becomes such. This is especially true of such diarrhoeal aft'ections as are produced by improper diet. Causes. — The causes of non-inflammatory diarrhoea are various. Influences, which in the adult would have no appreciable eflect, increase the number of evacuations in the infant. A common cause is food of unsuitable quality or quantity. Food that does not digest well is apt to stimulate the intestinal follicles to excessive secretion and accelerate the peristaltic action of the intestines. In infants diarrhoea is sometimes due to too frequent feeding. Many whose stomachs are overloaded obtain relief by vomiting, but others do not. The food not needed for nutrition serves as an irritant, and produces green and unhealthy evacua- tions. Dr. James Jackson, in his letters to a young physician, calls attention to this cause of diarrhoea. The mother's milk or the milk of the wet-nurse may disagree, either from some temporary derangement of her system, or con- tinued ill-health, or from causes which are not understood. Non- inflammatory diarrhoea in the nursling is the immediate result, but inflammation may afterwards occur. The milk in these cases fre- quentl}^ contains the elements of colostrum. Fright or strong mental impressions will also in some children increase the number of evacuations. This cause being transient, the diarrhoea soon subsides. Another cause is exposure to cold. Children who are insufii- ciently clothed in the winter season, who are taken from a heated room into a cool one without sufficient precaution, or who lie un- covered at night, are very subject to diarrhoeal attacks from the impression of cold on the system. The cause of non-inflammatory diarrhoea may exist in the child itself. In some children the evolution of the teeth is attended by a relaxed state of the bowels, which ceases when the gum is pierced. Worms in the intestines may also operate as a cause. Diarrhoea is occasionally salutary within certain limits, and of course it is not strictly correct to call it a disease when it is a means of relief. If occurring from an excess of food or from dentition, it may prevent convulsive seizures. SYMPTOMS. 587 Symptoms. — N'on-inflaminatoiy diarrhoea may come on suddenly; but at other times tlicre arc precursory symptoms continuing for some days. "Whether or not there are antecedent symptoms de- pends chiefly on the cause. If diarrhoea occur from fright, or from cokl, or from improper aliment, it commonly occurs immediately. If from painful dentition, there are previous symptoms referable to the eruption of the teeth. The prodromic symptoms are restlessness and disturbed sleep ; sometimes the physiognomy indicates transient abdominal pains. Indigestion, characterized by regurgitation, nausea, or even vomit- ing, is an occasional premonitory condition. Finally, diarrhoea * commences. The evacuations differ much in color and consistence in diflterent cases, and perhaps at different periods in the same case. In infants they are apt to be green. This color, which is a source of anxiety to the inexperienced, and especially to the parents, is often produced by trivial causes. Slight indigestion will produce' it. So will excess of food, even the most bland and unirritating.. Occasionally the stools consist in part of undigested portions. of food, especially the casein. In children advanced beyond the period of first dentition the evacuations do not differ materially in ap- pearance from those occurring in the adult. The stools are usually passed easily, but there is sometimes in infants more or less tenes- mus, if they are acid or in any way irritating. Occasionally there is a sensation of fulness in the abdomen. In the form of diarrhoea which has been designated acescent, not only is there an acid odor and reaction of the matter vomited, but also of the stools. At night, since less nutriment is taken, and the> patient is more quiet, the evacuations in non-inflammatory diar- rhoea are less frequent than in the daytime. If the complaint is slight, there is little desire for drink, but if the stools are frequent and thin, especially if they approach the serous character, thirst is often intense; the appetite varies; the tongue is moist, and covered' with a light fur ; there is often more or less meteorism, but no abdominal tenderness. The face in this disease is pale. In a few days if the evacua- tions continue, there is evident loss of weight and flesh. The rotundity of the limbs is gradually lost, and the tissues become soft and flabby. But in most cases, when the affection has reached this stage, its original character is lost, and it has become infla^m- matory. There is no constant fever in true non-inflammatory diarrhoea. 588 NON-INFLAMMATORY DIARRHCEA. Sometimes the pulse is accelerated in the latter part of the day, but usually only for a short time. Certain epiphenomena, as Bavrier terms them, occur at times in non-inflammatory as well as in inflammatory diarrhoea, for example a sympathetic cough, or, which is more serious, cerebral compli- cations. Convulsions or stupor, indicating the supervention of spurious hydrocephalus, may occur in either form of diarrhoea. This disease is described elsewhere. Anatomical Characters. — The structural changes observed in the intestines in those who die of non-inflammatory diarrhoea have been well described by Billard. "I have seen," says he, "isolated follicles, and follicular plexuses of the intestinal tube, in consider- able 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 appear at the commencement of denti- tion. Ten of these children were affected with diarrhoea of liquid, white, mucous matters. This is really the serous diarrhoea of au- thors ; and every symptom leads to the belief that there is a direct relation between the development of these follicles and the aug- mentation of their secretion." . . . "I do not consider this morbid development of the muciparous follicles as a true inflammation. Nevertheless, this state of excitability which causes the augmenta- tion of their secretion is, as it were, an intermediate stage between the normal state and the state of inflammation." Barrier's views also coincide, in the main, with those of Billard. One of the most common lesions observed in the intestines, in those who have died with non-inflammatory diarrhoea, is, as these authors remark, turgescence of the intestinal glands. In a large proportion of cases these glands will be found more distinct than in the healthy state. The solitary follicles of the large intestines, especially, are, in most cases, elevated, and their central depression distinct ; the patches of Peyer are also prominent. The following is an example of non-inflammatory diarrhoea in a young infant: — On the 7th of July, 1865, a foundling, one month old, died at the Infant Asylum. It was much emaciated, with eyes sunken and features pinched, at the time of its death. It was wet-nursed towards the close of its life, but the nurse's milk was insufficient. It did hot vomit ; did not have any marked acceleration of pulse (128 per minute), and its evacuations were about four daily, and DIAGNOSIS — PROGNOSIS. 589 thin. The stomach and intestines were pale throughout. The solitary glands, particularly those in the colon, and the patches of Peyer, were tumetied so as to be visible, and somewhat raised above the surrounding surface. There was probably slight thickening of the mucous membrane, and tumefaction of the muciparous follicles, but these changes were not clearly ascertained. Diagnosis. — The only disease with which there is liability of confounding non-inflammatory diarrhoea is enteritis or entero- colitis. From these it may be diagnosticated by the absence of continued fever and of abdominal tenderness. Sometimes, indeed, it is difficult to say whether the case is non-inflammatory or whether there exists a moderate degree of inflammation, though practically the determination of this point is not important. Prognosis. — In a large proportion of cases, non-inflammatory diarrhoea is not dangerous. With the adoption of suitable mea- sures to remove the cause, and the use of medicines to control the discharges, the patient recovers. The remark already made may be repeated here, that occasionally diarrhoea is salutary within cer- tain limits, as when there is a foreign substance in the intestines, either irritating mechanically or by its chemical properties, and which the diarrhoea serves to remove. The danger, in non-inflammatory diarrhoea, arises from compli- cations, as spurious hydrocephalus, or from the emaciation and exhaustion. There may also be danger of its eventuating in inflam- mation, which is always serious. "Whether or not the diarrhoea is in itself injurious to the child, and a source of danger, may be de- termined by observing whether or not there is emaciation. If the rotundity of the figure and firmness of the tissues are preserved, showing that alimentation is still sufficient, and no com- plication arises, the diarrhoea is not as a rule injurious. In infants that over-nurse and do not vomit the surplus milk, the evacuations are sometimes green and frequent, and yet fulness of figure is pre- served, and the development of the body proceeds as usual. The same state is sometimes observed in the diarrhoea accompanying dentition. In these instances a moderately relaxed state of the bowels is not injurious. On the other hand, diarrhoea attended by emaciation or softness or flabbiness of the flesh requires immediate treatment. Many lives are lost by the neglect of such patients till they are so reduced that they can no longer derive any material benefit from remedial measures. This fatal neglect is common during the process of dentition. 590 NON-INFLAMMATORY DIARRH(EA. Treatment. — It is necessary, in order to treat successfully diar- rhoea in infancy and childhood, to ascertain the cause, and, so far as possible, to remove it. It is not till the cause ceases to operate, that we can expect a satisfactory result from medication. The disease may be temporarily relieved by medicine, but it usually returns at once when treatment is omitted, unless the patient is removed from the influence of the agencies which produce it. These remarks are especially applicable to the diarrhoea of infants. With them very generally, when affected with this complaint, there is some fault as regards the quantity or quality of food. At- tention to this matter will show the need of a chano-e of wet-nurse, or, if the infant be spoon-fed, a change in the character of its food or the mode of preparation or even in the quantity given. In many cases, by change in the diet, and the adoption of hygienic measures, the complaint ceases, so as to require no medication. If medicines are needed, and the symptoms are not urgent, it is occa- sionally advantageous to commence treatment by the use of some of the milder purgatives in small doses. In the infant^ in whom the dejections are so generally acid, an alkaline laxative, or a laxa- tive conjoined with an alkali, often has a good effect as pi'eliminary treatment. Half a teaspoonful to one teaspoonful of castor oil, or a proportionate dose of Rochelle salts, removes any acid or irri- tating substance from the intestines, and is followed by a diminution in the number of stools. The improvement, however, without subsequent treatment, is usually only for a day or two. The use of a purgative should, therefore, be considered as preliminary to other measures. In this city a purgative dose of castor oil is often given as a domestic remedy in infantile diarrhoea, the beneficial effect from it having popularized its use for this purpose. Trous- seau usually gave Rochelle salts. If there has been previous constipation, and the diarrhoea has just commenced, a purgative is obviously indicated. With the operation of this medicine there is frequently marked improve- ment. West says: "Provided there be neither much pain nor much tenesmus, and the evacuations, though watery, are foecal, and contain little mucus and no blood, very small doses of the sulphate of ma(j;nesia and tincture of rhubarb have seemed to me more useful than any other remedy: — R. Magnesise sulphatis 5j ; Tinct. rhei 5j ; Syr. zingiberis 3j ; Aqute carui 3ix. Misce. 3j ter die for children one year old ; TREATMENT. 591 and I seldom fail to observe from it a speedy diminution in tlic frequency of tlie action of the bowels, and a return of the natural cliaracter of the evacuations." In diarrhoea of infants, due to indigestion, and attended by acidity, the following prescription is sometimes useful. By im- proving digestion and correcting acidity, it has a beneficial effect on the diarrhoea. The cases are, however, in my experience ex- ceptional in which this is the proper remedy. R. Pulv. ipccacuanliJB gr. j ; Pulv. rbei gr. ij ; Sodfe bicarb, gr. iv-vij. Misce. Divide in cbart. No. xij. One powder every four to six bours to an infant one year old. The effect of laxative medicines employed for the purpose of correcting the functions of the gastro-intestinal surface is uncer- tain. If there is no improvement from their use within two or three days, the}^ should be omitted. We must rely on astringents, opiates, and, in infants, also on alkalies. If the symptoms are urgent, if the evacuations are frequent and exhaustive, ,these agents should be employed from the lirst. Much harm is often done, and precious time lost, by prescribing laxative mixtures when opiates and astringents are required. I have known them to aggravate the complaint, when, by change of measures, there was immediate improvement. The majority of cases of non-in- flammatory diarrhoea, at the period when the physician is called, are best treated by the use of astringents and ojiiates exclusivelv, proper directions at the same time being given in reference to the diet and hygienic management. In the diarrhoea of infants the compound powder of chalk and opium is an excellent medicine, containing, as it does, an astrin- gent with the opiate and alkali. It may be given, in doses of three grains, to a child one year old, every three hours. I ordina- rily employ it with double its quantity of subnitrate of bismuth, and know no better remedy for ordinary cases. The following is also an old but useful prescrij^tiou in the simple diarrhoea of infants : — R. Tinct. opii campborat., Tinct. catecbu, aa gij ; Mistur. cretaj |j. Misce. Dose, one teaspoonful every two to four bours to a cbild one year old. If there is no acidity of the evacuation, the following mixture will often be found effectual, which is similar to one recommended by Dr. West :— 592 INTESTINAL INFLAMMATION OF INFANCY. R. Acid, tannic, gr. xij ; Tinct. opii gtt. xij ; Tinct. cinnamom. comp. gij ; Saccli. alb. gss ; Aq. cinnamom. 5^- Misoe. Dose, one teaspoonful every two or three hours, or longer time, according to the evacuations. Kino, krameria, or logwood may be used in place of the astrin- 2'ents mentioned above. If the diarrhoea is due to the feeble digestive powers of the patient, and its food is therefore irritating, powders of pepsin and subnitrate of bismuth may be employed. In the treatment of non-inflammatory diarrhoea occurring in infancy, it is rarely necessary to use the mineral astringents, as acetate of lead or nitrate of silver. If the patient is not relieved by opiates, alkalies, and the vegetable astringents, and by })roper regimen, in all probability there is inflammation of the intestinal mucous membrane. In patients over the age of two or three years, simple diarrhoea approaches in character that of the adult, and the treatment appropriate for the adult is proper in these cases, allowance being made for the difference of age. In infants, in whom this disease, if protracted, is very liable to eventuate in spurious hydrocephalus, stimulants are often required at an early period, on account of the prostration and feeble power of endur- ance. CHAPTEE VIII. INTESTINAL INFLAMMATION OF INFANCY. It is customary with writers to treat of inflammation of the small and large intestines in infancy as a single disease, for the following reasons : First, the symptoms of colitis, at this period of life, do not ordinarily differ, in any marked degree, from those of enteritis. The tormina, tenesmus, and abdominal tenderness, which characterize colitis in childhood and adult life, are ordinarily lacking, or are not appreciable by the observer; and the muco- sanguineous evacuations are oftener absent than present. On account of this absence of symptoms, Bouchut says: "Dysentery is a very rare disease amongst young children. Its existence might even be denied, if it had not been observed at the period of some severe epidemics of dysentery." If Bouchut refers, by the INTESTINAL INFLAMMATION OF INFANCY. 593 term dysentery, to tlie ordinary }»hcnomena of that disease, his remark is correct ; but, as regards the lesions, it is erroneous, for colitis is not so rare in infancy as his remark implies. Billard, after analyzing eighty cases of intestinal inflammation in infants, says: "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 diarrhoea, accompanied with vomiting; while in colitis, diarrhoea alone, without tympanitis, is the most freqtient." And again: "In con- sequence of the impossibility we have found to exist of tracing with exactitude the series of symptoms proper to inflammation of the different portions of the digestive tube, we shall content our- selves with presenting an analytical sketch of the causes, symp- toms, and ordinary course of inflammation of the mucous membrane of the intestines in general." ♦ The frequent absence of any pathognomonic symptom or sign, by which to determine the exact seat of intestinal inflammation in the infant, is admitted bv recent observers as well as Billard. The second reason why intestinal inflammation in the infant is described as a single disease is, that enteritis and colitis are in the majority of cases coexistent. This will be seen when we come to speak of the anatomical characters. I have hesitated in selecting a term for this inflammation. The expression inflammatory diarrhoea, used by West, is objection- able, because it designates a disease by a symptom when there are well-marked lesions. To the expression entero-colitis, employed by Bouchut, Meigs, and others, there is this objection, that some- times the disease is only enteritis, and sometimes colitis ; whereas entero-colitis would imply the presence of both inflammation of the small and the large intestines. Barrier uses the expression gastro- intestinal inflammation, but in a large proportion of cases gastric- inflammation is absent. I have treated of gastritis as an indepen- dent afltection, and it seems proper to exclude it from our descrij)- tion of the intestinal disease, except as a complication. Although I prefer the term intestinal inflammation, I shall use, in describing the disease, the expressions inflammatory diarrhoea and entero-colitis as synon3mious, in order to avoid too frequent repetition of words. Intestinal inflammation is one of the most common and fatal of infantile diseases. It is the great summer epidemic of the cities, in this country. Unfortunately for a correct understanding 38 594 INTESTINAL INFLAMMATION OF INFANCY. i of its prevalence and mortality in this city and perhaps elsewhere, it is very generally in the summer months when obstinate, and especially when fatal, called cholera infantum, although, in its symptoms and nature, it is very different from that disease. Intestinal inflammation is often a protracted complaint, having ordinal ily a mild commencement, while the true cholera infantum begins abruptly, is characterized by violent symptoms, and rapid and extreme exhaustion. The two diseases are, however, often associated as cause and effect. The 1500 fatal cases of so-called cholera infantum, reported every summer in this city, are, with now and then an exception, cases of inflammation, generally protracted. In like manner, the excess of reported cases of infantile marasmus, in the second half of the year, over those reported in the tirst half, should be added to the statistics of intestinal inflammation. This excess, which is noticed every year in the mortuary tables of this city, is due mainly to the death of those wasted infants who have lino-ered with entero-colitis from the summer months. Their marasmus is simply a result of the protracted inflammation. Causes. — Inflammatory disease of the intestines in infancy, I have said, is chiefly a summer affection — at least, in the cities. Occasionally it is observed in the winter, and it is then, when not due to error of diet, produced by exposure to cold. Infants who are taken from warm to cold rooms, or into the open air, by heed- less nurses, or who sleep uncovered at night, are especially liable to this disease. Entero-colitis produced by this cause occurs both in the country and city. In these cases the inflammatory process may not commence sud- denly. There is often a premonitory stage of simple diarrhoea, the first efi'ect of the impression of cold. Indeed, in a very large proportion of cases, whatever the cause, non-inflammatory precedes inflammatory diarrhoea. The influence of the summer season in the production of this disease is forcibly shown by the death statistics of this city. Thus, for the five years ending with 1863, there were 6379 deaths reported from cholera infantum, and of these all but 166 occurred in the months from June to October inclusive. The deaths reported for the same years from diarrhoea, dysentery, and inflammation of the bowels, were 5914, of which 3919 occurred in the months from June to October. ' Of the 5914, the number under the age of five years was 3257. Those familiar with the diseases of this city, and especially CAUSES. 595 with the autopsies of infants, will agree that four-fifths of the above cases which were reported as cholera infantum or diarrhoBa were cases of intestinal inflammation. There is no one disease, except consumption, so prevalent and fatal in this city as infantile entcro-colitis during the period of its epidemic occurrence in the summer months. The epidemic commences about the middle of May. From this time there is a gradual increase in the number affected, till the months of July and August, when the disease attains its maximum prevalence and mortality. During the months of September and October, the number of seizures and of deaths gradually abates till the epidemic character is lost. It is thus seen that the preva- lence of intestinal inflammation of infancy in the city bears a close relation to the degree of summer heat. That the high tem- perature of summer is not in itself sufficient to produce entero- colitis is, however, obvious. In elevated localities in the country there may be intense and long-continued heat, and yet in such places intestinal inflammation of infants is not common. It is no doubt the noxious exhalations from various sources with which the atmosphere is loaded, as a consequence of the heat, which render the disease so prevalent in certain localities in the summer months. The exact character of these exhalations or vapors is not fully known, but the following facts are clearly established by many observations. Entero-colitis prevails most on low grounds near the sea-shore. Thus, it is common in many parts of Long Island, on Staten Island, and on the flats of Westchester County. Experienced and observ- ing physicians of this city do not send infants affected in the summer months with entero-colitis to these localities, but to the high grounds west of the Hudson, and to the hilly parts of JS'ew Jersey, where there is comparative immunity from the disease, and recovery is more certain and speedy. But the state of atmosphere which is most favorable for the development of entero-colitis is found only in the cities. The filthy streets containing more or less decaying animal and vege- table matter, the crowded and unclean tenement houses, the ne- glected privies, the slaughter houses, pig-pens, bone-boiling estab- lishments, and the like, are so many sources of the most deleterious effluvia, which, inspired by the infant, produce diarrhoea and in- testinal inflammation. Those squares of the city where sanitary regulations are most neglected are the very ones where the mor- tality from this cause is largest. 596 INTESTINAL INFLAMMATION OF INFANCY. In the year 1864 the Citizens' Association of the City of IsTew York effected a complete and thorough sanitary inspection of New York island, and it was interesting as well as painful to note the facts observed by the inspectors in reference to the prevalence of the so-called cholera infantum (chiefly entero-colitis) along the streets and in the alleys where the causes of insalubrity were most abundant. Thus, one inspector says, of this disease, it " has probably con signed many more to the grave during the past summer than all other diseases in my inspection district. In every case examined, I have found it associated with some well-marked source of insalu- brity. Vegetable and animal decomposition has been the most prominent cause," Another inspector says of the same disease: " It was found between the and avenues, where the street, at every visit, was found in an indescribably filthy state, in conse- quence of deposits of garbage and slops. This was particularly noticed in front of the premises where cholera infantum had oc- curred." Such was the uniform testimony of all the inspectors. In the tenement houses and in portions of the city occupied by the poor, where the sources of insalubrity are most numerous, I believe, from personal observation, that a majority of the infants are more or less aflected with diarrhoea, often of an inflammatory character, during the months of July, August, and September. In the more salubrious localities of the city, there is less of this disease, but even here the liability to it is great, on account of the proximity of so many sources of impure air. But there is another and an important element in the causation of intestinal inflammation in the infant. I refer to the diet. Many an infant that now falls a victim would escape the disease, but for some fault in the character of its food. Those infants in the city who are bottle-fed from birth rarely go through the summer without being affected with diarrhoea, and a majority of such, if under the age of six months, when the warm weather commences, are saved from dangerous if not fatal inflammation only by removal to the pure air of the country. In the families of the poor the food which is given as a substi- tute for the mother's milk is very apt to disagree with the feeble digestive powers of the infant. The swill milk, about which so much has been said and written, is in common use in this city among these people, or has been till recently. This milk, in the proportion of its ingredients, and sometimes even in its chemical character, is very different from the milk of healthy and well-fed CAUSES. 597 cows of the country. Infants to whom this milk and other im- proper articles of diet are given are the first to suffer with diar- rhoea as warm weather commences, and finally with entero-colitis. It is seen that the causes of intestinal inflammation of infancy as it prevails in the cities during the summer are mainly twofold, atmospheric and dietetic — an insalubrious state of the air which the infant breathes, and unsuitable food. Among the poor of the cities, both these causes conspire to produce the diarrhoeal maladies. It is easy, then, to see why there is so much intestinal disease and so great mortality among the infants of the city poor. Moreover, on account of their feeble powers of resistance and endurance they are especially liable to be affected by morbific agencies. It is a common belief in the profession that dentition is one of the chief causes of diarrhoea in the infant, whether inflammatory or non-inflammatory. There is, indeed, great liability to this disease during the period of dental evolution. The following statistics, which were mostly collected during my term of service in one of the city dispensaries, and which comprise all the cases of diarrhoea under the age of about five years which were brought into that institution for treat- ment during the summer months of my attendance, show the pre- ponderance of cases in the time of teething. Most of these cases were apparently inflammatory. Stage of Dentition. No. of Cases. No teeth 47 Cutting incisors 106 ' ' anterior molars 41 " canines 40 " last molars 20 Having all the teeth 28 Total 28: 0, It is seen that although a large majority of the above cases occurred during dental evolution, yet in a certain proportion, about one in four, teething could not operate as a cause. My own opinion is that dentition is an occasional cause of simple diarrhoea though a subordinate one, but evidence is wanting that it is suffi- cient of itself to produce inflammation. The diarrhoea of dentition is probably non-inflammatory, terminating in inflammation, if such a result follow by the co-operation of other and distinct causes. This subject is treated of in our remarks relative to dentition. An important predisposing cause of intestinal inflammation in infants is the rapid development of the intestinal crypts and follicles. This development, which increases the liability to or- 598 INTESTINAL INFLAMMATION OF INFANCY. ganic diseases of the intestines, is coincident with dentition. An- other important cause remains to be noticed, namely, weaning. "Weaning is a subject to which less attention is given than its importance demands. The summer succeeding the change of diet is always in the city a time of great danger to the infant from diarrhoeal aifections. Mothers uniformly speak with dread of the second summer. In this city, nearly every infant taken from the breast between the months of April and October very soon be- comes aiFected with diarrhoea, which, if not inflammatory in its commencement, soon becomes such. Weaning in the cool months involves less danger, but even then the succeeding summer is one of peril. I have memoranda of the time of weaning in forty-six infants who were affected with diarrhoea apparently from its dura- tion and obstinacy of an inflammatory character. "Weaned in spring or summer 35 " " autumn or winter . . JL 11 W 46 The reader is referred, for other particulars in reference to wean- ing, to the chapter devoted to this subject. The above facts and statistics, to which more might be added, suffice to show the causative relation of foul atmosphere and inju- dicious feeding to the intestinal inflammation of infancy. Intestinal inflammation also occurs as a complication of certain diseases, especially the eruptive fevers. It is the opinion of some, that in measles and scarlatina there is mild inflammation of the intestinal mucous membrane, coexisting with the eruption upon the skin, and disappearing with it. But in a proportion of cases, most frequently in measles, a more intense inflammation arises, constituting a serious complication. The peculiar intestinal in- flammation in typhoid fever is well known. Age. — My observations in reference to the age at which this disease occurs were made in the summer months, and, therefore, relate to the summer epidemic. The cases embraced in the follow- ing table were nearly all observed between the months of May and October inclusive: — Age. No. of Cases. 5 months or under 58 From 5 months to 12 313 " 13 " " 18 174 " 18 " "24 93 " 24 " "36 36 Total 576 SYMTTOMS. 599 This table shows tluat the infant under the age of six months is less liable to entero-colitis than between the ages of six months and two years. The small comparative number, however, affected under the age of six months, I attribute to the fact that most of the infants under this age were wet-nursed. Observations made in the institutions of. this city in which foundlings are i'oceived show that the younger the infant is, the more liable it is to be affected with this disease, under unfavorable conditions of atmos- phere and diet. Thus, in the infant's service of Charity Hospital, prior to the adoption of wet-nursing, a large proportion of the foundlinofs received died of well-marked entero-colitis in the first and second months, and very few lived till the age of six months. A similar fact was observed in the N'ew York Infant Asylum in Bloomingdale.' During my term of service in this institution, I preserved notes of forty-nine fatal cases, which I diagnosticated entero-colitis, and in many of which post-mortem examinations were made. Of these cases, •feighteen wore one month old or under, fifteen from one month to three, eight from three to six, and only eight over the age of six months. Symptoms. — Intestinal inflammation in the infant usually com- mences with moderate diarrhoea. At first there may be no appre- ciable anatomical alteration of the mucous membrane except simple turgescence of the follicles. The number of evacuations at this period frequently does not exceed four to six daily. The color and consistence of the dejections vary. The color is sometimes yellow at this early stage of the disease, and sometimes green, especially in young infants. "Whatever the color or appearance of the stools, there is great uniformity in one respect, and that is their acidity. Litmus paper is reddened by them, and they have a decidedly acid odor. Often there is from the commencement more or less fretful- ness and febrile reaction. In a few days, the disease continuing, the infant, whose stomach was at first retentive, begins to vomit. This symptom I found, from observations made in 1863 and 1864, in the summer entero- colitis of infants, commences in less than a week in the majority of cases, though the time varies greatly. In consequence of the vomiting and diarrhoea, the patient becomes pallid, the flesh soft and flabby, and soon there is evident emaciation. If there is fret- • This institution was discontinued within a year from its establishment, all con- nected Avith it becoming discouraged from the great mortality of the foundlings, who were chiefly bottle-fed. 600 INTESTINAL INFLAMMATION OF INFANCY. fulness in the beginning of the sickness, it now ceases, and the patient lies quiet, having an exhausted appearance. As the disease advances, the features become pinched and wrinkled. The hollow- ness of the cheeks and sunken state of the eyes are in striking contrast with the appearance j)resented before the inflammation commenced. So feeble is the muscular tonicity in advanced cases, that the orbicularis oris and orbicularis palj^ebrarum lose in great part their contractile power, and the mouth and eyes continue open during sleej). In the beginning of the disease the tongue is moist and covered with a light fur. At a more advanced stage it is dry, and in dangerous forms of the disease the buccal membrane is red, the gums swollen, and sometimes ulcerated, and in young children thrush is apt to appear. Vomiting, commencing, as I have said, at a later period than the diarrhoea, continues, unless relieAd by medication or a favor- able change of the disease. It is soMfetimes very intractable. It is in most cases associated with an excess of acid in the stomach, and is probably mainly due to this, except at an advanced stage of the inflammation. The substance vomited has a sour odor, and produces a decided reaction with litmus paper. It contains coagu- lated casein and undigested particles of whatever food has been given. When the vital powers are much reduced and the inflam- mation is violent or protracted, spurious hydrocej^halus is present or threatening, and the vomiting appears then to be due to the cerebral aflfection. The stools sometimes continue, during the whole course of the entero-colitis, of nearly the same character as at first. In other cases they vary, at different periods, in color as well as consistence. They sometimes have a putty-like appearance, from the partly digested casein; at other times they are brown and offensive. A very common appearance is that which has been likened to spinach or chopped vegetables; occasionally the stools consist largely of mucus, with perhaps a little blood — the mucous diarrhoea of Barrier. This occurs when colitis is a principal part of the disease. The evacuations are seldom so watery as in true cholera infantum. Occasionally they are yellow when passed, but become green on exposure to the air, or from chemical reaction resulting from admixture of the urine. The microscojnc character of the stools in entero-colitis is inter- esting. Aside from undigested casein, I have found unaltered SYMPTOMS. 