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 » OCKEEJ 
 
 CASE 
 
 
LECTURES 
 
 DISEASES 
 
 INFANCY AND CHILDHOOD. 
 
 CHARLES WEST, M. D. 
 
 fellow op the royal college of physicians ; 
 
 physician to the hospital fob- sick children; 
 
 physician - accoucheur to, and lecturer on midwifery at, 
 
 saint Bartholomew's hospital. 
 
 SECOND AMERICAN, 
 
 FROM THE SECOND AND ENLARGED LONDON EDITION. 
 
 PHILADELPHIA: 
 BLANCHARD AND LEA 
 
 1854. 
 
]a 
 
 <i>\* 
 
 ^ 
 
I 
 
 TO 
 
 SAMUEL STEPHENS MARLING, Esq. 
 
 OF 
 
 EBLEY, near STROUD, 
 
 GLOUCESTERSHIRE, 
 
 Ifyese |Lecfqt*es %H Qctktf&fi 
 
 IN ACKNOWLEDGMENT OP THE EVER ACTIVE FRIENDSHIP, 
 
 AND MORE THAN BROTHERLY KINDNESS, 
 
 WHICH HAVE MADE A LIPE-LONG DEBTOR 
 
 OF HIS 
 
 AFPECTIONATE KINSMAN, 
 
 THE AUTHOR. 
 
 i 
 
 \ 
 
ADVEKT1SEMENT 
 
 TO THE SECOND EDITION. 
 
 In the preparation of the Second Edition of these Lectures, the 
 whole work has been carefully revised : a few formulae have been 
 introduced, and a minute alphabetical index has been appended: 
 while additions, amounting altogether to fifty pages, have been made 
 wherever I felt that more extended observation, or more careful reflec- 
 tion, had enabled me to supply some of those deficiencies which, I am 
 well aware, are still far too numerous. The work now contains the 
 results of 640 observations, and 199 post-mortem examinations, chiefly 
 made among 16,276 children who came under my notice during the 
 ten years of my connection with the Children's Infirmary in Lambeth. 
 
 Should hereafter a third edition be called for, I trust to prove that 
 I have not been unmindful of the duties and responsibilities imposed 
 on me by the honour of being appointed one of the medical officers to 
 the Hospital for Sick Children ; an institution which, it is hoped, will 
 henceforth afford to the profession a field for the minute and accurate 
 observation of the diseases of early life, such as neither dispensary 
 nor private practice can offer even to those most earnest in the 
 cultivation of medical knowledge. 
 
 96 Wimpole Street, 
 
 December 20, 1851. 
 
PREFACE 
 
 TO THE FIRST EDITION 
 
 The substance of a considerable part of the following Lectures was 
 addressed to the pupils of the Middlesex Hospital in the summer of 
 1847, and the form of lectures appeared to me to present advantages 
 which led me to retain it, when I determined to publish the results of 
 my observations on Children's Diseases. 
 
 These observations were made in the large field presented by the 
 Children's Infirmary, which was first thrown open to me in the year 
 1839, by the kindness of my friend Dr. Willis, then physician to that 
 institution ; to which office I succeeded on his resignation in 1842. 
 Very nearly 14,000 children have thus been brought under my notice 
 during the past nine years ; and I have kept accurate notes of the 
 diseases of 600, as well as of the results of 180 dissections of cases 
 in which those diseases terminated fatally. 
 
 The time that has elapsed since the appearance of these Lectures in 
 the Medical Gazette, has been too short to allow me, in preparing 
 them for separate publication, to do much toward supplying those 
 deficiencies in them of which I am fully sensible. If life and health 
 be spared me, it will be my constant endeavour to render those imper- 
 fections less numerous. I trust they may not be of a nature to detract 
 seriously from the usefulness of the work ; still less of a kind to lead 
 into error those to whom it has been my earnest wish to prove myself 
 a faithful guide. 
 
 Wimpolb Street, 
 
 September 20, 1848. 
 
CONTENTS 
 
 LECTURE 
 I. 
 II. 
 
 III. 
 
 IV. 
 
 V. 
 
 VI. 
 VII. 
 
 VIII. 
 IX. 
 X. 
 
 XI. 
 
 XII. 
 XIII. 
 
 XIV. 
 XV. 
 
 XVI. 
 
 XVII. 
 
 XVIII. 
 
 XIX. 
 
 XX. 
 
 XXI. 
 
 XXII. 
 
 XXIII. 
 
 XXIV. 
 
 XXV. 
 XXVI. 
 
 PAGE. 
 
 Introduction 17 
 
 Diseases of the Brain and Nervous System. General remarks upon them, 
 
 and on their symptoms in early life 26 
 
 Congestion of the Brain, its causes, symptoms, and treatment 34 
 
 Cerebral Haemorrhage and Cephalhematoma, or haemorrhage external to 
 
 the skull 46 
 
 Inflammatory Affections of the Brain. Acute Hydrocephalus, its morbid 
 
 appearances and symptoms 56 
 
 Acute Hydrocephalus, concluded: its symptoms and treatment 69 
 
 Simple Inflammation of the Brain. Inflammation succeeding to Disease of 
 
 the Ear. Inflammation of the Sinuses of the Dura Mater 82 
 
 Chronic Hydrocephalus 90 
 
 Hypertrophy and Atrophy of the Brain 101 
 
 Hydrocephaloid Disease. Tubercle of the Brain. Hydatids and Cancer of 
 
 Brain 110 
 
 Diseases of the Spinal Cord. Irritation and Congestion. Inflammation of 
 
 its Membranes and Substance. Trismus 122 
 
 Night Terrors. Epilepsy. Chorea. Paralysis. Facial Hemiplegia 133 
 
 Diseases of the Respiratory Organs : general remarks on the respiratory 
 
 functions in early life. Imperfect Expansion of the Lungs 146 
 
 Collapse of Lung after Birth. Induration of the Cellular Tissue 157 
 
 Inflammation of Respiratory Mucous Membrane. Catarrh. Coryza. Post- 
 mortem appearances of Bronchitis 166 
 
 Inflammation of Substance of Lung : its post-mortem appearances. Symp- 
 toms and treatment of Bronchitis 176 
 
 Pneumonia: its symptoms and treatment 191 
 
 (Edema of the Lungs. Gangrene of the Lung. Pleurisy, acute and chronic 203 
 Croup: its varieties, causes, post-mortem appearances. Symptoms and 
 
 treatment of its early stages 213 
 
 Croup : treatment of its advanced stages — tracheotomy. Diphtheritis as 
 a primary affection, and as a complication of measles. Laryngitis Stri- 
 dula, or Croup with predominance of spasmodic symptoms. Varieties 
 
 of Spasmodic Croup 226 
 
 Spasm of the Glottis 239 
 
 Hooping-cough: symptoms and Complications 250 
 
 Hooping-cough : its complications, continued — post-mortem appearances, 
 
 and treatment 263 
 
 Pulmonary Phthisis : its peculiarities, anatomical characters, and symp- 
 toms in childhood. General symptoms of Bronchial Phthisis, and of 
 
 Phthisis in early Infancy 278 
 
 Phthisis, continued : its auscultatory signs, its different forms, duration 
 
 and treatment 284 
 
 Diseases of the Heart 303 
 
8 CONTENTS. 
 
 LECTURE. PAGE. 
 
 XXVII. Diseases of Organs of Digestion and Assimilation. General remarks on 
 
 the Diet of Infants 323 
 
 XXVIII. Infantile Atrophy. Thrush. Dentition, and the Management of Chil- 
 dren during it 334 
 
 XXIX. Stomatitis — follicular, ulcerative, and gangrenous. Cynanche Tonsil- 
 laris. Hypertrophy of the Tonsils. Cynanche Parotidea 345 
 
 XXX. Diseases of the Stomach. Indigestion. Softening of the Stomach. 
 
 Hsematemesis and Mehena 358 
 
 XXXI. Jaundice. Constipation, and mechanical causes for it, as imperforate 
 
 anus and intussusception 371 
 
 XXXII. Diarrhoea : its symptoms and morbid appearances 381 
 
 XXXIII. Diarrhoea, continued: its treatment, and that of its complications 392 
 
 XXXIV. Peritonitis, its acute and chronic forms. Tubercular peritonitis. Tabes 
 
 mesenterica 402 
 
 XXXV. Intestinal Worms. Diseases of the Urinary Organs : albuminuria, 
 
 gravel, and calculus. Diabetes. Incontinence of Urine .?;... 416 
 
 XXXVI. Abdominal Tumors. Infantile Syphilis. Discharges from the Vulva 
 
 in Children 430 
 
 XXXVII. Fevers : general remarks on them. Simple or Remittent Fever : its 
 
 symptoms and treatment 443 
 
 XXXVIII. Small-pox. Modified Small-pox. Chicken-pox 455 
 
 XXXIX. Measles and Scarlatina 464 
 
 Index to the Subjects 477 
 
 Index to theFormulse 487 
 
LECTURES 
 
 ON THE 
 
 DISEASES OF INFANCY AND CHILDHOOD. 
 
 INTRODUCTORY LECTURE. 
 
 Causes of peculiarities presented by diseases in childhood — These peculiarities are 
 reasons for their special study — Difficulties of their study, and how to overcome 
 them — Rules for the examination of sick children, and for taking notes of Cases. — 
 General plan and objects of the Course. 
 
 Gentlemen, 
 
 It is not without hesitation that I have determined on adding 
 another to the already numerous courses of lectures that you are 
 called on to attend while engaged in the study of medicine. My 
 reasons — and I trust my justification — for so doing are furnished 
 partly hy the frequency of the diseases of infancy and childhood, 
 partly by their fatality, but still more by their many peculiarities. 
 
 Children will form at least a third of all your patients, and so 
 serious are their diseases, that one child in five dies within a year after 
 birth, and one in three before the completion of the fifth year. These 
 facts, indeed, afford conclusive arguments for enforcing on you the 
 importance of closely watching every attack of illness that may invade 
 the body while it is so frail; but they alone would scarcely be 
 adequate reasons for my bringing these diseases under your notice as 
 objects for special study. 
 
 The body, however, is not only more frail in infancy than it 
 becomes in after life, but the sympathies between its different parts 
 are more extensive and more delicate. One organ seldom suffers 
 alone, but the effects even of local diseases extend to the whole 
 system, and so disorder its workings that it is often no easy matter 
 to determine the seat of the original mischief. Nor is this all ; but 
 many important consequences result from the period of childhood 
 being one of unceasing development. In the adult the structure of the 
 body is complete, and its functions are the same to-day as they were 
 yesterday, but the child learns successively to breathe, to feel, to 
 think : and its body is daily undergoing modifications to fit it for new 
 duties, as well as daily growing in size and strength. Disease, 
 
 2 
 
18 PECULIARITIES OF THE DISEASES OF CHILDREN. — 
 
 therefore, not merely disturbs the present, but its influence reaches to 
 the future ; it not only interrupts the present function of the organ 
 that is affected, but it puts a stop for a time to the completion of the 
 general machinery of the body, or disarranges the due proportion of 
 one part of that machinery to another. Moreover, there are periods, 
 namely, those of the first and secoDd dentition, when very great 
 changes take place in the organism of the child, and when all these 
 dangers are especially to be feared. Disease is then frequent and 
 serious beyond what it is at other times, and every ailment then 
 warrants a double measure of anxiety; while, on the other hand, if 
 these epochs are safely passed, there succeeds a season of comparative 
 immunity from many affections that before were both common and 
 perilous. 
 
 But, if this be so, you will at once perceive that something more is 
 essential to the successful treatment of children's diseases than to 
 watch their advances carefully, and to adapt the strength and doses of 
 your remedies to the tender years of your patients. It is not mere 
 hyperbole to say that you have to study a new semeiology, to learn a 
 new pathology, and new therapeutics. Matters of such importance 
 cannot be properly examined at the end of a course of lectures on 
 midwifery. I have therefore preferred making them the subjects of 
 separate consideration during the summer, when the comparative 
 leisure of the season will, I hope, enable you to devote some of your 
 time to the practical as well as the theoretical study of the diseases of 
 children. 
 
 I must warn you, however, of one difficulty which you will encounter 
 at the very onset, — a difficulty that disheartens many, and makes 
 them abandon in despair the study of children's diseases. Your old 
 means of investigating disease will here to a great degree fail you, and 
 you will feel almost as if you had to learn your alphabet again, or as 
 if, entering a country whose inhabitants you expected to find speaking 
 the same language, and having the same manners as the people in the 
 land you had lately left, you were to hear around you everywhere the 
 sounds of a foreign tongue, and to observe manners and customs such 
 as you had never seen before. You cannot question your patient ; or 
 if old enough to speak, still, through fear, or from comprehending you 
 but imperfectly, he will probably give you an incorrect reply. You 
 try to gather information from the expression of his countenance, but 
 the child is fretful, and will not bear to be looked at ; you endeavour 
 to feel his pulse, he struggles in alarm : you try to auscultate his chest, 
 and he breaks out into a violent fit of crying. 
 
 Some practitioners never surmount these difficulties, and the diseases 
 of children are consequently a sealed book to them. After a time they 
 grow satisfied with their ignorance, and will then with the greatest 
 gravity assure you that the attempt to understand these affections is 
 useless. They have fallen into this unfortunate error from not taking 
 the pains to start aright : they have never learned how to interrogate 
 their little patients, and hence they have never received satisfactory 
 replies. I speak of interrogating them ; for though the infant cannot 
 talk, it has yet a language of its own, and this language it must be your 
 
EXAMINATION OF SICK CHILDREN. 19 
 
 first object to learn, if you mean ever to acquire the character of suc- 
 cessful practitioners in the diseases of children. But, if you have not 
 cultivated your faculties of observation, you cannot learn it, for it is a 
 language of signs, and these signs are such as will escape the notice of 
 the careless : if you are not fond of little children you cannot learn it, 
 for they soon make up their minds as to who loves them, and when ill 
 they will express their real feelings, whether by words or signs, to no 
 one else. 
 
 There is, moreover, a certain tact necessary for successfully investi- 
 gating the diseases of children. If, when summoned to a sick child, you 
 enter the room abruptly, and, going at once to your patient, you begin 
 to look closely at it, while at the same time you question the mother or 
 nurse about its ailments in your ordinary pitch of voice, the child, to 
 whom you are a perfect stranger, will be frightened, and will begin to 
 cry ; its pulse and respiration will be hurried, its face will grow flushed, 
 and you will thus have lost the opportunity of acquainting yourself with 
 its real condition in many respects. Besides this, the child's alarm, once 
 excited, will not subside so long as you are present : if you want to see 
 its tongue, or auscultate its chest, its terrors will be renewed, and it will 
 scream violently ; you will leave the room little wiser than you entered 
 it, and, very likely, fully convinced that it is impossible to make out 
 children's diseases. 
 
 Very different would be the result if you conducted this examination 
 properly ; and though I believe, where there is real love for children, 
 the tact necessary for examining into their ailments will not be long in 
 being acquired, still a few hints on this subject may not be out of place 
 in an introductory lecture. 
 
 The quiet manner and the gentle voice which all who have been ill 
 know how to value in their attendants, are especially needed when the 
 patient is a child. Your first object must be, not to alarm it; if you 
 succeed in avoiding this danger it will not be long before you acquire its 
 confidence. Do not, therefore, on entering the room, go at once close 
 up to the child, but, sitting down sufficiently near to watch it, and yet 
 so far off as not to attract its attention, put a few questions to its 
 attendant. While doing this, you may, without seeming to notice it, 
 acquire great deal of important information; you may observe the 
 expression of the face, the character of the respiration, whether slow 
 or frequent, regular or unequal, and if the child utter any sound you 
 may attend to the character of its cry. All your observations must be 
 made without staring the child in the face ; little children, especially if 
 ill, seem always disturbed by this, and will be almost sure to cry. If 
 the child be asleep at the time of your visit, your observations may be 
 more minute : the kind of sleep should be noticed, whether quiet or dis- 
 turbed, whether the eyes are perfectly closed during it, or partly open as 
 they are in many cases where the nervous system is disordered : you may, 
 too, if the sleep seem sound, venture to count the frequency of the 
 respiration, and the beat of the pulse, but in doing this you should be 
 careful not to arouse the child. It should be awakened gently by the 
 nurse or mother, and a strange face should not be the first to meet its 
 eye on awaking. If it were awake when you entered the room, it will 
 
20 EXAMINATION OP SICK CHILDREN. 
 
 probably in a few minutes have grown accustomed to your presence, 
 and will allow you to touch its hand, and feel its pulse. This must 
 always be done at as early a period in your visit as possible, in order that 
 you may count it while the child is undisturbed, since the pulsations of 
 the heart vary, in young children, as much as twenty in a minute under 
 comparatively slight disturbing causes, and any inferences that you 
 might draw from the pulse of the child, when frightened or excited, 
 would almost certainly be erroneous. Besides the pulse, the frequency 
 of the respiration should, if possible, be noticed, since the results ob- 
 tained by a comparison of the two are always more valuable than those 
 of either taken alone. But if this be your first visit to the child, do 
 not, for the sake of ascertaining either of these points exactly, persevere 
 in attempts which irritate or frighten it : probably you would, after all, 
 be unsuccessful, and even though you were to succeed, the knowledge 
 would not repay you for the loss of the child's confidence, which it must 
 be your grand object to acquire and keep. 
 
 With management and gentleness, however, you will comparatively 
 seldom fail, and while you are feeling the pulse, or with the hand on the 
 abdomen are counting the frequency of the inspirations, you will also 
 learn the temperature of the body and the condition of the skin. Sup- 
 posing your examination has thus far been pretty well borne, you may 
 now, probably, venture to talk to the child, or to show it something to 
 amuse it — as your watch or stethoscope, and while thus testing the state 
 of its mental powers, you may pass your hand over the head, and note 
 the state of the fontanelle, and the presence or absence of heat of the 
 scalp. 
 
 The examination of the state of the abdomen, though too important 
 to allow of its ever being omitted, will often lead to no satisfactory result 
 unless carefully managed. If you allow the nurse to change the child's 
 posture and to lay it back in her lap, in order that you may pass your 
 hand over its stomach, the child will often be alarmed, and begin to cry, 
 its abdomen then becomes perfectly tense, and you cannot tell whether 
 pressure on it causes pain, or whether the cries are not altogether the 
 consequences of fear. It is therefore the best plan to pass your hand 
 beneath the child's clothes, and to examine the abdomen without altering 
 its posture, while, at the same time, the nurse talks to it to distract its 
 attention, or holds it opposite the window or a bright light, which 
 seldom fails to amuse an infant. If there be no tenderness of the 
 abdomen the child will not cry on pressure, or if, during your examina- 
 tion, the presence of flatus in the intestines should occasion pain, gentle 
 friction, instead of increasing suffering, will give relief. 
 
 You must next examine the chest : and for this purpose immediate 
 auscultation is always to be preferred, since the pressure of the stetho- 
 scope generally annoys the child. If the child be not in its bed-gown, it 
 will usually be your best course to have the back of its dress undone, 
 and then, while it is seated on its mother's or nurse's lap, to kneel 
 down behind it, and apply your ear to its chest. In all acute diseases of 
 the lungs in infancy the condition of their posterior part is a sure index 
 to the extent of the mischief from which they are suffering ; for, owing 
 to the infant passing so much of its time in the horizontal position, the 
 
EXAMINATION OF SICK CHILDREN. 21 
 
 blood naturally gravitates towards the back of the lungs, and the secre- 
 tions are much more likely to accumulate in the bronchi in that situation 
 than elsewhere : hence, if air be heard permeating the lungs throughout 
 the whole posterior part of the chest, and unaccompanied with any con- 
 siderable amount of crepitation, it may fairly be inferred that their front 
 parts are free from serious disease, even though we should be unable to 
 ascertain the fact by actual observation. 
 
 When you have listened thoroughly to the back of the chest, you may 
 next percuss it. Your must not percuss first and listen afterwards, as 
 you often do in the adult ; for even when practised with the greatest 
 gentleness, percussion sometimes frets the child, and makes it cry, 
 whereby any subsequent attempt to listen to the breathing will often 
 be rendered unsuccessful. But you must not neglect percussion : it is 
 of peculiar value in childhood, since auscultation is then unavoidably 
 incomplete in many instances, sometimes quite impracticable. In prac- 
 tising it, however, there are some rules without attention to which you 
 will very likely fail of acquiring any information whatever. You must 
 never, in the child, attempt to percuss the walls of the chest immediately, 
 but should strike on your finger, and even then very gently. The chest 
 of the child is so resonant, that, if you percuss smartly, you will fail to 
 perceive the finer variations in sonoriety which would be readily appre- 
 ciable on gentle percussion. Always observe to compare the results 
 obtained by percussing opposite sides of the chest, since otherwise you 
 may overlook a very considerable degree of dulness. It often* happens, 
 too, that the lower lobes of both lungs are involved nearly equally ; you 
 must therefore notice the resonance of the lower as compared with that 
 of the upper part of the chest. Sometimes you are compelled, by the 
 fretfulness of the child, or by the tenderness of the walls of its chest, to 
 percuss so gently as scarcely to elicit any sound. It is of importance, 
 therefore, to attend to the sensation of solidity communicated to the 
 finger, as well as to the sound of dulness that falls upon the ear, since, 
 if your sense of touch be delicate, it will correct or confirm the evidence 
 of hearing. 
 
 Having thus examined the back of the chest, you may, if the child be 
 likely to tolerate it, try to listen at its sides, and then in front. You 
 can, however, scarcely auscultate the front of the chest in infancy with- 
 out a stethoscope, and this you will very seldom be able to use ; for, if 
 the child be not frightened, it will probably be so exceedingly amused 
 at what it regards as specially intended for its own diversion, that it 
 will join in the game, and disconcert you by playing with the instrument. 
 You will encounter this difficulty in cases of phthisis in early childhood, 
 and will often find it no easy matter to ascertain the character of the 
 respiration in the front of the chest. In such cases you will learn all 
 the value of percussion, which may be practised over the front of the 
 chest as well as the back, while the state of the breathing in the upper 
 and back part of the chest will generally be a correct index to its con- 
 dition in front. 
 
 Your examination of the chest will not be complete until you have 
 noticed the general character of the breathing, whether the whole of the 
 chest is expanded by it, or whether the respiration is merely abdominal 
 
22 CASE-TAKING. 
 
 — whether-the child breathes as deeply as it should, or whether it makes 
 frequent short inspirations which cannot fill the smaller bronchi. The 
 time for ascertaining these points must vary in each case ; but the 
 earlier they are observed the better, since otherwise you run the risk 
 of drawing your inferences not from the child's ordinary condition, but 
 from its condition when excited and alarmed. Some of these points may 
 be noticed though the child be so fretful that you cannot auscultate even 
 the back of its chest satisfactorily. An imperfect auscultation, however, 
 is better than none ; for at the very worst, during the deep inspirations 
 that are made at intervals in a fit of crying, you may ascertain how far 
 the lungs are permeable to air, and whether the bronchi are much loaded 
 with mucus. Independently of* auscultation, too, much may be learned 
 from the cry. If its two periods be clearly marked — the long loud cry 
 of expiration, and the shorter, less loud, but perfectly distinct sound 
 that attends inspiration — you may feel convinced that there exists no 
 important ailment of the respiratory organs. 
 
 It will still remain for you to examine the tongue, and to ascertain 
 the condition of the gums ; and it is wise to defer this to the last, since 
 it is usually the most grievous part of your visit to the child. If during 
 any part of your previous examination it had cried, you might seize that 
 opportunity to look at its tongue, and, if necessary, to pass your finger 
 over the gums, thus sparing it any further distress about the matter. 
 If you had not this opportunity, you will generally get a good view of 
 the. mouth and throat in young infants by gently touching the lips with 
 your finger ; the child opens its mouth instinctively, and then you can 
 run your finger quickly over its tongue, and down towards the pharynx, 
 and thus secure a perfect view of the mouth and throat. With older 
 children a good deal of coaxing is sometimes necessary to persuade them 
 to open their mouth : but, if once you get your finger on the gum, you 
 can usually keep them quiet by rubbing it, and by a little address will 
 then seldom fail in opening the mouth wide enough to get a view of 
 the tongue. 
 
 If little children be very ill, all this minute care in the order of your 
 examination is not so much needed, because they will not notice so 
 quickly ; but gentleness of tone and manner will be even more necessary 
 to soothe the pettishness and quiet the alarm of the little sufferer. 
 
 Many of the directions that I have just given you refer to the exami- 
 nation of infants, and become less applicable in proportion to the greater 
 age of the patient. Minute rules for your examination of children from 
 three years old and upwards are not needed ; but patience the most 
 untiring, and good temper the most unruffled, are indispensable. 
 
 The previous history of a patient, the circumstances under which his 
 present illness came on, and the symptoms that at first attended it, 
 often help to remove our doubts with reference to the nature of a disease, 
 and sometimes greatly modify our diagnosis and influence our plan of 
 treatment. Really trustworthy information on these points, however, is 
 often difficult to be obtained, and the attempt to elicit it is almost sure 
 to be unsuccessful, if the questions put to the patient are proposed at 
 random, and without some previously well-digested plan on the part of 
 the physician. One great object of clinical instruction is to teach the 
 
CASE-TAKING. 23 
 
 student so to conduct this as well as other parts of his examination of 
 the sick, as to throw from every source the greatest possible amount of 
 light upon the nature of the disease, and thus to fit himself to decide 
 with some approach to certainty on the means most likely to effect its 
 cure. Such instruction has been amply afforded you in the wards of 
 this hospital ; but you must allow me to detain you while I point out 
 the subjects towards which your inquiries must be especially directed in 
 the case of children, since they differ in many respects from the questions 
 that you would propose if your patient were an adult. 
 
 We will suppose, if you please, that a child is brought to you of whose 
 case you wish to preserve a record. Its name, age, sex, and resi- 
 dence will form of course the first entry in your note-book ; but your 
 next inquiries should be as to the number of living children that the 
 parents have had, whether any of those children have died, and, if so, at 
 what age, and of what diseases, and as to the health of both parents, 
 and of their immediate relatives. The object of these questions is to 
 ascertain whether there exists any hereditary tendency to disease in the 
 family, since that plays a most important part in many of the affections 
 of childhood, and symptoms that in the child of healthy parents would 
 cause you but little uneasiness, would at once excite serious alarm if 
 you knew that some members of the family had died of hydrocephalus, 
 or consumption, or had been the subjects of scrofula. 
 
 Many of the most serious affections of childhood occur within the 
 period of a few years, and after a certain age are comparatively rare in 
 their occurrence, and generally mild in their character. It is therefore 
 very desirable, when any ailment is coming on the nature of which is not 
 yet quite apparent, to know which of the diseases incidental to childhood 
 have already affected your patient. With this view you would ask 
 w T hether the child has been vaccinated, or has had the small-pox, and 
 whether it has passed through any other of those affections — such as 
 chicken-pox, hooping-cough, measles, or scarlatina, which generally come 
 on in early life. If the child had suffered from any other disease, you 
 should learn its nature, the age at which it occurred, and any other point 
 of importance connected with it. 
 
 In writing out our history of the case, these preliminary matters 
 would naturally be mentioned at the beginning, and though you would 
 not follow any very strict order in proposing your questions, yet it is 
 always desirable to obtain information on these points at an early stage 
 of your examination, since it may guide you in some of the questions that 
 you afterwards propose, or may lead you to pay particular attention to 
 symptoms which otherwise would not seem to be of much moment. 
 Besides, if you postpone these inquiries till you have nearly completed 
 your examination of the patient, the parents will probably apprehend that 
 they are suggested by some doubt and apprehension in your mind as to 
 the nature of the case, and will distress themselves by causeless fears, 
 or perhaps disconcert you by questions to which you are not prepared 
 to return a positive answer. 
 
 There are two other points which bear on- the general condition of the 
 child, to one or both of which your inquiries must in many instances be 
 directed. If your patient be an infant at the breast, you must learn 
 
24 CASE-TAKING. 
 
 ■whether it lives entirely on its mother's milk, or has other food besides. 
 If it has been weaned, you must ask its age at weaning — whether it was 
 taken from the breast on account of any failure in its own health, or its 
 mother's, and on what diet it has since been fed. The process of den- 
 tition is the other subject for inquiry ; and in reference to it, you must 
 ascertain how many teeth the child has, and which they are — whether 
 they were cut easily or with difficulty, the age at which teething com- 
 menced, and the time that has elapsed since any fresh teeth appeared. 
 You may now endeavour to obtain a clear and connected history of 
 the present illness ; and for this purpose it is well to begin with asking 
 when did the child last seem quite well ? since you thus get a fixed 
 starting point from which you can make the mother or nurse set out in 
 her detail of symptoms. The date thus assigned, indeed, will often be 
 a wrong one, the disease having begun before with some symptom that 
 was not noticed, or its real origin having been considerably subsequent 
 to its supposed commencement. But notwithstanding this possible 
 error, you derive much advantage from thus making sure of the symp- 
 toms being told you in something like their chronological order, since 
 otherwise it is very likely that those only would be mentioned which 
 had chanced to strike the mind of the mother or nurse, while the others 
 would be passed over in silence. Your object in the examination must' 
 not be to curtail the garrulity of the nurse, or to suppress the mother's 
 expression of her sometimes imaginary fears, but to get as clear an 
 account as possible of everything that has been observed. You must 
 be careful not to underrate the value of the information they communi- 
 cate, or even of the opinions they express. Both are much more likely 
 to be correct when your patients are children, than when they are 
 adults. A mother hanging over her sick infant, or a nurse watching 
 the child she has helped to rear from babyhood, may sometimes see 
 dangers that have no existence, but will generally be the first to per- 
 ceive the approach of such as are real. You see the child but for a 
 few minutes, and at distant intervals, and the excitement or alarm 
 which your presence is so likely to occasion may greatly modify its 
 condition during your visit. They tend the little one by day and 
 night, notice each movement, and seize the most transient variations 
 in its expression. 
 
 I need not say much concerning the necessity of inquiring about the 
 appetite and thirst, the state of the bowels, and the appearance of the 
 evacuations ; for these are points which you would investigate in 
 patients of every age. I will just mention, however, that the degree 
 of appetite and thirst cannot be so readily determined in the infant as 
 they may be in the adult, or even in the weaned child ; for an infant 
 may suck, not because it is hungry, but in order to quench its thirst. 
 That extreme craving for the breast, which is appeased only so long as 
 the child is sucking, while the milk swallowed is speedily vomited, may 
 be taken as a sign of thirst ; but it is always better to record the fact 
 than the inference, It is likewise often desirable to let the infant be 
 put to the breast in your presence, not only for the sake of observing 
 the above-mentioned facts, but also in order to notice the vigour with 
 which it sucks, the ease or difficulty with which it swallows, and other 
 
CASE-TAKING — PLAN OF THE COURSE. 25 
 
 similar points from which very important conclusions may often be 
 drawn. 
 
 Before you venture on drawing any inferences from the state of the 
 child at the time of your visit, you should ascertain whether it has just 
 before been taking food, or has been recently excited or fatigued by 
 being washed or dressed ; since comparatively trivial causes are suffi- 
 cient to accelerate the pulse and respiration, and to give rise to changes 
 which might, if unexplained, lead you to very erroneous conclusions. 
 Any such circumstances ought of course to be mentioned in your notes, 
 as should also the fact of the child being asleep at the time of your 
 visit, since that would explain even a very considerable diminution in 
 the frequency of the pulse and respiration. 
 
 But if you are carefully to observe all the points which I have men- 
 tioned, and to make yourselves thoroughly masters of a case, you must 
 be most lavish of your time ; you must be content to turn aside from 
 the direct course of investigation, which you would pursue uninter- 
 ruptedly in the adult, in order to soothe the waywardness of the child, 
 to quiet its fear, or even to cheat it into good humour by joining in its 
 play ; and you must be ready to do this, not the first time only, but 
 every time that you visit the child, and must try to win its affections 
 in order to cure its disease. If you fail in the former, you will often 
 be foiled in your attempts at the latter. Nor is this all : you must 
 visit your patient very often, if the disease be serious in its nature and 
 rapid in its course. New symptoms succeed each other in infancy and 
 childhood with great rapidity ; complications occur that call for some 
 change in your treatment, or the vital powers falter suddenly, when 
 you least expect it. The issues of life and death often hang on the 
 immediate adoption of a certain plan of treatment, or its timely discon- 
 tinuance. Do not wait, therefore, for symptoms of great urgency 
 before you visit a child three or four times a day, but if the disease be 
 one in which changes are likely to take place rapidly, be frequent in 
 your visits as well as watchful in your observation. 
 
 You will naturally think, that before I finish this lecture I should 
 tell you something definite about the subjects that I mean to bring 
 before your notice, and the manner in which I propose to treat them. 
 The title of these lectures can, I should think, scarcely need any 
 explanation, for by the diseases of infancy and childhood you will 
 naturally understand all those affections which are either limited in 
 the time of their occurrence to early life, or which, though incidental 
 to all ages, yet in the child present many peculiarities in their symp- 
 toms, and require many important modifications in their treatment. 
 Some of these diseases, indeed, are usually allotted to the care of the 
 surgeon, and on their examination I will not enter, since I could tell 
 you nothing more than has already been better said by others. They, 
 however, are but few in number, and most of them are purely local 
 affections, so that these omissions will not be many, and most of them 
 not important. 
 
 In the description of the diseases of children, no practically useful 
 end would be attained by following any elaborate nosological system. 
 I shall therefore adopt the most simple classification possible, and shall 
 
26 " FREQUENCY OF DISEASES OF THE NERVOUS SYSTEM. 
 
 treat in succession of the diseases of the nervous system, of the respi- 
 ratory and circulatory, and of the digestive systems and their 
 appendages. There will still remain one very important class of 
 affections, namely, fevers ; and these I propose to consider last of all, 
 because much of their danger arises from their complications, and to 
 treat them judiciously you must be familiar with the diseases of the 
 brain, the lungs, and the bowels. In this plan it will be easy to detect 
 a want, perhaps too great a want, of scientific arrangement, but the 
 one object of my endeavours will be to communicate to you, as clearly 
 as I can, such information as may be most useful to you in the dis- 
 charge of your daily duties. 
 
 With this view, I have, while composing these lectures, tried to 
 think over the doubts I felt, the difficulties I met with, and the errors 
 I fell into, when, some years ago, I entered on the office of physician 
 to a large institution for the cure of children's diseases. I have pre- 
 sumed that where I had encountered difficulties there you might meet 
 them too, — that where I had made mistakes there you would need a 
 guide, — and remembering the many anxious hours I passed when I 
 hesitatingly adopted some course of treatment which I feared might 
 after all be a mistaken one, it has been my endeavour to lay down, not 
 only the rules for the diagnosis, but also the indications for the treat- 
 ment of each disease as minutely as possible. 
 
 To the task before me I now apply myself, with a deep conviction 
 of the narrow limits of my own knowledge, but still feeling that I'have 
 contracted an obligation to impart to others what I trust experience 
 has taught me. My end will be answered, if you learn it at an easier 
 rate than I did; and if I can be the means of saving you from some of 
 those errors in diagnosis, and same of those mistakes in treatment, 
 which, for want of some one to guide me aright, I committed. 
 
 LECTURE II. 
 
 Diseases op the Brain and Nervous System. — Their extreme frequency in early life 
 favoured by the rapid development of the brain, and the wide variations in the cere- 
 bral circulation during childhood. — Peculiar difficulties of their study. — Symptoms of 
 cerebral disease in the child. — Convulsions, their frequency in great measure due to 
 the predominance of the spinal system in childhood — may be excited by many causes — 
 hence attention should always be paid to the precursors of an attack. Description of 
 a fit of convulsions. 
 
 It can scarcely be necessary to assign many reasons for beginning 
 this course of lectures with the study of the diseases of the nervous 
 system. The subject, although beset with many difficulties, has always 
 engaged mnch attention ; partly, no doubt, from the natural tendency 
 of the human mind to inquire most curiously into those truths that 
 seem most hidden ; but still more from the alarming nature of many of 
 the symptoms that betoken disturbance of the nervous system, and 
 from the frequently fatal issue of its diseases. But besides the general 
 
FREQUENCY OF DISEASES OF THE NERVOUS SYSTEM. 27 
 
 interest and importance of these affections, at whatever age they may 
 occur, their extreme frequency in early life gives them an additional 
 claim on our notice. 
 
 It appears from the Reports of the Registrar-General, that 16,258 
 out of 91,225 persons who died in the metropolis during the years 1842 
 and 1815, of ascertained causes, were destroyed by the various diseases 
 of the nervous system. But 9,350 of these 16,258 deaths took place 
 during the first five years of existence ; or in other words, 57 per cent. 
 of the fatal disorders of the nervous system occurred within that 
 period. 1 Even after making a very large allowance for the possible 
 errors of statistical data, this predominance of the diseases of the 
 nervous system in early life is far too remarkable to be overlooked ; 
 though some persons, not being able to account for the fact, have 
 affected to doubt its reality. 
 
 The fact is one which cannot be gainsaid ; and though we cannot 
 pretend thoroughly to account for it, yet two considerations may help 
 in some degree to explain it. 
 
 The first is derived from our knowledge of the circumstance, that 
 in an organ whose development is rapidly advancing, many diseased 
 processes also, if once set up, will go on with proportionate activity. 
 Now there is no organ in the body, with the exception of the pregnant 
 womb, which undergoes such rapid development as the brain in early 
 childhood. It doubles its weight during the first two years of life, 
 and reaches nearly, if not quite, its maximum by the end of the 
 seventh year. This same active state of the nutritive or vegetative 
 processes in the brain of the child renders the organ liable to have 
 disease set up in it by causes which would produce little or no 
 injurious effect on the brain of the adult. 
 
 In the second place, the brain in infancy is much more exposed to 
 disorder than that of the adult, owing to the far wider variations of 
 which the cerebral circulation is susceptible in early life than subse- 
 quently. Nor is the cause of this difficult to discover. The cranium 
 of the adult is a complete bony case, and the firm substance of the 
 brain affords a comparatively unyielding support to the vessels by 
 which it is nourished. It has been proved, indeed, by Dr. Burrows 2 
 that the quantity of blood which these vessels contain is not always 
 the same, as some have erroneously supposed : still its variations must 
 needs be circumscribed within far narrower limits than in the child, 
 whose cranium, with its membranous fontanelles and unossified sutures, 
 
 1 These numbers, -which yield results differing but very little from those given in the 
 former edition, are deduced from the returns given in the Fifth and Eighth Reports. 
 The returns for 184G, which are also given in the Eighth Report, are not included, 
 since, owing to the epidemic prevalence of diarrhoea in the autumn of 1846, they would 
 not yield average results. 
 
 2 In his Lumleian Lectures, published in the Medical Gazette, April 28, and May 6, 
 1843, and subsequently in his work on Disorders of the Cerebral Circulation, &c. 8vo. 
 Lond. 1846. The general accuracy of Dr. Burrows' conclusions, though called in question 
 by the late Dr. John Reid, in the London and Edinburgh Monthly Journal for Aug. 
 1846 ; and more recently by Dr. Hamernjk, of Prague, in the Vierteljahrschrift, fur die 
 praktische Heilkunde, Vol. xvii. p. 38, seems to be placed beyond doubt by the very 
 careful experiments of Dr. Berlin, published in the Nederlandsche Lancet, Feb. 1850; 
 and in Schmidt's Jahrbucher for 1851, No. 1, p. 14 — 15. 
 
28 SYMPTOMS OF CEREBRAL DISEASE. 
 
 opposes no such obstacle to the admission of an increased quantity of 
 blood, while the soft brain keeps up a much slighter counter-pressure 
 on the vessels than is exerted by the comparatively firm parenchyma 
 of the organ in the adult. If the circulation in the child be disturbed, 
 whether from difficulty in the return of venous blood, as during a 
 paroxysm of hooping-cough or from increased arterial action, as at the 
 onset of a fever, or during the acute inflammation of some important 
 organ, the brain becomes congested, and convulsions often announce 
 the severity of the consequent disturbance of its functions. The same 
 causes, too, which expose the brain to be overfilled with blood, render it 
 possible for it to be drained of its blood more completely than in the 
 adult. This fact, which you should always bear in mind when 
 treating the diseases of infants, is one reason why excessive depletion 
 induces a far more serious train of symptoms in young children than 
 succeed to it in the grown person. 
 
 It happens, unfortunately, that while there are special reasons for 
 studying the diseases of the nervous system in childhood, their study is 
 beset with special difficulties which we do not meet with in the adult. 
 Disordered intellect, altered sensation, impaired motion, are the three 
 great classes to which the symptoms of disease of the nervous system 
 may be referred. If our patient be an adult, he tells us of his altered 
 feelings ; he perhaps experiences some disorder of his intellectual 
 powers even before it has become observable to others, and, thus timely 
 w r arned, we can often take measures to prevent the advance of disease 
 and to ward off that impairment of the motor powers which in his case 
 we know usually indicates the occurrence of some grave organic lesion. 
 In the child things follow a very different course. At first it cannot 
 express its sensations at all, while, long after it has acquired the power 
 of speech, it knows too little how to shape its ideas into words to give 
 a correct account of what it feels ; and we cannot expect to learn much 
 from the disturbances of an intellect which as yet has scarcely asserted 
 its claim to be any higher than the instinct of the animal. The value 
 of the symptoms, too, is different ; for disturbance of the motor power, 
 which is comparatively rare in the adult, except as the consequence of 
 some serious disease of the brain, takes place in the child in cases of 
 the mildest as well as of the most serious ailments ; and we may even 
 observe convulsions recurring several times a day for many days 
 together, apparently without adequate cause, and not leading to any 
 serious impairment of the child's health. 
 
 How, then, are we to attain in the child to anything beyond the 
 merest guess-work in our diagnosis of diseases of the nervous system, 
 when we are deprived to so great an extent of that information which 
 the state of his intellect and the description of his sensations afford us 
 in the adult ? What meaning are we to attach to that symptom — the 
 impairment of the motor power, which in the adult we look on as of 
 such grave import, but which we meet with in the child under such 
 varying conditions and in by far the greater number of cases ? The 
 task, indeed, is attended with difficulty, and the solution of these 
 inquiries will need that you should devote to it some time and some 
 careful observation ; but if you do thi syou need not despair of learning 
 
CONVULSIONS. 29 
 
 much about an infant's sensations, and the state of its mind, and will 
 at length become able rightly to interpret the meaning even of a fit of 
 convulsions. 
 
 It may be well to pause here for a moment, and briefly to pass in 
 review the symptoms by which disease of the nervous centres, and 
 especially of the brain, manifests itself in infancy and early childhood. 
 
 The painful sensations which the infant experiences soon show them- 
 selves in the haggard, anxious, or oppressed look, which takes the place 
 of the naturally tranquil expression of its countenance. It often puts 
 its hand to its head, or beats or rubs it, or, while lying in its cot, bores 
 with its occiput in its pillow, owing to which, in children who have 
 suffered for any time from uneasy sensations in the head, you will often 
 find the hair worn quite off the occiput. It turns its head away from 
 the light, and lies much with its eyes half closed, in a state of apparent 
 drowsiness, from which it often arouses with a start, and cries. The 
 cry, especially in inflammatory disease, is peculiar ; it is generally a 
 low, almost constant moan, very sad to hear, — interrupted occasionally 
 by a sharp, piercing, lamentable cry, almost a shriek. If the child be 
 young it will often seem relieved by being carried about in its nurse's 
 arms, -and while she is moving will cease its wail for a time, but begin 
 it again the moment she stands still. You will sometimes observe, too, 
 that if moved from one person's arms to those of another, or even if its 
 position be but slightly altered, a sudden expression of alarm will pass 
 across its features ; the child is dizzy, and afraid of falling. 
 
 You see, then, that even in the infant there is a language of signs 
 by which we learn with certainty the existence of pain in the head, and 
 the connexion of this pain with dizziness and intolerance of light. You 
 must beware, however, of concluding from any one set of symptoms 
 that the head is the seat of real disease. The child, as well as the 
 adult, may have sick headache, and the degree of febrile disturbance, 
 of heat of surface, and of heat of head, together with the state of the 
 digestive organs, are all to be taken into account in forming your 
 diagnosis. 
 
 Something may be learned of the state of the mental powers and of 
 the feelings even in early infancy. Have you never watched an infant 
 on its mother's lap, and noticed the look of happy recognition with 
 which its eye meets that of its mother ? An early result of cerebral 
 disease is to interrupt this intercourse : the child now never seems to 
 catch its mother's eye, but lies sad and listless, as if all persons were 
 alike indifferent to it ; or at other times even familiar faces cause alarm, 
 the child apparently not recognizing those who yet have always'tended 
 it. This disturbance, however, is but momentary, and the child sub- 
 sides into its former condition, and allows itself to be taken by those 
 at whom a minute before it seemed frightened. 
 
 But these symptoms are to be interpreted by the light thrown on 
 them from other sources, and by the information, both positive and 
 negative, thus obtained. You fear that disease is going on in the 
 brain ; but is the skin hot ? — is there heat of head ? — are there fre- 
 quent flushings of the face, and does the accession of each flush seem 
 connected with an increase of agitation and distress, or followed by a 
 
30 CONVULSIONS. 
 
 deepening of the drowsiness ? Is the fontanelle prominent and tense, 
 or are the pulsations of the brain to be felt with unusual force through 
 it? — are the veins of the scalp full, or do the carotids beat with 
 unusual force ? What is the character of the pulse ? — is it not merely 
 increased in rapidity ; but even when examined under exactly similar 
 conditions, does it afford a different result each time ? Do you find it 
 irregular in frequency, or unequal in the force of its beats, or even 
 distinctly intermittent ? Again, what is the state of the pupil ? — is it 
 generally contracted, as if to exclude light as much as possible from 
 the over-sensitive retina ? or is it usually dilated, and does it act slowly, 
 as though disease had deadened the sensibility of the nervous system ; 
 or do the pupils of the two eyes not act simultaneously, but one more 
 readily than the other ? Do the pupils oscillate under the light ; at 
 first contracting, then dilating, and either remaining dilated or con- 
 tinuing to oscillate, though within narrower limits, and with a tendency 
 to remain more dilated than at first ? Or, lastly, do you find, when 
 the child is roused, this oscillation of the pupil going on under the 
 ordinary amount of light that enters the chamber ? Now all of these 
 are indications of disordered function of the brain, and many of them 
 point to disorder of a very serious kind. 
 
 But there are yet other sources from which we must not neglect to 
 seek for information. Much may be learned from the state of the 
 digestive functions. The bowels are almost always disturbed ; usually, 
 though not invariably, constipated, while nausea and vomiting are 
 seldom absent. I am not acquainted with any one symptom which 
 should so immediately direct your attention to the brain, as the occur- 
 rence of causeless vomiting, and especially its continuance. At first, 
 perhaps, the child vomits only when it has taken food ; but before long 
 the stomach will reject even the blandest fluid, and then the efforts at 
 vomiting will come on when the stomach is empty, a little greenish 
 mucus being rejected, with no relief, the retching and vomiting soon 
 returning. I shall have occasion to dwell again upon the importance 
 of this symptom, which I have known continue for several days before 
 any other indication of cerebral disease could be discovered. In 
 children of three or four years old this occurrence would scarcely be 
 overlooked ; but the case is different with infants, who so often vomit 
 the milk when ill, that the mother or nurse might fail to mention it to 
 you if you did not make special inquiries with reference to that point. 
 
 ,The manner in which the functions of the respiratory organs are 
 performed is also not to be overlooked. That peculiar, unequal, 
 irregular breathing, to which the name of cerebral respiration has 
 been applied, though of considerable value when present, is sometimes 
 not observed, or not until the disease of the brain is already so far 
 advanced that all questions of diagnosis have long been set at rest. 
 There is, moreover, a short, hard, hacking cough, which you may some- 
 times hear, and the import of which you ought to be acquainted with, 
 since it betokens disease of the brain, ^not of the lungs. There are 
 peculiar sounds, too, which sometimes attend respiration, and are 
 known as indicating disturbance of the nervous system. To these, 
 however, I shall have to return hereafter, since they betoken a disease 
 
CONVULSIONS — DUE TO PREDOMINANCE OP THE SPINAL SYSTEM. 31 
 
 of a serious nature, known by the name of spasmodic croup, and which 
 I must in the course of these lectures describe in full. 
 
 I have purposely delayed till now speaking of the indications of cere- 
 bral disease afforded by the occurrence of convulsions. The symptom is 
 one undoubtedly of great importance, since it is observed in almost 
 every case of serious disease of the brain, at some stage or other of its 
 progress. The very frequency of the phenomenon, however, and the 
 great variety of the circumstances under which it occurs, render it diffi- 
 cult for us rightly to interpret its meaning. Perhaps it will help us to 
 understand it, if we bear in mind that in a large proportion of cases 
 convulsions in the infant answer to delirium in the adult. In early life 
 the superintendence of the motor power is the chief function of the brain, 
 which has not yet attained to its highest office as the organ of the in- 
 tellect. Hence the convulsions which you may observe to come on in 
 infancy in the course of some acute diseases, such as inflammation of 
 the lungs, do not import that any new malady has invaded the brain, 
 but simply that the disease is so serious as to disturb the due perform- 
 ance of all the functions of the organism, and of those of the brain in 
 common with the rest. Convulsions at other times take place in infancy 
 not as the result of any abiding disease of the brain, but simply in con- 
 sequence of those anatomical peculiarities which allow of a much more 
 sudden and more considerable congestion of the cerebral vessels than 
 can occur in the adult. Of this kind are frequently the convulsions 
 that come on during a paroxysm of hooping-cough, which are induced 
 by the impediment to the return of blood from the head, and which 
 often cease so soon as that impediment is removed by the child taking 
 a deep inspiration. But these two considerations are, it must be owned, 
 by no means adequate to explain the very great frequency of convul- 
 sions in children, though they account for much that otherwise would 
 be inexplicable. 
 
 The grand reason of their frequency is no doubt to be found in the 
 predominance of the spinal over the cerebral system in early life. In 
 the adult, the controlling power of the brain checks the display of those 
 reflex movements which become at once evident if disease heighten the 
 excitability of the spinal cord, or cut off the influence of the brain from 
 the paralysed limb, or even if sleep suspend that influence for a season. 
 When the child is born the brain is but imperfectly developed, its func- 
 tions are most humble, and convulsions are then so frequent that they 
 are computed to occasion 73.3 per cent, of all deaths which take place 
 during the first year of existence, from diseases of the nervous system. 
 In the next two years the brain more than doubles its weight, and 
 deaths from convulsions sink to just a third of their former frequency. 
 In proportion as the brain increases in size, and its structure acquires 
 perfection, and its higher functions become displayed, convulsions grow 
 less and less frequent, until from the 10th to the 15th year they cause 
 less than 3 per cent., and above 15 less than 1 per cent., of the deaths 
 from diseases of the nervous system. 1 
 
 1 The first line in this table shows the proportion per cent, of deaths from diseases of 
 the nervous system at different ages, to the deaths from all causes at the same ages in 
 
32 
 
 CONVULSIONS — THEIR EXCITING CAUSES VARIOUS. 
 
 But a little observation will show you, that though convulsions are 
 often the immediate cause of death, yet this fatal event is rare during 
 childhood in comparison with those instances in which they pass off 
 without any serious result ; and that in proportion to their frequency 
 they less often betoken serious disease of the brain in the child than in 
 the adult, while any cause which greatly excites the spinal system may 
 be attended by them. The disturbance of the spinal system, which 
 ushers in fever in the adult, shows itself by shivering. In the child, the 
 same disturbance often shows itself not by shivering but by convulsions ; 
 or convulsions may be induced by a constipated state of the bowels, by 
 the presence of worms in the intestinal canal, or of a calculus in the 
 kidney, or by the pressure of a tooth upon the swollen gum. Hence 
 your first duty is, in every case, to ascertain where is the seat of the 
 irritation which excited the nervous system to this tumultuous reaction. 
 If the fits come on in an advanced stage of some serious disease, they 
 are probably only the indications that death is busy at the centres of 
 vitality ; if they attack a child labouring under hooping-cough, they 
 point to a congested state of the brain, the consequence of the impeded 
 circulation through the lungs ; if they occur in a child apparently in 
 perfect health, they probably indicate that the stomach has been over- 
 loaded, or that some indigestible article of food has been taken ; or, if 
 that be certainly not the case, one of the eruptive fevers is perhaps about 
 to come on ; most likely either small-pox or scarlatina. 
 
 To determine the cause of the convulsions you must acquaint yourself 
 with the history of the child's health for some time before any threaten- 
 ing of them had appeared ; you must learn whether the child has ever 
 suffered from worms, whether its digestive functions have long been out 
 of order, or whether the process of dentition, which is now perhaps going 
 on, has been attended with much constitutional disturbance. But, 
 besides all these points, your inquiries must be still more carefully 
 directed to ascertain whether any cerebral symptoms preceded the 
 attack, and if so, what was their nature, since it is seldom that acute 
 diseases of the brain sets in with convulsions. You will sometimes, 
 indeed, be told that the child was well until a convulsive seizure sud- 
 denly came on ; but on inquiring minutely it will usually be found that 
 some indications of cerebral disease had been present for days, though 
 not sufficiently severe to attract much attention. In cases of apoplexy, 
 of intense cerebral congestion, and of phrenitis, convulsions occur at a 
 
 the metropolis ; and the second line the proportion borne by deaths from convulsions to 
 deaths from diseases of the nervous system in general, 
 
 Under 1 
 year. 
 
 From 
 1 to 3 
 
 years. 
 
 From 
 3 to 5 
 years. 
 
 Total 
 under 5 
 years. 
 
 From 
 5 to 10 
 years. 
 
 From 
 
 10 to 15 
 
 years. 
 
 Total 
 
 above 15 
 
 years. 
 
 30.5 
 73.3 
 
 18.5 
 24.9 
 
 17.6 
 17.8 
 
 24.3 
 64.3 
 
 15.1 
 9.9 
 
 10.6 
 2.4 
 
 10.4 
 8 
 
 Deduced from the Fifth and Eighth Reports of the Registrar- General. 
 
PRECURSORS OP AN ATTACK. 66 
 
 very early period ; but even here, extreme drowsiness, great pain in the 
 head, and vomiting, usually precede for a few hours the convulsive 
 seizure. When the brain is thus seriously involved, the recovery from 
 the convulsions is very imperfect, coma perhaps succeeding to them, or 
 the evidence of cerebral disease being so marked as to leave no doubt of 
 the brain being affected. Tubercles sometimes remain for a long time 
 after its deposition in the brain, without giving rise to any well-marked 
 symptoms, its presence being at length announced by a fit of convul- 
 sions. These convulsions are seldom at first very severe, but you will 
 learn to dread them more than those which assume a more formidable 
 appearance, from noticing either that one side of the body is exclusively 
 affected, or, at least, that there is a marked preponderance of the affec- 
 tion on one side. It is well to bear in mind, too, that convulsions may 
 occur from a want of blood in the brain as well as from its excess, and 
 that the convulsions which come on in some ill-nourished infants may 
 indicate a state of atrophy of the brain. 
 
 I must, however, have said enough already to impress upon you the 
 importance of narrowly scrutinising the meaning of every attack of con- 
 vulsions. But, though so important, there are few tasks more difficult. 
 You have to maintain your own self-composure at a time when all 
 around you have lost theirs ; to extract truth as you best may from 
 the imperfect, often exaggerated, accounts of anxious relatives; to 
 observe not only minutely but quickly, and to come to a speedy deci- 
 sion : since while in those cases which require active treatment delay 
 is almost synonymous with death, there is at least as great danger of 
 destroying your patient by that "nimia diligentia" to which the pre- 
 judices of the nurse and the fears of the friends will often conspire to 
 urge you. 
 
 It is well to watch closely the first indications of that disturbance of 
 the nervous system which will be likely to issue in convulsions. And 
 here let me recommend you not to listen with too incredulous an ear 
 to old nurses, who may tell you that a child has been much convulsed, 
 while you find upon inquiry that it has not had any fit. When they 
 say that a child has been much convulsed, they mean usually that it 
 has shown many of the symptoms which forebode an attack of general 
 convulsions. These forebodings are often induced by dyspepsia, or 
 disorder of the bowels in young infants, and have been described by 
 writers under the name of "inward fits." A child thus affected lies 
 as though asleep, winks its imperfectly closed eyes, and twitches the 
 muscles of the face — a movement especially observable about the lips, 
 which are drawn as though into a smile. Sometimes, too, this movement 
 of the mouth is seen during sleep, and poets have told us that it is the 
 "angel's whisper" which makes the babe to smile, — a pretty conceit of 
 which we can scarce forgive science for robbing us. If this condition 
 increase, the child breathes with difficulty, its respiration sometimes 
 seems for a moment almost stopped, and a livid ring surrounds the 
 mouth. At every little noise the child wakes up ; it makes a gentle 
 moaning, brings up the * milk while sleeping, or often passes a great 
 quantity of wind, especially if the abdomen be gently rubbed. When 
 the intestinal disorder is relieved, these symptoms speedily pass away 
 
 3 
 
34 DESCRIPTION OF A FIT.' 
 
 nor have we much reason to fear general convulsions so long as no 
 more serious forebodings show themselves. There is more cause for 
 apprehension, however, when we see the thumbs drawn into the palm 
 either habitually or during sleep ; when the eyes are never more than 
 half closed during sleep ; when the twitching of the muscles is no longer 
 confined to the angles of the mouth, but affects the face and extremi- 
 ties ; when the child awakes with a sudden start, its face growing 
 flushed or livid, its eyes turning up under the upper eyelid, or the 
 pupils suddenly dilating, while the countenance wears an expression of 
 great anxiety or alarm, and the child either utters a shriek or some- 
 times begins to cry. 
 
 When a fit comes on, the muscles of the face twitch, the body is stiff, 
 immoveable, and then in a short time, in a state of twitching motion, 
 the head and neck are drawn backwards, and the limbs violently flexed 
 and extended. Sometimes these movements are confined to certain 
 muscles, or are limited to one side. At the same time neither con- 
 sciousness nor sensation is present. The eye is fixed and does not see ; 
 the finger may be passed over it without winking; the pupil is immove- 
 ably contracted or dilated ; the ear is insensible even to loud sounds ; 
 the pulse is small, very frequent, often too small and too frequent to 
 be counted ; the breathing hurried, laboured, and irregular ; the skin 
 bathed in abundant perspiration. 
 
 After this condition has lasted for a minute, or ten minutes, or an 
 hour or more, the convulsions cease ; and the child either falls asleep, 
 or lies for a short time as if it were bewildered, or bursts into crying, 
 and then returns to its senses, or sinks into a state of coma in which it 
 may either be perfectly motionless, or twitching of some muscles may 
 still continue ; or, lastly, it may die in the fit. This, however, is not 
 usual except when the convulsions have come on in subjects exhausted 
 by previous disease, or when they are the result of apoplexy or intense 
 cerebral congestion, such as takes place occasionally in hooping-cough, 
 or when they are associated with that closed state of the larynx which 
 occurs sometimes in spasmodic croup. 
 
 This preliminary examination of the symptoms of disturbance of the 
 nervous system has placed us in a position to commence our investiga- 
 tion of the different forms of cerebral disease, on which we will enter 
 at the next lecture. 
 
 LECTURE III. 
 
 Congestion of the Brain. — Active congestion may come on at the onset of eruptive 
 fevers, or be induced by exposure to the sun, or may attend dentition or be excited 
 by various other causes — Symptoms in each of its three stages — Treatment — Special 
 rules for depletion and the application of cold — Active measures not always appro- 
 priate — Passive congestion may supervene on hooping-cough, or be connected with 
 disorder of the digestive organs in weakly children, or be induced by unfavourable 
 hygienic causes — Its symptoms and treatment. 
 
 In my last lecture I endeavoured to point out to you some of the 
 reasons for the greater frequency of affections of the nervous system 
 
ACTIVE CONGESTION OE THE BRAIN. 35 
 
 in infancy and childhood than at other periods of life. I dwelt espe- 
 cially upon certain structural peculiarities of the brain, and of its bony 
 case, which render the cerebral vessels liable to become overloaded with 
 blood, under the influence of causes that would be wholly inadequate to 
 produce such an eiFect in the adult. With the advance of the ossifica- 
 tion of the skull, and the closure of its fontanelles and sutures, these 
 peculiarities are rendered fewer and less important; but still a remark- 
 able liability to congestion of its vessels continues to characterize the 
 brain through all the years of early childhood. A distinguished 
 German physician, Dr. Mauthner, of Vienna, 1 on examining the bodies 
 of 229 children who had died at different ages and of various diseases, 
 found a congested state of the vessels of the brain in 186 of the number. 
 In some of these cases it is probable that this condition had come on 
 only a short time before the patients' death, since in them no symp- 
 toms of cerebral disturbance had appeared during the progress of their 
 illness ; but in many it was not so ; and I shall have occasion to warn 
 you over and over again to be on the watch against congestion of the 
 brain, as a condition which is very likely to come on in the course of 
 affections even of distant organs. Nor is it merely as a serious com- 
 plication of many other diseases that this cerebral congestion deserves 
 your notice; its importance depends still more on its constituting the 
 first and curable stage of many diseases of the brain, which, unless 
 arrested at the outset, soon pass beyond the resources of our art. Neither, 
 indeed, must it be forgotten, that although inflammation, haemorrhage, 
 and the effusion of serum, are the three results to one or other of which 
 congestion of the cerebral vessels tends, yet the exceptions to their 
 occurrence are by no means few, even when that congestion has been 
 very considerable or of long continuance ; and that not only may the 
 functions of the brain be seriously disordered, but the life of the patient 
 may be destroyed, without the anatomist being able to discover any one 
 of these results, or, indeed, any thing more than a general repletion of 
 the vessels of the organ. 3 
 
 Any cause which greatly increases the flow of blood to the head, or 
 which greatly impedes its reflux, may give rise to a congested state of 
 the brain ; and, according as this state is induced by the one or the 
 other cause, it is said to be active or passive. The head symptoms which 
 sometimes usher in the eruptive fevers depend, in a measure, upon the 
 former cause ; the convulsions which frequently occur during a fit of 
 hooping-cough result from the latter. The brain may become actively 
 congested at the time of teething, or from exposure to the sun, or from 
 a blow on the head ; or a state of passive congestion may be induced by 
 some mechanical impediment to the return of blood from the organ — 
 such as the pressure of a hypertrophied thymus, or of enlarged and 
 tuberculated bronchial glands upon the jugular veins, or it may be merely 
 the result of a languid circulation from the want of pure air, or of 
 nourishing and sufficient food. 
 
 1 Die Krankheiten des Gehirns und Riickenmarks bei Kindern. 8vo. Wien, 1844, p. 12. 
 
 2 Dietl's Anatomische Klinik der Gehirnkrankheiten, 8vo. Wien, 1846, contains, at 
 pp. 53 — 73 5 a very able exposition and defence of views concerning cerebral congestion 
 in many respects similar to those expressed in this lecture. 
 
36 ACTIVE CONGESTION OF THE BRAIN. 
 
 Active cerebral congestion is not a very unusual consequence of the 
 disturbance of the circulation at the outset of the eruptive fevers. Con- 
 vulsions and apoplectic symptoms sometimes come on suddenly in a 
 child previously, to all appearance, in perfect health, and may even 
 terminate in death in less than twenty-four hours. The brain is found 
 loaded with blood, but all the other organs of the body are quite healthy. 
 A year or two ago I was requested to be present at the examination of 
 the body of a boy not quite two years old, who had been in perfect 
 health until the day before his death, which took place under such circum- 
 stances as I have just mentioned. The congested state of the cerebral 
 vessels gave but little satisfactory information ; but the same evening, 
 the brother of the child was taken ill with vomiting, intense fever, and 
 sore-throat. In a few hours a red rash appeared ; the case was one of 
 scarlet fever, and ran its course with considerable severity, though, 
 happily, to a favourable termination. It is probable that the poison of 
 the fever had affected the blood of both children, and that the conse- 
 quent disturbance of the cerebral circulation was so violent as at once 
 to destroy the life of the younger, while the elder brother survived the 
 shock, and in him the disease soon presented its usual features. The 
 history of most epidemics of scarlatina would afford you many instances 
 of a similar nature." 1 
 
 But, alarming though these symptoms are, it is comparatively seldom 
 they end in death ; for when they occur at the onset of the exanthe- 
 mata they generally disappear almost as if by magic on the appearance 
 of the eruption. 
 
 I was called one day to see a little girl two years old, who, until the 
 day before, had never had an hour's illness. She had eaten a hearty 
 dinner ; and, though she vomited soon afterwards, did not seem otherwise 
 indisposed, and slept well in the night. Immediately on waking in the 
 morning, however, she had a fit, during which she was insensible, squinted, 
 threw her limbs about, and occasionally screamed aloud. She continued 
 very^ill through the whole day; was hot and feverish during the night, 
 having occasional attacks of convulsions, in which she stretched out her 
 legs, threw back her head, now and then uttered a word or two, and then 
 relapsed into a state of insensibility. This was her state at half-past 
 10 A. M. — about twenty-four hours after the occurrence of the first fit. 
 I bled her, put eight leeches on her head, employed cold affusion, and 
 gave active cathartics during the day, but without much benefit ; and at 
 midnight she was still insensible, rolling uneasily from side to side, 
 boring with her head in the pillow, squinting, and making automatic 
 movements with her mouth and tongue. I now put eight more leeches 
 on the head, which bled profusely, and the bleeding was followed by 
 great diminution in the convulsive movements. About 4 A. M. of the 
 next day, the child fell asleep, and dozed for a few hours. She awoke 
 sensible, and continued so. On my visit in the morning, I found her 
 quiet and sensible, without any sign of convulsion ; her face was very 
 
 'See Armstrong's notice of this suddenly fatal form of the disease, at p. 30 of his' 
 work on Scarlet Fever, &c. 2d edit. London, 1817 ; and Von Amnion's mention of it in 
 his description of the epidemic of malignant scarlatina at Dresden in 1831-2, in the 
 Analekten ubcr Kinderkrankheiten, lltes Heft, p. 42. Stuttgart, 183(3. 
 
CAUSES PRODUCING IT. 37 
 
 pale ; her head, before so hot, was now quite cool; her pulse had sunk 
 in frequency, and lost its fulness. An eruption of a popular character 
 had appeared on the hands, arms, inside of the thighs, and slightly on 
 the face. This eruption was the small-pox, and the disease ran its course 
 with no unfavourable symptom. 
 
 It would not be right, indeed, to attribute the symptoms of disturbance 
 of the nervous system that sometimes occur at the commencement of the 
 eruptive fevers entirely to derangement of the cerebral circulation, for 
 something is probably due to changes in the blood itself; but we see 
 similar results produced by other causes, the immediate effect of which 
 is to disturb the circulation and to favour congestion of the brain. 
 Thus, exposure to the heat of the sun, even though the head had not 
 been unprotected from its rays, may be followed by convulsions or 
 other indications of an overloaded state of the brain, and these symp- 
 toms may all subside so soon as the excited circulation has recovered 
 its wonted balance. Of this I recently saw a striking instance in the 
 case of a delicate boy, who, when a year old, was taken out by his 
 nurse during one of the hottest days in June. He was quite well and 
 cheerful when he left the house, but, after being out for some time, 
 began to breathe hurriedly and irregularly, and his nurse, in conse- 
 quence, brought him home. I saw him about two hours afterwards. 
 He was then restless, fretful, and alarmed ; his surface generally hot, 
 and his head especially so, the. brain pulsating forcibly through the 
 anterior fontanelle ; the pulse too rapid to be counted ; the respiration 
 hurried, laboured, and irregular, and there were constant startings of 
 the tendons of the extremities. The child was on the eve of an attack 
 of convulsions, but the tepid bath relieved the heat of the skin, and the 
 pulse fell, and the subsultus diminished. Light and sound were 
 excluded from the room ; he fell asleep, and awoke in a few hours 
 refreshed and tranquillized, and on tbe next morning a little languor 
 was all that remained of an illness which had seemed likely to prove so 
 formidable. 
 
 Disorders of the nervous system are very frequent during the period 
 of teething, Many of the symptoms which then occur are the direct 
 result of irritation of the trifacial nerve, but others are the immediate 
 consequence of congestion of the brain. Febrile disturbance almost 
 always attends upon the process of dentition, and you can easily under- 
 stand that when the circulation is in a state of permanent excitement, 
 a very slight cause may suffice to overturn its equilibrium, and occasion 
 a greater flow of blood to the brain than the organ is able to bear. 
 
 But I need not occupy more time in pointing out to you the various 
 circumstances which may give rise to active congestion of the brain. 
 Let us now pass to a more minute examination of its symptoms. 
 
 Cerebral congestion may, as you have seen, come on very suddenly, 
 its symptoms from the first being alarming, and such as to call for 
 immediate interference ; or general uneasiness, a disordered state of 
 the bowels, which are generally, though not invariably constipated, and 
 feverishness, may have for a few days preceded the more serious attack. 
 The head by degrees becomes hot, the child grows restless and fretful, 
 and seems distressed by light, or noise, or sudden motion, and children 
 
38 " CEREBRAL CONGESTION — ITS SYMPTOMS. 
 
 who are old enough sometimes complain of their head; One little boy, 
 nearly three years old, who died of congestion of the brain, had seemed 
 to suffer for some days before any alarming symptom came on, from 
 severe pain in the head. He sometimes awoke crying from his sleep, 
 or when awake would suddenly put his hands to his ears, exclaiming, 
 " Oh, hurt ! hurt !" Usually, too, vomiting occurs repeatedly, a 
 symptom on the importance of which I have already insisted, since it 
 is not only confirmatory of others, but also may exist before there is 
 any well-marked indication of the head being affected, and when, 
 though the child seems ailing, there is nothing definite about its illness. 
 The degree of fever which attends this condition varies much, and its 
 accessions are irregular ; but the pulse is usually much and permanently 
 quickened ; and if the skull be unossified, the anterior fontanelle is 
 either tense and prominent, or the brain is felt and seen to pulsate 
 forcibly through it. The sleep is disturbed, the child often waking 
 with a start, while there is occasional twitching of the muscles of its 
 face, or the tendons of its wrist. 
 
 The child may continue in this condition for many days, and then 
 recover its health without any medical interference ; but a slight cause 
 will generally suffice to bring back the former indisposition. You will 
 sometimes see striking instances of this in children while teething ; 
 the fever subsiding, the head growing cool, and the little patient 
 appearing quite well, so soon as the tooth has cut through the gum, 
 but the approach of each tooth to the surface being attended by the 
 recurrence of the same symptoms. 
 
 But though the disturbance of the brain may pass away of its own 
 accord, yet we cannot reckon on such a favourable result occurring, 
 for symptoms such as I have mentioned are often the indications of the 
 organism generally having begun to suffer from mischief which has 
 been going on for months unnoticed, and which is now about to break 
 out with all the formidable characters of acute hydrocephalus. Or 
 should they have no such serious import, yet congestion of the brain is 
 itself a serious, sometimes a fatal malady. Even though no treatment 
 be adopted, indeed, the heat of head may diminish, and the flush of 
 the face grow slighter and less constant, but the countenance becomes 
 very heavy and anxious, the indifference to surrounding objects 
 increases, and the child lies in a state of torpor or drowsiness ; from 
 which, however, it can at first be roused to complete consciousness. 
 The manner, on being roused, is always fretful ; but if old enough to 
 talk, the child's answers are rational, though generally very short ; 
 and, murmuring "I am so sleepy, so .sleepy," it subsides into its 
 former drowsiness. The bowels generally continue constipated, and 
 the vomiting seldom ceases, though it is sometimes less frequent than 
 before. The pulse is usually smaller than in the other stage, and 
 there is often irregularity in its frequency, though no actual intermis- 
 sion. An attack of convulsions sometimes marks the transition from 
 the first to the second stage ; or the child passes, without any apparent 
 cause, from its previous torpor into a state of convulsion, which sub- 
 siding, leaves the torpor deeper than before. The fits return, and 
 death may take place in one of them, or the torpor growing more 
 
ITS TREATMENT. 39 
 
 profound after each convulsive seizure, the child at length dies 
 comatose. 
 
 This second stage, if so it may he called, is usually of short duration, 
 and if relief be not afforded by appropriate treatment, death is seldom 
 delayed beyond forty-eight hours from the first fit, though no graver 
 lesion may be discovered afterwards than a gorged state of the vessels 
 of the brain and its membranes, and perhaps a little clear fluid in the 
 ventricles and beneath the arachnoid. 
 
 Occasionally, indeed, death does not so speedily follow these symp- 
 toms ; but they continue slightly modified for days, or even weeks, and, 
 contrary to all expectation, recovery now and then takes place. This 
 protracted course of the affection is, I believe, met with only in the 
 case of very young children, in whom, the congestion having relieved 
 itself by a copious effusion of serum into the ventricles, the yielding 
 skull accommodates itself to its increased contents. The symptoms, 
 though to a great extent the same as before, are now due to the 
 presence of water in the brain — a disease which, though dangerous 
 and often fatal, is yet chronic in its course, and may even admit of 
 cure. 
 
 If active congestion of the brain may come on under so great a 
 variety of circumstances, it is evident that there can be no invariable 
 rule for its treatment, adapted alike to every case, but that the pecu- 
 liarities of each must be taken into your most careful consideration. 
 The little girl I have mentioned in whom convulsions preceded the 
 attack of small-pox, would most likely have died from apoplexy if she 
 had not been bled ; and it is probable that in her case the depletion 
 might have been carried still further with advantage. On the other 
 hand, the boy who had been exposed to the heat recovered under the 
 tranquillizing influence of a tepid bath, and there can be no doubt but 
 that to him depletion would have been injurious. You must, then, 
 always endeavour to make out what has been the antecedent of the 
 attack. If violent convulsions have come on suddenly, and without 
 apparent cause, in a child until a short time before in perfect health, 
 inquire whether your patient has had the eruptive fevers, especially 
 scarlatina and small-pox, or whether he has been recently exposed to 
 their contagion, and examine the arm to see whether there is a good 
 cicatrix as evidence of successful vaccination. When head symptoms 
 usher in the exanthemata, the danger for a time may be imminent, but 
 you know that if you can relieve the gorged vessels of the brain, and 
 thus ward off the immediate peril, nature herself will come to your 
 assistance, and the outbreak of the eruption will probably be followed 
 by the cessation of the cerebral disturbance. Or it may be that the 
 child has greatly overloaded its stomach, or partaken of some indiges- 
 tible substance, in which case you would give an emetic, though under 
 any other circumstances the attempt to induce vomiting would be not 
 only useless but dangerous. If the symptoms had succeeded to a blow, 
 you would not lose sight of the danger of inflammation of the brain 
 supervening : while if the head affection had been preceded by long- 
 continued gastric or intestinal disturbance, or if it had come on during 
 teething, you would bear in mind that a more cautious treatment must 
 
40 RULES FOR DEPLETION. 
 
 be pursued, lest you cause as serious mischief by doing too much, as 
 might in other cases result from your doing too little. 
 
 There are, however, but few exceptions to the rule which prescribes 
 the abstraction of blood, either locally or generally, as one of the most 
 important remedies in cases of active cerebral congestion. If the 
 symptoms set. in violently, as they did in the case of the little girl 
 whose history I mentioned to you, you must deplete freely, and will 
 find that relief will follow more speedily on the abstraction of blood 
 from the jugular vein than on venesection or the application of leeches. 
 It is not easy to define exactly the quantity of blood which may be 
 drawn, but from two to three ounces would probably be as much as you 
 would ever be warranted in taking from a child a year old ; and the 
 appearance of manifest relief to the symptoms should be a signal to 
 you for stopping its flow, even before that quantity had been obtained. 
 The removal of too large a quantity of blood would be at least as mis- 
 chievous as the abstraction of too little, while you would run some 
 hazard of confounding the effects of loss of blood with those of its 
 excess, and might thus be led further into error. It is, therefore, 
 better (although children bear repeated blood-letting ill) to take but a 
 moderate quantity of blood at first ; to watch its effects, and to repeat 
 the bleeding in a few hours, if it be necessary, rather than to subject 
 the system to the shock of an excessive loss of blood. 
 
 In children under eighteen months old, bleeding from the arm is 
 seldom practicable, and, without the case be very urgent, it is inex- 
 pedient to open the jugular vein. At this early age, however, almost 
 all the good effects of general bleeding can be obtained by the applica- 
 tion of leeches. You will, probably, not be far wrong if you estimate 
 the quantity of blood drawn by a healthy leech at about 3ij., and, if 
 the subsequent bleeding be encouraged, about as much will flow after- 
 wards. In cases such as these, however, where too little and too much 
 are alike attended by most serious danger, you must not content 
 your selves with ordering a certain number of leeches, and leaving their 
 application to a nurse, and the regulation of the subsequent bleeding to 
 accident, but must attend and watch the effects they produce. 
 
 If, on your second visit, you find that the child, although manifestly 
 relieved for a time by the depletion, is relapsing into a state of coma, 
 or that convulsions, checked for a season, are returning, or that the 
 head is nearly as hot, and the pulse nearly as accelerated as before, 
 and quite as hard, you may be warranted in bleeding again. Such 
 depletion should be local, and, if you can obtain the assistance of an 
 expert cupper, it will be better, in the case of children above three or 
 four years old, to draw blood by cupping from the back of the neck 
 rather than by leeches. You must not however, resort to a second 
 bleeding without the most evident necessity, nor without having tried 
 all those subsidiary means by the diligent employment of which you will 
 often be able to render further depletion unnecessary. Many of these 
 means, indeed, are so simple that their value is frequently underrated; 
 and it is so often said, almost as a matter of course, "keep the child 
 quiet and the room cool, and apply cold to the head," that it does not 
 strike the parents how much depends upon those directions on which 
 
APPLICATION OF COLD. 41 
 
 the doctor seems to lay so little weight. You must learn, however, that 
 in the treatment of children's diseases none of these things are trivial, 
 but that on their due performance often hangs the life of your patient. 
 Do not content yourselves, then, with merely giving directions, but 
 stay to see them attended to ; and do not leave the house till the 
 chamber has been darkened ; the cool air is freely admitted, the cold 
 application to the head has been properly adjusted, and all persons who 
 are not actually waiting on the child have left the apartment. 
 
 At the outset of the affection the bowels are usually constipated, so 
 that an active purgative is in most cases called for. You may give a 
 dose of calomel and jalap, or the calomel may be administered alone 
 and followed by the infusion of senna, which may be repeated every 
 three or four hours till the bowels act. Should the stomach be very 
 irritable, a larger dose of calomel may be given, and after the lapse of 
 a couple of hours an attempt may be made to quicken*its action by 
 administering a purgative enema, or by dissolving some sulphate of 
 magnesia in the child's drink, and giving it at short intervals. In 
 many cases the disorder will be speedily removed by this treatment, 
 and the child, whose life had seemed to be hanging. by a thread, will, 
 in the course of twenty-four hours, be almost well. 
 
 But it may happen that though the symptoms are increasing in 
 severity, though the convulsions are unchecked, or coma is evidently 
 coming on, yet the state of the pulse forbids a repetition of depletion ; 
 or it may even be that you dare not bleed at all, for fear of altogether 
 putting out the life which is in such urgent peril. Fortunately we have 
 another and very powerful remedy in store, which we may try in cases 
 where, otherwise we should be without resource : this remedy is the 
 cold affusion. There is something, however, apparently so formidable 
 in taking a child from its bed and pouring a stream of cold water on 
 its head for several minutes together, that you will be wise to explain 
 what you are about to do to the child's friends, and to obtain their 
 consent to the experiment, lest you be compelled by their alarm to 
 desist before you have done any real good. When you have de- 
 termined to resort to it, the child must be taken out of bed, wrapped 
 in a blanket, and laid upon the nurse's lap with its face downwards, 
 while you pour a stream of water, from a little height, upon its head. 
 The most effectual way of doing this, though one not always practicable, 
 is to place the child under the cock of a water cistern, or the spout of 
 a pump, since you can then continue the stream, uninterruptedly, for 
 five or six minutes. I have seen some remarkable instances of con- 
 vulsions arrested and of children aroused from coma, by these means ; 
 but you must bear in mind that the agent is one of great power, 
 and you must feel the pulse from time to time, during its employment, 
 lest you should, by its long continuance, produce too great a depression 
 of the vital energies. 
 
 But besides those cases in which you want to produce a sudden 
 effect by the application of cold with a shock, you often need the 
 sedative influence of cold constantly applied. A very intense degree 
 of cold may be kept up by allowing cold water to drip constantly upon 
 the patient's head, which may be managed, as suggested by Dr. 
 
42 APPLICATION OF COLD. 
 
 "Watson, by means of a sponge and funnel placed a little above the 
 head. This plan is, however, objectionable on account of its being 
 almost impossible, when it is adopted, to prevent the patient's person 
 from becoming extremely wet ; and, moreover, it is but seldom that so 
 powerful an agent is needed in the case of children. Few methods of 
 applying cold to the head are better than that which consists in half 
 filling two bladders with pounded ice or cold water, and placing them, 
 each wrapped in a napkin, the one under, and the other upon the 
 child's head. By pinning the corners of the napkins to the pillow you 
 can secure them from being displaced, and can also prevent the weight 
 of the upper bladder from resting too heavily on the child's head, while 
 all danger of the bed or the dress becoming wet is avoided. 
 
 Supposing, now, that by the employment of these means you have 
 removed the imminent danger, and that your patient is going on favour- 
 ably, still it Will be generally desirable to continue treatment for a few 
 days. Free action of the bowels must be secured ; for which purpose 
 small doses of calomel may be given two or three times a day, and it 
 may be desirable to accompany each powder with a dose of a mixture 
 containing nitre and sulphate of magnesia. 1 You must, however, bear 
 
 (No. l.) 
 
 1 R Potassse Nitratis, gr. x. 
 Magnesias Sulph. gj. 
 Syr. Limonum, sjiij. 
 
 Aquas destill. gix. M. sjij. ter quotidie. 
 For a child a year old. 
 
 in mind that you will do less harm by allowing a child to go without 
 medicine than by forcing on it remedies which it dislikes and resists 
 taking. Calomel, indeed, can almost always be given ; and even sul- 
 phate of magnesia will very often be taken if mixed with the drink, 
 or dissolved in a little veal broth. But how much soever a child may 
 resist medicine, the abstraction of blood, a spare diet, a cool and dark 
 and quiet chamber, are remedies always at command, the value of 
 which you must not underrate. 
 
 I need not tell you that all cases do not admit of this active treat- 
 ment. When the disease creeps on with febrile symptoms, occasional 
 vomiting, constipation, loss of appetite, and restless nights, with com- 
 plaints, if the child be old enough to speak, of pain in the head or 
 limbs, or vertigo, and with a quick and variable pulse, you must treat 
 it gently. If you deplete, it must be only by leeches, and then not in 
 large number, while you trust much to quiet and the careful regulation 
 of the diet. In such cases you will often find a tepid bath night and 
 morning soothe the child and tranquillize the circulation far more than 
 you might have expected from so simple a remedy. Drastic purgatives 
 must be avoided, but small doses of mercury and chalk, or of calomel, 
 either alone or combined with rhubarb, may be given with advantage 
 once or twice a day. Half a grain of calomel, or two grains of the 
 Hydr. c. Cret&, with four of rhubarb, would be a proper dose for a 
 child a year old. If there be much feverishness and restlessness 
 
ACTIVE SYMPTOMS SOMETIMES IMPROPER. 43 
 
 during the day, you may give a mixture of bicarbonate of potash not 
 quite saturated with citric acid, and containing small doses of ipeca- 
 cuanha wine, if the stomach be not extremely irritable, and of the 
 tincture of hyoscyamus ; the value of which last medicine as a seda- 
 tive in the diseases of children can scarcely be too highly estimated. 
 The addition of a little syrup of mulberries will render the above mix- 
 ture extremely palatable. 1 
 
 (No. 2.) 
 
 1 R Potassse Bicarbonat. 
 Acidi Citrici, aa. gr. xx. 
 Vin. Ipecac, rr^xij. 
 Trae. Hyosc. n^xviij. 
 Syr. Mori, giij. 
 
 Aqua? destill. gix. M. gij 6ta quaque hora. 
 For a child a year old. 
 
 You will sometimes meet with cases of cerebral congestion that 
 appear to have been brought on by exposure to the heat of summer. 
 In such cases it often happens that the bowels are not constipated, 
 but somewhat relaxed. You must not, however, aim at checking the 
 diarrhoea by direct astringents, but should rather pursue an alterative 
 plan. In most instances there is irregularity of the bowels rather 
 than diarrhoea ; the child having five or six unhealthy motions, for the 
 most part destitute of bile, in the course of one day, and passing the 
 succeeding twenty-four hours without any evacuation at all. In such 
 cases you will find the treatment I have just indicated very useful. 
 If the bowels be much disturbed, half-grain or grain doses of Dover's 
 powder may be combined with the mercurial with advantage. 
 
 I have not time to enter into more minute details with reference to 
 the management of every variety of active cerebral congestion, but 
 must briefly notice those cases in which the condition exists in what 
 may, perhaps not improperly, be called the passive state. In the 
 paroxysms of hooping-cough the brain becomes congested by the im- 
 pediment to the return of the blood from the head : and cerebral con- 
 gestion is induced in a similar manner when the larynx becomes spas- 
 modically closed in the disease known by the name of Laryngismus 
 Stridulus. But we likewise meet with cases where the passive succeeds 
 to the active form of cerebral congestion, or becomes more or less 
 gradually developed out of some disorder of the abdominal viscera : 
 or, lastly, where it supervenes towards the close of life in weakly 
 children, whose vital powers have at length become too feeble to 
 propel the blood. 
 
 In children who have suffered long and severely from hooping-cough, 
 you often notice a general lividity of the face and lips, a puffed and 
 anxious countenance, and the child makes grievous complaints about 
 its head, while the skin is moist and cool, and the pulse soft, though 
 frequent. Many of these symptoms indicate an overloaded state of 
 the cerebral veins ; and if a paroxysm of coughing occur, and the 
 circulation be thus further disturbed, the child may die in a fit, or may 
 
44 PASSIVE CONGESTION — 
 
 sink after some convulsive seizure into a state of coma, which sooner 
 or later proves fatal. In such a case you will find the vessels of the 
 brain and its membranes universally gorged with black blood, the 
 choroid plexuses of a deep purple colour, and more bloody points than 
 natural will present themselves on a section of the brain being made. 
 Both the symptoms during life, and the appearances after death, are 
 only a rather exaggerated illustration of what occurs in all cases of 
 passive congestion of the brain. It is not, however, always easy to 
 explain why this condition comes on. Among the poor you often find 
 it connected with general disorder of the digestive organs, and occur- 
 ring as one of a long train of ills induced by destitution and neglect. 
 It was so in the case of a little boy four months old, whom I saw a 
 years ago. His parents were young and healthy people, but they had 
 already lost three children, apparently in consequence of their inhabit- 
 ing one of those narrow courts so numerous in London, into which the 
 sun never shines, and where young children pine and fade like tender 
 plants shut up in a cellar. When ten weeks old, this little boy was 
 taken with pain in his bowels and diarrhoea, and at three months old 
 he began to suffer from fits, which came on daily, sometimes several 
 times a day. No efficient treatment had been adopted when he was 
 brought to me. He was then as large as most children of his age, 
 and by no means emaciated ; but his flesh was flabby, his face unintel- 
 ligent, puffed and livid, his head hot, the veins of the scalp and eyelids 
 turgid, the eyes prominent, lustreless, covered by mucus, and the pupils 
 not acting under light. He lay in his mother's lap, uttering a con- 
 stant hoarse moan; his head thrown rather back, and in incessant 
 rotatory motion ; his mouth was open, his tongue red and parched, and 
 the papillae on its surface were very prominent : his abdomen was rather 
 full, and his legs were constantly drawn up towards it. He vomited 
 much : his bowels were open three or four times a day, the motions 
 being green and offensive ; his pulse was frequent, but without power. 
 In this, as in many instances of passive congestion of the brain, local 
 depletion was resorted to at first, and, benefit resulting from it, was 
 repeated more than once. It is not, however, every case that will 
 admit of even local depletion, which, whenever employed, must be 
 practised only with the view of affording relief to the gorged cerebral 
 vessels, not with the idea of curing the patient by bleeding. The 
 greatest attention must in every case be paid to diet and to the state 
 of the bowels, and you will find no means of inducing their healthy 
 action better than the employment of small doses of mercury and 
 chalk two or three times a day. If the child be not weaned, you may 
 find it desirable, if there be constant sickness, to take it almost, or 
 entirely, from the breast for a day or two, and to substitute barley- 
 water, sugar and water, or a weak solution of isinglass, with the addi- 
 tion of one-third of milk, which should be given in quantities of one 
 or two spoonfuls at a time till the stomach becomes more settled. A 
 stimulating bath, as a hot salt-water bath, or a bath into which a 
 handful of mustard has been put, and in which the child is to be kept 
 for four or five minutes, night and morning, will often be found a 
 valuable auxiliary to the general treatment, as well as very useful, if 
 
ITS SYMPTOMS AND TREATMENT. 45 
 
 combined with the application of cold to the head, in cutting short the 
 convulsive seizures. 
 
 If the case be associated with much diarrhoea and general impair- 
 ment of nutrition, the extract of bark, with a few drops of sal volatile, 
 or of the compound tincture of bark, should be given two or three 
 times a day, and you should not let the head symptoms lead you to 
 keep the child on a low diet. 1 Remember, too, that when nutrition is 
 
 (No. 3.) 
 
 1 R Extr. Cinchonae, gj. 
 
 Tree. Cinch. Co. gij. 
 
 Aquae Carui, gx. M. £j. ter quotidie e lacte. 
 For a child a year old. The taste of the above mixture is best concealed by sweetening 
 it, and mixing it with twice the quantity of milk. 
 
 much impaired, farinaceous food is usually not well digested; you must, 
 therefore, be sparing of arrow-root, and give milk and water, or milk 
 and water with isinglass,' or veal- tea. If the broth should purge, as it 
 sometimes does, the white decoction of Sydenham 3 will form a cheap 
 substitute for isinglass. As the child improves, the ferrocitrate of 
 quinine will be one of the best tonics you can give, 3 and throughout 
 
 (No. 4.) 
 
 3 B Syrupi Quinse Ferro-Citrat. giss. 
 Syrupi Aurantii, sjiiss. 
 Aquae Flor. Aurantii, ^j. M. gj. ter die. 
 For a child a year old. 
 
 the whole progress of the case you will remember the tonic influence 
 of pure air ; and may even find the removal to a healthier spot and 
 purer atmosphere absolutely necessary to the recovery of your patient. 
 Lastly, I will just allude to the head symptoms that sometimes for a 
 few days precede death in children who have been long ill. You may 
 in such cases find the vessels of the brain turgid, and be disposed to 
 reproach yourselves for not having adoped active' treatment. Such 
 self-reproach would be unmerited ; the streams have stagnated, because 
 the vital powers were all too feeble to keep them in motion. 
 
 2 This, the Decoction Blanche of the French Pharmacopoeia, is made by boiling half 
 an ounce of hartshorn shavings, and the inside of one French roll, in three pints of 
 water, till reduced to two ; when it may be sweetened, and given either alone or with 
 the addition of one part of milk. 
 
46 CEREBRAL H-EMORRHAGE ONE CAUSE Or INFANTILE ASPHYXIA. 
 
 LECTURE IV. 
 
 Cerebral Hemorrhage. — The rupture of any large vessel in childhood very rare, but 
 effusion of blood into arachnoid frequent — reasons for its especial frequency in new- 
 born infants — its symptoms and treatment. — Blood sometimes effused external to the 
 skull in new-born infants. — Cephalhematoma, its characters, changes in the effused 
 blood, and process of cure — its treatment. — Haemorrhage into arachnoid in childhood 
 — changes in the effused blood — obscurity of the symptoms — occurs sometimes in very 
 feeble children, or in connection with changes in the blood — illustrative cases. — 
 Haemorrhage into cerebral substance in childhood extremely rare — cases in illustra- 
 tion of its causes and symptoms — capillary haemorrhage in connection with tubercle 
 in the brain. 
 
 When we last met, I called your attention to the very important 
 consequences that may result from the vessels of the brain becoming 
 overloaded with blood. I pointed out to you a train of symptoms, 
 rising in severity, from mere pain or heaviness of the head, to convul- 
 sions or coma, according to the degree of the cerebral congestion ; and 
 told you that death itself might take place, without any mischief 
 being discoverable, afterwards, more serious than a general turgesceuce 
 of the vessels of the brain and its membranes. Simple apoplexy, indeed, 
 is by no means rare in childhood, and the knowledge of this fact may 
 furnish encouragement to us in cases where the symptoms of present 
 danger are most alarming. We may hope, that if the instant peril 
 can be averted, the blood, which has not burst its vessels, will flow 
 again tranquilly through them, and the functions of life once more go 
 on in their wonted course. In the adult we could scarcely indulge such 
 an expectation, for the import of apoplectic symptoms is generally far 
 more serious. If the patient die, we look for, and seldom fail to find, 
 blood poured out into the brain, compressing its substance, and lace- 
 rating the delicate fibres along which the nervous influence travels. Or, 
 even should he survive, it often is to pass through a tedious convales- 
 cence, with palsy, and weakened senses, and impaired mental powers, — 
 the sad and standing evidence of the grievous injury which^he brain 
 has sustained. 
 
 You may naturally inquire how it happens that in the child, the very 
 structure of whose skull favours the occurrence of cerebral congestion, 
 haemorrhage into the brain is comparatively so rare : while in the 
 adult, whose unyielding cranium and firmer brain tend to check con- 
 gestion, the extravasation of blood into its substance takes place so 
 often? The changes which advancing age induces in the structure of 
 the cerebral vessels are probably the chief cause of this difference. In 
 early life, the arteries are yielding, and admit of being greatly dis- 
 tended without giving way : but in the course of years they lose their 
 elasticity, their calibre becomes diminished and unequal, and their 
 coats grow brittle by the deposit of a cartilaginous or earthy matter in 
 their tissue. 
 
 But though the larger arterial trunks withstand the constantly recur- 
 ring variations in the cerebral circulation during infancy and child- 
 
CEREBRAL HEMORRHAGE ONE CAUSE OF INFANTILE ASPHYXIA. 47 
 
 hood, the smaller and more delicate vessels of the brain are very liable 
 to give way, and capillary hemorrhage, or haemorrhage by exhalation, 
 as it has been often, though incorrectly, termed, takes place with 
 greater frequency than in adult age. 
 
 All periods of childhood are not equally exposed to this accident, 
 but it is oftenest met with immediately after birth ; and no circum- 
 stances can be imagined more favourable to its occurrence than those 
 which then concur to produce it. The head of /the infant has been 
 subjected to severe and long-continued pressure during its progress 
 through the mother's pelvis ; immediately on its birth, the course of 
 the circulation is altogether changed, and should any difficulty occur in 
 the establishment of the new function of respiration, a long time will 
 elapse before the blood flows freely through its unaccustomed channels. 
 !No one will wonder that death should frequently take place during this 
 transition to a new kind of existence. The tumid scalp and livid face 
 of many a still-born child point to one of its most important causes, 
 since they are but the measure of that extreme congestion of the 
 vessels within the skull that has at length ended in a fatal effusion of 
 blood upon the surface of the brain. 
 
 There would be reason to fear that this occurrence had taken place, 
 if an infant, when born, were to present great lividity of the surface, 
 and especially of the face; and if the heart were to beat feebly, and at 
 long intervals, although the pulsations of the cord were slow and faint, 
 or had altogether ceased. Under these circumstances, death sometimes 
 takes place without any effort at respiration being made, the beatings 
 of the heart growing feebler and fewer till they entirely cease ; but at 
 other times the child breathes irregularly, imperfectly, and at long 
 intervals. The hands are generally clenched, and spasmodic twitchings 
 are of frequent occurrence about the face, or these twitchings are more 
 general and more severe, and amount almost to an attack of convul- 
 sions. The symptoms, however, are by no means uniform, and 
 probably are in some degree modified by variations in the seat as well 
 as in the quantity of the effusion ; for it sometimes happens, even in 
 cases where a very large quantity of blood has been poured out into 
 the arachnoid cavity, that the breathing is little or not at all disturbed, 
 and after living for a few hours in a state of weakness and torpor, with 
 chilliness of the whole surface, the child dies without any sign of 
 convulsion. 
 
 Instances of this form of asphyxia will be sure to come under the 
 notice of those of you who engage in midwifery practice. I need 
 hardly remind you that the first indication to fulfil in their treatment 
 is to relieve the overloaded vessels of the brain, by allowing of the 
 escape of half an ounce or an ounce of blood from the divided umbilical 
 cord. When the diminished lividity of the surface shows that this end 
 has been attained, the cord should be tied, and the child may now be 
 plunged for a minute or two in a hot bath at 100° or 102° ; but pro- 
 longed immersion in a bath at a less elevated temperature is likely to 
 depress the nervous energy. While the body is in the bath, cold waxer 
 may be dashed rather smartly on the face or chest, by which means the 
 inspiratory muscles are often excited to action. If, however, the child 
 
48 CEPHALHEMATOMA. 
 
 do not soon begin to breathe, you must not continue too long the use of 
 these or of other subsidiary measures, such as the application of am- 
 monia to the nostrils, tickling the throat or nares with a feather, &c. 
 for you would thus fruitlessly consume that time which Would be much 
 more usefully spent in making a persevering trial of artificial respiration. 
 
 If no occurrence have taken place more serious than a very great 
 degree of congestion of the cerebral vessels, you will generally succeed, 
 by the use of these means, in restoring the child. Often, however, it 
 will happen that your attempts at resuscitation will fail completely, or 
 that after breathing imperfectly for a few hours without having ever 
 seemed thoroughly restored, the child will die, and you will then find 
 blood poured out into the cavity of the arachnoid. The extravasation 
 is sometimes limited to the neighbourhood of the cerebellum, but at 
 other times it covers a considerable part of the convex surface of the 
 brain, and even occupies the spinal canal ; as you see in this by no 
 means exaggerated representation of a case of infantile apoplexy in 
 Cruveilhier's great work on Morbid Anatomy. 1 
 
 It fortunately happens that the overcharged vessels of the head in 
 the new-born infant do no.t always relieve themselves by pouring out 
 blood within the skull, but sometimes the capillaries of the scalp give 
 way, and blood is extravasated into its tissue ; or, at other times, the 
 effusion of blood takes place between the bone and pericranium. 
 When this last accident occurs, it often gives rise to the formation of a 
 tumor upon the head, that presents peculiarities sufficient to call for 
 some notice. 
 
 This tumor (cephalcematoma, as it has been called, from xj$a%ti head, 
 and difiat^/.ia y from a*w<* blood) makes its appearance within forty- 
 eight hours after birth — often much sooner — on one or other parietal 
 bone, most frequently on the right, as a circumscribed, soft, elastic, 
 slightly fluctuating, painless swelling, beneath the unchanged integu- 
 ment. On a careful examination, it is generally felt to be bounded by 
 a firm, apparently osseous ridge, which usually encircles it completely, 
 though more distinct at one part than another. On passing the finger 
 over the summit of this ridge, and down towards the base of the tumor, 
 the impression is at once conveyed of the parietes of the skull being 
 deficient at this point, and of the ridge being the edge of a hole in the 
 bone. When first discovered, the tumor is usually small, but increases, 
 in the course of two or three days, from the size of a marble to that of 
 a chestnut, or of half a hen's egg. As it grows larger, it generally 
 becomes tenser, but still seems to cause no pain, and the child's health 
 continues good. After it has attained its full size, it often remains 
 stationary for a few days, and during this time a gradual increase in 
 the distinctness of the ring which surrounds it is the only change that it 
 undergoes. A slight diminution in the size of the tumor at length 
 becomes 'perceptible, and then it slowly disappears, though its removal 
 occupies a month, six weeks, or more, and a slight elevation of the 
 skull at the point where it was situated sometimes remains even longer. 
 The centre of the tumor generally retains its soft and fluctuating character 
 
 1 Anatomie Pathologique, liv. xv. pi. 1. 
 
CHANGES IN THE EFFUSED BLOOD. 49 
 
 nearly to the last, but occasionally it loses this, and communicates to 
 the finger a sensation of crackling such as we should experience if we 
 pressed on a piece of tinsel. 
 
 Although once the subject of much difference of opinion, the mode of 
 formation of these tumors, and the nature of the changes they 
 undergo, are now tolerably well understood. The edges of the os uteri, 
 compressing the fcetal skull during labour, just as, in this engraving, 1 
 the hands are represented compressing it, often produce an effect 
 similar to that which you see depicted here, and occasion an oozing of 
 blood from its surface. The quantity of blood thus poured out is 
 usually small, and is then speedily absorbed, without having at any 
 time produced a perceptible swelling. If, however, it be more consid- 
 erable, a tumor is formed on the exterior of the skull, and this tumor 
 may continue to enlarge for some time after birth, owing, possibly, to 
 the influence of causes calculated to keep up a congested state of the 
 brain, and to favour the effusion of blood. 2 
 
 The blood thus effused speedily coagulates, and the edge of the 
 coagulum sometimes conveys to the finger an indistinct sensation of a 
 raised border surrounding the tumor. The elevated ring that is after- 
 wards plainly felt circumscribing it, is, however, mainly the result of a 
 reparative process, in the course of which a fibrinous exudation is poured 
 out over that part of the skull whence the pericranium has been detached, 
 and is heaped up in great abundance just where the bone and its invest- 
 ing membrane come into apposition. This is proved to be its real 
 source, by the circumstance that the ring becomes much more evident 
 after the absorption of the blood has commenced, than it is at first 
 while in those cases where the effusion of blood has been very considerable , 
 no ring is perceptible during life, and it is found after death that scarcely 
 any attempt at reparation has been made, and that the fibrinous exudation 
 is very scanty, or altogether absent. 
 
 This exudation is generally absorbed in course of time, but sometimes 
 a process of ossification is set up in it : the fibrinous ring becomes 
 converted into an osseous ridge, and that part of the cranium over which 
 the blood had been poured out is roughened by the formation of new 
 bone upon its surface. The meaning of the appearances thus produced 
 was long misunderstood, and they were thought to be owing to a process 
 of destruction, not to one of cure. The roughened surface of the skull 
 was looked on as the result of ulceration by which its outer table had at 
 one part been destroyed, and the bony ridge around it was supposed to 
 be the edge of that part of the outer table to which the disease had not 
 yet extended. The real nature of these changes was extremely well 
 exemplified in a very remarkable case that came under my notice, in which 
 blood was effused between the skull and dura mater, as well as between 
 
 1 In Valleix's Clinique des Maladies des Enfants Nouveau-ne*s, Paris, 1839, planche 
 i. fig. 2. 
 
 2 The various questions relating to the mode of formation of these tumors are fully 
 discussed by Feist, Ueber die Kopfblutgeschwulst der* Neugebornen, 4to. Mainz, 1839 
 and by Burchard, De Tumore Cranii recens natorum sanguineo, 4to. Vratislaviae, 1837 
 where are likewise mentioned various exceptional cases in which the swelling formed 
 on the parietal bone that had been directed towards the sacrum, and not, as is usual, 
 on the bone which had presented during labour. 
 
 4 
 
50 CEPHALHEMATOMA — ITS TREATMENT. 
 
 it and the pericranium.* This drawing shews the processes of cure in 
 progress. First, however, you may notice the perfect smoothness of the 
 inner surface of the bone, in order to display which the edge of the clot is 
 raised. Its outer as well as its inner investment had been detached 
 from this portion of the skull by the effusion of blood beneath them, and 
 the bone continues unroughened, because an attempt at reparation was 
 impossible here. At the edge of the clot, the dura mater and the bone 
 come again into contact, and nature has here begun the cure. New bone 
 has been deposited, and an osseous ridge has been formed precisely 
 similar to that which in so many instances surrounds the external effusion. 
 Nor is this all ; but bony plates are beginning to be deposited between 
 the layers of the dura mater; exemplifying the manner in which, when 
 blood has been poured out beneath the pericranium, that membrane 
 sometimes becomes ossified, and accounting for the crackling sensation 
 that in these cases is felt on pressing the tumor. 
 
 The characteristics of these tumors are so well marked, that they are 
 not likely to be confounded with swellings of the scalp produced by any 
 other cause. A hernia of the brain, indeed, may present some resem- 
 blance to them, since it forms a soft painless tumor, unattended by dis- 
 colouration of the integuments ; and the edges of the aperture in the 
 bone through which the brain protrudes may easily be taken for the ring 
 which surrounds an effusion of blood beneath the pericranium. Inde- 
 pendently, however, of the pulsating character of the swelling formed by 
 hernia of the brain, its situation at one of the fontanelles, probably the 
 posterior, or in the course of One of the sutures, will generally distinguish 
 it sufficiently from these sanguineous tumors, which are almost always 
 seated on the parietal bone, and near to its protuberance. 
 
 While the nature of this affection was ill understood, many prac- 
 titioners regarded it as of very serious import, and thought that its cure 
 could be effected only by making a free incision into the tumor, and 
 emptying it of the effused blood, or else by applying caustic to its surface, 
 with the view of exciting suppuration within it. There is, however, no 
 real necessity for these severe measures, which appear in not a few 
 instances to have caused the death of the child ; for the blood will in the 
 course of a few weeks be absorbed, and the tumor diminish and disappear 
 of its own accord. The great difficulty, indeed, that you will encounter 
 will consist in persuading the parents to let the swelling alone, and to 
 wait till time effects its removal. While, however, the affection generally 
 requires no treatment, and is not attended by any danger, it is yet right 
 to bear in mind the possibility of internal as well as external effusion 
 having taken place ; in which case, as happened in an instance that came 
 under my notice, the sudden increase of the former may be followed by 
 apoplectic symptoms, and death. 
 
 Perhaps I may be pardoned if I digress for a moment to notice the 
 occasional pouring out of blood beneath the occipito-frontalis, or temporal 
 muscle in children as the result of a blow on the head. Unlike a bruise, 
 this effusion does not always take place at the precise spot where the 
 
 l A description of this case will be found at p. 397 of vol. xxviii. of the Medico- 
 Chirurgical Transactions. 
 
HEMORRHAGE INTO THE ARACHNOID. 51 
 
 injury was inflicted, but the greater size of the vessels that traverse the 
 skull at the side seems to be the reason why a shock, such as a fall on 
 the occiput, is sometimes succeeded by the formation of a tumor of this 
 kind at the side of the head, and not at the part which received the blow. 
 It has twice come under my notice under these circumstances. The 
 tumor thus formed is soft, painless, and fluctuating, and its size at first 
 increases very rapidly, but the integuments covering it are neither hot 
 nor discoloured. It is not surrounded by so well defined a ring as 
 circumscribes the swelling formed by the effusion of blood beneath the 
 pericranium ; the ridge is imperfect, its edge is much less sharp, and it is 
 often to be felt nowhere except near to the insertion of the temporal 
 muscle. 
 
 In this as in the other case nature herself is usually fully equal to 
 the removal of the blood, and the consequent dispersion of the 
 swelling. 
 
 Cerebral haemorrhage, though at no other time so frequent as imme- 
 diately after birth, may occur at any period of subsequent childhood, 
 under the influence of causes that favour congestion of the brain, or 
 even independently of any cause that we can discover. The hemor- 
 rhage still takes place almost invariably into the arachnoid cavity, and 
 blood is sometimes poured out there in very large quantity, but the 
 accident is neither so invariably nor so speedily fatal as in the new- 
 born infant. 
 
 If death should follow very soon after the occurrence of the effusion, 
 the blood is found unchanged, forming a more or less extensive layer 
 upon the convex surface of the brain, and extending downwards and 
 backwards towards the base of the organ, but seldom situated at its 
 anterior part unless the haemorrhage have been unusually profuse. If 
 life be prolonged, the clot speedily separates into serum and crassa- 
 mentum, and a series of changes commences in the latter, the effect of 
 which is to deprive it of its colouring matter, and to convert it, in 
 course of time, into a delicate false membrane, which lies in close appo- 
 sition with the parietal arachnoid. This transformation may sometimes 
 be observed while in course of progress, and a central clot may then 
 be seen gradually losing itself in a membrane that grows more and 
 more delicate towards its periphery. If, as occasionally happens, 
 successive effusions of blood take place at somewhat distant intervals, 
 this membrane may become thick and firm, and may even present a 
 pearly lustre ; which circumstance has led some observers into the 
 error of attributing the appearance to alteration and thickening of the 
 dura mater. The amount of the original effusion has much to do with 
 the rapidity of the changes in the clot. If the effusion were but incon- 
 siderable, the serum of the blood soon becomes absorbed, and no other 
 trace of the occurrence remains than the false membrane lining a 
 portion of the arachnoid. If the haemorrhage were at all abundant, 
 the reddish serum will, even after the lapse of a considerable time, be 
 very evident on opening the sac of the arachnoid, and some of it will 
 probably be found entangled in the substance of the clot. By degrees 
 the serum loses its colour, but its quantity may still continue for a long 
 time undiminished, or the efforts of nature may even entirely fail to 
 
52 OBSCURITY OP THE SYMPTOMS. 
 
 accomplish its absorption. The fluid in such cases is either simply 
 contained within the arachnoid cavity, or, having remained inclosed 
 within the clot during the changes which it underwent, appears at 
 length to be situated within a delicate cyst or shut sac. If the haemor- 
 rhage, in the first instance, were very considerable, or if it were to 
 recur two or three times, the yielding cranium of the child will enlarge, 
 the head will alter in form, and the case will assume many of the 
 characters of chronic hydrocephalus. 1 
 
 All writers, even those who, like MM. Rilliet and Barthez, have 
 thrown the most light on the anatomy and pathology of cerebral 
 haemorrhage in the child, concur in representing its symptoms as ex- 
 tremely obscure. Paralysis, which, in the grown person, is one of the 
 most frequent results of the escape of blood from the cerebral vessels, 
 is so rare in the child that it was observed by M. Legendre 2 only in 
 one out of nine cases, and by MM. Rilliet and Barthez 3 in one out of 
 seventeen cases. This peculiarity is doubtless in great measure 
 accounted for by the circumstance of the blood being almost always 
 poured out into the cavity of the arachnoid, so that the pressure which 
 it exerts on the brain is generally diffused over the surface of the 
 organ, and is no where very considerable. 
 
 The absence of paralytic symptoms, however, is not the sole cause 
 of the obscurity of these cases, but the indications of cerebral distur- 
 bance by which they are attended very greatly in kind as well as in 
 degree. The sudden occurrence of violent convulsions, and their 
 frequent return, alternating with spasmodic contraction of the fingers 
 and toes in the intervals, appear to be the most frequent indications 
 of the effusion of blood upon the surface of the brain. I need not say, 
 however, that such symptoms taken alone would by no means justify 
 you in inferring that effusion of blood had taken place. Many circum- 
 stances having reference to the previous history of the child, as well as 
 to its present condition, must be taken into account in forming a 
 diagnosis. Haemorrhage into the arachnoid cavity is most frequent in 
 early childhood, — symptoms such as have been enumerated then would 
 acquire additional diagnostic importance in proportion to the tender 
 age of the child in whom they occurred. The probability of their 
 betokening this accident would be still further strengthened if the child 
 who experienced them had previously suffered from frequent attacks of 
 cerebral congestion, or had been recently exposed to the sun without 
 proper covering to the head ; or had been placed in other circumstances 
 calculated to favour determination of blood to the head. 
 
 The popular notion that associates the idea of rude health and 
 general plethora with the occurrence of apoplexy in the adult, is in 
 many instances altogether fallacious. In the case of the child it has 
 
 1 Not having had the opportunity of observing the whole series of changes said to 
 take place in blood effused into the sac of the arachnoid, I have chiefly followed the 
 account given by MM. Rilliet and Barthez, in their Traite" des Maladies des Enfans, 
 vol. ii. pp. 32 to 42. 
 
 g Recherches Anatomo-Pathologiques sur quclques Maladies de l'Enfance, 8vo. Paris, 
 1846, p. 130. 
 
 3 Lib. cit., p. 43. 
 
ILLUSTRATIVE CASES. 53 
 
 still less foundation, since the effusion of blood upon the brain occurs 
 much more frequently in weakly children than in such as are robust. 
 There seems to be reason, indeed, for supposing that the haemorrhage 
 is sometimes of a purely passive character, and dependant on an altered 
 state of the blood. I will rekte to you a case or two as illustrations of 
 this cachectic form of cerebral haemorrhage. 
 
 Some years ago, I saw a little boy, five weeks old, the child of healthy 
 parents, and who had been perfectly well for the first fortnight after his 
 birth : he then, without any evident cause, grew drowsy, and vomited 
 often, and his skin became quite jaundiced. His abdomen at this time 
 was large and hard, and he cried when pressure was made on the right 
 hypochondrium : these symptoms still continued when he was brought 
 to me. A leech now applied on the right side drew a good deal of blood, 
 and the haemorrhage was stopped with difficulty ; the bowels, previously 
 constipated, were acted on by small doses of calomel and castor oil, and 
 in three days the child lost the yellow tinge of his skin, became cheerful, 
 and seemed much better. He was now, however, on the 18th of July, 
 suddenly seized with hurried respiration and great depression, soon fol- 
 lowed by violent convulsions, during which he screamed aloud. At the 
 same time it was observed that his left hand had begun to swell, and to 
 put on a livid hue, and on the 20th, the right hand also became ©edema- 
 tous. His whole surface grew quite sallow, and, on the day before he 
 died, the oedema of the left hand had much increased ; the livor had 
 become considerably deeper, and there were small spots of extravasatecl 
 blood over each knuckle. The right elbow was slightly livid; the right 
 hand much swollen, but of its natural colour ; and a small black spot 
 had appeared under the chin, corresponding to the knot of the cap-string. 
 The fits recurred very frequently, the child in the intervals lying quite 
 still ; the pupils were contracted, and the condition seemed to be one of 
 extreme exhaustion rather than of coma. On the 20th, the power of 
 deglutition was lost, and after several returns of less violent convulsions, 
 the child died at 9 A. M. on July 21st ; about sixty hours after the 
 occurrence of the first fit. 
 
 The sinuses of the brain were full of fluid blood; a black coagulum, 
 three or four lines thick, covered the whole posterior part of both hemi- 
 spheres, extending from the posterior third of the parietal bones, occu- 
 pying the whole concha of the occipital bone, and reaching along the 
 base of the skull to the foramen magnum. A little blood- was likewise 
 effused about the anterior part of the base of the brain, though the 
 quantity was very small in comparison with what was found at its 
 posterior part. The substance of the brain was very pale, and all the 
 organs of the body were anaemic, except the liver, which was gorged 
 with fluid blood, while the heart was quite empty. The ductus arte- 
 riosus was closed, the foramen ovale admitted a probe with ease, the 
 ductus venosus admitted one with difficulty. 
 
 Another instance has since then come under my notice, in which 
 passive haemorrhage took place into the arachnoid in a child exhausted 
 by long-continued illness, the effects of which were aggravated by poverty 
 and want. From the age of two to that of five months the child had 
 been under my care in consequence of frequent attacks of haematemesis 
 
54 HEMORRHAGE INTO THE SUBSTANCE OF THE BRAIN. 
 
 and purging of blood, and though his health afterwards improved, yet he 
 never became strong, and his evacuations were almost always white, and 
 deficient in bile. After he was weaned, the coarse food which his indi- 
 gent parents gave him did not nourish him; he lost flesh and strength, 
 and when almost three years old was puny and emaciated. Three days 
 before his death an attack of diarrhoea came on, which induced great 
 exhaustion; and while suffering from this affection, he suddenly became 
 comatose, cold, and almost pulseless, and his breathing became so slow 
 that he inspired only four or five times in a minute. In this state he 
 lay for twenty-four hours, and then died quietly. Nearly six ounces of 
 dark coagulated blood were found in the sac of the arachnoid, over the 
 right hemisphere of the brain; a little blood was likewise effused beneath 
 the arachnoid, and there was a very small clot in the lower and front 
 part of the right middle lobe of the brain, but no ruptured vessels could 
 be perceived. Great anaemia of every organ, and a state of extreme 
 attenuation of the walls of the heart, were the only other remarkable 
 appearances. 
 
 Haemorrhage into the substance of the brain, though extremely rare in 
 infancy and childhood, does sometimes occur, and then gives rise to 
 appearances similar to those with which we are familiar in the adult. 
 Death, however, usually takes place too speedily in these cases for any 
 of those changes to occur in the apoplectic effusions which are often 
 observed in the adult, and which betoken the advance that nature has 
 made in her efforts to repair the injury of the brain. 
 
 I have only twice met with distinct extravasation of blood into the 
 substance of the brain in children. In the first case, that of a little girl 
 11 months old, the occurrence was evidently due to the impediment to 
 the circulation through the brain produced by an attack of inflammation 
 of the sinuses of the dura mater. In addition to other appearances 
 which I shall describe in a future lecture, there was great venous conges- 
 tion of the membranes covering the middle lobe of the left hemisphere 
 of the brain, and the cerebral veins were distended with coagula, and 
 their coats were thickened. At the anterior part of the lower surface of 
 the left middle lobe of the brain there were four apoplectic effusions, in 
 all of which the blood still retained its natural colour, and each effusion 
 was situated close to an obliterated and distended vein. The largest 
 clot extended for an inch into the substance of the brain, the others 
 were of smaller dimensions. Head symptoms, as might be expected, had 
 existed in this little child for a long time before her death. The occur- 
 rence of the effusion was probably synchronous with a sudden attack of 
 extreme faintness that came on forty-eight hours before she died, and 
 from which she never completely rallied. 
 
 The other instance of hsemorrhage into the substance cf the brain 
 occurred in a girl 11 years old, the child of healthy parents, and whose 
 own health had been quite good until she was six years of age. At that 
 time the extraction of a molar tooth was followed by necrosis of a large 
 portion of the lower jaw, and by the formation of abscesses on the face 
 and head, from which bone escaped. An abscess, attended with simi- 
 lar exfoliation of bone, formed likewise on the right foot, and it was 
 three years before the child had recovered completely. Though much 
 
ILLUSTRATIVE CASES. 55 
 
 disfigured by the disease, her health ever after continued good until 
 April 12th, 1846. She was then suddenly and causelessly attacked 
 with vomiting and pain in the head, for which no other treatment was 
 adopted during ten days than the occasional administration of an 
 aperient. During this time, however, a condition of stupor gradually 
 stole over the child, for which, on April 21st, a blister was applied to 
 the back of her neck with great relief. On April 23d she had two 
 attacks of convulsions, with an interval of four hours between each. 
 She struggled much during their continuance, especially with the right 
 side ; when they subsided, partial palsy of the left side remained : the 
 child complained much of her head, and sank from time to time into a 
 state of stupor, from which, however, she could always be roused. 
 Very free purgation on the 24th of April, and the application of another 
 blister to the back of the neck, were followed by some amendment. On 
 the evening of the 25th another fit occurred, with symptoms similar to 
 those that had been observed on the previous occasions ; but it was not 
 followed by any increase in the palsy of the left side, nor was the 
 degree of stupor so considerable as on the former occasion. Mercurials, 
 which had been employed from the commencement of the attack, had 
 now produced a decided influence on the mouth, and the abundant 
 action of the bowels was again succeeded by much improvement in the 
 child's condition. The pulse, which had varied from 60 to 70, now 
 continued about 70, and was natural in character, and the child im- 
 proved daily, though taking no other medicines than occasional aperi- 
 ents. The headache returned occasionally, though each time it was less 
 severe than the time before ; but on the evening of May 15th, this 
 amendment was suddenly interrupted by an attack of violent pain in 
 the abdomen, which, was soon followed by convulsions and coma, and 
 the child died convulsed in sixteen hours ; on the 36th day from the 
 first attack of pain in the head. 
 
 On making an examination of the head, permission for which was 
 obtained with difficulty, blood was found to be effused into the sub- 
 arachnoid tissue over a great part of the right hemisphere of the brain. 
 The quantity of blood, however, was no where very considerable, but 
 merely occupied the sulci between the convolutions. The brain pre- 
 sented no remarkable appearance, except that on a level with, and just 
 exterior to the right lateral ventricle, there was a large clot of blood, 
 rather larger than a hen's egg, but of more irregular shape, around 
 which the brain was softened. This effusion was perfectly black through- 
 out, the coloring particles, of the blood being equally diffused through it,, 
 and no appearance betokened that haemorrhage had previously taken 
 place in this situation. The anterior cerebral artery ran for a conside- 
 rable distance just outside the clot, but it could not be ascertained that 
 it had given way at any point. 
 
 Cerebral haemorrhage is one of the few affections of early life con- 
 cerning the treatment of which but little can be said ; for where the 
 symptoms of a disease are so obscure, it would be idle laying down 
 elaborate rules for its cure. The general principles, according to which 
 you would manage a case of congestion of the brain, would still guide 
 you if haemorrhage had taken place. It cannot, however, be necessary 
 
56 CAPILLARY HEMORRHAGE. 
 
 for me to repeat to-day the observations on that point to which I 
 Yesterday directed your attention. 
 
 Before concluding, I must for a moment refer to a form of cerebral 
 hemorrhage, which, though of no great importance, yet forms an excep- 
 tion to what has been stated as to the rarity of the accident in early 
 life. In children who have been affected with tubercular disease of the 
 brain, it is by no means unusual to observe very small effusions of blood 
 in the midst of the softened cerebral matter that surrounds the deposit. 
 This capillary apoplexy, produced by some of the minute vessels of the 
 brain giving way, is, however, seldom extensive, and probably has but 
 little share even in accelerating the fatal event. 
 
 When next we meet, we shall pass from this subject, which, it must 
 be owned, has more of a pathological than of a practical interest, and 
 shall enter on the study of the inflammatory affections of the brain in 
 childhood. 
 
 LECTUEE V. 
 
 Inflammatory Affections of the Brain — frequent in childhood, but overlooked by 
 early writers — first noticed about a century ago — described under the name of acute 
 hydrocephalus, by Dr. Whytt. 
 
 Acute Hydrocephalus — progress of knowledge with reference to it. — The name re- 
 stricted in these lectures to scrofulous inflammation of the brain, which is much more 
 frequent than its simple inflammation in childhood. 
 
 Morbid appearances in acute hydrocephalus — due either to inflammation or to tuber- 
 cular deposit — alterations more apparent in the membranes at the base of the brain 
 than in those of its convexity. — Reasons for considering granulations of the mem- 
 branes as tubercular. — Increase of fluid in the ventricles almost invariable. — Central 
 softening of the brain not a post-mortem alteration — frequently connected with 
 changes in the lining of the ventricles. 
 
 Symptoms of the three stages of the disease. 
 
 Few of the diseases of childhood are more serious than those inflam- 
 matory affections of the brain on the examination of which we are now 
 about to enter. They occasion 9.8 per cent, of all deaths under 
 five years of age in this metropolis, while they are so especially the 
 diseases of early life, that 814 per cent, of all cases of fatal inflamma- 
 tion of the brain occur in children under five years of age, 90.2 per 
 cent, before the age of 10, and 92*4 per cent, before the age of 15. 1 
 
 But though the frequency of these affections in the young is a matter 
 of such popular notoriety that most of you were familiar with the fact 
 long before you were engaged in your present profession, yet if you 
 turn to the writings of any of the old physicians, you will find in them 
 no mention of inflammation of the brain in childhood. At first this 
 may surprise you, but a few moments' consideration will explain the 
 seeming oversight. Convulsions, which form a prominent symptom in 
 most cases of inflammation of the brain, occur, as I need not remind 
 
 1 Deduced from 5th and 8th Reports of Registrar-General for 1842-5. 
 
INFLAMMATORY AFFECTIONS OF THE BRAIN. 57 
 
 you, in the course of many other affections of the nervous system. An 
 accident so alarming as a fit of convulsions is sure to attract attention, 
 but much careful examination is often needed to distinguish those minor 
 differences between the symptoms which precede or accompany it, that 
 alone would indicate the cause to which it is due. It cannot, then, be 
 surprising, that in the absence of this minute care, many diseases, 
 though differing in most important particulars, should have long been 
 classed together under the head of convulsions, and that inflammation 
 of the brain should not have been recognized as a distinct affection. 
 The importance of some of those less obvious structural changes which 
 we know to be most significant of the nature of previous diseases was 
 not then understood, so that an alteration in the consistence of the 
 brain, or a diminution in the transparency of its membranes, often 
 passed unnoticed : and anatomical research was not exact enough to 
 make up for the deficiencies in clinical observation. 
 
 But just as the physician's attention was fixed on the convulsive 
 seizures which in so many cases affected his patients, so the eye of the 
 anatomist was often arrested by the discovery of a large quantity of 
 fluid in the interior of the brain. Sometimes this fluid had been 
 secreted in such quantity as not only to distend the ventricles of the 
 brain, but to occasion a manifest enlargement of the skull. In such 
 cases the disease was essentially chronic in its course, and was called, 
 from its most striking characters, dropsy of the brain, or chronic 
 hydrocephalus. 
 