601 fibres of meat, crystalline formations, epithelial cells, single or arranged regularly in clusters, as if detached from the villi, mucus, sometimes blood, and, in one case, an appearance resem- bling three or four crypts of Lieberkuhn united. If the stools are green, colored masses of various sizes, but mostly small, are also seen with the microscope. The microscopic elements, then, are the excrementitious substances, particles of undigested food, in- flammatory products, and epithelial cells or fragments of the mucous membrane, thrown off by the inflammatory process. The 'pnlse in cntero-colitis is accelerated. There is frequently increased heat of surface in the commencement, but, as the disease continues, the vital powers soon become reduced, and the surface is either of the natural temperature or cool. As death approaches, the pulse gradually becomes more frequent and feeble, and the extremities, sometimes for hours before life is extinct, have a cadaverous pallor and colduj^s. The skin, in intestinal inflam- mation, is generally dry, a'^ the urinary secretion diminished. In severer forms of the disease, attended by frequent evacuations from the bowels, the infant does not pass its urine oftener than once or twice daily. The imperfect action of the skin and kidneys is a noteworthy feature of the inflammation. The advanced stages of entero-colitis are apt to be complicated by two cutaneous affections, namely, erythema between the thighs, probably pro- duced by the acid and irritating character of the stools, and boils upon the forehead and scalp. The latter sometimes extend down to the pericranium, and leave permanent depressed cicatrices, ^'^he* external irritation caused by the furuncular affection has often seemed to me conservative, as it occurs at the time when there is danger of passive congestion of the brain and serous effu- sion. When entero-colitis is protracted, and the patient is much reduced, remaining constantly in the recumbent position, except when held in the arms of the mother or nurse, another symptom frequently arises, namely, a dry cough, which continues till the close of life, if the case be fatal, and subsides slowly if the disease termi- nate favorably. The complication which gives rise to this symptom will be considered hereafter. As death approaches, the infant sometimes becomes more fretful; it turns j)eevishly from play- things, rolls its head, or the head has an unsteady movement; and sometimes the stomach is more irritable. The experienced physi- cian rightly interprets these symptoms as the forerunner of cerebral accidents. In other cases there is too great prostration even for the exhibition of restlessness, and the infant lies quiet. As death G02 INTESTINAL INFLAMMATION OF INFANCY. approaches, the infant becomes drowsy. The limbs are cool. It refuses to nurse, or, if spoon-fed, takes nutriment apparently with- out relish. The pupils are contracted, and insensible to light. The eyes are bleared, and a puriform secretion occasionally collects between the lids. The stools are less frequent, and the vomiting, if previously present, ceases. Death occurs quietly. Sometimes, however, convulsive movements precede death, gene- rally slight, as of one arm, or of the limbs or one side. Uraemia may be the immediate cause of death in certain cases. In chronic entero-colitis there is extreme emaciation for a con- siderable time before death. The skin of the extremities lies in wrinkles; the joints, from contrast, a^^pear enlarged, and the fingers and toes elongated ; the angular projections of the bones are pro- minent. The hollowness of the cheeks and eyes causes the infant to appear much older than it really is. Death occurs in a state of extreme exhaustion. The above description applies to infantile entero-colitis, as it so frequently occurs in the cities. It is sometimes much more violent, attended by much greater febrile reaction, and is more speedily fatal. Especially is this the case when it is due to the impression of cold: such cases are not infrequent in the winter months, in the country as well as city. Instead of the mild and gradual commencement which I have described, infantile entero-colitis may be preceded by violent symptoms — a true cholera morbus. Vomiting and purging, more or less severe, precede the inflammation. Among my records are cases which commenced in the summer season from eating goose- berries, currants, cherries, and cheese : the cholera morbus pro- duced by these indigestible substances ending in protracted inflam- mation. Cholera infantum, in which the symptoms from the first are violent and alarming — a disease attended by vomiting and frequent watery stools, occasionally ends in the establishment of intestinal inflammation; and, as there are no symptoms by which it is possible to determine precisely when the inflammation begins, it seems as if the inflammation itself had this violent commencement. But the severe choleraic symptoms usually abate before the inflamma- tion is established. Anatomical Characters. — Billard says: "In eighty cases of inflammation of the intestines that I examined with great care, there were thirty of entero-colitis, thirty-six of enteritis, and fourteen of colitis." M. Legendre, in twenty-eight cases of diar- ANATOMICAL CHARACTERS. G03 rhoBa, found colitis alone in nine, and in the cases in which ente- ritis occurred colitis was also present. Rilliet and Barthcz state, that in certain rare instances almost the entire digestive tube is affected ; that in exceptional cases the principal lesion is found in the small intestines, while, on the other hand, the large intestine is the part of the alimentary canal which is most frequently and intensely inflamed. Billard describes four kinds of intestinal phlegmasia : First, erythematic ; second, with altered secretion ; third, follicular; fourth, with disorganization of tissue. In some of the best works on diseases of children, published subsequently to that of Billard, different forms of inflammation are described, according to the presence or absence of certain anatomical changes, as ulceration or softening. Practically little is gained by such a division of the general disease, and the lesions which are made the basis of the division are often merely the result of severe and protracted, simple or erythematic, inflammation. I have records of the post-mortem appearances in eighty-two cases of intestinal inflammation in the infant. Eleven of these occurred in private or dispensary practice ; about fifty in the Nursery and Child's Hospital, and the remainder in the Infant Asylum. Since pre- serving these records, I have witnessed a larger number of post- mortem examinations of infants who died of this disease in these institutions, and the lesions corresponded in general with those already observed. The question may properly be asked, can in- flammatory hypergemia of the intestinal mucous membrane be distinguished from simple congestion if there is no ulceration and no appreciable thickening of the intestine? This is sometimes difiicult, and it is possible that occasionally I have recorded as in- flammatory what was simply a congestive lesion, but I do not think that I have incorporated a suflficient number of such cases to vitiate the statistics. In a large proportion of the autopsies there was manifest thickening of the intestinal mucous membrane or other unequivocal evidence of inflammation. The following is an analysis of the eighty-two cases : — The upper part of the small intestine, embracing the duodenum and jejunum, was found inflamed in twelve cases. It was free from inflammation, and of a pale color, in fifty-one cases. The ileum was inflamed in forty-nine cases, and the coecal portion, in- cluding the ileo-coecal valve, was the part in which the inflamma- tion was uniformly most intense and to which it was often confined. In sixteen cases there was no ileitis, and in thirteen no enteritis whatever. Therefore, the ileum was inflamed in all but three of 60J: INTESTINAL INFLAMMATION OF INFANCY. the cases of enteritis, in which the records give the exact location of the disease. In fourteen cases there was vascularity in streaks or in patches, or simple arborescence in some part of the small intestines, the records not stating its exact location. In most cases the inflamed mucous membrane was perceptibly thickened. Occasionally, especially if the vascularity was slight, the thickening was scarcely appreciable. In one case there was 80 much tliickening of the ileum next to the ileo-coecal valve that the mucous coat appeared as if closely studded with small warts. Ulcers of small size were found in the mucous membrane of the small intestines in five cases. These ulcers in one case were in the jejunum, in two in the ileum, and in two in both these divisions of the intestine. They were for the most part quite superficial, and circular or oval. It is seen from the above records that the portion of the small intestine most frequently inflamed was the ileum. The inflamma- tion usually aifected the ileo-coecal valve, and extended from it to a greater or less extent along the small intestine. In general, when inflammatory patches were found in difierent parts of the small intestine, those in the ileum nearest the ileo-ccecal valve presented the greatest vascularity and thickening. Billard noticed in his cases the frequency and intensity of the inflammation in the terminal portion of the ileum, and the consequent thickening of the ileo-coecal valve, and conjectured that the vomiting so com- mon and obstinate in enteritis might be due to obstruction at the ileo-ccecal orifice in consequence of this thickening. I have often seen the orifice reduced to a very small size from the hyperemia and thickening of the valve, but have not seen any accumulation above it or other evidence of obstruction. The inflamed mucous membrane was softened in greater or less degree according to the intensity of the inflammation. Sometimes the vessels of the submucous connective tissue were injected, and this tissue infiltrated. The softening of the mucous coat, and the firmness of its attachment to the parts underneath, varied consider- ably in different specimens. I was able, in cases in which there was considerable softening, to detach readily the mucous coat with the nail or back of the scalpel, within so short a period after death that it was evident that the change of consistence could not have been cadaveric. The infants in whom the duodenum and jejunum presented the inflammatory lesions were, with few exceptions, under the age of ANATOMICAL CHARACTERS. 605 tliree months, and in many of these cases there was hypersemia of the ii'astric mucous membrane, and in some also stomatitis. In all the cases except one, namely, in eighty-one, there were lesions indicating inflammation of the mucous membrane of the colon. In thirty-nine, the inflammation had afl:ected nearly or (|uite the entire extent of this portion of the intestine ; in fourteen, it was confined to the descending portion entirely, or almost entirely ; in twenty-eight cases, the records state that colitis was present, but its exact location was not mentioned. In eighteen of the examinations, the mucous membrane of the colon was found ulcerated. According to these statistics, there is colitis in nearly every case of intestinal inflammation in infancy, and in a large proportion of cases also ileitis. The portion of the colon which is most frequently inflamed is that in and immediately above the sigmoid flexure. If the colitis affects other portions also, it is nevertheless in this part that we find the most marked inflamma- tory lesions. The solitary glands, both of the large and small intestines and Peyer's patches, are involved in nearly all cases of this disease. Even in non-inflammatory diarrhoea they become tumefied, so as to be distinctly visible and somewhat elevated. In entero-colitis, as we have already seen, they present different appearances, ac- cording to the degree and duration of the inflammation. In recent cases, and in parts of the intestine where the inflammatory action has been mild, there is often no perceptible change of these glands except slight enlargement with vascularity. This enlarge- ment is most apparent if the intestine is viewed by transmitted light, when not only the glands are seen to be swollen, but their central dark points are also quite distinct. If there is a higher grade of inflammation, or inflammation more protracted, the volume of the solitary follicles is so increased that they rise above the common level and present a papillary appearance. Peyer's patches are in a corresponding degree thickened. The enlargement of these glands is due to hyperplasia, namely, an augmentation in the number of the elementary cells. The ulceration in the cases which I have examined appeared to be primarily and chiefly follicular. . "While some of the solitary glands in a specimen were found simply tumefied, others were slightly ulcerated, and others still nearly or quite destroyed. The ulcers were usually from one to three lines in diameter, circular or oval, with edges a little raised, and red. They resembled in aiDpearance the ulcers in follicular stomatitis. In one or two 606 IXTESTIXAL INFLAMMATION OF INFANCY. iustances I have seen small coagula of blood in the ulcers, and I have also seen ulcers which had evidently been larger, having partially healed. The principal seat of the ulcers was in the descending colon. They were either found in this portion of the intestine only, or, if occurring elsewhere, they were here most abundant. Those in whom I have found ulcers have been ordinarily over the age of six months, which is the time when there is greatest development and activity of the glandular apparatus. In none of the cases observed by me were Peyer's patches ulcerated, though generally tumefied. In cases in which the caput coli was inflamed, I have sometimes found the mucous membrane of the appendix vermiformis also injected and thickened. In one case only was there pseudo- membrane upon the inflamed surface. This was in the descending colon, and it was thin like a film. The rectum presented no in- flammatory or other lesions, or but slight lesions in comparison with those in the colon. Often, when there was almost general colitis, the rectum was found of a pale color, or but slightly vascular. This may explain the rare occurrence of tenesmus in infantile entero-colitis. The amount of mucus secreted from the intestinal surface in this disease is considerably in excess of the normal quantity. It often forms a layer upon the mucous mem- brane of the intestines, and appears in the stools, mixed with epithelial cells and sometimes with blood or pus. If the quantity of mucus appearing in the stools is considerable, the disease has sometimes been designated mucous diarrhoea, or mucous disease ; but there does not seem to me suflS.cient reason, either anatomical or clinical, for considering it a distinct affection. The mesenteric glands are ordinarily enlarged, unless in very young infants. They are frequently found as large as a large pea, or even larger, and of a light color, from the anaemic state of the infant. In exceptional instances certavn of them are found to have undergone cheesy degeneration. The enlargement of these glands, like that of the solitary follicles and Peyer's patches, is from hyperplasia. The condition of the stomach was recorded in sixty- nine cases. In forty-two it was healthy ; in seventeen red, ap- parently inflamed; in seven of a pink color; and in three there were ulcerations, probably cadaveric. The usual healthy condition of the stomach is a noteworthy fact, taken in connection with the frequent vomiting, in entero-colitis. I have stated elsewhere that stomatitis is also a common complication in protracted and grave ANATOMICAL CHARACTERS. 607 cases, accompanied by sponginess of the gums, which bleed if pressecl or rubbed. The buccal surface in these cases is more vas- cular than natural, and, if the vital powers are much reduced, superficial ulceration is not infrequent, especially of the gums. In infants under the age of three or four months, a3sophagitis is also a common accompaniment of entero-colitis. Thrush, though a frequent complication under the age of three or four months, is rare in older infants. Thrush, in infants over the age of eight or ten months, occurring in connection with in- testinal inflammation, is an unfavorable prognostic sign, indicating a gravity of the intestinal disease, which commonly eventuates in death. There exists an opinion in the profession that the liver is in fault in this disease, especially in that form of it which I have described as a summer epidemic of the cities. This opinion is, probably, less prevalent than formerly, but it is still held by many, and it influences, more or less, the choice of therapeutic agents. In the appendix (E) is a table, which presents the condition of the liver in thirty -two cases of this disease. These cases occurred during the summer epidemic. There was no evidence, from the post-mortem appearance of the liver in these cases, of any congestion, or torpidity, or hyper- activity, or perverted secretion. The size of the liver was in some cases very diflerent in those of about the same age, but probably there was no greater difierence than usually obtains among glandular organs within the limits of health. The fol- lowing table gives the weight of the liver in twenty cases in which the weight of this organ and the age of the patient are recorded : — Age. Agp. 4 weeks 5 ounces. 10 months . 6:f ounces 2 months . H " 13 " 6 2 " 3i " 14 " . 9 " 4 " . . 5 " 15 " 6 5 " . . G^ " 15 " 7i " 5 " 9 " 15 " U " 7 " Ah " 16 " 6 7 " . . 6 " 19 " A^ " 7 " . . H " 20 " . . 9i " 9 " 8 " 23 " 15 I do not have access to tables giving the weight of the healthy liver at diflerent ages, but in none of the above cases did the size or the weight seem to me to be above the healthy standard, except 603 INTESTINAL INFLAMMATION OF INFANCY. in one, in which this organ was quite fatty. But in this case the decreneration and enlars-ement of the liver were doubtless due to the tubercular disease. In most of the cases the liver was examined microscopically, and the only fact worthy of note observed was the variable amount of fatty matter. Sometimes it was in excess, sometimes in moderate quantity or rather deficient, and sometimes in greater amount in one portion of the organ than in another. The prevalent belief, then, that the liver is greatly aifected in the summer epidemic of entero-colitis, receives no corroboration from the inspection of this organ. The only pathological state (if it be such) observed in it relates to the amount of oily matter, and this obviously requires no special treatment. The cutaneous aflections complicating entero-colitis have already been alluded to. Frequently, at post-mortem examinations of infants who have died of entero-colitis, intussusceptions are found in the small intestines. These probably in general occur at the moment of, or not long before, death, but I have in a few instances found intus- susceptions which sustained the weight of two feet or more of intestine without being reduced, and which, from being in their interior more vascular than the contiguous membrane either above or below, probably occurred some hours, possibly days, before death, but, being sufficiently pervious to allow the food to pass, symptoms of obstruction were absent. It has been said, in speaking of the symptoms, that a cough is common in the advanced stages of entero-colitis, particularly when the disease is protracted for weeks or months. From the great emaciation and the character of the cough, the physician as well as friends is very apt to suspect the presence of tubercles. In the eighty-two examinations, however, which I have made of entero- colitis of the summer season, in many of which emaciation was extreme, there were tubercles in only one case. The cough was found to be due to solidification of the posterior and dependent portion of one or both lungs. The exact pathological character of this solidification of lung (hypostatic pneumonitis) is treated of in our remarks on diseases of the respiratory organs. In the cases of entero-colitis which Avere complicated with this state of the lungs, I have not usually found enough of the lung tissue involved to make any perceptible difference in the sound on percussion. Its extent of solidification was sometimes not more than two or three lines, and frequently not more than a DIAGNOSIS — PROGNOSIS. 609 quarter to lifilf an incli in an antero-posterior direction, although it embraced nearly or quite the entire posterior surface of the lung. The state of the brain in the entero-colitis of inftincy is inter- esting to the pathologist. When the disease is protracted, this organ wastes like the body and limbs. In the young infant, in whom the cranial bones are still ununited, the occipital and some- times the frontal become depressed in proportion to the loss of brain substance, so that the cranium is quite uneven. In older children with the cranial bones consolidated, serous effusion occurs according to the degree of waste, thus preserving the size of the encephalon. The effusion is chiefly external to the brain, extend- ing on each side over the convolutions from the base to the vertex. The quantity of serum varies from one or two drachms to an ounce, or even more. The serous effusion is associated with passive congestion of the cerebral vessels and cranial sinuses. Diagnosis. — The only disease with which infantile inflammation of the intestines is likely to be confounded is non-inflammator}- diarrhoea. The means of diagnosticating the one from the other are indeed uncertain. There is no pathognomonic sign or symp- tom, in the majority of cases, in either affection. Occasionally we are able to diagnosticate colitis from the presence in the stools of mucus or mucus tinged with blood. Abdominal tenderness, which in the adult is so important a diagnostic symptom of intestinal inflammation, is generally absent in the infant, or, if present, is not easily ascertained. The presence of fever and the severity and persistence of the symptoms, render it probable that the disease is inflammatory. In general I have found that, if diarrhoea continued more than a week in the summer season, it had become inflammatory. Some- times, however, as I have in at least three cases seen, and as the French physicians state, diarrhoea may continue for a much longer time, attended by extreme emaciation and terminating fatally, and yet at the post-mortem examination no lesion of the intestines be found, except a tumefied state of the intestinal glands. Practi- cally it matters little whether we ascertain the inflammatory or non-inflammatory character of the disease, as we determine the proper mode of treatment from the symptoms and general condi- tion of the patient. Prognosis. — I have said that intestinal inflammation is one of the most fatal of infantile diseases. Still it is possible, by proper hygienic measures and a judicious selection and use of medicines, to save a large proportion of those aftected. Entero-colitis and 89 610 INTESTINAL INFLAMMATION OF INFANCY. most of its complications are of such a nature that we may have reasonable hope that the infant will recover if all measures cal- culated to control the disease are employed. Many do recover from a state of emaciation and feebleness which, occurring in any other pathological state, would be almost necessarily fatal. The most unfavorable symptoms in this disease, except those due to extreme prostration or collapse, arise from the state of the brain. Rolling the head, squinting, feeble action of the pupils, spasmodic or ir- regular movements of the limbs, indicate the near approach of death. There are many facts which should be taken into con- sideration in making a prognosis. The age of the infant, the time in the year, the surroundings, especially in reference to the impurity of the atmosphere, are to be considered, as well as the present state of the patient. Intestinal inflammation of infancy might, in many instances, be prevented by judicious measures. Especially is it preventable in those cases in which the exciting cause is dietetic. The reader is referred to the chapters on weaning and artificial feeding, for facts in reference to this matter. Unfortunately, however, the physician is not generally consulted in regard to the alimentation of the infant, or the time and manner of weaning, or other important matters of regimen, until diarrhoea, inflammatory or non-inflam- matory, is established; his purpose is then not to prevent, but to cure. Tkeatment. Begimenal Measures. — Intestinal inflammation of infancy requires somewhat difierent treatment, according to the cause, as well as the condition of the patient. If it occur in an infant of previous good health, and from exposure to cold, its diet should at first be reduced. If it be nursing, it should take the breast less frequently. It will then receive less nutriment, not only in consequence of the longer interval between the times of nursing, but because the milk remaining in the breast becomes more watery and less nutritious. If thirsty, it may take a little light barley-water or gum-water. If the infant be weaned, a corresponding reduction in its nutriment should be made. These cases require mild counter-irritation over the abdomen, followed by emollient poultices, or warm water applications covered with oil silk. After the acute stage has passed, more frequent nursing and more nutritious diet should be allowed. Often the alcoholic stimulants in barley-water, and sometimes the animal broths, are required in this stage of the disease. Exhaustion should be guarded against in the infant. TREATMENT. 611 As one of the chief causes of intestinal inflammation of infancy, particularly in the city, is the use of food which does not agree with the digestive system, feeble and easily deranged at that early age, attention should be directed, in those cases in which the dis- ease does not seem to be due to the impression of cold, not only to the nature of the food, but to the mode of its preparation and the quantity given. To the young infant with entero-colitis, no food is so easily digested, and is therefore so suitable, as human milk. The bottle-fed infant, under the age of twelve months, remaining in the city in the summer season, and aifected with intestinal inflammation, cannot in general be successfully treated unless it is provided with a wet-nurse. Frequently, when the diarrhoea continues in spite of all other measures hygienic and medicinal, the infant begins at once to improve by the employment of a wet-nurse. It is sometimes really surprising to observe as a consequence of this measure the rapid and complete restoration to health from a state of extreme emaciation. In certain cases the breast-milk, either of the mother or wet- nurse, disagrees with the infant, and its use aggravates the intes- tinal disease. In the country, or in the city in the cool months, weaning may be proper under such circumstances. Certainly weaning or the employment of another wet-nurse is required. In the city in the summer months, for reasons elsewhere fully stated, weaning is a very injudicious if not fatal measure, and, if the entero-colitis is aggravated by the character of the mother's milk, a wet-nurse should be engaged. If the breast-milk is susjDected as the cause or one cause of the infant's sickness, it should be examined by the microscope, before a change in diet or in nursing is recommended. It has been ascertained by the microscoj)e, that the elements of colostrum which have a purgative effect may return at any period of lactation. If the mother's milk disagrees, and a wet-nurse for any reason is not employed, it is then necessary to recommend a diet which will be the best possible substitute for the natural aliment. Well- boiled barley-water, or Ridge's food, the basis of which is wheat- flour, the upper third of cow's milk when it has stood two or three hours, the expressed juice of lean beefsteak slightly roasted, and scraped raw beef, may be mentioned among the articles of diet which I have found useful in these cases. For facts in reference to artificial feeding, and for dietary formulae, the reader is referred to chapters relating to the diet of infancy. Attention to the diet of infants affected? with intestinal inflam- 612 INTESTINAL INFLAMMATION OF INFANCY. mation is obviously of the utmost importance, but oue chief cause of the disease, especially of tlie great summer epidemic of the cities, we have seen to be atmospheric. This requires attention on the part of the practitioner to a different matter in the hygi- enic management of these cases, namely, the state of the air which the infant breathes. In the cool months, the atmosphere is more pure than in the summer months, as it contains less of those noxious gases which arise from decaying animal and vegetable substances. In those months, then, in which the weather is such that there is no decomposition of organic matter, the atmospheric cause of entero-colitis is not operative, and little is gained for the patient by change of locality. But in the summer season one of the most important conditions of successful treatment of this and the other diarrhoeal maladies of infancy is the removal of patients from an impure to a pure atmosphere. Physicians of experience all agree in the choice of elevated localities, containing a sparse population, and remote from the sea-shore. Many are the in- stances every summer in this city of infants removed to the country with intestinal inflammation, with features haggard and shrunken, with limbs shrivelled and skin lying in folds, too weak to raise or at least hold their heads from the pillow, vomiting nearly all the nutriment taken, with stools frequent and thin, re- sulting in great measure from molecular disintegration of the tissues, presenting indeed an appearance seldom seen in any other disease except in the last stages of phthisis, and returning in late autumn, with the cheerfulness, vigor, and rotundity of health. The localities usually preferred by the physicians of this city are the ^elevated portions of 'New Jersey and Eastern Pennsylvania, the Highlands of the Hudson, the central and the northern parts of New York State, and Northern New England. Taken to a salu- brious locality, the infant will soon begin to improve after it has recovered from the fatigue of travelling, unless the case is incu- rable. Sometimes parents, not noticing the immediate improvement which they had been led to expect, return to the city without giving the country fair trial, and the life of the infant is almost necessarily sacrificed. Eeturned to the foul air of the city while the weather is still warm, it sinks rapidly from an aggravation of the malady. Dr. James Jackson recommends, if the infant do not improve where it is taken, that it should be conveyed to another locality. This is good advice, provided the selection be made of a place elevated, remote from the sea-shore, and having a TREATMENT. 613 8[)iirso population. The infant, althougli it has recovered, should not be brous-ht back while the weather is still warm. One attack of the disease does not diminish but increases the liability to a second seizure. If the situation of the family is such that it is not practicable to take the infant to the country, and such cases are frequent among the poor, it should be kept much of the time in the open air; it is a common practice in this city to take such patients in the daytime to the sea-shore, or upon ferry boats. Dr. E. H. Parker says: "Many of my patients are sent to the ferries to cross them, so that the cool fresh sea breeze may fan them, and it acts some- times like magic, to raise their drooping heads." I have not observed such marked benefit in these cases from the sea breeze as from the air of elevated localities, which can generally be found in the vicinity of cities, and are easily accessible.^ Medicinal Treatment. — Someti^jes it is proper to commence treat- ment by the employment of a gentle purgative, particularly when the disease commences abruptly from a state of previous good health. It is then frequently caused by exposure to cold, or more rarely by some indigestible and highly irritating substance in the intestines. In such patients, there is often a full habit. The pulse is strong and quick, the heat of surface great, the face perhaps flushed, the stools sometimes slimy and bloody, sometimes green or brown. It is proper and often serviceable, when there is this commencement of the affection, to give a single dose of castor oil or syrup of rhubarb. Any indigestible substance, if present, is removed from the intestine, and opiates or other remedies designed to control the disease may then be more successfully employed. Such cases occur in the winter not less than in the summer, and in all localities, rural as well as in the city. But the summer epidemics of intestinal inflammation in the cities do not in general require such preliminary treatment. Diarrhoea, moderate, perhaps, has already continued for a time when the physician is called, and no irritating substance remains except the acid, which is abundantly generated in the intestine in this disease, and which we have a means of removing without purgation. Preliminary treatment having been employed or not, according to the nature of the attack ' The remarks made in reference to the use of pepsin in indigestion and non- inflammatory diarrhoea apply also to those cases of inflammatory diarrhoea which are due to feebleness of the digestive function. 614 INTESTINAL INFLAMMATION OF INFANCY. and condition of the patient, remedies calculated to arrest the inflammation should then be prescribed. The medicines which should be employed are chiefly of three kinds, namely, alkalies, opiates, and astringents ; sometimes one or two kinds only, and sometimes all three, according to the cha- racter of the evacuations. The antacid treatment is, of course, required in those numerous cases in which the stools are acid, and there is no better alkaline remedy for the diarrhoea in this disease than the preparations of chalk. The creta prseparata of the phar- macopoeias, in doses of two or three grains to a child one year old, or the mistura cretse in teaspoonful doses, are eligible preparations, and are commonly employed. These medicines should be repeated in two hours, or a longer time, according to the state of the patient. Chalk given for a moderate period is innocuous, and may be ad- ministered to the youngest child. In Europe the crab's eye is much used, and it is stated that it is sometimes eftectual in controlling the disease, when the chalk fails. The following is a formula recommended by Bouchut: — K- Ocul. cancror. pulv. gr. x ; Aq. foeniculi, Syr. rhei, aa ^ss. M. One teaspoonful every hour. In this country the same antacid has been also employed, though less frequently than the prepara- tions of chalk. J. F. Meigs, of Philadelphia, prescribes it as fol- lows: — R. Ocul. cancror. pulv. 5j ; Acacije pulv. 5'j ; Sacch. alb. 9j ; Aq. fontis, Aq. ciunamom., aa ^jss. M. A teaspoonful four, five, or six times daily. By means of this alkali alone, aided by proper hygienic measures, the disease is sometimes arrested, but, unless circumstances are favorable and the case is mild, other medicines are required. Opium is used by most practitioners in the treatment of intes- tinal inflammations of infancy. Either as a main remedy or ad- juvant it is employed, and properly, in nearly all severe cases. For a young infant paregoric is an eligible preparation of opium. For the age of one month, the dose is three to five drops ; for the age of six months, ten to twelve drops, repeated in three hours or a longer time, according to the state of the patient. After the age of six months, the stronger preparations of opium are more fre- TREATMENT. 615 quently used. At the age of one year, the liq. opii compositus or tincture opii may bo given in doses of one to two drops, Dover's powder is also an excellent medicine in this disease, given in doses of three-fourths of a grain to an infant one year old. Opium is, however, in general best given in mixtures which will be mentioned hereafter. It quiets the action of the bowels, and diminishes the number of evacuations. It is contra-indicated or should be used with caution if cerebral symptoms are present. Sometimes in the commencement of the disease, if there is much febrile reaction, the patient may be drowsy and in danger of con- vulsions. Then opiates should be given cautiously or withheld. Also in the advanced stages of this disease, when, perhaps, there is more or less serous effusion in the cranial cavity, opium should be cautiously used, as it might tend to produce that fatal stupor, in which the unfavorable cases are apt to terminate. Astringents are required when the evacuations are thin and fre- quent, and are not sufficiently controlled by the remedies already mentioned. Those of a vegetable nature are usually preferred, as they are compatible with chalk, and may be given in combination with it. The astringents commonly used are, catechu, kino, kra- meria, tannic and gallic acids. Logwood and blackberry roots are also occasionally employed. If the disease become chronic, nitrate of silver and acetate of lead are sometimes useful. Astringents should not be given if the stools are scanty and consistent though frequent, nor should they be employed if the evacuations are muco-sanguinolent, as in the dysentery of the adult. I will now mention the various combinations of medicines which have been found the most useful in intestinal inflammation. In all those cases in which the evacuations consist chiefly of mucus, or mucus and blood, and in all recent cases in which the evacuations are scanty, and there is considerable fever, one of the best formulae is the following, which is similar to that recom- mended by Dr. West: — ^. Tinct. opii gtt. xij ; Pulv, gum acac, Pulv. sacch. alb., aa 3j ; 01. ricini 3j to 3ij ; Aq. cinnamom. 5Jss. M. One teaspoonful every three hours. In these cases, also, Dover's powder, given at the same interval with half a teaspoonful of 616 INTESTINAL INFLAMMATION OF INFANCY. castor oil once or twice daily, will have good efiect in controlling the disease. In the more common forms of infantile entero-colitis, in which the stools are green, or brown, or yellow, and are watery and fre- quent, one of the best medicines is the pulv. cret. comp. c. opio, combining, as it does, alkali, opiate, and astringent. Three grains may be given every two or three hours to a child one year old, till the diarrhoea is controlled. For young infants paregoric, catechu, and chalk, as recommended in the treatment of non-inflammatory diarrhoea, is a useful mixture. Laudanum or liq. opii compos, in proper quantity may be substituted in place of the paregoric, and kino or krameria in place of the catechu. Gallic or tannic acid is sometimes administered with Dover's powder, or with the compound powder of chalk and opium, but given in this way it is nauseating and apt to be vomited. If the evacuations are not frequent or watery, the opiate and chalk mixture may be prescribed without the astringent with a good effect. I do not know that any benefit is gained in intestinal inflam- mation of the infant by the use of mercurials, and in many cases certainly much harm would result. They are not now commonly prescribed in the enteritis or colitis of adults, and there is no lesion in infantile entero-colitis, either as regards the liver or intestines, which requires their administration. In the choleriform diarrhoea, which sometimes precedes intestinal inflammation, the use for a day or two of small doses of calomel or hydrarg. cum cret. is thought by some judicious practitioners to be of service, but, when it has appeared to be beneficial in intestinal inflammation, the good effect is probably due chiefly to the opium which is administered with the mercurial. Often the disease continues, notwithstanding the use of the above remedies, or if temporarily relieved, the causes still opera- ting, it returns. In these protracted cases, attended perhaps with more or less ulceration of the mucous membrane, the mineral astringents may be prescribed. Acetate of lead may be given in doses of one-fourth of a grain to an infant one year old. Nitrate of silver is, however, more frequently prescribed in EurojDC, espe- cially on the continent. It may be given in doses of one-twentieth to one-twelfth of a grain in a little mucilage or simple syrup. Enemata. — These are of great service in many cases of intestinal inflammation. At any stage of the disease, when the stomach is irritable and medicines are not retained, they may be advanta- TREATMENT. 617 geously employed. Laudanum especially is often giveii in tliis way to the infant with great benefit. It may be prescribed mixed with a little starch water, and the best instrument for administer- ing it is a small glass or gutta-percha syringe, the nurse retaining the enema for a time by means of a compress. Beck, in his Infant Therapeutics^ advises to give by injection twice as much of the opiate as would be administered by the mouth. A somewhat larger proportion may, however, be safely employed. Astringents may also- be given by enema. Bouchut, speaking of these thera- peutic agents, says : "All these substances may be given as enemata, composed of three to six ounces of the vehicle holding in solution seven to ten grains of the extract of rhatany or monesia. If tannin is used, it should be in the dose of four to seven grains. In the same way and for the same end, fifteen to thirty grains of alum, or, better still, less than one grain of the nitrate of silver. These last enemata are daily employed at the E'ecker Hospital. If their use is not constantly followed by success, there always results, at least, a decided amelioration quite capable of dissipating the objections raised against their employment," Since the inflammation is ordinarily most intense in the descend- ing colon, and is sometimes confined to this portion of the digestive tube, benefit results in certain obstinate cases from the injection into the rectum of a solution of nitrate of silver in warm distilled water in the proportion of one grain to six or eight ounces. A little laudanum may be added. This treatment has been employed in the ]S"ursery and Child's Hospital, but only as an adjuvant to remedies administered by the mouth. In most of those cases of intestinal inflammation which occur under the depressing effect of warm weather, alcoholic stimulants are required almost from the commencement of the disease, and their use is beneficial in chronic or protracted cases, whatever the cause or season. Bourbon whiskey or brandy is the best of these stimulants, and it should be given in small doses, repeated at intervals of two hours. I have usually ordered three or four drops to an infant one month old, and an additional drop or two drops for each month. The stimulant is not only useful in sustaining the vital powers, but it also aids in relieving the irritability of stomach. The diarrhoea is, in general, more easily controlled than the vomiting, A remedy which with me has been useful in relieving the latter symptom is the neutral mixture: — 618 INTESTINAL INFLAMMATION OF INFANCY. I^. Potas. bicarbonate gr. xxv; Acid, citric, gr. xvij ; Aq. amygdal. amarse 5 j ; Aquae |ij. Misce. Dose, one teaspoonful to a child from eight to twelve months old, repeated according to the nausea or vomiting. The following prescription to relieve this symptom, which is similar to one em- ployed in the Nursery and Child's Hospital of this city, has the desired eiFect in a certain proportion of cases: — ^. Acid carbolic, gtt. ij ; Aq. calcis 3ij. Misce. Dose, one teaspoonful with a teaspoonful of milk, hreast-milk if the infant nurses, repeated according to the symptoms. Lime- water alone sometimes diminishes the vomiting when there is great acidity, hut it is rendered more effectual by the addition of carbolic acid. Vomiting is frequent in the summer epidemics of intestinal inflammation in the cities, and it is in this form of the disease, induced by an impure atmosphere and an unsuitable diet, that I have observed the greatest benefit from the above prescrip- tions. When the inflammation occurs in other seasons, and is produced by other causes, vomiting is less frequent, and is more easily controlled. It may then require no special treatment. "While I approve the above mode of treatment, which is re- printed from the first edition, more recent experience, and es- pecially observations made in the large class of children's diseases in the Out-door Department at Bellevue, convince me that the subnitrate of bismuth is a valuable remedy not only for this disease, but also for cholera i'nfantum, and one which is appropriate in most cases. It has, indeed, long been used in the diarrhceal affections of infancy, but in doses much too small. Its effect is be- lieved to be entirely local, namely upon the gastro-intestinal surface and its secretions. It undergoes or effects some chemical cha,nge, for the stools after its use become dark, and at the same time more consistent. While it diminishes the frequency of the evacuations, it is at the same time one of the most efficient antiemetics. The following formula is for an infant one year old: — K. Bismuth, subnit. 