 Speculation, however, was set afloat by the occasional notice of cases 
 in which, though fluid was found in large quantity within the brain, yet 
 the previous disease had been of short duration, its symptoms had been 
 acute, and the fever, drowsiness, and cerebral disturbance which attended 
 it, had run a very rapid course to their fatal termination. Dr. Whytt 
 was the first 1 who, in the year 1768, clearly pointed out the connexion 
 between these symptoms and the accumulation of fluid in the ventricles. 
 His attention, like that of previous observers, was mainly fixed on this 
 point, to the exclusion of other morbid appearances, and he was thus led 
 to regard the disease as an acute dropsy of the brain. Little can even 
 now be added to his description of the malady, but further observation 
 has shown that the presence of an increased quantity of fluid in the 
 brain, on which he laid so much stress, is not of invariable occurrence ; 
 that there is no certain relation between the amount of the fluid and the 
 intensity of the symptoms, or the rapidity of their course ; and that it 
 is almost always associated with other very important lesions, some of 
 which are the evident results of inflammation. Many years were occu- 
 pied in the investigations which led to this conclusion, so that long be- 
 fore Whytt's theory had been ascertained to be erroneous, people had 
 grown familiar with the name which he proposed for the disease, and 
 in this country it is still called hydrocephalus, or acute hydrocephalus. 
 
 A most important step towards a knowledge of the true pathology of 
 this disease, was the discovery that the fluid poured out into the ven- 
 tricles is not a mere dropsical effusion, but that it is the result of 
 
 1 In his Observations on the Dropsy in the Brain, 8vo. Edin. 1768. 
 
58 SCROFULOUS INFLAMMATION, OR ACUTE HYDROCEPHALUS. 
 
 previous inflammatory action. A difficulty, however, appeared when it 
 was ascertained that in those cases in which the signs of inflammation 
 of the brain were most evident during life, and its effects most marked 
 after death, both the symptoms and the morbid appearances differed in 
 some respects from those usually observed in Whytt's disease. The 
 almost invariable existence of a very obvious tendency to scrofula in 
 well-marked instances of Whytt's disease, and its frequent absence in 
 other cases of inflammation of the brain, did much towards solving this 
 difficulty. It was next discovered that in nearly every instance in 
 which Whytt's disease terminates fatally, tubercle is present in 
 greater or less abundance in various organs of the body ; and to the 
 acuteness of French anatomists we owe the last step in this investigation, 
 by which it has been shown that in the majority of cases the membranes 
 of the brain themselves are the seat of tubercular deposite. 
 
 We are thus led to the conclusion that inflammation of the brain 
 occurs in early life under two different conditions. It now and then 
 comes on in previously healthy children, but occurs much ofcener in 
 connection with the tuberculous cachexia, or as the result of tubercular 
 deposite in the brain or its membranes. The term encephalitis may be 
 properly used to denote the cases of simple inflammation of the brain, 
 while we may with advantage restrict the term acute hydrocephalus to 
 cases of cerebral inflammation in scrofulous subjects. Owing to the 
 extreme rarity of the former affection, it will, I think, be our better 
 plan first to study minutely all the characters of acute hydrocephalus, 
 and then to examine the points of difference between simple and 
 scrofulous inflammation of the brain. 
 
 W r e will commence this investigation with an inquiry into the nature 
 of the appearances found after death in cases where acute hydrocephalus 
 has had a fatal termination. These may be divided into two classes, 
 according as they are the result of inflammation or of the deposite of 
 tubercle ; and changes due to both of these causes are often found in 
 the membranes of the brain as well as in its substance. 
 
 The appearances which present themselves on the skull being opened 
 are seldom very striking, for the dura mater is usually healthy, and 
 the changes in the arachnoid are not in general of a kind at once to 
 attract attention. Sometimes, indeed, the eye is struck by an excessive 
 vascularity of the membranes, but this appearance often depends on 
 the overfilling of the large vessels as the result of position. Attentive 
 examination will usually enable us to distinguish between this, and 
 that increase of vascularity which is produced by a uniform injection of 
 the minuter vessels ; and moderate pressure, while it causes the 
 disappearance of the apparent vascularity in the former case, will 
 produce no effect on the true congestion in the latter. 
 
 The secretion that naturally moistens the sac of the arachnoid is 
 altered, increased, or suppressed; but the last of these changes is the 
 most frequent, while the first is seldom observed in cases of hydro- 
 cephalus. The preternatural dryness of the membrane is usually 
 connected with some diminution of its natural transparency ; it looks 
 dull and lustreless, and feels sticky, — a state to which the French have 
 applied the term "poisseux." The dulness of the_arachnoid is some- 
 
ACUTE HYDROCEPHALUS — MORBID APPEARANCES. 59 
 
 times more considerable, and it then presents an opaline appearance, 
 which is very evident at those parts where the membrane passes from 
 one convolution to another. This opalescence is not often general, but 
 is usually most marked about the upper part of the hemispheres, and 
 in the neighbourhood of the longitudinal fissure. 
 
 When any considerable degree of vascularity of the membranes is 
 evident, this is, of course, chiefly due to the injection of the minute 
 vessels of the pia mater. Such intense injection of the pia mater is, 
 however, far less frequent than the effusion of fluid between it and the 
 arachnoid, and it is still less common to find the two appearances in 
 the same subject. The effused fluid is for the most part colourless and 
 transparent, and if present in any considerable quantity, the surface 
 of the convolutions then appears as if covered by a layer of transparent 
 jelly, though on puncturing the membrane a drop of clear serum will 
 exude. The effusion of lymph or pus into the pia mater covering any 
 considerable extent of the convexity of the brain is very seldom met 
 with, but deposits of a yellow puriform lymph are not infrequently seen 
 occupying the depressions between the convolutions, or following the 
 course of the vessels along the sides, or at the upper surface of the 
 hemispheres. 
 
 But though the alterations presented by the membranes at the con- 
 vexity of the brain are often comparatively trivial, the membranes at the 
 base of the organ almost always show unequivocal traces of inflam- 
 matory action. The predominance of the affection of the membranes 
 at the base of the brain has indeed been regarded by some writers as 
 pathognomonic of scrofulous inflammation of the organ j 1 and though 
 this rule is not without exception still it holds good in the vast majority 
 of cases. In 30 out of 35 fatal cases of acute hydrocephalus, in which 
 I carefully recorded the condition of the membranes, those at the base 
 of the brain were found to be the seat of disease more or less extensive, 
 and always more considerable than that which existed at the vertex. 
 In one of the cases in which the membranes at the base w T ere healthy, 
 there was a good deal of serous effusion beneath the arachnoid at the 
 convexity ; and in another instance there was some fluid in the sac of 
 the arachnoid, and the pia mater covering the upper surface of the 
 brain was greatly injected; but in the two remaining cases the mem- 
 branes at the upper, as well as those at the lower part of the brain, 
 were perfectly healthy. 
 
 The least considerable of the morbid changes in the membranes at 
 the base of the brain consists in a milky or opaline condition of the 
 arachnoid and pia mater, but chiefly of the former, sometimes extending 
 over the whole lower surface of the cerebrum, but seldom being equally 
 apparent in that part of the membrane which invests the cerebellum. 
 But, besides this opacity, we usually observe much more distinct evi- 
 dence of inflammatory action in the effusion of yellow lymph beneath 
 the arachnoid. This is generally found about the olfactory nerves, 
 
 1 On which subject the valuable essay of M. Rilliet, De l'lnflammation franche des 
 Meninges chez les Enfants, in the Archives de Medecine, for Dec. Jan. and Feb. 1846-7, 
 may be consulted with advantage. 
 
60 GRANULATIONS OF THE MEMBRANES. 
 
 which are often completely imbedded in it, while a similar effusion 
 extending across the longitudinal fissure unites the two hemispheres of 
 the brain together. A deposit of the same kind likewise reaches up the 
 fissure of Sylvius in many cases, and connects the anterior and middle 
 lobes of the brain with each other ; or if poured out in less abundance, 
 it may be seen running up in narrow yellow lines by the side of the 
 vessels as they pass from the base of the brain towards its convexity. 
 It is in the neighbourhood of the pons Varolii, however, and about the 
 optic nerves, that the most remarkable alterations are met with. The 
 opacity of the arachnoid is here particularly evident, while the subjacent 
 pia mater is opaque, much thickened, and often infiltrated with a pecu- 
 liar semi-transparent gelatinous matter, sometimes of a dirty yellowish- 
 green colour. This matter is sometimes so abundant as perfectly to 
 conceal the third and fourth nerves, and at the same time to invest the 
 optic nerves with a coating two or three lines in thickness ; though, on 
 being dissec f ed off, the substance of the nerves beneath appears quite 
 healthy. When this morbid condition exists in any very considerable 
 degree it extends beyond the pons, and involves the membranes covering 
 the medulla oblongata, especially at its anterior surface. 
 
 It is only within the past sixteen or seventeen years that attention 
 has been drawn to the importance of another element besides mere 
 inflammation, in the production of acute hydrocephalus. The peculiar 
 granular appearances which various parts of the membranes of the brain 
 often present in this disease, though noticed many years before, began 
 then to engage the special attention of several French physicians. 1 
 The conclusion to which we are led by their careful investigation of the 
 subject, is, that this appearance is not due to inflammation, as was once 
 supposed, but that it is occasioned by the presence of tubercular deposits. 
 These deposits often assume the form of minute, flattened, spherical 
 bodies of the size of a small pin's head, or smaller, and either of a yel- 
 lowish colour, and rather friable under pressure, or greyish, semi-trans- 
 parent, and resistant, almost exactly resembling the grey granulations 
 which are sometimes seen in the lungs or pleurge of phthisical subjects, 
 They are likewise sometimes met with in what would seem to be an 
 earlier stage, when they'appear like small opaque spots of a dead white 
 colour, much smaller than a pin's head, and communicating no percep- 
 tible roughness to the membrane. This appearance is often observed 
 in the arachnoid covering the cerebellum, and those parts of the base 
 of the brain where the arachnoid is stretched across from one part of 
 the organ to another. The flattened yellowish bodies are most fre- 
 quently seen at the convexity of the brain, and on either side of the 
 hemispheres. They generally follow the course of the vessels that 
 ramify in the pia mater, and accordingly occupy the sulci between the 
 convolutions much oftener than their summit. The firm grey bodies are 
 mostly seen about the pons, or imbedded in the pia mater in the 
 neighbourhood of the optic nerves, or projecting from the surface of the 
 
 1 M. Papavoine appears to have been the first who, in the Journal Hebdomadaire for 
 1830, vol. vi. p. 113, clearly established the tubercular nature of these granulations of 
 the membranes of the brain. 
 
TUBERCULAR NATURE OF THE GRANULATIONS. 61 
 
 membranes that cover the medulla oblongata. They are also often 
 deposited in the arachnoid lining the occipital bone, and are then some- 
 times collected in considerable numbers around the foramen magnum. 
 These bodies, sometimes of a grey, at other times of a yellow colour, 
 are likewise met with, though less frequently, in the substance of the 
 velum interpositum, or imbedded in the choroid plexuses, and in both 
 of these situations they are sometimes very abundant. 
 
 These bodies, however, do not always retain the appearance of distinct 
 granules, but sometimes on separating two folds of the arachnoid which 
 had seemed to be glued together by an effusion of yellow lymph or con- 
 crete pus, we find that the matter which forms these adhesions is not 
 homogeneous, but that it consists of an aggregation of minute granular 
 bodies connected together by the lymph or pus in which they are im- 
 bedded. This appearance is often met with at the convexity of the 
 brain, and close to the longitudinal fissure, and rather more towards 
 its posterior than its anterior part ; a strip of this yellow matter, half 
 an inch long by two or three lines broad, connecting together the two 
 hemispheres of the brain or the two surfaces of the arachnoid. Some- 
 times two or three deposits of this kind are observed at the convex 
 surface of the brain, but they are generally more extensive at the base 
 of the organ, where they occupy the longitudinal fissure and the fissure 
 of Sylvius, and frequently connect opposite surfaces of the brain so 
 closely together as to render their separation impossible without injury 
 to its substance. But you may ask me for the proof of these granular 
 bodies being, as I have represented them to be, real tubercular deposits. 
 It would occupy nearly the whole of this lecture to detail all the argu- 
 ments that have been adduced on both sides of the question, for it is a 
 question which has been much disputed ; some persons being disposed 
 to regard them merely as products of inflammation. 
 
 The reasons which appear to me to be conclusive in favour of the 
 tubercular nature of these bodies, are — 
 
 1st. That they are always associated with tubercle elsewhere. 
 
 2d. That their abundance is not in proportion to the amount of 
 inflammatory mischief. 
 
 3d. That they are sometimes met with in cases where no head symp- 
 toms were observed during life, and unconnected with any sign of 
 inflammation discovered after death ; and 
 
 4th. That their chemical composition and their microscopic structure 
 are identical with those of tubercle in other organs of the body. 1 
 
 Notwithstanding the important nature of the changes presented by 
 the membranes of the brain in cases of acute hydrocephalus, it was 
 long before they attracted as much attention as the alterations in the 
 substance of the brain itself, and especially as that distension of its 
 cavities with fluid from which the malady has derived its name. The 
 surface of the brain, indeed, generally presents but few traces of disease, 
 though sometimes the convolutions are greatly flattened, and the sulci 
 
 1 With reference to these two points, see Becquerel, Recherches Cliniques sur la 
 Meningite des Enfans, 8vo. Paris, 1838, p. 20 ; and Lebert, Physiologie Pathologique, 
 &c. 8vo. Paris, 1845, vol. i. p. 440-449. 
 
62 SOFTENING OF THE CEREBRAL SUBSTANCE. 
 
 between them almost obliterated by the pressure of the fluid from 
 within. The cerebral substance is often healthy as low down as the 
 centre of Vieussens, or presents no change more important than the 
 presence of an unusual number of bloody points, the divided cerebral 
 vessels. But, though unaltered to the eye, a diminution of consistence 
 is often perceptible as the ventricles are approached. Sometimes the 
 whole brain seems softer than natural, while at other times, though not 
 actually softened, it is infiltrated with fluid, as though it had soaked up 
 the serum from the ventricles. 
 
 The presence of a larger quantity of fluid than natural in the lateral 
 ventricles is of almost constant occurrence. In 34 out of 36 cases in 
 which death had taken place under the symptoms of acute hydroce- 
 phalus, I found an appreciable quantity of fluid in the ventricles ; and 
 in 32 of these cases the quantity was considerable, amounting to several 
 ounces. The fluid is in general a perfectly transparent serum, resem- 
 bling passive effusions poured out from other serous membranes ; and 
 such it doubtless is in many cases in which it is found distending the 
 lateral ventricles. But, in a large proportion of instances of hydroce- 
 phalus, the increased secretion in the ventricles is associated with a 
 very notable change in the surrounding cerebral substance. This 
 change consists in a loss of the natural firmness of the central parts of 
 the brain, which varies in degree from a slight diminution of consistence 
 to a state of perfect diffluence, in which their texture becomes perfectly 
 disorganized, and they form a pulpy mass that is easily washed away 
 by a stream , of water ; or the softening may be even more considerable, 
 and the cerebral matter may become semifluid, and may closely resem- 
 ble thick cream. The parts thus affected are perfectly pale and blood- 
 less, and the cerebral substance in the neighbourhood is usually rather 
 ansemic. The fornix, septum lucidum, corpus callosum, and posterior 
 horn of the lateral ventricles, are the parts most frequently affected ; the 
 optic thalami, corpora striata, and lower parts of the middle and pos- 
 terior lobes of the brain, rank next in this respect, while the anterior 
 lobes are but seldom softened. In a few instances the cerebellum is 
 involved in the softening, and now and then the whole brain is found 
 to. have lost much of its natural firmness, — a change, however, which is 
 usually much more marked on one side than the other. Closely allied to 
 this softening is the state to which I have already referred, wherein the 
 wdiole brain appears perfectly infiltrated with serum, as though it had 
 been long soaked in it, and had imbibed it like a sponge. 
 
 A mechanical explanation has been frequently suggested to account 
 both for this appearance and the central softening of the brain, which 
 you will observe is most marked in those very parts to which the fluid 
 in the ventricles would naturally gravitate after death. Many facts, 
 however, are opposed to this view of the cause of softening of the brain. 
 If it were a change induced by the imbibition of fluid after death, we 
 should expect to find it as constant as is hypostatic congestion of the 
 lungs; but instead of this being the case, fluid is found in many 
 instances in the ventricles without the consistence of the brain being in 
 the least diminished. In a recent work on Acute Hydrocephalus, which 
 embodies the results of a very large number of dissections, it is stated 
 
SOFTENING NOT DUE TO IMBIBITION OF FLUID, 63 
 
 that central softening of the brain existed only in 47 out of 71 instances, 
 in which the ventricles contained a quantity of serum varying from 3 
 to 11 ounces. 1 In my records of the examination of the brain in hydro- 
 cephalus, I have preserved an accurate account of the condition of the 
 cerebral substance in 34 cases, and find that in 12 instances there was 
 not the least central softening, although the ventricles contained fluid 
 in every case but one, and the quantity amounted on seven occasions 
 to several ounces. M. Louis, too, mentions in his work on Phthisis, 3 
 that in 75 out of 101 tubercular subjects, each ventricle contained a 
 quantity of fluid varying from half an ounce to two or three ounces, 
 but yet in only 6 of these 101 cases were the central parts of the brain 
 at all softened. And, not to dwell on any other arguments which might 
 be adduced, it may be added that M. Rokitansky has subjected the 
 supposed hygroscopic property of the brain to the test of experiment, 
 and found that no change whatever was produced in slices of cerebral 
 matter by soaking them for hours in serum. 
 
 But if we reject the theory of this change in the brain being a mere 
 post-mortem occurrence, the question still remains, to what is it due ? 
 M. Rokitansky regards it as a condition of acute oedema of the brain, 
 often, though not invariably, associated with inflammation, since its 
 products, pus and exudation corpuscles, are usually found in the broken- 
 down or infiltrated nervous matter. 
 
 One very strong proof of the close connection that subsists between 
 softening of the brain and an inflammatory process going on in the 
 organ, is furnished by the changes which in many of these cases may 
 be observed in the lining membrane of the ventricles. In 20 cases of 
 acute hydrocephalus, in which central softening of the brain co-existed 
 with the presence of fluid in the ventricles, accurate notes were taken 
 of the condition of their lining, and in three instances only was it found 
 to be healthy. In one of these three cases the central softening was 
 very inconsiderable, and in the other two cases the softening of the 
 central parts was associated with very marked softening of other parts 
 of the brain, which were altered in colour as well as in consistence. 
 The lining of the ventricles in the remaining 17 cases was notably 
 altered, although the degree of its change was very variable. The first 
 alteration that takes place in it is the loss of its transparency, which is 
 often, though not always, associated with a turgid state of its vessels. 
 It next acquires an unnatural toughness, so that it can be raised by the 
 point of the scalpel : and sometimes it is not merely opaque and tough, 
 but greatly thickened, forming a dense firm membrane ; and once or 
 twice I have noticed its inner surface present a slightly granular ap- 
 pearance. These changes in the membrane do not bear any certain 
 relation to the quantity of fluid or to the degree of central softening, 
 though it is rare to find an extreme degree of change in the lining of 
 the ventricles without a considerable quantity of fluid in their cavity 
 and great softening of the brain around them. 3 
 
 1 Beobachtungen und Bemerkungen iiber den rasch verlaufenden Wasserkopf. Von 
 K. Herrich. 8vo. Regensburg, 1847, p. 161, g 126. 
 
 2 Recherches surla Phthisic 2de eU 8vo. Paris, 1843, p. 160, g 161. 
 
 3 The subjoined note contains an analysis of my dissections of 36 cases of acute 
 
64 BUT THE RESULT OF INFLAMMATION. 
 
 It happens sometimes that we find large patches of tubercular matter 
 deposited beneath the membranes on the convex surface of the brain, 
 and extending to the depth of about a line into its tissue, in children 
 who have died of acute hydrocephalus. Now and then, also, masses of 
 tubercle, of a spheroidal shape, and of various sizes, are found imbedded 
 in the cerebral substance. This latter appearance, however, is not 
 frequent ; it existed only in three out of the thirty-six cases on which I 
 have founded my remarks on the morbid anatomy of acute hydroce- 
 phalus ; and even in these cases peculiar symptoms existed which during 
 the lifetime of the patient led to the suspicion of the disease being 
 something else than an ordinary attack of water on the brain. 
 
 The complications of hydrocephalus consist almost entirely in the 
 deposit of tubercle in many organs of the body, and in various results 
 to which that tubercular deposit may have given rise. The lungs and 
 
 hydrocephalus, as far as respects the presence of fluid in the ventricles, the state of 
 their lining membrane, and the condition of the cerebral substance ; particulars the 
 mutual relation of which to each other have not yet been fully investigated. 
 
 In 12 of these 36 cases there is no express mention of the condition of the lining of 
 the ventricles. 
 
 In 2 the state of the cerebral substance is only imperfectly described. 
 
 In 84 the condition of the cerebral substance was carefully noted, and in 12 of these 
 cases the brain was not softened at its centre. 
 
 In 1 of these 12 cases the ventricles contained no fluid. 
 
 very little, 
 not above 1 oz. 
 l-£ oz. 
 
 3 oz. 
 
 4 oz. 
 6 oz. 
 a considerable quantity. 
 
 In 4 of these 12 cases the state of the lining of the ventricles^ is likewise expressly 
 described. 
 
 In 1, in which there was no fluid in the ventricles, and in 1 in which there was very 
 little fluid, their lining was not altered. 
 
 In 1, in which there was no fluid, the choroid plexuses were beset with tubercular 
 granulations. 
 
 In 1, in which there were 4 oz. of fluid, their lining was slightly opaque. 
 
 In 10 of these 12 cases the consistence of the cerebral substance was everywhere 
 natural. 
 
 In 1 the brain was generally firmer than usual. 
 
 In 1 the anterior parts of both posterior cerebral lobes, and the whole of the cere- 
 bellum, were softened, — changes which were most evident on the left side. 
 
 In 22 cases the central parts of the brain were softened. 
 
 In 8 of these 22 cases the softening was but slight at the centre. 
 
 In 1 of these 8 cases the substance of the brain elsewhere was healthy : six ounces 
 of fluid in the ventricles, their lining healthy. 
 
 In 2 of these 8 cases the substance of the brain elsewhere was healthy : four ounces 
 of fluid in the ventricles, their lining granular ; and lymph was in one of the cases 
 adherent to the choroid plexuses. 
 
 In 1 of these 8 cases the substance of the brain elsewhere was healthy ; much fluid in 
 the ventricles, their vessels large, choroid plexuses turgid. 
 
 In 1 of these 8 cases the substance of the brain elsewhere was healthy ; much fluid 
 in the ventricles, their lining opaque, and vessels turgid. 
 
 In 1 there was much yellow softening of the anterior and lower half of the middle 
 lobes, greater in degree and extent on the left side ; not above half an ounce of fluid in 
 the ventricles. 
 
 In 1, the substance of the brain generally was very vascular, the lining of the ven- 
 tricles tough ; there was some softening of each posterior horn ; considerable of the 
 left ; which moreover contained a good deal of fluid, great effusion of lymph, and hya- 
 line matter at base of the brain. 
 
ACUTE HYDROCEPHALUS — 65 
 
 the bronchial glands are the parts most frequently and most seriously 
 invaded by the tubercular deposit; the spleen, liver, mesenteric glands, 
 and intestines, rank next in frequency as the seat of tubercle. The 
 complication of hydrocephalus with tuberculous ulceration of the intes- 
 tines is one which, though not very frequent, must not be lost sight of, 
 since its existence may give rise to diarrhoea, and thus lead to an error 
 of diagnosis on your part, if you look for constipation of the bowels as 
 an invariable symptom of water on the brain. 
 
 But let us now pass to the examination of the symptoms of acute hy- 
 drocephalus. We cannot, however, do more to-day than familiarize 
 ourselves with the main features of the disease, and must leave all 
 attempts at filling up the outline to our next meeting. 
 
 The first or premonitory stage of the affection is attended with many 
 indications of cerebral congestion, coupled with general febrile dis- 
 turbance, and presenting exacerbations and remissions at irregular 
 periods. The child becomes gloomy, pettish and slow in its movements, 
 and is little pleased by its usual amusements. Or, at other times, its 
 spirits are very variable ; it will sometimes cease suddenly in the midst 
 
 And, lastly, in 1, the anterior horn of the left, and the posterior of the right ventricle, 
 •were softened • the ventricles contained four ounces of clear fluid ; their lining was 
 granular, much thickened, and its vascularity increased. 
 
 In 14 instances the central softening was considerable. 
 
 In 4 of these 14 cases the cerebral substance elsewhere was softened also. 
 
 In 1 of these 4 cases, both posterior lobes were softened, especially the right, and 
 the brain there had an uniform yellowish white colour. 
 
 In 1 of these 4 cases, the brain was very vascular down to the centre of Vieussens ; 
 the lower and posterior third of left posterior lobe was of a yellowish white colour, and 
 quite fluid. Six ounces of fluid in the ventricles. Cerebellum soft. 
 
 In 1 of these cases, there was great congestion of the brain, and general softening, 
 increased towards the centre. Much turbid reddish fluid in the ventricles. 
 
 In the last of these 4 cages the cerebral substance was natural down to the centre of 
 Vieussens, but below it was greatly softened, especially on the left side, where the grey 
 and white matters were scarcely distinguishable from each other. 
 
 In 5 other cases the lining of the ventricles was altered, but there was no softening 
 except at the centre. 
 
 In 2 it had lost its polish, and was slightly thickened. Six ounces of fluid in the 
 ventricles in one instance, and only two in the other. 
 
 In 1 it was thickened and dull. Much fluid in the ventricles. 
 
 In 1 it was opaque and thickened. Much fluid in the ventricles. 
 
 In 1 there were only three ounces of fluid in the ventricles, but their lining partook 
 of the general softening ; the central parts of the brain being almost diffluent. 
 
 In 5 instances the lining of the ventricles was altered, and the cerebral substance 
 elsewhere softened, viz. : — 
 
 In 1 the whole brain was softened ; the thalami optici were of a gelatinous consis- 
 tence for a quarter of an inch deep : there was much fluid in the ventricles, and their 
 lining was opaque. 
 
 In 1 there was increased vascularity and general softening of the cerebrum and cere- 
 bellum ; much fluid in the ventricles, and their lining very thick and firm. 
 
 In 1 softening began about half an inch below the surface of the brain, and increased 
 towards the centre ; much fluid in the ventricles, and their lining remarkably thick. 
 
 In 1 there was great softening of both posterior lobes, especially of the right ; two 
 ounces of fluid in the ventricles, and their lining but slightly opaque. 
 
 In 1 there was great vascularity, especially of the grey matter of the convolutions ; 
 extreme softening of the anterior and middle lobes, proceeding from the longitudinal 
 fissure outwards, most marked on the right side ; but the posterior lobe was not at all 
 affected. There was capillary apoplexy of the left corpus striatum. The ventricles 
 contained four ounces of turbid rose-coloured serum ; their lining membrane was 
 very vascular, thick, and firm in some parts, — thick, soft, and actually desintegrated 
 in others. 
 
 5 
 
66 SYMPTOMS OF ITS THREE STAGES. 
 
 of its play, and run to hide its head in its mother's lap, putting its hand 
 to its head, and complaining of headache, or saying merely that it is tired 
 and sleepy, and wants to go to bed. Sometimes, too, it turns giddy, as 
 you will know, not so much from its complaint of dizziness, as from its 
 suddenly standing still, gazing around for a moment as if lost, and then, 
 eithe^ beginning to cry at the strange sensation, or seeming to awake 
 from a reverie, and at once returning to its play. The infant in its 
 nurse's arms betrays the same sensation by a sudden look of alarm, a 
 momentary cry, and a hasty clinging to its nurse. If the child can walk, 
 it may be observed to drag one leg, halting in its gait, though but 
 slightly, and seldom as much at one time as at another, so that both 
 the parents and the medical attendant may be disposed to attribute it 
 to an ungainly habit which the child has contracted. The appetite is 
 usually bad, though sometimes very variable ; and the child when 
 apparently busy at play may all at once throw down its toys and beg 
 for food ; then refuse what is offered, or, taking a hasty bite, may seem 
 to nauseate the half-tasted morsel, may open its mouth, stretch out its 
 tongue, and heave as if about to vomit. The thirst is seldom con- 
 siderable, and sometimes there is an actual aversion to drink as well as 
 to food, apparently from its exciting or increasing the sickness. The 
 stomach, however, seldom rejects everything ; but the same food as 
 occasions sickness at one time is retained at another. Sometimes the 
 child vomits only after taking food ; at other times, even when the 
 stomach is empty, it brings up some greenish phlegm without much 
 effort and with no relief. These attacks of vomiting seldom occur 
 oftener than two or three times a day ; but they may return for several 
 days together, the child's head probably growing heavier, and its 
 headache more severe. The bowels during this time are disordered, 
 generally constipated from the very first, though their.condition in this 
 respect sometimes varies at the commencement of the disease. The 
 evacuations are usually scanty, sometimes pale, often of different 
 colours, almost always deficient in bile, frequently mud coloured, and 
 very offensive. The abdomen is seldom full ; the child sometimes com- 
 plains of pain in it, and it is tender on pressure. The tongue is not 
 dry, generally rather red at the tip and edges, coated with white fur 
 in the centre, which becomes yellowish towards the root. Occasionally 
 I have seen it very moist, and uniformly coated with a thin white fur. 
 The skin is harsh, but there is no great heat of surface ; the nares are 
 dry, the eyes lustreless, the pulse accelerated, but seldom exceeding 
 120 in children of four years old and upwards ; not full nor strong, but 
 often unequal in the force and duration of its beats. The child is 
 drowsy, and will sometimes want to be put to bed two or three times in 
 the day ; but it is restless, sleeps ill, grinds its teeth in sleep, lies with 
 its eyes partially open, awakes with the slightest noise, or even starts 
 up in alarm without any apparent cause. At night, too, the existence 
 of intolerance of light is often first noticed in consequence of the child's 
 complaints about the presence of the candle in the room. 
 
 I need scarcely say that you must not expect to find all these symp- 
 toms in every case, neither, indeed, when present are they persistent, 
 but the child's condition varies greatly in the course of a few minutes ; 
 
ACUTE HYDROCEPHALUS — 67 
 
 cheerfulness alternating with depression, and sound sleep being now and 
 then enjoyed in the midst of the unrefreshing dozes of the night. It 
 will not be by a hurried visit of a few minutes that you will learn these 
 things ; you must not grudge your time, if you hope ever to attain to 
 excellence in the management of children's diseases. 
 
 This precursory stage is of very variable duration, but on the average 
 does not exceed four or five days. If the disease be not recognised, or 
 if the treatment adopted be unsuccessful, it will pass into the second 
 stage, in which the nature of the affection is very apparent, though 
 unhappily the prospect of its cure is almost lost. The child no longer 
 has intervals of cheerfulness, nor attempts to sit up, but wishes to be 
 left quiet in bed, and the face assumes a permanent expression of anxiety 
 and suffering. The eyes are often kept closed, and the eyebrows are 
 knit, the child endeavouring to shut out the light from its morbidly 
 sensitive retina. The skin continues dry, the face is sometimes flushed, 
 and the head often hot ; and though these two symptoms vary much in 
 their duration, coming and going without any evident cause, yet there 
 is a permanently increased pulsation of the carotids, and if the skull be 
 not ossified the brain may be felt and seen forcibly beating through the 
 anterior fontanelle. The child is now very averse to being disturbed, 
 and often lies in a drowsy condition, unless spoken to, when, if old 
 enough to answer, it usually complains of its head, or of weariness or 
 sleepiness. Its replies are generally rational, but very short ; and if it 
 need anything, it asks in as few words as possible, in a quick, pettish 
 manner, and shows much irritability if not at once attended to. At 
 other times it lies with its face turned from the light, either quite quiet, 
 or moaning in a low tone of voice, and now and then uttering a short, 
 sharp, lamentable cry, which M. Coindet, of Geneva, regarded as 
 characteristic of the disease, and hence termed it crihydreneephalique ; 
 but making no other complaint than the low moan and the occasional 
 plaintive cry. To this, however, there are exceptions, and children 
 sometimes scream with the intensity of the pain, or cry out, " My 
 head ! my head !" most piteously. As night comes on there is almost 
 always a distinct exacerbation of the symptoms, and the quiet of the 
 day is frequently succeeded by a noisy and excited state, in which 
 vociferous cries about the head alternate with delirium. This, however, 
 is not by any means a constant occurrence ; an increase of restlessness 
 being often the only difference from the state of stupor in which the 
 child lay during the day. At the commencement of this stage the 
 pulse is quickened, sometimes very much so, and is in many cases 
 unequal in the force and quickness of the beats. Irregularity of its 
 rhythm, or distinct intermission in its beat, is the next change, and is 
 usually perceived at the same time with a great diminution in its fre- 
 quency, which often falls in a few hours from 120 to 90 or 80. At the same 
 time that these changes take place in the general characters of the 
 pulse, its power becomes manifestly diminished, while the slightest 
 exertion, such as attends any alteration in the child's position in the 
 bed, will often suffice to increase its frequency twenty beats or more in 
 the minute. The child sometimes keeps its eyes so firmly closed that 
 we can scarcely see the state of its pupils. Usually they are not much 
 
DO SYMPTOMS OP ITS THREE STAGES. 
 
 affected, but sometimes one is more dilated and acts more sluggishly 
 than the other, or in other cases, strabismus exists, though perhaps in 
 a very slight degree ; or confined to one eye. It is seldom that 
 vomiting continues beyond the commencement of this stage, but its 
 cessation is not followed by any desire either for food or drink. The 
 bowels usually become even more constipated than they were before, 
 and the evacuations continue quite as unnatural, while all flatus dis- 
 appears from the intestines, and the abdomen thus acquires that 
 shrunken form on which much stress has been laid by some writers as 
 characteristic of hydrocephalus. 
 
 The transition from this to the third stage of the disease is some- 
 times effected very gradually by the deepening of the state of drowsiness, 
 till it amounts to a stupor, from which it is impossible to rouse the child. 
 At other times, however, this stupor comes on very suddenly, succeed- 
 ing immediately to an attack of convulsions. These convulsions usually 
 affect one side much more than the other, and after the fit has passed 
 off one side is generally found partially or completely paralysed, while 
 the child makes constant automatic movements with the other, carrying 
 the hand to the head, and alternately flexing and extending the leg. 
 The side which is the most affected during the fit is generally, though 
 not invariably, the most palsied afterwards. When the third stage is 
 fully established, the child lies upon its back in a state of complete 
 insensibility, with one leg stretched out, the other drawn up towards 
 the abdomen. The tremulous hands are either employed in picking 
 the lips or nose till the blood comes, or one hand is kept on the genitals 
 while the other is rubbing the face or head. The head is at one 
 moment hot, and the face flushed, and then the heat disappears and 
 the flush fades, though usually there is a permanent increase in tem- 
 perature about the occiput. Sometimes the skin is dry, and then, 
 though the extremities are cold, a profuse sweat breaks out on some 
 part of the body or on the head. The pulse often loses its irregularity, 
 but at the same time it grows smaller and more rapid, till at length it 
 can be counted only at the heart. The eyelids now close only very 
 partially, and in most cases there is some degree of strabismus. Light 
 is no longer unpleasant, for the dilated pupils are either altogether 
 motionless, or they act very sluggishly, frequently oscillating under 
 the stimulus of a bright light, alternately contracting and dilating, till 
 at length they subside into their former dilated condition. The child 
 now often makes automatic movements with its mouth, as though 
 chewing, or as though endeavouring to swallow something. It gen- 
 erally happens that, although sensibility is quite extinguished, the 
 child will still swallow anything that is put into its mouth, and the 
 power of deglutition is in most cases one of the very last to be 
 abolished. 
 
 An attack of convulsions now sometimes puts an end to the painful 
 scene ; but often the child lives on for days, though wasted to a skele- 
 ton, and its features so changed by suffering that those persons who had 
 seen it but a short time before would now scarcely recognise it. The 
 head often becomes somewhat retracted, and the child bores with the 
 occiput in the pillow; the eyelids are wide open, and the eyes turned 
 upwards so as to conceal three-fourths of the iris beneath the upper lid, 
 
ACUTE HYDROCEPHALUS — 09 
 
 while the countenance is still further disfigured by a horrible squint, or 
 by a constant rolling of the eyes. The pupils are now fixed and glassy, 
 the white of the eyes is extremely bloodshot, and their surface is be- 
 smeared with a copious secretion from the Meibomian glands which col- 
 lects in their corners. One leg and arm are stiff and motionless, the 
 other in constant spasmodic movement, while the hands are often 
 clenched and the wrists bent upon the forearm. At the same time there 
 is frequently so much subsultus as to render it impossible to count the 
 pulse, and the muscles of the face are thrown from time to time into a 
 state of spasmodic twitching. Cold clammy sweats break out abun- 
 dantly about the head, the breathing is laboured, deglutition becomes 
 difficult, and the child almost chokes with the effort to swallow, or lets 
 the fluid run out at the corners of its mouth. It is uncertain how long 
 this condition may endure: the recurrence of convulsions usually 
 hastens the end, but sometimes many days will pass, during which 
 death is hourly expected, and earnestly prayed for, to put an end to 
 the patient's sufferings. 
 
 LECTURE VI. 
 
 Acute Hybkocephalus, continued. Diversities in its course and in its modes of 
 attack — insidious approach in phthisical subjects — resemblance of its symptoms 
 to those of remittent fever — of simple gastric disorder — serious import of continued 
 sickness in cases of gastric disorder. 
 
 Prognosis. Disease almost always fatal — appearances of improvement often delusive — 
 cautions against being misled by them. 
 
 Duration of the disease — real nature of cases of waterstroke. 
 
 Treatment. — Prophylaxis — Treatment of the disease — rules for depletion, for use of 
 purgatives, mercurials, application of cold. — Diet of patients — circumstances under 
 which opiates may be useful — when blisters are to be applied. Conclusion. 
 
 It can scarcely be necessary to observe that acute hydrocephalus does 
 not always run precisely that course which I described to you at our 
 last meeting. Almost every case, indeed, presents some slight peculi- 
 arity, either in the comparative severity of the different symptoms, in 
 the date of their occurrence, or in the order in which they succeed each 
 other. Convulsions, for instance, though hardly ever absent, occur 
 earlier in one case than in another, — affect in one the whole body, in 
 another are limited to one side, — are succeeded in one instance by 
 paralysis, in another by a stiff and contracted state of the limbs. Again, 
 coma sometimes comes on gradually, at other times takes place sud- 
 denly ; in one instance it continues long, in another is speedily followed 
 by death. The pupils sometimes become early insensible to light ; at 
 other times they continue to act, though slowly, almost to the time of 
 death ; and in like manner strabismus may exist in various forms, or 
 there may be constant rotation of the eyeball, or neither of these symp- 
 toms may be present ; and yet we cannot couple these diversities in 
 the signs of the disease with any certain differences in the morbid ap- 
 
70 DIAGNOSIS OF HYDROCEPHALUS. 
 
 pearances. But, how much soever one case of hydrocephalus may 
 differ from another in these respects, such differences are of compara- 
 tively hut little moment, since, whether these symptoms occur early or 
 late, — whether they are slight or severe, — short in their duration, or of 
 long continuance, — the appearance of any one of them stamps the 
 character of the disease too plainly for it to be mistaken, and indicates 
 not the incipient, but the fully developed evil. The deviations from 
 the ordinary mode of its attack are far more important, since they may 
 lead you to mistake the nature of the disease during the only time 
 when treatment is likely to be of much avail. 
 
 The healthy and robust are comparatively seldom attacked by hydro- 
 cephalus, and in many instances the indications of declining health 
 precede for weeks or months the real premonitory symptoms of the 
 disease. You may, however, be so much taken up with watching the 
 former as to overlook the latter, or to misinterpret their meaning. Your 
 solicitude is excited by the gradual decay of a child's strength, and the 
 wasting of its flesh. You observe that it becomes subject to irregular 
 febrile attacks, — that it coughs a little, — that it loses its appetite, — that 
 its bowels are almost always disordered, and generally constipated, — 
 and that it makes frequent vague complaints of pains in its limbs, or of 
 weariness or headache. These symptoms, which depend upon that ge- 
 neral deposit of tubercle in the different organs of the body which 
 almost every dissection of fatal cases of hydrocephalus reveals, make 
 you apprehensive lest phthisis be about to come on, and you often aus- 
 cultate the chest in the expectation of discovering some signs of disease 
 in the lungs. At length, the child seems worse, — he coughs more, and 
 is more feverish, — grows heavier and more dull, but does not complain 
 more about his head, — or, at most, says that the cough makes his head 
 ache. The parent thinks the child must have caught cold, and you do 
 not see the indication of any new disorder ; for though listless and 
 moody, he still moves about in the house, and sometimes plays, though 
 in a spiritless manner. Simple treatment seems to do a little good, and 
 you not unnaturally hope that the aggravation of the symptoms will 
 prove only temporary ; but after an usually restless night, a fit of con- 
 vulsions comes on, or the listlessness deepens in the course of a few 
 hours, and without any evident cause, into profound coma, and a very 
 few days terminate the patient's life. 
 
 In such a case as this, you would, it is true, most likely be able to do 
 little or nothing, even if you recognised the approach of hydrocephalus 
 from the earliest indication of its coming. But you would save your 
 patient's friends some sorrow, and yourself some reproach, if you disco- 
 vered the danger at a distance. Now, whenever any child, especially 
 if it be of a consumptive family, has been failing in health for some 
 weeks or months, without evident cause, I advise you to look with much 
 suspicion on the supervention of unusual drowsiness or listlessness, or 
 on any aggravation of the cough, for which you cannot find adequate 
 reason in the information afforded by auscultation. A frequent, short, 
 dry cough is not infrequent at the commencement of hydrocephalus ; 
 but in cases where cough has existed for some time, you are very likely 
 to refer its aggravation to mischief in the chest, and to lose sight of 
 
DIAGNOSIS Or HYDROCEPHALUS. 71 
 
 its possible connection with affection of the brain. Inquire, therefore, 
 in every doubtful case, whether there has been any vomiting, — for some- 
 times it is but slight, and occurs only after food has been taken, and 
 then only occasionally, so that it may seem to the parents to be a symp- 
 tom of little importance. Ascertain the condition of the bowels ; watch 
 the pulse most carefully; it may not be irregular nor intermittent, but 
 you will probably find a little inequality in the force and duration of 
 its beats ; if so, you may be sure that the head is suffering, and if the 
 head suffer in such a patient, it is ninety-nine cases out of a hundred 
 from the approach of hydrocephalus. Do not content yourself with 
 seeing your patient once a day; visit him at least morning and even- 
 ing, — stay sometime with him, watch him closely, and see how far he 
 is capable of being amused ; but if you be still strangers to that free- 
 masonry which assures a little child that you love it, you will very 
 likely fail of arriving at the truth. 
 
 But it may happen that a child, though not robust, had yet been to- 
 lerably well till a week or two before you visited it, and that it was then 
 attacked with febrile symptoms, with a little headache, and perhaps with 
 vomiting and constipation. You learn that these two symptoms were 
 but of short duration, but that the fever has continued ever since, and 
 that the child has been very taciturn, rather drowsy, and averse to 
 being disturbed, though giving rational answers when spoken to. You 
 regard the case as one of remittent fever, and treat it without either im- 
 provement or deterioration, till the appearance of convulsions or coma 
 corrects your diagnosis, though unfortunately too late. 
 
 It must be confessed that it is sometimes a matter of great difficulty 
 to distinguish between these two affections. It may help you, indeed, 
 to bear in mind that remittent fever is very rare before five years of 
 age, and is hardly ever met with in children under three ; while at 
 least half of all cases of hydrocephalus occur in children who have not 
 completed their fifth year. But still this is not the kind of evidence 
 on which you can place much reliance in a doubtful case. There are 
 differences in the symptoms, however, which will generally enable you 
 to discriminate between them, if you have acquired the habit of minute 
 and careful observation. The vomiting, on which I have laid so much 
 stress as a symptom of .approaching hydrocephalus, is often absent even 
 at the onset of remittent fever ; it soon ceases, and is not followed by 
 that abiding nausea which is frequent in hydrocephalus. In remittent 
 fever the bowels are often relaxed from the very outset, or speedily be- 
 come so, and the evacuations present no resemblance to the scanty, 
 dark, or mud coloured motions which are voided in hydrocephalus, but 
 are usually watery, faecal, and of a lightish colour. Tenderness of the 
 abdomen is nearly constant in remittent fever, and is greater in the iliac 
 regions than elsewhere, and wind can always be felt in the intestines. 
 The tongue is not moist as in hydrocephalus, and is seldom much 
 loaded, but has in general only a thin coating of yellow fur at the centre 
 and towards the root, while it is very red at the tip and edges, and be- 
 comes dry at an early stage of the disease. In hydrocephalus there is 
 frequently a great distaste for drink as well as for food, while although 
 the appetite is lost in cases of remittent fever, yet the patients have 
 
72 DIAGNOSIS OF HYDROCEPHALUS. 
 
 great desire for drink, especially for cold drink, to quench the urgent 
 thirst. The heat of the skin in remittent fever is extremely pungent, 
 and much greater than in hydrocephalus, in which, although there is 
 great dryness of the surface, yet the temperature is seldom much in- 
 creased. The pulse in remittent fever is much quicker than in hydro- 
 cephalus ; it continues quick throughout, and never becomes unequal 
 or irregular, while its frequency is in direct proportion to the elevation 
 of the temperature of the surface. In remittent fever the child makes 
 few complaints about its head, but delirium is of early occurrence, espe- 
 cially at night ; in hydrocephalus, on the contrary, true delirium hardly 
 ever occurs till an advanced period of the disease, and is sometimes ab- 
 sent altogether. In remittent fever, as its name implies, there are 
 distinct remissions and exacerbations of the symptoms, the patient get- 
 ting better towards morning, and worse again as night approaches; 
 while, though there are many fluctuations in the course of hydrocepha- 
 lus, yet we observe no definite periods at which the symptoms invariably 
 remit or are increased in severity. 
 
 With due caution you will scarcely take a case of incipient hydro- 
 cephalus for one of simple gastric disorder, though there are many 
 points of resemblance between the two. Vomiting and constipation 
 occur in both, and there is usually some degree of headache in the 
 latter affection, though seldom severe or lasting. Mere gastric dis- 
 order is not attended with much febrile disturbance ; the face, though 
 heavy, is not distressed nor anxious, while the tongue is usually much 
 more coated than at the onset of an attack of hydrocephalus. The 
 relief that follows the use of remedies in the less dangerous affection 
 is complete as well as speedy ; the sickness will cease after the opera- 
 tion of an emetic, the bowels will act copiously after the administration 
 of a brisk purgative, and in a day or two your patient will be quite 
 well. The persistence of vomiting, however, in any case which you 
 had thought to be one merely of gastric disorder, must be looked upon 
 by you with great suspicion, and this even though the bowels have 
 acted freely from medicine, and though there'be no obvious indication 
 of mischief in the head. I once saw a case in which the continuance 
 of intractable vomiting for more than six weeks after the cessation of 
 a short but severe attack of diarrhoea, was the only symptom of illness 
 in a boy five years of age. At length he became a little drowsy, and 
 once or twice, when closely questioned, said that his head ached. Not 
 quite two days after the first complaint of headache, the child had a 
 violent fit of convulsions, and in the course of the succeeding week he 
 died, having suffered during that time from all the symptoms of acute 
 hydrocephalus, and his body presenting after death its characteristic 
 lesions. 
 
 An inquiry of little less importance than that concerning the means 
 of distinguishing between one disease and another, respects the prog- 
 nosis that we are to form, the inferences that we may draw, from the 
 course of the malady, either to encourage hope or to excite anxiety. 
 Unfortunately the prognosis in hydrocephalus is so unfavourable that 
 we can scarcely speak of the circumstances which regulate it ; for 
 under almost every variety of condition, of symptoms, and of treat- 
 
PROGNOSIS OF HYDROCEPHALUS. 73 
 
 ment, the patients die. I have never yet seen an instance of recovery 
 from advanced hydrocephalus; I have seen but one in which the child 
 got well after the disease was well marked and the second stage had 
 commenced, and have observed only very few cases have a favourable 
 issue even though they came under treatment immediately on the 
 appearance of the premonitory symptoms of water on the brain. This 
 result is, I know, more discouraging than that which other practi- 
 tioners have arrived at ; but I regret that additional experience since 
 I first made this statement does not enable me to modify it; and 
 M. Guersant, of Paris, who probably had seen more than any man 
 now living of children's diseases, does not seem to have been more 
 fortunate. 
 
 " Tubercular meningitis," v says he (by which name French writers 
 have designated the disease that we are now studying), " may some- 
 times terminate by recovery in the first stage, though the nature of 
 such cases is always more or less doubtful ; in the second stage I have 
 not seen one child recover out of a hundred, and even those who 
 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 the third stage, I have never 
 seen them improve even for a moment."* 
 
 Since the fatality of the disease is so invariable, it may seem to you 
 superfluous for me to say anything more with reference to the prog- 
 nosis ; but I am desirous of guarding you against being deceived by 
 certain delusive appearances of improvement which are by no means 
 unusual even in cases where the real nature of the disease has for some 
 two or three days been clearly manifested. A few years ago, a little 
 girl, three years old, was brought to me in a state of profound coma, 
 and presenting the symptoms of the third stage of acute hydrocephalus, 
 of which she died forty-eight hours afterwards, without having had any 
 return of consciousness. I learned from the mother that, fourteen day 
 previously, the child had been attacked with vomiting, attended with 
 fever and great drowsiness ; but that these symptoms abated in three 
 days, and that the child improved and was regaining her cheerfulness 
 until the morning of the day before she was brought to me, when her 
 mother found her comatose, and in just the condition in which she was 
 when I saw her. A more acute observer than this child's mother would 
 probably have seen something to make her mistrust the apparent im- 
 provement ; but it is evident that the change was great from fever and 
 drowsiness, and frequent vomiting, to a cessation of the sickness, a 
 diminution of the fever, and a return of cheerfulness ; and yet during 
 all this time disease was going on, and producing the very extensive 
 softening of the central and posterior parts of the brain which was dis- 
 covered after death. The cases in which you are likely to fall into error 
 are for the most part such as have come on insidiously, unattended with 
 very violent symptoms, and about which you perhaps hesitated some 
 little time before you became convinced that so grave a malady as 
 
 1 Diet. Med. t. xix. p. 403; quoted by MM. Eilliet and Barthez, op. cit. t. iii. 
 p. 631. 
 
74 DELUSIVE APPEARANCES OF IMPROVEMENT. 
 
 hydrocephalus could wear so mild a form. Treatment for some days 
 produces no effect, the disease remaining stationary ; but at length 
 your hopes are raised by finding that the vomiting has ceased, and 
 that the constipated condition of the bowels has been overcome. The 
 heat of head has disappeared, the pulse presents much less irregularity 
 than before, or may even have lost it altogether ; and the child's rest- 
 lessness has subsided, and its manner is almost natural. Perhaps the 
 child seems rather drowsy, or it may be sleeping at the time of your 
 visit ; but the account you hear of it seems satisfactory : its repose is 
 quiet, and the mother rejoices : her little one has had no sound sleep 
 for many days, and will, she thinks — and you may think so too — be 
 much better when it awakes. It does not wake up, but swallows well 
 when some drink is given in a spoon, and the mother is still content. 
 Presently slight twitches of the face and hands are seen, but the child 
 does not awake, — you cannot rouse it : the sleep has passed into coma, 
 and the coma will end in death. Always suspect the sleep- which 
 follows continued restlessness in a case of hydrocephalus. 
 
 In other cases, although the disease did not come on so insidiously, 
 and although it has reached a stage at which all its characters are well 
 marked, you may yet be led for a few hours to entertain, and perhaps to 
 express, ill-founded hopes, in consequence of the symptoms having some- 
 what abated, of the child having had some hours of quiet sleep, or having 
 ceased to vomit, or no longer complaining of its head, or being visited by 
 a short gleam of cheerfulness. You must not forget, however, that it 
 is characteristic of hydrocephalus to present irregular remissions, that 
 they last but for a few hours, and that at your next visit you may find 
 every bad symptom returned, and, possibly, some fresh one superadded. 
 Usually, too, you may be guarded from error by observing the sudden- 
 ness of the change, and that the condition which has now come on is 
 the very opposite of that which before existed, preternatural excitement 
 having been succeeded by an equally unnatural apathy, or great talk- 
 ativeness having taken the place of obstinate silence, or the pulse, 
 which before was above 120, having sunk all at once to 90 in the minute. 
 At other times, though there is a general abatement in all the previous 
 symptoms, yet some new one may have appeared ; not more formidable, 
 perhaps, than the occurrence of a slight degree of strabismus which 
 had not existed before, but still enough to indicate that the mischief is 
 still going on, and that you must not dare to hope. 
 
 A still more remarkable temporary improvement is sometimes 
 observed, that " lightning before death" which seems, contrary to all 
 expectation, to warrant a hope of recovery even when dissolution is 
 impending. The only instance of it which has come under my notice 
 occurred in a^girl, aged seven years, who died on the fifteenth day of 
 an attack of acute hydrocephalus. She had been in a state of stupor 
 for six days, and profoundly comatose for two days, when she became 
 conscious, swallowed some drink, spoke sensibly, and said she knew her 
 father. She became worse again, however, in the course of an hour 
 and a half, though she did not sink into the same deep coma as before, 
 and in another hour she died. 
 
 A few points still remain on which I must touch before passing to the 
 
DURATION Or ACUTE HYDROCEPHALUS. 75 
 
 consideration of the treatment of hydrocephalus. One of these is the 
 question of its duration. The exact determination of this is not always 
 easy, owing to the insidious manner in which the disease comes on ; but, 
 on the whole, there is less discrepancy than might have been expected 
 between the statements of different writers. Of 117 cases observed or 
 collected by Dr. Hennis Green, 80 terminated within 14 days, and 111 
 within 20 days. Of 28 cases reported by Golis, 1 18 terminated within 
 14 days, and only 2 exceeded 20 days. MM. Rilliet and Barthez,* 
 state the average duration of 28 cases that came under their observa- 
 tion to have been 22 days ; and the average duration of 34 fatal cases 
 of which I have a complete record, was 20 days. Of these 84 cases, 
 that which ran the most rapid course terminated fatally in five days ; 
 death took place in 11 more before the fourteenth day ; in 14 others 
 during the third week, and in 3 during the fourth week. In the remain- 
 ing five cases indications of cerebral disturbance had existed for four, 
 six, or eight weeks ; ,but death took place in every instance in less than 
 21 days after the appearance of well-marked symptoms of hydrocephalus. 
 We are, then, warranted in stating that the disease usually runs its 
 course in from two to three weeks. 
 
 The late celebrated Dr. Golis, of Vienna, proposed the name of toater- 
 stroke for some cases in which the head symptoms were of such short 
 duration as not to exceed 24 or 48 hours. Such a rapid course, how- 
 ever, is not observed in true tuberculous hydrocephalus ; but the name 
 of water-stroke has been applied to a great variety of cases which have 
 presented little in common except the presence of head symptoms, and 
 their rapidly fatal termination. 3 The appellation has been sometimes 
 bestowed on cases of intense cerebral congestion ; at other times on 
 cases of simple meningitis. In a few instances the name may have been 
 given to cases of true hydrocephalus in which the rapid course of ths 
 disease has been apparent, rather than real, owing to its having succeeded 
 to chicken-pox, or come on in the course of that febrile disturbance 
 which vaccination sometimes excites, or which attends upon dentition. 
 Under such circumstances it often happens that the manifestations of 
 cerebral diseases are mistakenly attributed entirely to the previous 
 cause of irritation in the system, so that, when the signs of serious 
 mischief force themselves upon the notice, the hydrocephalus has well 
 nigh run its course. 
 
 In describing this disease I divided it into three stages, but did so 
 simply for convenience. Many physicians, however, have attached much 
 greater importance to this division, regarding the first as the stage of 
 turgescence ; the second as that of inflammation ; the third, that of 
 effusion. Again, the first has been characterised as the stage of increased 
 sensibility ; the second, of diminished sensibility ; the third, of palsy. 
 Lastly, Dr. Whytt proposed a division that has been much followed, 
 based on the variations of the pulse, which is usually quick and regular 
 in the first stage, slow and irregular in the second, and quick in the 
 
 1 Praktische Abhandlungen, etc. 8vo. Wien, 1820. Vol. i. 
 
 2 Op. cit. vol. iii. p. 497. 
 
 3 In proof of this statement, see Golis, lib. cit. Cases 1 to 9. 
 
76 THE THREE STAGES OF HYDROCEPHALUS. 
 
 third. There are too many exceptions, however, to the order of these 
 changes, for it to he right to make them the foundation of any division 
 of the disease into different stages; and the same remark may he made 
 with reference to any arrangement founded on the variations in the 
 sensibility of the patient. 
 
 I have said that the phenomena of the pulse are not constant: I need 
 scarcely add, that the slow irregular pulse is no proof of the occurrence 
 of effusion ; neither is the dilated pupil a proof of it : it is a proof of 
 great mischief having been inflicted on the brain : so are the strabismus 
 and the rolling of the eyes which frequently accompany it ; but you 
 cannot connect these symptoms with injuries of a special kind, or 
 involving particular parts of the brain. 
 
 Although a disease of childhood, acute hydrocephalus is by no means 
 most frequent in early infancy. In only five of 36 fatal cases in which 
 the diagnosis was confirmed by a post-mortem examination, were my 
 patients under a year old ; 9 were under 3 years of age ; 18 between 3 
 and 6; 3 between 6 and 9; and 1 between 10 and 11 years old. 1 
 
 From all that I have told you about hydrocephalus, you have, I doubt 
 not, already deduced the practical inference, that the only treatment 
 likely to avail much is the prophylactic ; and that, if you would hope 
 ever to save a patient, you must treat the mere threatenings of his dis- 
 ease, and not remain inactive until you see the malady fully developed 
 before you. 
 
 The prophylactic treatment of hydrocephalus must be in the main the 
 prophylactic treatment of consumption, since not only is tubercle inva- 
 riably present in the various organs of children who have died of hydro- 
 cephalus, but the disease itself often supervenes on more or less definite 
 phthisical symptoms. The influence of hereditary predisposition to 
 phthisis, in favouring the development of hydrocephalus, is shewn by 
 the fact that not only was the previous health of the children indifferent 
 in two-thirds of the cases that came under my notice, but that, in 
 sixteen out of twenty instances, in which the health of the relatives was 
 made the subject of special inquiry, it was ascertained that either the 
 father, mother, aunt, or uncle, had died of phthisis. 
 
 In any case where several children of the same family have already 
 died of hydrocephalus, or have shewn a marked tendency to the disease, 
 the mother should for the future abstain from suckling her infants, and 
 they should be brought up by a healthy wet-nurse. Under such circum- 
 stances, too, it would be desirable that a child should always live in the 
 country; its clothing should be warm, and flannel should be worn next 
 the skin. Its diet should be simple, and any change in it should be 
 made with the greatest caution,, while milk should for a long time form 
 one of its chief aliments ; and it would be desirable not to wean it until 
 after it had cut four molar teeth, as well as all the incisors. As it grows 
 
 1 This statement as to the time of life at which hydrocephalus is most frequent is 
 fully borne out by the Fifth and Eighth Reports of the Registrar-General, from which 
 it appears that while only 7 per cent, of the total deaths under one year old in this 
 metropolis resulted from cephalitis and hydrocephalus, these diseases caused 12.5 per 
 cent, of the deaths between 1 and 3: 12.5 per cent, of those between 3 and 5; 11.1 
 per cent, of those between 5 and 10 ; and 5 9 per cent, of those between 10 and 15. 
 
PROPHYLACTIC TREATMENT OF HYDROCEPHALUS. 77 
 
 up, over-exertion, either of mind or body, must be most carefully 
 avoided ; and on this account, though free exercise in the air is highly 
 beneficial, gymnastic exercises are by no means to be recommended. 
 The child must be watched carefully during the whole period of denti- 
 tion, and every precaution must be taken to shield it from the contagion 
 of measles, hooping-cough, or scarlatina ; since these diseases, which 
 tend to excite the tuberculous cachexy, would be likely greatly to 
 aggravate the disposition to hydrocephalus, or even to bring on an 
 attack of the disease. The condition of the bowels must be most care- 
 fully watched ; constipation must not be allowed to exist even for a 
 day, and the least indication of gastric disorder must be regarded as a 
 serious matter. It is not desirable that calomel should be used as a 
 domestic remedy ; but if the simplest aperients (such as castor-oil, or 
 the infusion of senna, or of rhubarb 1 ) do not act, the child should be 
 immediately placed under proper medical care. If at any time there 
 should be heat of head, and the child appear squeamish, you must be 
 at hand with your remedies, and those well chosen. Any bulky remedy 
 would probably be rejected ; but the stomach is almost sure to bear a 
 grain or two of calomel with sugar, and you may follow this up with 
 small quantities of the sulphate of magnesia 2 every hour until the 
 bowels act freely. A small dose of mercury and chalk, or of calomel, 
 may be continued every night for two or three times ; and if any fever- 
 ishness remain, or the bowels be disposed to be constipated, the sulphate 
 of magnesia may still be given twice or thrice a day. Leeches should 
 not be applied to the head without very obvious necessity, nor then in 
 large numbers, for strumous children do not bear the loss of blood well ; 
 and your endeavour should therefore always be, not simply to cure, but 
 to cure at the smallest possible expense to the constitution. After 
 attacks of this kind, children sometimes recover their health very 
 slowly, and much good may then be effected by a judicious use of 
 tonics. The infusion of calumba, 3 with small doses of rhubarb, is a 
 very suitable medicine, and one which children generally take tolerably 
 well. Or you may give the ferro-citrate of quinine in orange-flower 
 water, and sweetened with the syrup of orange-peel, 4 while you secure 
 the healthy action of the bowels by a grain or two of Hyd. c. Greta, 
 combined with five or six of rhubarb, administered every night, or 
 every other night. 
 
 (No. 5.) (No. 6.) 
 
 1 R Potassae Sulphat. gr. xij. 2 ]$ Magnes. Sulphat. ^ij. 
 
 Inf. Rhei, gvss. Syr. Aurantii, gij. 
 
 Trae. Aurant. gss. Aquas Carui, gvj. M. gij. omni hora 
 
 Aquae Carui, giss. M. ^ss. p. r. n. donee alvus responderet. 
 
 For a child three years old. For a child three years old. 
 
 (No. 7.) 
 
 3 R Inf. Calumbae, 51J. gij. 4 See Formula No. 4, page 34. 
 
 Inf. Rhei, ^ivss. 
 
 Trae. Aurantii, giss. M. Jjiij. bis die. 
 For a child three years old. 
 
78 TREATMENT OF THE ATTACK — DEPLETION. 
 
 If threatenings of head affection have frequently occurred, an issue 
 should be inserted in the back of the neck ; for the keeping up a constant 
 discharge from the neighbourhood of the head is certainly very ser- 
 viceable in many instances as a means of warding off hydrocephalus. 
 A most remarkable instance of this is recorded by Dr. Cheyne, who 
 mentions that all the children in a numerous family were carried off by 
 water in the brain, with the exception of one, in whose case the pre- 
 caution was adopted of putting a seton in the back of his neck. 
 
 But the opportunity may not be afforded you of adopting this pro- 
 phylactic treatment ; and when you first see your patient, the existence 
 of headache, vomiting, constipation, and a quickened pulse, with 
 perhaps a very slight inequality in its beat, may leave you but little 
 doubt as to the formidable nature of the disease, with which you have 
 to contend. In doing this, there are three remedies on which your 
 main reliance must be placed, — depletion, purging, and the adminis- 
 tration of mercury. 
 
 With reference to depletion, you must not forget that the disease in 
 which you are about to employ it, although of inflammatory nature, is 
 inflammation in a scrofulous subject, and is in many cases grafted on 
 previous organic disease; such as those tubercular deposits in the mem- 
 branes of the brain which I have already described to you. You 
 cannot, therefore, hope to cut short the affection by a large bleeding, 
 but your object must be to take blood enough to relieve the congested 
 brain, and no more than is necessary for that purpose. Avoid preci- 
 pitancy in what you do, and do not let your apprehensions betray you 
 into that over-activity which is sometimes more fatal to a patient than 
 his disease. If you feel any doubt as to the necessity of depletion, 
 visit your patient again before determining on it, but do not delay that 
 visit long. Order a dose of calomel, to be followed by some sulphate 
 of magnesia, if, as is most probable, the bowels be confined, and return 
 again in three or four hours. You may then find that the bowels have 
 acted, and the sickness has ceased ; that the head is cooler, and aches 
 less, and that depletion is, for the present at any rate, unnecessary. 
 Or the child's state may be the same, and you may still feel uncertain 
 as to the right course. In that case, at once obtain the assistance of 
 some other practitioner. This is the season when advice may be really 
 useful, for it is only at the outset of the disease that its cure is possible ; 
 when convulsions have occurred, or coma is coming on, your treatment 
 matters comparatively little, for the season of hope and the opportunity 
 for action have then fled. 
 
 Though you may have determined on the propriety of depletion, it 
 will be seldom found, even at the outset of the disease, that the cha- 
 racter of the pulse is such as to warrant venesection. Local bleeding 
 will generally answer every purpose, and the age and docility of 
 the patient will determine whether it shall be performed by cupping or 
 by the application of leeches. The former is more effective, and, from 
 its shorter duration, often occasions less excitement and annoyance than 
 the latter. In children who are very unmanageable, however, or in 
 very young children or infants, the employment of leeches is always 
 preferable. They should be applied to the vertex, because, if put on 
 
DEPLETION — PURGATIVES. 79 
 
 the temples, they hang down over the eyes and terrify the child ; if 
 behind the ears, they are very likely to be rubbed off as it rolls its 
 head from side to side. I will not say that this depletion is never to 
 be repeated, but I believe that in by far the greater number of cases 
 you will do no good whatever by its repetition, and the exceptional 
 cases will generally be those in which, very marked relief having 
 followed the first bleeding, the same symptoms of congestion of the 
 brain appear to be returning twenty-four or thirty-six hours afterwards. 
 If you do not see the child until the second stage of the disease 
 is far advanced, — till general convulsions have occurred, or twitchings 
 of the limbs, or of the muscles of the face, an appearance of extreme 
 alarm, or a state of alternate contraction and dilatation of the pupils, 
 show them to be impending, — you must be exceedingly careful in 
 abstracting blood. Under such circumstances, I have seen convul- 
 sions, to all appearance, induced, and the fatal course of the disease 
 accelerated, by a rather free, though by no means immoderate loss of 
 blood. 
 
 The value of purgatives in the treatment of hydrocephalus can 
 scarcely be overrated ; but they must be given so as not merely to 
 obtain free action of the bowels, but to maintain it for some days. After 
 having once overcome the constipation, you will secure this end best by 
 giving small doses of a purgative every four or six hours. The admin- 
 istration of a strong cathartic every morning will not answer this end 
 nearly so well : for, independently of the chance of its being rejected 
 by the stomach, you will find that the dose which sufficed the first time 
 will not be large enough the second, and that there will be a constantly 
 increasing difficulty in obtaining an evacuation. The nausea and vomit- 
 ing which at first stood in the way of your administering any medicine, 
 are often so much relieved by depletion, that the stomach will almost 
 immediately afterwards bear a dose of calomel and jalap, or calomel 
 and scammony, which may be repeated every three hours, until it acts, 
 while you at the same time endeavour to quicken its operation by the 
 administration of a purgative enema. There is no use, however, in 
 persevering with these medicines if they excite sickness, and it is then 
 better to give a single large dose of calomel in some loaf sugar, and to 
 follow it up by a solution of sulphate of magnesia, which should be re- 
 peated at short intervals. When free evacuation has been obtained, 
 the same salt, in combination with the nitrate of potash, will often keep 
 up a free action of the bowels, as well as stimulate the kidneys to in- 
 creased activity. These remedies may either be mixed with the child's 
 drink, or be dissolved in water flavoured with syrup of lemon or of 
 orange peel. 1 
 
 Hand in hand with purgatives I would have you continue the admi- 
 nistration of calomel; but I do not put faith in calomel alone, nor in 
 the production of salivation, as a means of curing hydrocephalus. I 
 have seen children die whose mouths have been made sore by mercury, 
 without any influence appearing to have been thereby exerted on the 
 disease ; and I recollect two who, at the time of their death, were in a 
 
 1 See Formula No. 1, page 30. 
 
80 CALOMEL IN HYDROCEPHALUS — LOCAL APPLICATION OP COLD. 
 
 state of most profuse salivation. Whatever good I have seen in these 
 cases from calomel has been when it was given in combination with 
 purgatives, or when it produced a purgative effect. 
 
 Let me, however, again remind you that you may have hydrocephalus 
 combined with tubercular ulceration of the intestines, and that in such 
 a case diarrhoea may exist from the outset, or may come on after a 
 mild dose of some aperient. Now and then, too, without such a cause, 
 constipation is absent, while diarrhoea comes on occasionally in the far 
 advanced disease. You must not, therefore, draw inferences as to the 
 state of the patient too exclusively from the condition of the bowels. 
 
 I insisted much on the local employment of cold when speaking about 
 the management of cases of cerebral congestion. It is likewise a very 
 valuable agent in the treatment of hydrocephalus, but its application 
 requires to be judiciously regulated. You will generally find it of ser- 
 vice after depletion, for you have abstracted blood on account of the 
 febrile disturbance and heat of head, and other indications of conges- 
 tion of the brain, all of which cold will be a powerful auxiliary in sub- 
 duing. So long as the signs of active congestion of the brain are pre- 
 sent, cold will be of service ; but it should not be employed indepen- 
 dently of those symptoms which betoken the existence of that condition ; 
 nor can you hope to see any benefit result from the cold applications 
 to the head in the advanced stages of the disease. I need scarcely say 
 that the application of cold with a shock, or the pouring cold water 
 from a height upon the head, though a very valuable means of arousing 
 a child from the state of coma into which it sinks in some cases of in- 
 tense cerebral congestion, is wholly inapplicable in the coma of hydro- 
 cephalus. The functions of the brain are here not merely interrupted 
 by the excess of blood in the organ, but they are abolished by the dis- 
 organization of its tissue, or the compression of its substance by the 
 effusion of fluid. 
 
 In the management of children attacked by hydrocephalus you must 
 not forget that for the most part they are of feeble constitution, and 
 that they will not bear too rigorous a diet. Just at first, indeed, while 
 the febrile symptoms run high, and the bowels' are unrelieved, or the 
 sickness is urgent, the less the patient takes the better. Afterwards, 
 however, it is desirable that he should be supplied with as much light 
 and unstimulating nutriment as he will take ; such, for instance, as ar- 
 row-root, or veal or beef-tea, either of which will often remain on the 
 stomach when most other articles of food or drink would be rejected. 
 
 In the treatment of many diseases you see physicians destroy the 
 sense of pain by narcotics, and the question naturally suggests itself 
 to you whether you may not sometimes venture, in the management of 
 hydrocephalus, to mitigate by their means your patient's sufferings. 
 The enquiry is one not very easy to reply to satisfactorily. I think, 
 however, that there are two conditions under which you would be justi- 
 fied in trying the experiment of giving them. Sometimes the disease 
 sets in with great excitement, and a condition closely resembling mania 
 in the adult, symptoms which may have been ushered in by convulsions. 
 In such a case, although the heat of head and the flush of the face may 
 have disappeared after free depletion and the copious action of purga- 
 
DIET IN HYDROCEPHALUS — USE OF NARCOTICS — OF BLISTERS. 81 
 
 tive medicine, and though the pulse is feeble as well as frequent, yet the 
 excitement may be scarcely if at all diminished. Here an opiate will 
 sometimes give the relief which nothing else will procure ; your patient 
 will fall asleep, and wake tranquillized in the course of two or three 
 hours. In other cases, which did not set in thus violently, restlessness, 
 talkativeness, and a kind of half delirious consciousness of pain in the 
 head, become very distressing as the disease advances, being always 
 aggravated at night, so that your patient's condition seems one of con- 
 stant suffering. But he is not able to bear any more active treatment, 
 and, indeed, you have already emptied your quiver of such weapons. 
 Under these circumstances I have sometimes given a full dose of mor- 
 phia, and have continued it every night for several nights together with 
 manifest relief. 
 
 Another inquiry that you may put is, when are you, to employ blisters t 
 Certainly not at the beginning of the disease, when they would increase 
 the general irritation, and do more harm than good. At a later period 
 they may be of service, when the excitement is about to yield to that 
 stupor which usually precedes the state of complete coma. They should 
 then be applied to the nape of the neck or to the vertex ; and I am dis- 
 posed to think the latter the better place, since, when applied to the 
 nape of the neck they often become displaced by that boring movement 
 of the head which the child in many instances keeps up unconsciously. 
 It is well, too, to remember that the skin in hydrocephalus is very inapt 
 to vesicate, so that a blister will require to be kept on for ten or twelve 
 hours ; contrary to what ought to be your usual practice with children. 
 Cases enough are on record proving the utility of blisters thus applied, 
 to render it your duty not to neglect this means. 
 
 Need I say that you must not think of treating a case of hydroce- 
 phalus throughout just in the same way as you did at its commencement. 
 There is, if the disease do not run a very rapid course, a stage of weak- 
 ness and exhaustion, often associated with a half comatose condition, 
 though sometimes attended with a considerable degree of suffering, 
 which frequently precedes the signs of approaching death. The bowels 
 are now sometimes relaxed, though oftener they continue constipated, 
 because the nervous energy which kept up the peristaltic movements of 
 the intestines is worn out. The powers of organic as well as those of 
 animal life are palsied. This is the time for the administration of quinine, 
 for the employment of nutritious'broths and jellies, and even of wine. 
 
 You may perhaps be disposed to ask me what I think of this remedy 
 or the other, which has at different times been boasted of, as having 
 done good when other means had failed. Now you must not infer from 
 my silence that I do not believe that other medicines besides those 
 which I have spoken of have been of service ; but to attempt to can- 
 vas the respective merits of each would, I fear, be a tedious task, and 
 one from which you would derive but little profit. 
 
 Besides, may I remind you of what Sydenham says, "* * * In eo 
 praecipue stat Medicina Practica, ut genuinas Indicationes expiscari 
 valeamus, non ut remedia excogitemus quibus illis satisfieri possit ; quod 
 qui minus observabant, Empericos armis instruxere, quibus Medicorum 
 opera imitari queant." 
 
82 
 
 LECTURE VII. 
 
 Simple Inflammation of the brain — its differences from hydrocephalus — occasional 
 extreme rapidity of its course — cases in illustration — morbid appearances — frequent 
 connection with meningitis of the cord — extreme rarity as an idiopathic affection 
 — treatment. 
 
 Inflammation of the Brain, succeeding to Disease of the Ear — digression con- 
 cerning otitis — its symptoms — distinctions between it and inflammation of the 
 brain — treatment — chronic otorrhoea, with disease of the temporal bone — case. 
 
 Phlebitis of the Sinuses of the Dura Mater — circumstances under which it occurs 
 — it sometimes succeeds to large collections of pus in distant organs — case in 
 illustration. 
 
 We have been engaged at our last two meetings with the study of one 
 form of inflammation of the brain in the young subject. We found hy- 
 drocephalus to be an affection almost exclusively confined to children 
 whose previous health had been indifferent, who had shown some indi- 
 cations of phthisis, or in whose family phthisical disease existed. We 
 observed its development to be gradual, its progress often tardy, and 
 attended with irregular remissions, but its issue almost always fatal. 
 The alterations of structure discovered after death were seen to be 
 slight at the convexity of the brain, but very obvious at its base, 
 where, in addition to the effects of inflammation, the membranes often 
 present a peculiar granular appearance. The fluid contained in the 
 ventricles of the brain is almost always transparent, and tubercle is 
 discovered in some, often in many of the viscera. 
 
 But we sometimes meet with cases in which inflammation of the brain 
 has given rise to changes that contrast remarkably with those which 
 true hydrocephalus produces. We find the cerebral membranes intensely 
 injected, the effusion of lymph or pus abundant, especially about the 
 convex surface of the brain, where it sometimes forms a layer concealing 
 the convolutions from view. Moreover, the fluid that occupies the cavity 
 of the arachnoid, as well as that within the ventricles, is turbid and 
 mixed with lymph, while the membranes present no trace of that granular 
 appearance so remarkable in true hydrocephalus, and the various organs 
 of the body are free from tubercle. 
 
 If we inquire as to the symptoms by which this disease was attended 
 during the life-time of the patient, we shall most likely find that they 
 present fresh reasons for distinguishing between it and hydrocephalus. 
 We shall learn that the attack came on in a previously healthy child, 
 that it was either ushered in by convulsions, or that they soon occurred, 
 that they returned often, and probably that they continued with but 
 little intermission until death took place. We shall be told, moreover, 
 that the disease set in with violent vomiting and intense febrile excite- 
 ment ; and that having commenced thus severely, it advanced rapidly, 
 and without remission, to its fatal termination, which may have arrived 
 in the course of a few hours, and is seldom delayed beyond the first 
 week. 
 
SIMPLE INFLAMMATION OF THE BRAIN. 83 
 
 Some cases of this simple encephalitis are recorded by Golis, under 
 the name of Water-stroke : I will select one of them, as affording a 
 good specimen of the most acute form of the disease. 1 
 
 " A little girl, 14 months old, who was healthy and strong and fat, was 
 suddenly seized at 5 o'clock in the morning, after a restless night, with 
 violent fever and frightful general convulsions. Medical assistance was 
 at once attained, and in less than thirty minutes from the commence- 
 ment of the attack, four leeches were applied behind the ears, which 
 drew three ounces of blood : calomel and other remedies were admi- 
 nistered internally, and mustard poultices were applied to the soles of 
 the feet. These measures soon alleviated the symptoms, but the relief 
 lasted for but a very short time; the fever returned as intensely as 
 before, convulsions came on again, attended with opisthotonos, and the 
 child became comatose. Hemiplegia succeeded ; the pupils became 
 extremely contracted : complete loss of vision, and spasmodic twitching 
 of the muscles of the face soon followed, and thirteen hours after the 
 first convulsive seizure, in spite of most appropriate and energetic 
 treatment, the little child died. 
 
 " The vessels of the scalp were loaded with blood, and the skull was 
 so intensely congested as to appear of a deep blue colour. The sinuses 
 were full of coagulated blood mixed with lymph, and all the vessels of 
 the brain and its membranes were enlarged and turgid with blood. 
 
 " A large quantity of coagulated lymph covered the convolutions of 
 the brain and the corpus callosum like a false membrane, and furnished 
 a delicate lining to the lateral ventricles, whose walls were softened 
 and in part broken down. The ventricles contained about three ounces 
 of turbid serum, and there was a considerable quantity of lymph at the 
 base of the brain." 
 
 As I have never seen an instance of this most rapid form of menin- 
 gitis, I will draw for another illustration of it upon that valuable store- 
 house of facts, Dr. Abercrombie's work on Diseases of the Brain. 2 
 
 " A child, aged 2 years, 21st May, 1826, was suddenly seized in the 
 morning with severe and long-continued convulsion. It left her in a 
 dull and torpid state, in which she did not seem to recognize the persons 
 about her. She had lain in this state for several hours, when the con- 
 vulsion returned, and during the following night it recurred a third time, 
 and was very severe and of long continuance. I saw her on the morning 
 of the 23d, and while I was sitting by her she was again attacked with 
 severe and long-continued convulsion, which affected every part of the 
 body, the face and the eyes in particular being frightfully distorted. 
 The countenance was pale, and expressive of exhaustion ; the pulse 
 frequent. Her bowels had been freely opened by medicine previously 
 prescribed by Dr. Beilby, and the motions were dark and unhealthy. 
 Farther purging was employed, with topical bleeding, cold applications 
 to the head, and blistering. After this attack she continued free from 
 convulsion till the afternoon of the 23d ; in the interval she had remained 
 in a partially comatose state, with frequent starting; pulse frequent, 
 
 1 Praktische Abhandlungen, etc. vol. i. Case 2. 
 
 2 Case 10, p. 52- 
 
84 SIMPLE INFLAMMATION OP THE BRAIN. 
 
 but feeble ; pupils rather dilated : she took some food. In the afternoon 
 of the 23d the convulsion returned with greater severity ; and on the 
 24th there was a constant succession of paroxysms during the whole 
 day, with sinking of the vital powers; and she died early in the 
 evening. 
 
 "On removing the dura mater, the surface of the brain appeared in 
 many places covered by a deposition of adventitious membrane betwixt 
 the arachnoid and pia mater. It was chiefly found above the openings 
 between the convolutions, and in some places appeared to dip a little 
 way between them. The arachnoid membrane when detached appeared 
 to be healthy, but the pia mater was throughout in the highest state of 
 vascularity, especially between the convolutions ; and when the brain 
 was cut vertically, the spaces between the convolutions were most strik- 
 ingly marked by a bright line of vivid redness, produced by the inflamed 
 membrane. There was no effusion in the ventricles, and no other 
 morbid appearance." 
 
 It would not answer any useful purpose to multiply the recital of 
 cases, since though there are great varieties in the duration of the 
 disease, yet its general features are the same in almost every instance, 
 and will, I think, readily be recognized by you as betokening an affec- 
 tion very different from ordinary hydrocephalus. 
 
 The morbid appearances are sometimes found to vary both in their 
 degree and in their extent, without any corresponding difference being 
 observed in the symptoms. With the exception of its course being more 
 rapid, Golis's case differed but little from that recorded by Dr. Aber- 
 crombie. I believe that in the majority of instances the lining of the 
 ventricles is affected ; and it is certainly more common for the mem- 
 branes at the base of the brain to be involved in the disease, than for it 
 to be entirely limited to those at the convexity. It may also be doubted 
 whether the membranes of the spinal cord are not also affected in 
 the greater number of cases ; but unfortunately the histories of but few 
 post-mortem examinations contain complete details with reference to 
 their condition. I have had the opportunity of examining five fatal 
 cases of acute meningitis in infants or children, and in three of these 
 there was not only abundant deposit of lymph on the surface of the 
 convolutions, but it was effused copiously at the base of the brain ; the 
 ventricles contained turbid serum intermixed with flakes of lymph ; and 
 the membranes of the spinal cord were inflamed, and coated in many 
 parts with lymph and pus. In all of these three cases the children were 
 under a year old, and the disease came on without any assignable cause, 
 as it did also in the case of another little boy, aged 13 months. In that 
 instance, however, no lymph was effused anywhere ; the ventricles con- 
 tained only a small quantity of transparent fluid, and the most remark- 
 able appearance consisted in an intense injection of the pia mater of the 
 convexity and of the surface of the convolutions for about two lines in 
 depth, the cerebral substance in that situation being softened, so that 
 portions of it were removed when the pia mater was stripped off. In 
 another instance, where all the symptoms of encephalitis succeeded to 
 an injury of the neck and head, the membranes at the convexity of the 
 brain, and also the choroid plexuses and the velum interpositum, were 
 
SIMPLE INFLAMMATION OF THE BRAIN. 85 
 
 intensely red; there was much effusion in the sub-arachnoid tissue ; not 
 much in the lateral ventricles, though their lining was considerably 
 thickened. The substance of the brain was injected and much softer 
 than natural, especially towards the centre of the organ and at its left 
 side. In both of these cases the membranes at the base of the brain 
 were perfectly healthy, but the spinal cord was not examined. 
 
 I have seen two other cases in which I believe that inflammation 
 existed of the meninges both of the brain and spinal cord, but in which 
 I had no opportunity of making an examination after death. These seven 
 cases constitute the whole of my experience in this formidable disease. 
 
 Acute inflammation of the brain or its membranes is fortunately of 
 very rare occurrence in childhood, except as the result of fracture of 
 the skull, or of injury to the head or neck. Exposure to the heat of the 
 sun has been known to induce it; sometimes it occurs in children who 
 are apparently recovering from scarlatina ; and at other times it occurs 
 without our being able to trace it to any definite cause. 
 
 In the treatment of this affection, our remedies must be, in the main, 
 the same as we should employ to combat the acute inflammation of any 
 other vital organ. Bleeding, purgatives, mercurials, and the application 
 of cold, are the grand means on which we must rely ; and these must 
 be used with an unsparing hand if we would have any chance of saving 
 our patient. Our prospect of success, however, depends almost entirely 
 upon our seeing the patient at the very outset. The case which I quoted 
 from Golis shewed you what extensive mischief may occur in thirteen 
 hours, and instances are on record in which a greater amount of injury 
 has been discovered after a still shorter train of symptoms. Even in 
 those cases which do not run this extremely rapid course, and in which 
 the mischief found after death is not so considerable, there is little less 
 need for speedy as well as active interference, for if life be prolonged 
 for a day or two without the disease being overcome, the patient often 
 sinks into an exhausted, or, as the French call it, an ataxic condition, 
 in which active treatment can no longer be ventured on. 
 
 Formidable though these cases are, yet if seen early, and treated 
 actively, they may be regarded more hopefully than those in which the 
 brain and its membranes become inflamed in consequence of the exten- 
 sion to them of disease beginning without the skull. You will occa- 
 sionally see instances of this occurrence in children who have suffered 
 from scrofulous disease of the cervical vertebrae, when a life of suffer- 
 ing is terminated by a most painful death ; or inflammation of the 
 brain, proving very quickly fatal, may come on in a child who has long 
 had discharge from the ear, with occasional attacks of ear-ache. Vague 
 threatenings of mischief in the head may perhaps have existed for 
 some time, just sufficient to excite your apprehension, but not so serious 
 or so definite as to call for decided interference ; and yet, when death 
 takes place, you will find it almost impossible to reconcile the existence 
 of lesions so extensive and of such long standing as a post-mortem 
 examination discovers, with the long-continued absence of definite 
 cerebral symptoms. 
 
 In Dr. Abercrombie's work on diseases of the Brain, 1 an account is 
 
 1 Page 37 ; quoted from Mr. Parkinson, in London Med. E-epository, March 1817. 
 
86 BEGINNING WITHOUT THE SKULL. 
 
 given of a boy, aged 14 years, who had been affected for two months 
 with headache and discharge of matter from the right ear. A week 
 before his death the pain increased, and was accompanied by great 
 debility, giddiness, and some vomiting. He continued in this state, 
 without stupor or any other remarkable symptom, until the day of his 
 death, when he was suddenly seized with convulsions, and died. An 
 abscess was found in the middle lobe of the right hemisphere of the 
 brain, and another in the cerebellum, and there was extensive caries of 
 the pars petrosa, with effusion of three ounces of fluid in the ventricles. 
 
 I have quoted this case in order to impress upon your minds that 
 every, even the slightest, indication of cerebral disturbance is to be 
 looked on with the greatest anxiety in children who have suffered from 
 chronic otorrhoea. Your solicitude must be redoubled if the discharge 
 from the meatus had ever been attended with the formation of abscesses 
 at the back of the ear, or burrowing between the cartilage and the 
 bone, since they would render it extremely probable that caries of the 
 bone had existed, and that the membranes of the brain had been 
 reached by the advance of the disease. 
 
 Inflammation of the brain occasionally supervenes on disease of the 
 internal ear, even though there have been no actual exposure of the dura 
 mater by destruction of the bone, and though attacks of otitis have not 
 been of frequent occurrence. Attacks of otitis, indeed, are of impor- 
 tance, not merely on account of the occasional supervention upon them 
 ,of inflammation of the brain, but also on account of the severe suffer- 
 ing by which they are always attended. In many instances, too, 
 needless alarm may be excited by the symptoms of inflammation of the 
 ear being supposed to betoken that the brain itself is the seat of the 
 mischief ; and hence it is very desirable to become familiar with the 
 diagnostic marks that distinguish the less from the more dangerous 
 affection. 
 
 Inflammation of the internal ear is most frequent before the com- 
 pletion of the first dentition, and is by no means rare in young children 
 who are perfectly unable to point out the seat of their sufferings. The 
 attack sometimes comes on quite suddenly, but usually the child is 
 fretful and languid for a period varying from a few hours to one or two 
 days before acute pain is experienced. In this premonitory stage, 
 however, it will often cry, if tossed or moved briskly, noise seems 
 unpleasant to it, and it does not care to be played with ; while children 
 who are still at the breast shew a disinclination to suck, though they 
 will take food from a spoon. The infant seeks to rest its head on its 
 mother's shoulder, or, if lying in its cot, moves its head uneasily from 
 side to side, and then buries its face in the pillow. If you watch 
 closely, you will see that it is always the same side of the head which 
 it seeks to bury in the pillow, or to rest on its nurse's arm, and that no 
 other position seems to give any ease except this one, which, after 
 much restlessness, the child will take up, and to which, if disturbed, it 
 will always return. The gentle support to the ear seems to soothe the 
 little patient ; it cries itself to sleep, but after a short doze some fresh 
 twinge of pain arouses it, or some accidental movement disturbs it, and 
 it awakes crying aloud, and refusing to be pacified, and may continue 
 
INFLAMMATION OF THE INTERNAL EAR. 87 
 
 so for hours together. Sometimes the external ear is red, and the hand 
 is often applied to the affected side of the head ; but neither of these 
 symptoms is constant. The intensity of the pain seldom lasts for more 
 than a few hours, when a copious discharge of offensive pus takes 
 place from the ear, and the child is well. Sometimes, indeed, this 
 complete cure does not take place, but the ear-ache abates, or alto- 
 gether ceases, for a day or two, and then returns ; no discharge, or 
 but a very scanty discharge taking place, while for weeks together the 
 child has but few intervals of perfect ease. In infants ear-ache seldom 
 follows this chronic course, though I have occasionally seen it do so in 
 older children. 
 
 In children who are too young to express their sufferings by words, 
 the violence of their cries, coupled with the absence of all indications 
 of disease in the chest or abdomen, naturally lead to the suspicion of 
 something being wrong in the head. There are three circumstances, 
 however, which may satisfy you that the case is not one of ordinary 
 hydrocephalus ; the child does not vomit, the bowels are not constipated, 
 and there is but little febrile disturbance. The loud and passionate 
 cry, the dread of movement, and the evident relief afforded by resting 
 one side of the head, are evidences of the ear being affected ; while 
 in many instances the movement of the hand to the head, and the red- 
 ness of the external ear, with the swelling of the meatus, concur to 
 make the diagnosis easy. Sometimes, when in doubt, you will be able 
 to satisfy yourself that the cause of suffering is in the ear, by pressing 
 the cartilages of the organ slightly inwards, which will produce very 
 evident pain on the affected side, while, if practised on the other side, 
 it will not occasion any suffering. 
 
 The treatment of this painful affection is very simple. In many 
 instances the suffering is greatly relieved by warm fomentations, or 
 by applying to the ear a poultice of hot bran or camomile-flowers. A 
 little oil, to which some laudanum has been added, may be dropped 
 into the ear, and repeated from time to time ; while if the pain be 
 extremely severe, or have continued for several hours, it may be wise 
 to apply a few leeches to the mastoid process. If the ear-ache return 
 frequently, a small blister should be applied behind the ear, or slight 
 vesication may be produced by means of the acetum cantharidis. 
 
 The possible supervention of inflammation of the brain must of course 
 be borne in mind, and any indication of its approach must be imme- 
 diately combated; but fortunately this occurs less frequently as a 
 complication of otitis than as a sequela of long-continued purulent 
 discharge from the ear, which has probably been attended with constant 
 though not very severe pain in the head. A little boy, four years old, 
 has for some time been under my care, who has suffered for the last 
 eighteen months from purulent discharge of a very offensive character 
 from both ears. After this discharge had continued for six months, an 
 abscess formed behind the left ear, which, on being opened, gave issue 
 to ^ij. of very foetid pus. A month afterwards a large portion of the 
 mastoid process of the left temporal bone was exfoliated, and for 
 several weeks after this occurrence the left side of the face was fre- 
 quently thrown into a state of twitching movement, which showed that 
 
88 TREATMENT OF OTITIS. 
 
 some of the branches of the portio dura had been Involved in the disease. 
 This symptom has disappeared for the past nine months, but the dis- 
 charge continues as foetid as ever, though now much more profuse from 
 the right than from the left ear ; and the abscess has long ceased to 
 discharge, though a fistulous opening still continues which leads down 
 to the diseased bone. This little boy is in almost constant suffering 
 from headache. Sometimes the pain is very severe, and quite prevents 
 his sleeping, and then it will abate for several days or weeks without 
 any evident cause. There can, however, be little doubt but that sooner 
 or later an acute attack of inflammation of the membranes of the brain 
 will come on, and prove quickly fatal. 
 
 In those cases where offensive puriform discharge from the ear has 
 been of long continuance, and the matter is sometimes tinged or streaked 
 with blood, astringent injections must be used only with the greatest 
 care, while their employment is not at all advisable if exfoliation of 
 bone have taken place, since in such a case not only is the internal ear 
 disorganized, but the dura mater has very probably become exposed. 
 Attention to cleanliness, by frequently syringing out the ear with warm 
 water, or with a solution of gr. j. or gr. ij. of the acetate of lead in an 
 ounce of water, constitute all the topical treatment on which it would 
 be safe to venture, while the most sedulous attention must be paid to 
 the general health of the patient. 
 
 It still remains for me to notice one singular form of cerebral disease, 
 which, though not confined to children, is seen much oftener among 
 them than among adults ; namely, phlebitis of the sinuses of the dura 
 mater. In grown persons it usually succeeds to some injury of the 
 head, but in the child it has generally been observed as a consequence 
 of long-continued purulent otorrhoea, combined with disease of the 
 temporal bone, or it has been connected with disease of the frontal 
 sinuses, or has followed an abscess of the scalp. In one or two 
 instances, also, it has seemed to be excited by the presence of large 
 collections of pus in distant parts of the body. JVL Tonnele, who has 
 written a very valuable paper on inflammation of the sinuses of the 
 dura mater in children, 1 records one instance in which it coincided with 
 a pleuritic effusion ; and a somewhat similar case has come under my 
 own notice, which I will relate, partly on account of its rarity, partly 
 because it illustrates exceedingly well the morbid appearances observed 
 in cases of this description. 
 
 A healthy little girl was attacked by scarlatina when eight months 
 old. The attack was not severe, but, after it had passed away, she did 
 not regain her previous health, but continued restless and feverish ; she 
 was sometimes sick, and her eyelids were often slightly swollen. A 
 fortnight after the rash appeared, she had one or two violent convulsive 
 seizures, but they ceased after her gums were lanced, and did not appear 
 to be in any way connected with her subsequent illness. She continued 
 out of health untill she was 10J months old, when her mother noticed, 
 in addition to the puffiness of the eyelids, a swelling of the legs and 
 abdomen, for which she came under my care when eleven months old. 
 
 1 Journal ITebdomadaire, vol. y. p. 337. 1825. 
 
INFLAMMATION OP THE SINUSES OP THE DURA MATER. 89 
 
 The legs were then very ©edematous, and fluctuation was distinctly felt 
 through the parietes of the abdomen, the urine being scanty and high 
 coloured. In the course of about three weeks her condition had 
 improved considerably, the urine having increased much, the anasarca 
 having greatly diminished, and the abdomen being 1J inch less in cir- 
 cumference. A fit of convulsions now came on without any apparent 
 cause, but no other symptoms of cerebral mischief followed it, and the 
 convulsion did not return. After the lapse of another week a discharge 
 of sero-purulent fluid took place from the umbilicus, and continued for 
 several days in quantities of from a quarter to half a pint daily. This 
 discharge was attended with an improvement rather than a deterioration 
 in the child's health ; but after it had continued for eleven days, fever 
 and dyspnoea suddenly came on, with dulness on percussion over the 
 right side of the chest, and absence of respiratory murmur in that 
 situation. The discharge ceased for a week during the urgency of the 
 thoracic symptoms, but then reappeared, though scantily. The child 
 now grew thinner and weaker, and sank into a state of hectic. No new 
 symptom came on till she was suddenly seized with extreme faintness, 
 amounting to almost perfect syncope. She rallied, however, under the 
 use of stimulants, but forty-eight hours afterwards the faintness 
 returned, and terminated in death, without any convulsion having pre- 
 ceded it, just five months and a half after the attack of scarlatina, and 
 two months after she came under my care. 
 
 On an examination of the body after death, pleurisy of the right side 
 was discovered, with about ^vj. of pus in the right pleura, and perito- 
 nitis, with Oiij. of pus in the abdomen ; the passage being still traceable 
 through which the fluid had escaped at the umbilicus. 
 
 The dura mater adhered firmly to the skull, along the posterior half 
 of the longitudinal sinus, at the torcular Herophili, and along the left 
 lateral sinus ; but elsewhere it was easily detached from the cranium. 
 
 The sinuses on the right side were healthy, but the blood within them 
 was almost entirely coagulated. The posterior half of the longitudinal 
 sinus, the torcular, the left lateral and left occipital sinuses, were blocked 
 up with fibrinous coagulum, precisely such as one sees in inflamed veins, 
 and the clot extended into the internal jugular vein. The coats of the 
 longitudinal and of the inner half of the lateral sinus were much 
 thickened, and their lining membrane had lost its polish, was uneven, 
 and presented a dirty appearance. 
 
 There was some congestion of the arachnoid, a considerable quantity 
 of fluid in the ventricles, and sections of the brain presented more 
 bloody points than natural, especially on the left side. The base of 
 the brain was perfectly healthy on the right side, but there was great 
 venous congestion beneath the middle lobe of the left hemisphere, and 
 the cerebral veins in that situation were distended with coagulum, and 
 their coats were thickened. Towards the anterior part of the left 
 middle lobe were four apoplectic effusions, in all of which the blood 
 retained its natural colour. Each of these effusions was connected 
 with an obstructed and distended vein. The largest clot extended 
 an inch into the substance of the brain ; the others were of smaller 
 extent. 
 
90 INFLAMMATION OF THE SINUSES OF THE DURA MATER. 
 
 I cannot speak to you of any symptom as pathognomonic of this 
 occurrence ; it usually comes on, as in this instance, in much debili- 
 tated children, and though it generally follows some injury or disease 
 in the neighbourhood of the brain, you will bear in mind the possibility 
 of its occurrence whenever large collections of pus exist in any part, 
 and would draw a very favourable prognosis in the event of head 
 symptoms coming on under such circumstances. 
 
 LECTUEE VIII 
 
 Chronic Hydrocephalus — Various conditions under which fluid collects in the skull 
 — divided into the.texternal and the internal — symptoms of both nearly identical — 
 changes in form and size of the head — and their mode of production — course of the 
 disease — termination almost always fatal. 
 
 Internal Hydrocephalus — important questions involved in its pathology — frequent 
 connection with malformation of brain — but also follows inflammation of lining of 
 ventricles — description of post-mortem appearances — case illustrative of its connec- 
 tion with inflammation — process of cure usually mere arrest of disease. 
 
 External' Hydrocephalus — circumstances under which it exists — its relation to 
 haemorrhage into the arachnoid. Treatment of both forms of the disease — Import- 
 ance, but difficulty, of distinguishing curable and incurable cases — Golis's plan 
 — Compression — Puncture — Cases suited for each mode of treatment. 
 
 We have now completed our examination of the acute inflammatory 
 affections of the brain, and with them we may consider that we have 
 dismissed the most important class of diseases of that organ. Before 
 we pass, however, to those in the production of which inflammation 
 bears no part, we must study one malady which forms a kind of con- 
 necting link between the two. 
 
 Chronic Hydrocephalus, or Dropsy of the Brain, is a morbid condition 
 met with in children at various ages, and coming on under a great 
 variety of circumstances. Sometimes it is congenital, and is then often, 
 though by no means invariably, associated with malformation of the 
 brain. In subsequent childhood, an excess of blood in the brain, or its 
 deficiency, or the existence of some impediment to the circulation 
 through the organ, are conditions all of which have been found to give 
 rise to the effusion of fluid into the cavities of the brain, or upon its 
 surface. Instances of chronic hydrocephalus are on record, which have 
 succeeded to haemorrhage into the sac of the arachnoid ; others, that 
 have been connected with wasting of the brain, in consequence of the 
 supply of blood being inadequate to its due nutrition, or in which oblit- 
 eration of the sinuses by disease, or the pressure of a morbid growth 
 upon some of the vessels of the brain, has interfered with the due per- 
 formance of the cerebral circulation. In many cases, however, I believe 
 as do MM. Rokitansky and Vrolik, 1 that the disease is not a mere 
 passive dropsy, nqr simply a consequence of arrested cerebral develope- 
 
 1 Rokitansky, Pathologische Anatomie, vol. ii. p. 754 ; Vrolik, Handboek der Ziekte- 
 dundige Ontleedkunde, Amsterdam, 1840, 8vo. p. 514-537. 
 
SYMPTOMS OP CHRONIC HYDROCEPHALUS. 91 
 
 merit, but that it is the result of a slow kind of inflammation of the 
 arachnoid, especially of that lining the ventricles, which may have 
 existed during foetal life, or may not have attacked the child until after 
 its birth. 
 
 According to the situation in which the fluid collects, a division has 
 been made of chronic hydrocephalus into the external and the internal ; 
 the former term being applied to cases in which the fluid collects in the 
 sac of the arachnoid ; the latter, to those in which it accumulates in the 
 ventricles of the brain. The two conditions sometimes coexist, but 
 generally they are independent of each other ; the internal hydroce- 
 phalus being the more frequent and the more important. To it, there- 
 fore, we will first direct our attention, premising, however, that the 
 symptoms of the two varieties are so nearly identical, that internal 
 hydrocephalus has often been supposed to exist in cases where an 
 examination after death has ascertained that the fluid was in reality 
 situated external to the brain. 
 
 The early symptoms of the disease vary. When it is congenital, 
 indications of cerebral disturbance are generally apparent from the 
 infant's birth. These are sometimes serious — such, for instance, as 
 convulsions, recurring almost daily; at other times they are compara- 
 tively slight, and consist in nothing more than strabismus, or a strange 
 rolling of the eyes, unattended by any very definite sign of affection of 
 the brain. The size of the head generally attracts attention before 
 long, and causes importance to be attached to symptoms which otherwise 
 might have given rise to but little anxiety. In some instances, however, 
 the increased size of the head is not very obvious until the child is a few 
 weeks old, although well-marked symptoms of mischief in the brain 
 existed from its birth. Enlargement of the head, indeed, is by no means 
 invariably the first indication of chronic hydrocephalus. In 12 out of 
 45 cases, fits, returning frequently, had existed for some weeks before 
 the head was observed to increase in size ; in 6, the enlargement of the 
 head succeeded to an attack resembling acute hydrocephalus ; and in 4 
 other instances, it had been preceded by some well-marked indication 
 of cerebral disturbance. In the remaining 23 cases, no distinct cerebral 
 symptom preceded the enlargement of the head ; but in almost every 
 instance the child's health had been noticed to be failing for some time, 
 although the cause of its illness was not apparent. 
 
 In whatever way the disease begins, impairment of the process of 
 nutrition is sure to be one among its earliest symptoms. The child may 
 suck well, and, indeed, may seem eager for food, but it loses both flesh 
 and strength ; and often, although the head has not yet attained any 
 disproportionate size, the child is unable to support it, either losing the 
 power it had once possessed, or never attaining that which, with its 
 increasing age, it ought to acquire. The bowels are usually, though not 
 invariably, constipated. Sometimes diarrhoea comes on for a day or 
 two ; but, under either condition, the evacuations are almost always of 
 an unhealthy character. Thus far, indeed, there is but little to dis- 
 tinguish the case from any other in which a young infant is imperfectly 
 nourished ; but even though no well-marked cerebral symptom be present, 
 occasional attacks of heat of the head will be observed, attended with 
 
92 CHANGES IN THE FORM OP THE SKULL. 
 
 pulsation or tension of the anterior fontanelle, while crying and restless- 
 ness often alternate with a drowsy condition, though the child almost 
 always sleeps ill at night. In many instances, too, the open condition of 
 the fontanelles and sutures excites attention long before any enlargement 
 of the head becomes perceptible. 
 
 By and by, however, the increased size of the head grows very 
 manifest, and the child's physiogonomy soon assumes the distinguishing 
 features of chronic hydrocephalus. As the disease advances the unos- 
 sified sutures become wider, the fontanelles increase in size, their angles 
 extend far into the sutures in "which they terminate, while the fluid, 
 pressing equally in all directions, tends to impart a globular shape to 
 the receptacle in which it is contained. Some of the casts upon the 
 table afford striking illustrations of this change in the form of the cra- 
 nium, which would be still more remarkable were it not for the very 
 unequal resistance of different parts of its parietes. The bones at the 
 vertex of the skull are much less firmly fixed than the others, and 
 ossification is nowhere so tardy as at the anterior fontanelle, and along 
 the inner edges of the parietal bones. Hence it results that the great 
 increase in the size of the head is effected by enlargement of the anterior 
 fontanelle, and by widening of the sagittal suture. The os frontis 
 consequently becomes pushed forwards, the parietal bones are driven 
 backwards and outwards, and the occipital bone downwards and back- 
 wards. The displacement of the bones is very obvious in this hydro- 
 cephalic skull, but it is still more striking in the two engravings which 
 I here show you. 1 You notice the great prominence of the forehead, 
 and the alteration in the position of the parietal bones, which are driven 
 backwards as well as outwards, so that the natural relations of their 
 protuberances are altogether changed ; while in this remarkable case of 
 a man named Cardinal, who, though hydrocephalic from his infancy, 
 lived to the age of 29 years, the occipital bone lies almost completely 
 in a horizontal position. You will observe, too, another remarkable 
 alteration produced by the yielding of the orbitar plates of the frontal 
 bone, which are driven by the accumulating fluid from a horizontal into 
 an oblique direction. Sometimes, indeed, they become nearly perpen- 
 dicular, when by contracting the orbits, they give to the eyeballs that 
 unnatural prominence, and that peculiar downward direction, which 
 constitute one of the most remarkable features in cases of chronic 
 hydrocephalus. 
 
 Few objects are more pitiable than a little child who is the subject of 
 far advanced chronic hydrocephalus. While the skin hangs in wrinkles 
 on its attenuated limbs, the enlarged head appears full, almost to 
 bursting, owing to the stretching of the scalp ; and the scanty growth 
 of hair does not at all conceal the distended veins that run over its 
 whole surface. The size of the skull, too, appears greater than it really 
 is, since the face not only does not partake of the enlargement, but 
 retains its infantile dimensions much longer than natural. The eyes 
 are so displaced by the altered direction of the orbitar plates, that the 
 
 1 Baillie's Morbid Anatomy, fasc. x. plate iii. fig. 1, and the drawing of Cardinal's 
 skull, in 13right's Reports, vol. ii. part 2, plate xxxv. 
 
COURSE AND TERMINATION OF THE DISEASE. 93 
 
 white sclerotica projects below the upper lid, and the iris is more than 
 half hidden beneath the lower. Often, too, there is a considerable 
 degree of convergent strabismus, or a constant rolling movement of the 
 eyeball, which the child is unable to control ; or the pupil is dilated, 
 and quite insensible to light. 
 
 The symptoms of cerebral disturbance that attend the advance of the 
 disease differ much in severity. Sometimes there is little besides a state 
 of uneasiness and restlessness, aggravated at intervals when the head 
 grows hot and the fontanelle becomes tense. In other cases convulsions 
 occur very frequently, being induced by extremely slight causes, or 
 coming on without any. In several instances I have observed spasmodic 
 attacks of difficult breathing, attended with a crowing sound in inspira- 
 tion, and those symptoms which constitute spasmodic croup, seizures of 
 which sometimes come on even before there is much enlargement of the 
 head. But, whether the cerebral symptoms are slight or severe, almost 
 every case of chronic hydrocephalus has pauses in its course, during 
 which the child seems to enjoy comparative immunity from suffering, 
 and gains flesh, while its head ceases for a time to enlarge. Nothing, 
 however, can be more variable than the frequency of these pauses, or 
 their duration. 
 
 Though almost every case of chronic hydrocephalus is fatal, yet death 
 takes place in very different ways. Children who are the subjects of 
 the disease are almost always very weakly : hence, they often give way 
 under the first serious illness that attacks them, and are carried off by 
 maladies totally unconnected with their head affection ; while many 
 others sink into that state of atrophy by which the disease of the brain 
 is often accompanied, and die exhausted. Others are carried off sud- 
 denly by convulsions, or fall victims to some severe paroxysm of spas- 
 modic croup : and there are other instances in which the disease seems 
 lighted up again, after a pause, by the irritation of teething, or by some 
 trivial accident, and death is preceded by the indications of acute 
 cerebral mischief. 
 
 The pathology of chronic internal hydrocephalus involves questions 
 not merely of scientific interest, but of great practical moment ; for 
 if we come to the conclusion at which some observers of high authority 
 have arrived, that it is almost invariably the effect of arrest of the 
 developement of the brain, all therapeutical proceedings must be worse 
 than useless. The early date of the occurrence of its symptoms, in the 
 great majority of cases, lends support, indeed, to the opinion that the 
 causes to which it is due must generally have existed before birth ; for 
 I find, on examination of the history of 54 cases, 18 of which came 
 under my own observation, that some indications of it were observed in 
 50 of this number, before the child was six months old ; that in 14 of 
 these its symptoms existed from birth; and that in 21 more, they 
 appeared before the completion of the third month. The knife of the 
 anatomist, too, has discovered evidences of congenital malformation of 
 the brain, in some instances in which no sign of hydrocephalus was 
 apparent until several weeks after the child's birth ; a fact which still 
 further deepens the dark colours in which this malady has been pour- 
 trayed. 
 
94 PATHOLOGY OF CHRONIC INTERNAL HYDROCEPHALUS. 
 
 Still, large as is the proportion of cases in which symptoms of chronic 
 hydrocephalus have existed from birth, I am disposed to believe the 
 exceptions to this not to be so extremely rare as some imagine, and am 
 further of opinion, that, even in cases of congenital hydrocephalus, 
 inflammation of the lining of the lateral ventricles, such as produces it 
 after birth, may, in some instances at least, have excited it during 
 foetal life. 
 
 In six post-mortem examinations of children affected with chronic 
 internal hydrocephalus, who died at the respective ages of 16 months, 
 3 years, 8 months, 19 months, 2 years, and 3£ years, I found the corpus 
 callosum perfect in every instance. In all, also, the fornix was present ; 
 thrice it and the septum lucidum were thickened and tough ; once they 
 were found torn and softened ; acute hydrocephalus having supervened 
 on the chronic disease. Once the septum lucidum was absent, and 
 once both it and a large portion of the fornix also were wanting. In 
 one case the state of the membranes lining the ventricles was not noted ; 
 in the other five it was thickened, four times very remarkably ; and 
 twice it was roughened and granular, a condition which is also occa- 
 sionally to be seen in fatal cases of acute hydrocephalus. 
 
 With the exception of one instance in which the accumulation of a 
 large quantity of fluid in the ventricles coexisted with a cancerous tumor 
 of the brain, the above cases constitute the whole of my experience of 
 the post-mortem appearances of chronic internal hydrocephalus ; and 
 they certainly tend to support the opinion that its connection with 
 inflammation of the lining of the ventricles is of less rare occurrence 
 than some observers have supposed. The granular condition of the 
 arachnoid lining the ventricles varies from a very slight degree, in which 
 it is perceptible only in certain lights, and scarcely conveys a sense of 
 roughness to the finger, to an unevenness as marked as that of sha- 
 green, or even to a condition in which the granulations still retaining 
 their transparency, become distinct, slightly prominent, flattened bodies, 
 a third of an inch or more in diameter, as I once observed them to be ; 
 or even acquire, as Professor Rokitansky says, 1 distinct pedicles, and 
 hang down into the cavity of the ventricles. These granulations are, 
 as far as I know, usually associated with traces of inflammation of the 
 arachnoid at other parts, while they are met with in cases where the 
 ventricles contain no excess of fluid, and in adults as well as in children, 3 
 and are far from being necessarily connected with the evidences of 
 tubercular disease, either in the brain or in other parts of the body. 
 My friend, Dr. Ormerod, has kindly communicated to me the particulars 
 of six cases in which he observed this granular state of the lining mem- 
 brane of the ventricles in the adult; and in every instance it was 
 associated with other indications of old inflammation of the arachnoid. 
 More recently, too, my friend and colleague, Dr. Kirkes, from his large 
 opportunities of observation at St. Bartholomew's Hospital, has fur- 
 nished me with an account of 24 cases, in 20 of which the subjects were 
 
 1 Pathologische Anatomie, vol. ii. p. 748. 
 
 2 The condition was, I believe, first noticed by Dr. Bright in his Medical Reports, 
 vol. ii. part 2, p. 693. 
 
INTERNAL HYDROCEPHALUS — MORBID APPEARANCES. 95 
 
 adults, the lining of whose ventricles presented this granular condition 
 in a more or less marked degree. In every instance it was associated 
 with other morbid appearances in the 'brain ; and in 16 of the number 
 the most important of these appearances were such as indicated the 
 arachnoid in other parts to have been the seat of inflammation. 1 
 
 In some cases — as, for instance, in this drawing by Professor Vrolik, 2 
 of the brain of a young man who died of chronic hydrocephalus at the 
 age of 20, — a false membrane is found in the interior of one or other 
 ventricle, and may even occlude the foramen of Monro ; an accident 
 which, by interrupting the communication between the two sides of the 
 brain, may serve to account for the unequal distension of the two ven- 
 tricles, and the great want of symmetry occasionally observed in hydro- 
 cephalic skulls. The marks of inflammation of the membranes at the 
 base of the brain are, moreover, in many instances, very evident ; and 
 there is often an extremely abundant effusion of that hyaline matter in 
 the meshes of the pia mater, to which I called your attention when 
 speaking of acute hydrocephalus. 
 
 Lastly, I may remark, that the observation in a large number of 
 instances, that the cerebral substance has been simply unfolded by the 
 accumulation of the fluid in the ventricles, so that even when of extreme 
 tenuity, the gray and white substance could still be distinguished, proves 
 not merely that the brain was not melted down by the action of the 
 fluid, but also that its accumulation could not, in these instances, be 
 due to the arrest of cerebral development. 
 
 Besides the evidence which post-mortem examinations often furnish 
 of the connection of chronic internal hydrocephalus with previous in- 
 flammatory action, the history of the patient's illness sometimes affords 
 distinct proof of its occurrence. A striking instance of this has been 
 lately published by M. Rilliet, of Geneva, 3 in the case of a little girl 
 10| years old, in whom the symptoms of acute cerebral inflammation 
 were succeeded by those of chronic disease in the brain, which termi- 
 nated fatally at the end of four months. Ten ounces of transparent 
 but highly albuminous fluid were contained in the lateral ventricles, the 
 lining membrane of which was nearly half a line thick, having a gela- 
 tinous appearance, as if softened, but being in reality so tough that it 
 could be torn away from the cerebral substance in long strips. 
 
 Though in the following history the connection between the acute 
 and the chronic evil is far less striking than in M. Billiet's case, yet I 
 think few would refuse to admit the injury to the head and the subse- 
 quent cerebral symptoms as the first steps in the chain of morbid pro- 
 cesses which led to the distension of the ventricles of the brain with 
 fluid, and to the development of all the symptoms of chronic hydro- 
 cephalus. 
 
 1 Of the 34 cases on which the above statements are founded, 8 occurred in children, 
 under 10 years old; the remainder in persons of 18 and upwards. In 11 instances, 6 
 of which occurred in children, the granular condition of the lining of the ventricles was 
 associated with tubercular disease of the brain or its membranes ; and in two others 
 tubercle was deposited in other organs; but in the remaining 21 cases neither of these 
 complications existed. 
 
 2 Traite" sur la Hydrocephalic Interne, 4to. plate iii. Amsterdam, 1839. 
 
 3 Archives Gen. de M6decine, Dec. 1847. 
 
96 INTERNAL HYDROCEPHALUS — MORBID APPEARANCES. 
 
 A little girl, the child of healthy parents, was healthy when born, 
 and continued so until she was five months old, when she fell out of the 
 arms of the person who was nursing her, and on the same day was 
 taken in a fit, and lay stupid and senseless for some hours. She was 
 leeched and blistered for these and other head symptoms which the 
 parents were unable to describe very accurately, and to all appearance 
 recovered. When a year old, however, head symptoms returned, and 
 for several weeks convulsions were of extremely frequent occurrence; 
 but at length ceased. About that time, the child being then 15 months 
 old, her mother first noticed that her head was beginning to enlarge, 
 since which time she had had no return of fits, but the head continued 
 to increase in size down to the time when I first saw her, she being 
 then just three years old. 
 
 Her countenance presented all the peculiarities of chronic hydroceph- 
 alus in a very marked degree : her head was large, measuring 20 inches 
 in circumference, and 13J from one meatus auditorius to the other ; her 
 forehead was prominent, and her eyes were directed downwards, while 
 her body was very ill nourished. Her bowels were regular, her bodily 
 functions generally natural, and she was very voracious. She was by 
 no means stupid, but on the contrary, shewed much shrewdness, though 
 she was noisy, and almost constantly chattering. 
 
 I had not seen her above once or twice when she was attacked with 
 measles, on the second day of which convulsions came on, and she sank 
 into a comatose state, interrupted only by convulsive twitchings of the 
 limbs, and died in this condition on the fourth day of her illness. 
 
 The head was examined 48 hours after death. 
 
 The bones of the cranium were quite firm and hard ; the posterior 
 fontanelle was closed, but the anterior was open ; its diameter in either 
 direction being about 3J inches. 
 
 There was no fluid in the sac of the arachnoid, nor any morbid con- 
 dition of the membranes either at the vertex or base of the brain. 
 
 A very small quantity of fluid was in the sub-arachnoid tissue, and 
 a pint of perfectly transparent serum in the lateral ventricles. 
 
 The convolutions of the brain were quite flattened : its cortical sub- 
 stance of natural thickness, the white substance very thin, and expan- 
 ded around the ventricles, which were dilated to four times their natural 
 size. 
 
 The white substance of the wall of the ventricles was quite firm, and 
 separable into a thin tough layer, leaving the substance of the brain 
 quite natural beneath. The septum lucidum was tough and membranous, 
 and much thickened. The edges of the fornix were firmly adherent to 
 the upper surface of the optic thalamus, and included between them a 
 portion of the choroid plexus. 
 
 The membrane lining the ventricles was universally thickened ; where 
 it covered the corpora striata, the optic thalami, the commissures, and 
 the floor of the fourth ventricle, it was not only peculiarly tough, but 
 granular, and presented an appearance just like shagreen. 
 
 The size of the head in this case had been increasing but slowly, and 
 probably, had the child not been cut off by the intercurrent attack of 
 measles, the effusion of fluid would at length have come to a stand-still, 
 
INTERNAL HYDROCEPHALUS— MORBID APPEARANCES. 97 
 
 and the hydrocephalus would have been cured ; at least, as much as hydro- 
 cephalus usually is. Strictly speaking, however, there is in general no 
 cure of the affection, but merely an arrest of its progress : no more 
 fluid is poured out, but that already effused is unabsorbed ; the sutures 
 and fontanelles become ossified, and the enormous size of the head 
 attracts leSs attention, not because there is any diminution in its dimen- 
 sions, but because the disproportion between the cranium and the face 
 becomes less striking owing to the development of the latter as the child 
 grows older. In some instances, indeed, Professor Otto 1 is of opinion 
 that a real cure is effected by an increased activity of the nutrition of 
 the brain producing hypertrophy of the organ ; the fluid being absorbed, 
 and nervous matter deposited in its stead. This, however, is in all 
 probability a purely exceptional occurrence ; and the majority of hydro- 
 cephalic patients who survive the advance of the disease still have their 
 lateral ventricles distended with fluid. This was all that occurred in 
 the well-known case of Thomas Cardinal, whose bust I here show you, 
 Having been hydrocephalic from infancy, he yet lived to the age of 29, 
 in the possession of a tolerable amount of bodily and mental activity. 
 On examination of his body after death, between seven and eight pints 
 of fluid were found in his cranium. In the greater number of instances 
 symptoms exist during life which show clearly enough that the arrest 
 of the disease differs widely from its cure, or that the malady of the 
 brain which it produces, or with which it was associated, is irreparable, for 
 the intellectual powers are generally feeble, and the temper very irritable, 
 while the child is often unable to walk, and its sight is very imperfect. 
 
 The presence of a large quantity of fluid in the sac of the arachnoid, 
 constituting what is called external hydrocephalus, may arise from 
 several causes. 
 
 1st. The commissures of the distended brain may yield, and a portion 
 or the whole of the fluid which it contained may escape into the cavity 
 of the cranium. This seems to have taken place in the case of Cardi- 
 nal, whose skull contained seven or eight pints of fluid, while "the 
 brain lay at its base, with its hemispheres opened outwards like the 
 leaves of a book." 2 
 
 2d. An atrophied condition of the brain may exist, and fluid may be 
 poured out to fill up the vacuum thus produced in the skull ; and such 
 cases are generally of a very hopeless kind, the defect of cerebral 
 development being almost always the result of congenital malformation 
 or intra-uterine disease. 
 
 3d. A large quantity of fluid is sometimes found in the sac of the 
 arachnoid, as the result of haemorrhage into its cavity, and of the 
 changes subsequently undergone by the effused blood. MM. Rilliet and 
 Barthez, who have most ably investigated the subject of haemorrhage 
 into the arachnoid, believe that chronic hydrocephalus frequently has 
 this origin. I have seen a few cases which I suspect were of this 
 nature, but have never had the opportunity of confirming my suspicions 
 by a post-mortem examination. 
 
 1 Rokitansky's Pathologische Anatomie, vol. ii. p. 749—769. 
 
 2 Brigkt's Reports, vol. i. part 1, p. 433. 
 
98 TREATMENT OF CHRONIC HYDROCEPHALUS. 
 
 In cases of this last kind, more may be expected both from nature's 
 own reparative powers, and from the resources of art, than in any other 
 form of chronic hydrocephalus. Unfortunately, their symptoms, as I 
 stated at the beginning of this lecture, so closely resemble those of the 
 other less hopeful varieties of the disease, that their diagnosis is atten- 
 ded with much difficulty and uncertainty, and must be founded, in great 
 measure, on the previous history of the patient. "It is never congeni- 
 tal, but generally begins about the tenth month ; that is to say, about 
 the time when the teeth begin to appear. The head, indeed, enlarges 
 gradually, but does not acquire so large a size as in internal hydroce- 
 phalus : while lastly, it is always preceded by repeated convulsions, or 
 by some other form of active cerebral disturbance, which marks the 
 date of the occurrence of haemorrhage." 1 
 
 The obsenation has often been made, that the reputed means of cure 
 of any disease are generally numerous in a directly inverse proportion 
 to its curability ; and to this rule chronic hydrocephalus certainly forms 
 no exception: "its remedies have been derived," as Golis says, " from 
 all the kingdoms of nature, and include almost every kind of surgical 
 contrivance and pharmaceutical compound." It would be an almost 
 endless task to attempt estimating the comparative value of them all ; 
 and I think it more useful to direct your attention to a few points of 
 real importance. 
 
 First of all, I would have you bear in mind that there are some cases 
 in which you can do no permanent good, but in which treatment must 
 fail, not because it is improper, but because the malady does not admit 
 of cure. Such cases are those in which the accumulation of fluid within 
 the brain is associated with extensive congenital disease, or malforma- 
 tion of the organ. If aware of its existence, our treatment would, of 
 course, be simply palliative, and our efforts would be limited to securing 
 euthanasia, since we could not hope to avert death. We should suspect 
 the affection to be incurable, if, though the head were large, and its 
 ossification very imperfect, the forehead were low and shelving ; if a 
 considerable degree of paralysis were present, if convulsions occurred 
 daily and causelessly, and especially if these or other indications of 
 serious cerebral disorder had existed almost from birth. Unfortunately, 
 these hopeless cases are by no means invariably characterized by 
 peculiar symptoms, and the amount of functional disturbance often 
 affords but a very incorrect index to the extent of organic lesion : your 
 prognosis, therefore, must always be most guarded, and even when you 
 see every reason to expect success, you must yet- be prepared for failure. 
 
 On the other hand, you must not regard a case as hopeless, and 
 abstain from remedial measures, merely on account of the head having 
 been larger than natural at birth, or its ossification having been less 
 advanced than usual, since we have evidence of perfect recovery from 
 chronic hydrocephalus in cases where many circumstances had appeared 
 to indicate that the disease was congenital. The state of the cerebral 
 functions must influence your prognosis as much as the size of the head, 
 or even more. 
 
 1 Legendre, Recherclies Anatomo-pathologiques, p. 135. See also Rilliet et Bartliez, 
 op. cit. yoI. ii. p. 46. 
 
GOLIS'S PLAN — COMPRESSION OF THE HEAD. 9$ 
 
 In either form of chronic hydrocephalus, the success of treatment 
 mnst depend, to a great degree, upon its being adopted early, but in 
 no stage of the disease can good be expected from violent remedies ; 
 rough measures would be likely to destroy the patient rather than the 
 malady. I do not know of any plan, on the whole, more likely to be 
 of service, than that which Professor Golis, of Vienna, recommended 
 as the result of many years' experience. He advises that the head of 
 the child be shorn, or its hair cut, close, and that one or two drachms 
 of the mild mercurial ointment be rubbed daily into its scalp. At the 
 same time, the head is to be kept constantly covered with a flannel cap, to 
 prevent the risk of the perspiration being checked by the cold air, and 
 gr. J, or gr. ss. of calomel, should be given twice a day, unless 
 diarrhoea come on, when the inunction alone must be employed. This 
 plan should be persevered in for thirty or forty days, when, if the 
 patient appear improving, the remedies may be very gradually dimin- 
 ished, but the cap should be still worn even after the inunction has 
 been discontinued. Should no great improvement appear after a lapse 
 of six or eight weeks, some mild diuretic may be conjoined with the other 
 remedies, and a couple of issues may be inserted in the occiput. For 
 this measure, however, I have always substituted the frequent appli- 
 cation of blisters to the back of the neck. 
 