5j ; Pulv. cret. comp. c. opii 5ss. Misce. Divid. in chart. No. x. One powder every three hours. I believe that this is the best remedy that can be prescribed for the epidemic entero-colitis of the summer months in the cities, in TREATMENT. 619 which disease there is ordinarily great irritahility of the stomach. It is readily administered mixed with a little sugar and moistened. It is useful in recent as well as protracted cases. If there is no decided irritability of stomach or acidity of the stools, Dover's powder may be substituted for the powder of chalk and opium, and it is preferable in those cases in which the entcro-colitis results from taking cold, and there is a strong febrile reaction. "When the disease is chronic, and the vital powers begin to fail, as indicated by pallor, more or less emaciation, and loss of strength, the following is the best tonic mixture with which I am acquainted. It aids in restraining the diarrhoea, while it increases the appetite and strength. It should not be prescribed until the inflammation has assumed a subacute or chronic character. R. Tinct. colombse. 5iij ; Liq. ferri nitratis gtt. xxiv ; Syr. simplic. giij. Misce. Dose, one teaspoonful every four hours to an infant of one year. In the Out-door Department at Bellevue we commonly give this tonic alternately with the bismuth powders. JExternal Treatment. — Some writers recommend depletion in this disease by leeches, advice likely to do much harm, unless the particular cases are described in which it may possibly be of service. It can be useful only in those cases in which the infant is robust and of full habit, and the disease commences suddenly with decided febrile reaction. Such cases are oftenest seen with us in the winter season, and even these are ordinarily best treated without loss of blood. Sinapisms and poultices usually are suffi- cient as local measures. In these cases, also, the warm mustard foot-bath should be employed, and repeated if there is restlessness or cerebral symptoms. In all forms of intestinal inflammation in infancy and in all its stages, mild counter-irritation over the abdomen is often useful, but vesication, by increasing the restlessness of the infant and reducing its strength, without materially modifying the severity or duration of the disease, does more harm than good. It is not to be thought of as a remedial measure. I have known a trouble- some sore continuing till death, and probably hastening this result, to occur from this treatment. Poultices or fomentations over the abdomen are sometimes beneficial, especially those of a mildly irritating nature. A poultice of powdered cloves, cinnamon, and ginger, or of linseed meal to which a little mustard is added, may G20 ENTERITIS AND COLITIS IN CHILDHOOD. be employed, or, better than either, a linseed poultice spread thin, under which a single layer of muslin is placed, saturated with tincture of camphor, and over both oil silk. In the entero-colitis of infants, occurring in the cool months, and due to exposure to cold, this treatment is especially useful. In the epidemic entero- colitis of the summer months, which may be aggravated by heat, treatment by poultices may be injudicious, but in such cases it is proper to produce moderate redness over the abdomen by temporary applications. Some physicians believe that dentition is a cause of infantile entero-colitis, and advocate lancing the gums if they are found swollen. In my opinion, this treatment, in genuine inflammation, is opposed by both reason and experience. CHAPTER IX. ENTERITIS AND COLITIS IN CHILDHOOD. Intestinal inflammation in childhood difiiers materially from the form or type which it commonly presents in infancy. Its causes, symptoms, and extent differ in important particulars in the two periods. In childhood there is not ordinarily such extensive inflammation of the mucous membrane of the intestines as we have seen is present in the majority of cases in infancy, and it may, therefore, be properly treated as two diseases, according to the seat of the morbid process, namely, enteritis and colitis. Both these affections in the child resemble so closely the form which they exhibit in adult life, that no extended description is needed in this connection. Causes. — These are vicissitudes of temperature, especially sud- den change from warm to cold, which checks the perspiration, and causes a determination of blood from the surface to the viscera. These inflammations are also caused sometimes by irritating sub- stances in the intestines. I have known faecal accumulations as well as worms to produce severe dysentery in the child, accom- panied by the characteristic tenesmus and muco-sanguineous stools, and ceasing as soon as the offending substances were expelled. The use of unripe or stale vegetables, if there is a strong predis- position to mucous inflammation, may be a sufficient cause, and SYMPTOMS. G21 some of the most dans-eroiis cases are due to the accumulation in the intestines of seeds and the parenchyma of fruits. But the most common cause is that mentioned, namely, sudden exposure to cold when the body is heated, a danger to which children are especially liable, on account of the easy disturbance of the circula- tory system in them, and their heedless exposure of themselves, unless incessantly watched. Enteritis and colitis are also frequently secondary diseases. They occur in children as complications or sequelae of the eruptive fevers, especially measles. Symptoms. — The alvine discharges in enteritis and colitis in childhood are such as occur in these diseases at a more advanced age. In enteritis they are thin and of the natural color, or occa- sionally green; in colitis they are more consistent than in enteritis, and are largely muco-sanguineous. Sometimes in enteritis, if the inflammation is not intense, the diarrhoea is slow in appearing, or it may be slight, so as not to attract special attention. The dis- ease may then resemble remittent fever, for which it is at times mistaken. The upper part of the small intestines is less frequently affected than the lower. If there is duodenitis, the flow of bile is occasionally impeded from tumefaction at the mouth of the common bile-duct, and the icteric hue appears. In both enteritis and colitis there is abdominal tenderness, with more or less constant pain if the disease is severe, and in colitis, tormina, and tenesmus. The pulse is accelerated, the heat of surface augmented, the face flushed, and, except in mild cases, indicative of suftering. In many children at the commencement of the inflammation the nervous system is profoundly affected, as indicated by headache, stupor, twitching of the limbs, and sometimes by convulsions. The chief danger at the commencement of the disease is, indeed, from this source. Sometimes there is irritabilitv of the stomach, and the food is rejected, though much less frequently than in the intestinal inflammation of infancy. Anorexia and thirst are com- mon symptoms. If the inflammation continue, there is soon per- ceptible emaciation, with loss of strength. The eyes become hollow, the face pale, and the surface cool. Death may occur at an early period, the vital powers succumbing from the intensity of the inflammation. In other cases, the acute disease ends in a subacute or chronic inflammation; the patient becomes gradually more reduced, till he dies in a state of extreme emaciation, such as we often observe in the entero-colitis of infancy, or from this state he may recover by degrees, though perhaps with an irritable 622 ENTERITIS AND COLITIS IN CHILDHOOD. state of the bowels, which continues for months. In a majority of cases, however, enteritis and colitis in childhood, if not neglected soon begin to yield, and terminate favorably in one or two weeks. Diagnosis. — It is not difficult to determine the existence of the inflammation. This is indicated by the fever, abdominal tender- ness, and the relaxed state of the bowels. "Whether the disease is enteritis or colitis is determined by the character of the stools, the seat of the tenderness, and the presence or absence of tenesmus. Prognosis. — It has been stated above that enteritis and colitis in children commonly terminate favorably. The result depends not only on the extent and severity of the inflammation, but the constitution and previous health. The inflammation is more seri- ous when secondary than when primary. Extensive and great tenderness of the abdomen, features pale, anxious, and indicative of sufiering, pulse frequent and feeble, should excite the most serious apprehensions. Frequent vomiting also denotes a grave form of the disease. Stupor, and especially convulsive movements, show that the nervous centres are afi:ected, and should make us guarded in the prognosis. Improvement in the disease, on which to base a favorable prognosis, is apparent in the diminution of the tenderness, improvement in the pulse and character of the stools, a more cheerful countenance, and less disrelish of food. Treatment. — This should be similar to that employed in the adult. In enteritis at the commencement of the disease, if there is reason to suspect the presence of any irritating substance in the intestines, and ordinarily in colitis, it is advisable to commence treatment by the use of some simple evacuant, like castor oil. After this our reliance, so far as internal treatment is concerned, must be mainly on opiates, or opiates with diaphoretics. One of the best remedies of this class is the Dover's powder, which may be given to a child five years old in doses of three grains every three hours. A corresponding dose of any of the other opiates may be given, but with less sudorific effect. In colitis the occasional administration of a laxative should not be neglected, if the stools are entirely or mainly muco-sanguineous. It should be employed so as to prevent accumulation of fsecal matters in the colon, which would serve as an irritant and increase the inflammation. The dose should be small, merely sufficient to produce a feecal evacua- tion, and repeated as required, daily or less frequently. The laxative commonly preferred is Rochelle salts or castor oil. The physician may prescribe an opiate mixture containing sufficient of the laxative to have the eft'ect desired, though ordinarily it is 1 I TREATMENT. 023 better to prescribe the two separately, so that the laxative can be given or withheld, according to circumstances, while the opiate is continued more regularly. When the stage of active inflammation has passed, if there is still looseness of the bowels, astringents should be employed in connection with the opiate. The tincture of catechu or kino may 1)0 given with an equal quantity of paregoric. The subnitrate of bismuth in doses of from Ave to ten grains in combination with Dover's powder or other opiate will also be found useful. Acetate of lead with opium, so much used in adult cases, is equally serviceable in children. One grain may be given to a child of five years with one-third of a grain of opium. Injections properly administered aid in controlling the inflammation. Those containing opium are especially serviceable in relieving the tenesmus of dysentery. When the stomach is irritable, or when it is desired to use a medicine like tannic acid, which is unpleasant to the taste, it is often best to administer it in the form of enemata or suppositories. Local treatment is highly important in the enteritis and colitis of childhood. Leeches in the commencement of the inflammation have a good effect in moderating its intensity. If the disease is secondary, or there is scrofula or a state of feebleness, depletion is contra-indicated. Apart from leeching, the local treatment should consist in the use of emollient applications covered with oil-silk, and made sufiiciently irritating by mustard or otherwise to cause constant redness. If there are symptoms threatening convulsions, a mustard foot- bath repeated occasionally will usually tranquillize the nervous system and avert the danger. The diet should be bland and unirritating. In the first stages of the inflammation, ricexor barley-water, or arrowroot boiled in water, and similar drinks should constitute the main diet. When the active inflammation has abated, and at any period of the dis- ease if there is a tendency to prostration, more nourishing food should be given. Milk and animal broths may then be allowed. In cases which are protracted, or attended with symptoms of exhaustion, alcoholic stimulants are required. 624 CHOLERA INFANTUM. CHAPTER X. CHOLERA INFANTUM. Cholera infantum, or, as it is sometimes called, clioleriform diarrhoea, is a disease of the summer months ; and, with excep- tional cases, of the cities. It receives the name which designates it from the violence of its symptoms, which closely resemble those in Asiatic cholera. It is, however, quite distinct in its nature, occurring independently of the epidemics of that disease. Post- mortem examinations establish the fact that it is a non-inflamma- tory diarrhoea, but on account of the violence and striking character of its symptoms, and its great mortality, it is proper to describe it as a distinct disease. I have elsewhere stated that, as regards at least this city, the term cholera infantum has been so extended as to embrace a large part of the diarrhoeal maladies afl:ecting infants in the summer months. Some physicians apply it even to mild but protracted cases of ordinary non-inflammatory or inflammatory diarrhoea occurring in the season mentioned. I employ it, and it should, in my opinion, only be employed, to designate that form of infantile diarrhoea in which there are frequent watery, perhaps serous stools, accompanied by vomiting and rapid and great emaciation. More- over, when the disease ceases to be of this character, the term cholera infantum should no longer be applied to it, but it should receive another name indicative of the pathological state which has supervened. Intestinal inflammation frequently succeeds cholera infantum, and certain writers describe it as a stage of that disease. Properly, the inflammation should be regarded as a dis- tinct afl'ection, just as the enteritis, which sometimes results from cholera morbus, is not considered as a stage of that disease, but as a disease in itself. The number of deaths from cholera infantum reported in our bills of mortality is so large, while the number from the same disease embraced in the death statistics of European cities is so small comparatively, that some have been led to believe that this affection, whether termed cholera infantum, or, as l^y French CAUSES — SYMPTOMS. ()25 writers, cholerlform diarrlicea, is much more prevalent and fatal in this country than in Europe, wliereas, were these terms employed in all places to designate precisely the same disease, probably no great difference would be found in the prevalence of cholera infantum on the two sides of the Atlantic. Causes. — It has been stated that cholera infantum prevails mainly in the cities and in the summer months. Cases occur from .the month of May to October. Its maximum frequency and severity correspond with the degree of heat, and it is therefore most prevalent in the months of July and August. One of the chief causes of this disease is, doubtless, residence in an atmosphere loaded with noxious vapors, especially gases arising from animal and vegetable decomposition, or an atmosphere rendered impure by overcrowding and by personal and domiciliary uncleanliness. It is, therefore, much more common in tenement-houses and parts of the city occupied by the poor than in cleaner and less crowded streets and apartments. Summer heat and the anti-hygienic conditions to which it gives rise in the cities, sometimes appear to be sufficient in themselves to develop cholera infantum ; at least it occurs without other obvious cause. In other, and probably the majority of cases, another cause co-operates, namely, the use of improper food. Atmospheric heat and its depressing influences are then predis- posing causes, while the use of indigestible or irritating food is the exciting cause. Infants upon whom both causes are operative are most liable to cholera infantum in its severe form. Hence bottle- fed infants of the city are especially liable to it, and infants whose food is carelessly and improperly prepared. Often in the hot months, acid and indigestible fruits, as currants, heedlessly given to an infant, occasion the attack. Cholera infantum occurs commonly under the age of two years. It is so frequent during the period of first dentition, that some writers consider dentition a cause. At this period, however, as has been stated elsewhere, there is great functional activity, and rapid development of the intestinal follicles, and the peculiar liability to cholera infantum at this age should be attributed to this cause rather than to dentition. Symptoms. — Cholera infantum sometimes commences abruptly^ the previous health having been good. In other cases it is pre- ceded by a premonitory stage, that of simple diarrhoea. The stools are thinner than natural, and somewhat more frequent, but not such as to excite alarm. Suddenly the evacuations become more 40 626 CHOLERA INFANTUM. frequent and watery, and the parents are surprised and frightened by the rapid sinking and real danger of the infant. Occasionally this antecedent diarrhoea has continued several weeks, attended with emaciation, and associated, perhaps, with intestinal inflam- mation. This disease is characterized by the discharge of thin stools, designated by some watery, by others serous. The first evacuations, unless there has been previous diarrhcea, contain considerable faecal matter. They are so thin as to soak into the diaper almost like urine, and in some cases they scarcely produce more of a stain than does this secretion. The odor is peculiar, not fsecal, but musty and oftensive; occasionally the stools are almost odorless. Com- mencing simultaneously with the watery evacuations, or soon after, is another symptom, namely, irritability of the stomach, which increases greatly the prostration and danger. "Whatever is swal- lowed by the infant is rejected immediately, or after a few minutes, or there may be retching without vomiting. The appetite is lost, and the thirst is intense. Cold water, especially, is taken with avidity, and if the infant nurses, it eagerly seizes the breast, in order to relieve the thirst. The tongue is moist at first, and clean or covered with a light fur. The pulse is accelerated, while the respiration is either natural or somewhat increased in frequency ; the surface is warm, but its temperature is speedily reduced. There is no abdominal tenderness, and no evidence of pain. The infant is often restless at first, but its restlessness is due to thirst, or that unpleasant sensation which the sick exj^erience when the vital powers are rapidly reduced. The urine is scanty in propor- tion to the gravity of the attack. The loss of strength and the emaciation are more rapid than in any other diarrhceal malady, except Asiatic cholera, and the most severe form of cholera morbus. The parents scarcely recognize in the changed and melancholy aspect of the infant any resemblance to the features which it exhibited a day or two before. The eyes are sunken, the eyelids and lips are permanently open from the feeble contractile power of the muscles which close them, while the loss of the fluids from the tissues and the emaciation are such that bony angles become more prominent, and the skin in places lies in folds. As the disease approaches a fatal termination, which often occurs in two or three days, the infant remains quiet, not disturbed even by the flies which alight upon its face. The limbs and cheeks become cool ; the eyes bleared, and pupils contracted. A state of ANATOMICAL CHARACTERS. 627 stupor results, from which there is no relief, and which after a few hours ends in death. Often, even in cases which are ultimately fatal, there is not such a speedy termination of the disease. The choleriform diarrhoea ends in inflammation, which runs a protracted and ohstinate course. The disease then becomes the entero-colitis, inflammatory diarrhcea, or intestinal inflammation of writers. In the most favorable cases of cholera infantum the patient re- covers before the supervention of inflammation. Anatomical Characters. — Rilliet and Barthez, who of foreign writers treat of this disease at greatest length, describe it under the name of gastro-intestinal choleriform catarrh. "The perusal," they remark, "of the anatomico-pathological description, and es- pecially the study of the facts, show that the gastro-intestinal tube in subjects who succumb to this disease may be in four diflferent states: (a), either the stomach is softened without any lesion of the digestive tube ; (6), or the stomach is softened at the same time that the mucous membrane of the intestine, and especially its fol- licular apparatus is diseased ; (c), or the stomach is healthy whilst the follicular apparatus, or the mucous membrane, is diseased ; (d), or, finally, the gastro-intestinal tube is not the seat of any lesion appreciable to our senses in the present state of our knowledge, or it presents lesions so insignificant that they are not suflScient to explain the gravity of the symptoms. "So far the disease resembles all the catarrhs, but what is special is the abundance of the serous secretion, and the disturbance of the great sympathetic nerve. "The serous secretion, which appears to be produced by a per- spiration (analogous to that of the respiratory passages and of the skin) rather than by a follicular secretion, shows, perhaps, that the elimination of substances is efi'ected by other organs than the follicles ; perhaps, also, we ought to see a proof that the materials to eliminate are not the same as in simple catarrh. Upon all these points we are constrained to remain in doubt. We content our- selves with pointing out the fact." American writers very generally divide cholera infantum into three stages, the first characterized by turgescence of the intestinal follicles without inflammation, but perhaps attended by more or less softening of the mucous membrane. In the second stage intes- tinal inflammation is present. The mucous membrane of the in- testines is vascular in patches and streaks, sometimes thickened, and the solitary glands and patches of Peyer are inflamed, and oc- 628 CHOLERA INFANTUM. casionally certain of them are ulcerated. In tlie third stage the brain is involved. The cranial sinuses, veins, and capillaries of the brain are congested, and there is transudation of serum upon the surface of the brain or in the ventricles. But the second and third stages of these writers pertain, in my opinion, as I have already said, to entero-colitis, a supervening disease, and distinct from cholera infantum. The anatomical character of the first stage alone is that of cholera infantum, as the disease is understood by us. In our restricted use of the term, the appreciable lesions in cholera infantum are seen to be similar to those in the common forms of non-inflammatory diarrhoea. The following observations show the character of these lesions : — On the first of August, 1861, 1 made an autopsy of an infant sixteen months old, who died of cholera infantum, with a sickness of less than one day. The examination was made thirty hours after death. Il^othing unusual was observed in the brain, except, perhaps, a little more than the ordinary injection of vessels at the vertex; no disease of stomach and intestines except enlargement of the patches of Peyer as well as the solitary glands ; mucous membrane pale. In this and the following cases there was appa- rently slight softening of the intestinal mucous membrane ; but whether it was pathological or cadaveric is uncertain, as the weather was very w^arm. The liver seemed healthy. Examined by the microscope, it was found to contain about the normal amount of oil-globules. The second case was that of an infant seven months old, wet- nursed, who died July 26th, 1862, after a sickness also of about one day. He was previously emaciated, but without any definite ailment. The post-mortem examination was made on the 28th. The brain was somewhat softer than natural, but was otherwise healthy. There was no abnormal vascularity of the membranes of the brain, and no serous eftusion within the cranium. The mucous membrane of the intestines was of healthy appearance throughout, except that the solitary glands of the colon were enlarged. The patches of Peyer were not distinct. At the New York Prostestant Episcopal Orphan Asylum, an infant twenty months old, previously healthy, was seized with cholera infantum on the 25th of June, 1864. The dejections, as is usual in that disease, were frequent and watery, and attended by obstinate vomiting. Death occurred in slight spasms, in thirty- six hours. The exciting cause was apparently the use of a few currants, which were eaten in a cake the day before, some of which ANATOMICAL CnARACTERS, 629 fruit was contained in the first evacuations. The hrain was not examined. The only pathological changes which were observed in the stomach and intestines were slight vascular patches in the small intestines, scarcely sufficient to be considered inflammatory or even congestive, and an unusual prominence of the solitary glands in the colon. These glands resembled small beads imbed- ded in the mucous membrane. The lungs in the above cases were health}^, excepting hypostatic congestion. The lesions in the above cases obviously lacked those characters which indicate an inflammatory disease. The observations of others correspond with our own in reference to these severe and suddenly fatal cases. Dr. Hallowell, in a paper on this disease published in the Ame?-i- can Journal of the Medical Sciences^ J^^ly? 1847, says of the anatomical characters of the first stage: " These consist in an undue develop- ment of the follicles, both of the stomach and intestines, or of one of those organs, without inflammation of the mucous membrane." Dr. E. H. Parker, in a paper read before the IsTew York State Medical Society, February 4th, 1857, says : " When death occurs from the exhaustion produced by the profuse vomiting and diar- rhoea, a condition to which is given in this country the name of cholera infantum, we find the intestines to contain more or less of a soft, usually light yellow foecal matter, and the stomach a fluid resembling a thin gruel. The walls of the stomach are natural, unless the epithelial lining be a little too easily removed, the epi- thelial lining of the small intestines and sometimes of the large being in a similar state. The walls of the intestines are almost translucent, bloodless and apparently thin. Throughout their whole extent the solitary and agglomerated glands are very prominent, setting up almost like beads upon the surface." Both these writers, as well as Stewart in his monograph on cholera infantum, admit the frequent termination of the patho- logical state just described, in other words, of cholera infantum, according to our restricted use of the term, in entero-colitis. Most writers, as we have elsewhere stated, regard the entero-colitis as an advanced stage of cholera infantum. I believe that the opinion of writers is correct, that there is usually in chlorea infantum soft- ening of the gastro-intestinal mucous membrane, at least in places. But as the autopsies in this disease are made in the warmest weather, and after the lapse of several hours, it is difficult to de- cide how much of this change pertains to this disease and how much is post-mortem. 630 CHOLERA INFANTUM. "With the exception of the organs of digestion, no uniform lesion is observed in any of the viscera, unless such as is due to change in the quantity and fluidity of the blood, and in its circulation. Writers describe an anaemic appearance of the thoracic and abdomi- nal viscera, and occasional passive congestion of the cerebral ves- sels. The cerebral symptoms often present towards the close of life in unfavorable cases of cholera infantum may arise from a state of the brain similar to, if not identical with, spurious hydro- cephalus, which state is not attended by any uniform or certain lesion of this organ. As the urinary secretion is scanty or sup- pressed, cerebral symptoms may in certain cases be due to uraemia. Diagnosis. — This disease is diagnosticated by the symptoms, and especially by the frequency and character of the stools. The stools have already been described as frequent, often passed with considerable force, deficient in faecal matter, and thin, so as to soak into the diaper almost like urine. The vomiting, thirst, rapid sinking, and emaciation serve to distinguish cholera infantum from other diarrhoeal affections. When Asiatic cholera is prevalent, the differential diagnosis of the two diseases is difficult if not impossible. Prognosis. — This is one of those diseases in regard to which physicians often injure their reputation by not giving sufficient notice of the danger, or even by expressing a favorable opinion, when the case soon after ends fatally. A favorable prognosis should seldom be expressed without qualification. If the urgent symp- toms are relieved, still there is danger of the occurrence of intes- tinal inflammation, which, in hot weather, is formidable and often fatal. If the stools become more consistent and less frequent, without the occurrence of cerebral symptoms, we may confidently express the opinion that there is no present danger. The duration of true cholera infantum is short. It either ends fatally, or it begins soon to abate and ceases, or it is transformed into an inflammation. Death may occur, in twenty-four or forty- eight hours, in a state of collapse, from the frequency of the stools, or not till after three or four days. In general, if the patient is not relieved in three or four days, entero-colitis commences. Treatment. — The frequency and watery character of the stools in cholera infantum, and the consequent rapid sinking of the infant, call for prompt measures for the arrest of the disease. If there is any irritating substance in the stomach or intestines, which acts as an exciting cause of the vomiting or diarrhoea, or at least aggravates it, it is proper to commence treatment by the use TREATMENT. 631 of some cvacuant. Dr. James Jackson [Letters to a Young Physi- cian) says: "In the acute attacks of cholera infantum, the first object is the dislodgement of offending materials from the alimen- tary canal. In most cases the spontaneous efforts suffice to clear the stomach. But, occasionally, it is evident that these efforts fail to remove a load which the patient has imprudently been per- mitted to take into the stomach. Then small doses of ipecacuanha may be given with benefit till the burden is thrown off. Two to four grains will usually suffice. Much more frequently the efforts of the bowels are not successful in carrying off" their contents, and the stomach is at the same time so irritable as not easily to retain medicine. Then calomel is the great remedy. Whatever objec- tions theoretical men may make to the use of so potent a drug for a tender infant, few practical men, after having tried it, are willing; to treat this disease without this article. It is not offensive to the taste ; it can be retained when scarce any other medicine can be ; and, if vomiting follows a dose of it, the stomach becomes less irritable, so that a way is open for other medicines or for nourishment. By its operation the bowels are disburdened of their load with benefit. But it is a medicine which is slow in its operation, and castor oil may be used after it with advantage." Unless the stomach is quite irritable, castor oil, syrup of rhubarb, or, if there is a state of acidity, rhubarb and magnesia, are generally sufficient to remove the indigestible substance. Dr. E. H. Parker prefers the syrup of rhubarb in such cases. If the stomach is irri- table, so that the purgatives mentioned would be vomited, calomel is certainly the best medicine. This should not be given to the extent of more than one or two doses, and it may be aided by a simple enema. If there is no indigestible substance in the intestines, purgatives should not be used, as they would then do more harm than good. If the disease has continued several hours, it is probable that any irritating substance, which might have been present at first, has passed from the bowels, and no purgative is required. Treatment designed to diminish the frequency of the evacuations 'and improve their character, should be commenced at the earliest moment. Every hour that cholera infantum continues unchecked reduces the strength of the infant and diminishes his chance of recovery. Our main reliance must be on opium in some form. Dr. Jackson truly remarks that we have no substitute for it. "From three to five drops of the tincture of opium," says he, " may be given, and 632 CHOLERA INFANTUM. the dose may be repeated in eight or twelve hours." This he recommends "after the bowels are unburdened." It is better to give a smaller dose of opium and repeat it often. If laudanum is used, it may be given in one drop doses eYery two or three hours to a child one year old, its effect being watched. There is danger in this disease of the sudden supervention of stupor, amounting even to coma and ending fatally. In these cases the stools are g-enerally suddenly checked, and the opiate might aid in producing this result. In a few instances which I can recall to mind, where death occurred in this way, the friends believed that the melancholy result was hastened by the medicine. If the evacuations are partially checked and there are signs of stupor, the oj^iate should either be omitted or given less frequently. Explicit and positive directions to this effect should be given. Eligible preparations of opium for this disease are paregoric, tincture of opium, pulv. cretse comp. c. opio, and, if there is no irri- tability of stomach, Dover's powder. Astringents and often alkalies are useful employed as adjuvants of the opiate. The chief danger is from the frequent watery evacuations, and both these remedies certainly aid materially in restraining them. Astringents are less tolerated by an irritable stomach than either opium or chalk, so that it is often advisable to discontinue their use when they are vomited, in cases in which they would be very beneficial if the stomach were retentive. The opiate and alkali may be employed in the following combination: — ]^. Tinct. opii gtt. xij ; Mistur. cretse §iss. Misce. One teaspoonful eyery two or three hours to an infant one year old. To this mixture an astringent may be added, as tincture of catechn or kino. f I prefer for ordinary cases, as it is astringent, alkaline, opiate, and anti-emetic, the powder of subnitrate of bismuth and chalk with opium, already recommended for intestinal inflammation. By this mode of treatment the stools are generally in a few hours rendered less frequent and more consistent. There are physicians who believe that calomel given in small and repeated doses has a beneficial eft'ect in choleriform diarrhoea, but those who use it employ it in combination with opium, and it is probable that the good effect observed is largely due to the latter remedy. From the anatomical characters of cholera-infantum there is apparently no indication for a medicine that affects the function of the liver, and there is no evidence that calomel exerts any good effect on the follicular apparatus of the intestines, which, INTESTINAL WORMS. 