 The woollen cap, recommended by Golis, often seems agreeable to 
 the child, but sometimes I have had to discontinue it, in consequence 
 of the heat of head which it produced. In most cases, too, you will 
 be compelled to resort to occasional leeching, in order to subdue the 
 attacks of heat of head and restlessness, which are exacerbated from 
 time to time, and often attended with other symptoms that threaten the 
 supervention of acute disease. 
 
 The observation that in some cases where spontaneous cure of a 
 chronic hydrocephalus takes place, the ossification of the head, pre- 
 viously so imperfect, makes rapid advances, and the bones become early 
 united, led Mr. Barnard, 1 of Bath, to imitate nature's processes, and 
 to bandage the head so as to prevent its yielding to the accumulating 
 fluid. He has related several cases of the successful adoption of this 
 practice, though, like many other persons, he rides his hobby rather 
 too hard, aud advocates his mechanical method to the exclusion 
 of all other treatment. It is, however, a valuable adjunct to other 
 treatment in some cases. Unless you apply it well it will be of little 
 service, and the plasters by which the compression is exerted will come 
 off. You cannot do better than follow M. Trousseau's rules for their 
 application. 2 He uses strips of diachylon plaster about one-third of 
 an inch broad ; and applies them — 1st, from each mastoid process to 
 the outer part of the orbit of the opposite side ; 2d, from the hair 
 at the back of the neck along the longitudinal suture to the root of the 
 nose ; 3d, across the whole head, in such a manner that the different 
 strips shall cross each other at the vertex ; 4th, a strip is cut long 
 enough to go thrice around the head. Its first turn passes over the eye 
 
 1 Cases of Chronic Hydrocephalus, &c. by J. H. Barnard, 8vo. London, 1839. 
 8 Journal de MSdecine, April 1843. 
 
100 PUNCTURE OP THE HEAD IN CHRONIC HYDROCEPHALUS — 
 
 brows, above the ears, and a little below the occipital protuberance, so 
 that the ends of all the other strips shall project about one-fourth of 
 an inch below the circular strip. These ends are next doubled up on 
 the circular strip, and its remaining two turns are then to be passed 
 over them just in the same direction as the first turn. By this means 
 you secure a firm, and equal, and very powerful, pressure on the head. 
 You must watch the results of this proceeding very carefully, and 
 loosen the plasters if symptoms of compression appear, since it once 
 happened to M. Trousseau, from neglect of this precaution, that the 
 fluid acted on the base of the skull, detaching the ethmoid bone from 
 its connections, and thus occasioned the infant's death. 
 
 You will naturally inquire whether pressure is applicable to every 
 case, and if not, when should it be employed ? I regret that I cannot 
 answer these inquiries so satisfactorily as I could wish. It is my belief, 
 however, that cases of external hydrocephalus, which have succeeded 
 to previous haemorrhage into the arachnoid, would be found better 
 adapted than any others to treatment by mechanical means ; while I 
 am quite sure, from actual experience, that when there is any appear- 
 ance of active cerebral disease, pressure will not do good. 
 
 Puncture of the cranium, and the evacuation of the fluid, is another 
 proceeding which has been occasionally resorted to from a very early 
 period in the history of medicine, and which is even at the present day 
 strongly advocated by some writers ; not merely as a palliative measure; 
 or as an adjunct to other remedies, but as a means of effecting the 
 radical cure of the disease. Opinion, however, is much divided as to 
 the propriety of this practice, the statistics of which certainly do not 
 yield any very encouraging results. Fify-six cases, the particulars of 
 which I published some years ago, 1 as I found them recorded in various 
 publications, yielded a proportion of fifteen alleged recoveries ; but Jon 
 subjecting these cases to a rigid analysis, it appeared that in only four 
 of this number were the particulars recorded with sufficient accuracy, 
 or had the interval since the performance of the operation been long 
 enough to warant our admitting them as permanent cures. The very 
 unfavourable conclusions which I then expressed with reference to this 
 operation were afterwards criticised by M. Durand-Fardel, 2 a gentle- 
 man whose opinion on any question connected with cerebral disease is 
 entitled to very great weight. He observed, that while it is admitted 
 that in a few cases puncture of the cranium has been followed by com- 
 plete and permanent cure, its failure on other occasions was often mani- 
 festly due to the existence of utterly incurable malformation of the brain ; 
 while in very many instances, though the operation failed to effect a 
 cure, yet the very frequency with which it was repeated proved that 
 in itself it is not usually attended with any considerable danger. Since, 
 then, it may do good, — since, if it should fail, its failure is often due to 
 causes which no remedy could remove, — since, even if it should do no 
 good, yet in the majority of instances it will do no harm, while if left 
 to itself the course of the disease is almost invariably to a fatal result, 
 
 1 In the Medical Gazette, April 1842. 
 
 2 In the Bulletin G<5n<Srale de ThOapeutique, vol. xxiii. p. 190. 
 
CASES SUITED FOR IT. 101 
 
 he advocates its performance in cases of chronic hydrocephalus. Though 
 I cannot but fear that this gentleman rather underrates the amount of 
 immediate risk attendant on the operation, yet I think that his authority 
 ought at least to have so much weight with you as to prevent your 
 looking upon its performance as altogether unjustifiable, and the rather 
 since there is good reason for believing that the accumulation of fluid 
 in the ventricles is frequently the result of previous inflammation of 
 their lining membrane, and that puncture of the cranium may therefore 
 contribute to the cure of dropsy of the brain, just as tapping the abdo- 
 men does to the cure of ascites. 1 
 
 I should regard any case as favourable for the operation, which, on the 
 whole, there was good ground for believing to be one of external hydro- 
 cephalus, or in which the enlargement of the head had not been attended 
 with indications of active cerebral disease. Though less promising, 
 I should not reject the operation simply because enlargement of the 
 head had been congenital ; while I should always be more ready to 
 operate if nutrition were well performed than if the child were emaciated. 
 I would not, however, have you operate simply because the head is large ; 
 for it does not appear that diminution in its size has resulted from the 
 puncture, but only arrest of its enlargement ; and if the disease be at a 
 stand-still, and the cerebral functions tolerably well performed, you 
 would risk much with the chance of gaining but very little. 
 
 The proper situation for the puncture is the coronal suture, about an 
 inch or an inch and a half from the anterior fontanelle. A fine trocar 
 and canula are the best instruments ; and care must be taken not merely 
 to withdraw only a very few ounces of fluid at a time, but to keep up 
 pressure both during the escape of the fluid as well as afterwards. 
 
 LECTURE IX. 
 
 Hypertrophy op the Brain — usually associated -with general disorder of nutrition — 
 symptoms and course — seldom directly fatal — nature of change in brain — alterations 
 in form "of skull, and difference from chronic hydrocephalus — Treatment — Partial 
 hypertrophy. 
 
 Atrophy op the brain — case illustrative of its defective developement — Wasting of the 
 brain in protracted illness. — Temporary retrocession of mental powers in children 
 after long illness. — Case of partial atrophy. 
 
 The anxiety of parents is sometimes needlessly excited in consequence 
 of an infant's head being larger than common, and even though the 
 child's health be good the relations are apprehensive lest it should be 
 affected with water in the brain. Now you must not be too ready to take 
 up this cry, which is one often raised by nurses and ignorant persons, or to 
 suppose that every large head is therefore unnatural ; for one child may 
 have a bigger head than another, just as it may have a bigger hand or 
 
 1 See, moreover, some remarks on this operation, and cases of its successful perform- 
 ance, in the Oesterr. Med. Jahrbucher, vol. xxii. p. 27, by Dr. Schopf-Merei, now of 
 Manchester, late the distinguished director of the Children's Hospital at Pesth. 
 
102 HYPERTROPHY OP THE BRAIN. 
 
 foot. But it may be that the child's head is not only larger than 
 natural, but that well-marked symptoms of cerebral disturbance are 
 present, and you may feel yourselves compelled to adopt the opinion 
 that the case is one of incipient chronic hydrocephalus. The subsequent 
 history of the patient may in many respects confirm your original diag- 
 nosis, so that great will be your surprise, on examining the body after 
 death, at not finding a drop of serum in the ventricles, although, when 
 you opened the skull, the cerebral convolutions had appeared flattened, 
 as if the brain were greatly distended with fluid. 
 
 Individual cases of this kind had been mentioned by medical writers at 
 different times, but Laennec 1 was the first who drew attention to hyper- 
 trophy of the brain as a condition resembling chronic hydrocephalus 
 in many of its symptoms, and liable to be mistaken for it. It has since 
 then been frequently noticed, and I am not sure that an undue impor- 
 tance has not sometimes been attached to it, as though it were of much 
 more common occurrence than you will really find it to be in practice. 
 
 I have placed upon the table a cast taken from the head of a child 
 who was affected with hypertrophy of the brain, and whose very remark- 
 able case is related by Dr. Watson. 2 He came under the care of the 
 late Dr. Sweatman when two years old, and his head, which had been 
 gradually increasing from the age of six months, was then so large as 
 by its weight to prevent the child from continuing long in the upright 
 posture. The boy was active and lively, though thin. He had never 
 any fit or convulsion, but occasionally seemed uneasy, and would then 
 relieve himself by laying his head upon a chair. He had never squinted, 
 nor was he subject to drowsiness or starting during sleep, and his 
 pupils contracted naturally. His appetite was good, and all the animal 
 functions were well performed. The case was supposed to be one of 
 chronic hydrocephalus, but no urgent symptoms being present, active 
 remedies were not employed. About six months afterwards the child 
 died of inflammation of the chest, and Dr. Sweatman examined the 
 head. It measured 12 inches from ear to ear over the vertex, 13 inches 
 from the superciliary ridges to the occipital, and 21 inches in circum- 
 ference. The anterior fontanelle, which was quite flat, measured 2\ 
 inches by 1J- across its opposite angles ; the posterior fontanelle was 
 completely closed, as was the frontal suture. The skull generally was 
 increased in thickness ; the morbid appearances in the membranes of the 
 brain were quite trivial ; the ventricles were empty, not dilated ; the con- 
 volutions were perfectly distinct, and retained their proper rounded shape. 
 The medullary matter, however, presented a very unusual vascularity. 
 
 It is not merely on account of the great size which the head attained 
 that I have quoted this history, but because it affords an instance of 
 the overgrowth of the brain unconnected with any general disorder of 
 the process of nutrition. Such an occurrence is very rare, for hyper- 
 trophy of the brain is usually only one manifestation of a deep-seated 
 disorder of the nutritive process, and is met with, in connection with 
 rickets or scrofula, in the narrow lanes of a crowded city, or in the 
 
 1 Journal de Mddecine, Chirugie, et Pharmacie, 1806. t. xi. p. 669. 
 
 2 Lectures, vol. i. p. 413. 
 
SYMPTOMS OP HYPERTROPHY OF THE BRAIN. 103 
 
 unhealthy valleys of mountainous districts, where goitre and cretinism 
 are endemic. 
 
 The majority of cases of hypertrophy of the brain that have come 
 under my notice in London, have occurred in infants about six or eight 
 months old. Their history has usually been, that without any definite 
 illness, they had lost their appetite, and grown by degrees dull and 
 apathetic, though restless and uneasy. Notwithstanding the general 
 apathy, this restlessness is often very considerable, though it does not 
 show itself in cries so much as in a state of general uneasiness, and in 
 frequent startings from sleep. Short gleams of cheerfulness occur 
 when the children are awake, but these are usually very transient. 
 The head seems too heavy to be borne, and even when its size is not 
 much greater than natural it hangs backwards, or to one side, as if 
 the muscles were too weak to support it. If placed in its cot, a child 
 who is thus affected bores with its occiput in the pillow, while its head is 
 almost constantly in a state of profuse perspiration. Convulsions some- 
 times occur without any evident cause, but threatenings of their attack 
 are much more frequent than their actual occurrence, the child awaking 
 suddenly with a start and a peculiar cry, like that of spasmodic croup, 
 the surface turning livid, and the respiration becoming difficult for a 
 few moments, and the symptoms then subsiding of their own accord. 
 Such attacks may issue in general convulsions, which may terminate 
 fatally ; but infants thus affected do not by any means invariably die of 
 the cerebral disorder, but being weakly, they are often cut off by the 
 first malady which attacks them. 
 
 If life be prolonged, it becomes more and more evident that the pro- 
 cess of nutrition is imperfectly performed: the child loses flesh, and 
 looks out of health, the enlargement of the wrists and ankles shows the 
 connection between this disease and rickets, — a connection which 
 becomes more evident in the second and third years of the child's life. 
 When the child survives infancy, or when, as occasionally happens, the 
 symptoms of hypertrophy of the brain do not come on until dentition 
 has been in a great measure accomplished, convulsions are of very rare 
 occurrence. Complaints of headache, however, are frequent and severe : 
 and, though drowsy in the day-time, the child generally rests ill at 
 night, and often awakes crying and alarmed. Besides these symptoms, 
 too, the child has occasional attacks of feverishness, with great increase 
 of the headache, and giddiness, which lasts for a few hours or a day, 
 and then subside of their own accord, while it grows by degrees more 
 and more dull and listless, and its mental powers become obviously 
 impaired. 
 
 It happens in some cases, that as the child grows older, these symp- 
 toms become less and less severe ; the health improves, the rickety 
 deformity of the limbs gradually disappears, and the infant who had 
 excited so much solicitude becomes at length a healthy child. There 
 is a termination in complete idiocy, which I have never seen in this 
 country, but a few years ago I observed some instances of it in the 
 Hospital for Cretins, near Interlachen; and Dr. Guggenbiihl, the 
 director of the institution, informed me that the association of cretinism 
 and idiocy with hypertrophy of the brain is by no means of unusual 
 
104 ITS DIAGNOSIS FROM CHRONIC HYDROCEPHALUS. 
 
 occurrence. Death is not often the direct result of the affection of 
 the brain, but generally takes place owing to the supervention of some 
 other disease. The affections, however, which prove most fatal are 
 those which favour cerebral congestion, — such as hooping-cough, or the 
 eruptive fevers, especially scarlatina. 
 
 You must not infer that hypertrophy of the brain has existed in 
 every instance in which the organ may appear to be large, and its 
 convolutions somewhat flattened, although the ventricles are free from 
 fluid. The weight and apparent size of the brain are much influenced 
 by the quantity of blood contained within it, and it may appear too 
 large for the skull simply because its vessels are over-full. 1 In true 
 hypertrophy, on the contrary, the brain is generally pale and anaemic, 
 unless death should chance to have taken place as the result of an attack 
 of cerebral congestion. Neither, indeed, is the process one of mere 
 increased growth, but the nutrition of the organ is modified in character 
 as well as increased in activity. The grey matter of the brain is but 
 little involved in it, and, with the exception of its colour being some- 
 what paler than natural, it shows scarcely any alteration. The white 
 matter, on the contrary, is both paler and firmer than in a state of 
 health ; and Professor Rokitansky 2 states, as the result of many micro- 
 scopical examinations, that its augumented bulk is not produced either 
 by the development of new nervous fibrils, or by the enlargement of 
 those already existing, but by an increase in the intermediate granular 
 matter. These changes, too, do not affect indifferently all parts of 
 the brain, but are confined to the hemispheres, and do not implicate 
 either the base of the organ or the cerebellum. 
 
 Chronic hydrocephalus is the only affection with which hypertrophy 
 of the brain is liable to be confounded : the diagnosis between the two 
 affections is often by no means easy, though it is of much importance 
 with reference both to our prognosis and our treatment, for we should 
 have more hope of the recovery of a child whose brain is merely hyper- 
 trophied, than of one whose brain is distended with fluid, while the 
 means by which we should endeavour to effect a cure would differ widely 
 in the two cases. The history of the patient would afford some help 
 towards determining this question ; for the symptoms of chronic hydroce- 
 phalus generally come on earlier, and soon grow much more serious, than 
 those of hypertrophy of the brain, and the cerebral disturbance is 
 throughout much more marked in cases of the former than in those of 
 the latter kind. The form and size of the head, too, present peculiarities 
 by which you may often be enabled to distinguish between the two 
 conditions. Both diseases are attended by enlargement of the head, 
 and in both the ossification of the skull is very tardy, but the head does 
 not attain so large a size in hypertrophy of the brain, as in chronic hy- 
 drocephalus, neither are the fontanelles and sutures so widely open. 
 The skull, likewise, presents some peculiarities in form, which are so re- 
 markable as to have attracted the attention of several observers, though 
 
 1 See Mauthner's elaborate tables of the weight of the brain under various circum- 
 stances, lib. cit. sect. v. 
 * Lib. cit. vol. ii. p. 771. 
 
TREATMENT OP HYPERTROPHY OF THE BRAIN. 105 
 
 I must own that I do not thoroughly understand how they are produced. 
 The head not merely shews no tendency to assume the rounded form 
 characteristic of chronic hydrocephalus, but its enlargement is first 
 apparent at the occiput, and the bulging of the hind head continues 
 throughout especially striking. The forehead may, in the course of 
 time, become prominent and overhanging, but the eye remains deep sunk 
 in its socket, for no change takes place in the direction of the orbitar 
 plates such as is produced by the pressure of fluid within the brain and 
 which gives to the eye that unnatural prominence, and that peculiar 
 downward direction, which are so striking in cases of chronic hydroce- 
 phalus. In hydrocephalus the anterior fontanelle is tense and prominent, 
 owing to the pressure of the fluid within, but when the brain is hypertro- 
 phied there is no prominence, but an actual depression in this situation. 
 I have more than once observed this condition in a very remarkable 
 degree, the depression not being limited to the anterior fontanelle, but 
 being observable at all the sutures ; and you may notice something of 
 the kind in this cast. 
 
 When hypertrophy of the brain occurs in the adult, the symptoms 
 that arise are in great measure due to the compression which the organ 
 undergoes from its bony case being too small to contain it. These symp- 
 toms are of course obscure, while, even if the nature of the affection 
 could be recognised, its cure must be hopeless. In the infant, however, 
 and the child whose head is incompletely ossified, the immediate conse- 
 quences of the evil are far less serious, while some benefit may be 
 expected from the judicious employment of remedies, since over-devel- 
 opment of the brain in childhood is almost always associated with 
 general disorder of the process of growth and nutrition. We are not, 
 indeed, acquainted with any means by which we can directly check the 
 morbid increase of the brain, but all our efforts should be turned towards 
 improving the general health, while we interfere directly with the 
 cerebral symptoms only in so far as their urgency may render it abso- 
 lutely necessary. The child, therefore, must not be dosed with calomel 
 merely because its head is affected, though the deficient secretion of 
 bile may often render the employment of small doses of mercurials 
 necessary. Similar restrictions would apply to depletion, for we have 
 seen that the hypertrophied brain is characterised by want of blood 
 rather than by its superabundance ; but nevertheless, occasional attacks 
 of cerebral congestion may render local depletion necessary, and the 
 exacerbations of headache, with vertigo and fever, will, if severe, be 
 often benefited by its employment. I have now and then tried counter- 
 irritation by means of the tartar emetic ointment rubbed into the back of 
 the neck, with much relief to the head symptoms, in the case of children 
 who were suffering from the indications of hypertrophy of the brain, 
 but I should fear to have recourse to this measure in infants. In them, 
 indeed one of our first efforts must be to relieve the brain from the 
 constant irritation to which it is exposed when the child is in the recum- 
 bent posture, and the head rests on the yielding and imperfectly ossified 
 occiput. For this purpose we cannot do better than follow the sugges- 
 tion of a German physician, Dr. Elsasser, 1 and have a small horsehair 
 1 Der weiche Hinterkopf, 8vo. p. 205. Stuggart, 1843. 
 
106 TREATMENT OF HYPERTROPHY OF THE BRAIN. 
 
 cushion prepared for the child's head to rest on, a piece being cut out 
 of it large enough to receive the occiput. In cases both of hypertrophy 
 of the brain and of chronic hydrocephalus, I have seen the adoption of 
 this simple contrivance followed by almost immediate cessation of the 
 rotatory movement of the head, and by quiet sleep in its cot, to which 
 perhaps for weeks before the child had been a stranger. 
 
 It is not desirable that a child who suffers from this affection should 
 sleep entirely without covering to the head. The profuse perspiration 
 of the head is more effectually checked by a thin linen cap, which may 
 be changed once or twice in the night, while at the same time the child 
 is saved from the danger of catching cold. 
 
 While these hygienic proceedings, which have especial reference to 
 the head, are attended to, the child should be daily sponged with salt 
 and water, or with sea water, if it be possible to remove it to some place 
 on the coast, such as Brighton ; or it would probably be benefited by 
 immersion in a tan-bath, in which it should remain for several minutes. 
 
 The remedies under the continued use of which I have seen the most 
 good result are the extract of bark, from which you may pass to the 
 preparations of iron — such as Vinum Ferri, or the ferro-citrate of 
 quinine. 2 I have not made much trial of the iodide of potassium, since 
 in all the cases that I have seen some more decided tonic appeared 
 necessary. I have, however, given the syrup of the iodide of iron some- 
 times with advantage ; and in cases where the tendency to rickets was 
 well marked, I have observed a most decided improvement follow the 
 use of the cod-liver oil, in doses of a drachm twice a day for a child of 
 three years old. I may just mention that, notwithstanding its nauseous 
 taste, this medicine is usually readily taken by children, some of whom 
 even become fond of it. 
 
 With reference to diet, it will probably be desirable, if the child be 
 not weaned, to obtain for it a healthy wet-nurse ; while, after weaning, 
 a diet of milk, with an egg once or twice daily, will often agree better 
 than any other food. In cases of this kind, and, indeed, in all where 
 the digestive powers are feeble, a preponderance of farinaceous food is 
 not desirable, while the child may with safety be allowed a little veal 
 broth or beef-tea daily, or even a little meat if it have cut some of its 
 molar teeth. 
 
 Cases of 'partial hypertrophy of the brain are on record, in which one 
 hemisphere alone was affected, or in which some one or more of the 
 central parts of the brain greatly exceeded the natural size, whilst the 
 rest of the organ deviated in no respect from its normal condition. An 
 instance of the kind you see represented in this drawing of Dr. Mau- 
 thner's, 3 in which the right optic thalamus was as large as a hen's egg 
 in a girl of three years old. In cases of this sort sometimes no symp- 
 
 1 The tan-bath, which I have employed with very marked benefit in the case of 
 weakly and rickety children among the poor, is prepared, as directed by Dr. Els'asser, 
 by boiling three handfuls of bruised oak bark, tied up in a linen bag, in three quarts of 
 water for half an hour, and adding the jdecoction to the water of the child's bath. 
 These baths should be employed tepid, and their use should be continued every day for 
 several weeks. 
 
 2 See formulas Nos. 3 and 4 at pages 33 and 34. 
 
 3 Lib. cit. plate i., and page 189. 
 
ATROPHY OF THE BRAIN — 107 
 
 toms are present, and the anomaly is only accidentally discovered after 
 death ; whilst in others, although there are indications of cerebral dis- 
 turbance, yet they are not such as to enable us to determine the nature 
 of the evil of which they are the expression. 
 
 There is a condition of the brain the direct opposite of that which we 
 have been examining, in which the organ falls below the natural size, 
 or in which atrophy of the train exists. I do not refer here to those 
 cases where the brain is imperfectly formed/ the head exceedingly 
 small, and the child idiotic from birth ; but this state of microcephalus 
 appears sometimes to come on afterwards, owing probably, as has been 
 suggested, to premature closure of the fontanelles and sutures. Such 
 a case I saw several years ago, when a woman brought to me her boy, 
 who was three years old, the elder of two children of perfectly healthy 
 parents, none of whose relatives had ever shown any sign of consump- 
 tion, idiocy, or mental derangement. When born, this boy was perfectly 
 well formed, neither did he present any peculiarity till he was six 
 months old, when his mother began to observe that he did not look any 
 one in the face, and that he seemed to take but little notice of anything. 
 When eight months old, he began to have fits, which had since returned 
 about once a week, being preceded by extreme restlessness for a day 
 or two. The fits lasted for a quarter of an hour ; they were attended 
 by convulsive movements of both sides, and followed by drowsiness, which 
 continued for some days. The child ate and drank, though not heartily, 
 and he never seemed anxious for food. He did not distinguish between 
 what was nice and what was nasty, swallowing all things with the same 
 readiness, though deglutition appeared to be difficultly performed. He 
 had cut all his teeth, he seemed tolerably well nourished, and his body 
 and limbs were well formed. He was, however, quite unable to stand ; 
 he passed his urine and faeces under him without appearing to take the 
 slightest notice of it, and he seemed destitute of every glimmering of 
 understanding. His mother said that his head was smaller than that 
 of her infant which was only six months old. It measured 17 inches 
 in circumference around the parietal protuberances, and 11 inches 
 across the head from the centre of the meatus of one ear to the same 
 point on the opposite side. The forehead was extremely narrow, and 
 the head shelved upwards quite in a sugar-loaf shape. All the sutures 
 and fontanelles were firmly ossified, but I have unfortunately omitted 
 to record at what age they became so. I never saw this boy again, 
 but two or three similar cases have since come under my notice. I have 
 nothing more to say about them, for their cure is manifestly quite 
 hopeless, and, therefore, though they may interest us as pathologists, 
 they scarcely concern us as practical physicians. 
 
 Of much higher practical importance are those instances in which 
 the brain of children ivastes during long-continued illness. The scalp, 
 in such cases, will usually be found bloodless, the fontanelles collapsed, 
 and the process of ossification will be seen to have been unusually tardy. 
 Fluid will be found within the sac of the arachnoid, and effused into 
 the subjacent pia mater. The brain will be far from filling up the 
 cavity of the skull, so that a knife may be passed in many places 
 between it and the cranial walls. The sulci between the convolutions 
 
108 AN OCCASIONAL RESULT OF CONTINUED ILLNESS. 
 
 appear unusually deep, and fluid will be found both at the base of the 
 brain and in the ventricles, as well as in the pia mater. The cerebral 
 substance is pale, and its texture firmer than usual. 
 
 The important point about such cases is, that cerebral symptoms and 
 frequently recurring convulsions may be observed in a child whose brain 
 is nevertheless not diseased, but too feeble and too wasted to perform 
 its functions. If, then, you find indications of cerebral disturbance 
 come on in infants who have been exhausted and emaciated by previous 
 illness, you must not interpose too hastily with remedies directed against 
 a supposed disease of the brain, but bethink you whether these symp- 
 toms may not be merely the signs of the brain having become unequal 
 to its duties from its having been imperfectly nourished : and do not, 
 without consideration, abandon the tonic plan of treatment which you 
 had been previously pursuing. 
 
 It is only in infants that accidents of this grave nature are likely to 
 ensue, from the imperfect nutrition of the brain consequent on pro- 
 tracted illness ; but symptoms arise in older children, under similar 
 circumstances, well calculated to excite the apprehension of parents. 
 In children who have but lately learned to talk, I have sometimes known 
 loss of speech follow a long illness, the child being too weak to talk, 
 just for the same reason as it is too weak to walk. Occasionally, how- 
 ever, the child apparently regains its previous health, and yet makes 
 no efforts to articulate, even for two or three months. In cases of this 
 kind I have seen parents thrown into great anxiety from the fear lest the 
 child's continued silence should be the result of the intellect having 
 become impaired during its illness. I imagine that in many of these 
 cases the child has forgotten during its illness much of its newly- 
 acquired knowledge, and that it is some time before it again feels equal 
 to the mental effort of shaping its ideas into words. Usually, however, 
 when it begins to make the effort, it recovers its speech rapidly ; and 
 you may therefore console the parents with this prospect. 
 
 Even a manifest retrocession of the intellectual endowments should 
 not be regarded with too much anxiety, when it has followed some long- 
 continued disease, for it may be the result of mere weakness ; the vacant 
 look, the unmeaning laugh, and the silly manner, gradually disappear- 
 ing as the child gains strength. The brain seems to regain its lower 
 powers, and to perform its humbler functions, before it resumes its 
 nobler office as the organ of the mind. 
 
 Partial Atrophy, like partial hypertrophy of the brain, may occur 
 we know not why, and may be discovered, after death, where the exis- 
 tence of cerebral disease had never been suspected ; or we may find the 
 explanation of a number of anomalous symptoms which had existed 
 during life, in a wasted condition of some portion of the organ. This 
 state may be the result of original conformation, or it may come on as 
 the result of disease, in which latter case the substance of the wasted 
 portion of the brain is usually found to be much firmer than natural. 
 We are greatly in the dark as to the nature of the process by which 
 this change is effected ; but it is thought in some cases to be the remote 
 consequence of haemorrhage into the cerebral substance, and in others, 
 to be induced by a slow kind of inflammation. One case of this kind 
 
PARTIAL ATROPHY OP THE BRAIN. 109 
 
 has come under my own notice, which, for its rarity, I will relate to 
 you. 
 
 The patient was a little girl, aged 3 years and 10 months, the child 
 of phthisieal parents, but whose health, though delicate, had never been 
 interrupted by any serious illness until she had an attack of remittent 
 fever in the early part of the spring of 1845 : she recovered from it with- 
 out any bad symptom, and seemed doing pretty well for about a month, 
 when she became sleepy and heavy, and feverish, for which symptoms 
 she was brought to me on May 19th. After being under a mild anti- 
 phlogistic treatment for a week, she got better, and was beginning to 
 walk about again, when she awoke one morning with her face drawn to 
 one side, — a condition, however, which did not continue. When she at- 
 tempted to walk, it was noticed that she halted very much on her left leg, 
 and that it sometimes gave way under her, so that she fell down on 
 that side, and then turned round upon her back. She had, besides, 
 but little power with her left hand and arm, so that she could not grasp 
 any thing firmly, nor hold it steadily. The child's bowels were at that 
 time constipated : I purged her freely and sent her into the country, 
 when she returned in the beginning of August, much improved in every 
 respect, though still limping a little with the left leg, and using her 
 right arm in preference to the left. At the end of September I saw 
 her again, she having then a bad impetiginous eruption on the scalp, 
 which was treated with warm poultices and water dressing ; when, on 
 October 6th, she began to limp with her right leg, just as she had pre- 
 viously done with her left ; though in other respects she continued 
 pretty well. On October 17th, the affection of the right leg was a good 
 deal less marked ; but the child now became unwilling to walk, often 
 turning giddy, and always catching hold of something by which to 
 steady herself. When attempting to walk, she often fell down into a 
 sitting posture ; and then would sit on the floor, laughing loudly. Fits 
 of uncontrollable laughter often came on without any cause, and the 
 face began to assume an idiotic expression. There was occasionally 
 slight inward strabismus with both eyes, but the pulse was soft and 
 undisturbed ; the bowels were regular, and the evacuations natural, and 
 the child rested well at night, though her head was often rather hot. 
 A week afterwards there was no new symptom, except that the child 
 kept her neck quite stiff, as though she feared to move it. Her head 
 grew hotter, and she began to have a frequent teasing cough, while her 
 power of walking varied almost every day ; she now, too, grew more 
 restless at night. On the morning of the 27th, frequent convulsive 
 twitches of the muscles of the face and extremities came on, and the 
 left eye became permanently turned inwards. She had no sleep in the 
 night ; general convulsions came on at 8 A. M. on the 28th, and she 
 died convulsed two hours afterwards. 
 
 I found some deposit of tubercle in the bronchial glands, but none in 
 the brain, where I had expected to discover it. The left hemisphere of 
 the cerebellum, however, was, as you see both in this drawing and in 
 the other preparation itself, fully a third smaller than the right ; it was of 
 extremely firm consistence, quite leathery, and on making a section of 
 it, its surface presented arose tint. The halves of the pons and medulla 
 
110 PARTIAL ATROPHY OP THE BRAIN. 
 
 oblongata were of equal size, as were the two hemispheres of the cere- 
 brum. It was evident, too, that this condition was not congenital, since 
 the two halves of the skull were of equal size, and the elevations and 
 depressions in the interior of its base were precisely similar on both 
 sides. There was a little fluid at the base of the brain, but none in the 
 ventricles ; a state of general congestion of the brain and its mem- 
 branes being the only other remarkable appearances. 
 
 The spinal cord could not be examined. 
 
 There was no trace of any old effusion of blood in the substance of 
 the cerebellum, though the symptoms that occurred in May, and the 
 subsequent gradual improvement of the patient, are not easily expli- 
 cable on any other supposition than that the haemorrhage had at that 
 time taken place into the substance of the brain. The history of the 
 case presents another difficulty, in the circumstance that the disease 
 was seated on the same side as that to which the symptoms had been 
 chiefly referred. Another problem which I cannot pretend to solve is, 
 why the paralysis should in the first instance have affected the left side, 
 while, on the recurrence of the relapse in October, the right leg was 
 palsied. I must therefore content myself with the bare relation of this 
 history. 
 
 LECTUEE X. 
 
 Hydrocephaloid Disease — often succeeds to sympathetic disturbance of brain in course 
 of various affections — supervening on diarrhoea, pneumonia, and cerebral congestion 
 — diagnosis under elich of these circumstances. — Prophylaxis, and treatment. 
 
 Tubercle of the Brain — its frequency in childhood — its anatomical characters — 
 symptoms — occasionally absent — generally very obscure — diversities in this respect 
 cannot be explained by the morbid appearances. — Occasional recovery where 
 symptoms of cerebral tubercle have long existed. — Treatment. 
 
 Hydatids and Cancer of the brain. 
 
 Closely connected with the state of atrophy of the brain, which we 
 examined in the last lecture, is that condition which is induced if the 
 organ be somewhat suddenly deprived of its usual supply of blood. 
 Even in the adult a profuse loss of blood is followed, as you well know, 
 by extremely severe headache, and by various other cerebral symptoms. 
 In the child, whose brain needs for the due performance of its functions 
 a proportionably larger quantity of blood, the symptoms that follow its 
 excessive loss are of a corresponding gravity. Often, indeed, they 
 present a striking similarity to those which betoken inflammation of 
 the brain ; a fact implied in the name of the hydrocephaloid disease, by 
 which Dr. Marshall Hall, who was among the first to call the notice 
 of the profession to this affection, has proposed that it should be 
 designated. 
 
 " This affection," says he, in his admirable essay on the subject, 1 
 
 1 Republished in his work On the Diseases and Derangement of the Nervous System, 
 8vo. chap. v. sect, iii., London, 1841. It can scarcely be necessary to refer to Dr. 
 Gooch's paper "On Symptoms in Children erroneously attributed to Congestion of the 
 Brain," for another most graphic account of this disorder. 
 
HYDROCEPHALOID DISEASE. Ill 
 
 " may be divided into two stages : the first, that of irritability ; the 
 second, that of torpor. In the former there appears to be a feeble 
 attempt at reaction ; in the latter, the powers appear to be more pros- 
 trate. These two stages resemble in many of their symptoms the first 
 and second stages of hydrocephalus respectively. 
 
 " In the first stage the infant becomes irritable, restless and feverish ; 
 the face flushed, the surface hot, and the pulse frequent ; there is an 
 undue sensitiveness of the nerves of feeling, and the little patient starts 
 on being touched, or from any sudden noise ; there are sighing and 
 moaning during sleep, and screaming; the bowels are flatulent and 
 loose, and the evacuations are mucous and disordered. 
 
 " If, through an erroneous notion as to the nature of this affection, 
 nourishment and cordials be not given, or if the diarrhoea continue, 
 either spontaneously, or from the administration of medicine, the 
 exhaustion which ensues is apt to lead to a very different train of 
 symptoms. The countenance becomes pale, and the cheeks cool or 
 cold ; the eyelids are half closed ; the eyes are unfixed, and unattracted 
 by any object placed before them, the pupils unmoved on the approach 
 of light ; the breathing, from being quick, becomes irregular, and 
 affected by sighs*; the voice becomes husky ; and there is sometimes a 
 husky, teasing cough , and eventually, if the strength of the little 
 patient continue to decline, there is a crepitus or rattling in the 
 breathing. The evacuations are usually green ; the feet are apt to be 
 cold." 
 
 In early infancy symptoms of this kind sometimes succeed to prema- 
 ture weaning, especially if that be followed by an unsuitable diet ; but 
 afterwards they generally succeed to some definite attack of illness, 
 either exhausting in itself, or for the cure of which active measures had 
 been necessary. It is important, too, to bear in mind that they are 
 not equally apt to come on in the course of all diseases, but that those 
 in the early stages of which considerable cerebral irritation has existed, 
 are much more likely to assume the characters of this spurious hydro- 
 cephalus when the bodily powers' are exhausted. 
 
 There is no disorder in which the two conditions of considerable 
 sympathetic disturbance of the brain, coupled with rapid exhaustion of 
 the vital powers, are so completely fulfilled as in infantile diarrhoea, 
 and in no other affection do we meet with such frequent or such well- 
 marked instances of the supervention of the hydrocephaloid disease. 
 
 It is not long since' a previously healthy boy, aged 18 months, was 
 brought to me suffering from vomiting and diarrhoea, which had existed 
 for three days previously. After treatment had been continued for two 
 days the purging ceased, but the child seemed to have a distaste for all 
 nourishment, and refused both milk and arrow-root, and the mother 
 made but few attempts to overcome this repugnance ; so that for 
 twenty-four hours the child took hardly anything except water and 
 barley-water, and those in small quantities. On the afternoon of the 
 sixth day the child became faint, and seemed so feeble during the night 
 that the mother became much alarmed, and came again to me on the 
 morning of the seventh day. The child's face was then sunken and 
 very anxious ; it lay, as if dozing, with half-closed eyes ; breathing 
 
112 SYMPTOMS OF HYDRO CEPHALOID DISEASE. 
 
 hurriedly ; suddenly waking up from time to time in a state of alarm 
 and restlessness, and then in a few moments subsiding into its former 
 condition. The skin was dry but cool ; the extremities were almost 
 cold ; the lips were dry and parched, and some sordes had collected 
 about the teeth ; the tongue was dry, red, and glazed, and coated in 
 the centre and towards the root with yellowish fur. The pulse was 
 extremely feeble. There was very great thirst. The bowels had not 
 acted for twelve hours. 
 
 I ordered the child a table-spoonful of equal parts of milk and barley 
 water every half hour, with the addition of fifteen drops of brandy every 
 hour, and directed that some strong veal broth should be prepared and 
 given every two hours. At the same time, a draught containing ten 
 grains of aromatic confection, half a drachm of the compound tincture 
 of bark, and six drops of sal volatile, was given every three hours, and 
 a grain of Dover's powder was directed to be taken at bed-time. 
 
 Within six hours after the commencement of this treatment the child 
 began to improve ; it slept tolerably well in the night, and the next day 
 was lying tranquilly in bed, looking about and smiling cheerfully ; the 
 extremities were warmer, and the skin had lost its harshness ; the tongue 
 was no longer dry, and the pulse had increased in power. The stimu- 
 lants were gradually withdrawn ; no further bad symptoms came on, and 
 the child was soon convalescent. 
 
 It is of great importance rightly to interpret the meaning of the 
 symptoms which attend the first stage of this affection, and to discrimi- 
 nate between the cerebral disturbance of approaching exhaustion, and 
 that which implies the existence of real mischief in the brain. 
 
 A little girl was seized with diarrhoea on August 8th, which at first 
 was severe but soon yielded to treatment, and she was again conva- 
 lescent; when, on the 15th, vomiting and purging returned with great 
 violence, and were attended with much febrile disturbance. On the 
 following day she was still worse in all respects, but was not brought to 
 me again until the 17th. She then looked exceedingly ill ; her face was 
 sallow, but with a flush on each cheek, and her eyes were deeply sunk. 
 She lay in a half dozing state, with her eyelids half closed, and the eye- 
 balls turned upwards, so that nothing but the sclerotica was visible ; but 
 from this condition she awoke frequently and suddenly in a state of great 
 alarm, and looking as if she were about to have a fit of convulsions. 
 Her skin was hot and very dry ; her pulse very frequent, but not strong ; 
 and there was some subsultus of the tendons of the wrist. The abdomen 
 was rather tympanitic ; the tongue red, coated with white mucus ; the 
 thirst was great, the vomiting very frequent, and the bowels acted two 
 or three times in the course of an hour, the evacuations having the 
 appearance of dirty water. 
 
 The child was immediately placed in a tepid bath ; an enema con- 
 taining five drops of laudanum was next administered, and the abdomen 
 was covered with a large bran poultice. The extreme irritability was 
 almost immediately relieved by the warm bath, and still further soothed 
 by the enema. The bowels ceased to act so frequently, and the stomach 
 began to bear small quantities of barley water and other drinks, which 
 were given cold. In a few hours the imminent danger had passed away, 
 and the child recovered in the course of a few days. 
 
SYMPTOMS OF HYDROCEPHALOID DISEASE. 113 
 
 If, in a case of this kind, you fall into the error of regarding the 
 cerebral symptoms as the signs of active disease, and withhold the 
 Dover's powder, or the opiate enema that might have checked the 
 diarrhoea and soothed the irritability, while you apply cold lotions to 
 the head and give the child nothing more nutritious than barley water 
 in small quantities, because the irritability of the stomach which results 
 from weakness seems to you to be the indication of disease in the brain, 
 the restlessness will before long alternate with coma, and the child will 
 die either comatose or in convulsions. 
 
 But it is not only in the course of diarrhoea that errors of this sort 
 may be committed. The early stages of pneumonia are often attended 
 with so much sympathetic disturbance of the brain, as to throw the other 
 symptoms into the background. The child vomits, it refers all its suf- 
 fering to its head, and possibly has an attack of convulsions almost at 
 the outset. You not unnaturally assume the case to be one of cerebral 
 congestion, and treat it accordingly with free local depletion. On the 
 next day the indications of disordered respiration are more apparent; 
 you think your former diagnosis was incorrect, and probably apply more 
 leeches to the chest to combat the pneumonia you had overlooked. The 
 urgency of the symptoms may be relieved by these means, or, if that be 
 not the case, still the reaction will diminish with the diminished power, 
 and the child for a short time seems to suffer less. But soon the rest- 
 lessness of exhaustion comes on, and then follow the soporose condition 
 and the apparent coma ; you condemn yourself for having overlooked the 
 cerebral mischief, of which you fancy you now have most convincing 
 proof; you renew your antiphlogistic measures, to arrest, if it be not 
 too late, this imaginary hydrocephalus, and your patient dies. 
 
 Something of the same kind, too, may happen in cases where the 
 brain has really been congested, and where the depletion, which you 
 practised somewhat too freely, was in reality indicated, though to a 
 smaller amount. The restlessness and heat of head may have been 
 diminished by your treatment, and the bowels may have been relieved 
 by the purgatives you administered. In a few hours, however, rest- 
 lessness returns, though not to so great a degree as before, the child 
 moans sadly when awake, and this suffering state alternates with a 
 drowsy condition, while the stomach, irritable before, now rejects every 
 thing almost as soon as shallowed, though the child still seems eager 
 for drink. The previous arrest of very similar symptoms, though but 
 for a few hours, by active treatment, seems to you to indicate the pro- 
 priety of continuing the same plan, but nevertheless, the drowsiness 
 deepens into coma, and the child dies, of hydrocephalus, as you sup- 
 pose, — in reality of the nimia eura medici. 
 
 " Forewarned, forearmed," says the old proverb. When head symp- 
 toms come on in the infant, do not judge of their import simply from 
 the present condition of the child, but ascertain its previous history. 
 Learn whether any other members of the family have had hydrocephalus 
 or been consumptive. Inquire whether this infant has thriven at the 
 breast, or whether it has for some time been drooping ; if already 
 weaned, ascertain on what it is now fed, whether signs of declining 
 health soon followed on the change of diet, while it throve so long as 
 
114 DIAGNOSIS FROM ACTIVE CEREBRAL DISEASE. 
 
 it was suckled. Ask what signs of disorder of the bowels there have 
 been, and observe at what times the vomiting comes on ; whether only 
 after sucking, or taking food, or whether efforts to vomit occur when 
 the stomach is quite empty. 
 
 In a case where the symptoms of cerebral disturbance, and those of 
 disordered respiration, come on almost at the same time in a previously 
 healthy child, and so alternate with each other as to render your 
 diagnosis difficult, you will do well to remember that pneumonia often 
 sets in with much sympathetic disorder of the nervous system, and 
 that the disease is much more likely to be seated in the lungs than in 
 tha brain. In most cases auscultation will enable you to decide the 
 question, and if you once accustom yourselves to listen to a child's 
 chest as invariably as you would look at its tongue or count its pulse, 
 you will but seldom have to reproach yourself for the uncertain diag- 
 nosis and the vacillating treatment into which, in cases of this descrip- 
 tion, you will otherwise be too often betrayed. 
 
 In a child suffering from diarrhoea, you will be prepared to meet 
 with sympathetic disturbance of the brain, and will not allow the occur- 
 rence of its symptoms to deter you from adopting the treatment which 
 the diarrhoea requires. If doubts cross your mind as to their signifi- 
 cation, and you fear lest mischief be really going on in the brain, it 
 will usually suffice to watch the symptoms closely, in order to detect a 
 want of correspondence between them, which would not exist if true 
 cerebral disease were present. Attention to this point will guard you 
 from error during the stage of excitement, as well as in that of exhaus- 
 tion and stupor, which simulates the last stage of hydrocephalus. 
 
 Under no circumstances are mistakes more easily committed, and 
 never are their results more mischievous, than when real congestion of 
 the brain has been somewhat over-treated, and the consequent symp- 
 toms of exhaustion are supposed to be those of advancing disease. In 
 such a case, however, it would usually be observed that great faintness 
 had been induced by the first depletion, and that the quiet which suc- 
 ceeded it was that of exhaustion as much as of mitigated suffering. If 
 so, the returning restlessness would probably be the index of the feeble 
 power of the brain, no longer adequate to the performance of its wonted 
 functions, rather than the evidence of active disease of the organ. Nor 
 would the history be the only safeguard from error, but the fontanelle 
 sunk below the level of the cranial bones, instead of being tense and 
 pulsating, the cool surface, and the pulse presenting no other characters 
 than those of frequency and feebleness, would all point to the real nature 
 of the case. You do not need to be told that to deplete under such 
 circumstances would be to destroy your patient — that food is needed, 
 not physic. The sunken powers of life are to be rallied, and as their 
 strength returns, the functions of the brain will again go on harmo- 
 niously. 
 
 Although the diagnosis of this affection is sometimes attended with 
 difficulty, the rules for its prevention and its cure are happily very 
 simple. Bearing in mind the possible supervention of the hydrocephaloid 
 disease, you would never keep an infant from the breast nor put a 
 young child on a spare diet for several days, without most absolute 
 
TREATMENT OF THE AFFECTION. 115 
 
 necessity ; you would pay especial attention to its food, if the diseases 
 from which it suffers be, like diarrhoea, such as interfere directly with 
 its nutrition. Again, you would not trust depletion of a young child, 
 especially if suffering from head affection, to a nurse, but would your- 
 selves exercise the supervision of it. And, lastly, in the treatment of 
 every disease you would at once suspend the antiphlogistic measures 
 that you had previously been adopting, and resort to the use of stimu- 
 lants and tonics so soon as any of the symptoms that we have been 
 examining make their appearance. 
 
 The state of general restlessness and irritability that attends the 
 early stages of exhaustion is often greatly soothed by the tepid bath, 
 continued for not more than five minutes, for fear of still further 
 depressing the infant's powers. While you secure a free access of air, 
 too, you must be extremely cautious to maintain the room at a sufficient 
 temperature; for the power of generating heat is diminished in 
 a very remarkable degree in young animals who from any cause are 
 insufficiently nourished. The irritability of the stomach is best over- 
 come by giving nourishment in extremely small quantities, — as a dessert- 
 spoonful of asses' milk for an infant, or of veal-tea for an older child, 
 given by little and little every half hour. If the symptoms have suc- 
 ceeded to weaning, a healthy wet-nurse should, if possible, be at once 
 obtained ; but as the effort to suck seems sometimes to exhaust the 
 child, and, probably thereby to favour vomiting, it is sometimes better 
 at first to give the nurse's milk by a tea-spoon. If the exhaustion be 
 very great, and a state analogous to coma be impending, a hot mustard 
 bath is sometimes serviceable in rousing the child ; while, at the same 
 time, a few drops of sal volatile, or of brandy, may be given every few 
 hours. It is desirable, however, to suspend the use of the more powerful 
 direct stimulants so soon as it can safely be done, though a nutritious 
 diet will be necessary for some time. Tonic medicines, likewise, are 
 often of much service, few of which are preferable to the extract of 
 bark, which, dissolved in carraway water, mixed with a few drops of the 
 tincture, and well sweetened, will be taken very readily by most children. 
 The addition of a little milk to the medicine when taken still further 
 covers any unpleasant taste. 1 
 
 Those cases in which the brain becomes the seat of various morbid 
 growths still remain for us to consider, before we pass to the study of 
 affections of the spinal cord, 
 
 In the child, as in the adult, the brain may become the seat of hydatid 
 cysts, or of cancerous tumours, or of tubercular deposits ; but I should 
 not detain you long with their study, if it were not that the last of these 
 three morbid conditions, though exceedingly rare in the adult, is by no 
 means unusual in the child. Thus, while M. Louis met with only a 
 single case in which the brain contained tubercle, out of 117 examina- 
 tions of adults who had died of phthisis, MM. Rilliet and Barthez 
 discovered tubercle in the brain of 37 out of 312 children, between the 
 ages of 1 and 15, in some organ or other of whose body this morbid 
 deposit existed. You will remember that I am not now speaking of 
 
 1 See Formula No. 3, at page 33. 
 
116 TUBERCLE OF THE BRAIN. 
 
 cases where tubercle is present merely in the membranes of the brain, 
 producing that granular appearance to which I called your attention 
 when treating of acute hydrocephalus ; but my remarks refer to separate 
 deposits of tubercular matter in the substance of the brain. These 
 deposits are for the most part distinctly circumscribed, of a rounded 
 form, and varying in dimensions from the size of a millet-seed to that 
 of a split pea, or of a bean, or even larger. The largest mass that I 
 ever met with in the brain of a child was almost as big as a sugared 
 almond, but they have been seen three or four times as large. Some- 
 times there is but a single deposit in the brain, but in the majority of 
 cases there are three or four small deposits, of the size of a millet-seed, 
 or rather larger, as well as a single mass of great magnitude. Some- 
 times, though not often, the deposits of tubercle are limited to one 
 hemisphere of the brain; but it generally happens that there is a 
 marked preponderance of the affection on one side. The situation of 
 these deposits varies greatly, and they have been found in all parts of 
 the brain, both on its surface and in its interior. The smaller deposits 
 are, I think, most frequently observed on the convexity of the brain, 
 and they are then found closely adherent to the pia mater, to which 
 they remain attached if that membrane be stripped off. They seem, 
 however, to have some connection with the cerebral substance besides 
 mere juxta-position, since a thin investment of it clings to them, and 
 the place where they were situated may be seen after their removal to 
 be quite uneven. Even when situated at the base of the brain, or in 
 the cerebellum, they often retain this relation to the pia mater ; and 
 those larger masses, which generally appear more deeply seated, will 
 often be found, if the convolutions be unfolded, to have been in reality 
 not far removed from the surface. Now and then a distinct, firm, 
 fibrous capsule may be found investing the deposit; but this is oftener 
 absent, or at any rate so delicate as not to be clearly perceptible. I 
 have never seen these deposits presenting throughout the characters of 
 the grey semi-transparent tubercle frequently noticed in the lungs, but 
 once I found the exterior of a small deposit in this stage, while its cen- 
 tral part had undergone the transformation into the ordinary friable 
 yellow tuberculous matter, — a condition which Rokitansky has also occa- 
 sionally met with. Softening sometimes goes on in cerebral tubercles ; 
 the process beginning in the centre, and gradually extending towards 
 the periphery, — a condition which I have observed in 3 out of 14 cases. 
 The brain around the softened deposit is almost always of a rose tint, 
 and more or less softened, though this alteration seldom extends for a 
 distance of more than two or three lines ; and once I observed the cere- 
 bral substance perfectly unchanged around a small tubercle, in which 
 the process of softening was already considerably advanced. As a 
 general rule, the brain around deposits of crude tubercle still retains its 
 natural characters ; but to this I have seen one exception. 
 
 If death usually occurs before the process of softening has taken place 
 in the tubercular deposit, still rarer is it for life to be so prolonged as 
 to give opportunity for the occurrence of that cretaceous transformation 
 by which the disease in other organs is sometimes arrested. MM. Rilliet 
 and Barthez have observed it only twice out of 87 cases of cerebral 
 
TUBERCLE OF THE BRAIN — MORBID APPEARANCES. 117 
 
 tubercle ; and but one instance of it has come under my notice, in a boy 
 &h years old, in whom but one deposit existed, of the size of a large pea, 
 situated in the left hemisphere of the cerebellum. The change was in 
 this instance incomplete, when death took place from acute hydroce- 
 phalus, succeeding to the sudden cessation of otorrhoea. Had the child 
 lived, however, it is probable that the disease would have been altogether 
 cured, for no tubercles were present in any other organ of the body, 
 with the exception of the bronchial glands; and in them the same 
 curative process was going on. 
 
 Cerebral tubercle does not invariably affect the rounded form, but it 
 occasionally extends as a patch, half an inch or more in length, by two 
 or three lines in breadth, immediately beneath the pia mater, and not 
 reaching above one or two lines deep into the cerebral substance, which 
 is usually slightly softened beneath it. Now and then, too, the deposit 
 takes place not in distinct and isolated masses, but in the form of infil- 
 tration into the tissue of the brain, which, in this situation, is of a rose- 
 red colour, and extremely soft. This condition has come twice under 
 my notice, and was associated on both occasions with abundant tuber- 
 cular deposit in almost all the viscera. 
 
 These tubercular deposites in the cerebral substance are very often, 
 but by no means invariably, associated with that granular state of the 
 membranes which I described to you as occurring in many cases of 
 hydrocephalus. Thickening of the membranes, and effusion of hyaline 
 matter into the pia mater at the base of the brain, — the evidences, in 
 short, of meningitis, — are often present, as well as abundant effusion of 
 fluid into the ventricles, and softening of the central parts of the brain. 
 Sometimes, however, the signs of inflammation of the membranes exist 
 without any effusion into the ventricles ; and in a few instances the 
 ventricles contain an abundance of fluid, but no softening of the central 
 parts of the brain exists, nor any sign of inflammation of the membranes. 
 I know of no instance in which tubercle was limited to the brain in 
 childhood ; but if present there, it always exists in other viscera, and 
 is but one of the results of that general cachexia which may shew itself 
 in any of the various forms of scrofulous or phthisical disease. 
 
 I am unacquainted with any special cause that renders the brain 
 more liable to this disease in childhood than in adult age, or even in 
 youth. It certainly is not owing simply to the intensity of the tuber- 
 culous cachexia, and the consequently greater abundance of the morbid 
 deposit, for I have met with many instances of far more extensive 
 tubercular degeneration than existed in those cases where the brain had 
 Become its seat. 
 
 Cases are not yet recorded in numbers sufficient for us to determine 
 accurately the time of the greatest liability to this affection : Dr. Green 
 states from three to seven years of age to be the period of its greatest 
 frequency ; and MM. Rilliet and Barthez likewise consider it to be less 
 usual before than after three years of age. Their observations, it 
 should be remembered, were made at the Hopital des Enfans at Paris, 
 into which children under three years old are comparatively seldom 
 admitted. It seems probable that their estimate of the age at which 
 the disease most commonly occurs is somewhat too high, for 17 out of 
 
118 SYMPTOMS OP TUBERCLE OP THE BRAIN. 
 
 32 cases recorded by Dr. Mauthner occurred in children whose age did 
 not exceed three years ; and the same holds good with reference to 9 
 out of 14 fatal cases that came under my own notice. 
 
 We come now to the examination of a very difficult question — namely, 
 that of the symptoms of this affection. The difficulty arises from many 
 sources ; for sometimes the disease gives rise to no symptoms at all, and 
 its existence is not discovered till after death : and even when symptoms 
 are present, neither their character nor their intensity bears any inva- 
 riable relation to the extent of the local mischief or its seat ; while, 
 lastly, the symptoms that usually betoken tubercle of the brain some- 
 times exist where no such morbid growth occupies the organ. 
 
 Cases in which no symptom whatever marks during life the presence 
 of the morbid deposit in the brain, are unusual. Much more frequent 
 are those in which the sign3 of cerebral disturbance, though not entirely 
 absent, are too vague to excite much attention, and too slight to occa- 
 sion much suffering ; so that, if they do not wholly escape notice, they 
 are confounded with other indications of ill health attendant on the 
 general tuberculization with which this disease of the brain is frequently 
 associated. No reason can be assigned for this latency of the affection 
 in some instances, for it does not appear to depend either on the small 
 size of the tubercle or on its situation. To the best of my knowledge, 
 however, the brain in the immediate neighbourhood of the tubercular 
 deposit does not present any sign of softening in cases which have been 
 characterised by this absence of the signs of cerebral disturbance. It 
 would be a plausible way of explaining these cases, to assume that, 
 when symptoms are observed, they do not depend simply on the presence 
 of the tubercle, but rather on the changes in the surrounding brain. This 
 hypothesis, however, is contradicted by the fact that cerebral symptoms 
 sometimes occur in cases where no perceptible disorganization of the 
 brain has taken place either around the tubercle or elsewhere. 
 
 In the greater number of instances, the absence of cerebral symptoms 
 lasts only to within a short time of the patient's death, which takes 
 place rather suddenly under the indications of most serious cerebral 
 disease. This acute stage lasts sometimes for a few hours only, and a 
 child who had shown no sign of head affection, though probably the 
 symptoms of phthisis had long been present, suddenly sinks into a state 
 of stupor, which deepens into profound and fatal coma. In other cases 
 a fit suddenly takes place, followed by paralysis of one limb, or of the 
 whole of one side, and either is immediately succeeded by coma, or the 
 comatose condition comes on after the recurrence once or oftener of the 
 convulsions. In other instances the fatal event is preceded by t& 
 symptoms of acute hydrocephalus, which make their appearance sud- 
 denly, and run their course in a few days ; and this is, perhaps, the 
 most frequent termination of the disease. This sudden outbreak of 
 symptoms usually takes place causelessly ; but I have seen it succeed 
 to a blow on the head, even though not severe, or follow the sudden dry- 
 ing-up of an eruption on the scalp, or the sudden suppression of a dis- 
 charge from the ear. You must here observe, that, though I have 
 mentioned various ways in which the cerebral disturbance may manifest 
 itself, yet we cannot predicate, from differences in this respect, either 
 
SYMPTOMS OP TUBERCLE OP TIIE BRAIN. 119 
 
 the seat of the extent or the deposite, or the nature of the mischief that 
 is associated with it. 
 
 Quite as variable, and equally difficult of interpretation, are the 
 symptoms of the previous stage, in which, though life is not. in imme- 
 diate jeopardy, yet the functions of the brain are manifestly disordered. 
 Dr. Hennis Green, in his valuable paper on Tubercle of the Brain in 
 Children, published in Vol. XXV. of the Medico-Chirurgical Transac- 
 tions, mentions pain in the head as the most constant symptom of this 
 stage of the affection, he having met with it as a prominent feature of 
 the disease in 17 out of 20 cases. The symptom is certainly of frequent 
 occurrence, but it attends upon so many other affections, that, taken 
 by itself, its diagnostic value is but small. 
 
 It is but seldom that any connection can be traced between the seat 
 of the tubercle and the situation of the pain, which is, for the most part, 
 referred to the forehead. It is often very severe, so that during its 
 continuance the child is entirely taken up with its suffering, and shrieks 
 with the severity of the pain ; but it does not continue with this inten- 
 sity for more than a few hours, and on the next day the child will be 
 found to be no worse than usual. Vomiting in many instances attends 
 these exacerbations of pain ; and, when this is the case, the absence of 
 any gastric disorder sufficient to account for it will lead you to suspect 
 the presence of tubercle in the brain. In some cases, however, the 
 headache, though severe, does not present this remarkable intensity, 
 while there is so much permanent impairment of the general health, 
 that an occasional attack of sickness does not surprise you. On the 
 other hand, you will meet with delicate children in whom attacks of 
 violent headache, sometimes accompanied by vomiting, will come on 
 from very slight causes, or apparently without any cause at all, and will 
 return at irregular intervals for years together, till they gradually 
 subside as the health becomes more robust, and cease altogether at the 
 period of puberty, or sooner. In infants, and in children under two 
 years of age, we of course lose the evidence which is afforded by the 
 patient's complaints of headache, and can only infer it to be present 
 from the occasional loss of cheerfulness, and the attacks of fretfulness and 
 crying. Sometimes, too, the suffering of the brain shows itself in other 
 ways besides headache. The temper becomes wayward and passionate, 
 or a general dulness steals over all the faculties, and the child grows 
 quite indifferent to what is going on around it. One little boy, aged 
 two years, whom I watched for some weeks before his death, never 
 made any complaint of headache. He was fretful, and cried if moved, 
 but was perfectly quiet if allowed to remain in his chair, where he 
 would sit half dozing for hours together. 
 
 Affections of the motor system are often among the early indications 
 of this disease, but neither are they so definite as to present anything 
 pathognomonic of cerebral tubercle. A boy who died at three and a 
 half years old, and in the left hemisphere of whose cerebellum there was 
 a tubercle as large as a pea, had been subject from his earliest infancy 
 to an almost constant and involuntary rotatory movement of the head 
 when in the recumbent posture. And in another boy, who was two 
 years old at death, the head had hung for four months towards the left 
 
120 SYMPTOMS OP TUBERCLE OF THE BRAIN. 
 
 shoulder before any other symptom of mischief in the brain appeared : 
 convulsions then suddenly came on, and the child died in 72 hours. 
 Sometimes paralysis of a limb comes on gradually ; or, though actual 
 paralysis does not exist, yet the power over one side becomes greatly 
 weakened, and the child drags one leg, or is observed invariably to use 
 one arm in preference to the other. Convulsive movements, however, 
 are the most frequent of the affections of the motor system ; and para- 
 lysis of a limb, or impaired power over it, usually succeeds to their 
 occurrence, and but seldom takes place independently of them. Some- 
 times we observe nothing more than occasional attacks of convulsive 
 twitching of one limb (oftener of the arm than of the leg), unattended 
 by any loss of consciousness or impairment of intellect ; but the seizure 
 is more frequently attended by insensibility, though the convulsive 
 movement may be limited to one side, or even to one limb. Convulsions 
 affecting one side only are sometimes seen, although tubercle is present 
 in both hemispheres ; or in other instances both sides are affected by 
 the convulsions, and yet the deposite is found only in one hemisphere 
 of the brain. When convulsions, whether general or partial, have once 
 occurred, they are seldom absent for many days together, though to 
 this there are occasional exceptions, in which a pause of many months 
 ensues after the first convulsive seizure ; the general health, indeed, 
 being impaired, but no sign indicating the special mischief that exists 
 in the brain. 
 
 The transition from the premonitory to the acute stage sometimes 
 takes place gradually, the convulsions becoming more and more fre- 
 quent, and the other cerebral symptoms more serious, and the intervals 
 of freedom from suffering shorter ; or the change takes place suddenly, 
 and without such previous increase in the severity of the child's 
 sufferings as to make you anticipate its approaching death ; and yet 
 we cannot always discover such differences between the morbid appear- 
 ances in the two cases as suffice to explain the dissimilar course of the 
 disease. 
 
 Wide as the differences are between the effects mentioned as produced 
 by cerebral tubercle in one case, from those which are observed in 
 another, they are not, perhaps, so altogether inexplicable as at first 
 sight they may appear. The size or position of the deposit, or the 
 rapidity of its growth, may in one case produce pressure on the brain, 
 occasion the effusion of fluid, and thus cause the patient's death ; or the 
 accidental congestion of the brain following the arrest of some dis- 
 charge, or the healing of some eruption, or attending on some inter- 
 current febrile disorder, may render it sensible of the presence of the 
 morbid deposite which it had endured quietly for weeks or months, and 
 all the indications of serious cerebral irritation may at once become 
 apparent. In another case softening may take place in the tubercular 
 mass, and extending to the adjacent tissue, inflammation of the brain 
 may be lighted up; or the deposite not being limited to the brain itself, 
 but affecting its envelopes also, tubercular meningitis may supervene, as 
 it often does, and destroy the patient. 
 
 These considerations may serve to explain cases where the tubercular 
 deposit has been found external to the substance of the brain, merely 
 
SYMPTOMS OP TUBERCLE OP THE BRAIN. 121 
 
 pressing on it, but in no way altering its tissue. Such a case I once 
 saw in the person of a little girl, 10 years old, who for five months had 
 suffered from strumous disease of the knee-joint, but had never mani- 
 fested any head symptom during her six weeks' stay in the Middlesex 
 Hospital. She was taken home at the end of this time, but had not 
 left the hospital many hours when convulsions of the right side came 
 on, which were succeeded by coma ; and this deepened, till in the course 
 of forty-eight hours it became absolute. Convulsions occasionally 
 returned, always affecting the right side, which from the first con- 
 tinued paralysed in the intervals between their occurrence. She lay 
 thus for eight days without any sign of amendment, and then died. 
 There was a large quantity of clear serum in the lateral ventricles, and 
 much escaped from the spinal canal. There was no disease of the brain, 
 nor any important morbid appearance in the spinal cord ; but there was 
 disease about the odontoid process and its articulation with the atlas, 
 with a collection of tubercular matter around it, forming a tumor which, 
 situated in the mesial line, encroached somewhat on the occipital fora- 
 men, though pressing but very slightly on the cord. In the quiet of 
 the hospital this disease had produced no symptom ; the excitement of 
 her return home kindled the spark, and destroyed the patient. 
 
 Bearing these things in mind, too, we can account for the sudden 
 death of a child, in whom a solitary tubercle in the brain had already 
 passed into the cretaceous state, but where habitual otorrhoea had ceased 
 suddenly ; and we can understand the reason for the intermittent cha- 
 racter which the symptoms of cerebral tubercle so frequently assume. 1 
 
 I do not wish for one moment to exaggerate the difficulties that attend 
 the diagnosis of this affection ; but at the same time, if we assume that 
 we have to do with an incurable disease, we are less likely to use effi- 
 cient means of treatment than if we felt that there is still some room 
 for hope. While, therefore, I would have you bear in mind that the 
 symptoms which we have been passing in review, especially if associated 
 with indications of tubercle in other organs, render the presence of 
 tubercle in the brain in the highest degree probable, they yet do not 
 afford absolutely certain evidence of it. Headache, aggravated at 
 intervals, and associated with occasional convulsive movements of one 
 limb, and even with attacks of an epileptic character, may occur in 
 children who yet after a time recover, and shew, by the robust health 
 they subsequently attain to, that some cause of a less abiding nature 
 than tubercular deposit must have given rise to the disturbance of the 
 brain ; or, on the other hand, though serious cerebral disease may exist, 
 and such as gives rise at length to a fatal result, yet it may appear 
 after death that it was such as would have been mitigated, if not cured, 
 by appropriate treatment. 
 
 You must not, then, be merely passive spectators of these symptoms ; 
 and, if you watch cases of this kind with attention, you will generally 
 find that they afford you some clue to the treatment that you should 
 follow. Either there is manifest gastric and intestinal disorder, or 
 
 1 See, with reference to the various effects of cerebral tubercle, and the different 
 ■ways in which it may prove fatal, the excellent chapter on tubercle of the brain in 
 Dietl's work, already referred to, p. 346 — 35b*. 
 
122 DIAGNOSIS AND TREATMENT OE TUBERCLE OP THE BRAIN. 
 
 there are indications of a state of general debility, or there are signs of 
 inflammatory disease in the brain. In the first case, the regulation of 
 the bowels, and the careful management of the diet, are obviously indi- 
 cated; in the second, iron may be given with advantage, and the 
 shower-bath may be cautiously tried, and, if it do not alarm the child, 
 it may often be continued with much benefit. In those cases where 
 there seems to be some slow mischief in the brain, I have once or twice 
 seen recovery take place, contrary to all my anticipations, from the 
 employment of small doses of mercury night and morning, persevered 
 with for many weeks. In such cases, too, counter-irritation by means 
 of the tartar-emetic ointment rubbed into the back of the neck is often 
 followed by the happiest effects. A little girl, 14 months old, was 
 some time since under my care for the frequent recurrence of convul- 
 sive attacks of a very anomalous character. So long as a discharge was 
 kept up from her neck by the tartar-emetic ointment, the fits did not 
 occur ; but if the discharge ceased for two or three days, they were 
 sure to return. 
 
 These are the principles by which your conduct must be governed ; 
 but you will find that each case will present some special peculiarity, 
 and will need to be studied and treated for itself. 
 
 Tumors of other kinds may exist in the brain in childhood, though 
 they appear to be more frequent in the middle-aged or the old. I once 
 saw a case in which hydatids had formed in the substance of the brain 
 in a girl of seven years old ; and once also I saw cancer affecting the 
 brain and its membranes in a boy two and a half years old. But, 
 though such occurrences are interesting from their rarity, I do not 
 know any circumstance, except the absence of the signs of tubercular 
 disease in the patient, by which you could determine during life that 
 certain cerebral symptoms arise from hydatids or cancer of the brain, 
 and not from tubercle in that organ. 
 
 LECTUEE XI. 
 
 Diseases of the Spinal Cord — their study rendered more difficult by the tender age 
 of children. 
 
 Irritation and Congestion of the Cord. 
 
 Inflammation of the Membranes of the Cord — sometimes epidemic — not common as a 
 sporadic affection. Illustrative cases. — Inflammation of the Substance of the 
 Cord— extremely rare in its acute form — in its chronic form gives rise to symptoms 
 similar to those which occur when bones of the spine are diseased. Cases. 
 
 Trismus — extremely rare in this country — symptoms — post-mortem appearances — 
 uncertainty as to natural vascularity of the cord in early infancy. Causes of the 
 disease — influence of vitiated air — treatment almost hopeless. 
 
 At the commencement of these lectures I called your attention to 
 the predominance of the spinal over the cerebral part of the nervous 
 system, as constituting one of the grand characteristics of early life. 
 Since then, our daily course of inquiry has brought before us numerous 
 confirmations of this truth, and has shown us how slight a disturbance 
 
IRRITATION AND CONGESTION OF THE SPINAL CORD. 123 
 
 of the functions of the brain may suffice to destroy the harmony of those 
 which belong to the spinal cord. 
 
 This morning we pass from the consideration of those cases in which 
 the brain is the original seat of disorder, and in which the spinal cord 
 suffers only secondarily, to the study of others, in which that organ is 
 itself primarily affected. I need not remind you how much obscurity 
 hangs over the ailments of the spinal cord at all periods of life ; but in 
 the young subject this is not a little increased by the difficulty that 
 attends the observation of some of those symptoms which would be 
 obvious enough in the adult. Thus, for instance, while impairment or 
 loss of the locomotive power in the grown person could hardly escape 
 our notice for a moment, it might fail to attract much attention in a 
 young child, who often totters in his gait, or even becomes unable to 
 walk, if from any cause his health should fail. Or, again, the impaired 
 sensation, or the vague pains in the limbs, which the adult would be 
 sure to tell us of, would be but ill described by a child, even though it 
 had long been able to talk, while terror might cause it to cry if any 
 attempt were made to examine its back, and might thus prevent our 
 ascertaining the presence or absence of tenderness of the spine. These 
 are difficulties, however, which patience and tact will overcome ; for not 
 only the diseases of the spinal cord, but the symptoms by which they 
 manifest themselves, are much the same at all ages, the chief difference 
 being that in the one case they strike the eye even of the careless, 
 while in the other, careful observation is necessary for their detection. 
 
 Irritation of the cord, however produced, gives rise in the child, as 
 well as in the adult, to impairment of the motor power. A little boy, 
 between two and three years old, remarkably strong and healthy, was 
 observed, without any obvious cause, to fail in his general health, and 
 at the same time to totter in his gait, to become indisposed to move, 
 and, at last, almost entirely to cease walking ; and this impairment of 
 his power of walking was quite out of all proportion to the signs of ill 
 health by which it was attended. After watching him for a time, it 
 was discovered that the child had become addicted to the practice of 
 masturbation. This was put a stop to, and he soon regained his health, 
 and with it his power of walking. 
 
 The mischief to the cord may be more serious, and the symptoms 
 will then present a corresponding increase of severity. 
 
 In May, 1845, a little girl, four years old, was brought to me by her 
 mother, who said that ten days before, the child had had a fall on her 
 back, while left in tn*e charge of a servant, and that on the following 
 morning she was unable to stand or move, unless supported; and that 
 she had ever since continued in the same condition. Her appearance 
 was rather anxious ; her face slightly flushed ; skin warm and dry ; 
 tongue slightly furred ; pulse frequent, and with power. If placed on 
 her feet she clung hold of her mother, sank down into a stooping, half- 
 squatting posture, and immediately began to cry. She could walk if 
 firmly supported, but hurriedly and unsteadily, stepping on her toes, 
 her legs moving in a semi-circle with her toes turned inwards, and one 
 foot being put down just in front of the other. On examining the 
 spine, the integuments from the tenth to the twelfth dorsal vertebra 
 
124 MENINGITIS OF THE SPINAL CORD. 
 
 presented a little puffiness, and there was very great tenderness of the 
 spine in that situation ; and even when not touched, the child com- 
 plained of pain in her hack. There was no appetite, hut great thirst ; 
 the bowels were constipated ; the appearance of the urine was natural, 
 and neither feces nor urine were voided unconsciously. 
 
 She was cupped on the loins to Sit., and on the following day w'as 
 much relieved, moving her legs more readily, and suffering much less 
 from pain in the back. On the 17th she was able to stand, and could 
 walk a little without suffering. Attention was paid to keep the bowels 
 open, and in a few days she wa3 quite well. 
 
 It is probable that in this case nothing more serious was the matter 
 than some degree of congestion of the spinal cord or its membranes ; 
 but we likewise meet occasionally with instances of inflammation of 
 these parts. 
 
 Inflammation of the membranes of the spinal cord prevailed epidemi- 
 cally in many parts of France from 1842 to 1844. The victims of the 
 disease, which proved very fatal, were almost entirely youths a little 
 past the period of puberty. An epidemic of a similar kind was lately 
 prevalent in many of the hospitals and workhouses of Ireland ; but in 
 that country boys under twelve years of age were almost the only per- 
 sons who suffered from it. The arachnoid of the spinal cord was found 
 in every instance to be the part chiefly affected, though in most cases 
 the membranes of the brain seem to have been slightly involved in the 
 disease. Notwithstanding the great extent of the inflammation of the 
 membranes of the cord, and the effusion of lymph beneath them, the 
 nervous substance appears to have been comparatively seldom attacked 
 by it, and never with much severity. The disease generally came on 
 very suddenly, and its course was often extremely rapid, some patients 
 dying in twenty-four hours, while few survived the fourth day. Severe 
 pain in the abdomen, attended with vomiting and purging, and a con- 
 dition of general collapse, marked the outset of the affection. A state 
 of reaction soon succeeded, the surface in the course of a few hours 
 becoming hot, the pulse full, and its frequency varying from 120 to 
 140, while the face assumed a tetanic expression, and the head was 
 retracted and firmly fixed. General convulsions, or coma, succeeded 
 to this condition, and the failure of deglutition, with a slow and laboured 
 pulse, followed as the immediate precursors of death. 
 
 I must refer you to Dr. Mayne's account of this epidemic, which is 
 contained in the Dublin Quarterly Journal for August, 1846, for I have 
 not seen the disease in any other than a sporadic form, and even then 
 but seldom. Perhaps, therefore, I shall convey to you a more truthful 
 impression of the general characters of inflammatory affections of the 
 spinal cord and its membranes, by relating to you a few of those 
 instances that have come under my own notice, rather than by 
 attempting to draw a general portraiture of them from too small a 
 number of examples. 
 
 A boy, aged 11 years, of phthisical family, who seven months pre- 
 viously had had severe and long-continued attacks of headache, was 
 greatly distressed by hearing of the sudden death of a relation. On the 
 following day he had slight nausea, with pain in the head ; but in a day 
 
MENINGITIS OF THE SPINAL CORD. 125 
 
 or two lie suffered more from pain in his limbs, especially in the calves 
 of the legs, and also shooting from the situation of the coccyx to the 
 middle of the back. He complained, moreover, of a constant pain at 
 the epigastrium, which, as well as that about the lower part of the back, 
 was always much aggravated when the bowels acted ; they being, how- 
 ever, usually constipated. These symptoms were associated with great 
 weakness of the legs, which he dragged when walking, and reached the 
 Children's Infirmary, from which his home was about a mile distant, 
 with much difficulty. On the following day I visited him, and ascer- 
 tained; on examining the spine, that there was considerable tenderness 
 on pressure from about the middle of the dorsal vertebrae to the apex 
 of the sacrum, but greatest about the lumbar region. There was no 
 intolerance of light, but very distressing sense of giddiness, complete 
 loss of appetite, constant sensation of sickness, and a nasty taste in the 
 mouth. The intellect during the whole illness was only once affected, 
 and then but for a few hours ; and the child was remarkably acute, 
 and described his different sensations with great exactness. 
 
 The pain in the loins was relieved by cupping ; but on the next day 
 the headache was increased in severity, and there was some subsultus 
 of the tendons of the forearms, and a good deal of twitching of the 
 hands. This symptom disappeared after the boy had been depleted 
 copiously by leeches to the head, and after his gums had begun to be 
 affected by mercury, which was freely administered to him ; but his 
 pulse, which during the whole of his illness never exceeded 75, sank to 
 60 in the minute, and its beat became irregular. As the mouth became 
 decidedly sore, first the shooting pains in the back and limbs ceased ; 
 then the pulse became regular, and rose in frequency ; then the epi- 
 gastric pain disappeared, and was succeeded for a time by a sense of 
 weight there. By degrees the tenderness of the spine diminished, and 
 finally ceased, and the headache grew less ; but his legs long continued 
 weak, so that he could not tread firmly, and the slightest noise, or any 
 kind of over-exertion, brought on an immediate increase of his sufferings. 
 A seton was put in the back of his neck, and the influence of mercury 
 on the system was cautiously maintained for four months before the 
 boy appeared sufficiently well to justify the discontinuance of remedies. 
 
 But the disease may run a more acute course, and to a less favourable 
 termination. 
 
 A little boy, one year old, who had cut four incisor teeth, and whose 
 health had been habitually good, was brought to me by his mother after 
 three weeks' illness. She told me that he had been suddenly seized with 
 great fever and heat of skin, accompanied, after the lapse of four days, 
 by violent screams. At the outset of his illness he had been cupped at 
 the back of his neck, and leeches had been applied to the head, without 
 amendment, and for a week before I saw him all treatment had been 
 discontinued. The child then lay in his mother's lap, frequently crying 
 with a low distressed whimper ; his face was usually pale, but occasion- 
 ally flushed ; his head was thrown back, so that the occiput and back of 
 the neck were nearly in contact with each other. The sterno-mastoid 
 muscles were rather rigid, though there was no trismus. The hands were 
 clenched, the thumbs drawn into the palm, and occasional attacks came 
 
126 MENINGITIS OF THE SPINAL CORD. 
 
 on, in which he uttered a scream, and then bent his body back into an 
 arch. The child sucked eagerly, but frequently dropped the nipple as if 
 in pain ; the pupils acted naturally ; the pulse was frequent, small, and 
 hard. In the course of the succeeding day frequent convulsive twitch- 
 ings and startings of the limbs took place, affecting the left arm more 
 than any other part. His face grew habitually pale and more sunken, 
 and the spine became habitually, though slightly, curved forwards, not- 
 withstanding which, occasional attacks of opisthotonos still occurred. 
 The pupils still acted well, but a new symptom appeared, in the laboured 
 breathing, which sometimes became so difficult that the child seemed 
 almost choking, while phlegm collected in his throat, which he appeared 
 unable to get rid of. This dyspnoea would almost imply that the inflam- 
 mation had been gradually travelling upwards till it began to involve the 
 origins of the cerebral nerves — a supposition still further confirmed by 
 finding two days afterwards that the eyeballs were in a state of constant 
 convulsive rotation. After this, which was the fifth day from that on 
 which I first saw the child, he was not again brought to me ; but, though 
 this case is incomplete, it yet helps to fill up the portraiture of the 
 disease. To complete it, however, I must relate one instance more, in 
 which the results of examination after death confirmed the diagnosis. 
 
 Some years ago, I saw a little boy, five months old, of whom his 
 mother gave me the following history : — A month before he had been 
 attacked with shivering (an unusual occurrence in a young child), and, 
 in the night following this seizure, had many fits, during which he 
 screamed much and became very stiff. After they had continued for 
 three days, returning at intervals of an hour or half an hour, a little 
 diminution in their severity followed the use of some medicine pre- 
 scribed for him by a surgeon ; but, even when I saw him, ten or twelve 
 often occurred in the twenty-four hours, though a day would now and 
 then pass without any. The fits were described as presenting the 
 characters of opisthotonos, though in a less marked degree than when 
 they first came on. The retraction of the head with which they were 
 attended at first, subsided after their cessation ; but in the course of 
 two or three days a tendency to keep the head constantly thrown back 
 became evident, and for a fortnight the head had never been brought 
 out of that position. The mother thought, too, that the child had been 
 blind for that period. 
 
 The child appeared well grown and well nourished, and the face was 
 not expressive of particular suffering, but the head was drawn back so 
 that the occiput rested between the shoulders, while the back was bent 
 forwards in a state of perfect emprosthotonos : the legs were drawn up 
 towards the abdomen, the palms of the hands turned backwards and 
 outwards, the fingers clenched, and the thumbs drawn into the palm. 
 On turning the child round on its face, its body formed a complete arch 
 resting on the chin and knees. The whole spine was very tender, and 
 this tenderness was greatest about its upper part. The pupils were 
 dilated and immoveable ; suction was difficultly performed, though there 
 was no trismus, but the child vomited everything it took almost imme- 
 diately. The pulse was at this time too rapid and too feeble to be 
 counted, and the child died in a fit of convulsions twenty-four hours 
 afterwards. 
 
ACUTE INFLAMMATION OF THE SUBSTANCE OF THE CORD. 127 
 
 On examining the body, blood was found effused, though not in any 
 considerable quantity, within the spinal canal, but external to the dura 
 mater, from the third cervical to the third dorsal vertebra. A thick 
 layer of white lymph was present both under the arachnoid and in its 
 cavity along the whole posterior surface of the lumbar and dorsal por- 
 tions of the cord, and likewise existed in the cervical portion, though 
 in a less degree. Anteriorly, blood and lymph occupied the whole cer- 
 vical portion of the sac of the arachnoid, and were effused beneath the 
 membrane ; but in the remainder of the front of the cord there were 
 merely patches of lymph beneath the arachnoid. The substance of the 
 cord was apparently healthy. On lifting up the cerebellum, a con- 
 siderable quantity of serum, with flakes of lymph, escaped from the 
 base of the skull, and the whole under surface of the cerebellum had a 
 uniform coating of white lymph at least a line and a half in thickness, 
 which extended over the medulla oblongata, and was continuous with 
 the deposit of lymph along the spinal cord. The lateral ventricles of 
 the brain were much distended with fluid, in which large irregular 
 masses of yellow lymph were floating. The corpora striata and the 
 fornix were much softened, but the rest of the brain and the membranes 
 at its convexity were quite healthy. 
 
 It can scarcely be necessary that I should comment on these cases, 
 either to point out to you the many respects in which inflammation of 
 the spinal cord differs from that of the brain, or to insist on the absolute 
 necessity of active antiphlogistic treatment being adopted at the very 
 outset of the disease. 
 
 I apprehend that in the case that recovered, as well as in the other 
 two which terminated fatally, the membranes were chiefly, if not exclu- 
 sively, affected. I have not met with any instance of acute inflamma- 
 tion and consequent softening of the substance of the spinal cord, 
 although there are many such on record. It has been supposed that 
 paralytic symptoms usually attend this affection, while stiffness and 
 spasms of the muscles characterise spinal meningitis ; but though this 
 is probably true in many instances, yet it does not by any means hold 
 good in all. Three cases are related by MM. Rilliet and Barthez, in 
 which the disease ran its course with symptoms of tetanus and trismus, 
 which continued up to the time of the patient's death. In one of these 
 cases the child died in 36 hours ; in the second, in 96 hours ; but in the 
 third, a temporary remission having occurred, the patient survived for 
 thirteen days. 
 
 I select from Dr. Mauthner's valuable treatise on the Diseases of the 
 Brain and Spinal Cord in Children, a very characteristic case of acute 
 inflammatory softening of the spinal marrow. 1 
 
 A girl aged 11 years, whose occupation as a sempstress compelled 
 her to remain for many hours daily in a sitting posture, with her head 
 bent forwards, while she was at the same time much exposed to currents 
 of cold air, was seized, after she had followed this employment for three 
 weeks, with dragging and tearing pains in the back of her neck. As 
 these pains increased, voluntary power over the arms became impaired, 
 
 1 Lib. cit. p. 421, case 117. 
 
128 ACUTE INFLAMMATION OP THE SUBSTANCE OP THE CORD. 
 
 and, the paralysis increasing rapidly in spite of the application of 
 leeches to the back of the neck, she was admitted into the Hospital for 
 Children at Vienna, under Dr. Mauthner's care, on Dec. 26th. «Both 
 arms were at that time completely palsied, flaccid, cool, and almost 
 insensible ; the lower extremities still obeyed the will, but the girl was 
 unable to stand firmly. The mind was perfectly clear, the appetite 
 good, deglutition easy, and pulse natural ; and in these respects her 
 condition continued unchanged to the very last, except that the pulse 
 became very frequent on the day of the child's death. On the 28th, 
 tlie legs were palsied, and the urine was passed involuntarily. On the 
 29th, voluntary power over the hands and feet was likewise completely 
 lost, and sensation in them was very imperfect. On the 30th, sensa- 
 tion was perfectly lost in all the extremities. The child had desire to 
 pass feces, the bowels not having acted for three days, but she had not 
 power to do so. On the 31st, the sphincter ani was likewise paralysed, 
 and opened to the size of a shilling. On January 4th the hardened 
 faeces began to fall out of the gaping anus ; the respiration was feeble, 
 articulation difficult. On the 6th the child was in much distress, and 
 for many days had scarcely slept at all ; the whole left side of the body 
 was completely paralysed, and only the right side of the chest moved 
 in respiration. Her exhaustion was so extreme that her voice was 
 scarcely audible, but the muscles of the face still retained the power of 
 motion and sensation perfectly, and the intellect was quite clear, though 
 the child died the same night. 
 
 The spinal cord presented the only morbid appearance, the mem- 
 branes being perfectly healthy. The medulla oblongata was as soft as 
 butter, of a yellow colour, not presenting a trace of its natural organi- 
 sation ; and the same condition was presented by the whole of the 
 spinal cord as low as the cauda equina, where it once more resumed its 
 natural appearance and characters. 
 
 The chroicn form of inflammation of the cord will much oftener 
 come under your notice as one of the consequences of caries of the ver- 
 tebrae. You will remember, too, that this serious result, and the para- 
 lysis to which it gives rise, are not produced simply by the distortion 
 of the spine and the mechanical compression of the cord, but rather by 
 extension to it of the inflammatory action. You have, then, in these 
 cases a double danger to combat ; both that which arises from the dis- 
 ease in the spinal column itself, and that which depends on the probable 
 extension to the cord of the disease which began in the bones. The 
 symptoms of the two affections present likewise so many points of 
 resemblance in their early stages that you can never feel sure that the 
 cord is uninvolved. Of this we have ample proof in those rare cases in 
 which chronic softening of the cord occurs independent of any affection 
 of the bones of the spine. You will find a case that illustrates this fact 
 very well in M. Louis's valuable paper, On the Condition of the Spinal 
 Marrow in Cases of Caries of the Vertebrae ;* and I will relate to you 
 another still more remarkable instance of it, which came under my notice. 
 
 1 M6moires, ou Recherches Anatomico-Pathologiques, 8vo., Memoires viii. Observ. i. 
 p. 411. Paris, 1826. 
 
CHRONIC INFLAMMATION OF THE SUBSTANCE OF THE CORD. 129 
 
 On March 31, 1846, a little girl, aged three years and a quarter, the 
 strumous child of unhealthy parents, in whose family phthisis was 
 hereditary, was brought to me by her mother. Nine months previously 
 her father having taken her in his arms and tossed her, she suddenly 
 cried out that she was hurt, and for several days afterwards refused to 
 walk, and seemed unable to stand, sinking down on her hams if set on 
 her feet. She made no definite complaint, however; no injury was 
 anywhere observable, and in about three weeks she seemed to have 
 recovered her health, and continued well until the middle of March. 
 At that time, however, her frequent complaints of pain in the neck 
 attracted her mother's attention. The appearance of the little girl, 
 when first placed under my care, was very remarkable ; for though the 
 face wore no expression of suffering, yet the neck was so much bent as 
 to give an unusual prominence to the seventh cervical vertebra, and the 
 head was constantly directed downwards. No part of the spine seemed 
 particularly tender ; but any attempt to raise the head was forcibly 
 resisted, and seemed to occasion considerable pain. The child walked, 
 though with a tottering gait, and if left alone for a few minutes sank 
 down upon her knees to play. Her constant complaint was of being 
 tired and drowsy, notwithstanding which she slept ill ; her appetite was 
 bad, and her bowels were constipated. I regarded the case as one of 
 incipient disease of the cervical vertebrae, and was anxious to make an 
 issue in the back of the neck, but the parents refused to consent to this 
 proceeding. Medical treatment, therefore, was confined to the admin- 
 istration of the cod-liver oil, and afterwards of the syrup of the iodide 
 of iron ; but though no fresh symptoms appeared, the child gradually 
 lost strength. On the 12th of May she was able to walk a distance of 
 nearly half a mile ; but on the 14th, though not worse in other respects, 
 she was unable to raise her hands, and was forced to be fed by another 
 person. In the evening she complained of her eyes aching, but never- 
 theless slept tolerably well till 1 A. M. She then awoke crying and 
 fretful ; but on being taken up passed an evacuation, and on lying down 
 again, after a few efforts to vomit, which soon subsided, spoke a few 
 words to her mother, in whose arms she was lying. After breathing 
 in a sighing manner for a few moments she seemed to fall asleep, and 
 in this sleep died so quietly, that her mother was ignorant of it until 
 awakened by her daughter's corpse beginning to grow cold. 
 
 On examining the body after death the brain was found to be quite 
 healthy, with the exception of some venous congestion of the arachnoid. 
 The muscles of the back and the bones of the spinal column were per- 
 fectly healthy ; but on laying "open the vertebral canal, the spinal cord, 
 from a level with the third down to the seventh cervical vertebra, bulged 
 considerably, so as completely to occupy the canal, though above and 
 below this its size was natural. 
 
 In this situation the two layers of the arachnoid of the cord were 
 firmly connected together by numerous filamentous adhesions, and the 
 membrane itself was opaque and thickened. 
 
 The cord in the situation of this bulging had a shining gelatinous 
 appearance, not unlike turbid and badly made jelly, with a yellowish 
 lymph-like matter infiltrated into it. This softening involved the pos- 
 
 9 
 
130 INFANTILE TRISMUS — ITS SYMPTOMS. 
 
 terior columns of the cord much more than the anterior ; the bulging, 
 too, seemed due to the posterior columns, though the anterior presented 
 some degree of softening. 
 
 Three apoplectic effusions were discovered in the spinal cord. The 
 first was situated just below the calamus scriptorius, and was about the 
 size of a lentil ; the nervous matter all around being perfectly healthy. 
 The second, which was larger, was just at the commencement of the 
 swelling of the cord, and partially extended into the sound parts. It 
 just shewed through the surface of the cord, as big as half a pea, but 
 on longitudinally dividing the cord, was seen to be the bigness of a 
 kidney bean ; and the third effusion, just above the termination of the 
 swelling of the cord, was about as large as a big pea. Besides these 
 there were several small ecchymosed spots in the softened parts of the 
 cord, but all the effusions of blood were strictly limited to the posterior 
 columns of the cord. 
 
 This case presents many points of interest. The scrofulous diathesis ^ 
 in the family; the probable injury to the spine, followed for a short 
 time, by impairment of the motor power ; the subsequent occurrence of 
 pain in the bended neck, and the fixed position of the head, ail seemed 
 to warrant the opinion that the vertebrae were diseased ; but all resulted 
 from inflammatory softening of the spinal cord, while the bones were 
 perfectly healthy. The softening of the posterior columns of the cord, 
 and the extravasation of blood into their substance, while the anterior 
 columns were in a state of comparative integrity, are occurrences very 
 remarkable when coupled with the impaired motor power. 1 Cases such 
 as this are warnings to us to avoid hasty generalizations on physiolo- 
 gical subjects; they show us how hard some of the Sphinx's riddles are 
 to read. 
 
 There still remains one affection which we must notice in connection 
 with the disease of the spinal cord, although it is one whose pathology 
 is by no means thoroughly understood. The trismus or tetanus of new- 
 born children is a malady which, though frequent in the West Indian 
 Islands, is seldom seen in this country. Four instances of it have come 
 under my own notice, three of which occurred in the Dublin Lying-in 
 Hospital, while for the opportunity of observing the fourth I am indebted 
 to the courtesy of Mr. Stone, of Christ's Hospital. 
 
 The disease may come on within twelve hours after birth, or, on the 
 other hand, may not occur for several days ; but it rarely makes its 
 appearance after the lapse of a week. I once saw it attack a child 
 fifteen hours after its birth, but in the other cases it came on upon 
 the fifth day in one instance, and the sixth in the other two. Though 
 it runs a rapid course, yet its onset is gradual ; one of the first 
 things that attract the mother's notice being, in general, that the child 
 does not take the breast when put to it, but utters a whimpering cry, 
 and if the mouth be then examined it will be found more or less firm- 
 ly fixed. Sometimes general convulsions come on suddenly, and usher in 
 the other symptoms, but they more frequently follow than precede the 
 
 1 It is almost impossible in so young a subject to ascertain accurately the state of 
 sensation, but there was no obvious indication of its impairment in this case. 
 
TRISMUS — ITS PATHOLOGY DOUBTFUL. 131 
 
 trismus. When fully developed, these fits, which come on in paroxysms, 
 are ushered in by a screech, or attended with some impairment of the 
 respiration, and during their continuance the whole surface becomes livid. 
 The hands are strongly clenched, the feet forcibly flexed on the ankles, 
 and the toes bent, and remain so during the fit, while the trunk is curved 
 backwards in a condition of opisthotonos : the mouth is generally 
 drawn slightly open, and the lower jaw firmly fixed. When the fit 
 subsides, the muscles do not become generally relaxed, but the child 
 still lies with its hands clenched, and its thumbs drawn into the palm, 
 the legs being generally crossed, and the great toe separated widely 
 from the others, while the head is thrown back, and the opisthotonos 
 continues, though in a diminished degree. The condition of the mouth 
 is peculiar and characteristic. The jaws at first are slightly open, 
 and the corners of the mouth drawn downwards and backwards, but as 
 the disease advances the jaws become quite closed, the corners of the 
 mouth even more drawn down, and the lips firmly compressed against 
 the gums. The power of suckingis early lost, but for some time the clild 
 continues able to swallow ; at length, however, it accomplishes this 
 with great difficulty, a convulsion sometimes following the attempt, 
 while even that fluid which had apparently been swallowed is for the 
 most part speedily regurgitated. The child dies either during some 
 paroxysm of convulsions, or, seeming much exhausted, it sinks into a 
 comatose condition, and so expires. There are few affections that run 
 so fearfully rapid a course as this ; its fatal termination almost always 
 taking place within thirty-six, often within twenty-four hours from the 
 appearance of the first symptoms. 
 
 The most frequent post-mortem appearance in these cases, and that 
 which I found in the bodies of all the four children whom I observed, 
 consists of effusion of blood, either fluid or coagulated, into the cellular 
 tissue surrounding the theca of the cord. Conjoined with this there is 
 generally a congested state of the vessels of the spinal arachnoid, and 
 sometimes an effusion of blood or serum into its cavity. The signs of 
 congestion about the head are less constant, though much oftener 
 present than absent, and sometimes existing in an extreme degree, 
 while in one instance, I found not merely a highly congested state of 
 the cerebral vessels, but also an effusion of blood in considerable quan- 
 tity between the skull and dura mater, and also a slighter effusion into 
 the arachnoid cavity. 
 
 In spite, however, of the striking nature of these morbid appear- 
 ances, I formerly hesitated in referring the symptoms of trismus with 
 certainty to this apoplectic condition of the cord. My hesitation arose 
 from the circumstance that on examining some years ago the bodies of 
 infants who died soon after birth in the Dublin Lying-in Hospital, I 
 very frequently found great fullness of the vessels of the cord, and a 
 gelatinous matter, which was frequently deeply tinged with blood, 
 effused around its theca. It therefore became a question whether 
 appearances such as are met with in cases of trismus might not 
 in reality be due to the position in which the bodies had been allowed 
 to remain, resting on the back, and be rather the result of simple 
 gravitation, than the consequences of the disease. These doubts how- 
 
132 CASES OF TRISMUS. 
 
 ever, have been set at rest by the very excellent observations of Dr. 
 Weber, of Kiel, 1 who placed the bodies of infants in various positions 
 before examining them, and thus was able to descriminate between 
 morbid and pseudo-morbid appearances, and who, moreover, although 
 he on every occasion placed children who had died of trismus upon 
 their face immediately after death, yet found on every occasion intense 
 injection of the minute vessels of the cord and its membranes, extrava- 
 sation of blood external to the theca, and other appearances similar to 
 those which I have just described to you. 
 
 There are few diseases respecting the cause of which opinions so 
 various have prevailed as with regard to trismus. Bearing in mind the 
 frequency of external injury as a cause of locked-jaw in the adult, some 
 writers have sought to find in every case the history of some blow or 
 other injury to which it might possibly be attributed, while others have 
 conceived that it depended on awkward management of the navel- 
 string, or injury of some kind or other inflicted on it. This last opinion 
 has appeared to derive support from some cases in which the umbilical 
 vein has presented the signs of phlebitis : but further observation has 
 shewn these appearances to be anything but constant, and though 
 carefully sought for, they were not found in any of the cases which 
 came under my notice. Moreover, a German physician, Dr. Mildner, 
 of Prague, 2 who has recorded the results of 46 cases of fatal inflamma- 
 tion of the umbilical vessels in children born in the Lying-in Hospital 
 in that city, states that convulsions occurred in only 5 of the number, 
 and that in no instance had these convulsions the least resemblance to 
 those which characterise trismus. Congestion of the liver, impairment 
 of its functions, and icterus, were among the symptoms which attended 
 it, as well as, in many of the cases, peritonitis, inflammation of the 
 abdominal integuments, purulent injection of the blood, and the forma- 
 tion of abscesses in the joints, which occurred 33 times, while in 4 
 cases haemorrhage took place from the umbilicus. We may, then, 
 fairly conclude that the connection between this disease and trismus is 
 merely an accidental coincidence. 
 
 The remarkable frequency of the disease in hot climates, where the 
 heat of the day is succeeded by intense cold at night, favours the 
 opinion that interruption of the function of the skin, by sudden alter- 
 nations of temperature, is a powerful cause of the disease. In an 
 epidemic of this disease in the Lying-in Hospital at Stockholm, in 
 1834, 3 there seemed also to be a most marked connection between the 
 periods of its greatest prevalence and the fluctuations of temperature. 
 Nothing, however, can be more satisfactorily proved, than the tendency 
 of a vitiated state of atmosphere to produce it. Where such a condi- 
 tion exists, there trismus abounds, be the peculiarities of climate or 
 temperature what they may. It is very frequent among the children 
 of the negroes in the slave states of America : it is depopulating the 
 island of St. Kilda, and 64 per cent, of the infants born in Wcst- 
 
 1 Beitr'age zur pathologischen Anatomie der Neugebornen, 8vo. part i. pp. 6, 63, and 
 73. Kiel, 1851. 
 
 2 Prager Vierteljahrschr. v. 2. 1848; and Schmidt's Jahrb. No. 7, p. 64, 1848. 
 
 3 Cederscbjoid, in Buscb's Zeitschrift far Geburtsk, x. 345. 
 
 
CAUSES AND TREATMENT OP TRISMUS. 133 
 
 manno, a small islet off the coast of Iceland, die of it between the 5th 
 and 12th day from birth. 1 Dirt, and defective ventilation, are probably 
 almost the only points in common between the dwellers in the southern 
 states of the Union and the inhabitants of Northern Europe and the 
 Arctic Regions. But, if any further proof were needed that to this 
 cause, and not to some fancied displacement of the cranial bones, 3 this 
 disease is really to be attributed, we are furnished with it in the 
 records of the Dublin Lying-in Hospital, which point out both the evil 
 and its remedy. Sixty years ago, every sixth child born in that 
 institution died within a fortnight after birth, and trismus was the 
 cause of the death of || of these children. Dr. Joseph Clarke adopted 
 means to secure the efficient ventilation of the hospital, and the 
 mortality of the children fell at once to 1 in 19J ; and during Dr. 
 Collins's mastership, from 1826 to 1833, was only 1 in 98|, and but 
 little more than the ninth part of that mortality depended on trismus. 3 
 But though we may hope by wise hygienic measures to avert this 
 disease, yet, when once it has become developed, our prospects of cure 
 are so slender that I may almost say the task is hopeless. I have not 
 seen leeches employed, but, bearing in mind the post-mortem appear- 
 ances, should certainly be disposed to apply them freely at the outset 
 of the disease. I have seen the hot bath used with temporary relief ; 
 but though I have witnessed the employment of calomel and of anti- 
 spasmodics, as assafoetida, and the administration of an enema of gr. 
 iij. of tobacco infused for half an hour in ^viij. of water, yet I have 
 never known any of these means followed by even a temporary pause 
 in the symptoms ; and the endeavour to excite the action of the skin is 
 the only measure that in the cases which I witnessed seemed to be of 
 the slightest service. 
 
 LECTURE XII. 
 
 Night Terrors — usually depend on intestinal disorder, not on primary disease of the 
 brain — their symptoms not to be mistaken for those of incipient hydrocephalus — 
 — sometimes continue to occur for many weeks — Treatment. 
 
 Epilepsy — a disease of youth rather than of childhood — frequently recurring convul- 
 sions in childhood never to be neglected. 
 
 Chorea — often connected with disorders of approaching puberty — not peculiar to 
 childhood — principles of treatment — Partial chorea. 
 
 Paralysis — sometimes congenital — often follows very slight and temporary symptoms 
 of cerebral disturbance — most frequent during process of dentition — Recovery very 
 uncertain — great importance of early treatment — serious results of its remaining 
 uncured — Diagnosis — Treatment. 
 
 Facial Hemiplegia in new-born infants. 
 
 We have now nearly completed our examination of the disease of the 
 brain and spinal cord in childhood, but there are some affections of the 
 
 1 See a very interesting notice, in the British and Foreign Medico-Chirurgical Review 
 for April 1850, of a work by Dr. Schleisner on the Sanitary Condition of Iceland. 
 
 2 A theory prepounded by Dr. Sims, of Alabama, in the American Journal of the 
 Medical Sciences for 1846, and further expanded in the same journal for July and 
 October 1848. 
 
 3 Collins's Treatise on Midwifery, p. 513. 
 
134 NIGHT TERRORS. 
 
 nervous system which are often independent of any change in the 
 nervous centres such as our means of anatomical investigation can 
 discover, or which are but the expression of the sympathy of the brain 
 and spinal cord with the sufferings of some distant organ. To their brief 
 study we must devote the present hour. 
 
 It happens sometimes that a child who has gone to bed apparently 
 well, and has slept soundly for a short time, awakes suddenly in great 
 terror, and with a loud and piercing cry. The child will be found 
 sitting up in its bed, crying out, as if in an agony or fear, " Oh dear ! 
 oh dear ! take it away ! father! mother !" while terror is depicted on 
 its countenance, and it does not recognize its parents, who alarmed by 
 the shriek have come into its room, but seems wholly occupied with the 
 fearful impression that has aroused it from sleep. By degrees con- 
 sciousness returns, the child now clings to its mother or its nurse, 
 sometimes wants to be taken up and carried about the room, and, by 
 degrees, sometimes in ten minutes, sometimes in half an hour, it grows 
 quiet, and again falls asleep. As the terror abates, the child in some 
 instances grows quiet at once, but frequently it bursts into a fit of 
 passionate weeping and sobs itself to rest in its mother's arms. In 
 some instances a quantity of limpid urine is voided as the fit passes 
 off; but this occurrence is by no means constant. Usually the remainder 
 of the night is passed in tolerably sound sleep, and the following night 
 the child may rest quite undisturbed, or the terrors may again return, 
 and with precisely the same symptoms as before. The attack usually 
 comes on after the child has been from half an hour to a couple of 
 hours asleep ; and two attacks do not generally occur in the same night. 
 They are always more or less distinctly associated with the impression 
 of some object which occasions alarm, — as a cat or dog, which is 
 fancied to be on the bed ; and this illusion continues even after the 
 child has recognized those who are around it. The condition is not 
 one of delirium, for the child has no other hallucinations, but the attack 
 may return night after night with precisely the same characters. The 
 previous sleep sometimes seems sound, and though often uneasy, yet 
 talking in the sleep does not usually occur, and after the child has been 
 pacified it generally sleeps heavily, perhaps till morning, or till a 
 second, usually slighter attack comes on ; but this scarcely ever occurs 
 until after sleep has again lasted for an hour or longer. 
 
 Seizures of this kind may come on under a great variety of circum- 
 stances and, according to the cause whence they have arisen, may 
 continue to return for many weeks together, or may occur but a few 
 times. As far as I have had the opportunity of judging, they are never 
 the indications of primary mischief in the brain, but are always asso- 
 ciated with some disturbance of the intestinal canal, and more or less 
 obvious gastric disorder. 
 
 A few months ago I saw a little boy, aged 11 months, in whom the 
 process of dentition was just beginning, and who for ten days had had 
 slight diarrhoea, with dark and slimy evacuations. He then awoke one 
 night, though before apparently sleeping soundly, with a sudden start, 
 and a scream so violent that all the people in the house heard it. When, 
 taken out of bed he continued crying loudly for some minutes, but by 
 
SYMPTOMS USUALLY DEPEND ON INTESTINAL DISORDER — 135 
 
 degrees grew quiet and fell asleep again, sweating profusely. This 
 sleep was as heavy as it had been before, though the eyes were not 
 always closed during it, but after an uncertain interval of from half an 
 hour to two hours he would again awake with the same loud and ter- 
 rified scream, and again in a - few minutes sink into a slumber. The first 
 of these attacks had taken place six days before the child was brought 
 to me : they were increasing in frequency, as many as seven or eight 
 having occurred in the course of a single night, and even during his 
 sleep in the day time the child was not free from them. He was 
 cheerful, however, at other times ; he sucked well, did not vomit, his 
 head was not hot, and the anterior fontanelle was depressed rather than 
 prominent ; but the abdomen was rather full, and somewhat tender ; 
 the gums were much swollen, and the tongue rather furred. 
 
 The gums were lanced, the child was put in a tepid bath every night : 
 a powder containing one grain of Hydr. c. Cretan, and one of Dover's 
 powder, was given daily at bed-time, and 3j. of castor oil every morning, 
 and the attacks subsided. 
 
 Cases of this kind illustrate a point of practice, which, though impor- 
 tant in the adult (you will find it insisted on by Andral in his Clinique 
 Medicale) is still more so in the child. It is, that in many affections of 
 the brain there is a stage quite at the commencement in which depletion 
 may be out of place, but opiates or sedatives will allay the irritation, 
 which, if left alone, would issue in dangerous or fatal congestion, or 
 inflammation. 
 
 In the majority of cases of these night terrors the condition of the 
 bowels is one of constipation, not of diarrhoea. Sometimes, after gastric 
 disorder has continued for a few days, in the course of which perhaps 
 vomiting may have occurred, an attack of this nocturnal alarm may 
 throw the parents into a state of great apprehension lest hydrocephalus 
 should be impending. I have seen a very severe attack of jaundice 
 come on with these symptoms ; and in such a case it is important to 
 bear in mind the difference between the sudden, sympathetic disturbance 
 of the brain, and the more gradual aproach of hydrocephalus, with the 
 drowsiness the child experiences, and yet the difficulty it has in going 
 to sleep, the restlessness all night long, or the unquiet slumber, with 
 the moaning and starting which I pointed out to you when speaking of 
 that disease. If, then, bearing in mind these facts, you find that the 
 child who has had this attack in the night yet does not complain of 
 intolerance of light, or of much or any headache, and that while the 
 head is cool and the pulse regular, the abdomen is full and hard, and 
 perhaps slightly tender, you will scarcely take the less for the more 
 dangerous affection. 
 
 But these symptoms may last for weeks or months together, neither 
 diminishing or much increasing in severity, so that they seem almost 
 to constitute an independent disease : a view which Dr. Hesse of 
 Altona, 1 who has written a very good pamphlet on it, is disposed to 
 take somewhat too generally. 
 
 Such a case was that of a delicate boy, 7 years old, who during the 
 previous twelve months, had been cutting his first permanent molar 
 
 1 Ueber das n'achtliche Aufschrecken der Kinder im Schlafe. 8vo. Altenburg, 1845. 
 
136 ' _ NOT ON PRIMARY DISEASE OP THE BRAIN. 
 
 teeth, and for the whole of that time had suffered from attacks of night 
 terrors, which usually came on about half an hour after he had fallen 
 asleep. He then started up with a wild and terrified look, and loud 
 outcries, appearing not to know any one for some time, then begging 
 to be taken up, and becoming pacified after being carried about for half 
 an hour in his father's arms. As the seizure passed off he used to void 
 a large quantity of limpid urine, and having fallen asleep again, never 
 but once had a second attack of it in the same night, while sometimes 
 none occurred for two or three nights together. In other respects he 
 seemed to be tolerably well, and was a lively and intelligent child, 
 though for about fourteen days before he was brought to me his health 
 had appeared less good, and there were evident indications of gastric 
 disorder. I never saw this child but once again, so I cannot tell you 
 his subsequent history ; but his case affords a good illustration of the 
 occasional persistence of these symptoms for a long time without the 
 supervention of any really serious disease. 
 
 Although these symptoms may be the result of sympathetic affection 
 of the brain through the medium of the abdominal viscera, still you 
 should watch a child in whom they had frequently occurred with 
 especial care, knowing that long-continued irritation of the nervous 
 centres may, under the influence of comparatively trivial causes, issue 
 in serious disease. Your chief attention, however, must be directed to 
 the removal of the disorder of the intestinal canal ; and this should be 
 attempted by gentle means, — by the careful regulation of the diet, and 
 the judicious combination of aperients and tonics, rather than by 
 drastic purgatives. At the same time, too, it is right that the child 
 should not be left in the dark, or alone : the affection resembles night- 
 mare, and in childhood dream-images seem to mingle with the waking 
 impressions much more than in adult age. A light burning brightly 
 in the room, and a familiar face meeting the child's eye at once on 
 awaking, will do much towards breaking the spell, and towards allaying 
 its fears. Harshness in such cases is quite out of place, and few pieces 
 of cruelty can be greater than forcing a timid little child, in whom 
 threatenings of these attacks have occurred, to go to bed in the dark, or 
 to lie there without a candle, while its active imagination conjures up 
 before its eyes out of the bed-curtains, or other objects in the room, 
 the outlines of all sorts of terrific forms. 
 
 But occurrences much more alarming may take place independent of 
 any primary disease of the nervous centres. Convulsions may come 
 on; and these convulsions may occur again and again until the patient 
 dies, and yet we may find few or no morbid appearances in the brain or 
 the spinal cord to account for their occurrence. I shall not, however, say 
 more on this subject now, for I explained to you some time since that, 
 in the great majority of instances, such attacks of convulsions depend 
 on a state of temporary congestion of the brain produced in some 
 indirect way. Any other remarks that it may be desirable to make 
 upon them will be most in place when I speak of the different diseases 
 in the course of which they are likely to occur. 
 
 When general convulsions continue to recur at intervals, and without 
 any very evident cause, for weeks or months together, the affection 
 
EPILEPSY. 137 
 
 then receives the name of epilepsy. Epilepsy is a disease of all ages ; 
 its foundation may even be laid in early infancy, and the fits may con- 
 tinue to recur up to adult age ; though my own experience leads me to 
 believe that this is an exceptional occurrence, and that the history of 
 epilepsy comparatively seldom dates back to a period prior to the 
 second dentition. It seems, indeed, to be less one of the diseases of 
 childhood, than of that period of youth during which the great changes 
 that are accomplished at puberty are preparing or being carried out. 
 In fact, it was but seldom that I saw cases of epilepsy at the Children's 
 Infirmary ; and, in the few instances where I met with it, it was usually 
 traceable either to a fall, or a blow on the head, or to fright. Terror 
 I believe to be by no means an infrequent exciting cause of epileptic 
 seizures in childhood. A little girl, 10 years old, was some time since 
 under my care, who, I fear, became permanently epileptic, and whose 
 first fit was induced by this cause. She was at home, in the same room 
 with her parents, when a quarrel arose between them, and her father 
 struck her mother. The child in terror ran into the street, and was 
 picked up in a fit. After this had passed off she continued well for five 
 clays ; but another fit then came on while she was at Sunday school, 
 and was followed on the succeeding day by a third. For fourteen days 
 the fits recurred daily, and sometimes two or three in a day. They 
 then grew less frequent ; but at the end of six weeks still came on once 
 or twice a week. Whether they eventually- ceased entirely I do not 
 know, but much fear the contrary. 
 
 The sight of another person in a paroxysm of epilepsy has been 
 mentioned by many writers as peculiarly likely to give rise to its occur- 
 rence. Some time since, I had the painful task of watching the gradual 
 blunting of all the mental powers in a fine boy, between 13 and 14 
 years old, who had been epileptic since his fifth year. Down to that 
 time he had had no cerebral affection ; but then, while weak from a 
 recent attack of remittent fever, he saw his elder brother fall down in a 
 fit of convulsions. This so frightened the child that he was immediately 
 seized with violent convulsions, which lasted for twelve hours. Con- 
 sciousness was restored only after very copious depletion and other 
 active remedies ; but he remained an epileptic for life, and when I last 
 saw him was fast sinking into a state of idiocy. 
 
 Hereditary tendency to epilepsy seems to be a very frequent cause 
 of its occurrence early in life ; but besides this, there seem to be few so 
 powerful as the practice of masturbation, to which, unhappily, children 
 sometimes become addicted long before puberty. 
 
 Fits may occur in' children, and return at intervals, even for several 
 weeks, owing to the irritation of ascarides in the intestines. In such 
 cases, however, you would generally have good evidence of the presence 
 of the entozoa : and you would find the fits permanently subside on 
 obtaining their complete expulsion. 
 
 I do not know that there are any points which call for your special 
 attention in the treatment of epilepsy during childhood. You must look 
 on the frequent recurrence of convulsions in early life as of the greatest 
 moment, and must not allow yourselves to be seduced into inertness in 
 their treatment, by the hope, which you will generally find a very mis- 
 
138 CHOREA. 
 
 taken one, that they will cease with the changes in the system that 
 puberty brings with it. 
 
 There is a form of partial convulsion, in which, while the consciousness 
 is unimpaired, and the muscles to a certain extent obey the will, they do 
 not completely so, but some of them are in a state of almost constant 
 involuntary movement. With this affection, Chorea, or St. Vitus' s dance 
 as it is called, you are doubtless acquainted. Though more frequent 
 before puberty than afterwards, it is by no means of common occurrence ; 
 but it certainly is not so rare, as I judged merely from my own ex- 
 perience at the Children's Infirmary, where I did not meet with it in 
 above 1 out of 1000 cases, I might conclude it to be. Sydenham, and 
 other writers of his day, supposed that it was almost peculiar to the 
 period shortly preceding puberty, and the circumstance that it attacks 
 girls almost thrice as often as it does boys, seems to favour the supposi- 
 tion that it depends on some interruption of the great processes which 
 ought at that time to take place in the organism. And it unquestionably 
 does so in many instances, though by no means so constantly as was 
 once supposed ; for, on a comparison of a large number of cases, we find 
 that it occurs nearly as frequently between the ages of six and ten years, 
 as between the latter date and the period of puberty. The predominance 
 of females over males, among those who are attacked by it, though 
 especially marked in chorea, is observed in the case of many of the non- 
 inflammatory affections of the nervous system in childhood as well as in 
 adult life. 
 
 When chorea does not come on in connection with that derangement 
 of the general health which often precedes puberty, a sudden fright 
 seems to be one of its most frequent exciting causes. At other times 
 it appears to be connected with a state of intestinal disorder, or with 
 some irregularity in the progress of the second dentition ; while occa- 
 sionally we cannot detect any signs of disease to which the involuntary 
 muscular movements may be attributed. In some few instances of 
 organic disease of the brain or spinal cord, involuntary movements 
 have been noticed like those of chorea ; and you are doubtless aware 
 of the connection that has now and then been observed between chorea 
 and pericarditis. 
 
 The study of all points connected with this disease would bring before 
 us many questions of physiological and pathological interest, but at 
 the same time would lead us away from the special object of these lec- 
 tures, which is, the investigation of diseases that are either peculiar to 
 childhood, or which undergo important modifications when they occur 
 during early life. 
 
 For this reason it is that I have noticed this affection so briefly, and 
 that I shall be equally short in speaking of its treatment. In the great 
 majority of cases purgatives are indicated not only at the commencement 
 but throughout the course of the disease, the bowels having a great ten- 
 dency to become constipated, even though the functions of the diges- 
 tive organs be not otherwise disordered. At the outset it is often 
 necessary to administer the more active purgatives, such asscammony; 
 but you will, I think, find that the due action of the bowels is better 
 secured by some of the warmer aperients, such as aloes, which, though 
 
PARTIAL CHOREA. 139 
 
 so bitter, is generally readily taken by children, since, owing to its small 
 bulk, it can be very well given in a little coarse sugar or treacle. Tonics 
 most generally go hand in hand with aperients ; and by common con- 
 sent the ferruginous preparations are regarded as of peculiar value in 
 this affection. Though much has been said about the virtues of the 
 carbonate of iron, I do not apprehend that any one preparation has a 
 decided superiority over others ; but having continued one for a time, it 
 will usually be desirable to substitute for it another form of the remedy. 
 The cold shower bath is a tonic often of remarkable service in this dis- 
 ease. Its use, however, must be begun with care ; the child must not 
 be frightened by being subjected all at once to too copious or too cold 
 an affusion, but if you begin with but a small quantity of water, and 
 that tepid, you will generally be able in the course of a few days to 
 employ the bath in such a manner as shall be really efficacious. 
 
 Of course, while you are pursuing this tonic plan of treatment, the 
 general management of the child must be in harmony with it. Residence 
 in the country, sea-air and sea-bathing, a well-regulated but nutritious 
 diet, from which even wine is not always to be excluded, will, when com- 
 bined with the avoidance of over-excitement in any form, often do as 
 much as medicine, or even more, for the restoration of your patient. 
 
 In the great majority of cases of chorea you may assure the friends 
 of your patient that the disease will ultimately subside, though it may 
 last for several weeks. You cannot however, speak with the same con- 
 fidence, with reference to a kind of partial chorea that you will occa- 
 sionally meet with, and in which some muscles only are affected. 
 
 A few years ago, I saw a young lady, nine years old, whose health 
 had never been robust, and who had often suffered from headache and gas- 
 tric disorder. When seven years of age, she began, without any special 
 cause, to have frequent twitchings of the muscles of the face ; and almost 
 ever since, some muscles, either of the face, neck, mouth, or extremities, 
 had been similarly affected, though it had scarcely ever happened that 
 two sets of muscles were thus disturbed at the same time. She had 
 been under the care of several practitioners, and by some had been 
 leeched and mercurialized with manifest disadvantage. Some benefit 
 had been derived from large doses of carbonate of iron, and, when in the 
 country during the summer before I saw her, the involuntary movements 
 had almost entirely ceased. She had not long returned home however, 
 when a slight twitching began about the muscles of the lower jaw; but 
 this ceased in a few weeks, and, instead of it, there was now a convul- 
 sive twitching of the head towards one or other shoulder. A month 
 afterwards she began to have occasional contractions of the muscles of 
 the right hand, so that the pen would drop from her hand while writing, 
 and the fingers would be gathered up into the hand. On the last time 
 that I saw her, the contraction of the fingers had ceased to occur ; the 
 spasmodic movement of the neck was much less frequent, and was slight- 
 er, but there were slight movements of the back. This child's bowels 
 had been disordered and constipated, and her general condition was 
 weakly. I regulated the bowels, gave the ferro-citrate of quinine, and 
 afterwards other preparations of iron, and when the spring came on, sent 
 her into the country, where, as I afterwards heard, she became quite 
 well. 
 
140 PARALYSIS — SOMETIMES CONGENITAL. 
 
 The danger in these cases, and one which you cannot even with the 
 most judicious management always guard against, is, lest some one or 
 two muscles should become permanently affected by this spasmodic 
 movement — an occurrence which, though not otherwise of importance, is 
 very distressing if that patient be a female. 
 
 Disturbance of the nervous system shews itself in children as well by 
 loss of the motor power as by the occurrence of involuntary movements ; 
 and such an accident as the palsy of a limb naturally occasions the parents 
 the greatest anxiety. In the adult, a paralytic seizure is generally the 
 result of a very serious disease either in the brain or spinal cord, and 
 the sign of the commencement of a series of morbid processes, which 
 issue sooner or later in the destruction of the patient's life. Non- 
 professional persons are aware of this fact, and suppose that the same 
 rule holds good in the case of the child as in that of the adult ; but you 
 may in most instances quiet their fears with the assurance that paralysis 
 in infancy and childhood seldom betokens any peril to life, though the 
 affection is often very slow in disappearing, and sometimes is quite 
 incurable. 
 
 Paralysis in childhood occasionally dates from so early a period that 
 there seems every reason for believing it to be the result of some original 
 defect of conformation. In such cases the power over both extremities 
 on one side is greatly impaired, and the limbs on that side are much 
 smaller and less well-nourished, and sometimes the defective growth and 
 want of power are evident on the whole of the same side of the face and 
 body. Some years ago, I saw a girl, 18 years old, in whom not only 
 were the left extremities much shorter and smaller than the right, but 
 the left half of the face and body was so likewise. The parents of the 
 girl stated that this inequality in size of the two halves of the body had 
 existed from earliest infancy, and that the defective power over her 
 limbs had not succeeded to a fit, nor to any other indication of acute 
 cerebral disease. The left side was weak, and motion imperfect, but 
 sensation seemed to be unimpaired. The patient in this case was rather 
 deficient in intellectual endowments. In another instance the body was 
 well formed, but the patient, a girl of eight years of age, had had from 
 her earliest infancy but very imperfect use of her right side. She limped 
 with her right leg as she walked, always treading on her toes, with the 
 heel raised considerably above the ground, and turning her foot inwards 
 at every step. She had but very incomplete power over her right arm ; 
 the fingers of that hand were constantly flexed and drawn into the palm; 
 and though by a great effort she could extend them, yet the moment 
 her attention was withdrawn they returned to their former flexed position. 
 Sensation was as perfect in the right limbs as in the left, but their 
 wasted condition and smaller size, as compared with the left extremities, 
 shewed that their nutrition had been but very imperfectly carried on. 
 
 It is almost needless to observe, that in cases such as these there is 
 no room for treatment other than the employment of such mechanical 
 means as may be calculated to relieve inconvenience or to diminish 
 deformity. * 
 
 Real congenital paralysis, however, is a much less frequent accident 
 than the occurrence of partial or complete loss of power over certain 
 
PARALYSIS UNCONNECTED WITH SERIOUS CEREBRAL DISEASE — 141 
 
 limbs or muscles at a subsequent period. In many instances its com- 
 mencement can be traced to some attack, though often a very brief one, 
 of cerebral disturbance, which showed itself perhaps by nothing more 
 than a single convulsive seizure, or by an unusual heaviness of the head 
 that lasted for a day or two, and then subsided of its own accord. In 
 the majority of cases, indeed, the cerebral disturbance that precedes 
 infantile paralysis is neither severe nor long-continued ; and only two 
 instances have come under my notice in which there seemed to be reason 
 for supposing that it was associated with abiding mischief in the brain. 
 It is therefore of importance to examine an infant carefully, even after 
 a very mild convulsive seizure, in order to make sure that it moves its 
 limbs as freely as before, or that, if its power over them be impaired, 
 appropriate treatment may be at once adopted. 
 
 Paralysis sometimes comes on independently of any evident cerebral 
 disturbance, seeming to be induced by the irritation of dentition, or 
 supervening on the long continuance of a constipated state of the bowels, 
 or appearing in connection with all the indications of general debility, or 
 succeeding to a short feverish seizure which came on suddenly when the 
 child was in bed at night, and left it with one limb palsied in the morning. 
 The local action of cold sometimes produces paralysis. I have met 
 with one or two instances, in which, after sitting for some time on a stone 
 step, a child has lost power over one leg ; and paralysis of the portio 
 dura is doubtless in some cases produced by cold air, though I do not at 
 this moment recall an instance of this having been the case in children. 
 