633 80 far as wc can localize the disease, seems to be most in fault of any part of the digestive apparatus. On theoretical grounds, ^'\^ therefore, I should oppose the employment of this agent, and my observations of its effects have been such that I entirely discard its use while we have other safe and efficient remedies to meet every indication. Ordinarily, as the diarrhoea is relieved, the vomiting ceases. The opiate and alkaline remedies employed for the former are also curative of the latter ; still the vomiting, if frequent and obstinate, sometimes does require special treatment, and there are no better anti-emetic mixtures than those recommended in our remarks on the treatment of intestinal inflammation. In robust infants at the commencement of the attack, small pieces of ice taken in the mouth aid in diminishing the irritability of stomach. Mustard should also be applied to the epigastrium. In most cases alcoholic stimulants are required. The best of these is Bourbon whiskey or brandy, which should be used from an early period of the disease. Aside from its sustaining the vital powers, it aids also in relieving the irritability of stomach. The diet in cholera infantum should be simple but nutritious. It should be given little at a time and often. If the infant nurse, it should be confined to the breast. If weaned, cold barley or rice-water should be given, with whiskey or brandy, in the first stages of the disease, and afterwards milk or broths may be em- ployed in addition. If cholera infantum end in inflammation, the treatment already described for that disease should be adopted. CHAPTER XI. INTESTINAL WORMS. The belief has been prevalent in the profession, and is now in the community,' that the presence of worms in the intestines con- stitutes a frequent disease in early life. As the pathology of in- fancy and childhood, and especially the means of diagnosticating diseases, are better understood, this idea is gradually abandoned by the profession. Still, intestinal worms must be considered an occasional cause of serious derangement or even disease, and of death also. 634 INTESTINAL WORMS. Worms, indeed, may exist in the intestines without any appre- ciable deviation in the individual from a state of health. Ordi- narily, however, they in time give rise to symptoms so as to require the use of remedies for their expulsion. There are five kinds of worms whose habitat is the human intestines, namely, the ascaris lumbricoides, ascaris vermicularis, or, as it is sometimes called, the oxyuris vermicularis, the tricho- cephalus dispar, and two species of taenia. The ascaris lumbri- coides, when matured, measures from five inches to about a foot in length. Young ones are sometimes expelled not more than two inches in length. The color is a reddish-brown, with a shade of yellow. The dead worm has a paler color. The females are in numerical excess of the males, and their size is also greater. The worm in shape resembles the common earthworm, from which it derives the name lumbricus. It is, however, more pointed at both extremities than the earthworm, and the color is a paler red. The tail of the male worm is curved, while that of the female is straight. The mouth is triangular, and is surrounded by three tubercles. The ascaris lumbricoides resides usually in the small intestines. It occasionally enters the stomach, from which it is vomited, or it crawls up the oesophagus into the fauces, from which it is soon removed by the efforts of the individual. Cases are on record, one of which Andral witnessed, in which the worm entered the larynx, producing suftbcation and speedy death. M. Tonnelle also witnessed such a case. A child nine years old was suddenly seized with great difficulty of respiration and pain in the uj)per part of the chest. A careful examination of the thorax gave a negative result. Death occurred in from twelve to fifteen hours, and at the post-mortem examination a lumbricus was found filling the cavity of the larynx. M. Blandin, also, witnessed a case, when interne of the Hopital des Enfants. An infant was suffo- cated by one of these worms, which had penetrated as far as the right bronchus. Very rarely they crawl from the fauces into the nasal passages. This worm is so strong and active, that there is no recess or reflexion of the mucous membrane of the digestive apparatus which it could possibly penetrate, in which it has not been found. It has been discovered in the appendix vermiformis, in the pancreatic duct, in the common bile-duct, and even in the gall-bladder. The number of these worms found in the intestines is very various. There may be only one, or the number may be almost incredibly large. ASOARIS LUMBRIC0IDE3, 635 Thus, Barrier relates the case of an infant thirty months old, who died in Hospital Nccker. It was believed to be tubercular. Numerous tumors, which could be felt in the abdomen, were sup- posed to be tubercular masses. On making the post-mortem ex- amination, the mesenteric glands were found healthy, but the in- testines throughout their entire extent were filled with lumbrici. The masses which, during life, were believed to be tubercular glands, were found to consist of worms. The coecum, especially, was greatly distended by them. The intertwining or collection in balls of these worms constitutes, indeed, one of the chief dangers, as it renders them so much the more difficult of expulsion. The round worm, as this worm is commonly called, possesses no organs of penetration, still, if the intestine is weakened by disease, especially by ulceration, it may, by pressure with its head, force an opening through which it escapes into the cavity of the abdomen, causing peritonitis and death. This worm is often found, whether single or in masses, surrounded with mucus, which serves as a partial protection to the intestines. The portion of the mucous membrane in contact with lumbrici is often found inflamed, either from movements of the worm, or from pressure of a mass of worms, or even of a single worm in a confined position, as the appendix vermiformis. This inflamma- tion, continuing and increasing, may end in ulceration, and thus a weakened spot be produced, which may be ruptured by simple pressure of the mouth of the worm. In this way are, probably, to be explained those apparent cases of perforation, which have led some observers to believe that lumbrici had actually the power of penetrating the healthy coats of the intestines. M. Guersant describes a case in which the appendix vermiformis was found with an opening through which two lumbrici had partly passed into the abdominal cavity. The effect of their impaction in this narrow cul-de-sac was much like that of a bean or a seed lodged in the same situation. Lumbrici are sometimes found in a most remarkable location, namely, in little abscesses, external to the intestines, situated generally in the abdominal walls. These, after a time, in cer- tain cases, open externally, discharging pus, one or more worms, and perhaps a little excrementitious matter. They result from an opening in the intestine, through which the worm has passed, pro- ducing circumscribed inflammation and an abscess, and the intes- tine, now relieved of the irritant, heals before the abscess reaches the surface. 636 INTESTINAL WORMS. The mucous membrane in contact with the worm sometimes presents the natural appearance; in other cases, it is red, being evidently inflamed. ^ The ascaris vermicularis, or oxyuris vermicularis, or, as it is termed in the vernacular, the threadworm, is also frequent in childhood, and is the cause sometimes of much suifering, though generally of less dangerous symptoms than the round worm. Its habitat is the large intestine, commonly the rectum. Bremser states that he found it even in the caecum. This worm resembles pieces of white thread, and hence its common name. The female is larger than the male, measuring about half an inch in length, while the length of the male is not more than two or three lines, and it is pro]3ortionately more slender. It exists often in vast numbers in the rectum, from which it is expelled with the excre- mentitious matter. The head of the worm is blunt, and is furnished with a transparent vesicle. The tail is very slender, terminating in a spiral in the male, while it is straight in the female. These worms multiply rapidly, and they move actively their anterior extremity. In girls they sometimes enter the vagina, producing a leucorrhoeal discharge. The trichocephalus dispar, or the long threadworm, is also found in the large intestine, but oftener in the caput coli or ascending colon than elsewhere. It measures in length one and a half inches, sometimes even two inches. The anterior two-thirds are slender, resembling in size and appearance a hair, whence its name tricho- cephalus. The posterior third is considerably larger than the anterior, being, like the ascaris vermicularis, spiral in the male and straighter in the female. The worm is of a light color. Children are less frequently affected with the trichocephalus than with the two kinds just described. It rarely, if ever, produces any symptoms or does any appreciable injury. The tfenia, or tapeworm, is much less frequent than the round or threadworm. There are two recognized species, the taenia solium and taenia lata. These worms have minute heads, which are different in the two species. Their bodies consist of white flat segments, which are united in a diflferent manner in the two species. These segments near the head are small, as if rudimental, but as the distance from the head increases they enlarge, till their full development is attained. They are quadrilateral, having, when fully developed, greater length than breadth in the taenia solium, greater breadth than length in the taenia lata. The taenia is an hermaphrodite, each segment containing the CAUSES. 637 reproductive organs complete. The oviduct opens in the centre of the flat surface in the taenia solium, upon the edge of the segment in the taenia lata. The taenia attains a great length, but its maximum of growth is not ascertained, as pieces are generally detached and expelled from time to time before the removal of the entire worm. The taenia lata is supposed to attain the length of about fifteen feet. The taenia solium is considerably longer. The taenia is rare in early life, but cases now and then occur. I have met but one case in this city under the age of five years. Rosen and Bremser report cases between the ages of six and eleven years, and Ilufeland, one at the age of six months. "Wawruch collected 206 observations of taenia, in 22 of which the age was less than fifteen years ; the youngest was a girl of three years. A most remarkable case of taenia is reported in the Gazette Medicale of Paris in 1837. M. MuUer was called to treat a foster child five days old for slight constipation. The bowels were evacuated by the use of rhubarb, manna, and a few grains of salt, and in the excrement a foot and a half of taenia were discovered. This worm had evidently existed during the foetal life of the infant. A similar case was treated by Prof. Skene, in the Long Island Hospital, in September, 1871, and reported by Dr. Armor in the New York Medical Journal. The infant was born, September 3d, of a hearty Irish servant girl. On the 7th it refused to nurse, and was observed to have a mild form of tetanus. On the 8th small doses of calomel having been given, followed by castor oil, two segments of a taenia solium were passed from the bowels, and on subsequent days ten more segments, after which the tetanus ceased. The remedies employed after September 8th were the oil of male fern and turpentine. The mother, who had presented no symptoms of taenia, was ordered an emulsion of pumpkin-seeds, which " she faith- fully took for twenty-four hours, at the end of which she passed over seventy segments of taenia." This case is interesting as throwing light on a possible mode of the production of taenia, quite difterent from the ordinary and recognized mode, and also as showing the causative relation of intestinal worms to tetanus infantum. Causes. — The vermicular disease is much more common in one locality than another. Thus, in Paris there are few cases, while in the provinces of France and many other parts of Europe it is a common affection. It is more common in this city among the children of the poor than those in the better walks of life. 638 INTESTINAL WORMS. In the same region, with an identity of regimen, pursuits, and habits, it is sometimes common in one season, and rare in another. It is an interesting fact, also, as showing the influence of local causes, which we often cannot appreciate, that, in countries where the disease prevails, the relative frequency of the diiFerent kinds of worms is often different. Thus, in England, Holland, and Ger- many, the taenia solium is common, and the tsenia lata rare, while the reverse is true of Russia, Poland, and Switzerland. There is often some derangement or disease of the digestive system, which is favorable for the growth of intestinal worms. In cases of continued indigestion, accompanied by irritation or sub- acute inflammation of the mucous surface, with an excessive secre- tion of mucus, worms are apt to be generated, which aggravate the primary affection. Children in the last stages of typhoid fever not infrequently pass lumbrici in the evacuations from the bowels. It has long been a common and correct belief that the use of certain kinds of food favors the development of worms. Fruits in excess, food of an inferior quality, or but partially cooked, remain- ing an unusual time unassimilated in the intestines, afford a nidus in which worms are very apt to appear. The same may be said of saccharine substances, taken in too large quantity or too fre- quently. An excess of food, even of good quality, is also a cause, since this gives rise to the predisposing condition of undigested nutriment in the intestines. The period of childhood is mentioned by writers as one of the predisposing causes. Both the round and threadworms occur oftenest in children between the ages of three and ten years, but they are not very infrequent at any age between the first year and puberty. I have witnessed a large number of autopsies of infants in the institutions of this city, and, although the intestines in a large proportion of them were examined, I can recall only one instance in which intestinal worms were present when death had occurred in the first year. This immunity is, however, in great part attri- butable to the simple diet of these institutions. The infrequency of worms in the first year of life is an important practical fact. The immunity is greatest, for obvious reasons, in those who are nourished entirely or almost entirely at the breast. In this city, children of the poor, living in almost total disregard of sanitary requirements, are especially liable to worms. This is attributable not only to the character of their food, which is often of inferior quality and poorly prepared, but also to the filthy and insalubrious state of the domiciles and streets in which they reside. SYMPTOMS. 639 and the consequent cachexia. One of the older writers remarks that intestinal worms, like confervoid growths, thrive best where it is filthy and dark. Though such analogical reasoning is not to be accepted, the fact remains of the great liability to worms of those children who reside in insalubrious and humid localities which are favorable also for cryptogamic vegetation. Symptoms op Lumbrici. — These are in part constitutional or sympathetic, and in patt local, due to the mechanical effect of these entozoa on the coats of the intestines. Writers, especially Rillict and Barthez, have described the symptoms supposed to indicate lumbrici with minuteness. Those of a constitutional or sympathetic character are the following : Features sometimes flushed, sometimes pallid, and sometimes of a leaden hue ; lower eyelids swollen, and sometimes surrounded by a blue semicircle ; thirst, nausea, or even vomiting ; appetite diminished, or entirely lost, or, on the other hand, augmented ; breath foul ; papillae of the tongue red and projecting ; pulse accelerated and irregular. Rilliet and Barthez state that they observed this irregularity in a boy three years old, at the time he was passing a large number of lumbrici. The irregularity afterwards disappeared. Accele- ration of the pulse is one of the most common symptoms of these worms. The popular idea of " worm fever" has indeed a founda- tion in fact. This fever is often remittent and mild, but occasion- ally it is continuous and intense. The symptoms pertaining to the nervous system are important. In mild cases they may be absent, as when there are few lumbrici, and the child is robust, and over the age of five years, but in severe cases more or fewer of these symptoms are commonly present. They are dilation of the pupils, especially inequality of dilation, to which Munro attached diagnostic value ; strabismus, twitching of the muscles, clonic convulsions, somnolence, headache, neuralgic pains, delirium. Rarely chorea, deafness, and paralysis, it is be- lieved, may result. (M. Bouchut, Gaz. des Hopitaux, 1867.) Hy- persesthesia of the abdominal surface was present in a case which I attended, and which subsided as soon as the lumbrici were ex- pelled. Grinding the teeth in sleep, and picking the nostrils, are symptoms to which families attach great value. Observations, however, show that, though sometimes due to worms, they more fre- quently have another cause. The local symptoms or disorders, in other words those having a mechanical origin, are colicky pains, experienced chiefly in the umbilical region ; in some patients, simple non-inflammatory diar- 640 INTESTINAL WORMS. rhoea ; in others, enteritis ; and in others still, colitis ; stools some- times natural ; in other cases, liquid but fecal ; and in others still, muco-sanguineous ; flatulence. M. Davaine, at a recent period, made the important discovery that the feeces of patients aftected with worms contain the ova of the particular species present, in large numbers. The ovum of the lumbricus is oval and granular, while that of the trichocephalus is spherical, with a small projec- tion at each end, those of the threadworm oval and irregular, and those of the taenia round. These ova can be seen through a lens magnifying 150 diameters. In exceptional cases, there are local symptoms due to the pre- sence of worms in unusual situations, such as a crawling sensation in the oesophagus; a sense of constriction in this tube or the pharynx; nausea and vomiting; a cough, especially if the worm has crawled to the upper part of the oesophagus; rarely the most urgent dyspnoea, and probable suflbcation, if a lumbricus has entered the larynx. The enteritis and colitis, to which these worms sometimes give rise, is ordinarily mild, but in rare instances ulceration occurs, which ma}^ be attended by profuse and even fatal hemorrhage. Occasionally very painful and dangerous constipation results from an accumulation of worms, in a ball or mass, too large to be ex- pelled, unless with much delay and suffering, preventing the pas- sage of faecal matter, and producing severe abdominal pains. The symptoms in these cases resemble closely those of intussusception. A marked example of constipation produced in this way occurred in a family with whom I am acquainted, and who then resided in the interior of this State. A little girl of three or four years was suddenly affected with obstinate constipation. The physicians prescribed active purgatives, calomel among others, and finally croton oil, and various injections, without relief. There was great pain, with distension of the abdomen, and death seemed inevitable, when, after the lapse of several days, a free evacuation occurred, and in the stool was a mass of worms firmly intertwined. Children often have lumbrici without any appreciable impair- ment of the general health, but their presence may intensify the symptoms of intercurrent diseases, and greatly increase the danger. Thus, I recollect two children of three and three and a half years, with pneumonitis, who, at the same time, had lumbrici, one passing in the course of a few days thirty and the other twelve of these entozoa. Both presented well-marked physical signs of pneumo- nitis, and, though they recovered, the febrile movement and nervous DIAGNOSIS. 641 symptoms wore 722 APPENDIX, C). All glasses, cups, or otlier vessels, used bj^ or about the patient, are scrupulously cleaned before being used b}^ others. T. The discharges from the bowel and kidnej' are received, on their very issue from the body, into vessels charged with disinfectants. By these measures, the greater part of the germs which are thrown oft" by internal surfaces are robbed of their power to propagate the fever. Those which are thrown off" by the skin require somewhat different management. If my information do not mislead me, it is in dealing with these that the practice of medical men generally is most defective. There are, no doubt, distinguished exceptions ; but for the most part, either nothing is done, or what is done is done imj^erfectly or too late. And yet to destroy from the first, as far as possible, the infectious power of what emanates from the skin, is, for obvious reasons, the most important object of all in the way of prevention. In the first place, as the skin is at once the most extensive surface of the body, and is, par excellence, the seat of what, b}^ a very just figure, is called the eruption, the crop of new poison which escapes by the skin probably far exceeds in amount that which escapes by the other surfaces. It is impossible to speak in exact figures here. We cannot count these things as we count peas, or beans, or grains of wheat. But the care of smallpox furnishes us with a standard which cannot far mislead us. And, as we know that, in a case of confluent smallpox, enough new poison is thrown off actually to inoculate with smallpox myriads of others, so there is every reason to believe that the skin-crop in a severe case of scarlet fever is little, if at all, less prolific. In the next place, as the process of desquamation, by which this crop is finally cast loose, is a ver}'- slow one — lasting, for the most part, over many weeks — the infection from this source is much more abiding than that from the internal sources. But what renders it still more so is the all-important fact that the poison which is liberated by the skin is liberated in the dried state. It is well known — and, indeed, the circum- stance has been taken advantage of in the practice of inoculation by cowpox and other poisons — that animal poisons, when dried at a gentle heat, retain their powers for quite indefinite periods of time. But to be dried at a gentle heat — a heat lower in fact than that which attended its own generation — is precisely the case of the scarlet fever poison, as cast off" by the skin. Another danger is created by the minute and impalpable form in which the particles armed with the poison are set free. The skin peels oft' in part, no doubt, in flakes of palpable size, but in still greater part, under the guise of dust, which floats in the air, impalpable like motes in the sunbeam. Each of these little atoms is, potentiall}', the scarlet fever. While the}'- adhere to the body, the}^ may be readily disarmed; but once .afloat, they are in great degree beyond our power. APPENDIX. 72 It is to these various circumstances — to the countless profusion of the new seed, if I may so speak, which is generated and sown broadcast bj' every fresh case — to the length of time during which it hangs about the sick, capable every moment of being transferred, with all its deadly power, to thing or person — to the impalpable minuteness of the organic particles in which this seed is iniV)cddcd — and, lastly, to the long reten- tion of their properties, in virtue of being in the dried state — that we must look mainly for the true explanation of the well-known subtleness and tenacity of this particular infection. To the many striking illus- trations of this subtlety and tenacity on record, I could, if there were need, add many of my own, quite as striking, and free from all ambiguity; but it is a waste of time and space to burden the page with what is already conceded, and with what most men must be sufficiently familiar. These same circumstances are the source of the peculiar embarrass- ment and perplexit3% which, in scarlet fever, hang over the disposal of the convalescent, and the period, so much debated, and at present con- fessedly undetermined, at which he may be safely restored to society. According to my own experience, these difficulties and perplexities may be entirely averted by the employment of the simplest precautious. To be successful, these precautions must be put in force earlj^, and must be thoroughl}' carried out. The first thing to aim at, is, to prevent the minute particles, which are the carriers of the poison, from taking wing, until they can be disenfected in situ. This, I find, can be perfectly effected by simply anointing the surface of the bod^^, scalp included, twice a day with olive oil. The oil I use is, generally, slightly impreg- nated with camphor. As far as the main object is concerned, the addition is perhaps unimportant; but it is agreeable to the patient, and probably has some part in the relief, which almost always follows the inunction, from the troublesome itching, which is a well-known incident of some stages of the disorder. Current views would, perhaps, indicate carbolic acid as a fitter adjunct; but, having found the camphorated oil to answer perfectly, I have thought it tl>e part of wisdom to make no change. I may add, that the process, so far from being trying, is very soothing to the sick; and, if it exert any influence at all on the evolu- tion of the disorder, this influence appears to be beneficial rather than otherwise. The precise period at which it should be begun varies somewhat, no doubt, in different cases. As early as the fourth day of the eruption, a white efflorescence may often be observed on the skin of the neck and arms, which marks the first liberation of the new death- giving brood. This efflorescence should be made the signal for the first employment of the oil. From this time, the oiling is continued until the patient is well enough to take a warm bath, in which the whole person — scalp again included — is well scrubbed, disinfecting soap being 72-i APPENDIX. abundantl}^ used during the process. These baths are repeated every other day, until four have beeu taken, when, as far as the skin is con- cerned, the disinfection may be regarded as complete. If the health be quite recovered — if, in particular, there be no disease of kidney and no discharge from throat or nostril — the patient (equipped, of course, in a new or perfectly untainted suit) may generally be restored without risk to his famil}'. A week or ten days' additional quarantine is, however, seldom objected to; and is, on the whole, perhaps more prudent. Many medical men are in the habit of fumigating the sick-room, either con- stantly or several times a da}^, with chlorine or sulphurous acid, pending the whole course of the fever. There can be no objection to this measure; but I do not myself attach much importance to it. Experience of the largest and most decisive kind has shown that chlorine — and I believe the observation applies equally to the other chemical agent — in the degree of atmospheric impregnation respirable by man, has no appreciable influence in preventing the spread of infectious disorders. To complete the preventive code, immediately after the illness is over — whether ending in death or recover}^ — the dresses worn by the nurses (which, where possible, should be of linen, or some smooth thing) are washed or destroyed, and the bed and room that have been occupied by the sick are thoroughly disinfected. With these measures, when well and thoroughly done, the taint is finally extinguished. ThQ success of this method, in my own hands, has been ver}- remarkable. For a period of nearly twenty j^ears, during which I have employed it in a ver^'^ wide field, I have never known the disease to spread in a single instance ])eyond the sick-room, and' in very few instances within it. Time after time I have treated this fever in houses crowded from attic to base- ment, with children and others, who have nevertheless escaped infection. The two elements in the method are, separation on the one hand, and disinfection on the other. (British Medical Journal, Jan. 9th, 1869.) The Health Board of ^S'ew York enforce the following Sanitary Reg-ulations against Scarlatina and Measles: — Every case must be reported to the City Sanitary Inspector upon its first recognized appearance. Care of Patients. — The patient should be placed in a separate room, and no person except the phj'sician, nurse, or mother, allowed to enter the room, or to touch the bedding or clothing used in the sick-room, until ih&y have beeu thoroughly disinfected. Infected Articles. — All clothing, bedding, or other articles not absolutely necessary- for the use of the patient, should be removed from the sick-room. Articles used about the patient, such as sheets, pillow cases, blankets, or clothes, must not be removed from the sick-room until they have been disinfected, by placing them in a tub witli the following disinfecting fluid: eight ounces of sulphate of zinc, one ounce of carbolic acid, three gallons of water. APPENDIX. 725 ThcN'' should be soaked in this fluid for at least one hour, and then placed in boiling water for washing. A piece of muslin, one foot square, should be dipped in the same solution and suspended in tlie sick-room constantly, and the same should be done in the hallway adjoining the sick-room. Feather l)eds and pillows, liair pillows and mattresses, and flannels or woollen goods, require fumigation, and should not be removed from the sick-room until after this has been done. Whenever the patient is removed from the sick-room, notify the Bureau of Sanitary Inspection, when the disinfecting corps will as soon as possible thereafter perform the work of fumigation. All vessels used for receiving the discharges of patients should have some of the same disinfecting fluid constantly therein, and immediately after use by the patient be emptied and cleansed with boiling water. Water closets and privies should also be disinfected daily with the same fluid, or a solution of chloride of iron, one pound to a gallon of water, adding one or two ounces of carbolic acid. All straw beds should be burned, but must not be removed from the sick-room without a permit from this department. They will be removed by the disinfecting corps. It is advised not to use handkerchiefs about the patient, but rather soft rags for cleansing the nostrils and mouth, which should be imme- diatel}'" thereafter burned. The ceilings and side walls of the sick-room after removal of the patient should be thoroughly cleaned and lime washed, and the wood- work and floor thorougly scrubbed with soap and water. C. REMARKS ON THE DIPHTHERITIC MEMBRANE. By Dr. Edward Rindfleisch, Professor of Pathological Anatomy in Bonn. Genuine diphtheritis has no claim to be regarded as a specific process in the same measure as croup. That which microscopically characterizes it, and has become the occasion of placing it as a membranous inflam- mation by the side of the pseudo-membranous inflammation, is the formation of a whitish-graj', often discolored by reddish and green (blood-coloring matter) tints, compact, felted membrane, which is ele- vated, perhaps, to the height of one-half line alone the level of the mucous membrane, but penetrates just as deep into the substance of the mucous membrane, and is most intimately connected with the latter. This membrane is nothing that is superimposed, nothing secreted, but 726 APPENDIX. the mucosa itself, as far as it has been partly tumefied, partly rendered anosraic, even by the excessive infiltration with cells. This condition has not improperly been compared with a mortification by a chemical agent, with a corrosion, and the diphtheritic membrane has been desig- nated as diphtheritic scab ; in fact the diphtheritic membrane is a caput mortuum, it can undergo no other changes than those of putrefaction, of decomposition ; and the question only is, how it is loosened and removed from the intimate organic connection in which it stands with the mucous membrane. A sharply defined boundary line separates, as we can convince ourselves with the naked ej'e, the living from the dead ; but numerous connective-tissue fibres, bloodvessels, nerves, and elastic fibres, pass over from the living into the dead ; they must all have separated ere the loosening can proceed. The means which are placed at the command of the organism are inflammation and suppuration. We call this inflammation "reactive," and unite with it the idea as though this were an answer to the irritation, which the diphtheritic scab exerts upon the surrounding mucous membrane; yet a portion of the hyperemia also may be explained according to static principles as collateral fluxion. The pus collects between the scab and the healthy parts and always, accordingly as the fibrous bridges mentioned melt down and tear, the separation begins now at the edges, then at the centre. After it is completed an ulcer remains behind which is disposed to rapid cicatrization ; not unfrequently, however, the process repeats itself again at the same place ; we have a new scab, and with it anew the necessity of a purulent separation, after whose termination a very considerable loss of substance remains. The cicatrices finally resulting distinguish themselves by their capacit}'^ of vigorous retraction, so that the danger of subsequent contraction of mucous membrane canals, especially of the large intestine after dj^sentery, threatens so much the more, the more diff'used the ulceration was. (^Text-hook of Pathological Histology, translated, page 354.) E. The following observations relate to the state of the liver in that form of infantile entero-colitis which prevails in the summer months, especially in the cities. They were made in order to determine the correctness or falsity of a prett}'^ general belief on the part of city practitioners, arising probably from the frequent green appearance of the stools, that the function of the liver is perverted, and the bile there- fore unhealth}', in this disease. These observations are sufficiently numerous, in my opinion, to prove that mercurial or other treatment ArrEN])ix. 727 designed to modify or correct the function of this organ is not justified by the anatornicid characters of the disease. Juno 8, 1850. Aij^c'd 5 months; duratinii of sickness, G days. Liver appeared liealtliy; about the usual size. June 8, 1850. A_<,n'd :! uionlhs; duration of sickness, 20 days. Liver of usual size and color ; it contained tiic usual amount of oil globules; from one to six or eight globules in each hepatic cell. June 10, 1850. Aged 4 months; duration of sickness, 5 days. Liver of ordinary appearance; contains rallier less fatty matter than usual; few hepatic cells con- tained nu)re than tive or six oil glolMilcs. July 4, 1850. Agetl 7 nu)nths ; duration of sickness, 3 weeks. Liver of yellower hue than natural ; not enlarged; the oil globules considerably exceeded the usual amount. July 10, 1850. Aged weeks ; duration of sickness, 3 weeks. Liver small and almost destitute of oil globnles ; nine-tentlis of the hepatic cells (iontained none. August 8, 1850. Aged 7 months ; duration of sickness, 1 month. Liver appeared healthy; weighing oz. iv. August 15, 1859. Aged 19 months ; duration of sickness, several weeks. Liver extended half an inch below the margin of tlie ribs ; weighed oz. ix ; but few oil glob\iles in most of the hepatic cells ; a few contained numerous small glo1)ules. August 15, 1859. Aged 15 months ; duration of sickness, 2 months. Liver of usual appearance ; weight, oz. vijss ; nothing unusual observed in this organ under the microscope. August 15, 1859. Aged 14 mouths ; duration of sickness, 3 weeks. Liver weiglied oz. ix ; its appearance natural both to the naked eye, and under the microscope. August 17, 1859. Aged 15 montlis ; duration of sickness, several weeks. Liver appeared healtliy ; weight, oz. vj. August 22, 1859. Liver of normal appearance; it contained the usual amount of oil globules; weight, oz. viij. August 27, 1859. Aged months. Liver of natural color generally, but yellow in places ; weight, oz. viij ; no more than the usual amount of fatty matter dis- covered by the microscope. August 31, 1859. Aged 5 months ; duration of sickness, at least one month. Surf^ice of liver mottled of a yellow color ; no excess of oil globules generally ; weight of liver, oz. vjss. September 4, 1859. Aged 2 months ; duration of sickness, one week. Liver of normal appearance ; few hepatic cells contained more than four oil globules and many contained none ; little free oily matter. September 5, 1850. Age 16 months. Liver small ; weighing oz. vj, and con- taining very little oily matter. September 15, 1859. Aged 23 months ; duration of sickness, all summer. Liver quite fatty ; weighing oz. xv ; had tuberculosis. July 3, 1860. Aged 13 months ; duration of sickness, nearly one month. Liver of yellow color ; weight, oz. vj ; hepatic cells contained somewhat more than the usual oily matter. July 3, 1860. Aged 4 weeks. Liver extended two inches below the ribs ; weight, ■oz. V ; contained few oil globules. August 4, 1860. Duration of sickness, 2 weeks. Liver weighed oz. ix ; mottled yellow ; very fatt3^ August 7, 1860. Aged 2 months ; duration of sickness, 10 days. Anterior bor- der of liver even with the margin of the ribs ; weight, oz. iijss ; usual color ; very few oil globules, free or in the heijatic cells. August 8, 1860. Aged 2 years. Liver mottled with yellow, evidently fatty spots or patches. August 17, 1800. Liver extended half an inch below the lower margin of the ribs ; of usual color ; weight, oz. v. August 30, 1860. Aged 5 months ; duration of sickness, 1 week. Liver extended half an inch below the margin of the ribs ; rather yellow ; weight, oz. ix ; numerous oil globules, both free and in the hepatic cells. July 18, 1861. Liver about the usual size and appearance, except that the color is lighter in some places than in others. August 1, 1861. Aged 2 months; dui'ation of sickness, about 1 week. Liver small and very dark ; the microscope showed it to be almost destitute of oily matter. 728 APPENDIX. Axignst 12, 1861. Aged 3i months. Anterior margin of liver even with the ribs ; weight, oz. vss. August 19, 1861. Aged 15 months. "Weight of liver, oz. ixss ; contained the normal amount of fat. August 21, 1861. Aged a few months. Liver of usual appearance ; weight oz. iijss. October 9, 1861. Aged 20 months; duration of sickness, all summer. Liver rather j-ellow, but not uniformly ; weight, oz. ix ; some hepatic cells free from fat ; others loaded with it. July 7, 1862. Aged 4 months; duration of sickness, several weeks. Weight of liver, 'oz. v ; yellow, very fatty. August 27, 1862. Aged 7 months; duration of sickness,^ several weeks. Liver examined bv the microscope seemed healthy ; weight, oz. vi:^. August 29, 1862. Aged 10 months ; duration of sickness, 1 week. Weight of liver, oz. vif^ ; appeared healthy, except an increase in the amount of oil globules. F. INTUSSUSCEPTION IN SMALL INTESTINE. No. 1. Aged 12 years. Had pain in abdomen two or three weeks previously. Died the fifth day. Twelve inches of the upper part of the jejunum invaginated in the next twelve inches below. (M. R. Trevor, Amer. Journ. Med. Sci., Jan. 1852.) No. 2. Aged 3 years. Previous health not stated. Died the second day. At about the junction of the jejunum and ileum, twenty-six inches of intestine had been received into six inches. (Isaac Thomas, M.D., Amer. Med. Recorder. 1823.) No. 3. Aged 4^ months. Previous health good. Died the fourteenth day. Locality of disease, upper part of ileum ; the mass Avas two-thirds of an inch long. (Dr. J. L. Smith, Amer. Med. Times, July 18, 1863.) No. 4. Aged 4 months. Had entero-colitis previously to and during the intus- susception. Four invaginations in the jejunum, each from one to one and a half inches in extent. (Records of N. Y. Infant Asylum, July 18, 1803.) INTUSSUSCEPTION 0^ ILEUM INTO COLON. No. 5. Age not stated. Had previously constipation, followed by diarrhoea and convulsions. Died on the fifth day. Two inches of the ileum projected into the ccecum. (Dr. Mayne, Path. Soc. Dublin, March 16, 1839.) No. 6. Aged 2 years. Previously well. Died the second day. About three inches of the Ileum Inverted had passed through the ileo-coecal valve into the colon. (Dr. Coggswell, Lond. Lane, July, 1853.) No. 7. Aged 4 years. Previously well, except slight diarrhoea. Died the tenth day. Thirteen inches of the ileum had passed through the ileo-ccecal valve into the coecum. (Mr. Filleter, Lond. Lane, May, 1855.) No. 8. Aged 3 years. Previous health not given. Died after seven days. At least a foot of the ileum had passed through the ileo-coecal valve. (Mr. Nunnelly, Path. Soc. London, ]\rarch 20, 1860.) No. 9. Aged 4 months. Previous health good. Died after six weeks. The ileum, still adherent, had passed through the entire colon, so as to protrude six inches beyond the anus. (S. Jones, Lond. Path. Soc, 1857.) No. 10. Aged 6 months. Previously well. Died the third day. The ileum had passed through the ccecum and into the ascending colon. (Dr. Cotting, Bost. Soc. for Med. Improvement, July, 1852.) No. 11. Aged 4 years and 9 months. Had a cough, and since the age of eigh- teen montlis, tliread worms; was annoyed by these tiie day before the sickness. Died the fiftli day. Seven inches of the ileum had passed through the ileo-ca?cal valve. (Dr. Hare, Lond. Path. Soc, October 16, 1848.) APPENDIX. 729 INVAGINATION OF THE CCECUM, ILEUM AND CCECUM, Oil ILEUM, C(ECUM, AND COLON. No. 13. Aged 5 months. Previous health good. Died the fifth day. Six inches of the ileum and the ascending colon were invaginated in the sigmoid flexure and rectum. (Thomas lUi/ard, IMed-Ciiir. Trans., vol. i.) No. 13. Aged 4 months. Previous health good. Lived more than one week. A small portion of the ileum and the entire colon to the sigmoid flexure, Avere iml)edded in the latter. (Alfred Markwick, Lond. Lane., 1846.) No. 14. Aged 1 year. Diarrha\a previously. Died on the seventh day. A portion of the ileum with the co'cum invaginated in the ascending and transverse colon. (Di-. O'Ferrall, Lond. Med. Times, January 1(5, 1847.) No. 15. Aged G months. Previous health good. Died the third day. Several inches of the ileum, the ccecum, the ascending and the transverse colon, were lodged in the remainder of the transverse and in the descending colon. (Chas. Clarke, Lond. Lane, August 18, 1849.) No. 10. Aged 4 months. Previous health good. Died the third day. Lower part of the ileum, the coecum, ascending colon, and greater part of the transverse were imbedded in the descending portion. (E. Y. Steele, Lond. Lane, June 23, 1849.) No. 17. Aged 4 months. Sick two days previously. Died the third day. Ca?cum and ascending colon invaixinated in the transverse and descending colon. (P. P. Nind, Lond. Lane, June 23, 1849.) No. 18. Aged 20 months. Previous health not stated. Died on the fourth day. Six or seven inches of the lower portion of the ileum, the ccecum, and the ascending colon were filled with inverted intestine ; the six or seven inches of the ileum were drawn together so as to measure only one inch, and this part of the ileum had formed a second invagination in the ccecum to the extent of two inches. (Mr. Ta.ylor, Loud. Lane., 1843.) No. 19. Aged 4 years. Previous health not stated. Lived three days. Lower part of the ileum and the entire colon were invao'inated in the rectum. (W. S. Partridge, Prov. Med. and Surg. Jouru., May 3, 1848.) No. 20. Aged 5 months. Previous health not stated. About one inch of the ileum and the entire colon to the left hypochoudrium were lodged in the remaining portion of the colon and in the rectum. (R. Harlan, M.D., F.R.S., Med. and Phys. Researches.) No. 21. Aged 6 years. Diarrhoea and pain in abdomen. The caput coli and the first half of the colon had descended through the other half and the rectum ; the lower part of the ileum was drawn down through the centre of the iutusus- ceplion to the anus. (Mr. Davis, Med. Repos., December, 1824.) No. 23. Aged 9 months. Had occasional diarrhoea. Died the third day. A considerable portion of the ileum and the caput coli had been forced up the ascend- ing colon, across the transverse and down to the rectum. (H. Cunningham, Lond. Med. Gaz., September 15, 1838.) No. 23. Aged 4 months. Previous health not given. Died the fourth day. Lower portion of the ileum, the ascending cohm, and a part of the transverse colon were invaginated in the remaining portion of the colon and the rectum. (Alex. Munro, Path. Anat. of the Aliment. Canal.) No. 24. Aged 4 mouths. Previous health good. Died the third day. Ccecum and ascending colon were lodged in the transverse and beginning of the descending portions : in the interior of the mass was a second invagination, that of the ileum. (Dr. Ryan, Med. Soc. of Lond., October 27. 1835.) No. 25. Aged 4 months. Previous health good. Died the second day. Part of the ileum and cn:>cum and a considerable portion of the colon were invaginated. (Evory Kennedy, Dub. Jouru. of Med. Sci., March 1, 1844.) No. 86. Aged 7 months. Previous health good. Died the third day. Part of the ileum and the coecum had descended through the colon and rectum to within half an inch of the anus. (Dr. Buchanan, Lond. Path. Soc, Maj' 3, 1859.) No. 27. Aged 6 months. Previous health good. Died the fifth day. A part of the ileum and the whole upper portion of the large intestines were inclosed in the descending colon and the rectum, to within two inches of the anus. (Mr. Ballard, Lond. Path. Soc, January 6, 1857.) No. 28. Aged 3 months. Previous health good. Died the third day. Part of the ileum and the ascending and transverse colon were lodged in the 'descending colon. (J. W. Perriu, Lancet, March 26, 1853.) 730 APPENDIX. No. 29. Aged 3 months. Previous health not stated. Died the first day. A large part of the ileum, the ascending and transverse colon were iuvaginated in the descending portion. (M. Judson,'Gaz. Med., Decembre, 1837.) No. 30. Aged 3i years. Almost constant pain in the bowels for three months before death. The coecum and entire colon, to within eleven inches of the anus, were invaginated in the remainder of the colon and in the rectum. The inclosed intestine protruded five or six inches beyond the anus. (M. Robin, Mem. de I'Acad. Roy. de Chirurg., 1784.) No. 31. Aged 4 years. Had dysentery previously. Died after sickness of nearly a month. The ascending and transverse colon were found in the sigmoid flexure and rectum ; the ileum extended uninverted through the whole mass. (John C. Lettsom. M.D., F.R.S.) No. 32. Aged 9 months. Previous health delicate, but without disease. Died the second day. Six inches of the ileum, the ascending and transverse colon lay within the descending colon and the rectum. (Mr. Young, Brit. Med. Jouru., September 24, 1859.) No. 33. Aged lU months. Previous health not stated. Died the third day. About four inches oT the ileum, the ascending and transverse colon, were invagi- nated in the descending colon. (Mr. Clarke, "Lond. Lane, February 17, 1838.) No. 34. Aged 6 months. Previous health not stated. Died the eighth day. The coecum, ascending and transverse portions of the colon were invaginated in the descending colon. (E. Smith, Lond. Path. Soc, December 4, 1848. No. 35. Aged 4 months. Previous health good. Died in nineteen hours. Lower portion of the ileum incarcerated in the ascending colon, which was also invaginated in the arch. (Mr. Gorham, Guy's Hosp. Reports, October, 1838.) No. 36. Aged 3 months and 4 days. Previous health good. Died on the eighth day. Twelvd inches of the ileum doubled on itself had descended the whole length of the colon, so as to protrude from the anus; colon drawn together, the mass occupying less than a Toot. (Dr. J. L. Smith, N. Y. Path. Soc, June, 1801.) No. 37. Aged 3 years and 4 months. During two years before death complained of pain in abdomen. The coecum was inverted, and had descended to the lower portion of the rectum. (Wilmer Worthington, M.D., Amer. Journ. of Med. Sci., January, 1849.) No. 38. Aged 10 months. Previous health good, except liability to constipation. Lived two days. A double intussusception ; the inferior portion of the ascending colon was invaginated in the superior, and the whole again invaginated in the transverse colon. (Dr. Blake, Prov. Med. and Surg. Journ., May 3, 1848.) No. 39. Aged 11 years. Previous health not stated. Recovered. On the sixth day, the caput coli and a portion of the colon, with the meso-colon, measuring thirteen and three-fourths inches, were passed fi-om the bowels. (J. W. Bowman, Edin. Med. and Surg. Journ., October, 1813.) No. 40. Aged 6 years. Previous health not stated. Recovered. On the eleventh day voided the cojcum and a part of the colon, (Chas. King, Lond. Lane, 1854.) No. 41. Aged 4 months. Previous health good. Died the third day. The copcum had descended through the colon, nearly to the rectum. (Dr. Penquier, L'Uuion Medicale, Aug. 22, 1861.) No. 42. Aged 5 years. Was ill witli fever and pain in region of bladder for four months; dateof commencement of intussusception not known. Recovered, Passed by stool eight inches of the ileum, the crecum, and four inches of the colon, (Dr, Quain, Lond. Path. Soc, Aug. 10, 1859.) No. 43 Age not stated. Previous liealth good. Died the third day. The upper part of the descending colon had descended into the inferior part to the extent of two inches. (Dr. Montgomery, Lond. Med. Times, December 23, 1848.) No. 44. Aged months. Slight diarrhoea two or three days previously to sick- ness. Intussusception in the transverse colon to the extent of two or three inches. (E. Y. Steele, Lond. Lane, June 23, 1849.) No. 45. Aged 4 montlis. Had nausea with vomiting for three weeks previously to severe symptoms. Died after six days. The loAver portion of the colon, and the upper part of the rectum, had descended into the portion below. (Mr. Howship, Edin. Med. Journ., April, 1812.) APPENDIX. 731 UNCERTAIN. No. 40. A^od 4 months. Had disordered bowels from birth. Died on the sixth dav. An intussusception was found in the left iUac region. (II. F. Carter, Lond. Lane, June 3, 1849.) No. 47. Aged years. Previous health not stated. Recovered. Twcnty-tliree inches of intestine were discharged. (Levi Gaylord, Amer. Journ. of Med. Sci., (.)ctol)er, 1837.) No. 48. Aged 13 years. Previous liealth not stated. Recovered. Fifteen or eighteen inches of ileum were passed by stool. (F. Bush, Lond. Med. and Phys. Journ., December 18, 1833.) No. 49. Aged 13 years. Had occasional purging and pain in the bowels. Recovered. A portion of ileum twelve inches long was passed. (John Lang, Lond. Lane, October, 1855.) No. 50. Fatal. An invagination of the intestine was found in the rectum. (Dr. Jacobi, N. Y. Path. Soc, August 8, 1801.) No. 51. Aged 9 years. Had dysentery previously. Recovered. A portion of intestine measuring ten inches was passed. (Dr. Patterson, Medico-Chirurg. Soc, Edin.) No. 53. Aged 8 months. Previous health good. Died the second day. A portion of intestine protruded. (E. Y. Steele, Lond. Lane, June 23, 1849.) INDEX. A BDOMINAL viscera, tubercles in, 123 J\ Abscess, peri-pliaryugeal, 559 Abscess in lungs, 48P Acarus scabiei, 711 Accidents, incidental to birth, G3 Acephalus, 298 anatomical characters, 298 sj'mptoms, 299 prognosis, 299 Acid, hydrocyanic, in pertussis, 257 Acue, syphilitic, 153 Attusions, cold, in scarlet fever, 189 AUin, Dr., statistics of peri-pharyngeal abscess, 559 Animal heat, 85 Apncea of the new-born, 63 causes, 62 treatment, 63 Appendix A., dietetic formula?, 715 Ap])endix B., Wm. Budd on prevention of scarlet fever, 720 Appendix C, Prof Rindfleisch, remarks on the diphtheritic membrane, 725 Appendix E., statistics of state of liver in entero-colitis, 720 Appendix F., statistics of intussuscep- tion, 728 Aqueous cancer of infants, 544 Armor, Dr., case of ta?uia, 637 Arteritis, umbilical, 69 Artiticial feeding, 57 Ascaris vermicularis, 636 lumbricoides, 634 Asphyxia of the new-born, 62 Atrophy of brain, 301 Attitude in disease, 79 BARKER, Prof Fordyce, on turpeth mineral in croup, 467 Baths, 60 Billard, case of tetanus infantum, 383 cases of gangrene of mouth, 540 Bouchut's views of scrofula, 116 on santonin as an anthelmintic, 643 Bowditch, Dr., mode of performing thoracentesis, 522 Brain, its chemical analysis, 297 its growth, 297 absence of, 298 imperfect, 299 atrophy, 301 hypertrophy^ 304 congestion, 314 Bretonneau, on diphtheria, 238 Brodie, Sir Benjamin, on cliorea, 424 Bromides in pertussis, 254 Bronchitis in measles, 163 Bronchial phthisis, 132 physical signs, 140 Bronchitis, 476 causes, 477 anatomical characters, 477 capillary, 478 Complications, 480 pneumonia, 480 abscesses, 480 dilation of bronchial tubes, 481 symptoms, 481 in capillary bronchitis, 483 chronic, 484 diagnosis, 485 prognosis, 485 treatment, 486 Brown-Sequard, on compression of sym- pathetic nerve for eclampsia, 379 Bruit de soufflet of anterior fontanelle, 101 Biichler, Dr., cases of intussusception, 670 Bulbous fingers, 78 Bum stead on syphilis, 151 CALOMEL, its use in croup, 467 Cancrum oris, 538 Caput succedaneum, 64 Care of mother in pregnancy, 20 Carswell, Dr., on softening of stomach, 582 Castor-oil plant as a galactogogue, 47 Catamenia, its effect on the milk, 40 Cavities in lungs, 131 Cellulitis, scrofulous, 111 rr-j, f INDEX. Cephalfpmatoraa, 64 Cerebro-spinal system, diseases, 295 Clienopodium, G-l-i Chickciipox, 224 Chiklhood, 19 Cholera infautum, 624 causes, 02o symptoms, 625 anatomical characters, 027 diagnosis, 630 prognosis, 630 treatment, 630 Chorea major, 421 Chorea (.chorea minor), 415 age, 416 causes, 416 sex, 417 uterine irrritation, 417 anfemia, 417 rheumatism, 418 embolism, 420 fright, 420 irritation, 421 intestinal irritation, 421 lesions of brain and spinal cord, 422 anatomical characters, 423 symptoms, 424 prognosis, 426 cause, 426 treatment, 427 regimenal, 427 medicinal, 428 Church, Dr. A. S., case of tonic con- vulsions from dentition, 550 Cimicifuga in treatment of chorea, 429 Circulatory system, 82 Cirrhosis, syphilitic, 154 Clark, Prof. A., case of syphilis from vaccination, 219 Clarke, Dr. Joseph, on treatment of tetanus infantum, 387 Clothing, 60 Coates, Dr., treatment of gangrene of mouth, 545 Colitis in childhood, 620 causes, 620 symptoms, 621 diagnosis, 623 prognosis, 622 treatment, 622 CoUes, Dr., on tetanus infantum, 388 Colostrum, 34 Condie, Dr. D. F., on erysipelas, 289 on turpentine as an anthelmintic, 645 erysipelas, 289 Congestion of brain, 314 causes, 314 symptoms, 317 anatomical characters, 317 prognosis, 317 treatment, 318 Congestion of stomach, 574 Conjunctivitis of the new-born, 65 causes, 66 Conjunctivitis — symptoms, 66 treatment, 67 Convulsions, 369 mtcrnal, 405 Coryza, acute and chronic, 445 anatomical characters, 440 symptoms, 446 prognosis, 447 treatment, 447 syphilitic, 152 Cranial sinuses, thrombosis of, 308 Craniotabes, 96 Croup, talse or spasmodic, 452 true, or pseudo-membranous, 458 Cruveilhier, M., on gelatinous softening, 581 Cummings, Dr. W. H., on amount of milk secreted, 41 Curvatures in rachitis, 97 Cyanosis, 674 literature of, 675 sex,' 678 causes of malformations, 678 time of commencement, 680 symptoms, 681 prognosis, 686 mode of death, 687 modes of compensation, 689 morbid anatomy, 689 theories relating to its etiology 691 treatment, 693 D ALTON, Prof., effect of maternal emotions, 23 on iodide of starch, 119 Dartrous diathesis, 707 Dentition, 546 physiological, 547 pathological results of, 548 geugivitis, 548 stomatitis, 548 diarrhoea, 549 convulsions, 549 tonic, 550 case, 550 paral3'sis, 550 diagnosis, 551 treatment, 551 second, 554 in rachitis, 99 Diagnosis of infantile diseases, 000 Diarrho-a, 585 choleriform 624 non-intlammatory, 585 causes, 586 symptoms, 587 anatomical characters, 588 diagnosis, 589 prognosis, 589 treatment, 590 Diday, on syphilis, 157 Diet, improper, a cause of infantile mor- tahty, 27 1 N JJ E X . 735 Digest idii, post-mortoni, 580 Diii'cslivc yysU'in, 8G Diplillii'dii, 238 Ibniis. 22S anatoiuiciU characters, 228 appearance ofiiseudo-nieiiibrane, 229 coiil'ervoid growtli on it, 2^50 adenitis, cervical, in, 232 symptoms, 2;!2 alliuminiiiia in, 235 nature, 2;«7 contagiousness, 238 incubative period, 239 secpiela^ 239 pai'alysis, 240 prognosis, 241 diagnosis, 242 treatment, 243 Diseases of umbilicus, 69 Donne, Dr., on ascertaining the capa- bilit}^ for wet-nursing, 29 discovery of pus in the milk by the microscope, 33 Dysentery, in childhood, 020 Dyspepsia, 507 ECLAMPSIA, 369 causes, 370 premonitory stage, 371 sj'mptoms, 372 anatomical characters, 375 diagnosis, 376 prognosis, 377 treatment, 378 Ecthyma, 153 Eczema, 704 varieties, 704 diagnosis, 706 treatment, 707 general, 708 local, 709 Electricity as a galactogogue, 45 Elliott, Prof. Geo. T., cases of peri-pha- ryugeal abscess, 560, 565 use of raw meat, 719 Emotions, effect in pregnancy, 20 Emphysema in tuberculosis, 131 Enteritis in cliildhood, 620 causes, 630 symptoms, 621 diagnosis, 622 prognosis, 622 treatment, 622 Entero-colitis 593 Erysipelas from vaccination, 218 Erysipelas, 284 cases, 285 age, 286 point of commencement, 286 causes, 286 from vaccination, 287 during epidemics of puerperal fever, 288 symptoms, premonitory, 289 Erysipelas — syni])1oms, 290 prognosis, 391 duration, 291 modes of death, 292 pathological anatomy, 292 treatment, 293 Erythema, 695 forms and causes, 695 prognosis, 697 diagnosis, 697 treatment, 697 Ether, in spasmodic laryngitis, 456 Evanson and Maunsell, on treatment of gangrene of mouth, 545 T^ACIAL paralysis, 440 1 Falkland's, Prof., preparation of milk for infants, 715 Features in disease, 76 Feeding, a cause of infantile mortality, 26 artificial, 57 Fever and ague, 263 Fleming, Mr., on retro-pharyngeal ab- scess, 560 Flint, Prof. Austin, Jr., on the diet of children, 27 Flint, Prof. Austin, Sen., prevention of pitting in smallpox, 211 on thoracentesis, 531 Foetus, elfect on it of maternal emotions, 21 Fox, Tilbury, on seat of strophulus, 703 Friedleben, Dr., on state of thyroid gland in internal convulsions, 406 Fungus of umbilicus, 71 GALACTOGOGUES, 45 electricity, 45 ricinus communis, 47 Galactorrhoia, causes, 48 treatment, 49 Gangrene in scarlatina, 177 of the mouth, 538 anatomical characters, 538 age, 539 causes, 540 sjnnptoms, 540 diagnosis, 543 prognosis, 543 treatment, 544 Gastric tuberculosis, 133 Gastritis, 574 causes, 575 age, 576 case, 576 symptoms, 577 anatomical characters, 577 diagnosis, 578 prognosis, 578 treatment, 578 diphtheritic, 579 736 INDEX. Gastritis — follicular, 579 Gastro-intestinal liemorrliage, 646 Gelatinous softoning, 580 Giltillau, Dr., on use of ricinus communis as a galactogogue, 48 Glottis, spasm of, 405 Granulations, umbilical, 71 Grease in the horse, its identity with vaccinia, 214 Guersant, M., on prognosis in meningitis, 359 on thoracentesis, 522 extent of pseudo-membrane in croup, 461 HALL, Marshall, on treatment of in- ternal convulsions, 414 on spurious In'drocephalus, 365 Hall, Prof., case of unusual lactation, 45 Hammond, Prof., on maternal emotions, 22 Harris, Dr. Elisha, prevention of scarlet fever, 200 Hassel, Dr., on Liebig's soup, 717 Ha-svley's pepsin, 573 Heart, diseases of, 674 Heimacy. tetanus in, 386 Helmerich's ointment, 713 Hemorrhage, intra-crunial, 319 causes, 319 anatomical characters, 320 meninareal, 321 cerebral, 323 svmptoms, 324 capillary, 327 diagnosis, 328 prognosis, 329 treatment^ 329 umbilical, 72 causes, 73 sex, age, 73 jaundice in cases of, 74 symptoms, 75 prognosis, 75 treatment, 75 gastro-intestinal, 646 first variety, 647 second varietv. 648 third variety,'649 case, 648 prognosis, 650 treatment, 650 Hewitt, Dr. Graily, case of post-mortem digestion, 567 j Hillier, on choreic heart murmurs, 415 j causes of urticaria, 701 Hogarth's essence of meat, 720 Holmes, on scrofulous atfections, 113 Hooping-cough, 247 Hutchinson, on syphilis, 155 Hydrocephalus, congenital, 330 anatomical characters, 331 case, 334 Hydrocephalus, congenital — symptoms, 334 diagnosis, 336 prognosis, 337 treatment, 337 acquired, 338 causes, 338 anatomical characters, 335 symptoms, 340 prognosis, 340 treatment, 341 spurious, 363 anatomical characters, 363 case, 364 symptoms, 365 case, 366, 367 diagnosis, 368 prognosis, 368 treatment, 369 Hypertrophy of brain, 303 anatomj', 303 causes, 304 symptoms, 305 case, 306 diagnosis, 307 prognosis, 307 treatment, 307 ICTERUS of the new-born, 76 i Impetigo, syphilitic, 153 Imperfect brain, 299 case, 300 symptoms, 300 prognosis, 301 Indigestion, 567 causes, 568 sj'uiptoms, 569 prognosis, 571 treatment, 571 Infancy, 17 its anatomical characters, 17 causes of great mortality in, 18 Inflammation of stomach, 574 of umbilicus, 70 Intermittent fever, 263 . in fo'tus, 263 symptoms, 264 three stages of paroxysms, 264 congestive or pernicious, 265 treatment, 266 Internal convulsions, 405 causes, 406 anatomical characters, 408 symptoms, 409 case, 410 diagnosis, 411 prognosis, 411 treatment, 412 Intestines, inflammation of, 592 invagination of, 652 Intestinal inflammation, 592 causes. 594 age, 598 symptoms, 599 INDEX. 737 Intestinal inflammation — anatomical characters, G03 diagnosis, GO'J prognosis, 009 Ireatniont, GIO regimenal, GIO nu'dicinal, GKJ oiicmata, GIG external treatment, G19 Intestinal worms, 633 nscaris lumbricoides, 634 vermieularis, 636 triclu)ce])iialus dispar, 636 ta;nia, God canses, 637 symptoms, 639 diagnosis, 416 prognosis, G43 treatment, 643 Intussusception, 653 Avithout sj-mptoms, 653 with sj-mptoms, 653 previous liealth, 653 causes, G54 age, 655 seat and pathological anatomy, 656 of small intestines, 656 cases, 057 in large intestines, 659 symptoms, 653 diagnosis, 6G5 duration, 665 prognosis, 066 mode of death, 668 treatment, 668 Iodine in scrofula, 119 JACKSON, Dr. James, on treatment of bronchitis, 486 on second dentition, 554 treatment of cholera infantum, 631 Jacobi, Prof A., on laryngismus, 407 statistics of croup, 473 Jaundice in the new-born, 76 Jenkins, Dr. J. Foster, on umbilical hemorrhage, 73 Jenner, Edward, introduction of vacci- nation, 313 Jenner, Sir Wm., heart murmurs in chorea, 415 Jesty, Benjamin, the first vaccinator, 313 TT'ERMES mineral, a cause of gastritis, JV 575 Kilda, St., tetanus in, 386 Krackowizer, Dr., cases of tracheotomy in croup, 473 LACTATION, 38 course of, 54 hindrances to, 39 47 Lactation — facts and rules in reference to, 33 Lanugo, 17 Laryngitis, simple, acute, 449 symptoms, 449 chronic, 450 anatomical characters, 451 treatment, 451 spasmodic, 453 causes, 453 symptoms, 453 anatomical characters, 454 pathology, 454 diagnosis, 454 prognosis, 455 treatment, 455 pseudo-membranous, 458" causes, 459 anatomical characters, 459 symptoms, 463 pathological characters, 464 diagnosis, 4G5 prognosis, 465 treatment, 466 tracheotomy, 473 Leaming, Dr. J. 11., case of erysipelas, 388 Lewis, Dr. Caspar, use of raw meat, 718 Liebig's beef-tea, 719 soup, 716 Liver, its state in entero-colitis, 607 Livingston, Dr., case of peri-pharj^ngeal abscess, 565 Lungs, tubercles in, 139 MALFORMATIONS, a cause of death, Maternal emotions, effect of, in preg- nancy, 30 Measles, 159 symptoms, 159 anomalies, 163 complications, 163 anatomical characters, 166 nature, 1G6 diagnosis, 106 prognosis, 167 treatment, 1G7 Meigs, Dr. J. F., on chenopodium as an; anthelmintic, 644 and Pepper, Drs., treatment of chronic coryza, 448 Meningitis, simple and tubercular, 343 age, 344 anatomical characters, 344 causes 349 premonitory stage, 349 symptoms, 350 case, 355 diagnosis, 356 prognosis, 357 treatment, 359 Microcephalus, 301 Milk, human, 36 738 INDEX. Milk- modifications, from diet, 36 from retention in breast, 38 by age and nervous impressions, '34 by catamenia and pregnancy, 40 quantity, required, 41 scantiness, 43 examination of, 51 excess of salines in, 53 vibriones in, 53 its composition, 58 of animals, 58 Minchin's mode of examining milk, 51 Minot, Dr. Francis, on umbilical hemor- rhage, 73 Morbilli, 159 Mortality of early life, 23 causes, 24-28 Mother, care of, in pregnancy, 20 effect of maternal impressions, 21 Mouth, inflammation of cavity of, 524 Movements in disease, 79 Mucuna ])ruriens as an anthelmintic, 645 Muguet, 533 Mumps, 261 NECROSIS, infantilis, 538 Nephritis in scarlatina, 180 Nervous svstem, 88 Nestle' s food, 59 Noma, 538 Noyes, Prof. H. D., on use of ophthal- moscope, 296 ffiSOPIIAGITIS, 566 anatomical characters, 566 treatment, 567 Oidium all)icans in sprue, 534 Ophthalmia neonatorum, 65 two forms, 67 symptoms, 66 treatment, 67 Ophthalmoscope in diseases of brain, 396 Ostco-malacia, 92 Otitis, scrofulous, 113 Otorrhoea, 183 PAIN as a svmptom, 88 Papnhp, 703 Paralysis, diphtheritic, 240 facial, 440 causes, 440 symptoms, 440 prognosis, 440 treatment, 441 Paralysis, infantile, 431 causes, 431 symptoms, 433 prognosis, 433 progress, 433 etiology, 434 Paralysis, infantile — anatomical characters, 435 diagnosis, 437 prognosis, 437 treatment, 438 Paralysis with apparent hypertrophy, 441 symptoms, 442 anatomical characters, 443 causes, 444 prognosis, 444 treatment, 444 Parker, Dr. E. H., treatment of entero- colitis, 613 lesions of cholera infantum, 639 Parker, Prof Willard, case of peri- pharyngeal abscess, 564 Parotiditis, 361 symptoms, 361 nature, 203 diagnosis, 363 treatment, 263 Peacock, on growth of brain, 397 Pemphigus, syphilitic, 153 Pepsin in indigestion, 573 Peritoneal tuberculosis, 133 Peritonitis, tubercular, 133 Peri-pharyngcal abscess, 559 age, 559 causes, 559 anatomical characters, 561 symptoms, 561 case, 562 duration, 563 diagnosis, 564 prognosis, 565 treatment, 565 Pertussis, 247 symptoms, 247 three stages, 248 complications, 350 convulsions. 350 bronchitis, 351 pneumonitis, 251 emphj'sema, 253 diagnosis, 253 prognosis, 254 treatment, 255 belladonna, 256 hydrocyanic acid, 257 bromides, 258 emetics, 259 Pharyngitis, simple, 555 anatomical characters, 555 causes, 556 , symptoms, 556 prognosis 557 diagnosis, 557 treatment, 557 Phthisis, 122 Phlebitis, umbilical, 69 Pleuritis, 507 causes, 508 cases, 510, 517 anatomical characters, 511 symptoms, 513 INDEX. 739 Plcuritis — physical sip;ns, 514 diagnosis, ol7 l^roii'iiosis, ."its trciUnicnt, 51!) thoracentesis, 531 Pneumonitis, 41)0 causes, 491 anatomical cliaracters, 493 croupous, 4!)4 catarriial, 495 cheesy, 407 symptoms, 499 physical si_i;-ns, 501 diagnosis, 502 prognosis, 504 treatment, 504 in measles, 164 Post-mortem digestion, 580 Pock, vaccine, its anatomy, 217 Post, Prof. A., case of peri-pharyngeal abscess, 564 Pregnancy, its efiTect on the milk, 40 Protection from vaccination, 321 Pulmonary cavities, 131 tuberculosis, 139 Pulse in health, 83 in disease, 84 RACHITIS, 91 causes, 93 age, 91 anatomical characters, 94 craniotabes, 96 curvatures, 97 symptoms, 100 complications, 103 diagnosis, 103 prognosis, 103 treatment, 104 Radclifle, Mr., on treatment of chorea, 430 Remittent fever, 267 symptoms, 268 diagnosis, 268 treatment, 268 Respiration in health, 80 in disease, 81 Respiratory sj'stem in children, 80 diseases of, 445 Retro-pharyngeal abscess, 559 Revaccination, 321 Reynolds, Dr. J. B., case of diphtheria, 240 Rheumatism, acute, 377 its frequency in children, 377 causes, 278 symptoms, 378 complications, 380 duration, 280 prognosis, 380 diagnosis, 381 treatment, 383 Ricinus communis, as a galactogogue, 47 Rickets, 91 Rokitansky on hypertrophy of brain, 304 Roseola, 698 symi)toms, 699 causes, 700 prognosis, 700 diagnosis, 700 treatment, 700 Routh, Dr., mortality from change of tcm]ierature, 2{> plethora, a cause of insufficient milk, 44 Rubeola, 159 OCABIES, 711 U acarus scabiei, 711 symptoms, 713 diagnosis, 712 treatment, 713 Scantinesss of milk, 43 Scarlatina, 169 symptoms, 169 irregular form, 173 malignant form, 174 complications, 175 sequela3, 178 nephritis, 183 otorrha?a, 183 anatomical characters, 183 nature, 183 incubative period, 185 diagnosis, 187 prognosis, 188 treatment, 189 prophylaxis, 198 Scrofula, 104 causes, 105 vaccination as a cause, 106 commuuicabllity, 106 anatomical cliaracters, 109 symptoms, 110 • ^ coryza, 113 otitis, 113 cellulitis. 111 its relation to tuberculosis, 114 prognosis, 117 treatment, 118 Scrofulous affections, 113 Seguin, Dr., effect of maternal emotions on foetus, 33 Skene, Prof., case of taenia, 637 Skin diseases, 695 Smallpox, 301 Smith, Prof Stephen, on umbilical hem- orrhage, 73 operation for congenital hydrocepha- lus, 336 Softening, gastro-intestinal, 580 Spasm of glottis, 405 Spigelia marilandica, as an anthelmintic, 643 Sprue, 535 Steam, its employment in croup, 469 Stille, Dr. Moreton, on cyanosis, 677 740 INDEX. Stomach, congestion of, 574 inflammation of, 5G6 tubercles in, 18;> Stomatitis, simple, 534 causes, 524 symptoms, 526 appearances, 526 treatment, 527 ulcerous, 537 causes, 528 symptoms, 557 prognosis, 529 treatment, 529 follicular, 530 causes, 531 symptoms, 531 diagnosis, 533 prognosis, 533 treatment, 232 Strabismus, 78 Strophulus, 703 varieties, 703 causes, 703 treatment, 703 St. Guy's dance, 415 St. Vitus' dance, 415 Strychnine in treatment of chorea, 428 Swett, Prof, case of hemorrhage, 649 Swinepox, 224 Syphilis, 149 etiology, 149 clinical history, 150 coryza, 152 mucous patches, 152 roseola, 153 pemphigus, 153 acne, 153 impetigo, 158 ecthyma, 153 visceral lesions, 154 prognosis, 156 treatment, 156 T^NIA, 636 1 Teething, 546 Temperature, 85 Tetanus infantum, 383 cases, 383 period of commencement, 385 frequency, 385 causes, 387 unclcanliness, 388 irritation in bowels, 388 changes of temperature, 389 inflammation of umbilical ves- sels, 390 meningitis, 393 injury of brain, 395 anatomical characters, 396 symptoms, 398 mode of death, 400 prognosis, 400 duration of fiital cases, 401 of favorable cases, 402 Tetanus infantum — diagnosis, 403 preventive treatment, 403 treatment, 403 Thorax, shape, in tuberculosis, 143 Thrombosis in cranial sinuses, 308 causes, 311 anatomical characters, 309 symptoms, 313 diagnosis, 313 prognosis, 313 treatment, 313 Thrush, 533 anatomical characters, 533 symptoms, 535 causes, 535 diagnosis, 536 prognosis, 536 treatment, 536 Thymic asthma, 405 Trismus, 383 Trousseau, on syphilitic tint, 151 Tuberculosis, 133 its relation to scrofula, 115 etiology, 133 anatomical characters, 126 symptoms, 135 anasarca, 136 emaciation, 136 fever, 136 in bronchial phthisis, 139 in pulmonary phthisis, 140 in tubercles of pleura, 143 in gastric and intestinal tu bercles, 144 diagnosis, 144 prognosis, 147 treatment, 148 Tubercles in lungs, 128 stomach, 133 intestines, 133 bronchial gland^lSl Typhoid fever, 269 ^ causes, 269 anatomical characters, 270 symptoms, 271 complications, 273 diagnosis, 274 duration, 275 prognosis, 275 treatment, 276 TTLCERATION of umbilicus, 70 U Umbilicus, diseases, 69 inflammation of vessels, 69 of umbilicus, 70 ulceration of, 70 treatment, 71 granulations, 71 fungus, 71 hemorrhage, 72 inflammation of, 284 Urticaria, 701 causes, 701 IN])EX. 741 Urticaria — pro^'iiosis, 701 diiii^'iiosis, 701 treatment, 703 yACCINATIONS, subsequent, 230 » sinirious, 231 Vaccinia, 212 history of, 213 appearance, 21G symptoms, 21G anomalies, 217 complications, 217 sccpu'ls, 217 subsecpient vaccinations, 220 protection from, 31G, 221 revaccination, 231 selection of virus, 223 Varicella, 334 symptoms of, 224 diagnosis, 235 prognosis and treatment, 236 Variola," 301 incubative period, 201 stage of invasion, 201 of eruption, 203 of desiccation, 204 Varioloid, 205 mode of death, 206 anatomical characters, 307 complications, 308 Varioloid — prognosis, 308 diagnosis, 200 treatment, 209 Vibriones in milk, 52 Villemin on origin of tulierclcs, 124 Virus, vaccine, its selection, 223 Voice in disease, 79 Voss, Dr. , cases of tracheotomy in croup, 473 WARE, Dr., statistics of croup, 461 Waxy degeneration in rachitis, 99 Weaning, 54 age for, 55 mode, 56 West, Dr. Chas., case of thrombosis, 310 treatment of chorea, 439 on gelatinous softening, 581 Wet-nurse, selection of, 49 syphilis in, 50 Whitehead, Dr., effect of maternal emo- tions on the foetus, 33 White softening, gastro-intestinal, 580 White, Prof. J. P., case of cyanosis, 694 Whytt, Dr., on meningitis, 3*41 Worms intestinal, 633 'INC, oxide of, in eczema, 710 THE END. THOMAS ON DISEASES OF WOMEN.— Now Ready. A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. By T. GAir.LARD THOMAS, M.D., Professor of Obstetrics and Dispasps of Woiiieu ami Cliildren in the Collego of Physicians and Surgeons New York; ()l)stetric Physiciau to tlie Strangers' and llie Uoosevelt Hos- pitals; Consulting Pliysician to the N. Y. State Women's Hospital, &c. With about Two Hundred and Fifty Illustrations. THIKD EDITION, ENLAEGED AND THOROUGHLY REVISED. In one large and handsome octavo volume of 784 pages : leather, $6 00 ; cloth, $5 00. The exhaustion of two very large editions in a little more than three years shows that the author hiis not failed in his endeavor to supply the admitted want of a work which should, in a moderate compass, furnish a complete view of all the modern aspects of gyna;cology. Stimulated by the very favorable reception accorded to his labors, he has sought to render the present edition still more worthy than its predecessors. Every portion of the work has been thoroughly revised, several new chapters and a number of new illustrations have been introduced, and the most painstaking care has been bestowed to make it a full and trustworthy guide for the student and practitioner. To accommodate the numerous additions the size of the page has been enlarged, notwithstanding which the number of pages has been increased by nearly one hundred and fifty; in fact, the present edition contains nearly one -third more matter than the preceding, notwith- standing which it has been kept at the former very moderate price. The work, it is therefore hoped, will continue to maintain its position as the favorite book for consultation by all who have to treat this frequent and important class of diseases. From Prof. Fordvce Barker, Bdlevue Hospital Miidical College, New York. A work which I estimate very highly and which I have always taken every opportunity to commend to students and the profession. I have carefully looked over this edition, and comparing it with the two former ones, I have been greatly impressed with the conscientious labor, as well as the ability, with which Professor Thomas has kept the work up to represent the advanced and progressing science of the day. From Prof. De Laskie Miller, Hush Medical College, Chicago. My appreciation of the work is indicated by the fact that I always mention it first when recommending works on this department to students or others. From Prof. J. Algernon Temple, Trinity College, Toronto. I can only say that in my opinion it is now the most complete work of its kind. The well-known reputation of the author and the many improvements in this edition place it in the foremost rank of medical literature. I shall have great pleasure in recom- mending it to my class. From Prof. Alex. J. C. Skene, Lo7ig Island College Hosx>ital. This edition shows that the professor is determined to keep fully up to the times. I shall have the plea- sure of continuing to recommend this work to my class of students as the best on the subject to be found anywhere. From Prof. J. S. D. Cullen, Iledical College of Virginia. A work which I prize very much both for the text and for the admirable manner in which it is pub- lished. It is the text-book which I recommend to my class and to my professional friends. From Prof. F. M. Eobrrtson, Charleston Medical College. I have no doubt that I shall find it worthy of even greater commendation than the preceding editions, as I find that it has been greatly enlarged and brought fully up with the times. From Prof. Fra.vk Wells, Cleveland Medical College. The book has been for some time used in our school, and on the perusal of the new edition I am led to more strongly than ever recommend it to the students and to the practitioners of our city as a work furnishing a very comprehensive treatise on the subject. From Prof. A.. F. A. Kino, National 3Iedical College, Washington, D. O. On referring to it for advice in regard to some diffi- cult cases now under treatment I have been delighted with its practical character, and shall take pleasure in recommending it as a text-book to my class. From Prof. J. C. Shrader, Iowa State University. I shall take great pleasure in recommending it to the students in the Medical Department uf the Iowa State University, as the standard work on gynaeco- logy. Its able author need not fear comparison between it and any similar work in the English language; nay more, as a text-book for students and as a guide for practitioners, we believe it is unequalled. In the libraries of reading physicians we meet with it oftener than any other treatise on diseases of women. We conclude our brief review by repeating the hearty commendation of this volume given when we com- menced : if either student or practitioner can get but one book on diseases of women, that book should be "Thomas " — Am. Journ. Med. Sciences, April, 1S72. Of the work itself, in the original block, we need hardly make any criticism at this date. It has firmly established itself as the American text-book of gyne- cology. Without being prolix, it treats of the disor- ders to which it is devoted, fully, perspicuously, and satisfactorily.- It will be found a treasury of know- ledge to every physician who turns its pages. — Am. Journ. of Syphilography, April, 1872. No book in American medical literature has been so flatteringly received by the profession as this, and no one making the least pretensions to the study of uterine diseases can do without it. For clearness of style and therapeutics, it has no parallel.— Fa. Clin. Record, April, 1872. It better represents the present condition of gynae- cology than any work in the English language of which we know. W^ant of space forbids our entering into details ; nor is it necessary, for all our readers who are not already supplied with a copy of one of the previous editions will be sure to get this; that is, if at all interested in the treatment of diseases of wo- men.— .•I?7ie)-Jca7i Practitioner, April, 1872. HENRY C. LEA, Philatlelphia. WORKS ON DISE ASES OE CHILDEEN. SMITH ON WASTING DISEASES OF CHILDEEN. THE WASTING DISEASES OF INFANTS AND CHILDREN. By EUSTACE SMITH, M.D. Second American, from the Second and Enlarged London Edition. In one very handsome octavo volume of 2&G priges ; extra cloth, §2 50. {Just Issued.) The final chapter on the diet and treatment of chil- ' children. The author, as physician to the largest free dren in health and disease will be found especially Dispensary for children in London, has enjoyed an useful to the juuiorpractitioner, who is often at a loss experience equalled by few, and surpassed by none, in the management of children as regards the food to j —Richmond and Louisville Medical Journal, Aug. be administered It contains very minute and elabo- i 1S71. rate directions, and scales of dieting for different ages ' Xu a highly creditable manner the doctor has ex- and conditions. We are glad to be able to recommeud piored this important field, and has brought out prac- this work as one of sterling merit, and one which we tically the prominent salient points on tlie causes, have no doubt will be very favorably received and diagnosis, prognosis, pathology, morbid anatomy, and considered by the profession. — 2>it&Zi« Quarterly the treatment of the diseases of childhood of which Journal, Aug. 1S71. ! wasting is a symptom. The clinical facts thus made As the first edition of this admirable work was re- \ applicable give this work a special value. It is a viewed carefully in this journal, it is unnecessary to bo.)k well worthy of careful perusal, and we would add much in regard to it. It has been enlarged by the cordially recommend it to those who are interested addition of most valuable matter in connection with in the diseases of infancy and childhood.— jTft* New mucous diarrhoea, and the proper diet for invalid York Journ. of Psijchological Medicine, April, 1S72. "WEST ON CHILDREN". LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. By CHARLES WEST, Physician to the Hospital for Sick Children, &c. FOFRTH AmEHICAX, FEOM THE FiFTn AXD REVISED ExGLISII EdITIOX. In one large and handsome octavo volume of65& pages ; cloth, $4 50 ; leather, $5 50. All our readers are, doubtless, familiar with Dr. i The work of West on the Diseases of Children is West's admirable volume, and will welcome the ap- translated into the chief European languages, and pearauce of a new edition. No praise is needed of a extensively used ; and the reason is, we believe, sim- book so well known, which has placed its author in ply, that there is nothing to be found in any language the first rank of British physicians, and gained him at all equal to it.— Edinburgh Med. Journal, May, an enduring reputation as an authority on infantile 1S69. disease. — Brit, and For. Med.-Chir. Rev., Oct. 1S70. By the same Author— Just Issued. ON SOME DLSORDERS OP THE NERVOUS SYSTEM IN CHILDHOOD. Being the Lumleian Lectures delivered at the Royal College of Physicians of London, in March, 1871. In one neat volume, small 12mo. ; cloth, $1. With the assurance to our readers that this little book abounds in valuable practical hints which will assist them in the treatment of this, confessedly the most difiionlt class of disease, we recommend it to their studv.— SY. Louis Medical and Surgical Jour- nal, Jan. 1S72. CONDIE ON CHILDEEN. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. By D. FRANCIS CONDIE, M.D. SIIXTII EXDITIOnsr, T1^0TiOTJG:B3ilL,-^r K,EV"ISEI3- Li one large and handsome octavo volume of nearlij SOO closely fruited pages ; extra cloth, $5 25; leather, $6 25. A work which has passed through five bona fide gone a careful and thorough revision, and the ad- editions, and uf which a sixth has been called "for, vances recently made in our knowledge of the various may be regarded as being beyond the bounds of cri- diseases of childliood have been carefully incorpo- ticism ; that high tribunal, tlie profession, having rated in the several chapters. This will be manifest already recorded a verdict in its favor. All that is on a comparison of the present with the previous needed, in a notice of the present edition of Dr. Con- edition. — Am. Journ. Med. Sciences, April, 1S6S. die's well-known treatise, is to state that it has under- GUEESANT ON SURGICAL DISEASES OF CHILDREN. SURGICAL DISEASES OF INFANTS AND CHILDREN. By M. p. GUERSANT, Honorary Surgeon to the Hospital for Sick Children, Paris. Translated by RICHARD J. DUNGLISON, M.D. This work, now appearing in the "Medical News and Library," will be continued to comple- tion in 1872, when it will be issued sejjarately in a handsome octavo volume of nearly 400 pages. It will be found to contain much which, while of everyday importance to the practitioner, can scarcely be found in the ordinary text-books. HENRY C. LEA, Philadelphia. (latk lea 4. blanchap.d's) OF MEDICAL AND SURGICAL PUBLICATIONS. • In asking the attention of the profession to tlie works contained in the following^ pages, the publisher would state that no pains are spared to secure a continuance of the confidence earned for the publications of the house by their careful selection and accuracy and finish of execution. The printed prices are those at which books can generally be supplied by booksellers throughout the United States, who can readily procure for their customers any works not kept in stock. Where access to bookstores is not convenient, books will be sent by mail post-paid on receipt of the price, but no risks are assumed either on the money or the books, and no publications but my own are supplied. Gentlemen will therefore in most cases find it more convenient to deal with the nearest bookseller. An Illustrated Catalogue, of 64 octavo pages, handsomely printed, will be for- warded by mail, postpaid, on receipt of ten cents. HENRY C. LEA. No8. 