 The duration of infantile paralysis, under whatever circumstances it 
 may have come on, is extremely variable. In some instances it dis- 
 appears during the employment of some simple remedy directed against 
 the symptoms of constitutional disorder with which it was accompanied, 
 and the same medicine suffices at once to remove the child's indisposition, 
 and to cure its paralysis. In other cases, even though all signs of 
 disordered health may pass away with the same rapidity, the child may 
 continue for weeks or months with the power over one side of its body, 
 or one half of its face, or one of its limbs, greatly impaired ; or this 
 condition may persist through the remainder of its life. 
 
 Cases might be related in illustration of all these varieties in the form 
 of infantile paralysis, in its onset and its duration ; but time will not 
 allow me to do more than to refer you to this Table which embodies the 
 most important points in the history of twenty cases of paralysis in 
 infants or children. — [See pp. 142-3.] 
 
 If we leave out of the question the two cases in which the paralysis 
 seemed to be congenital, we shall find that, in thirteen out of eighteen 
 instances, it occurred between eight months and three years of age, — 
 or, in other words, during that time when the process of dentition is 
 going on most actively. In many of these cases, indeed, it was not 
 preceded by any of the local signs of difficult dentition ; but still it is 
 quite apparent that the changes that are going on in the constitution 
 during that important period of development powerfully predispose to the 
 affection. There were but two instances in which there seemed to be 
 any reason for regarding the paralysis as connected with permanent 
 disease of the brain ; and in eight out of the eighteen cases no indica- 
 
142 
 
 HISTORY OF TWENTY CASES OP 
 
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PARALYSIS IN INFANTS OR CHILDREN. 
 
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144 MOST COMMON DURING DENTITION. 
 
 tion of cerebral disturbance occurred before the paralysis, or came on 
 afterwards. 
 
 In the two cases in which the disorder was congenital, both extrem- 
 ities of one side were palsied, and in one of them the power over the same 
 side of the face was likewise impaired. In seven of the other eighteen 
 cases the leg only was affected, and in two of these the power over both 
 legs was lost ; in fiVe both the leg and arm were palsied, while in six 
 instances facial paralysis existed. In four of these six cases the paralysis 
 of the portio dura was not associated with impaired power over any of 
 the limbs ; once it was combined with palsy of the leg, and once with 
 a general impairment of the power of walking. 
 
 One point which it behooves us to bear in mind in connection with 
 these cases is, that though cerebral symptoms, or any other form of dis- 
 turbance of the general health that may have preceded the paralysis, 
 usually subside in a short time, there is still very great danger of the 
 paralysis continuing in such a degree as to cause much disfigurement, or 
 as to interfere greatly with the usefulness of the limb. In only six of 
 the eighteen cases did a cure of the palsy take place : in two of these 
 cases the portio dura alone was affected; in two others the paralysis of 
 both leg and arm was incomplete, and was associated with a state of 
 general debility; and in one the loss of power over one leg had come on 
 after the child had been sitting for some hours on a stone door-step. In 
 four of these cases treatment was commenced within two or three days 
 after the occurrence of the paralysis, and continued uninterruptedly until 
 the patient's recovery. In one the treatment was begun after the lapse 
 of nearly three weeks ; and in another, though begun immediately, it 
 was discontinued for some weeks. In four instances partial improve- 
 ment took place, and there seems reason for anticipating that in one (No. 
 20) this improvement will go on to complete recovery. In Nos. 7 and 
 17 the improvement was but slight ; in both these cases, however, there 
 was more serious cerebral disease than in any others. The treatment 
 of No. 14 was continued only for a week; and though the child gradu- 
 ally recovered power over the arm, yet the leg remained quite useless. 
 In the other three cases treatment was begun within a few days, and 
 was continued without interruption. In the eight cases in which no treat- 
 ment was adopted,, or not till after the lapse of a period of six months, 
 no improvement took place in the patient's condition. It would be dif- 
 ficult to find an argument to enforce the necessity for the early adoption 
 of appropriate treatment more cogent than is furnished by these facts. 
 The evil results of neglecting it, too, are in some respects more 
 serious in the child than in the adult, since the disfigurement that is 
 produced by paralysis is greater in childhood than in adult age. The 
 muscles of a paralysed limb are almost always observed to be wasted ; 
 but in childhood the growth of the part becomes arrested, and in the 
 course of a year or two it will be half or three-quarters of an inch 
 shorter than the corresponding member on the opposite side. On two 
 occasions I have seen the arm completely dislocated, owing to its long 
 standing paralysis, the ligaments about the shoulder-joint having become 
 so relaxed that the head of the humerus hung quite out of the glenoid 
 cavity ; and, on measuring the distance from the acromion to the tip of 
 
INFANTILE PARALYSIS — RECOVERY UNCERTAIN. 145 
 
 the finger in one of these cases, I found that an apparent elongation of 
 the paralysed limb, to the extent of three-quarters of an inch, had thus 
 been produced. 
 
 The diagnosis of these cases is not likely to be attended with any 
 difficulty ; for the history of the case, and the painlessness of the affect- 
 ed limb, will at once show that the loss of power over it is not the result 
 of any injury. Now and then, however, sensation in the affected limb 
 appears to be exalted, — a circumstance which, when the leg is the seat 
 of the affection, and the paralysis is incomplete, may lead to the appre- 
 hension of hip-joint disease. In such a case the child bears all its 
 weight on the healthy limb, turns the foot of the affected side inwards 
 when walking, and stands with the toes of that foot resting on the dor- 
 sum of the foot of the healthy side. Still it will usually be found that 
 the exaggerated sensibility of the paralysed limb varies greatly at dif- 
 ferent times, while that extreme increase of suffering produced in cases 
 of hip-joint disease, on striking the head of the femur against the ace- 
 tabulum by a blow upon the heel, and the fixed pain in the knee of the 
 affected side, so characteristic of disease of the hip-joint, are absent ; 
 and these points of difference will usually enable you to distinguish be- 
 tween the two affections. 
 
 Another important question is, how we may distinguish between forms 
 of paralysis, such as I am here speaking of, and those more serious cases 
 in which the palsy is a sign of organic disease in the brain. In many 
 cases the history of the patient will of itself be sufficient to guard you 
 from error ; for if paralysis occur suddenly, affecting both limbs on one 
 side, and be neither preceded by nor attended with any cerebral symptom, 
 it is almost certain that it.does not depend on serious organic disease of 
 the brain. Our decision will be more difficult if the loss of power have 
 been gradual, and especially if only one limb be affected ; but if the brain 
 be diseased, you will rarely find a mere weakening of the motor power ; 
 for connected with it there will usually be occasional involuntary tremor 
 or nervous twitching of the limb, or contraction of the fingers or toes. 
 When the paralysis succeeds to convulsions, the case will be still more 
 obscure. In most cases of simple paralysis, however, the palsy comes 
 on after a single fit ; while, if it depend on some local mischief in the 
 brain, it is generally preceded by several convulsive seizures, during 
 each of which the limb that afterwards becomes palsied is in a state 
 of peculiar movement, or is sometimes the only part where convulsive 
 movements occur. 
 
 Each one of these cases must be treated according to the peculiar 
 features that it may present. Purgatives and tonics are the remedies 
 which I have most frequently employed ; for the bowels are usually 
 constipated, and the child is often debilitated. The gentler aperients 
 are more suitable in these cases than drastic purgatives ; and you will 
 gain more good from the preparations of iron than from other tonics. — 
 I have sometimes used stimulating embrocations to the spine and to the 
 paralysed limb, though rather for the sake of satisfying the relations, 
 than with the hope of doing any very great good to the patient. Elec- 
 tricity applied to the affected limb, in the form of weak currents from 
 an electro-magnetic machine, t^ice in the day, is a most valuable adjunct 
 
 10 
 
146 INFANTILE PARALYSIS — TREATMENT. FACIAL HEMIPLEGIA. 
 
 to other treatment, so soon as any symptoms of general constitutional 
 disturbance, that may have attended the onset of the affection, have 
 been removed. Like other remedies in such cases, the chances of doing 
 good by its employment seem to depend in no small measure on its 
 being resorted to early : while it must further be confessed, that it is 
 rather uncertain in its action ; for while sometimes very marked 
 improvement has followed its use, in other cases, for which it seemed 
 equally suitable, its employment has occasioned much pain, without being 
 followed by any increase of power over the limbs. In Case XX., the 
 application of blisters to the spine, was succeeded by marked im- 
 provement, though, as I was giving at the same time the spirituous 
 extract of the nux vomica, I do not know how much of the improvement 
 to attribute to the external, and how much to the internal remedy. 
 
 If the portio dura be paralysed, you must adopt the same general 
 treatment, but must bear in mind the possibility of the nerve having 
 undergone pressure from some enlarged gland ; and if you find reason 
 to believe this to be the case, you may apply a leech in the situation 
 where the nerve passes out of the skull, — a proceeding which I once 
 adopted with advantage. 
 
 Lastly I will mention that infants are sometimes born with facial 
 hemiplegia, as the result of injury to the nerve from application of the 
 midwifery forceps, or, as has in one or two cases been observed, from 
 injury received during the passage of the head through the pelvis without 
 any instruments having been employed. Such occurrences are rare, but 
 it is well that you should be aware of the possibility of their being met 
 with, independent of any injury to the brain. The paralysis in these 
 cases generally disappears in the course of a few days or weeks. 1 In 
 the only case of the kind which has come under my own observation, 
 the distortion of the face, though very great at birth, — one eye being 
 wide open, and the corresponding side of the face powerless, so that the 
 child was unable to suck, — had already greatly diminished within forty- 
 eight hours, and had quite disappeared within a week. 
 
 LECTUEE XIII. 
 
 Diseases op the Respiratory Organs, their frequency and fatality. — Peculiarities of 
 the respiratory function in early life — causes of the rapid pulse and quick breathing 
 in infancy — feebleness of inspiratory power, and consequent tendency to collapse of 
 the lung. 
 
 Imperfect Expansion of the Lungs — sometimes congenital. — Appearance of the lung 
 — influence of inflation upon it — its causes and symptoms. — Case of its fatal termina- 
 tion — case of recovery from it. — Diagnosis from congenital phthisis. — Treatment. 
 
 We now come to the examination of the diseases of those two grand 
 systems of the organism by which the blood is kept in motion, the 
 
 1 Kennedy's Observations on Apoplexy, Paralysis, &c. of New-born Infants, — in 
 Dublin Journ. of Med. Science, 1836 ; and Landouzy sur I'He'miple'gie Faciale chez les 
 enfans nouveau-n6s. 8vo. Paris, 1839. 
 
 
PECULIARITIES OF THE RESPIRATORY FUNCTIONS IN EARLY LIFE. 147 
 
 requisite changes in it are effected, and the animal heat is maintained. 
 Your attention was lately called to the fatality of the diseases of the 
 nervous system in early life as one grand reason for their attentive 
 study ; but this argument is still more cogent if applied to the maladies 
 of the organs of respiration and circulation, since they destroy a far 
 greater number of children, and occasion a mortality almost equal to 
 that produced by diseases of the nervous and digestive systems together. 
 It appears, indeed, from our tables of mortality, that very nearly a 
 third of all deaths under five years of age are due to the diseases of the 
 respiratory organs ; while not above one child in four dies under that 
 age from diseases of the nervous system, and not above one in seven 
 from those of the digestive system. 1 
 
 While the study of these diseases is of paramount importance, we 
 meet with inducements to their investigation which in a great measure 
 failed us in the case of diseases of the nervous system. Peculiar diffi- 
 culties then attended us, and the truth was veiled in so much obscurity, 
 that we often saw it but indistinctly — sometimes, perhaps, altogether 
 failed to perceive it. The same means, however, as have enabled us to 
 bring medical knowledge, with reference to the diseases of the chest in 
 the adult, almost to the state of one of the exact sciences, still stand us 
 in stead here ; and care and patience will enable us to discover the 
 condition of the lungs with nearly as much certainty in an infant as in 
 a grown person. 
 
 Nor is the greater facility of their diagnosis the only circumstance 
 that lightens their study, but a feeling of hopefulness attends their in- 
 vestigation /which we often missed in the subjects that have lately 
 engaged our attention. They, indeed, furnish us with interesting 
 pathological studies : we stood around the sick bed, and watched nature's 
 struggles with disease that was irremediable, and we traced its effects 
 afterwards as we examined the dead body ; but the diagnosis of the 
 affection was in many instances but the sentence of the patient's death ; 
 and we often felt that, as practical physicians, there was but little for 
 us to do. We shall, it is true, meet with some such affections in our study 
 of diseases of the chest, but happily they are few in comparison with 
 those which, in addition to much that would interest the mere pathol- 
 ogist, present still more that will give ample scope for all the skill of 
 the practical physician. 
 
 1 Table showing the proportion per cent, of deaths from different causes in childhood, 
 in the metropolis, as compared with subsequent life. [Deduced from the 5th and 8th 
 Reports of the Registrar-General, for 1842 and 1845.] 
 
 From Diseases of the Nervous 
 System 
 
 Ditto, ditto, Respiratory System.. 
 Ditto, ditto, Digestive System 
 
 Under Between 
 1 year. 1 and 3. 
 
 30.5 18.5 
 
 I 
 
 26.9 
 17.5' 
 
 39.5 
 12.8 
 
 
 
 
 
 At all 
 
 Between 
 3 and 5. 
 
 Under 
 5. 
 
 5 to 10. 
 
 10 to 15. 
 
 Ages 
 
 above 
 
 15. 
 
 17.6 
 
 24.3 
 
 15.1 
 
 10.6 
 
 10.4 
 
 33. 
 
 32.8 
 
 29.5 
 
 30.7 
 
 38.0 
 
 5.5 
 
 14.1 
 
 6.5 
 
 8.8 
 
 7.7 
 
148 CAUSES OF RAPID PULSE AND QUICK BREATHING IN INFANCY. 
 
 At first sight, it may seem to you that there can be little in the 
 organs of respiration and circulation in early life different from their 
 condition in riper years. And it is true that the part they play is as 
 important at the first hour of existence as in the most advanced old age, 
 and that their structure and functions undergo no such changes as we 
 have noticed taking place in the brain during infancy and childhood ; 
 but nevertheless, they present some important peculiarities in the young, 
 with which you must be acquainted before you can hope to treat their 
 diseases with success. 
 
 The condition of infancy is one of unceasing development ; all the 
 organs of vegetative life have, so to speak, double work to do, — not 
 merely to supply the daily waste, and to remove effete and useless 
 matter, but to build up that wondrous edifice, the human body. It is 
 probably in great measure on this account that the blood in infancy and 
 childhood runs its course more rapidly, and that the lungs vivify it more 
 frequently than in adult age. We shall probably not be far wrong if 
 we estimate the average frequency of the pulse in the grown person, 
 when making no exertion, at 75, and of the respirations at 12 in the 
 minute. 1 In infants not above a week old, the average frequency of 
 the respiration is 39, and of the pulse 102 ; but the former may rise to 
 84, and the latter to 140, as the result of some transient excitement or 
 disturbance, and wholly independent of disease. Until the sixth year 
 the average frequency of the pulse continues at 102 ; and though that 
 of the respiration diminishes, yet it does not fall below 30. The varia- 
 tions between their maximum and minimum frequency are now, however, 
 circumscribed within limits which grow narrower as the child approaches 
 manhood. 2 
 
 Although the rapid pulse and quick breathing of early life are pro- 
 bably in great measure due to the activity of the vital processes, yet 
 the wide variations in their frequency induced by very slight accidents 
 lead to the suspicion that this is not their only cause, but that both 
 phenomena are to a certain extent indications of the infant's weakness. 
 This suspicion is still further strengthened by our knowledge of the 
 fact, that the quantity of carbonic acid exhaled at each expiration 
 diminishes in proportion as the expirations are more frequent ; 3 so 
 that it is plain that the rapidity of the respiratory movements is not of 
 itself a measure of the activity of the respiratory process. But still 
 stronger proof of this fact may be adduced. Animal heat is generated 
 almost entirely by respiration. If, therefore, the activity of the vital 
 processes were in proportion to the rapidity of the breathing, the new- 
 born infant should be warmer than the child, and the child than the 
 youth. But this is not so, for M. Roger has found, as the result of 
 many most elaborate investigations, that the temperature of the child 
 at six years of age exceeds that of the infant of a week old by more 
 
 1 This result is afforded by the numerous and careful observations of Professor 
 Vierordt: see his article Respiration, in Wagner's Handworterbuch der Physiologie, 
 Part 12, 8vo. Brunswick, 1845, p. 874. 
 
 The chief authority for the statement in the text is the valuable essay of M Roger, 
 De la Temperature chez les Enfants, 8vo. Paris, 1844. 
 
 a See Vierordt's experiments on this subject, loc. cit p. 887. 
 
 
FEEBLENESS OF THE INSPIRATORY POWER. 149 
 
 than half a degree of Fahrenheit, although the respiration is nearly a 
 fourth less frequent. 1 
 
 There seems, then, good reason for believing that the rapid breathing 
 of the child is to some extent the result of its more delicate frame, 
 rendering it unable, at a single effort, to inspire as deeply as the more 
 robust adult, so that it is compelled, by the frequent repetition of its 
 efforts, to make up for their comparative feebleness. Quite in keeping 
 with this is the small power of resisting cold, or of maintaining an 
 independent temperature, which is the distinguishing peculiarity of 
 early life. If the young of any warm-blooded animal be exposed to a 
 low temperature, its respiration at first increases in frequency, but if 
 not soon restored to a warmer atmosphere, the nervous energy that 
 should set the respiratory apparatus in motion becomes still more 
 depressed ; air enters the lungs imperfectly, the inspirations grow less 
 frequent, and the warmth of the body sinks rapidly down to that of the 
 surrounding medium. Nor is this all ; but it often happens, if a young 
 infant has been thus exposed to the cold, and especially if this has been 
 done before the respiration had become properly established, that no 
 subsequent removal to a warmer atmosphere will suffice to raise the 
 temperature, or to set in proper activity the respiratory process. 
 
 But not merely is the respiratory apparatus more delicate in the 
 child than in the adult, for so are all the organs in early life, but it is 
 feebler, as compared with the work it has to do, with the difficulties it 
 has to overcome : and this constitutes a most important peculiarity in 
 the physiology of respiration in early life, and greatly modifies its 
 pathology. 
 
 The interesting researches of Mr. Hutchinson 3 have shown us that 
 in the case of the adult "the resistance to the ordinary breathing force, 
 independently of the elastic power of the lungs, is equal to lifting more 
 than 100 lbs. at every ordinary inspiration." The elasticity of the 
 walls of the chest which present this resistance, is, in proportion to the 
 size of the thorax, nearly as great in the infant as in the adult ; but 
 how much smaller is the muscular power by which this resistance is to 
 be overcome ! You see proof of it in the ordinary mode o£ respiration 
 of a young infant, which presents something almost of difficulty. The 
 breathing is quick and short, then after a few seconds there succeeds a 
 pause, and then the hurried respiratory movements begin again, while 
 the slightest disturbance, or the most trivial excitement, will at any 
 time raise the frequency of the inspirations by ten or twelve in the 
 minute. This respiration, too, is almost entirely abdominal ; the chest 
 moves but little, its walls are but little expanded, and the ear detects 
 in the respiratory murmur little or nothing of that clear loud sound 
 which is so characteristic of a subsequent period of childhood, and with 
 which you all are familiar by the name of puerile respiration. This pecu- 
 liarity of the breathing in early infancy, to which M. Trousseau was, I 
 
 1 The recent researches of Dr. v. B'arensprung, published in Miiller's Archiv. 1851, 
 p. 125, do not confirm the above statement, but they are too few in number to invalidate 
 it, and therefore it is still retained in the text. See \ 5 of v. Barensprung's essay. 
 
 2 On the Respiratory Functions, in vol. xxix. of the Medico-Chirurgical Transactions. 
 
150 IMPERFECT EXPANSION OF THE LUNGS. 
 
 believe, the first to call attention, is another token of the feebleness of 
 the inspiratory power. As the child grows older, and its strength 
 increases, and its muscular system becomes more developed, the chest 
 expands with each inspiration, and the faint respiratory murmur is suc- 
 ceeded by the loud puerile breathing which is heard as the air enters 
 into the smaller air-cells. 
 
 The resistance of the walls of the chest, however, is not the only 
 obstacle to be overcome, at each inspiratory effort, but the lungs them- 
 selves are .furnished with an elastic fibrous investment, processes of 
 which dip down into their substance, and form the parietes of the dif- 
 ferent lobules. If you blow air forcibly into the lungs after their 
 removal from the body, the resiliency of their tissue will expel a large 
 proportion of the air the moment your effort at inflation is suspended. 
 This elasticity of the lungs, then, which has been estimated as offering 
 in the adult male an obstacle to each inspiration equal to 150 lbs., and 
 in the female equal to 120 lbs., avoirdupois, is constantly tending to 
 empty them of air, and constantly resisting the introduction of more. 1 
 The want of breath, however, puts the respiratory muscles into play ; 
 the man takes a deep inspiration, and by this effort he unconsciously 
 overcomes the resistance of the chest and the elasticity of the lungs. 
 The new-born infant feels the same want, and makes the same effort, 
 but its muscular power is small, and its inspirations are often so 
 feeble as to draw the air in some parts only into the larger bronchi, 
 while many of the smaller air-tubes remain undilated, and much of the 
 lung continues in its foetal state. The blood being thus but imperfectly 
 aerated, all the processes of nutrition go on imperfectly ; the vital 
 powers languish, the inspiratory efforts become more and more feeble, 
 the temperature sinks, and the infant dies. But not only may this 
 state persist as the result of imperfect respiration at birth, but cold, or 
 the want of sufficient food, or any other cause that impairs the already 
 feeble muscular power, favours its supervention. As the power of the 
 inspiratory muscles is impaired, the air no longer penetrates into the 
 lungs so far as it once did, while the residual air is gradually driven 
 out of the pulmonary cells by the elasticity of the lung, and portions 
 once permeable to air become, in the course of time, altogether useless. 
 Or, an increase of the ordinary resistance to the entrance of the air 
 will have the same effect ; and if the pouring out of mucus into the 
 bronchial tubes should much obstruct them, large portions of lung will 
 by degrees become emptied and collapse, the dyspnoea will grow urgent, 
 and the child will die from symptoms such as, in the adult, result only 
 from most serious structural disease. 
 
 The possibility of a large portion of the respiratory apparatus 
 remaining useless from the birth, or becoming so afterwards without any 
 serious disease of these organs, is a most important element in the 
 
 1 The investigations of Professor Donders, and of Mr. Hutchinson, into the amount of 
 this elasticity of the lungs, though carried on independently, conduct to very similar 
 results : the former estimating it as equal to ^ix. gx. avoirdupois per square inch as a 
 maximum : the latter estimating it on the average at Ibss. per square inch. See the 
 researches of Prof. Donders, in the Nederlandsche Lancet, Dec. 1849 ; and Schmidt's 
 Jahrb. Dec. 1850 ; and article Thorax, by Mr. Hutchinson, in Cyclopaedia of Anatomy 
 and Physiology, .vol. xiv., p. 1058. 
 
IMPERFECT EXPANSION OF THE LUNGS. 151 
 
 pathology of infancy and early childhood. It warns us to be on our 
 guard during the course of various maladies, against a danger which, in 
 more advanced life, we have not to apprehend ; while, at the same time, 
 it teaches us that the dyspnoea, the hurried breathing, and many other 
 symptoms which, in the adult, would call for most active treatment, may 
 result, in infancy, from simple weakness, and require stimulating rather 
 than the depletory measures. 
 
 Before we proceed to study the diseases of the respiratory organs in 
 infancy and childhood, we must make ourselves thoroughly acquainted 
 with this state of imperfect expansion of the lungs. It presents itself 
 to us under two different circumstances. 
 
 1st. As a congenital condition : a more or less considerable portion 
 of the lung never having become penetrated by air, but having remained 
 in its foetal state. 
 
 2d. As an acquired condition : portions of the lung which once 
 were freely traversed by air ceasing to admit it ; and this not from 
 alteration of structure, but from a simple collapse of the pulmonary 
 tissue. 
 
 It is now nineteen years since Dr. Edward Jorg gave the first clear 
 description of the former of these two conditions, to which he applied 
 the rather cramp name of atelektasis, from a**^, imperfect, and 
 txtaats, expansion. 1 We will first study this, which is the simpler form 
 of the affection, and the examination of which will give us a clue to the 
 understanding of the second form. 
 
 If you examine the body of a new-born infant, or of one that has 
 survived its birth but a few days, you will sometimes find patches of 
 the lung of a dark red colour, and depressed below the surrounding 
 tissue, thus giving to the surface of the organ an uneven appearance. 
 These darker portions, which exactly resemble foetal lung, are solid to 
 the touch, do not crepitate at all under the finger, and sink immediately 
 if thrown into water, while no minute air-bubbles are intermingled 
 with the small quantity of reddish serum which pressure causes to exude 
 from their divided substance. They are not friable nor as easily torn, 
 their cut surface is perfectly smooth, closely resembling a piece of 
 muscle, and, if examined under a lens, the pale collapsed air-tubes are 
 seen intersecting their substance, and scarcely distinguishable from the 
 small vessels, which are almost devoid of blood. 
 
 If air be blown into a lung some lobules of which have this appear- 
 ance, it will permeate the collapsed air-tubes ; the pulmonary vesicles 
 will by degrees become distended, and the, solid lobules will rise to a 
 level with the rest of the lung, will acquire the same colour and con- 
 sistence, and, like other parts of the organ, will float in water. A 
 single inflation, however, is by no means sufficient to render this change 
 permanent, but the moment the tube is withdrawn the air will escape, 
 and the lobules recently distended will again collapse, and sink below 
 the rest of the lung ; and their colour, too, will become dark, though 
 less so than before. Even if after you have distended the lung to the 
 
 1 In his dissertation De pulmonum vitio organico, fee., Leips. 1832 ; and afterwards 
 more fully in his work Die Fotuslunge in gebornen Kinde, 8vo. Grimma, 1835. 
 
152 EFFECTS OF INFLATION. 
 
 utmost, you then pass a ligature round the bronchi, and allow the lung 
 to dry, a difference will still in general be very perceptible between the 
 size of the air-vesicles which had been inflated by your efforts, and of 
 those which had been distended during life by the natural process of 
 respiration. 
 
 The force required thus to distend the collapsed portions of the lung 
 is very variable : sometimes it requires all the force you can possibly 
 exert, and continued for some minutes. If the child have survived for 
 several weeks, the air will penetrate only very imperfectly into the 
 collapsed lobules, while in some parts the resistance will be greater 
 than it can overcome, and the most forcible inflation will be followed 
 by no effect. The situations in which this condition is most frequently 
 met with, are the languette and lower edge of the upper lobes, the 
 middle lobe of the right lung, and the posterior part and lower edge of 
 the lower lobes; and inflation restores these parts to a natural condition 
 much less easily than it does any patches of the same kind in other 
 situations. Whether the impermeability of some collapsed lobules is 
 owing to adhesions having taken place between the opposite surfaces of 
 the minuter bronchi, as has been suggested, I cannot pretend to say, 
 but the supposition is plausible, and microscopical researches, according 
 to which the bronchi of a portion of collapsed lung lose their lining of 
 tesselated epithelium, lend it a still further degree of probability. 1 
 
 It is usual to find, in connection with this state of the parenchyma of 
 the lungs, that the pulmonary vessels contain less blood than usual, 
 that the foramen ovale is unusually open, and the ductus arteriosus but 
 very imperfectly closed. If the child have survived its birth but a 
 short time, the brain is frequently found congested ; but otherwise there 
 is often nothing observable more than anaemia of all the organs, together 
 with a general state of atrophy. Sometimes bronchitis attacks a lung 
 thus affected, and, besides the presence of mucus in the air-passages, 
 there is then very often a state of congestion of the lungs, which 
 renders the contrast between the collapsed and the healthy lobules less 
 striking. 
 
 The causes of this condition are not clearly made out. Dr. Jorg has 
 attributed great importance to precipitate labour as a frequent cause of 
 its occurrence, and has suggested a somewhat fanciful theory to explain 
 its mode of production. He conceives that one grand use of the 
 uterine contractions is gradually to enfeeble the circulation through the 
 placenta, and thus to induce in the foetus that besoin de respirer which 
 shall excite the complete establishment of respiration immediately on 
 its birth. If, however, by the very rapid course of labour, the child 
 should be born while the foetal circulation is still going on with unim- 
 paired vigour, the want of air will not be experienced by the child, and 
 its attempts to breathe will be feeble and imperfect. It is probably 
 better, instead of indulging in speculations of this sort, to content our- 
 selves with the simple statement that when, from any cause whatever, 
 the establishment of respiration at all has been attended with difficulty, 
 
 1 See a paper on this subject by Trof. Kostlin, in Schmidt's Jahrbucher, 1850, No. 1, 
 p. 28. 
 
CAUSES OF IMPERFECT EXPANSION OF THE LUNGS — 153 
 
 there is a very great probability that its establishment will never be 
 complete, but that some lobules only will receive the air, while it will 
 not penetrate into other parts of the lung. The probability of this 
 occurring, too, will be still greater if the children be 'weakly, or ill- 
 nourished when born, or if they be exposed soon after birth to cold or 
 other unfavourable hygienic influences, such as are calculated to 
 interfere with the due performance of respiration. 
 
 Cases in which this condition of the lungs exists usually present the 
 history of the child having been apparently still-born ; and, though 
 resuscitated after a time, yet still continuing unable to utter a strong 
 and loud cry like that of other children. Even after breathing has 
 gone on for some time, such children usually appear feeble ; and though 
 they may have attained the full term of foetal life, yet they can 
 scarcely suck, although they often make the effort. An infant thus 
 affected sleeps even more than new-born infants usually do ; its voice is 
 very feeble, and rather a whimper than a cry ; and the chest is seen to 
 be very little, if at all, dilated by the respiratory movements. The 
 temperature falls, the skin becomes pale, and the lips grow livid, and 
 often slight twitching is observed in the course of a few hours about the 
 muscles of the face. The difficulty in sucking increases, the voice 
 grows weaker and more whimpering, or even altogether inaudible, 
 while respiration is attended with a slight rale, or an occasional cough ; 
 and the convulsive movements return more frequently, and are no 
 longer confined to the face, but affect also the muscles of the extremities. 
 Any sudden movement suffices to bring on these convulsive seizures ; 
 but even while perfectly still the child's condition is not uniform, but 
 it will suddenly become convulsed; and during this seizure the 
 respiration will be extremely difficult, and death will seem momentarily 
 impending. In a few minutes, however, all this disturbance ceases, 
 and the extreme weakness of the child, its inability to suck, its feeble 
 voice, and its frequent and imperfect inspirations, are the only 
 abiding indications of the serious disorder from which it suffers. But 
 the other symptoms return again and again, till at length, after the 
 lapse of a few days, or a few weeks, the infant dies. 
 
 But I will relate a case which may serve to impress these charac- 
 teristics on your memory. A little boy, three weeks old, was brought 
 to me at the Children's Infirmary, on March 13, 1846. He was puny, 
 emaciated, with a cold surface and bloodless conjunctiva. His face, 
 which was wizened like that of an old man, was occasionally distorted 
 by slight convulsive twitches ; and these fits, as the mother termed them, 
 were, according to her account, sometimes much more severe. The 
 abdomen was tympanitic, and it alone was seen to move during respi- 
 ration, there being hardly any lateral expansion of the chest. The ear 
 applied to the chest heard but little air entering ; and the cry was a 
 stifled whimper, in which none of the inspiratory sound, the reprise of 
 French writers, was distinguishable. The child sucked with difficulty, 
 and had wasted ever since its birth, though no diarrhoea existed, but 
 the bowels, on the contrary, shewed a tendency to constipation. 
 
 The chest was rubbed twice a day with a stimulating liniment, and a 
 mixture was given containing some ammonia and the compound tincture 
 
154 CASES ILLUSTRATIVE OP ITS SYMPTOMS. 
 
 of bark. Under this treatment the child appeared to improve; it 
 began to breathe less rapidly and in a less laboured manner, and its 
 cry became louder. The parents, however, were miserably destitute, 
 the mother in an ill state of health, so that her milk afforded but a 
 very imperfect sustenance for the child. From the beginning of April 
 he grew less well, and began to have occasional attacks of general 
 convulsions, in one of which he died on April 26, 1846. 
 
 On examining the body, large portions of both lungs presented the 
 appearance which I have described as characteristic of their imperfect 
 expansion ; but inflation restored them to a crepitant state. Some 
 patches, however, though they admitted air and assumed the same 
 colour as the rest of the lung, yet could not by any effort be dilated so 
 completely as to rise to a level with the surrounding tissue. The 
 foramen ovale was open, the margin of the valve for fully half its 
 circumference not being adherent, although the valve was sufficiently 
 large for its closure. The ductus arteriosus also was quite permeable, 
 although of considerable less calibre than during foetal life. 
 
 This case affords a very good specimen of one way in which the 
 affection leads on to a fatal termination ; but sometimes, and probably 
 in those instances in which the affected portion of lung is not so 
 considerable, a less formidable train of symptoms usher in the fatal 
 event. Convulsive twitchings, such as I have before mentioned, do not 
 occur, nor are periodic exacerbations of the symptoms observed ; but 
 the child is merely feeble and its breath is short, and it has an occa- 
 sional cough. It sucks, though with difficulty, but it loses flesh, the 
 bowels become disordered, and medicine is unable to restrain the 
 diarrhoea. The unchecked diarrhoea increases the emaciation and 
 exhaustion of the child which dies at length worn out and wasted 
 to a skeleton. 
 
 Sometimes, too, we meet with cases in which the child eventually 
 recovers, and it is then very interesting to watch the gradual diminu- 
 tion in the frequency and violence of the paroxysms of dyspnoea, while 
 the respiration grows by degrees more equable, and the cry louder, the 
 power of sucking increases, and the child at length attains to perfect 
 health. 
 
 A little boy, four months old, was placed under my r care by his 
 mother, who informed me that the child had presented in some unnat- 
 ural position during labour, so that manual interference was required 
 to effect her delivery : and when born the infant appeared dead, and 
 was recovered only after very great difficulty, and after the occurrence 
 of convulsions : the convulsions had since returned almost every day, — 
 sometimes indeed they occurred several times in the same day, — and 
 always came on with greater frequency by day than by night. The 
 attempt to suck often induced them, as did also any rapid movement 
 about the room, or any sudden change of posture. During the fits the 
 child did not struggle much, but he always turned extremely livid 
 about the face and mouth. No fit ever lasted longer than five 
 minutes, and during the intervals between them the child seemed 
 pretty well, except that he often suffered from a suffocating cough. 
 
 He appeared tolerably well-grown and well-nourished, and the tern- 
 
ILLUSTRATIVE CASES. 155 
 
 perature of the surface was nearly natural. The respiration, however, 
 was very hurried, and was almost entirely abdominal, the chest being 
 hardly at all expanded. The cry, moreover, was feeble, and without 
 reprise. There was a considerable want of resonance of both sides of 
 the chest posteriorly, and deficient entrance of air into the back of 
 both lungs. Both the dulness and the scanty admission of air were 
 more obvious in the left than in the right infra-scapular region, and 
 some mucous rale was heard in the former situation. 
 
 The child was placed in a hot bath, and an emetic was given it 
 every night ; the chest both in front and back was rubbed twice a day 
 with a stimulating liniment, and the face was ordered to be sprinkled 
 with cold water whenever any threatenings of the fits came on. 
 
 At the end of five days the child was better, and the cry louder, 
 though without any distinct reprise. Small doses of the ferro-citrate 
 of quinine were now combined with the other remedies, while the 
 emetics were discontinued, as on some occasions they had appeared to 
 excite the convulsions. First the cry grew louder, then the appearance 
 improved, and the manner became more cheerful, then the cough was 
 less troublesome and the breathing less habitually wheezing, and at the 
 same time the chest began to expand more, and the marked dulness of 
 its lower parts gradually diminished. At the end of five weeks the 
 child was discharged with increased flesh and invigorated strength, 
 and with no ailment more serious than a slight degree of wheezing 
 respiration. 
 
 The history of this patient may serve to show us that even very 
 serious symptoms should not lead us to despair of recovery, while it 
 illustrates the importance of forming an accurate diagnosis between 
 this affection and congenital phthisis, (the only malady with which it is 
 likely to be confounded,) lest we either cherish unfounded expectations, 
 or discourage hopes that might reasonably be entertained. 
 
 A little care will usually suffice to enable us to distinguish between 
 these two affections, notwithstanding some general points of resem- 
 blance between them. The symptoms of the imperfect inflation of the 
 lungs dated from the infant's birth : but it scarcely ever happens that 
 turberculous disorganization of the lung is so extensive in the new-born 
 child as to interfere with the establishment of the respiratory function. 
 But not only do not the symptoms of phthisis appear so early, but they 
 likewise seldom advance so rapidly as those of atelektasis. Phthisis, 
 too, is not from the beginning attended with the same debility, nor with 
 difficulty in sucking, while it is associated with a febrile action which is 
 quite wanting in atelektasis. The head symptoms which in so large a 
 number of cases attend the imperfect inflation of the lungs, are absent 
 in phthisis ; while, lastly, auscultation would furnish some clue to the 
 real nature of the case : in the one instance there would, in general, 
 be simply a deficiency of air ; in the other, respiration, accompanied 
 with rales, and often with bronchial breathing. 
 
 The treatment required by this affection need not detain us long. 
 The importance <of maintaining an equable temperature around every 
 child in whom respiration is not duly performed, cannot be too much 
 insisted on ; and the power of generating heat being as you know much 
 
156 TREATMENT OF THIS CONDITION. 
 
 diminished, this temperature ought not to be below 70°, and in bad 
 cases may be even 10° higher. Besides attending to preserve this 
 "warmth around the child, benefit often accrues from the employment 
 of the hot bath once or twice every day, at a temperature of 100° 
 Fahrenheit, to which mustard may be added to render it more stimu- 
 lating to the surface. The child should not be allowed to remain 
 longer than five minutes in the bath, and should be enveloped in hot 
 flannels immediately afterwards, to prevent its taking cold. The back 
 and chest should be rubbed twice or oftener every day with a stimu- 
 lating liniment, as camphor or soap liniment, which may be diluted with 
 a little oil, if it be too irritating to the skin. If the child be very 
 feeble, stimulants may be given ; of which there are none better than 
 the compound spirits of ammonia or ether ; or the spiritus ammonise 
 succinatus ; the unpleasant pungency of which remedies is concealed by 
 milk better than by any other menstruum. The daily employment of a 
 gentle emetic of ipecacuanha has in some instances appeared to be of 
 service, not merely by relieving the air-tubes of any mucus that may 
 have accumulated there, but by inducing several deep inspirations, and 
 thus aiding the complete establishment of respiration. As the child 
 improves, the more directly stimulating medicines may be withdrawn, 
 and tonics substituted for them, among which few are better than the 
 extract of cinchona. 1 It has the great advantage of not disordering 
 the bowels ; a point of no small importance in any case in which 
 diarrhoea is likely to occur. In some cases there is a sluggishness of 
 the bowels, and a deficiency in the secretion of bile ; very minute doses 
 of the Hydr. c. Creta will often remedy the latter, and the use of a 
 soap suppository will frequently render the internal employment of any 
 purgative needless. The child should be put to the breast unless it be 
 very feeble, but in that case should not be allowed to exhaust its 
 strength in fruitless attempts to suck. It will be better to draw the 
 breast, and give the child its mother's milk by means of a spoon or 
 from a bottle, which latter plan has this advantage, that while it costs 
 the child but little effort to get its food, we avoid the risk of its 
 forgetting how to suck, an inconvenience which attends the use of the 
 spoon if continued for any length of time. Artificial feeding is not at 
 all desirable in such cases, though sometimes, if the child be very weak, 
 it may be necessary at first to give a few drops of brandy in its milk 
 every three or four hours. This plan of treatment must be patiently 
 persevered in, nor must the supervention of symptoms of an apparently 
 acute character induce too wide a deviation from it. The head symp- 
 toms in particular must be combated cautiously, lest by too great a 
 solicitude to overcome them w T e destroy the patient rather than the 
 disease. 
 
 ' See Formula No. 3, p. 45. 
 
157 
 
 LECTUKE XIV. 
 
 Collapse of Lung that has once been expanded — described as lobular pneumonia 
 by various writers — its characters — symptoms and differences from true pneumonia. — 
 Observations of Bailly and Legendre. — Is not to be regarded as a post-mortem occur- 
 rence. — Illustrative cases. — Instances of its occurrence in the adult. — Similar causes 
 tend to produce it at all periods of life — hence very frequent in old age. 
 
 Induration of the Cellular Tissue — its characters — remarkable reduction of tempera- 
 ture that attends it — appearances after death — condition of deficient expansion, or of 
 collapse of the lung, noticed by many observers, though misunderstood by most, is 
 probable cause of the induration, or the oedema of the surface. 
 
 The condition of the lungs which we were occupied in examining at the 
 last lecture is of importance, even if regarded merely as a congenital 
 state, the result of nature having failed in the attempt to establish 
 respiration, and to fit the child thoroughly for the new mode of existence 
 to which it is destined after birth. But its claims on our attention are 
 still greater when we bear in mind the possibility of its occurrence in 
 consequence of a variety of causes operating after birth, so that lungs 
 once permeable to air may cease to admit it, and death at length occur 
 from apnoea without any serious structural change having taken place 
 in the organs of respiration. 
 
 Appearances supposed to be the result of pneumonia had long attracted 
 the notice of writers on diseases of children, by the wide differences which 
 they presented from those which inflammation of the lungs give rise to 
 in the adult. It had been observed that infants and children under five 
 years of age often died after presenting some of the symptoms of inflam- 
 mation of the lungs, such as cough and difficult breathing, together with 
 more or less extensive dulness of the chest on percussion, and some or 
 other of the auscultatory signs of solidification of the lung. In such 
 cases these peculiar morbid appearances were especially well marked. 
 But while they seemed to prove that these changes in the lung were 
 the consequences of pneumonia, it happened not infrequently that the 
 fever and the pneumonic symptoms underwent a great abatement before 
 any sign of approaching death appeared, or that children who had seemed 
 to die worn out from various causes, and during whose lifetime no 
 indication of inflammation of the lungs had existed, presented the sup- 
 posed anatomical evidences of pneumonia in a most remarkable degree. 
 The frequency of occurrences of this kind led to the assumption that 
 pneumonia was an extremely frequent concomitant of almost all the 
 diseases of infancy and early childhood, — that this pneumonia was very 
 often latent (that is to say, that it did not manifest its existence by 
 those symptoms which usually attend it), and lastly, that owing to 
 causes which were differently stated by different observers, it gave rise 
 to alterations in the lung very dissimilar from those which it occasioned 
 in the adult. 
 
 One of the most remarkable peculiarities of this supposed infantile 
 pneumonia led to its receiving the appellation of lobular pneumonia, 
 
158 COLLAPSE OP LUNG APTER BIRTH — 
 
 as expressive of the fact that it did not attack a large tract of lung, or 
 the whole of a lobe at one time, but that it affected isolated lobules, 
 which might be seen of a dark colour, solid, often depressed below the 
 surrounding parts, and sinking in water if detached from the healthy 
 / tissue in the midst of which they were situated. Sometimes the affection 
 was strictly limited to a single lobule, the boundaries of which could be 
 exactly traced ; and though it often happened that a cluster of lobules 
 was thus hard, and dark, and solid, still there was no gradual shading 
 off from the darker to the lighter parts, so that it was evident that, in 
 whatever way the disease extended, at any rate it did not advance by 
 mere continuity of tissue. Sometimes almost the whole of one lobe 
 was thus affected, a few lobules only still retaining a healthy aspect, and 
 crepitating under the finger, and it often happened that the bronchi 
 leading to it were full of mucus or pus, while at other times there was 
 marked congestion of the lung, and in the midst of this congested tissue 
 were two or three solid, hepatized patches. All these circumstances, as 
 it may be conceived, variously modified the morbid appearances. In 
 the last case the lobular pneumonia was thought to be becoming gener- 
 alised, or, in other words the inflammation originally limited to certain 
 lobules was supposed to have begun to extend to the adjacent tissues, 
 constituting a kind of transition state between lobular and lobar pneu- 
 monia. The lower edge of the different lobes, the whole of the middle 
 lobe of the right lung, and often a very considerable portion of the 
 whole of one or other lower lobe, were also sometimes found in a state, 
 to which, among other names, that of carnification was applied, on 
 account of its close resemblance to a piece of muscular tissue. A por- 
 tion of carnified lung showed the closest possible similarity to a lung 
 that had been compressed by effusion into the pleura. It was dark, 
 tough, solid, contained no air, presented a smooth surface when cut, 
 yielded a small quantity of bloody serum, when pressed, and, indeed, 
 seemed almost like a piece of flesh, in all which respects it resembled 
 a portion of lung hepatized by lobular pneumonia, and differed from 
 the lung of the adult when that has been rendered solid by inflamma- 
 tion. 
 
 The course of the disease in many of these cases during the life-time 
 of the patient, and the results of medical treatment, tended to enhance 
 the difficulties which the above-described anatomical peculiarities placed 
 in the way of referring lobular pneumonia to the same category of affec- 
 tions with the pneumonia of the adult. Venesection, leeches, and mer- 
 curials, the ordinary antiphlogistic apparatus in the pneumonia of the 
 adult, often appeared to hasten the child's death ; blisters rarely effected 
 any good, and the blistered surface often showed a remarkable indisposi- 
 tion to heal. On the other hand,emetics and rubefacients were frequently 
 of service ; a stimulant plan of treatment was almost always necessary 
 at an early period, and sometimes seemed to be required almost from 
 the outset of the affection. The rapidity of the changes that took 
 place in the physical condition of the lung was another peculiarity which 
 rendered the nature of the affection still more obscure , for where air 
 was heard entering freely on one day, none would be perceptible on the 
 morrow, but percussion of that part of the chest would yield a sound of 
 
MISTAKEN FOR LOBULAR PNEUMONIA. 159 
 
 complete dulness. On the other hand, it happened sometimes, though 
 much less often, that dulness was succeeded just as quickly by resonance 
 on percussion, and that breathing became distinctly audible where on 
 the previous day no sound of air was to be heard. 
 
 Nothing can show more forcibly the influence of a name, than the 
 fact that this condition of the lungs should have been described by all 
 writers as lobular pneumonia, and that its symptoms should have been 
 attributed to inflammation, while yet it was evident from the concurrent 
 testimony of every one that neither in its progress nor in its results was 
 it similar to inflammation of the lungs in the adult, much less identical 
 with it. Having, however, once been called pneumonia, every person 
 continued to call it so, though often with a full recognition of its pecu- 
 liarities. Even the close resemblance which the lung presented to foetal 
 lung, or to those undilated portions which are characteristic of atelec- 
 tasis, was noticed and discussed by myself, and by many far better 
 observers, apparently without a suspicion that both states were iden- 
 tical. 
 
 But while the peculiarities of lobular pneumonia were thus generally 
 commented on, it seems strange that no one should have had recourse to 
 the experiment of inflation in order to obtain a solution of some of the 
 difficulties that existed with reference to its nature. This oversight 
 seems the more extraordinary, when we call to mind that this very means 
 had cleared up so many doubts concerning appearances in the lungs of 
 new-born infants, which had once been supposed to be the result of 
 pneumonia in the foetus, or of some arrest of developement. At length 
 the experiment was tried by MM. Bailly and Legendre, 1 and though, 
 as in the old tale of Columbus and the egg, the thing seems so obvious 
 that there is some risk of our undertaking the merit of those who were 
 the first to do it, it must not be forgotten, that, by that simple means 
 they have thrown more light on the affections of the lungs in infan- 
 cy and childhood, than all the writers of the previous ten years taken 
 together. 
 
 MM. Bailly and Legendre state as the result of their observations 
 that the appearances, to which the name of lobular pneumonia has 
 commonly been given, are in reality produced by an occlusion of the 
 pulmonary vesicles. This occlusion, say they, — and the correctness of 
 this opinion is now universally admitted, — is due to the inspiratory 
 power having been inadequate to overcome that elasticity of the lung 
 concerning which I spoke to you at the last lecture ; while it is in many 
 instances favoured by the accumulation of secretions in the bronchi 
 partly obstructing their canal and interposing a more than ordinary 
 obstacle to the entrance of the air. Besides this cause they assign a 
 second, in the direct compression of the air vesicles by an unusually 
 congested state of their vessels ; but in this opinion, in which I former- 
 ly coincided, they are now generally believed to have been mistaken, 
 and the congestion is probably a secondary and accidental occurrence. 
 Be this as it may, however, inflation of the lung will in either case 
 
 1 Nouyelles Recherches sur quelques Maladies du Poumon ; in the Arch. Gdn. deMe'd., 
 Jan., Fevr., Mars, 1814. 
 
160 RESEARCHES OP BAILLY AND LEGENDRE. 
 
 remove the solidity of the lobules, and restore them almost or quite to 
 their natural appearance. 
 
 It may, however, be objected that this is not in reality a morbid con- 
 dition of the lung, but that it is only the effect of a somewhat 
 greater degree than usual of that collapse of the organ which takes 
 place when the breath leaves the body. It may be suggested that noth- 
 ing more is needed to produce the complete emptying of some portions 
 of the lung, and their consequent solidification, than the resiliency which 
 they retain after death, coupled with the pressure of theparietes of the 
 thorax upon them. The possibility of this condition supervening after 
 death cannot be denied, but still it may safely be affirmed, that it is not 
 usually, nor, indeed frequently a post-mortem occurrence. The fre- 
 quency with which isolated lobules are found dark, unaerated, and solid, 
 while all the surrounding tissue is perfectly healthy, can hardly be 
 accounted for on the supposition that the state comes on after death. 
 But conclusive evidence is afforded by the physical signs of solidifica- 
 tion of the lung being observed in many cases in which this condition 
 is found after death, and by the frequency with which sudden and fatal 
 dyspnoea comes on in the course of various affections in early infancy, 
 and leaves no trace of its cause other than a collapsed state of a consid- 
 erable portion of the lungs. 
 
 A little girl was attacked, when a month old, by very severe diarrhoea 
 which lasted for three weeks, arid then left her greatly exhausted and 
 much emaciated. No return of the purging occurred, and the child 
 lived, though in a state of great weakness, till she was five months old. 
 For the last five weeks of her life, she was under my care, and some- 
 times she seemed, for a day or two, as if she were gaining strength and 
 might recover ; but these signs of improvement were never of long du- 
 ration. Three days before she died, her breath grew suddenly hurried ; 
 the dyspnoea was not attended with any cough, but, from the time of its 
 coming on, the child's exhaustion increased, and her respiration grew 
 more rapid until her death. 
 
 No organ showed any sign of disease, but all presented a most remark- 
 able degree of anaemia. Two-thirds of the upper, and almost the whole 
 of the lower lobe of the right lung, were dark, solid, and non-crepitant; 
 and a few lobules of the left lung presented the same appearance. — 
 Inflation restored them to exactly the same state as the rest of the lung. 
 The bronchi were preternaturally pale, and contained no secretions. It 
 is not possible to say why the child's inspiratory power grew too feeble 
 to fill the lungs at one moment rather than at another, but few will doubt 
 that it had become so just at the time when the dyspnoea occurred. A 
 portion of the lung having become collapsed, the elastic ribs tended to 
 render abortive any faint effort to draw in more air, and thus the vital 
 flame went out for want of air to feed it. 
 
 Sometimes the occurrence of this condition is long preceded by indi- 
 cations of the imperfect performance of the respiratory functions, but 
 yet they go on sufficiently to keep the machinery of life in motion, till 
 some trivial, perhaps some inappreciable cause, — a draught of cold air, 
 a little over-exertion, the horizontal posture too long continued, the 
 customary food delayed an hour beyond the usual time, — sinks them so 
 low that they soon cease forever. 
 
CASES OP COLLAPSE OF THE LUNG. 161 
 
 Some time ago I saw a little girl ten months old, who had lost her 
 mother soon after her birth, and had been indebted to a stranger for 
 what should have been a mother's cares. She never throve ; her chest 
 presented that peculiar malformation commonly called pigeon-breast, 
 and the diaphragm drew her yielding ribs inwards, and thus produced 
 a circular constriction around the base of the thorax. 1 But though she 
 was a backward child, and though her respiration was always almost as 
 abdominal as that of a new-born infant, there was no definite evidence 
 of disease until she was nine months old. She then lost flesh rapidly, 
 and began to cough without having had any previous catarrh. Her 
 case seemed to be one of bronchial phthisis. 
 
 Four days before she died her breath suddenly became much op- 
 pressed, and her cough far more severe than it had been before. The dys- 
 pnoea rapidly increased, but her cough soon became less frequent. A 
 few hours before her death her lips were quite livid ; she was breathing 
 from 80 to 86 times in the minute, the abdominal muscles acting most 
 violently, but the chest being scarcely at all expanded. Auscultation 
 detected nothing more than some rather large mucous rale in the lung. 
 
 After death no tubercle was found in any organ, but large portions 
 of both lungs presented the undilated condition, which disappeared en- 
 tirely on inflation. The bronchi were pale, and contained very little 
 mucus, but the right side of the heart was greatly distended with coag- 
 ulated blood, which its thin, pale, and flaccid substance had evidently 
 been unequal to propel with the requisite vigour. 
 
 The imperfect respiration had here for some time manifested itself ; 
 the vital powers had long been feeble; nutrition had been ill performed, 
 and the heart itself had shared in the general feebleness, till at length 
 air ceased to permeate a large extent of the pulmonary substance, and 
 the child died for want of air to produce the requisite changes in the 
 blood. 
 
 In both of these cases the lung collapsed, because the inspiratory 
 powers were too feeble to fill the minuter vessels with air. The result 
 is the same if the obstacle be increased as if the power be diminished ; 
 and hence the supervention of this state of lung becomes one of the 
 most perilous, while it is one of the most frequent, complications of infan- 
 tile bronchitis. A little girl, previously quite healthy, was seized when 
 ten months old with symptoms of acute bronchitis, a suffocative cough 
 returning in paroxysms, and sometimes followed by the rejection of a 
 muco-purulent fluid. The symptoms throughout did not seem to allow 
 of depletion ; but ammonia, with decoction of senega and tincture of 
 squills, and other expectorants of a stimulating kind, were given with 
 temporary amendment. The child did not, however, appear to have 
 undergone any marked change, either for better or worse, except that 
 she had certainly lost both flesh and strength, when coldness, faintness, 
 and exceedingly laboured respiration, suddenly came on, under which 
 symptoms she died in the course of twenty-four hours. 
 
 A few recent adhesions were found on each side of the chest, between 
 
 1 A very interesting explanation of the mechanism by which this deformity of the 
 chest is produced is given by MM. Rilliet and Barthez, op. cit. vol. iii., p. 640. 
 
 10 
 
162 CONDITION PRODUCED BY SAME CAUSES AT ALL PERIODS OF LIFE. 
 
 the costal and pulmonary pleura. The trachea contained a large quan- 
 tity of muco-purulent matter, and the same secretion abounded in the 
 bronchial tubes, many of which were filled by it, while nowhere did air- 
 bubbles appear intermixed with it. There was some congestion of both 
 lungs, especially posteriorly; the upper and posterior part of the upper 
 lobe of the right lung, the whole of the middle lobe, and the posterior 
 part and lower edge of the lower lobe, were dark, solid, non-crepitant, 
 and depressed below the adjacent tissue. The same state existed in the 
 w T hole inferior third of the upper lobe, and the lower edge of the lower 
 lobe of the left lung. On inflating the lung, most of these parts were 
 restored to a perfectly natural condition, but some patches still remained 
 less dilated than the others, and some of the darker, almost violet- 
 coloured portions of the lower lobes appeared but little affected by it. 
 
 But you may naturally inquire whether any occurrence of a similar 
 kind is ever met with in the adult, since there is certainly no such pecu- 
 liarity in the structure of the lung in childhood as should render it then 
 exclusively liable to a morbid process from which at all other ages it is 
 exempt. My own experience would not enable me to answer this 
 inquiry ; but my friend, Dr. Baly, has communicated to me the particu- 
 lars of three cases in which he found large portions of the lung in the 
 adult presenting the characters that we have been studying in the child, 
 and like it resuming a natural appearance on the insufflation of air into 
 the bronchi. The patients, in all of these cases, died of fever, attended 
 with dysenteric symptoms ; and for some days before their death were 
 in a state of great exhaustion, such as appeared to indicate the free 
 employment of stimulants. In two of the cases extreme dyspnoea 
 occurred some days previous to death ; but though the chest lost its 
 resonance in the situation of the affected parts of the lung, and the 
 breathing there was deficient, yet the minute crepitation of pneumonia 
 was not detected in either case, but merely some large mucous rale. In 
 addition to extensive disease, which in each instance existed in the intes- 
 tines, this collapsed condition of portions of the lung was found ; un- 
 connected with any disease of those organs in one of the cases, combined 
 with the effusion of tenacious mucus in the bronchi leading towards the 
 collapsed portions in a second, and associated with true pneumonia and 
 a state of red or yellow hepatization of other parts in a third. 1 
 
 But these are by no means isolated cases ; for it would seem as if in 
 some diseases which are attended with much depression of the vital 
 
 1 The minute accuracy of Dr. Baly's description induces me to subjoin the following 
 particulars of one of the examinations, as he allows me to extract them from his case- 
 book : — " No effusion, lungs healthy, except in lower and posterior fourth of right 
 inferior lobe, which is of a dark purple colour, is depressed somewhat below the level of 
 other parts, does not crepitate, feels solid, but flexible and tough, almost leathery, and 
 sinks quickly in water : the part having these characters is distinctly defined by 
 boundaries of lobules. The whole lung being inflated, the part just described receives 
 air with greater difficulty than the other parts, but at length becomes distended, lobule 
 by lobule, and assumes the same pale red colour as the rest of the lungs. The change 
 takes place, as has been stated, lobule by lobule, separate lobules appearing suddenly 
 of the paler colour, not merely at the margins of the dark mass, but also in this centre. 
 On cutting through the lungs and tracing the bronchi, it is found that the ramifications 
 of those tubes which go to the dark, contracted, and condensed parts, are filled up with 
 tough mucus, from which those going to other parts are free." 
 
COLLAPSE OF THE LUNG IN THE ADULT. 163 
 
 powers, this collapse of the lungs were by no means unusual. To ad- 
 duce but one illustration of this, it may be mentioned that M. Louis 1 
 found in nineteen out of forty-six post-mortem examinations of patients 
 who had died of typhoid fever, a condition of the lungs which he calls 
 " carnification," and which it is evident (although he did not try the effect 
 of inflation) was identical with the state so frequent in the child. He 
 describes the parts thus affected as of a deep purple red, having lost the 
 natural suppleness of the lung, being solid, and sinking in water : they 
 were, moreover, tougher than healthy lung : if divided, the section 
 became covered with a reddish fluid, perfectly destitute of air, while 
 the tissue neither resembled that of healthy lung, nor presented the 
 peculiar granular appearance characteristic of lung in the second stage 
 of pneumonia. More recently, too, Dr. Grairdner, of Edinburgh, in 
 his very important essays 2 on the " Pathological Anatomy of Bronchi- 
 tis," &c. has mentioned this condition of the lungs as having been of fre- 
 quent occurrence during the epidemic fever of 1847. 
 
 It is true, however, that in these cases the condition of the lungs 
 was merely superadded to other lesions in themselves adequate to occa- 
 sion the patient's death ; and hence, though interesting to the mere 
 pathologist, it yet loses much of its value in the eyes of the practical 
 physician. But it will not seem to you that too much stress has been 
 laid on this state, if it should appear that whenever the power of the 
 inspiratory muscles is much diminished there is a tendency to its super- 
 vention, so that it alone may be the cause of death ; and this, which I 
 have put hypothetically, really does occur in old age. 
 
 The term second childhood is not a mere figure of speech, expressive 
 solely of the decay of the mental powers, by which the evening of life 
 is obscured and made like the twilight of the mind in early infancy, but it 
 is in many points the expression of a physical truth. Thus as old age 
 creeps on, and the nutrition is no longer adequate to supply the waste, 
 the respiration loses the character which it presented in the adult, and 
 the extremes of life in this respect present a close resemblance to each 
 other. The muscles of the chest are no longer strong enough to dilate 
 it fully ; the diaphragm becomes as it was in early infancy, the princi- 
 pal inspiratory muscle, and the vertical diameter of the thorax is that 
 in which its chief enlargement takes place. The ear applied to the 
 chest no longer detects the puerile breathing of youth, nor the clear 
 vesicular murmur of manhood ; but the respiration is coarser, sometimes 
 almost bronchial. There is not occasion, as in infancy, for more rapid 
 breathing to maintain the high activity of the vital processes, but the 
 worn-out machinery needs to be put in motion more frequently than 
 in the adult, in order to obtain oxygen enough to support existence ; 
 and, accordingly, MM. Hourman and Dechambre 3 found the average 
 frequency of the respiration in 255 old women at the Salpetriere to be 
 21.79 in the minute, while in some whose frame seemed most decayed 
 
 1 Recherches sur la Gastro-enterite. 8vo. Paris, 1829 ; tome i., pp. 3G1-364. 
 
 2 Reprinted from the Monthly Journal of Medical Sciences for 1850 and 1851. 
 
 3 The above facts with respect to the respiration in the aged are derived from the 
 interesting papers of MM. Hourman and Dechambre, in the Arch, de Med. for 1835 and 
 1836. See especially the number for Nov., 1835. 
 
64 INDURATION OF THE CELLULAR TISSUE. 
 
 it was far more rapid. Just as in infancy, too, so in old age, these respi- 
 ratory movements are most irregular. Sometimes the parietes of the 
 thorax continue for a long time motionless, and then there succeed 
 a series of rapid movements, while at other times the intervals between 
 the inspirations are irregular, but the inspiratory movements are of the 
 same intensity and duration. Here then, without pursuing the compar- 
 ison further, we have ample proof of the many points of resemblance 
 between the physiological condition of the respiratory function in early 
 life and in old age. The respiratory organs, too, in their pathological 
 state, present, as might be expected, the same resemblance ; and accor- 
 dingly MM. Hourman and Dechambre 1 notice a state in which the pul- 
 monary parenchyma is of a very deep, sometimes almost of a blue 
 colour, or nearly black, non-crepitant, and presenting a smooth surface 
 on a section of it being made. The lung thus altered is often remark- 
 ably tough, almost like Indian rubber ; while under pressure, a viscous 
 fluid, generally of a reddish colour, and containing no air-bubbles, exudes 
 from it. The idea of inflating the lung had not occurred to these ob- 
 servers ; but they remark, that if portions of lung presenting these 
 characters be dried, the air-cells have a tendency to re-appear without 
 having undergone any other change than a well-marked contraction. 
 
 I have dwelt long on this pathological condition, though I think not 
 longer than its importance demands, because we shall find that in some 
 form or other it presents itself, modifying the symptoms, determining 
 the prognosis, and influencing the treatment of almost all the affections 
 of the lung in early infancy. 
 