706 and 708 Sansom St., Philadelphia, April, 1873. ADDITIONAL INDUCEMENT FOR SUBSCRIBERS TO THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. THKEE MEDICAL JOUENALS, containing over 2000 LAEGE PAGES, Free of Postage, for SIX DOLLAES Per Annum. TERMS FOE 1873: The American Journal of the Medical Sciences, and "I Five Dollars per annum. The Medical News and Library, both free of postage, j inadvance. O R., The American Journal of the Medical Sciences, published quar-^ ^^^ Dollars terly (1150 pages per annum), with | The Medical News and Library, monthly (384 pp. per annum), and [- per anaum The Half-Yearly Abstract of the Medical Sciences, published j -^ advance Feb. and August (GOO pages per annum), all free of postage. J SEPARATE SUBSCRIPTIONS TO The American Journal of the Medical Sciences, subject to postage when not paid for in advance. Five Dollars. The Medical News and Library, free of postage, in advance, One Dollar. The Half-Yearly Abstract, Two Dollars and a Half per annum in advance. Single numbers One Dollar and a Half. It is manifest that only a very wide circulation can enable so vast an amount of valuable practical matter to be supplied at a price so unprecedentedly low. 'J'he pub- lisher, therefore, has much gratification in stating that the rapid and steady increase in the subscription list promises to render the enterprise a permanent one, and it is with especial pleasure that he acknowledges the valuable assistance spontaneou.sly rendered by so many of the old subscribers to the "Journal," who have kindly made (For " American Chemist," see p. 11.) (For "Obstetkical Jourjial," aee p. 22 ) 2 Henry C. Lea's Publications — (Am. Journ. Med. Sciences). known among iheir friends the advantages thus ofiFered and have induced them to suliscribe. Eelying upon a continuance of these friendly exertions, he hopes to be alile to maintain the unexampled rates at which these works are now supplied, and to succeed in his endeavor to place upon the table of every reading practitioner in the United States a monthly, a quarterly, and a half-yearly periodical al the comparatively trifling cost of Six Dollars per annum. These periodicals are universally known for their high professional standing in their several spheres. I. THE AMERICAN JOmiS^AL OF THE MEDICAL SCIENCES, Edited by ISAAC HAYS, M. D., is published Quarterly, on the first of January, April, July, and October. Each number contains nearly three hundred large octavo pages, appropriately illustrated, wherever necessary. It has now been issued regularly for nearly fifty years, during almost the whole of which time it has been under the control of the present editor. Throughout this long period, it has maintained its position in the highest rank of eiedical periodicals both at home and abroad, and has received the cordial support of the entire profession in this country. Among its Collaborators will be found a large number of the most distinguished names of the profession in every section of the United States, rendering the department devoted to ORiaiNAL COMMIJNIOATIC^NS full of varied and important matter, of great interest to all practitioners. Thus, during 1872, articles have appeai'ed in its pages from nearly one hundred gentlemen of the highest standing in the profession throughout the United States.* Following this is the "Review Department," containing extended and impartial reviews of all important new works, together with numerous elaborate "Analytical AND Bibliographical Notices" of nearly all the medical publications of the day. This is followed by the " Quarterly Summary of Improvements and Discoveries {N THE Medical Sciences," classified and arranged under different heads, presenting a very complete digest of all that is new and interesting to the physician, abroad as well as at home. Thus, during the year 1872, the "Journal" furnished to its subscribers Eighty-fonr Original Communications, Out Hundred and Twenty-nine Reviews and Bibliograph- icarNotices, and Three Hundred and seven articles in the Quarterly Summaries, mak- injy a total of about Five Hundred articles emanating from the best professional minds in America and Europe. That the efforts thus made to maintain the high reputation of the " Journal" are successful, is shown by the position accorded to it in both America and Europe as a national exponent of medical progress : — Dr. Hays keeps his great Araerirnn Quarterly, in matter it contains, and has established for itself a which he is now assisted by Dr. Minis Hays, at the reputation in every country where medicine is ciil- head of his country's medical periodicals — Dublin tivated as a science. — Brit, and For. Jiled.-Chirurg. Medical Press and Circular, March S, 1S71. I Review, April, 1S7I. Of English periodicals the Lnncft, and of American I One of the best of its Vi^A.— London Lancet, Anc. Almost the only one that circulates everywhere, all over the Uniun and in Europe. — London, Medical the Am. Journal of the Medical Hciences, are to be regarded as necessities to the reading practitioner. — A' r Medical Ga.zeite, Jan. 7, 1S71. The American Journal of the Medical Sciences ! Tinier, Sept. 5, 1868. yields to none in the amount of original and borrowed | The subscription price of the "American Journal of the Medical Sciences" has never been raised, during its long career. It is still Five Dollars per annum ; and when paid for in advance, the subscriber receives in addition the "Medical News and Library," making in all about 1500 large octavo pages per annum, free of postage. II. THE MEDICAL 1ST.WS AND LIBRARY is a monthly periodical of Thirty-two large octavo pages, making 384 pages per annum. Its "News Department" presents the current information of the day, with Clinical Lectures and Hospital Gleanings; while the "Library Department" is de- voted to publishing standard works on the various branches of medical science, paged separately, so that they can be removed and bound on completion. In this manner subscribers have received, without expense, such works as " Watson's Practice," " Todd and Bow.man's Physiology," "West on Children," " Malgaigne's Surgery," &c. &c. And with January 1873 will be commenced the publication of Dr. McCall » <;.iinn!unication8 are invited from gentlemen in all pane of the cooniry. Elaborate uriiilee lagerted by the Editor Are paid for by cue Pablistier. Henry C. Lea's Publications — (Am. Journ. Med. Sciences). AiNDERSON's new work "On tiik Tkeatmknt of Diskases of the Skix, with a.n Ana- lysis OF Kl.KVEN 'I'llOUSAND CoNRKCUTIVE CaSKS." As stated above, the subscription price of the "Medical News and Library" is One Dollar per annum in advance; and it is furnished without charo-e to all advance paying subscribers to the "American Journal of the Medical Sciences." III. THE HALF-YEARLY ABSTRACT OF THE MEDICAL SCHoNCES is issued in half-yearly volumes, which will be delivered to subscribers about the first of February, and First of August. P^ach volume contains about 300 closely printed octavo pages, making about six hundred pages per annum. "Ranking's Abstract" has now been published in England regularly for more than twenty years, and has acquired the highest reputation for the ability and industry with which the essence of medical literature is condensed into its pages. It pur- ports to be "-4 Digest of British and Continental Mtdicine, and of the Progress of Medicine and the Collateral Sciences," and it is even more than this, for America is largely represented in its pages. It draws its material not only from all the leading American, British, and Continental journals, but also from the medical works and treatises issued during the preceding six months, thus giving a complete digest of medical progress. Each article is carefully condensed, so as to present its substance in the smallest possible compass, thus affording space for the very large amount of infor- mation laid before its readers. The volumes of 1872, for instance, have contained SIXTY-FOUR ARTICLES ON GENERAL QDESTIONS IN MEDICINE. NiNETY-SIX ARTICLES ON SPECIAL QUESTIONS IN MEDICINE. TWELVE ARTICLES ON FORENSIC MEDICINE. NINETY THREE ARTICLES ON THERAPEUTICS. FORTY-TWO ARTICLES ON GENERAL QUESTIONS IN SURGERY. ONE HUNDRED AND THIRTY-THREE ARTICLES ON SPECIAL QUESTIONS IN SURGERY EIGHTY ARTICLES ON MIDWIFERY AND DISEASES OF VS^OMEN AND CHILDREN EIGHTEEN ARTICLES IN APPENDIX. Making in all nearly five hi\ndred and fifty articles in a single year. Each volume, moreover, is systematically arranged, with an elaborate Table of Contents and a very full Index, thus facilitating the researches of the reader in pursuit of particular sub- jects, and enabling him to refer without loss of time to the vast amount of information contained in its pages. The subscription price of the "Abstract," mailed free of postage, is Two Dollars and a Half per annum, payable in advance. Single volumes, $1 50 each. As stated above, however, it will be supplied in conjunction with the "Amerk^an Journal of the Medical Sciences" and the "Medical News and Library," the whole/ree of postage, for Six Dollars per annum in advance. For this small sum the subscriber will therefore receive three periodicals costing separately Eight Dollars and a Half, each of them enjoying the highest reputation in its class, containing in all over two thousand pages of the choicest reading, and pre- senting a complete view of medical progress throughout both hemispheres. In this effort to bring so large an amount of practical information within the reach of every member of the profession, the publisher confidently anticipates the friendly aid of all who are interested in the dissemination of sound medical literature. He trusts, especially, that the subscribers to the "American Medical Journal" will call the attention of their acquaintances to the advantages thus offered, and that he will be sustained in the endeavor to permanently establish medical periodical literature on a footing of cheapness never heretofore attempted. rilEMlUM FOR NEW SLBSCBIBEBS. Any gentleman who will remit tlie amount for two subscriptions for 1873, one of which must be for a new subscriber, will receive as a premium, free by mail, a copy of the new edition of Tanner's Clinical Manual, for advertisement of which see p. .o, or of Chambers' Restorative Medicine (see p. 17), or West on Nervous Disorders OF Children (see p. 21). *^* Gentlemen desiring to avail themselves of the advantages thus offered will do well to forward their subscriptions at an early day, in order to insure the receipt of complete sets for the year 1873, as the constant increase in the subscription list almost always exhausts the quantity printed shortly after publication. t^ The safest mode of remittance is by bank check or postal money order, drawn to tne order ol the undersigned. Where these are not accessible, remittances for the "Journal" may be made at the risk of the publisher, by forwarding in reqistkred letters. Address, HENRY C. LEA, Nob. 706 and 708 Sansom St., Philadelphia, Pa. Henry C. Lea's Publications — {Dictionaries). jyUNGLISON [ROBLEY), 31. D., Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. MEDICAL LEXICON; A Dictionary of Medical Science: Con- taining a concise eKplanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of the Terms, and the French and other Synonymes; so as to constitute a French as well as English Medical Lexicon. Thoroughly Revi.'^ed, and very greatly Modified and Augmented. In one very large and handsome royal octavo volume of 1048 double-columned pages, in small type ; strongly done up in extra cloth, $6 00 ; leather, raised bands, $li 75. The object of the author from the outset has not been to make the work a mere lexicon or dictionary of terms, but to afford, under each, a condensed view of its various medical relatiom, and thus to render the work an epitome of the exi.'iting condition of medicnl science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the position of a recognized and standard authority wherever the language is spoken. The mechanical exe- cution of this edition will be found greatly superior to that of previous impressions. By enlarging the size of the volume to a royal octavo, and by the employment of a small but clear type, on extra fine paper, the additions have been incorporated without materially increasing the bulk ni the volume, and the matter of two or three ordinary octavos has been compressed into the space of one not unhandy for consultation and reference. It is undoubtedly the mcst complete and useful medical dictionary liitberto published in this country. — Ohicago Med. Examiner, February, 1*6:5. It would \>f a work of Bupererogation to bestow a word of praise upon this Lexicon. We can only wonder at the labor expended, for whenever we refer to its pages for information we are seldom disap- pointed in finding all we desire, whether it be in ac- centuation, etymology, or definition of terms. — New York MedicalJournal , November, lSt).5. It would be mere waste of words in us to express our admiration of a work which is so universally and deservedly appreciated. The most admirable work of its kind in the English language. As a buck of reference it is invaluable to the medical practi- tioner, and in every instance that we have turned over its pages for information we have been charmed by the clearness of lauguage and the accuracy of detail with which each abounds. We can most cor- dially and confidently commend it to our readers. — Glasgow MedicalJournal, January, ISGti. A work to which there is no equal in the English lauguage. — Edinburgh Medical Journal. It is something more than a dictionary, and some- thing less than an encyclopsedia. This edition of the well-known work is a great improvement on its pre- decessors. The book is one of the very few of which It may be said with truth that every medical man should possess it. — London Medical Tinies, Aug. 26, Few works of the class exhibit a grander monument of patient research and of scientific lore. The extent of the sale of this lexicon is suUicient to testify to its u.-^efulness, and to the great service conferred by Dr. Eubley Dunglison on the profession, and indeed on others, by its issue. — London Lancet, May 13, 1865. The old edition, which is now superseded by the new, has been universally looked upon by the medi- cal profession as a work of immense research and great value. The new has increased usefulness; for medicine, in all its branches, has been making such progress that many new terms and subjects Lave re- cently been introduced : all of which may be found fully defined in the present edition. We know of no other dictionary in the English language that can bear a comparison with it in point of completeness of subjects and accuracy of statement. — N. Y. Jjrug- gt.its' Circular, ISbo. For many years Dunglison's Dictionary has been the standard book of reference with most practition- ers in this country, and we can certainly commend this work to the renewed confidence and regard of aur readers. — Cindnnaii LiirLCtt, April, lS6o. What we take to be decidedly the best medical dic- tionary in the English language. The present edition is brought fully up to the advanced state of science. For many a long year " Dunglison " has been at our elbow, a constant companion and friend, and we greet him in his replenished and improved form with especial satisfaction. — Pacific Med. and Snrg. Jour- nal, June 27, 1S6.5. This is, perhaps, the book of all others which the physician or surgeon should have on his shelves. It is more needed at ihe present day than a few years back. — Canada Med. Journal, July, 1865. It deservedly stands at the head, and cannot be surpas.sed in excellence. — Buffalo Med. and Surg. Journal, April, 1S65. We can sincerely commend Dr Dunglison's work as most thorough, scientific, and accurate. We have tested it by searching its pages for new terms, which have abounded so much of late in medical nomen- clature, and our search has been successful in every instance. We have been particularly struck with the fulness of the synonymy and the accuracy of the de- rivation of words. It is as necessary a work to every enlightened physician as Worcester's English Dic- tionary is to every one who wonld keep up his knowl- edge of the English tongue to the standard of the present day. It is, to our mind, the most complete work of the kind with which we are accinainted. — Boston, Med. and Surg. Journal, June 22, 1&65. We are free to confess that we know of no medical dictionary more complete; no one better, if so well adapted for the use of the student; no one that may be consulted with more satisfaction by the medical practitioner. — Am. Jour. Med. Sciences, .^pril, Ibiia. The value of the pre.sent edition has been greatly enhanced by the introduction of new subjects and terms, and a more complete etymology aiiU accentua- tion, which renders the work not only satisfactory and desirable, but indispensable to the physician. — Ohicago Med. Journal, April, 1S60. No intelligent member of the pr.jfession can or wi il be without it. — St. Louis Mett. and Surg. Journal, April, IStio. It has the rare merit that it certaiuly has no rival in the English language for accuracy ani extent of references. — London Medical Gazette. LJOBLYN [RICHARD D.), M.D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. Revi.sed, with numeroui- additions, by I.saac Hays, M.D., Editor of the " American Journal of the Medical Sciences." In one large royal 12mo. volume of over 60(1 double-columned pages ; extra cloth, $1 50 ; leather, S'2 00. It is the best book of definitions we have, and ought always to be upon tlie student's labia. — Sc lUfv.rn tSed. and Surg. Journal Heney C. Lea's Publications — (Manuals). ]\JEILL {JOHN), M.D., and j^MITR {FRANCIS G.), M.D., •^ » '^-' Pr'if. of the. Inntitrdes (if 'Mf.dirine. in the Univ. of Penna. AN ANALYTICAL COMPENDIUM OP THE VARIOUS BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A new e.iition, revised and improved. In one very large and hand.somely printed royal 12mc. volume, of about one thou.«and pages, with 374 wood cuts, extra cloth, $4 ; strongly bound in leather, with raised bands, $4 75. The Compend of Drs. N^'illand Smith Ik incompara- bly the most valiiableworkof itsclawn evpr published In this couutry Attempts havebeeu made iu various quarters to squeeze Anatomy, Physiology, Surgery, the Practice of Medicine, Obstetrics, Maieria Medica, and Chemistry into a single manual; but the opera- tion has signally failed in the hands of all up to the advent of" Neill and Smith's" volume, which is quite a miracle of success. The outlines of the whole are admirably drawn and illustrated, and the authors are eminently entitled to the grateful consideration of the student of every class.— iV. 0. Mad. and Surg. Journal. There are but few students or practitioners of me- dicine unacquainted with the former editions of this anassuming though highly Instructive work. The whole science of medicine appears to have been sifted, as the gold-bearing sands of EI Dorado, and the pre- cious facts treasured up In this little volume. A com- plete portable library so condensed that the student may make it his constant pocket companion. — West- urn L'incet. In the rapid coarse of lectures, where work for the students is heavy, and review necessary for an exa- mination, a compend is not only valuable, but it is almost a Sine '/?t« ?iort. The one before us is, in most of the divisions, the most unexceptionable of all booVs of the kind that we know of. Of course it is uselefs for us to recommend it to all last course students, bnt there is a class to whom we very sincerely commend this cheap book as worth its weight in silver — that class is the graduates in medicine of more than ten years' standing, who have not studied medicine since. They will perhaps find out from it that the science is not exactly now what it was when they left it off. — r/ie Stethoscope. TTARTSHORNE {HENRY), M. D., Professor of Hygiene in the University of Pennsylvania. A CONSPECTUS OF THE MEDICAL SCIENCES; containing Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, Surgery, and Obstetrics. In one large royal 12rao. volume of 1000 clo.sely printed pages, with over 300 illustrations on wood, extra cloth, $4 50 ; leather, raised bands, $5 2ft. {Lntehj Puhlished.) The ability of the author, and his practical skill in condensation, give assurance that this work will prove valuable not only to the student preparing for examination, but also to the prac- titioner desirous of obtaining within a moderate compass, a view of the existing condition of the various departments of science connected with medicine. less valuable to the beginner. Every medical student who desires a reliable refresher to his memory whea the pressure of lectures and other col lege work crowds to prevent him from having an opportunity to drink deeper iu the larger works, will find this one of th« greatest utility. It is thoroughly trustworthy from beginning to end; and as we have before intimated, a remarkably truthful outline sketch of the present slate of medical science. We could hardly expect it should be otherwise, however, under the charge of such a thorough medical scholar as the author has already proved himself to be. — N. York Med. Record, March 1.5, 1869. This work is a remarkably complete one in its way, and comes nearer to our idea of what a Conspectus gbo^jld be than any we have yet seen. Prof. Harts- horne, with a commendable forethought, intrusted the preparation of many of the chapters on special subjects to experts, reserving only anatomy, physio- logy, and practice of medicine to himself. As a result we have every department worked up to the latest dale and in a refreshingly concise and lucid manner. There are an immense amount of illustrations scat- tered throughout the work, and although they have often been seen before in the various works upon gen- eral and special subjects, yet they will be none the T UDLOW {J.L.), M.D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enlarged. With 370 illustrations. In one handsome royal 12mo. volume of 816 large pages, extra cloth, $3 25; leather, $3 75. The arrangement of this volume in the form of question and answer renders it especially suit- able for the office examination of students, and for those preparing for graduation. * rfANNER {THOMAS HA WKES), M. D., ^-c. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- NOSIS. Third Americ.m from the Second London Edition. Revised and Enlarged bf Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, &c. In one neat volume small 12mo., of about 375 pages, extra cloth. $150. (jfust Iss2ce,d.) *;)(:* By reference to the " Prospectus of Journal" on page 3, it will be seen that this work 13 offered as a premium for procuring new subscribers to the "American Journal of the Medicai. Sciences." The objections commonly, and justly, urged against the general run of " compend s," "conspectuses," and other aids to indolence, are not applicable to this little volume, which contains in concise phrase just those practical details that are of most use in daily diag- nosis, but which the young practitioner finds it difll- cult to carry always in his memory without some quickly accessible means of reference. Altogether, I he book is one which we can heartily commend lo those who have not opportunity for extensive read- ing, or who, having read much, still wish an occa- sional practical reminder. — N. Y. Med. Gazette, Nov. 10, 1870. Taken as a whole, it is the most compact vade me- cum for the use of the advanced student and junior practitioner with which we are acquainted. — Boston Med. and Surg. Journal, Sept. 22, 1870. It contains so much that is valuable, presented in 80 attractive a form, that it can hardly be spared even iu the presence of more full and complete works. The additions made to the volume by Mr. Fox very materially enhance its value, and almost make it a new work. Its convenient size makes it a valuable companion to the country practitioner, and if con- stantly carried by him, would often render him good service, and relieve many a doubt and perplexity. — It^aventoorth Med. Herald, July, 1870. 6 . Henry C. Lea's Publications — {Anatomy). pRAY [HENRY), F.R.S., ^^ Lecturer on Anatomy at St. George's Hospital, London. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawinprs by H. V. Carter, M. D., late Demonstrator on Anatomj' at St. George's Hospital ; the Dissec- tions jointly by the Author and Dr. Carter. A new American, from the fifth enlarged and improved London edition. In one magnificent imperial octavo volume, of nearly 900 pages, with 4fi6 large and elaborate engravings on -wood. Price in extra cloth, $6 00 ; leather, raised bands, $7 00. (Just Issued.) The author has endeavored in this work to cover a more extended range of subjects than is cus- tomary in the ordinary text-books, by giving not only the details necessary for the student, but also the application of those details in the practice of medicine and surgery, thus rendering it both a guide for the learner, and an admirable work of reference for the active practitioner. The en- gravincs form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of fiffures of reference, with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Notwithstanding the enlargement of this edition, it has been kept at its former very moderate price, rendering it one of the cheapest works now before the profession. The illustrations are beautifully executed, and ren- der this work an indispensable adjanct to the library of the surgeon. This remark applies with great foice to those surgeons practising at a distance from our large cities, as the opportunity of refreshing their memory by actual dissection is not always attain- able —(7anf"?tf Med Journal, Aug. 1870. The work is too well known and appreciated by the profession to need any comment. No medical man c^n afford to be without it, if its only merit were to serve as a reminder of that which so soon becomes forgotten, when not called into frequent use, viz , the relations and names of the complex organism of the human body. The present edition is much improved. —Californin Jlled. Gazette, July, 1870. From time to time, as snccessive editions have ap- peared, we have had much pleasure in expressing the general judgment of the wonderful excellence of Gray's Anatomy. — Cincinnati Lancet, July, 1870. Altogether, it is unquestionably the most complete and serviceable text-book in anatomy that has ever been presented to the student, and forms a striking contrast to the dry and perplexing volumes on the same subject through which their predecessors strug- gled in days gone by. — N. Y. Med. Record, June 15, 1870. To commend Gray's Anatomy to the medical pro- fession is almost as much a work of supererogation as it would be to give a favorable notice of the Bible in the religious press To say that it is the most Gray's Anatomy has been so long the standard of j complete and conveniently arranged text book of its perfection with every student of anatomy, that we need do no more than call attention to the improve- ment in the present edition. — Detroit Review of Med. and Pharm., Aug. 1S70. kind, is to repeat what each generation of students has learned as a tradition ff thf elders, and verified by personal experience. — N. Y. Med. Gazette, Doe. 17, 1870. (^MITH {HENRY n.), M.D., and TJORNER ( WILLIAM E.), M.D., Prof, of Surgery in the Univ. of Penna., &c. Late Prof . of Anatomy in the Univ. of Penna., &e. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about sis hundred and fifty beautiful figures. $4 60. The plan of this Atlas, which renders it so pecu- the kind that has yet appeared; and we must add, liarly convenient for the student, and its superb ar- the very beautiful manner in which it is "got up," tistical execution, have been already pointed out. We is so creditable to the country as to be flattering to must congratulate the student upoa the completion our national pride. — American MedicalJournal. of this Atlas, as it is the most convenient work of (^HARPEY ( WILLIA3I), M.D., and Q UAIN [JONES ^ RICHARD). HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy, M.D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, of about 1300 pages, with 611 illustrations; extra cloth, $6 00. The very low price of this standard work, and its completeness in all departments of the subject, should command for it a place in the library of all anatomical students. jrODGES, [RICHARD M.), M.D., J- J- Late De.monstrator of Anatomy in the Medical Department of Harvard. University. PRACTICAL DISSECTIONS. Second Edition, thoroughly revised. In one neat royal 12mo. volume, half-bound, $2 00. The object of this work is to present to the anatomical student a clear and concise description of that which he is expected to observe in an ordinary couise of dissections. The author has endeavored to omit unnecessary details, and to present the subje jl in the form which many years' experience has shown him to be the most convenient and intelligible to the student. In the revision of the present edition, he has sedulously labored to render the volume more worthy of tile favor with which it has heretofore been received. Henry C. Lea's Publications — {Anatomy). -irriLSON [ERASMUS), F.R.S. A SYSTEM OF HUMAN ANATOMY, General and Special. Edited by W. 11. QoBKECHT, M. D., Professor of Generalaud Surgical Anatomy in tlje Medical Col- lego of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In one liirge and handsome octavo volume, of over 000 large pages; extra cloth, $4 00; lea- ther, $1} 00. The publisher trusts that the well-earned reputation of this long-established favorite will be more than maintained by the present edition. Besides a very thorough revision by the author, it has been most carefully examined by the editor, and the efl'orts of both have been directed to in- troducing everything which increased experience in its use has suggested as desirable to render it a complete text-book for those seeking to sbtain or to renew an acquaintance with Human Ana- tomy. The amount of additions which it has thus received may be estimated from the fact that the present edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged page reciuisite to keep the volume within a convenient size. The author has not only thus added largely to the work, but he has also made alterations throughout, wherever there appeared the opportunity of improving the arrangement or style, so as to present every fact in its most appropriate manner, and to render the whole as clear and intelligible as possible. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustrations, of which there are about one hundred and fifty more in this edition than in the last, thus bringing distinctly before the eye of the student everything of interest or importance. ' J-TEATH [CHRISTOPHER), F. R. C. S., ■^J- Teacher of Oiieration Surgery in University College, London. PRACTICAL ANATOMY: A Manual of Dissections. From the Second revised and improved London edition. Edited, with additions, by W. W. Keen, M. D., Lecturer on Pathological Anatomy in the Jeiferson Medical College, Philadelphia. In one handsome royal 12mo. volume of 578 pages, with 247 illustrations. Extra cloth, $3 60 ; leather, $4 00. {Lately Fublisked.) Dr. Keen, the American editor of this work, in his preface, says: "in presenting this American edition of 'Heath's Practical Anatomy,' I feel that I have been instrumental in supplying a want lung felt for a real dissector's manual," and thi.-, assertion of its editor we deem is fully justified, after an examina- bion of its contents, for it is really an excellent work. Indeed, we do not hesitate to say, the best of its class with which we are acquainted ; resembling Wilson iu terse and clear description, excelling most of the go-called practical anatomical dissectors iu the scope of the subject and practical selected matter. . . . in reading thie work, one is forcibly impressed with the gi'eat pains the author takes to impress the sub- ject upon the mind of the student. He is full of rare and pleasing little devices to aid memory in main- taining its hold upon the slippery slopes of anatomy. St. Louis Med. and Surg. Journal, Mar. 10, 1871. It appears to us certain that, as a guide in dissec- tion, and as a work containing facts ol anatomy in brief and easily understood lurm, this manual is ciimplete. This work contains, also, very perfect illustrations of parts which can thus be mure easily understood and studied; in this respect it compares favorably with works of much greater pretension. Such manuals of anatomy are always favorite works with medical students. We would earnestly recom- mend this one to their attention; it has excellences which make it valuable as a guide in dissecting, as well as in studying anatomy. — Jiuffaio Medical and Surgical Journal, Jan. ISVl. The first English edition was issued about six years ago, and was favorably received not only on account of the great reputation of its author, but also from its great value and excellence as a guide-book to the practical anatomist. The American edition has un- dergone some alterations and additions which will no doubt enhance its value materially. The conve- nience of the student has been carefully consulted in the arrangement of the text, and the directions given for the prosecution of certain dissections will be duly appreciated. — Canada Lancet, Feb. li)71. This is an excellent Dissector's Manual ; one which is not merely a descriptive manual of anatomy, but a guide to the student at the dissecting table, enabling him, though a beginner, to prosecute his work intel- ligently, and wituout assistance. The American edi- tor has made many valuable alterations and addi- tions to the original work. — Am. Journ. of Obstetrics, Feb. 1S71. MACLISE [JOSEPH). SURGICAL ANATOMY^ By Joseph Maclise, Surgeon. In one volume, very large imperial quarto; with 68 large and splendid plates, drawn in the best style and beautifully colored, containing 190 figures, many of them the size ot lite; together with copious explanatory letter-press. Strongly and handsomely bound in extra cloth. Price f 14 00. As no complete work of the kind has heretofore been published in the English language, the present volume will supply a want long felt in this country of an accurate and comprehensive Atlas of Surgical Anatomy, to which the student and practitioner can at all times refer to ascer- tain the exact relative positions ol the various portions of the human frame towards each other and to the surface, as well as their abnormal deviations. Notwithstanding the large size, beauty and finish of the very numerous illustrations, it will, be observed that the price is so low as to place it within the reach of all members of the profession. We know of no work on surgical anatomy which refreshed by those clear and distinct dissections, can compete with it. — Lancet. The work of Maclise on surgical anatomy is of the highest value. In some respects it is the best publi- cation of its kind we have seen, and is worthy of a place in the libiary of any medical man, while the student could scarcely make a better investment than this. — The Western Journal of Medicine and Surgery. No such lithographic illustrations of surgical re- gions have hitherto, we think, been given. While the operator is shown every vessel and nerve where an operation is contemplated, the exact anatomist is which every one must appreciat.e wUo has a particle of enthusiasm. The English medical press has quite exhausted the words ot pz-aise, in recommending this admirable treatise. Those who ha»e any curiosity to gratify, in reference to the perfectibility of the lithographic art in delineating the complex mechan- ism of the human body, are invited to examine our specimen copy. If anything will induce surgeons and students to patronize a book of such rare value and everyday importance to them, it will be a survey of the artistical skill exhibited in these fac-similes of nature. — Boston Med. and Surg. Journal. HORNER'S SPECIAL ANATOMY AND HISTOLOGY. 1 Eighth edition, extensively revised and modified. 1 In 2 vols. 8vo., of over 1000 pages, with more than 300 Wood-cuts ; extra cloth, ^\i Oo. 8 Henry C. Lea's Publications — (Physiology). lU'ARSHALL {JOHN), F. R. S., J.tL Pro/tssor of Surgery in University College, London, Ae. OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIVE. "With Additions by Francis Gurnet Smith, M. D., Professor of the Institutes of Medi- cine in the University of Pennsylvania, Ac. With numerous illustrations. In one large and handsome octavo volume, of 1026 pages, extra cloth, $6 60 ; leather, raised bands, $7 60. In fact, in every respect, Mr. Marshall has present- ed U8 with a most complete, reliable, and scientific work, and we feel that it is worthy our warmest commendation. — St. Louis Med. Reporter, Jan. 1S69. This is an elaborate and carefully prepared digest of human and comparative physiology, designed lor the use of general readers, but more especially ser- viceable to the student of medicine. Its style is con- cise, clear, and scholarly; its order perspicuous and exact, and its range of topics extended. The author and his American editor have been careful to bring to the illustration of the subject the important disco- veries of modern science in the various cognate de- partments of investigation. This is especially visible in the variety of interesting information derived from the departments of chemistry and physics. The great amount and variety of matter contained in the work is strikingly illustrated by turning over the copious index, covering twenty-four closely printed pages in double columns. — Sillirnan's Journal, Jan. 1869. We doubt if there is in the English language any compend of physiolugy more useful to the student than this work. — St. Louis Med. and Surg. Journal, Jan. 1869. It quite fulfils, in our opinion, the author's design of making it U\i\y educational in its character — which is. perhaps, the highest commendation that can be asked. — Am. Journ. Med. Sciences, Jan. 1869. We may now congratulate him on having com- pleted the latest as well as the best summary of mod- ern physiological science, both human and compara- tive, with which we are acquainted. To speak of this work in the terms ordinarily used on such occa- sions would not be agreeable to ourselves, and would fail to do justice to its author. To write such a book requires a varied and wiJe range of knowledge, con- siderable power of analysis, correct judgment, skill in arrangement, and conscientious spirit. It must have entailed great labor, but now that the task has been fuldl led, the book will prove not only invaluable to the student of medicine and surgery, but service- able to all candidates in natural science examinations, to teachers in schools, and to the lover of nature gene- rally. In conclusion, we can only express the con- viction that the merits of the work will command for it that success which the ability and vast labor dis- played in its production so well deserve. — London Lancet, Feb. 22, 1868. If the possession of knowledge, and peculiar apti- tude and skill in expounding it, qualify a man to write an educational work, Sir. Marshall's treatise might be reviewed favorably without even opening the covers. There are few, if any, more accomplished anatomists and physiologists than the distinguished professor of surgery at University College ; and ha has long enjoyed the highest reputation as a teacher of physiology, possessing remarkable powers of clear exposition and graphic illustration. We have rarely the pleasure of being able to recommend a text-book so unieservedly as this. — British Med. Journal, Jaa. 25, ISbS. nARPENTER [WILLIAM B.), M.D., F.R.S., ^^ Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A new American from the last and revised London edition. With nearlj' three hundred illustrations. Edited, with additions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the University of Pennsylvania, T THE SAME AUTHOR. MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Ess.ay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Penn.syl- vania. With illustrations on wood. Ie one very handsome octavo volume of 336 pageg, estra cloth. $2 25. 10 Henry C. Lea's Publications — (Chemistry). ATTFIELD (JOHN), Ph.D., Pro/es-t'ir of Prnnticnl Chemistry to the. Phnrmnceutieal Society of Great Britain, A-e. . CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL; inchuline: the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. Fiflh Edition, revised by the author. In one handsome royal 12mo. volume We commend the work heartily as one of the hest text-books extant for the medical student. — Detroit Sev. of Med. aiui Pharm., Feb. 1S72. The best work of the kind in the English language. —N. Y. Psychologicol Journal, Jan. 1872. The work is constructed with direct reference to the wants of medical and pharmaceutical students; and, although an English work, the points of differ- ence between the Bi-itish and United States Pharma- copoeias are indicated, making it as useful here as in England. Altogether, the book is one we can heart- ily recommend to practitioners as well as students. — i\'. Y. Med. Journal, Dec. 1S71. It differs from other text-books in the following particulars: first, in the exclusion of matter relating to compounds which, at present, are only of interest to the scientific chemist ; secondly, in containing the ch'emistry of every substance recognized offlcially or in general, as a remedial agent. It will be found a roost valuable book for pupils, assistants, and others engaged in medicine and pharmacy, and we heartily commend it to our readers. — Canada Lancet, Oct. 1871. When the original English edition of this work was published, we had occasion to express our high ap- preciation of its worth, and also to review, in con- siderable detail, the main features of the book. As the arrangement of subjects, and the main part of the text of tiie present edition are similar to the for- mer publication, it will be needless for us to go over the gronud a second time ; we may, however, call at- tention to a marked advantage possessed by the Ame- {Neariy Readij.) rican work— we allude to the introduction of the chemistry of the preparations of the United States Pharmacopoeia as well as that relating to the British authority. — Canadian Pharmaceutical Journal, Nov. 1S71. Chemistry has borne the name of being ahard sub- ject to master by the student of medicine, and chiefly because so much of it consists of compounds only of interest to the scientific chemist ; in this work such portions are modified or altogether left out, and in the arrangement of the subject matter of the work, practical utility is sought after, and we think fully attained We commend it for its clearness and order to both teacher and pupil. — Oregon 3Ied. and Surg. Reporter, Oct. 1S71. It contains a most admirable digest of what is spe- cially needed by the medical student in all that re- lates to practical chemistry, and consitntes for him a sound and useful text-book on the subject We commend it to the notice of »very medical, as well as pharmaceutical, student. We only regret that we had not the book to depend upon in working up the subject of practical and pharmaceutical chemistry for the University of London, for which it seerns to ua that it is exactly adapted. This is paying the book a high compliment. — T^ie Lancet. Dr. Attfield's book is written in a clear and able manner; it is a work siu generis and without a rival ; it will be welcomed, we think, by every reader of the 'Pharmacopoeia,' and is quite as well suited for the medical student as for the pharmacist. — The Chemi- cal News. w VHLER AND FITTIG. OUTLINES OP ORGANIC CHEMISTRY Translaterl with Ad- ditions from the Eighth German Edition. By Ira Eemsex. M.D., Ph.D., Profe.ssor of Chemistry and Physics in Williams College, Mass. In one handsome volume, royal 12mo. of 550 pp. extra cloth, ,$.3. {Just Ready.) As the numerous editions of the original attest, this worl? is the leading text-hook and standard authority throughout Germany on its important and intricate subject — a position won for it by the clearness and conciseness which are its distinguishing characteristics. The translation has been executed with the approbation of Profs. Wbhler and Fittig, and numerous additions and alterations have been introduced, so as to render it in every respect on a level with the most advanced condition of the science. DUNG [WILLIAM), Lectiirer on Chemistry at St. Bartholomew's ffospitjl, Ac. A COURSE OF PRACTICAL CHEMISTRY, arranged for the Use of Medical Students. With Illustrations. From the Fourth and Revised London Edition. In one neat royal 12mo. volume, extra cloth. $2. {Lately Issued.) Asa work for the practitioner it cannot be excelled. It is written plainly and concisely, and gives in a very small compass the information required by the busy practitioner. ' It is essentially a work for the physi- cian, and no one who purchases it will ever regret the outlay. In addition to all that is usually given in connection with inorganic chemistry, there are most valuable contributions to toxicology, animal and or- ganic chemistry, etc. The portions devoted to a dis- cussion of these subjects are very excellent. In no work can the physician find more that is valuable and reliable in regard to urine, bile, milk, bone, uri- nary calculi, tissue composition, etc. The work is small, rea.'-onable in i)rice, and well published. — Richmond and Louisville Med. Journal, Dec. 1869. flALLOWAY [ROBERT), F.C.S., \jr Prof, of Applied Cliemistry in the Royal College of Science for Ireland, &c. A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lon- don Edition. In one neat royal 12iuo. volume, with illustrations ; extra cloth, $2 60. {Just Issued.) The success which has carried this work through repeated editions in England, and its adoption as a text-book in several of the leading institutions in this country, show that the author has suc- ceeded in the endeavor to produce a sound practical manual and book of reference for the che- mical student. Prof Galloway's books are deservedly in high esteem, and this American reprint of the fifth edition (1869) of his Manual of Qualitative Analysis, will be acceptable to many American students to whom the Enclish edition is not accessible. — Am.. Jour, of Sci- ence and Arts, Sept. 1872. We regard this volume as a valuable addition to the chemical text-books, and as particularly calcu- lated to instruct the student in analytical researches of the inorganic compounds, the importaut vegetable acids, and of compounds and various .'■ecretious and excretions of animal origin. — Am. Journ. of Phiirtn., Sept. 1872. Henry C. Lea's Publications — (Ghemistry, Pharmacy, Sc). 11 nHAMDLER {CHARLES F.). and fillANDLER [WILLIAM H.), vy Prdf.ofdhtmislrijiiitheN. Y. Cull, of vy Prof of Ulimaiistry in the, Lnhtyk riiiirinticij. UnivernUy. THE AM^:HrOA^^ chemist : A Monthly Journal of Theoretical, Analyticiil, and Technical Chemistry. Each number aveniging forty large double col- umned pages of reading matter. Price $5 per annum in advance. Single numbers, 50 cts. CC?" Specimen numbers to parties proposing to subscribe will be sent to any address on receipt of 25 cents. *^* Subscriptions can begin with any number. The ra|)id growth of the Science of Chemistry anil its infinite applications to other sciences and iirts render a journal speinally devoted to the subject a necessity to those whose pursuits reijuire familiarity with the details of the science. It has been the aim of the conductors of "The Amkbucan Chemist" to supply this want in its broadest sense, and the reputation which the ])eriodical has alreacly attained is a sufficient evidence of the zeal and ability with which they have discharged their task. Assisted by an able body of collaborators, their aim is to present, within a moderate compass, an abstract of the progress of the science in all its departments, scientific and technical. Import- ant original communications and selected papers are given in full, and the standing of the " Chem- ist" is such as to secure the contributions of leadini; men in all portions of the country. Besides this, over one hundred journals and transactions of learned societies in America., Great Britain, France, Belgium, Italy, Russia, and Germany are carefully scrutinized, and whatever they offer of interest is condensed and presented to the reader. In this work, which forms a special feature of the "Chemist," the editors have the assistance of M. Alsberg, Ph.D., Prof. G. F. Barker, T. M. Blossom, E.iM., H. C. Bolton, Ph.D., Prof. T. Egleston, E.M , H. Endemann, Ph.D., Prof. C. A. Goe.ssmnnn, Ph.D.,S. A. Goldschmidt, A.M., E.M., E. J. Hallock. Prof. C. A. Joy, Ph.D., J. P. Kimball, Ph.D., 0. G. Mason, H. Newton, E.M., Prof. Frederick Prime, Jr., Prof. Paul Schweitzer, Ph.D., Waldron Shapleigh, Rorayn Hitchcock, and Elwyn Waller, E.M. From the thoroughness and completeness with which this department is conducted, it is believed that no periodical in either hemisphere more faithfully reflects the progress of the science, or presents a larger or more carefully garnered store of information to its readers. F' VWNES (GEORGE), Ph.D. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. With one hundred and ninety-seven illustrations. A new American, from the tenth and revised London edition. Edited by Robert Bridges, M. D. In one large royal I2mo. volume, of about 850 pp., extra cloth, $2 75 ; leather, $3 25. {Lately Issued.) This work is so well known tliat it seems almost superfluous for us to speak about it. It has been a favorite text-book with medical students for years, and its popularity has iu no respect diminislied. Whenever we have been consulted by medical stu- dents, as has frequently occurred, what treatise on chemistry they should procure, we have always re- commended Fownes', for we regarded it as the best. There is no work that combines so many excellen- ces. It is of convenient size, not prolix, of plain perspicnous diction, contains all the most recent discoveries, and is of moderate price. — Cincinnati Med. Sepeiiory, Aug. 1869. Large additions have been made, especially in the department of organic chemistry, and we know of no other work that has greater claims on the physician, pharmaceutist, or student, than this. We cheerfully recommend it as the best text-book on elementary chemistry, and bespeak for it the careful attention of students of pharmacy.— CTucaao Pharmacist, Aug. 1869. J y > 6 The American reprint of the tenth revised and cor- rected English edition is now issued, and represents the present condition of the science. No comments are necessary to insure it a favorable reception at the hands of practitioners and students. — Boston Med. and Surg. Journal, Aug. 12, lSd9. Here is a new edition which has been long watched for by eager teachers of chemistry. In its new garb, and under the editorship of Mr. Watts, it has resumed its old place as the most successful of text-books. — Indian Medical Gazette, Jan. 1, 1S69. It will continue, as heretofore, to hold the first rank IS a text-book for students of medicine. — Chicago Med. Examiner, Aug. 1809. Thiswork, long the recognized Manual of Chemistry, appears as a tenth edition, under the able editorship ■)f Bence Jones and Henry Watts. The chapter on the General Principles of Chemical Philosophy, and the greater part of the organic cliemi.'stry, have been jewritten, and the whole work revised iu accordance with the recent advances in chemical knowledge. It remains the standard text-book of chemistry. — Dub- lin Quarterly Journal, Feb. 1S69. There is probably not a student of chemistry in this country to whom the admirHble manual of the late Professor Fownes is unknown. It has achieved a success which we believe is entirely without a paral- lel among scientific text-books in our language. This success has arisen from the fact that there is no En- glish work on chemistry which combines so many excellences. Of convenient size, of attractive form, clear and concise in diction, well illustrated, and of moderate price, it would seem that every rc'iuisite for a student's haud-book has been attained. — The Chemical Ntws, Feb. 1S69. ^0 WMAN [JOHN E.) , 31. D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C. L. Bloxam, Professor of Practical Chemistry in King's College, London. Fifth American, from the fourth and revised English Edition. In one neat volume, royal 12mo., pp. 351, with numerous illustrations, extra cloth. |2 25. J^T THE fiA3IE AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Fifth American, from the fifth and revised London edition. AVith numer- ous illustrations. In one neat vol., royal I2mo., extra cloth. $2 25. KNAPP'S TECHNOLOGY ; or Chemistry Applied to the Arts, and to Manufactures. With American additions, by Prof. Walter R. Johsbon. In two very handsome octavo volumes, with £00 ■wood engravings, extra cloth, (ii6 00. 12 Henry C. Lea's Publications — (Mat. Med. and Therapeutics). pARRISH [EDWARD], ■'- Proftsfior of MrUeria Medica in the Philadelphia College of Pharmacy. A TREATISE ON PHARMACY. Designed as a Text-Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. Third Edition, greatly improved. In one handsome octavo volume, of 850 pages, with several hundred illustrations, extra cloth. $5 00; leather, $6 00. The immense amount of practical information condensed in this volume may be estimated from the fact that the Index contains about 4700 items. Under the head of Acids there are 312 refer- ences ; under Emplastrum, 36 ; Extracts, 159; Lozenges, 25; Mixtures, 55; Pills, 56 ; Syrups, Tinctures, 138; Unguentum, 57, &c. 131 We have examined this large volume with a good d'?al of care, and find that the author has completely exhausted the subject npou which he treats ; a more complete work, we thinli, it would be impossible to find. To the student of pharmacy the work is indis- pensable ; indeed, so far as we know, it is the only one of its kind in existence, and even to the physician or medical student who can spare five dollars to pur- chase it, we feel sure the practical information he' will obtain will more than compensate him for the outlay. — Canada Med. Journal, Nov. 1S64. The medical student and the practising physician will find the volume of inestimable worth for study and reference. — San Francisco Med. Press, July, 1S64. When we say that this book is in some respects the best which has been published on the subject in the English language for a great many years, we do not wish it to be understood as very extravagant praise. In truth, it is not so much the best as tha jnly book. — !ZVie London Chemical News. An attempt to furnish anythitg like an analysis ol Parrish"s very valuable and elaborate Treatise on Practical Pharmacy would require more space than ve have at our disposal. This, however, is not so much a matter of regret, inasmuch as it would he difficult to think of any point, however minute and apparently trivial, connected with the manipulation if pharmaceutic substances or appliances which has not been clearly and carefully discussed in this vol- ume. Want of space prevents our enlarging further on this valuable work, and we must conclude by a simple expression of our hearty appreciation of it» merits. — DtMiii Qiiarterly Jour, of Medical Science, August, 1S64. OTILLE {ALFRED), M.D., ^ Professor of Theory and Practice of Medicine in the University of Penna. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History Fourth edition, revised and enlarged. In two large and handsome octavo volumes. {Pre- paring.) Dr. Salle's .>plendid work on therapeutics and ma- teria medica. — London Med. Times, April 8, 1865. Dr. Still6 stands today one of the best and most honored representatives at home and abroad, of Ame- rican medicine ; and these volumes, a library in them- selves, a treasuje-house for every studious physician, assure his fame even had he done nothing more. — The Western Journal of Medicine, Dec. 18B8. We regard this work as the best one on Materia Medica in tlie English language, and as such it de- serves the favor it has received. — Am. Journ. Medi- cal Sciences, July 1S6S. We need not dwell on the merits of the third edition of this magnificently conceived work. It is the work on Materia Medica, in which Therapeutics are prima- rily considered — the mere natural history of drugs being briefly disposed of. To medical practitioners this is a very valuable conception. It is wonderful how much of the riches of the literature of Materia Medica has been condensed into this book. The refer- ences alone would make it worth possessing. But it is not a mere compilation. The writer exercises a good judgment of his own on the great doctrines and points of Therapeutics. For purposes of practice, Still6's book is almost unique as a repertory of in- formation, empirical and scientific, on the actions and uses of medicines. — London Lancet, Oct. 31, 1868. Through the former editions, the professional world l8 well acquainted with this work. At home and abroad its reputation as a standard treatise on Materia Medica is securely established. It is second to no work on the subject in the English tongue, and, in- deed, is decidedly superior, in some respects, to any other. — Pacific Med. and Surg Journal, July, 1868. Stilld's Therapeutics is incomparably the best work on the subject.— iV. T. Med. Gazette, Sept. 26, 1868. Dr Still6's work is becoming the best known of any of our treatises on Materia Medica. . . . One of the most valuable works in the language on the subject* of which it treats. — N. Y. Med. Journal, Oct. 186S. The rapid exhaustion of two editions of Prof. Still6» scholarly work, and the consequent necessity for a third edition, is BUtticient evidence of the high esti- mate placed upon it by the profession. It is no exag- geration to say that there is no superior work upon the subject in the English language. The present edition is fully up to the most recent advance in the science and art of therapeutics. — Leavenworth Medi- cal Herald, Aug. 1S68. The work of Prof. Still6 has rapidly taken a high place in professional esteem, and to say that a third edition is demanded and now appears before us, suffi- ciently attests the firm position this treatise has made for itself. As a work of great research, and scholar- ship, it is sale to say we have nothing superior. It is exceedingly full, and the busy practitioner will find ample suggestions upon almost every important point of therapeutics. — Cincinnati Lancet, Aug. 1S68. o RIFFITH [ROBERT E.), M.D. A TJNIYERSAL FORMULARY, Containing the Methods of Pre- paring and Administering Oflncinal and other Medicines. The whole adapted to Physiciana and Pharmaceutists. Second edition, thoroughly revised, with numerous additions, by Robert P. Thomas, M.D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavo volume of 650 pages, double-columns. Extra cloth, $4 00; leather, $5 00. Three complete and extended Indexes render the work especially adapted for immediate consul- tation. One, of Diseases and their Remedies, presents under the head of each disease the remedial agents which have been usefully exhibited in it, with reference to the formuljB containing them — while another of Pharmaceutical and Botanical Names, and a very thorough General Index afford the means of obtaining at once any information desired. The Formulary itself ia arranged alphabetically, under the heads of the leading constituents of the prescriptions. We know of none in our language, or any other, so comprehensive in its details. — London Lancet. One of the most complete works of the kind in any language. — Edinburgh Med. Journal. We are not cognizant of the existence of a parallel work. — London Med. Oaietle. Henry C. Lea's Publications — {Mai. Med and Titer apeutics). 13 pEREIRA [JONA THAN), M. /)., F. R.S. and L.S. MATERIA MEDICA AND THERAPEUTICS; being an Abridii- ment of the late Dr. Pcreira's Elements of Materia Medica, arranged in conformity with the British Phiirmacopocia, and adiipted to the use of Medical Pracjtitioners, Cheinista and Drufrj^ists, Medical and Phnrinaceiitical Students, Ac. By F. J. Faiike, M.D., Senior Physician to St. Bartliolotnevv's Hosjiital, and London Editor of the British Pharniacopceia ; assisted by Robert Bentley, M.R.C.S., Professor of Materia Medica and Botany to the Pharmaceutical Society of (ireat Britain; and by Robert VVarington, F.R.S., Chemical Operator to the Society of Apotheonries. With numerous additions and references to the United States Pharmacopoeia, by Horatio C. Wood, M.D., Professor of Botany in the University of Pennsylvania. In one large and handsome octavo volume of 1(140 tdosely printed pages, with 2;^6 illustrations, extra cloth, $7 00; leather, raised bands, $8 00 The ta.sk of tlie .\iuerican editor has evideutly been no winecui'e, for not ouly hiis he giv(ui to us all tliat Is coutrtiiied in the ahritlgmeut useful for our piir- pose.s, but by a careful and judicious embodiuient of over a hundred new remedies has increased the size of the former work fully one-third, besides adding many new illustrations, some of which are original. We unhesitatingly say that by so doing he has pro- portionately increased tlio value, not only of the con- densed edition, hut has extended the applicahility of the great original, and lias placed his medical coun- trymen under lasting obligations to him. The Ame- rican physician now nas all that is needed in the shape of a complete treatise on materia medica, and the mediqal student has a text-book which, for prac- tical utility and intrinsic worth, stands unparalleled. Although of considerable size, it is none too large for the purposes for which it has been intended, and every medical man should, in justice to himself, spare a place for it upon his book-shelf, resting assured that the more he consults it the better he will be satisfied of its excellence. — N. Y. Mc/l. Record, Nov. 15, 1866. It will fill a place which no other work can occupy lu the library of the physician, student, and apothe- eary. — Boston Med. and Surff. Journal, Nov. 8, 1866. Of the many works on Materia Medica which have appeared since the issaing of the British Pharmaco- poeia, none will be more acceptable to the student and practitioner than the presoul. Pereira's Materia Medica had long ago asserted for itself the position of being tlie most complete work on the subject in the- English language. But its vary completeness stood in the way of its success. Except in the way of refer- ence, or to those who made a special study of Materia Medica, Dr. Pereira's work was too full, and its pe- rusal required an amount of time which few had at their disposal. Dr Farre has very j udiciously availfd himself of the opportunitv of the publication of the new Pharmacopoeia, Dybrindngout an abridged edi- tion of the great work. This edition of Pereira is by no means a mere abridged re-issue, but contains many improvements, both in the descriptive and thera- peutical departments. We can recommend it as a very excellent and reliable text-book. — Edinburgh Med. Journal, February, 1S66. The reader cannot fail to be impressed, at a glance, with the exceeding value of this work as a cornpend of nearly all useful knowledge on the materia medica. We are greatly indebted to Professor Wood for his adaptation of it to our meridian. Without his emen- dations and additions it would lose much of its value to the American student. With them it is an Ameri- can book..— Po.cijio Medical and Surgical Journal, December, 1866. fjLLIS [BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Pvescripiions derived from the writings and practice of mnny of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparation.? and Antidotes for Poisons. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- tion, carefully revised and much improved by Albert H. Smith, M. D. In one volume Sv- . of 376 pages, extra cloth, $3 00. (Lately Published.) This work has remained for some time out of print, owing to the anxious care with which the Editor has sought to render the present edition worthy a continuance of the very remarkable favor which has carried the volume to the unusual honor of a Twelfth Edition. He has sedu- lously endeavored to introduce in it al! new preparations and conibinntions deserving of confidence, besides adding two new classes, Antemeties and Disinfectants, with brief references to the inhalation of atomized fluids, the nasal douche of Thudichum, suggestions upon the method of hypodermic injection, the administration of anaesthetics, . 700, ex- tra cloth. $3 00. OHRISTISON'S DISPENSATORY. With copious ad- dUioas, and 213 large wood-engraviugB. By G Eqlespei.d Grtppith, M. D. One vol. Svo., pp. 1000 ; extra cloth. $4 no. CARPENTER'S PRIZE ESSAT ON THE USE OF Alcoholic Liquors in Health and Disease. New edition, with a Preface by D. F. Condie, M.D., and explanations of scientific words. In one neat )2mo. volume, pp. 17S, extra cloth. 60 cents. De JONGH on the THREE KINDS OF COD-LIVEB Oil, with their Chemical and Therapeutic Pro- perties 1 vol. 12mo., cloth. 75 cents. 14 Henry C. Lea's Pl'blications — {Pathology^ <&c.) riREEN ( T. HENR Y) , M. D., Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School. PATHOLOGY AND MORBID ANATOMY. With numerous Hlus- trations on Wood. In one very handsome octavo volume of over 250 pages, extra cloth, §2 50. {Lately Published ) The scope and object of this volume can be gathered from the following condensed We have been very much pleased by oar perusal of thology and morbid anatomy. The author shoirs that this little volume. It is the ouly one of the kind with he has been not only a student of the teachings of his which we are acquainted, and practitioners as well confreres in this branch of science, but a practical as students will find it a very useful guide ; for the and conscientious laborer in the post-mortem cham- iuformalion is up to the day, well and compactly ar- ber. The work will prove a useful one to the great vauged, without being at all scanty. — London Lan- ' mass of students and practitioners whose time for de- cet, Oct. 7, 1871. votion to this class of studies is limited. — Am. Joiirn. It embodies in a comparatively small space a clear i of Sijphilography, April, 1S72. statement of the present state of our knowledge of pa- 1 GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by Joseph Leidt, M. D. In one volume, very large imperial quarto, with 320 copper-plate figures, plain and colored, extra cloth. $4 00. tical Relations. In two large and handsome octavo volumes of nearly 1.500 pages, extra cloth. $7 00. HOLLAND'S MEDICAL NOTES ANI KEFLEC- TiONS. 1 vol. Svo., pp. 500, extra cloth. $3 .50. SI.MON'S GENERAL PATHOLOGY, as conducive t< i WH.\TTOOBSERYEATTHE BEDSIDE AND AFTER the Establishment of Rational Principles for th» | Death in llEDic.iL Cases. Published under the Prevention and Cure of Disease. In one octavo authority of the London Society for Medical Obser- volume of 212 pages, extra cloth. $12.5. i vation. From the second London edition. 1 vo). SOLLY ON THE HUMAN BRAIN ; its Structure, Phy- siology, and Diseases. From the Second and much enlarged London edition. In one octavo volume of JjOOpages, with 120 wood-cuts; extra cloth. $2 50. LA ROCHE ON YELLOW FEYER, considered in its Historical, Pathological, Etiological, andTherapeu- royal 12mo., extra cloth. $1 00. LAYCOCK'S LECTURES ON THE PRINCIPLES . AXD Methods of Medical Observation and Re- search. For the use of advanced students and junior practitioners. In one very neat royal 12ino. volume, extra cloth. $1 00. pROSS [SAMUEL D.), M. D., V-^ Professor of Surgery in the .Jefferson Medical College of Philridelphia. ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly revised and greatly improved. In one large and very handsome octavo volume of nearly 800 pages, with about three hundred and fifty beautiful illustrations, of which a large number are from original drawings ; extra cloth. $4 00. TONES [G. HANDFIELD). F.R.S., and SIEVEKINO [ED. H.), M.D., *J Assistant Physicians and Lecturers iti St. Mary's Hospital. Physicians and Lecturers :"?i St. Mary's Hospital. A MANUAL OF PATHOLOGICAL ANATOMY. First American edition, revised. With three hundred and ninety-seven handsome wood engravings. In one large and beautifully printed octavo volume of nearly 750 pages, extra cloth, $3 50. B ARCLAT [A. W.), 31, D. A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Signs and Symptoms of Disease. Third American from the second and revised London edition. In one neat octavo volume of 451 pages, extra cloth. $3 50. lyiLLIAMS [CHARLES J. B.), M.D., ' ' Professor of Clinical Medicine in University College, London. PRINCIPLES OF MEDICINE. An Elementary View of the Causes, Nature, Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the preservation of health. A new American, from the third and revised London edition, In one octavo volume of about 500 pages, extra cloth. $.3 50. TyUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics, Di.seases of Women and Children, Medical Jurisprudence, &c. Ac. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound in leather, $15; extra cloth. $11. *^* This work contain? no less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians. TPOX [ WILSON). M. D., -'- Holme Prof, of Clinical Med., Vniversify Coll., London. THE DISEASES OF THE STOMACH: Being the Third Edition of the "Diagnosis and Trenlment of the Varieties of Dyspepsia." Revised and Enlarged. With illustrations. In one handsome octavo volume. (In Press.) The present edition of Dr. Wilson Fox's very admi- ' Dr. Fox has put forth a volume of uncommon ex- ruble wiirk differs from the preceding in that it deals cellence, which wo feel very sure will takf a high with other maladies than dyspepsia ouly. — London , rank among works that treat of the stomach. — Am. Med. Times, Feb. S, 1873. I Practitioner, March, 1S73. Henry C. Lea's Publications — (^Practice of Medicine). 15 J^LINT {A USTIN), M. D., -*• ProfiKstir of llu, Princiiden iind Practice of yTnlicinf. in BellKVue Me.d. Colh-ge, N. T. A TREATISE OX THE PKIXCIPLES AXD PRACTICE OF MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth edition, revised and onlar^red. In one large and closely printed octavo volume of about 1 1 DO pases; handsome extra cloth, $6 00; or strongly bound in leather, with raised bands, $7 00. (Nearly Ready.) By common consent of the Engli.<(h and American medical press, this work has been assigned to the highest position as a complete ami comjiendious text-book on the most advanced condition of medical science. At the very moderate price at which it is offered it will be found one of the cheapest volumes now before the profession. Admirable and uaequalled. — Wtsttrn Journal of Medicine, Nov. 1869. Dr. FliQt's work, though claiming no higher title than that of a text-book, is really more. He is a tiiau of large clinical experience, and his book is full of such masterly descriptions of disease as can only be drawn by a man intimaiely acquainted with their various forms. It is not so Ions; since we had the pleasure of reviewing liis first edition, and we recog- nize a great improvement, especially in the general part of the work. It is a work which we can cordially recommend to our I'eaders as fully abreast of the sci- ence of the day. — Edinburgh Med. Journal, Oct. '69. One of the best works of the kind for the practi- tioner, and the most convenient of all for the student. — Am. Jourii. Med. Sciences, Jan. 1S69. This work, which stands pre-eminently as the ad- vance standard of medical science up to the present time in the pra<;tice of medicine, has for its author one who is well and widely known as one of the lewdiug practitioners of this continent. In tact, it is seldom that any work is ever issued from the press more deserving of universal recommeadatiou. — Do- minion Med. Journal, May, 18ti9. The third edition of this mostexcellont book scarce- ly needs any commendation from us. The volume, as it stands now, is really a marvel: first of all, it is sxcellontly printed and hound — and we encounter that luxury of America, tho ready-cut i)ages, which the Yankees are 'cute enough to insist upon — nor are these by any means trifles ; but the contents of the book are astonishing. Not only is it wonderful that Anyone man can h.ive grasped in hismiud thewhole ■!Cope of medicine with that vigor which Dr. Flint ihows, but the condensed yet clear way In which this is done Is a perfect literary triumph. Dr. Flint IS pre-eminently one of the strong men, whose right to do this kind of thing is well admitted ; and we say ao more than the tiuth when we aflirm that he is very nearly the only living m;in that could do it with such results as the volume before us. — T lie London Practitioner, March, 1869. This is in some respects the best text-hook of medi- cine in our language, and it is highly appreciated ou the other side of the Atlantic, inasmuch as the first edition was exhausted in a few months. The second sdition was little more than a reprint, but the present has, as the author says, been thoroughly revi.-ed. Much valuable matter has been added, and by ma'iC- ing the type smaller, the bulk of the volume is not much increased. The weak point in many American works is pathology, but Dr. Flint has taken peculiar pains on this point, greatly to the value of the book. — London Med. Times and Gazette, Feb. 6, lSt59. BARLOW'S MANUAL OF THE PRACTICE OF MEDICINE. With Additions'by D. F. Cokdie, M. D. 1 vol. 8vo., pp. 600, cloth. $2 50. TODD'S CLINICAL LECTURES ON CERTAIN ACUTE Diseases. In one neat octavo volume, of 320 pages, extra cloth. $2 50. F .ArY{F.W.),M.D.,F.R.S., Senior Asst. Physician to and Lecturer on Physiology, at Guy's ffospitnl, Ac. A TREATISE ON THE FUNCTION OF DIGESTION; its Disor- ders and their Treatment. From the second London edition. In one handsome volume, small octavo, extra cloth, $2 00. {Lately Publisked.) The work before us is one which deserves a wide treatise, and sufficiently exhaustive for all practical circulation. We know of no better guide to the study purposes. — Leavenworth Med. Herald, July, 1S69. of digestion and its disorders.— Sf. Louvi Med. and ^ ^^^y valuable work on the subject of which it Surg. Journal, July 10, 1SB9. treats. "Small, yet it is full of valuable information. A thoroughly good book, being a careful systematic — Cincinnati Med. Repertory, June, 1869. jDRINTON {WILLIAM), M.D., F.R.S. -^LECTURES ON THE DISEASES OF THE STOMACH; with an Introduction on its Anatomy and Physiology. From the second and enlarged London edi- tion. With illustrations on wood. In one handsome octavo volume of about 300 pages, extra cloth. $3 25. (CHAMBERS {T.K.), M.D., ^ Gunmdting Physician to St. Mary's Hospital, London, &c. THE INDIGESTIONS; or, Diseases of the Digestive Organs Functionally Treated. Third and revised Edition. In one handsome octavo volume of 383 pages, extra cloth. $3 00. {Lately Published.) So very large a proportion of the patients applying 1 merit, we know of no more desirable acquisition to to every general practitioner suffer from some form j a physician's library than the book before us. He of indigestion, that whatever aids him in their man- i who should commit its contents to his memory would agement directly "puts money in his purse," and in- find its price an investment of capital that returned directly does mure than anything else to advance his i him a most usurious rate of interest. — N. T. Medical reputation wiih the public. From this purely mate- i Gazette, Jan. 28, 1871. rial point of view, setting aside its higher claims to | -nr THE SAME AUTHOR. {Lately Published) RESTORATIVE MEDICINE. An Harveian Annual Oration, deliv- ered at the Royal College of Physicians, London, on June 24, 1871. With Two Sequels. In one very handsome volume, small 12mo., extra cloth, $1 00. Ifi Henry C. Lea's Publications — {Practice of Medicine). PRACTICE OP MEDI- Third edition, revised and im- fTARTSHORXE {HENRY.). M.D., J-J- PrnfeiKor of Hygiene in the vniverMty of Pennxylvania. ESSENTIALS OF THE PRINCIPLES AND CINE. A handy-book for Students and Practitioners. proved. In one handsome rov.'tl ]2u30. volume of 487 pages, clearly printed on small type, cloth, $2 .38; half bound, $2"6.3. (Now Heady.) The very remarkable favor which has been bestowed upon thi.s work, as manifested in the ex-" hau.-:tion of two large editions within four years, shows that it ha.'j successfully supplied a want lelt by both student and practitioner of a volume which at a moderate price and in a convenient size fhould afford a clear and compact view of the most modern teachings in medical practice. In preparing the work for a third edition, the author has sought to maintain its character by very numerous additions, bringing it fully up to the science of the day, but so concisely framed that the size of the volume is increased only by thirty or forty pages. The extent of the new informa- tion thus introduced may be estimated by the fact that there have been two hundred and sixty separate additions made to the text, containing references to one hundred and eighty new authors. This little epitome of medical knowledge has al- ; mulas are appended, intended as examples merely, ready been noticed by us. It is a vade mecum of value, including in a short space most of what is es- sential in the science and practice of medicine. The third edition is well up to the present day in the modern methods of treatment, and in the use of newly discovered drugs. — Boston Med. and Surg. Jo^lrnal, Oct. If), 1871. Certainly very few volumes contain so much pre- cise information within so small a compass. — N. Y. Med. Journal, Nov. 1S71. The diseases are conveniently classified; symptoms. Causation, diagnosis, prognosis, and treatment are CHrefuUy considered, the whole being marked by briefness, but clearness of expression. Over 2.50 for- not as guides for unthinking practitioners. A com- plete index facilitates the use of this little volume, in which all important remedies lately introduced, such as chloral hydiate and carbolic acid, have received their full shareof attention. — Am. Joiirn. of P harm,., Nov. 1S71. It is an epitome of the whole science and practice of mpdiciue. and will be fuuud most valuable to the practitioner for easy reference, and especially to the student in attendance upon lectures, whose time is too much occupied with many studies, to consult the larijer works. Such a work must always be in great demand. — Cincinnati Med. Repertory, Aov. 1871. ViTATSON [THOMAS], 31. D., ^c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- vised and enlarged English edition. Edited, with additions, and several hundred illus- trations, by Henry Hartshorne, M.D., Professor of Hygiene in the University of Penn- sylvania. In two large and hauilsoine 8vo. vols. Cloth, §9 01); leather, $11 dO. (J nut ready.) With the assistance of Professor George Johnson, his successor in the chair of Practice of Medi- cine in King's College, the author has thoroughly revised this WQrk, and has sought to bring it on a level with the most advanced condition of the ubject. As he himself remarks : "Consider- ing the rapid advance of medical science during the last fourteen years, the present edition would be worthless, if it did not differ much from the last" — but in the extensive alterations and addi- tions that have been introduced, the effort of the author has been to retain the lucid and collo- quial style of the lecture-room, which has made the work so deservedly popular with all classes of the profession. Notwithstanding these changes, there are some subjects on which the American reader might reasonably expect more detailed information than has been thought requisite in England, and these deficiencies the editor has endeavored to supply. ■ The large size to which the work has grown seems to render it necessary to print it in two vol- umes, in place of one, as in the last American edition. It is therefore presented in that shape, handsomely printed, at a very reasonable price, and it is hoped that it will fully maintain the position everywhere hitherto accorded to it, of the standard and classical representative of Eng- lish practical medicine. At length, after many months of expectation, we have the satisfaction of finding ourselves this week in possession of a revised and enlarged edition of Sir Tliomas Watson's celebrated Lectures It is a sub- ject for congratulation and for thankfulness that Sir Thomas Watson, during a period of comparative lei- bi-.re, after a long, laborious, and most honorable pro- fessional career, while retaining full possession of his high mental faculties, should have employed the op- portunity to submit his Lectures to a more thorough revision than was possible during the earlier and busier period of his life. Carefully passing in review some of the most intricate and important pathological and practical questions, the results of his clear iubight an.l his calm judgment are now recorded for the bene- fit of mankind, in language which, lor precision, vigor, and classical elegance, has rarely been equalled, and never surpassed The revision has evidently been most carefully done, and the results appear in almost every page. — Brit. Med. Jotirn., Oct. 14, 1871. No words can convey the pleasurable satisfaction that we feel in looking over the revised edition of the admirable lectures of this distinguished author. The earnestness which marked his whole profes- sional career leads him, in a chara., Lecturer on Medicine in the Manchester School of Medicine, Ac. PRACTICAL TREATISE OX URINARY AND RENAL DIS- EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Sec- ond American, from the Second Revised and Enlarged London Edition. In one large and handsome octavo volume of 616 pages, with a colored plate ; extra cloth, $4 50. {Just Ready.) The author has subjected this work to a very thorough revision, and has sought to embody in it the re.^ults nf the latest experience and investigations. Although every effort has been made to keep it within the limits of its former size, it has been enlarged by a hundred pages, many new wood-cuts have been introduced, and also a colored plate representing the appearance of the different varieties of urine, while the price has been rettiined at the former veiy moderate rate. In every respect it is therefore presented as worthy to maintain the position whieh.it has acquired as a leading authorit}' on a large, important, and perplexing class of affections. A few notices of the first edition are appended. The plan, it will thus be seen, is very complete, anl the manner in which it has been carried out is in the highest degree satii^factory. The characters of tlie different deposits are very well described, and the microscopic appearances they pre.sent are illus- trated by numerous well executed engravings. It only remains to us to strongly recommend to our readers Dr. Roberts's work, as containing an admira- ble risrL'nit of the present state of knowledge of uri- nary diseases, and as a safe and reliable guide to the clinical observer. — Edin. Med. Jour. The most complete and practical treatise upon renal diseases we have examined. It is peculiarly adapted to the wants of the majority of American practition- ers from its clearness and simple announcement of the facts in relation to diagnosis and treatment of urinary disorders, and contains in condensed form the investi- gations of Bence Joues, Bird, Beale, Hassall. Prout, and a host of other well-known writers upon this sub- ject. The characters of urine, physiological and pa- thological, as indicated to the naked eye as well as by microscopical and chemical investigations, are con- cisely represented both by description and by well executed engravings. — Cincinnati Journ. of Med. B ASEA31 {W.R.), M.D., Senior Physician to the Westminster Hospital, &c. RENAL DISEASES: a Clinical Guide to their Diagnosis and Treatment. With illustrations. In one neat royal 12mo. volume of 304 pages. $2 00. {Just Issued.) The chapters on diagnosis and treatment are very j raent render the book pleasing and convenient. — Am,. good, and the student and young practitioner will find tReni full of valuable practical hints. The third part, on the urine, is excellent, and we cordially recommend its perusal. The author has arranged his matter in a somewhat novel, and, we think, use- ful form. Here everything can be easily found, and, what is more important, easily read, for all the dry details of larger books here acquire a new interest from the author's arrangement. This part of the book is full of good work. — Brit, and For. Medico- Chirurgical Keview, July, 1870. The easy descriptions and compact modes of state- Journ. Med. Sciences, July, 1S70. A book that we believe will be found a valuable assistant to the practitioner and guide to the student. — Baltimore Med. Journal, July, 1870. The treatise of Dr. Basham differs from the rest in its special adaptation to clinical study, and its con- densed and almost aphorisrnal style, which makes it easily read and easily understood. Besides, the author expresses some new views, which are well worthy of consideration. The volume is a valuable addition to this department of linowledge. — Pacific Med. and Surg. Journal, July, 1870. MORLAND ON RETENTION IN THE 1 vol. Svo., extra cloth. 75 cents. TONES [G. HANDFIELD), M. " Physician to St. Mary's Hospital, &c. BLOOD OF THE ELEMENTS OF THE URINARY SECRETION. D., OBSERVATIONS Second American Edition. 25. CLINICAL DISORDERS, extra cloth, $.3 Taken as a whole, the work before us furnishes a short but reliable account of the pathology and treat- ment of a class of very common but certainly highly obscure disorders. The advanced student will find it a rich mine of valuable facts, while the medical prac- titioner will derive from it many a suggestive hint to aid him in the diagnosis of "nervous cases," and in determining the true indications for their ameliora- tion or CMve.—Amer. Journ. Med. Sci., Jan. 1867. ON FUNCTIONAL NERVOUS In one handsome octavo volume of 348 pages. We must cordially recommend it to the profession of this country as supplying, in a great measure, a deficiency which exists in the medical literature of the English language. — New York Med. Journ., April, 1867. The volume is a most admirable one — full of hints and practical suggestions. — Canada Med. Journal, April, 1867. s N DISEASES OF THE SPIRAL COLUMN AND OF THE NERVES. By C. B. Eadclifp, M. D., and others. 1 vol. 8vo., extra cloth, $1 50. LADE [D. D.), M.D. DIPHTHERIA; its Nature and Treatment, with an account of the His- tory of its Prevalence in various Countries. Second and revised edition. In one neat royal 12mo. volume, extra cloth. $1 25. H UDSON {A.), M. D., M. R. 1. A., PUyfiician to the .Meath Hofipital. LECTURES ON THE STUDY OF FEYER. In one vol. 8vo., extra Cloth, $2 50. TTONS [ROBERT D.), K~C~C. A TREATISE ON FEYER; or, Selections from a Course of Lectures on Fever. Being part of a Course of Theory and Practice of Medicine. In one neat ootavo volume, of 362 pages, extra cloth. $2 25. Henry C. Lea's Publications — ( Venereal Diseases, etc.). 19 L> UMS TEAD {FREEMAN J.), M.D., -*-' Pri>/c.ti«ir of Vene.rndl DiKKases ntthe Old. of Phys. and Rurg., New York, Ac. THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- EASES. Incluilinp; the results of recent investigations upon the subject. Third edition, reri.sed and enliirjit'd, with illustrations. In one large and handsome octavo volume of over TOO piiRes, extra cloth, $f) 00; leatlier, $0 00. {Ju.st Issiwd.) In prt'p;iriiig this! standard work again for tlie press, the author has subjected it to a very thorough revision. Many portions have been rewritten, and much new matter added, in order to bring it completely on a level with the most advanced condition of sypliilography, but by careful compression of the text of jjvevious editions, the work has been incrensed by only sixty-four pages. The labor thus bestowed upon it, it is hoped, will insure for it a continuance of its position as a complete and trustworthy guide for the practitioner. It is the most complete book with which we are ac- quaiuted in the laugiiaji;©. The latest views of the best authorities are put forward, and the iafovmation is well arranged — a great point for the student, and still move for the pvactilionor. The subjects of vis- ceral syphilis, syphilitic all'ections nf tlie eyes, and the treatment of syphilis by repeatedinoculations, are very fnlly discussed. — London Lanett, Jan. 7, IS71. Dr. Bumstead's work is already so universally known as the best treatise in the English language on venereal diseases, that it may seem almost superflu- ous to say more of it than that a new edition has been issued. Hut the author's industry has rendered this aew edition virtually a new work, and so merits as much special commendation as if its predecessors had not been published. As a thoroughly practical book on a class of diseases which form a large share of nearly every physician's practice, the volume before us is bv far the best of which we have knowledge. — N. Y. Me.dicnl OnzMte, Jan. 28, 1S71. It is rare in the history of medicine to find any one book which contains all that a practitioner needs to know; while the possessor of "Bumstead on Vene- real" has no occasion to look outside of its covers for anything practical connected with the diagnosis, his- tory, or treatment of these allections. — N. Y. Medical Journal, March, 1871. JDUMSTEAD [FREEMAN J.), -'-' Proff-isor of Venereal Diseases in the C College of (lULLERIER [A.), and V-/ Surgeon to the Hdpital dti Midi. Physicians and Surgeons, N. Y. AN ATLAS OF VENEREAL DISEASES. Translated and Edited by Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life: strongly bound in extra cloth, $17 00; also, in five parts, stout wrappers for mailing, at $3 per part. (^Lately Ptihlished.) • Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- lars a Part, thus placing it within the reach of all who are interested in this department of prac- tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. A specimen of the plates and text sent free by mail, on receipt of 25 cents. We wish for once that our province was not restrict- ed to methods of treatment, that we might say some- thing of the exquisite colored plates in this volume, — London Practitioner, May, 1869. As a whole, it teacl;es all that can be taught by means of plates and print. — London Lancet, March 13, 1665. Superior to anything of the kind ever before issued on this continent. — Canada. Med. Journal, March, '69. The practitioner who de.sires to understand this branch of medicine thoroughly should obtain this, the most complete and best work ever published. — Dominion Med. Journal, May, 1869. This is a work of master hands on both sides. M. CuUerier is scarcely second to, we think we may truly say is a peer of the illustrious and venerable Ricord, while in this country we do not hesitate to say that Dr. Bumstead, as an authority, is without a rival. Assuring our readers that these illustrations tell the whole history of venereal disease, from its inception to its end, we do not know a single medical work. which for its kind is more necessary for them to have. — Calif yrnia Med. Gazette, March, 1869. The most splendidly illustrated work in the lan- guage, and in our opinion far more useful than the French original. — Am. Journ. Med. Sciences, Jan. '69. The fifth and concluding number of this magnificent work has reached us, and we have no hesitation in saying that its illustrations surpass those of previous numbers.— £osio» Med. and Surg. Journal, Jan. 14, 1869. Other writers besides M. CuUerier have given us a good account of the diseases of which he treats, but no one has furnished us with such a complete series of illustrations of the venereal diseases. There is, however, an additional interest and value possessed by the volume before us ; foritis an American reprint and translation of M. CuUorier's work, with inci- dental remarks by one of the most eminent American syphilographers, Mr. Bumstead. — Brit, and For. iledico-Ohir. Review, July, 1S69. // 7LL [BERKELEY), Surgeon to the Lock Hospital, London. ON SYPHILIS AND LOCAL one handsome octavo volume ; extra cloth Bringing, as it does, the entire literature of the dis- ease dowu to the present day, and giving with great ibility the results of modern research, it is in every respect a most desirable work, and one which should find a place in the library of every surgeon. — Cali- fornia Med. Gazette, June, 1869. Considering the scope of the book and the careful attention to the manifold aspects and details of its subject, it is wonderfully concise. All these qualities render it an especially valuable book to the beginner. In CONTAGIOUS DISORDERS. , $3 25. {Lately Published.) to whom we would most earnestly recommend its study ; while it is no less useful to the practitioner. — St. Louis Med. and Surg. Journal, May, 1869. The most convenient and ready book of reference we have met with.— iV^. r. Med. Record, May 1, 1869. Most admirably arranged for both student and prac- titioner, no other work on the subject equals it ; it is more simple, more easily studied. — Buffalo 3Ied. and Surg. Journal, March, 1869. ^EISSL [H.], M.D. A COMPLETE TREATISE ON VENEREAL DISEASES. Trans- lated from the Second Enlarged Germnn Edition, by Frederic R. Sturgis, M.D. In one octavo volume, with illustrations. {Preparing.) 20 Henry C. Lea's Publications — {Diseases of the Skin). TU^ILSON {ERASMUS), F.R.S. ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- enth American, from the sixth and enlarged English edition. In onelarge octavo volume of over 800 pages, $5. A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- EASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thir- teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and embracing accurate representations of about one hundred varieties of disease, most of them the size of nature. Price, in extra cloth, $5 50. Also, the Text and Plates, bound in one handsome volume. Extra cloth, $10. No one treating skin diseases should he without a copy of this standard work. — Canada Lancet, iugust, 1863. We can safely recommend it to the profession as the best work on the subject now in existence in the English language. — Medical Times and Gazette. Sucti a work as the one before us is a most capita! aad acceptable help. Mr. Wilson has long been held as high authority in this department of medicine, and his book on diseases of the skin has long been re- garded as one or the best text-books extant on the subject. The present edition is carefully prepared, Aud brought up in its revision to the present time. In th's edition we have also included the beautiful series of plates illustrative of the text, and in the last edi- tion published separately. There are twenty of these plates, nearly all of them colored to nature, and ex- hibiting with great tidelity the various groups of diseases. — Cincinnati Lancet. Mr. Wilson's volume is an excellent digest of the actual amount of knowledge of cutaneous diseases; it includes almost every fact or opinion of importance connected with the anatomy and pathology of the skin. — British and Foreign Medical Review. B T THE SAME AUTHOR. THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- EASES OF THE SKIN. In One Very handsome royal 12mo. volume. $3 60. (Lately Issued.) J^ELIGAN {J.MOORE), M.D.,M.R.I.A. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Fifth American, from the second and enlarged Dublin edition by T. W. Belcher, M. D. In one neat royal 12mo. volume of 462 pages, extra cloth. $2 25. Fully equal to all the requirements of students and young practitioners. — Dublin Med. Press. Of the remainder of the work we have nothing be- yond unqualified commendation to offer. It is so far the most complete one of its size that has appeared, and for the student there can be none which can com- pare with it in practical value. All the late disco- veries in Dermatology have been duly noticed, and )r THE SAME AUTHOR. — •heir value justly estimated; in a word, the work is fully up to the times, and is thoroughly stocked with most valuable information. — New York Med. Record, Jan. 16, 1&67. The most convenient manual of diseases of the skin that can be procureo by the student. — Chicago Med. Journal, Dec. 1866. B' ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, &g., presenting about one hundred varieties of disease. Extra cloth, $5 50. The diagnosis of eruptive disease, however, under all circumstances, is very difficult. Nevertheles.s, Dr. Neligan bas certainly, "as far as possible," given a faithful and accurate represeatation of this class of diseases, and there can be no doubt that these plates will he of great use to the student and practitioner in drawing a diagnosis as to the class, order, and species to which the particular case may belong. While looking over the "Atlas" we have been induced to examine also the "Practical Treatise," and we are inclined to con.sider it a very superior work, com- bining accurate verbal description with sound vievv's of the pathology and treatmeut of eruptive diseases. — Gla-sgino Med. ■Journal. A compend wliich will very much aid the practi- tioner in this difficult branch of diagnosis Taken with the beautiful plates of the jVtlas, which are re- markable for their accuracy and beauty of coloring, it constitutes a very valuable addition to the library of a practical man. — Buffalo Med. Journal. TJILLIER {THOMAS), M.D., -* Pky.iicinn to the Skin Department of University College Hospital, &c. HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. Second American Edition. In one royal 12mo. volume of 358 pp. With Illustrations. Extra cloth, $2 25. We can conscientiously recommend it to the stu- dent; the style is clear and pleasant to read, the matter is good, and the descriptions of disease, with the modes of treatment recommended, are frequently Illustrated with well-recorded cases. — London Med. I^mes and Gazette, April 1, 1865. It is a concise, plain, practical treatise on the vari- ous diseases of the skin ; just such a work, indeed, as was much needed, both by medical students and practitioners. — Chicago Medical Examiner, May, 1865. A NDERSON {McCALL), M.D., -^^ Pliy.'iician to the Disiiensnrji for Skin Diseases, Glasgow, Ae. ON THE TREATMENT OF DISEASES OF THE SKIN. With an Annlysis of Eleven Thousand Consecutive Cases. In one vol. Svo. {Publisking in ths Medical News aiid Library for 1873.) The very practical, character of this work and the extensive experience of the .author, cannot fail to render it acceptable to the subscribers of the " A\iEKit;.\.v JoiJH>fAL of thk Mkrical, Sciences." When completed in the "New.s and Library," it will be issued separately in a neat octavo volume. Henry C. Lea's Publications — (Diseases of Children). 21 UMITH {J. LK WIS). M. D., '^ Pni/fuxiir 1)/ Mnrhid Anntnmy in the FeUnmic Hnnpifnl Med. C'dlegu, N Y. A COMPLI-yrE PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Second Editiop, revised iind grently enlnrged. In one handsome octavo volume ol' 742 pages, ektra cloth, $5; leather, $6. (Now Ready.) FnOM THE PUEFACE TO THE SECOND EDITION. In presenting to the profession the second edition of his work, the author gratefully acknow- ledges the fiivoriible reception accorded to the first. lie has endeavored to merit a continuance of this approbation hy rendering the volume much more complete than before. Nearly twenty additional disea.'^es have been treated of, among which may be named Diseases Incidental to Birth, R:iehitis, Tuberculosis, Scrofula, Intermittent, Remittent, and Typhoid Fevers, Chorea, and the various forms of Paralysis. Many new formuliB, which experience has shown to be useful, have been introduced, portions of the text of a less practical n;iture have been con- densed, and other portions, especially those relating to pathological histology, have been rewritten to correspond with recent discoveries. Every effort has been made, however, to avoid an undue enlargement of the volume, but, notwithstanding this, and an increase in the size of the page, the number of pages has been enlarged by more than one hundred. 227 West 49th Street, New York, April, 1872. The work will be found to contain nearly one-third more matter than the previous edition, and it is confidently presented as in every respect worthy to be received as the standard American text-book on the subject. Eniineotly practical as well as judicious in its teachings. — Oincinntiti Lancd and Obs., July, 1872. A .standard work that leaves little to be desired. — Indiana Jimrnal of Medicine, July, 1872. We know of no book on this subject that we can more cordially recommend to the medical student and tbepractitioner. — Cincinnati Clinic, June29, '72. We regard it as superior to any other single work on the di-ieases of infancy and childhood. — Detroit Rev. of Med. and Pharmacy, Aug. 1S72. We confess to increased enthusiasm in recommend- ing this second edition. — St Louis Med. and Surg. Journal, Aug. 1S72. ftONDIE {D. FRANCIS), M.D. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- printed pages, extra cloth, $6 25 f leather, $6 25. (Lately Issued.) The present edition, which is the sixth, is fully up I teachers. As a whole, however, the work is the best to the times in the discussion of all those points in the | imerican one tliat we have, and in its special adapt a- pathology and treatment of infantile diseases which I tion to American practitioners it certainly has no have been brought forward by the German and French | equal. — New York Med. Record, March 2, 1S6S. l^EST {CHARLES), M.D., ' ' Physician to the Hospital for Sick Children, A-c. LECTURES ON THE DISEASES OP INFANCY AND CHILD- HOOD. Fourth American from the fifth revised and enlarged English edition. In one large and handsome octavo volume of 656 closely-printed pages. Extra cloth, $4 60 ; leather, $5 50. Of all the English writers on the diseases of chil- I living authorities in the difBcult department of medi- dren, there is no one so entirely satisfactory to us as | cal science in which he is must widely linown. — Dr. West. For years we have held his opinion as I Boston Med. and Surg. Journal, April 26, 1866. judicial, and have regarded him as one of the highest | DF TEE SAME AUTHOR. (Lately Issued ) ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of Lon- don, in March, 1871. In one volume, small ]2mo., extra cloth, $1 00. ^MITH [EUSTACE), M. D., Physician to the Northwest London Free Dispensary for Sick Children. A PRACTICAL TREATISE ON THE WASTIN(J DISEASES OF INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged English edition. In one handsome octavo volume, extra cloth, $2 50. (Lately Issued.) scribed as a practical handbook of the common dis- eases of children, so numerous are the alfectiuns con- sidered either collaterally or directly. We are acquainted with no safer guide to the treatment of children's diseases, and few works give the insight into the physiological and other peculiarities of chil- dren that Dr. Smith's book dues. — Brit. Med. Journ., April S, 1S71. This is in every way an admirable book. The modest title which ihe author has chosen for it scarce- ly conveys an adequate idea of the many subjects upon which it Ireais. Wasting is so constant an at- tendant upon the maladies of childhood, thHt a trea- tise upon the wasting diseases of children must neces sarily embrace the consideration of many atfeclions of which it is a symptom ; and this is excellently well done by Dr. Smith. The book might fairly be de- QUERSANT {P.), M. D., Honorary Surgeon to the HospUalfor Sick Children, Paris. SURGICAL DISEASES OF INFANTS AND CHILDREN. Trans- lated by R. J. Dunglison, M. D. In one neat octavo volume, extra cloth, $2 50. (Nojv Ready ) ©■BWEES ON THE PHYSICAL AND MEDICAL TKEATMENT OF CHILDEEN. Eleventh edition. 1 vol. 8to. of 648 pages. $2 80. h 22 Henry C. Lea's Publications — (Diseases of Women). A VELING (JAMES //.), -^T- Phy-sieinn to the Hospital jf Chihtren. nnd Women and ryiLTSHlRE [ALFRED), M.D., ' ' Assistant Pfii/xifiaii-Acooucheur to St. Mary's Hospital. THE OBSTETRICAL JOURNAL of Great Britain and Ireland; Including Midwiferv, nnd the Diseases op Women and Infants. With an American Supplement, edited by William P. Jenks, M.D. A monthly of about SO octavo pnges, very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 cents each. Commencing with April, 1873, the Obstetrical Journal will consist of Original Papers by Brit- ish nnd Foreign Contributors ; Transactions of the Obstetrical Societies in England and abroad ; Keports of Hospit:il Practice; Reviews and Bibliographical Notices; Articles and Notes, Edito- rial, Historical, Forensic, and Miscellaneous; Selections from Journals; Correspondence, Ac. Collecting together the vast amount of material daily accumulating in this important and ra- pidly improving department of medical science, the value of the information which it will pre- sent to the subscriber may be estimated from the character of the gentlemen who have already promised their support, including such names as those of Drs. Atthill, Robert Barnes, llENav Bennet, Thomas Chambers, Fleetwood Churchill, Matthews Duncan, Grailv Hewitt, Braxton Hicks, Alfred Meadows, W. Leishjian, Alex. Simpson Tyler Smith, Edward J. Tilt, Spencer Wells, &c. Ac. ; in short, the representative men of British Obstetrics and Gynae- cology. In order to render the Obstetrical Journal fully adequate to the wants of the American profession, each number will contain a Supplement devoted to the advances made in Obstetrics and G3'na?cology on tliis side of the Atlantic. This portion of the Journal will be under the editorial charge of Dr. William F. Jenks, to whom editorial communications, exchanges, books for review, Ac, may be addressed, to the care of the publisher. *.::;.* Gentlemen desiring complete sets will do well to forward their orders without delay. &o. rPHOMAS [T.GAILLARD),M.D., •*- Professor nf Obstetrics, &c., in the Collfge of Physicians and Surgeons, N. Y., A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Third edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 784 pages, with 246 illustrations. Cloth, $5 00; leather, $6 00. (Jjist Issued.) The author has taken advantage of the opportunity afforded by the call for another edition of this work to render it worthy a continuance of the very remarkaljle favor with which it has been received. Every portion has been subjected to a conscientious revision, several new chapters have been added, and no labor spared to make it a complete treatise on the most advanced con- dition of its important subject. The present edition therefore contains about one-third more matter than the previous one, notwithstanding which the price has been maintained at the former very moderate rate, rendering this one of the cheapest volumes accessible to the profession. We are free to say that we regard Dr. Thomas the As cornparml with the first edition, five new chap- ters on dysmenorrhiea, peri-uterine fluid tniD^M-s, composite turaor.s of the ovary, solid tumors of the ovary, and chlorosis, have been adiled. Twenty- Seven additional wood cuts have heen introduceil, many suhjects have been subdivided, and all have received important interstitial increase. In fact, the hook has been practically rewritten, and greatly in- creased in value. Briefly, we may say that we know of no hook which so completely and concisely repre- best American authority on diseases of women. Seve- ral others have written, and written well, but none have so clearly and carefully arranged their text and instruction as Dr. Thomas. — Oinoinaait Lancet and Observer, May, 1872. We deem it scarcely necessery to recommend this work to physicians as it is now widely known, and most of them already possess it, or will certainly do 80. To students we unhesitatingly recommend it as gents the present state of gynajcology ; none so tail i the besttext-book on diseases of females extaut.-S< of well-digested and reliable teaching ; none which i,,.,,,-^ j^^.j Reporter, June, 1S69. bespeaks an author more apt in research and abun- i „-,-,,,, , ^, dant in resources.— iV^. Y. Med. Record May 1, 1872 Of all the army of books that have appeared of lato \ur readers to the volume produced by Dr. Tanner, the second edition of a work that was, in its original state even, acceptable to the profession. We recom- mend obstetrical students, young and old, to have this volume in their collections. It contains not only a fair statement of the signs, symptoms, and diseases of pregnancy, but comprises in addition much inter- esting relative matter that is not to be fnund in any other work that we can name. — Edinburgh Med. Journal, Jan. 1868. s WAYNE {JOSEPH GRIFFITHS), M. D., Physician-Accoucheur to the British General Hospital, &c. OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- MENCING MIDWIFERY PRACTICE. Second American, from the Fifth and Revised London Edition, with Additions by E. R. Hutchins, M. D. With Illustrations. In one neat 12mo. volume. Extra cloth, $1 25. (Noiv Ready.) acswers the purpose. It is not only valuable for young beginners, but no one who is not a proficient in the art of obstetrics should be without it, because it condenses all that is necessary to know for ordi- nary midwifery practice. We commend the book most favorably. — St. Louis Med. and Surg. Journal, Sept. 10, 1870. It is really a capital little compendium of the sub- ject, and we recommend young practitioners to bny it and carry it with them when called to attpud cases of labor. They can while away the otherwise tediou.? hours of waiting, and thoroughly fix in their memo- ries the most important practical suggestions it con- tains. The American editor has materially added by his notes and the concluding chapters to the com- pleteness and gfjieral value of the book. — Chicago Med. Journal, Feb. 1S70. The manual before us containsin exceedingly small comp.iss — small enough to carry in the pocket — about all there is of obstefiics, condensed into a nutshell of Aphorisms. The illustrations are well selected, and serve as excellent reminders of the conduct of labor — regular and difficult. — Cincinnati Lancet, April, '70. "^v-isU a most admirable lit tie work, and completely A studied perusal of this little book has satisfied us of its eminently practical value. The object of the work, the author says, in his preface, is to give the stud«nt a few brief and practical directions respect- ing the management of ordinary cases of labor; and also to point out to him in extraordinary cases when and how he may act upon his own responsibility, and when he ought to send for assistance. — iV. T. Medical Journal, May, 1870. TF INC K EL (F.). rrofessiir and Director of the Gyncecologicul Clinic in the University of RnsfncTc. A COMPLETE TREATISE] ON THE PATHOLOGY AND TREAT- MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent of the author, from the Second German Edition, by James Read Chadwick, M D. In one octavo Volume. {Prfjfariiig ) Henry C. Lea's Publications — {Midwifery). 25 JifErGS [CHARLES D.), M.D., ■*-^ Liilily Prii/f.t.7. The original edition is already bo extensively and favorably known to the profession that no recom- mendation is necessary ; it is sufflcient to say, the present edition is very much extended, improved, and perfected Whilst the great practical ♦alents and unlimited experience of the author render it a most valuable acciuisition to the practitioner, it is so con- densed as to constitute a most eligible and excellent text-book for the student.— i'ou^/t'-.rJi Med. and liary. Journal, July, 1S(J7. PAMSBOTHAM [FRANCIS IL), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDL CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the author. MMth additions by W. V. Keating, M.U., Professor of Obstetrics, CK) pages. 13 60. 26 Henry C. Uea's Publications — (Surgery). fyROSS {SAMUEL D.), M.D., ^J" Proftssor 0/ Surgery in the Jefferson Medical CoUege of Philadelphia. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition, carefully revised, and improved. In two large and beautifully printed imperial octavo vol- umes of about 2300 pages, strongly bound in leather, with raised bands, $15. {Jnst Ready.) The continued favor, shown by the exhaustion of successive large editions of this great work, proves that it has successfully supplied a want felt by American practitioners and students. In the present revision no pains have been spared by the author to bring it in every rei^pect fully up to the day. To effect this a large part of the work has been rewritten, and the whole enlarged by nearly one fourth, notwithstanding which the price has been kept at its former very moderate rate. By the use of a close, though very legible type, an unusually large amount ol matter is condensed in its pages, the two volumes containing as much as four or five ordinary octavos. This, combined with the most careful mechanical execution, and its very durable binding, renders it one of the cheapest works accessible to the profession. Every subject properly belonging to the domain of surgery is treated in detail, so that the student who possesses this work may be 3aid to have in it a surgical library. hesitation In pronouncing it without a rival in our language, and equal to the best .sy.stems of surgery in any language. — N. T. Med. Journal. Not only by far the best text-book on the subject, as a whole, within the reach of American students, but one which will be much more than ever likely to be resorted to and regarded as a high authority ibniad. — Am. Journal Med. Sciences, Jan. 1665. The work contains everything, minor and major, operative and diagnostic, including mensuration and examination, venereal diseases, and uterine manipu- lations and operations. It is a complete Thesaurus of modern surgery, where the student and practi- tioner shall noi seek in vain for wiiai they desire.— San Fi-aneisco Med. Press, Jan. IStio. Open it where we may, we find sound practical in- formation conveyed in plain language. This book is no mere provincial ur even national system of sur- gery, but a work which, while very largely indebted to the past, has a strong claim on the gratitude of the future of surgical science. — Edinburgh Med. -journal, Jan. 1S65. A glance at the work is sufficient to show that the author and publisher have spared no labor in making it the most complete "System of Surgery" ever pub- lished in any country. — St. Louis Med. and Surg. Journal, April, 18tio. A system of surgery which we think unrivalled in our language, and which will indelihly associate his name with surgical science. And what, in our opin- ion, enhances the value of the work is that, while the practising surgeon will find all that he requires in it, it is at the same time one of the most valuable trea- tises which can be put into the hands of the student seeking to know the principles and practice of this branch of the profession which he designs subse- quently to follow. — Tlie Brit. Ain.Journ., Montreal. It must long remain the most comprehensive work on this important part of medicine. — Boston Medical and Surgical Journal, March 23, IStjo. We have compared it with most of our standard works, such as those of Erichseu, Miller, Feigusson, Syme, and others, and we must, in justice to our author, award it the pre-eminence. As a work, com- plete in almost every detail, no matter how minute or trifling, and embracing every subject known in the principles and practice of surgery, we believe it stands without a rival. Dr. Gross, in his preface, re- marks "my aim has been to embrace the whole do- main of surgery, and to allot to every subject its legitimate claim to notice;" and, we assure our readers, he has kept his word. It is a work which we can most confidently recommend to our brethren, for its utility is becoming the more evident the longer it is upon the shelves of our library. — Canada Med. Journal, September, 1S6j. The first two editions of Professor Gross' System of Surgery are so well known to the profession, and so highly prized, that it would be idle for us to speak in praise of this work. — Chicago Medical Journal, September, 1S6.5. We gladly indorse the favorable recommendation of the work, both as regards matter and style, which we made when noticing its first appearance. — British and Foreign Medico-Chirurgical Review, Oct. IStJo. The most complete work that has yet issued from the press on the science and practice of surgery. — London Lancet. This system of surgery is, we predict, destined to take a commanding position in our surgical litera- ture, and be the crowning glory of the authors well earned fame. As an authority on general surgical subjects, this work is long to occupy a pre-emineni place, not only at home, but abroad. We have no UY THE SAME AUTHOR. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PASSAGES. In 1 vol. Svo. cloth, with illustrations, pp. 458. $2 75. SKET'S OPERATIVE SURGERY. In 1 vol. Svo. cloth, of over 650 pages ; with about 100 wood-cuts. COOPER'S LECTURES OX THE PRINCIPLES AND Pkactice OF Surgery, Inl vol. Svo. cloth, 7.50 p. -$'2. GIBSON'S INSTITUTES AND PRACTICE OF SUR- OERV. Eighth edition, improved and altered. With thirty-four plates. In two handsome octavo vel- umes, about lOUO pp., leather, raised bands. $6 50. lillLLER {JA3IES), •*■'-'- Late Professor of Surgery in the University of Edinburgh, &e. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with two hundred and forty illustrations on wood, extra cloth, %'i lb. DF THE SAME AUTHOR. THE PRACTICE OF SURGERY. Fourth American, from the last Edinburgh edition. Revised by the American editor. Illustrated hy three hundred and sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, extra cloth. $3 75. ^ARGENT {F. W.), M.D. ON BANDAGING AND OTHER OPERATIONS OF MINOR SUR- GERY. New edition, with an additional chapter on Military Surgery. One handsome roya) lime, volume, of nearly 400 pages, with ls4 wood-cuts. Extra cloth, $1 76. Henry C. Lea's Publications — (Surgery). 27 j^SHIIUKST {JOHN, Jr.), M.D., Surgeon to the Epincopnl Hsopital, Philadelphtn. THE PRINCirLES AND PRACTICE OF SURGEPY. In one very large nnd handsome octavo volume of ahout 1000 pages, with nearly 5J0 illustrations, extra cloth, $(i 50; leather, raised bands, $7 50. (Just Is-iueil.) The object of the author has been to ])resent, within as condensed a compass as possible, a complete treatise on Surgery in all its branches, suitable both as a text-book for the student and a work of reference for the j)ractitioner. So much has of late years been done for the advance- ment of Surgical Art and Science, that there seemed to Be a want of a work which should present the latest aspects of every subject, and which, by its American character, should render accessible to the profession at large the experience of the jtractitioners of both heuiisjiheres. This has been the aim of the author, and it is hoped that the volume will be found to fulfil its purpose satisfac- torily. The plan and general outline of the work will be seen by the annexed CONDENSED SUMMARY OF CONTENTS. Chapter I. Inflammation. II. Treatment of Inflammation. HI. Operations in general: Anajsthetics. IV. Minor Surgery. V. Amputations. VI. Special Ami)utations. VII. Effects of Injuries in General : Wounds. VIII Gunshot Wounds. IX. Injuries of Bloodvessels. X. Injuries of Nerves, Muscles and Tendons, Lymphatics, Bursas, Bones, and Joints. XI. Fractures. XII. Special Fractures. XIII. Dislocations. XIV. Effects of Heat and Cold. XV. Injuries of the Ilead. XVI. Injuries of the Back. XVII. Injuries of the Face and Neck. XVIII. Injuries of the Chest. XIX. Injuries of the Abdomen and Pelvis. XX. Diseases resulting from Inilammation. XXI. Erysipelas. XXII. Pyaemia XXIII. Diathetic Diseases: Struma (in- cluding Tubercle and Scrofula) ; Rickets. XXIV. Venerea 1 Diseases ; Gonorrhoea and Chancroid. XXV. Venereal Diseases continued ; Syphilis. XXVI. Tumors. XXVTI. Surgical Diseases of Skin, Areolar Tissue, Lymphatics, Muscles, Tendons, and Bursas. XXVIII. Surgical Disease of Nervous System (including Tetanus). XXIX. Surgical Diseases of Vascular System (includ- ing Aneurism). XXX. Diseases of Bone. XXXI. Diseases of Joints. XXXII. Excisions. XXXIII. Orthopasdic Surgery. XXXIV. Diseases of Head and Spine. XXXV. Diseases of the Eye. XXXVI. Diseases of the Ear. XXXVII. Diseases ot the Face and Neck. XXXVIII. Diseases of the Mouth, Jaws, and Throat. XXXIX. Diseases of the Breast. XL. Hernia. XH. Special Herni.'B. XLII. Diseases of Intestinal Canal. XLIII. Diseases of Abdominal Organs, and various operations on the Abdomen. XLIV. Urinary Calculus. LXV. Diseases of Bladder and Prostate. XLVI. Diseases of Urethra. XLVII. Diseases of Generative Organs. Index. Its author has evidently tested the writings and i Indeed, the work as a whole must be regarded as z ^1- .1. _ -. - ^ . . ] . ; „ .1, ^ .1,1^ I « .. .,,.....11 .^.. . ., „ .4 «...«!.,., ^^^. * .-. P ™...l experiences of the past and present in the crucible of a careful, aDalyiic, aud h