 We shall pass to the study of some of these diseases at the next lec- 
 ture ; but, before doing so, may notice an affection about whose nature 
 much controversy has arisen, but to which, thanks to the researches 
 of MM. Bailly and Legendre, we may now assign a place as one of the 
 results of the imperfect expansion of the lungs, and of the consequently 
 incomplete performance of the respiratory functions. Though very 
 rare in this country, induration of the cellular tissue is extremely 
 common in the foundling hospitals of the Continent, where so many 
 causes contribute to depress the new-born infant's feeble powers. 
 The children in whom it occurs are usually weakly, not seldom pre- 
 mature, and its first symptoms generally appear between the first and 
 fifth day after birth, though occasionally they do not come on till later. 
 In many instances a livid redness of the whole surface is obvious from 
 birth ; but the appearance of a circumscribed hard spot on one or other 
 extremity, or on some prominent part of the face, as the end of the 
 chin, or the cheek bone, is the first sign of the commencement of this 
 affection. Other spots of a similar kind are soon discovered on 
 different parts of the surface ; and the. body generally, and the hardened 
 spots in particular, are found to present a temperature much below the 
 natural warmth of the body. It appears, indeed, from M. Roger's 
 researches, 2 that a general reduction of the temperature precedes the 
 induration, or, at least, exists in a very marked degree, while the 
 
 1 Op. cit. Mars 1836, p. 272. 
 
 2 Op. cit. pp. 124, 151. * 
 
INDURATION OF THE CELLULAR TISSUE. 165 
 
 induration is still extremely slight. The sinking of the temperature 
 and the extension of the induration advance together, and the warmth 
 of the surface may eventually fall from 100° to 90°, 80°, or even 
 lower. If the induration become very extensive, it affects the integu- 
 ments of the chest and abdomen, as well as the extremities, and tlie 
 body feels cold and stiff, as though it were frozen. 
 
 This condition is, as might be expected, attended with great impair- 
 ment of the general health. Children suffering from it are extremely 
 weak, often too weak to suck ; their pulse is very small, their respiration 
 abdominal, and their cry faint and whimpering, wholly unlike that of 
 a healthy infant. In some of the worst cases, too, a bloody fluid is 
 discharged in considerable quantity from the nose and mouth. If the 
 indurated parts be punctured, a small quantity of reddish serum escapes 
 from them, though generally without much diminution of their previous 
 hardness. 
 
 If the induration be at all general, death almost invariably takes 
 place ; and so great is the fatality of the affection, that, including even 
 slight cases, five-sixths of those children who are attacked by it in the 
 hospitals of Paris, die. In very slight cases, however, if the infant be 
 at once placed in favourable circumstances, recovery need not be 
 despaired of. 
 
 The hardness of the surface still persists after death, and the absence 
 of any peculiarity in the effused serum, or of any sign of active disease, 
 left writers generally in much perplexity as to its cause. The venous 
 system is usually found gorged with fluid blood, and this congestion is 
 often apparent in the cerebral vessels, as well as in those of the 
 abdominal viscera, particularly the liver. Both the thorax and abdo- 
 men also frequently contain a quantity of serum, often tinged with 
 blood, — effusions which are evidently of a passive nature, since they 
 are unattended with any trace of inflammation either of the pleura 
 or peritoneum. None of the viscera present any morbid appearances 
 of half so much importance as those which are met with in the lungs, 
 a very great part of which displays those changes to which your 
 attention has already been directed as characteristic of their deficient 
 expansion. 1 This condition of the lungs had been noticed and' most 
 carefully described many years ago, as one of the most striking 
 attendants on induration of the cellular tissue. It was thought by 
 
 1 The observations of J. A. Troccon, in his dissertation, "Sur la maladie connue sous 
 le nom d'endurcissement du tissu cellulaire," 4to. Paris, 1814, are especially remark- 
 able, since he not only described with accuracy the physical condition of the lungs, but 
 even tried the experiment of inflating them, in order to prove that they were not, as had 
 been erroneously supposed, in a state of gangrene. He says — " J'ai insuffle" ensuite de 
 l'air dans les poumons par la trach£e, aussitot le couleur noire qui e"tait a leur base s'est 
 changee en une couleur rouge claire, laquelle s'est etendue de proche enproche a mesure 
 que je continuais ces insufflations." After removing a ligature which he had applied 
 around the veins and allowing the escape of the blood with which the heart and lungs 
 were gorged, he resumed the inflation of the lungs, and "les organes de la respiration 
 ont 6te presque de suite dans un 6tat absolument naturel, et aussi beaux que ceux Ton 
 voit pendus devant nos boucheries." — pp. 37-8. 
 
 It seems strange that neither M. Troccon nor subsequent observers perceived the full 
 bearing of these experiments till similar ones were instituted by MM. Bailly and 
 Legendre. 
 
166 TREATMENT OF INDURATION OF THE CELLULAR TISSUE. 
 
 some of those who described it to be the result of pneumonia ; while 
 other observers, justly insisting on the absence of the other effects of 
 inflammation of the pulmonary tissue, yet drew the attention of patho- 
 logists too much away from the chest, where the clue to the solution of 
 the question as to the cause of the affection was to be found, had they 
 but known how to use it. We, however, are aware that those appearances 
 once thought to be the result of pneumonia are in reality due to the 
 unexpanded condition of the lung; and we can understand how it may 
 happen, if children be exposed to cold immediately after birth, and then 
 transferred to the ill-ventilated wards of a foundling hospital, and there 
 fed with food far other than that which nature destined for them, that 
 respiration may be but very imperfectly established ; that their tem- 
 perature may consequently fall, and the blood flowing in part through 
 the unclosed foetal passages may stagnate in its course, may give rise 
 to passive effusions into the great cavities of the body, and to an 
 anasarcous swelling of the surface. There are, it is true, some peculia- 
 rities in this form of oedema, but not such as to invalidate the above 
 explanation of the cause to which it is due. 
 
 The treatment of this affection implies the removal of every cause 
 likely to induce it. Hence warmth stands foremost as a curative as well 
 as a preventive measure. The warm bath may be resorted to as a means 
 of raising the child's surface to a proper temperature, provided its 
 extreme weakness do not contra-indicate that measure. Gentle friction 
 with warm oil is a means which has been tried for this purpose with 
 advantage. The child should be nourished with breast-milk, even if it 
 be too feeble to suck, and stimulants, of which white-wine whey is a very 
 good one, will in many instances be needed. Defective respiration 
 being the ultimate source of all the symptoms, the main principles of 
 all your treatment must be the same as have been already laid down for 
 your guidance in cases of atelektasis of the lung ; and these it can hardly 
 be necessary to recapitulate. 
 
 I should have said more about this affection, its nature and treatment, 
 if it were one with which you were likely to meet often ; but in conside- 
 ration of its extreme rarity in this country, I may perhaps be excused 
 for passing it over with this cursory notice. 
 
 LECTURE XV. 
 
 Inflammatory Affections of the Respiratory Mucous Membrane — comparative 
 rarity of catarrh during the first weeks of life. — Coryza — simple and pseudo-mem- 
 branous, or malignant. — Catarrh, causes adding to its importance in early life — its 
 treatment — danger of bronchitis or pneumonia. 
 
 Post-mortem appearances of Bronchitis — redness of the membrane — nature of the con- 
 tents of the bronchi — dilatation of their cavity. — Extension of the inflammation to the 
 lining of the pulmonary vesicles, producing vesicular bronchitis. 
 
 State of the lungs in bronchitis — frequency of congestion — carnification of some lobules 
 — possible extension of inflammation to the pulmonary tissue, producing lobular pneu- 
 monia — suppuration of these patches producing vomicae. 
 
 Although two lectures have already been devoted to the pathology 
 of the respiratory organs, yet, until to-day, we have not been able to 
 commence the study of their special diseases. 
 
AFFECTIONS OF THE RESPIRATORY MUCOUS MEMBRANE — CORYZA. 167 
 
 They may be divided into the three grand classes — of the inflamma- 
 tory, the nervous, and those which result from morbid deposits. We 
 will examine these in the order in which I have enumerated them. 
 
 At every age inflammatory affections of the respiratory mucous 
 membrane exceed all others in frequency ; and even when the pulmonary 
 substance becomes eventually involved, it is often by the extension to it 
 of mischief which began in the mucous membrane. But in infancy 
 and childhood this is pre-eminently the case, for the delicate and highly 
 vascular lining of the respiratory organs resists but feebly the influence 
 of noxious impressions from without, while it sympathises most acutely 
 with many morbid processes within. 
 
 This extreme susceptibility of the mucous membrane of the respira- 
 tory organs in childhood renders its disorders of very frequent 
 occurrence, while we are compelled to study closely the signification of 
 symptoms that may betoken disturbance from such various causes. — 
 Something of this sympathy with the affections of other parts exists 
 even in the adult, as we may see exemplified in the cough that attends 
 upon affections of the liver, but in the child the sympathetic disorder of 
 the respiratory mucous membrane is vastly more frequent ; and nurses, 
 taught by experience, will speak to you about a tooth cough, a stomach 
 cough, a worm cough ; while you will soon find for yourselves that the 
 intestinal mucous membrane is seldom affected without that of the 
 respiratory apparatus suffering too. 
 
 It is a curious fact, however, to which Professor Jorg of Leipsic 1 was 
 the first person to call attention, that this extreme susceptibility of the 
 lining of the respiratory apparatus does not exist to the same degree 
 during the first month or two of life as it does afterwards. The exposure 
 of an infant two or three weeks old to a low temperature or to a vitiated 
 air, will be followed by disturbance of the function of the liver, and 
 the occurrence of jaundice ; or, perhaps, the muscular power may be 
 so far depressed as to render the child incapable of taking a full 
 inspiration, so that its lungs collapse, and it dies from disorder of the 
 respiratory organs, but without the cough or bronchitic symptoms, 
 which would not fail, if it were a little older, to announce the irritation 
 of the raucous membrane of the air-tubes. Why this is so I do not 
 know, but I suppose it to be the result of the generally feeble vitality 
 which renders the lining of the bronchi less susceptible ; just as that 
 of the intestine also seems to be, at the same period, since, while 
 constipation is frequent, diarrhoea is comparatively rare during the first 
 two months of life. 
 
 The mucous membrane of the nares, however, has not by any means 
 this insensibility, and coryza is an affection most frequent, and most 
 important during the first two months of life, when the other forms of 
 catarrh are comparatively rare. 
 
 This affection, in its most frequent form, is a source of discomfort 
 rather than of danger. Its most prominent symptom has given rise to 
 its vulgar name of a the snuffles;" for the mucous membrane of the 
 nares being swollen, the child is no longer able to breathe through its 
 
 1 Handbuch der Kinderkrankheiten, 8vo. Leipsig, 1836, p. 531. 
 
168 CORYZA MALIGNA. 
 
 mouth, and its difficult inspirations are attended with a peculiar 
 snuffling noise, which, during sleep, sometimes amounts to a complete 
 snore. As in common catarrh, the secretion from the membrane is at 
 first suppressed, afterwards it flows in an increased quantity, and then 
 at length it is altered in character, and becomes thicker and puriform ; 
 and then it sometimes dries and forms crusts about the nostrils, which 
 interfere greatly with free respiration, and cause the child much annoy- 
 ance. At the outset there is often a degree of heat of skin and febrile 
 disturbance, but these symptoms soon subside, and, with the exception 
 of the snuffling respiration, the child seems quite well. If the attack 
 be more severe, however, it may occasion a good deal of suffering, for 
 if respiration through the nose be very much impeded or altogether 
 prevented, the child is rendered unable to suck, and so soon as it has 
 seized the nipple and begun to draw the milk, it is compelled to leave it 
 in a state of threatening suffocation. Its distress, too, is further 
 increased by the circumstance that its mouth, being constantly kept 
 open in order to breathe, the tongue and throat become extremely dry, 
 and deglutition, even when the child is fed with a spoon, is often attended 
 with difficulty. . Any such severity of the disease, however, is very un- 
 usual, though such cases do sometimes occur, and even prove fatal ; the 
 difficulty of breathing and sucking, together, wearing out the patient. 
 When this event occurs, something more seems to exist than a simple 
 inflammation of the Schneiderian membrane, since it either secretes a 
 very tenacious mucus in extreme abundance, or becomes coated with 
 false membrane which sometimes extends even to the tonsils and palate. 
 Cases of this kind are usually associated with extreme depression of 
 the vital powers, and have received on this account the name of coryza 
 maligna. In the Foundling Hospitals of the continent this malignant 
 coryza is not very uncommon. I have never but once, however, seen 
 anything approaching to it in severity, except where it has occurred as 
 a complication of scarlatina. In that instance, a little boy, six months 
 old, was brought to me on the 25th of October, 1842. His health had 
 been good until the 20th, when he became hoarse ; on the 22d this 
 hoarseness had much increased, and he became unable to suck, since 
 which time he had continued to grow worse. When I saw him his skin 
 was warm, face rather flushed, eyes watering, and a thick ropy mucus 
 obstructed his nostrils. He cried with a suppressed but squeaking 
 voice, and breathed with a peculiar wheezing noise, though air entered 
 the chest unattended with any rale. The child was unable to suck, and 
 even when he drank from a cup the fluid often returned through his 
 nose. The inside of the mouth was very red, and the tonsils and soft 
 palate were especially so. The mouth was full of an extremely tenacious 
 mucus, which it was necessary from time to time to take out with the 
 hand. 
 
 A lotion was injected up the nostrils, composed of 5j- of alum to *ij. 
 of water, with great relief to the child, the secretion from the nares 
 becoming more decidedly puriform, but less adhesive ; and the child 
 became able to suck a little. On the 28th, however, the child's powers 
 seemed much depressed ; it sucked eagerly, for the secretion from the 
 nose had become almost watery, but it swallowed with much difficulty. 
 
TREATMENT OP CORYZA. 169 
 
 A layer of false membrane of a yellowish-white colour had now appeared 
 on the soft palate and back of the hard palate, and on the tonsils. 
 
 A lotion of three grains of the nitrate of silver to an ounce of water 
 was applied to the back of the throat, and a mixture of the extract of 
 bark with ammonia was given every six hours. On the first of Novem- 
 ber the child was better, could both swallow and suck well, and the 
 false membrane had entirely disappeared from the mouth ; but the 
 palate was still red, and presented some broad superficial patches of 
 ulceration. The subsequent recovery was tardy, but the immediate 
 danger was over, and no relapse occurred. 
 
 The simple coryza, calls, as I have already observed, for but little 
 treatment, and, indeed, treatment appears to exert but little influence 
 over it. It is desirable, however, if there be much difficulty in breathing, 
 that the child be taken from the breast, though it may still be fed with 
 its mother's milk by means of a spoon, since the fruitless efforts to suck 
 aggravate its sufferings, and should therefore be prevented. If heat of 
 skin and other indications of fever attend its onset, some mild diapho- 
 retic medicine, with a few drops of ipecacuanha wine, may be given \ l 
 
 (No. 8.) 
 1 R Liq. Am. Acet. gj. 
 Vin. Ipecac. TTLxvj. 
 Pot. Nitratis, gr. viij. 
 
 Mist. Amygdalae, gvij. M. gj. 4tis. horis. 
 For a child six months old. 
 
 attention must be paid to the state of the bowels, and in the course of 
 ten days or a fortnight the infant will be found again breathing quietly, 
 and the disease will have subsided. As the secretion becomes thicker, 
 care must be taken to prevent its accumulating and drying at the open- 
 ing of the nostrils, by which it would cause serious discomfort to the 
 child. In the malignant variety of the disease local as well as general 
 treatment becomes necessary. The tendency to the formation of false 
 membrane in the nares must be combated by injections of alum or 
 nitrate of silver, while the condition of the fauces must be watched as 
 narrowly as that of the nares, and similar applications must be made to 
 them on the appearance of any unusual redness there, since such increase 
 of vascularity is only the first stage of that process which would issue 
 in the exudation of false membrane. At the same time, a general tonic 
 plan of treatment will be called for, and care will be needed to ensure 
 the child's taking a proper quantity of nutriment, since its powers of 
 sucking and of deglutition will in all probability both be impaired. 
 
 Cases are sometimes met with, in which coryza, though not of a 
 severe kind, is troublesome by its continuance for weeks together. This 
 chronic coryza is, I believe, almost always connected with a syphilitic 
 taint. I have on several occasions met with it when there were not 
 above one or two spots of copper-coloured eruption to mark its charac- 
 ter ; and a few instances of it have come under my notice in which no 
 positive evidence of venereal taint, either past or present, could be 
 obtained, but which nevertheless got well under the use of small doses 
 of Hydrarg. c. Creta. 
 
170 CATARRH — ITS IMPORTANCE IN EARLY LIFE. 
 
 With the increasing age of the infant there is a growing liability to 
 catarrh, and during the period of dentition the susceptibility of the 
 mucous membrane of the respiratory organs appears to have attained 
 its maximum. Slight variations of temperature now induce catarrhal 
 seizures ; or even, independently of any such exciting cause, the mere 
 approach of a tooth towards the surface of the gum often gives rise to 
 its symptoms, which subside when the source of irritation ceases. Such 
 attacks often alternate with attacks of diarrhoea, or the two coexist ; 
 the symptoms of disturbance of the intestinal mucous membrane pre- 
 dominating at one time, those of disturbance of the respiratory mem- 
 brane at another. The preponderance of one or the other affection seems 
 much to depend on atmospheric causes ; and children who, during the 
 months of June, July, August, and September, would suffer from diar- 
 rhoea, will, under precisely similar circumstances in the earlier months 
 of spring, or the later months of autumn, suffer from catarrh. From 
 the extreme susceptibility of these two great mucous surfaces arise a 
 large proportion of the ailments, and many even of the serious diseases 
 of infancy. Morbid as well as reparative processes go on most rapidly 
 in early life : the flux of to-day may to-morrow be attended with dysen- 
 teric symptoms ; the catarrh of to-day may to-morrow have put on the 
 grave features of acute bronchitis. 
 
 Now these two circumstances taken together, — the extreme suscepti- 
 bility of the respiratory mucous membrane, and the rapidity with which 
 its trivial disorder sometimes becomes a grave disease, — give to the 
 catarrhal affections of infancy an importance which in more advanced 
 life they do not possess. This importance, too, is still further increased 
 by the tendency of the lung to become collapsed when the entrance of 
 air into its minuter cells is impeded even by a comparatively trivial 
 cause ; while in other cases, or even in connection with the collapsed 
 condition of the lung, the inflammatory process may invade the pul- 
 monary cells and the general tissue of the lung, and that which had 
 seemed a slight cold may grow to a dangerous bronchitis, or a still more 
 dangerous pneumonia. 
 
 Of catarrh itself and its general characters little need be said. 
 Allowing for the difference between the ages of the patients, its symp- 
 toms are the same as in the adult. Sneezing and running at the eyes 
 and nose, and cough, a hot skin and quickened pulse, attend it. In 
 some children the febrile disturbance with which even a common attack 
 of cold sets in is very severe for the first twenty-four hours or more, and 
 then the more threatening symptoms subside, and the true nature of 
 the affection becomes apparent. At other times, when catarrh is 
 extremely prevalent, — epidemic in short, this severe onset is usual ; and 
 the affection closely resembles, or is probably identical with, influenza. 
 Often, too, you will find the commencement of an epidemic of hooping- 
 cough preluded by an unusual prevalence of catarrh, the cough by 
 degrees assuming in more and more numerous cases the paroxysmal 
 character and peculiar sound of pertussis. It is unnecessary to allude 
 to the catarrhal symptoms which precede measles ; but bearing in mind 
 that what seems to be a mere cold may turn out to be the first stage of 
 a very serious malady, you are furnished with an additional reason for 
 

 TREATMENT OF CATARRH. BRONCHITIS. 171 
 
 not slighting it. Lastly, you must not forget that the frequent return 
 of attacks of catarrh is sometimes an indication of that irritable state 
 of the bronchial membrane which the abundant deposit of tubercle in the 
 lungs occasions : and this, again, yields another argument for not 
 neglecting an apparently trivial ailment. 
 
 While it is your duty, however, on so many grounds, to watch closely 
 every child, although its indisposition may not seem to be more than a 
 simple catarrh, yet in the way of actual medical treatment very little is 
 required. The child must be kept in one temperature ; and, if the nursery 
 be an airy room, it is desirable that it be confined to that apartment. 
 If already weaned, it may be well to withdraw some of the more solid 
 articles of diet ; if not, care must be taken that the child does not, in 
 consequence of its thirst, suck too much ; and a little barley-water 
 should therefore be given it from time to time. A warm bath at night 
 will do much to allay the heat of skin ; and, if the febrile disturbance be 
 considerable, a couple of grains of James's powder, with half a grain of 
 calomel, may be given to a child a year old, at bed-time. During the 
 day, a mixture, containing a few drops of ipecacuanha and antimonial 
 wine, with a little of the compound tincture of camphor, if the cough 
 irritate by its frequent return, may be given with advantage ; and, as 
 the fever subsides, the spirits of nitrous ether may be substituted for the 
 antimonial wine. 1 
 
 (No. 9.) (No. 10.) 
 
 R Vin. Ipecacuanhae, n^x. R "Vin. Ipecac, n^x. 
 
 Vin. Ant. Pot.-Tart. tt^xxx. Oxym. Scillae, rr^xl. 
 
 Tinct. Camph. co. n^xx. Spir. iEth. Nitr. r^xx. 
 
 Mist. Amygdalae, ^vij. Tinct. Camph. co. tt^xx. 
 
 M. gij. 4tis horis. Aquae Anisi, gviss. 
 
 M. gij. 4tis horis. 
 For children of one year old. 
 
 The danger, however, in these cases, is of a more grave disorder of 
 the air-passages coming on ; and this brings us to a subject which we 
 cannot pass over hurriedly — namely, the bronchitis and penumonia of 
 infancy and childhood. 
 
 The study of these affections in childhood is beset by some difficulties 
 which we do not meet with in the adult. The points of difference 
 between bronchitis and pneumonia are sufficiently well marked in the 
 adult for all purposes of practical utility, although many inquiries may 
 be started with reference to the intimate nature of the morbid processes 
 which we may be unable to answer satisfactorily. Besides, whether the 
 capillaries, or the pulmonary cells, or their parietes, be the structures 
 first attacked, it is clear that they are all involved in pneumonia from a 
 very early stage of the disease ; and hence we find it attended from the 
 outset with peculiar symptoms, such as do not occur in bronchitis. 
 Pneumonia similar to that of the adult is sometimes observed even in 
 early childhood ; but it often happens that, though the pulmonary sub- 
 stance becomes eventually a partaker in the disease, it yet was not so at 
 first ; but the inflammation, beginning in the larger air-tubes, has passed 
 along them to the smaller bronchi, and then at length involving the 
 
172 MORBID APPEARANCES OF THE BRONCHI. 
 
 tissue of the lung, the case comes to be one neither of pure bronchitis 
 nor of pure pneumonia, but a mixture of the two, which has not inaptly 
 been termed bronchio -pneumonia. Another source of difficulty in the 
 study of these affections, as well as an occasion of the great peril that 
 attends them, is the tendency which we have already observed in the 
 lung during early life to become collapsed, and no longer to admit that 
 air without which the changes in the blood cannot take place, and the 
 absence of which naturally aggravates the mischief that the inflammatory 
 disease itself tends so immediately to produce. 
 
 I must beg you, therefore, to pardon me if I enter rather more 
 minutely than is my custom into the description of the morbid appear- 
 ances produced by inflammation of the lungs and air-tubes in infancy 
 and childhood. 
 
 An increased degree of redness of the mucous membrane of the bronchi 
 is almost constantly observed in the case of children who have died of 
 inflammation of the lungs or air-tubes. There are three sources of 
 error, however, against which it is essential to guard when examining 
 the bronchi with reference to this point. The first is the occasional 
 disappearance of redness after death, even where the presence of an 
 abundant muco-purulent secretion in the tubes bears evidence to the 
 activity of the inflammatory process ; the second is the apparent red- 
 ness of the smaller tubes in cases where the lungs are congested or 
 inflamed, and which may be due not to the increased vascularity of the 
 bronchi themselves, but to their transparency, allowing that of the sub- 
 jacent tissue to be seen through them. The third is the ocasional 
 staining of the mucous membrane, owing to the transudation of the 
 blood through the coats of the vessels after death. With care, however, 
 none of these circumstances will lead you astray. 
 
 The redness of the bronchi varies much both in degree and extent, 
 and in some cases which have approached to the character of pneumonia 
 rather than of bronchitis, is sometimes limited to the inflamed lobes. 
 In cases, however, in which much bronchitis has existed, very marked 
 redness generally begins about an inch above the bifurcation of the 
 trachea, and pervades all the bronchi, being deeper in the secondary 
 than in the primary tubes, and retaining nearly as great an intensity 
 even in the tertiary branches. It may stop here, or it may extend 
 even into the ultimate ramuscules, or into the pulmonary cells them- 
 selves. 
 
 In the majority of cases no other change besides this intense redness 
 is perceptible in the mucous membrane, but sometimes it appears both 
 thickened and softened ; and on one occasion in which a fatal attack of 
 acute bronchitis supervened on a long continuance of the chronic stage 
 of the disease, the bronchial mucous membrane was intensely red, and 
 so thickened as to have an almost villous appearance, and closely to 
 resemble red velvet. Ulceration of the mucous membrane of the 
 trachea and larger bronchi, which is occasionally met with in the bron- 
 chitis of adults, I never observed but once. In that case, a little boy, 
 twenty months old, who had suffered from a not very severe attack of 
 bronchitis, in the course of which, however, he had occasional difficulty 
 in deglutition, with return of fluids by the nose, died rather suddenly. 
 
DILATATION OF THE BRONCHI 173 
 
 The only remarkable appearance besides a general redness of the bron- 
 chial tubes consisted in the presence of several small excavated ulcera- 
 tions or erosions in the upper part of the larynx, just above the chordae 
 vocales. 
 
 Associated with the changes in the mucous membrane of the bronchi 
 there is an alteration in the character of their secretion. At first, no 
 doubt, this secretion is suppressed, just as we see that furnished by the 
 Schneiderian membrane to be in a common cold ; but afterwards it is 
 poured out abundantly, and next ceases to present its natural characters 
 of a glairy mucus, becoming opaque, thick, puriform, or actually puru- 
 lent, while in a few less common instances the secretion assumes the 
 form and consistence of false membrane, constituting a true croup of 
 the bronchi. Any traces of blood are but very seldom observed in the 
 secretion, and the quantity of air-bubbles intermingled with it is usually 
 in inverse proportion to the thickness of the secretion and its abundance. 
 
 But not only are the contents of the air-tubes altered in character, 
 and for the most part increased in quantity, but the tubes themselves 
 often undergo a marked alteration in their calibre, and become greatly 
 dilated. This dilatation is usually observable from the secondary 
 bronchi to the minutest air-tubes ; the branches often being as large as 
 the parent trunk, or even larger : but that fusiform dilatation which is 
 met with in the adult has never come under my notice. On one occa- 
 sion, however, in addition to a general cylindrical enlargement of the 
 tubes many of them presented a marked dilatation about half an inch 
 from their termination ; the tube expanding into a cavity big enough to 
 hold half a nut. The interior of these cavities was not perfectly smooth 
 and regular, but its thickened lining was in many parts thrown into 
 folds or wrinkles. The case in which this appearance was observed was 
 the one already mentioned, where the mucous membrane of the bronchi 
 presented so extraordinary a degree of thickening. 
 
 Dilatation of the bronchi was once supposed to be the purely 
 mechanical effect of the accumulation of the secretions within them. 
 There is, however, no constant relation between the quantity of the 
 liquids within the bronchi and the degree of their dilatation, and we 
 must look to two other circumstances as being the primary causes of 
 the occurrence. The first of these is the weakening of the muscular 
 fibres of the bronchi by the inflammatory action ; the other, the loss of 
 the ciliary epithelium which lines the air-tubes when in a state of health, 
 and contributes by the incessant vibration of its cilia to keep them free 
 for the access of air. 
 
 Whenever bronchitis has reached such an intensity as to give rise to 
 the abundant pouring out of thick fluid into the air-tubes, so that the 
 air can no longer permeate them with facility, while this difficulty is 
 still further increased by the loss of the ciliary epithelium and by the 
 weakening of the contractile power of the bronchi, which would have 
 helped to keep them free, it often happens that the feeble inspiratory 
 power of the child becomes wholly inadequate to fill the lungs; large 
 portions of them collapse, and bronchitis thus becomes the indirect 
 cause of carnification of the lung. 
 
 In some cases, the inflammation of the respiratory mucous membrane 
 
174: CONGESTION OF THE LUNG. 
 
 extends further than usual along the smaller bronchi, until it involves 
 their extremities and the pulmonary vesicles themselves, when it pro- 
 duces an appearance almost peculiar to childhood, and which has been 
 described under the names of vesicular pneumonia or vesicular bronchitis. 
 A lung, or a portion of a lung, thus affected, no longer contains any air 
 — it is dark in colour, and feels tough, though solid ; its surface is beset 
 by a number of small, circular, yellow, slightly prominent spots, of the 
 size of a millet-seed, or smaller, which, on a hasty glance, present a very 
 great resemblance to crude tubercles. A very little attention, however, 
 suffices to distinguish between them ; for not only do these yellow spots 
 differ from tubercle in their favourite seat being along the lower margins 
 of the different lobes, but on puncturing any of them with the point of 
 a scalpel, a drop of pus will exude, and the yellow spot will disappear. 
 Sometimes, too, a minute bronchus may be traced running to its termi- 
 nation in one of these little sacs. It has been suggested that this 
 appearance may be due to the secretions formed in the air-tubes being 
 forced by the column of air which enters in inspiration into the smaller 
 bronchi and pulmonary vesicles, the cavities of which thus become 
 mechanically distended. The opinion that the secretions which occupy 
 these parts are produced at the spot where they are discovered by inflam- 
 mation of the ultimate ramuscules of the bronchi, is, however, generally 
 entertained, and is supported by very conclusive evidence. Bronchitis 
 often exists unattended with this peculiar appearance ; and on the 
 other hand, vesicular bronchitis is met with independent of general 
 inflammation of the air-tubes, while, though usually partial, and often 
 limited to the lower border of one or other lobe, it is sometimes very 
 extensive, and occupies nearly the whole of the lower lobe on either 
 side, constituting the most important of the morbid appearances 
 discovered on examining the chest. 
 
 It may, and unquestionably often does, happen that children die of 
 bronchitis alone, and without any notable affection of the pulmonary 
 tissue. But it is much more frequent for the pulmonary substance to 
 bear a part in the morbid process ; and this share may either be limited 
 to mere congestion, or may rise in degree until it produces all those 
 consequences which we find attendant on inflammation of the tissue of 
 the lung in the adult. 
 
 Some degree of congestion of the lung is almost constant if bronchitis 
 be at ail severe, for the circulation through the organ is disturbed, the 
 blood flows less freely than natural, and its changes take place more 
 slowly. It stagnates first in those depending parts whence position 
 renders its return most difficult ; and the portions of the lung thus 
 affected become by degrees more and more extensive. Dark, solid, 
 non-crepitant patches may be often seen in the midst of a lung thus 
 congested ; and until the results of inflation shewed that a wrong 
 interpretation had been given of the appearance, these patches were 
 regarded as the centres whence the inflammation was extending to the 
 surrounding tissue. You do not need to be reminded that they are 
 lobules which have collapsed, and become impervious to air ; and 
 portions of lung in which this occurrence has taken place seem to have 
 but little disposition to become the seat of active inflammation, and to 
 
TRUE LOBULAR PNEUMONIA. 175 
 
 pass into a state of red or grey hepatization. At the same time, how- 
 ever, it must be borne in mind that this indisposition to active inflam- 
 mation does not by any means amount to actual immunity from it, and 
 that carnified lung may sometimes become softened, or even infiltrated 
 with pus. 
 
 It does, however, happen now and then that the lung is found in a 
 condition which may justly be called lobular pneumonia, as the result 
 of the extension to the surrounding tissue of inflammation beginning 
 in the air-tubes. Patches of lung will then be interspersed through the 
 surrounding pulmonary tissue, of a vivid red colour, of various sizes, 
 from that of a pea to that of an almond, irregular in shape, and not 
 circumscribed exactly by the margins of lobules, as is the case with 
 portions of .carnified lung. This process going on in a number of 
 different situations, the affected parts may at length coalesce, and a 
 pneumonia, at first lobular, may thus eventually become generalized. 
 Or, though this should not occur, the inflammation may yet go- on in 
 the isolated portions of lung to the infiltration of pus into its substance, 
 or the actual destruction of its tissue, when a portion of the lung will 
 appear riddled with small distinct abscesses, seldom larger than a pea, 
 irregular in form, and communicating more or less evidently with a 
 minute air-tube. They may be distinguished from the vomicae 
 produced by softened tubercle, partly by the absence of tubercular 
 deposits in other parts of the body, and by their being almost always 
 limited to a single lobe of one lung. Their own characters, however, 
 are sufficiently well marked, for they are altogether destitute of those 
 solid walls which the tubercular deposit forms around a phthisical 
 cavity ; though the yellow lymph which often lines them may be mis- 
 taken by the inattentive observer for tubercle. MM. Rilliet andBarthez 
 mention having found the pulmonary substance healthy, except in the 
 immediate periphery of these abscesses ; but no instance of this kind 
 has come under my own observation, the pneumonia having in each 
 instance become generalised. 
 
 The appearances we have hitherto been considering are due almost 
 exclusively to inflammation of the air-tubes ; and many of them are 
 peculiar to infancy and childhood. We might next proceed to study the 
 symptoms that betoken their existence; but on the one hand, they 
 seldom exist quite alone, and, on the other hand, their symptoms pre- 
 sent so many points of resemblance to those of pneumonia strictly so 
 called, that it may be better to complete our survey of the morbid 
 appearances that result from inflammation affecting either the air-tubes 
 or the parenchyma of the lung, before we pass to the study of the 
 symptoms that attend the one or the other during life. 
 
 The completion of this subject, however, must be postponed to the 
 next lecture. 
 
176 LOBULAR PNEUMONIA — NOT UNUSUAL IN CHILDHOOD. 
 
 LECTURE XVI. 
 
 Inflammatory Affections of the Tissue of the Lung — Lobar Pneumonia — More 
 common in early life than has been supposed — Its general characters the same as in 
 the adult — Some morbid appearances deserving special notice ; viz. sub-pleural 
 ecchymoses, pneumonic abscess, and emphysema of the uninflamed portions of the 
 lung. 
 
 Frequency and causes of inflammation of the respiratory organs — Influence of age — of 
 previous attacks — of various diseases. 
 
 Bronchitis — its Symptoms and Treatment — A more serious disease than in the adult, 
 and why — Symptoms of capillary bronchitis — Illustrative case — Results jof auscultation. 
 
 Treatment of bronchitis — Rules for depletion and the use of antimony — The dyspnoea 
 not always dependent on severity of the inflammation — Treatment of this nervous 
 dyspnoea — Treatment of bronchitis in its chronic stage. 
 
 'We were occupied during the last lecture with the examination of 
 some of the results of inflammation of the respiratory organs in early 
 life, and considered more especially those changes which inflammation 
 produces in the air-tubes. You were told on that occasion that the 
 disease does not always remain limited to the bronchi or pulmonary 
 vesicles, but that it sometimes involves the substance of the lung, and 
 thus gives rise to the appearance of a number of small circumscribed 
 patches interspersed throughout its tissue, either red, hard, and solid, 
 or grey from the infiltration of pus; while, if the mischief advance 
 one step farther it may lead to the destruction of the parenchyma of 
 the organ at these points, and thus produce numerous minute abscesses 
 — a condition which has thrice come under my own observation. Cases 
 of this kind, constituting true lobular pneumonia, though somewhat 
 less rare than in the adult, are yet of very frequent occurrence. It is 
 almost needless to remind you that the contrary opinion resulted from 
 persons not having learned till very lately to distinguish between that 
 solidity of the lung which is produced by inflammation, and that which 
 results from the mere collapse of its air-cells. 
 
 The exaggerated estimate of the frequency of lobular pneumonia, and 
 the peculiar character of the field presented at the Hospital for Children 
 at Paris, in which the most diligent and most successful students of 
 children's disease laboured, led to an underrating of the frequency and 
 importance of lobular pneumonia such as is met with in the adult ; and 
 hence you will find but little said concerning it in many of the most 
 valuable works of our continental neighbours. Lobar pneumonia, 
 however, is often met with in early life, both as an idiopathic and a second- 
 ary affection, giving rise to the same morbid appearances as in the adult 
 and requiring a very similar treatment. 
 
 Not only are the physical characters of the lung in lobar pneumonia 
 the same in childhood as in adult age, but the three stages of engorge- 
 ment, of red and of grey hepatization, are observed with much the same 
 frequency at the one period of life as at the other. I find that after 
 rejecting all cases in which pneumonia occurred as a complication of 
 phthisis, or of acute pleurisy, and in which the results might be modified 
 
LOBAR PNEUMONIA — NOT UNUSUAL IN CHILDHOOD. 177 
 
 by the disease to which the inflammation of the lung succeeded, I have 
 a record of 47 cases in which the condition of the inflamed lung was 
 carefully noticed. 
 
 In 5 of these cases the 1st and 2d stages of pneumonia co-existed. 
 
 " 4 " " 1st and 3d " " 
 
 " 13 " " 2d and 3d " 
 
 " 11 " " all 3 stages 
 
 M 3 " w lung was in the 1st stage only. 
 
 " 6 " " lung was in the 2d " 
 
 " 5 " " lung was in the 3d " 
 
 u a 
 
 47 
 
 This result tallies very closely with that obtained by M. Grisolle, 1 on 
 an examination of 40 cases of pneumonia in the adult. 
 
 In 4 cases the 1st and 2d stages of pneumonia co-existed. ' 
 " 3 " 1st and 3d " " 
 
 " 16 " 2d and 3d " " 
 
 " 2 " all 3 stages " " 
 
 * 7 M lung was in the 2d stage only. 
 " 8 " lung was in the 3d " . 
 
 40 
 
 It will be seen, on a comparison of these tables, that the third stage 
 of pneumonia occurs very nearly as often in children as in adults, 
 having been met with in the former in theproportion of68, in the latter 
 in the proportion of 72 per cent. ; and the main difference between the 
 two consists in the greater frequency with which all three stages of 
 pneumonia co-exist in the young subject. This peculiarity of pneu- 
 monia in childhood is probably due to the tendency which the disease 
 then displays to involve a large extent of pulmonary tissue ; and to the 
 same cause we must attribute the frequency of double pneumonia in 
 early life, which, in the cases that came under my notice, preponderated 
 greatly over those wherein only one lung suffered. The well-known 
 law, according to which pneumonia of the right lung is more common 
 than pneumonia of the left, holds good in childhood ; nor is the 
 frequency of the concomitant pleurisy, much, if ,at all, less in the child 
 than in the adult. The contrary opinion arose from the error to which 
 reference has so often been made, of regarding cases of collapsed lung, 
 either with or without bronchitis, as instances of red hepatization 
 of the pulmonary substance. 
 
 Instead of inflammation of the lungs being less active in the child 
 than in the adult, there are some facts which would seem to lead to a 
 directly opposite conclusion. Such are the frequency with which, in 
 fatal pneumonia in children, ecchymoses are found beneath the pleura 
 covering the inflamed lung, the more common occurrence of pulmonary 
 abscess in early than in adult life, and the very extensive emphysema 
 
 1 Traitd de la Pneumonie, 8vo. Paris, 1841, p. 18. 
 12 
 
178 PULMONARY ABSCESS. 
 
 which is often observed in those parts of the lung to which the inflam- 
 mation has not extended. 
 
 These sub-pleural ecchymoses appear to result from the rupture of 
 some of the minute capillaries of the lungs in consequence of the great 
 disturbance of the circulation through them. They are usually small, 
 like petechia, but occasionally they attain a larger size, and once or 
 twice they have presented themselves to me extending a little way into 
 the tissue of the lung, constituting little spots of pulmonary apoplexy, 
 about the size of a millet-seed, or even a little larger. They are most 
 numerous on the posterior surface of the lungs, and especially in parts 
 where the lung has become hepatized, though by no means confined to 
 those situations. 
 
 The termination of pneumonia in abscess of the lung is so rare an 
 occurrence in the adult, that Laennec did not meet with it above five or 
 six times in the course of several hundred examinations of persons who 
 had died of inflammation of the lungs. In the child, however, the case 
 is otherwise, for abscess of the lung has come under my observation in 
 three out of the forty-seven examinations of cases of lobar pneumonia, 
 on which my present remarks are founded. In one of these cases, that 
 of a boy, aged 20 months, who died on the fourteenth day after the 
 commencement of an illness which resembled remittent fever in many 
 of its symptoms, but was associated from the outset with the indications 
 of pneumonia, the following appearances we're observed : — The upper 
 and middle lobes of the right lurtg were connected to each other, and to 
 the walls of the chest, by adhesions which were chiefly recent. Nearly 
 the whole of the upper lobe was solid, and sank in water. It was of a 
 mottled reddish grey colour, in which grey predominated ; it broke with 
 a granular fracture, and was readily reduced to a dirty putrilage. Near 
 the apex was a portion the size of a walnut, which was already soft and 
 in a state of quagmire. The upper two-thirds of the middle lobe were 
 in the same condition as the upper lobe ; the lower third was emphy- 
 sematous. In the centre of the middle lobe was a cavity the size of a 
 bean, irregular in form, intersected by the remains of some vessels, 
 lined by a thin layer of yellow lymph, and surrounded by lung in the 
 third stage of pneumonia ; but neither in that lobe nor in any part of 
 the pulmonary tissue was there the least trace of tubercle, and the only 
 indication of phthisical disease consisted in one bronchial gland having 
 become converted into tubercle which had undergone the cretaceous 
 transformation. The lower lobe of the right lung was in the first stage 
 of pneumonia ; the left upper lobe was quite healthy ; the left lower 
 lobe was in a state of mingled red and grey hepatization. The other 
 two cases occurred in children who had suffered for some weeks from 
 hooping-cough, and in both the lungs contained numerous semi-trans- 
 parent, grey, tubercular granulations. One of the children was a boy, 
 five years old ; the other a little girl, aged two years. In the case of 
 the former, the abscess, as large as a walnut, was situated at the lower 
 border of the upper lobe, extending a little into the lower lobe. In the 
 latter it was of the size of an unshelled almond, and occupied a simi- 
 lar position with reference to the right upper and middle lobes. The 
 characters of the abscess were the same in both instances, being situated 
 
 
CAUSES OF PNEUMONIA. 179 
 
 almost immediately beneath the pleura; from which a wall of lung not 
 above two lines in thickness separated it. Its cavity was partly filled 
 with a yellowish, puriform, very tenacious fluid, like very tenacious pus, 
 and which did not bear any resemblance to softened tubercle. It was 
 not lined by any membrane : there was no appearance of tubercular 
 deposit in the hepatized lung in its immediate vicinity, which was gene- 
 rally in the second stage of pneumonia, nor was it situated near to, nor 
 in communication with any large bronchial tube. 
 
 The lung in childhood shows a much greater tendency to pass into a 
 state of gangrene, than in adult age. It may be doubted, however, 
 whether this gangrene is the result of the intensity of the inflammation 
 so much as of some peculiar change of blood which favours the occur- 
 rence of mortification. The occasional prevalence of gangrene of the 
 lung and of other parts, as an endemic affection, in the Hopital des 
 Enfans at Paris, favours the latter supposition, and the only instance 
 of it that has come under my own observation in the child is quite in 
 accordance with it. 
 
 The emphysematous condition of the uninflamed portions of the lung, 
 in cases of fatal pneumonia in early life, seems to be connected with 
 the rapidity of the advance of the disease. It is usually most obvious 
 at the anterior part of the upper lobes of the lungs, and at the margin of 
 the other lobes, and always bears a marked relation to the shortness of 
 the patient's illness, and the extent of lung which has been invaded by 
 the inflammation. The delicate structure of the lung in early life 
 seems to be the cause why the pulmonary vesicles so easily become 
 dilated during the hurried inspiratory efforts, by which the child endea- 
 vours to make up for the derangement of a part of that machinery by which 
 the vital changes in the blood are effected. It is probably, as suggested 
 by MM. Rilliet and Barthez, to its production in this way, that may be 
 referred the origin of many of those cases of emphysema which we meet 
 with in the adult, but which date back from early childhood. 
 
 The causes which give rise to inflammation of the lungs and air-tube? 
 are, to a great extent, the same at all periods of life ; so that we need 
 not devote much attention to the special study of those which tend to 
 produce it in childhood. It should be borne in mind, however, that the 
 fluctuations in temperature, or the biting wind, or the cold weather, 
 which may be encountered with impunity by the robust adult, may 
 prove most deadly when they act on the feeble frame and delicate or- 
 gans of the child. Hence it is, in great measure, that inflammation of 
 the respiratory organs is so much more frequent, and so much more 
 fatal, in childhood than in adult age, and in infancy than in childhood. 
 The fact is well shown by the Reports of the Registrar-General for the 
 years 1842 and 1845, from which it appears that 67-1 per cent, of the 
 total mortality from inflammation of the lungs and bronchi, in the 
 metropolis, took place in persons under fifteen years of age ; 63.2 per 
 cent, under five ; 57.1 under three ; and 28.7 per cent, under one year. 
 But the tendency to these affections, as is shown in the following table, 
 is not greatest in the first month of life, diminishing in proportion as 
 the child advances in age and increases in strength ; but the time when 
 they are most prevalent coincides exactly with the time when the sus- 
 
180 
 
 CAUSES OF PNEUMONIA. 
 
 ceptibility of all the mucous membranes is at its highest point, namely, 
 the period of dentition. 
 
 Table, showing out of 183 cases of children dying from various 
 diseases, in whom I carefully examined the thoracic viscera, the 
 number of instances in which the lungs, bronchi, and 'pleura, pre- 
 sented no signs of recent inflammation, and also those in which 
 signs of it were discovered. [The first line represents the former, 
 the second the latter class of cases.] 
 
 Under 
 
 From From 
 
 From 
 
 From 
 
 From 
 
 From 
 
 From 
 
 From 
 
 From 
 
 From From 
 
 From 
 
 From 
 
 From 
 
 Total. 
 
 1 m'th. 
 
 1-6. 1 6-12. 
 
 12-18. 
 
 18-2. 
 yrs. 
 
 2-3. 
 
 3-4. 
 
 4-5. 
 
 5-6. 
 
 6-7. 
 
 7-8. 
 
 8-9. 
 
 9-10. 
 
 10-11. 
 
 11-12. 
 
 
 5 
 
 13 
 
 17 
 
 13 
 
 5 
 
 11 
 
 9 
 
 5 
 
 6 
 
 
 3 
 
 2 
 
 2 
 
 2 
 
 
 93 
 
 
 3 
 
 10 
 
 13 
 
 15 
 
 12 
 
 10 
 
 8 
 
 5 
 
 3 
 
 5 
 
 2 
 
 2 
 
 
 2 
 
 90 
 
 This table illustrates the fact mentioned in the last lecture, that, 
 when the child is first born, the mucous membrane of the respiratory 
 organs is endowed with but little of that susceptibility which it after- 
 wards acquires, and that accordingly, those diseases whose point of 
 departure is from that membrane, are far less frequent during the first 
 six months of life, than they become during the succeeding eighteen 
 months ; while, from the completion of the second year up to the time 
 of puberty, they go on diminishing in frequency and fatality. And 
 there are important practical inferences which may be deduced from 
 the facts we have just mentioned. They teach us not only that a 
 catarrh is a much more serious thing in infancy than in adult age, but 
 also that it is more serious at one period of infancy than at another, 
 and they warn us to guard a child, during the time that the process of 
 teething is going on, with double care against all causes that are likely 
 to excite inflammation of its respiratory organs. 
 
 There are some diseases which, after having occurred once, confer 
 on persons an immunity from subsequent attacks. This, however, is 
 far from being the case with bronchitis or pneumonia in early life, but 
 the susceptibility of the respiratory organs appears to increase in exact 
 proportion to the frequency with which they have already suffered, 1 and 
 a child who has once been attacked by inflammation of the lungs or 
 air-tubes, is more likely to have a second attack brought on by a slight 
 change of temperature, than another who had never suffered from it 
 would be to experience a seizure from a much graver cause. With 
 advancing age, this susceptibility seems to wear out, — the child out- 
 grows it ; but we should act most unwisely if we were to sanction 
 
 1 In a tract on Pneumonia in Children, published some years ago in the British and 
 Foreign Medical Review, I mentioned that of 78 children who came under my care for 
 inflammation of the lungs, 31 were stated to have had previous attacks of the disease ; 
 21 once ; 4 twice ; 2 four times ; and 4 were said to have had it several times, though 
 the exact number of seizures was not mentioned. Of these 31, 10 were under two years 
 of age, 10 between two and three, and the remaining 11 between three and six. 
 
DISEASES PREDISPOSING TO PNEUMONIA. 
 
 181 
 
 exposure to the cold, with the view of hardening a child against its 
 influence. 
 
 The importance of inflammatory diseases of the respiratory organs, 
 depends not merely on the frequency of their occurrence as idiopathic 
 affections, but also on their tendency to supervene in the course of 
 other maladies. This tendency, though very evident at all ages, is 
 especially remarkable in early life, as is apparent from the fact that, 
 in 26 only of the 90 cases enumerated in the former table, was the 
 inflammation an idiopathic affection. When we come to the subject of 
 measles, hooping-cough, croup, diarrhoea, and remittent fever, it will 
 be necessary to study these secondary attacks of bronchitis and pneu- 
 monia with attention, since they constitute frequent and serious com- 
 plications of those diseases, against which it behoves us to be most 
 anxiously on the watch. 
 
 Before we pass to the examination of the symptoms of bronchitis and 
 pneumonia, it may be as well to see whether any light can be thrown, 
 from the table we have more than once referred to, on the question of 
 what diseases predispose to inflammation of the respiratory organs. 
 The number of observations on which it is based is too small to warrant 
 any very positive conclusions, but some of the results which it yields 
 are not without interest. 
 
 In 77 cases the respiratory organs presented no sign of recent inflam- 
 mation ; the children having died of the following diseases : — 
 
 Trismus 3 
 
 Meningeal apoplexy 2 
 
 Cerebral congestion ...... 3 
 
 Inflammation of the brain ..... 2 
 
 Acute hydrocephalus 29 
 
 Cerebro-spinal arachnitis ..... 3 
 
 Chronic hydrocephalus 1 
 
 Tubercle of the brain 7 
 
 Cancer of the brain ...... 1 
 
 Croup . . . . ... . . 2 
 
 Malformed Heart, pericarditis .... 1 
 
 Laryngismus stridulus ..... 2 
 
 Phthisis 5 
 
 Anasarca ........ 1 
 
 Anasarca after scarlet fever .... 1 
 
 Diarrhoea . . . . . . . . 4 
 
 Atrophy 3 
 
 Congenital syphilis ...... 1 
 
 Cancrum oris 2 
 
 Lumbar abscess 1 
 
 Scrofulous disease of the vertebrae ... 1 
 
 Fungus hsematodes of the liver .... 1 
 
 " " " kidney . . I 
 
 In 16 other cases, though there was no sign of inflammation, yet a 
 more or less considerable portion of the lung was collapsed, but restored 
 by inflation to its natural condition, or presented the physical characters 
 
182 
 
 DISEASES PREDISPOSING TO PNEUMONIA. 
 
 of collapsed lung in so marked a degree as to preclude the possibility 
 of error. 
 
 The cause of death in these 16 cases was — 
 Congenital atelektasis .... 
 
 Induration of the cellular tissue ... 
 Convulsions ...... 
 
 Trismus 
 
 Meningitis of the convexity of the brain 
 Congestion of the brain occurring in the course of 
 hooping-cough ..... 
 
 Tubercle of the brain 
 
 Atrophy of one hemisphere of the cerebellum 
 
 Atrophy 
 
 Laryngismus stridulus ... * 
 
 Fungus hasmatodes of the kidney 
 
 Anasarca after scarlet fever, with serous effusion 
 
 into the pleurae 
 
 In 52 of the above 93 cases, the pulmonary tissue was quite free 
 from tubercle. 
 
 In 80 the lungs contained crude tubercle only ; chiefly, but not 
 entirely, in an early stage. 
 
 In 4, some softened tubercles. 
 
 In 7, some tubercular cavities. 
 
 In the remaining 90 cases, either the pulmonary substance, the 
 bronchi, or the pleura, showed signs of recent inflammation. 
 
 The pleura was mainly affected in twelve of these cases, its inflam- 
 mation having been idiopathic only in 4. In 6 of these cases the lung 
 was inflamed ; in the other 6 merely compressed. 
 
 In 21 cases the inflammation was chiefly or entirely confined to the 
 bronchi, and in 6 of these the inflammation was idiopathic. 
 
 In 57 cases pneumonia prevailed, which was idiopathic in 17, and 
 secondary in 46 instances. ' 
 
 In the 61 cases of acute secondary inflammation of the lungs or 
 bronchi, the patients had suffered from the following diseases : — 
 
 Acute pleurisy . 
 
 . . • 
 
 6 
 
 Hooping-cough . 
 
 . . • 
 
 16 
 
 Chronic bronchitis 
 
 ... 
 
 1 
 
 Coryza .... 
 
 . . • < 
 
 1 
 
 Croup . . . 
 
 • 
 
 5 
 
 " consequent on measles 
 
 . . • 
 
 2 
 
 Measles . . 
 
 . . . « 
 
 5 
 
 Scarlatina 
 
 ... 
 
 3 
 
 Anasarca after scarlatina . 
 
 ... 
 
 1 
 
 Remittent fever . 
 
 ... 
 
 2 
 
 Cancrum oris after remittent fever 
 
 1 
 
 Diarrhoea . 
 
 ... 
 
 3 
 
 Acute rheumatism 
 
 ... 
 
 1 
 
SYMPTOMS OF BRONCHITIS. 
 
 18 
 
 Dilatation of the heart 
 
 • « 
 
 1 
 
 Phthisis 
 
 . , 
 
 7 
 
 Convulsions 
 
 . , 
 
 1 
 
 Acute meningitis 
 
 , . 
 
 2 
 
 Acute hydrocephalus . 
 
 • 
 
 3 
 
 Of the whole 90 cases — 
 
 In 72 the pulmonary tissue was free from tubercle. 
 " 10 it contained tubercle unsoftened. 
 " 5 " " softened. 
 
 " 3 " tubercular cavities. 
 
 "We will now pass to the study of the symptoms of bronchitis, and 
 will commence with the examination of the most simple form of inflam- 
 mation of the air-tubes, — namely, that which develops itself out of ordi- 
 nary catarrh. In such a case, the child has for some days seemed to 
 suffer from nothing more serious than a common cold ; but, by degrees, 
 instead of the cold and cough subsiding, the heat of skin becomes 
 more considerable, the cough tighter, more frequent, and more painful, 
 the child sometimes crying after each cough : the pulse becomes more 
 rapid, the respiration wheezing, hurried, and often somewhat irregular. 
 These graver symptoms often steal on very gradually, and among the 
 poor it by no means seldom happens that the disease has already 
 attained an advanced stage, and the condition has become one of very 
 considerable peril, before the parents, never very observant of those 
 ailments that are not attended with acute suffering, take the alarm. 
 The flush of the face, and the heat of skin become increased, the res- 
 piration grows more laboured, and the cough more troublesome towards 
 evening ; and the first hours of the night are usually very restless, but 
 the child then falls asleep, and often dozes tranquilly for some hours ; 
 it then generally awakes with its respiration very oppressed, for the 
 secretions have been accumulating in the smaller bronchi, and have now 
 begun to impede the entrance of the air. An attack of cough probably 
 comes on, which very likely ends in vomiting and the rejection of some 
 mucus, and then by degrees the breathing becomes more easy, and the 
 child may for a short time seem comparatively cheerful. The tempera- 
 ture of the surface, though increased, is' variable; and, if the disease 
 continue for several days, perspiration will be observed occasionally 
 to break out on the body, while the pulse, though quickened, is not 
 very much accelerated, and the tongue continues moist throughout. 
 The ear detects nothing in the chest besides a mixture of rhonchus, 
 sibilus, and largish crepitation ; the dry sounds preponderating at the 
 upper, the moist at the lower part of the chest, and being vastly more 
 abundant behind than in front. Now in the adult, a condition such as 
 this, would excite but little apprehension, but in the child it must be borne 
 in mind that nothing more is needed than a copious secretion of mucus 
 in the bronchi, or a feeble condition of the vital powers, to prevent the 
 air from freely entering the pulmonary vesicles, and thus to induce the 
 collapse of a large portion of the lung. Thus it is, at least as I appre- 
 
134 SYMPTOMS OF CAPILLARY BRONCHITIS. 
 
 hend, that we must explain many of the instances in which urgent 
 dyspnoea, and all the symptoms of serious pulmonary disease have 
 developed themselves in the course of a few hours out of what had 
 seemed to be nothing more than a rather severe cold, or a bronchitis of 
 moderate intensity. This, too, accounts for the occasional sudden 
 supervention of dulness on percussion, and of bronchial respiration in 
 the child ; so that you may discover them in the morning in a situation 
 where over night the percussion was good, and no sound was heard of 
 graver import than large crepitation ; changes which, unlike those 
 dependent on solidification of the lung from inflammation, you may 
 find, as has been remarked by Dr. Gairdner, of Edinburgh, unaccom- 
 panied by any exacerbation of the febrile symptoms. This rapid 
 change in the auscultatory phenomena, has been noticed by Dr. Stokes 
 as occasionally happening in the pneumonia of the adult. 1 That dis- 
 tinguished physician offered no explanation of the occurrence ; but we 
 can now understand what is its true import, and what the reasons are 
 for its being met with so much oftener in the child than in the adult. 
 
 But, notwithstanding this danger, which is great in proportion to the 
 youth of a child, yet most cases of idiopathic bronchitis that come on 
 gradually, developing themselves out of previous catarrhal symptoms, 
 have a favourable termination ; and, as a general rule, it may be 
 stated that an attack which is long in arriving at its acme is seldom 
 very dangerous in its character. Pure idiopathic bronchitis, occurring * 
 in an otherwise healthy child, in most cases subsides in the course of a 
 few days, leaving the patient with an increased susceptibility to the 
 influence of those causes which brought on the first attack, and perhaps 
 with a degree of debility, the recovery from which may be protracted 
 for many weeks. 
 
 There is, however, a form of acute bronchitis which is often, though 
 not always, idiopathic, that runs its course with much rapidity, and 
 generally tends to a fatal termination. In this, the suffocative catarrh 
 of some writers, — the capillary bronchitis of others, — the smaller air- 
 tubes throughout the whole or a considerable portion of the lungs are 
 attacked either in connection with the larger bronchi or independently 
 of them ; and the inflammation, which is very intense, usually termi- 
 nates in the abundant secretion of pus, or in the formation of false 
 membrane that nearly obliterates their cavity, or, involving the pulmo- 
 nary vesicles themselves, it gives rise through a considerable extent of 
 the lungs to those appearances which have been described under the 
 names of vesicular pneumonia and vesicular bronchitis. 
 
 Its attack is sometimes sudden, though in the great majority of cases 
 
 it is preceded for a few days by the ordinary symptoms of catarrh, or it 
 
 supervenes on that condition of bronchial irritation whieh accompanies 
 
 or follows one or other of the eruptive fevers. Under these latter 
 
 circumstances there is either a progressive though rapid increase in the 
 
 severity of the bronchitic symptoms, or there is a sudden outbreak of 
 
 fever and dyspnoea, and the cough becomes all at once frequent, short, 
 
 and hacking. The disease soon attains a very considerable intensity ; 
 
 i 
 
 1 On the Diseases of the chest. 8vo. Dublin, 1837, pp. 311 and 327. 
 
SYMPTOMS OF CAPILLARY BRONCHITIS — 185 
 
 the face becomes anxious and oppressed, the eyes heavy, the manner 
 distressed ; the respiration very hurried, generally irregular, and inter- 
 rupted by the cough, which frequently seems to occasion pain. The 
 restlessness is often extreme, and the position which the child assumes 
 very variable ; 'but, in whatever attitude it may have placed itself, it 
 does not like to be disturbed, and endeavours at once to return to its 
 former posture. If spoken to, the child's answers are hurried, and its 
 manner impatient, as though it were too much taken up with its suffer- 
 ing, or with the business of respiration, to be able to reply to questions. 
 Sometimes it will say that it feels stuffed, or will complain of distress 
 about the sternum, or of pain at the epigastrium; while pressure on 
 the abdomen, by interfering with the free descent of the diaphragm, 
 always produces much discomfort. There is no appetite ; and, though 
 at first the thirst is very considerable, yet the child soon ceases to take 
 much drink, for it wants breath to swallow fluids in any quantity, and 
 therefore does little more than moisten its lips. At the same time the 
 tongue is moist, and either differs but little from its condition in health, 
 or it has a thin coating of yellowish fur ; the bowels are usually con- 
 stipated, and not only are nausea or vomiting seldom present, but 
 emetic remedies often fail of their ordinary effect when given in the 
 course of this affection. As the disease advances the cough becomes 
 less hacking, though it continues very frequent : it sometimes puts on 
 a paroxysmal character, and returns in fits somewhat like those of 
 hooping-cough, except that each fit of coughing is shorter, does not 
 terminate with a whoop, and is seldom attended with expectoration. 
 Even if the cough be accompanied by expectoration, it is seldom that 
 any thing is spit up more than a little mucus tinged with blood, or now 
 and then a little pure blood, while in a few instances small shreds of 
 false membrane have been seen intermingled with the mucus. For a 
 time the respiration grows more and more hurried, and paroxysms of 
 dyspnoea continue to occur at irregular intervals almost to the last. 
 In these paroxysms the child's distress and restlessness are extreme, 
 and it sometimes throws itself wildly about the bed. The breathing 
 does not, however, go on increasing in rapidity until the patient's 
 death; but, after the disease has reached its acme, the respiration often 
 grows less frequent, though more irregular and more variable. The 
 face loses its flush, and, instead, acquires a livid hue ; the cough 
 becomes smothered, and occurs less often; the pulse grows in frequency 
 and fails in power ; and though there is often a diminution of the rest- 
 lessness, yet, if able to talk, the child will generally say that it is no 
 better. As death approaches, though the respiration grows more 
 laboured and more abdominal, yet the child's suffering generally 
 diminishes, or a state of somnolence gradually steals over it, in which 
 it lies till roused by an attack of cough or by a paroxysm of dyspnoea, 
 and then, after a struggle for breath, it subsides into its former drow- 
 siness. The struggles for breath grow feebler with each returning 
 paroxysm, the droAvsiness becomes more profound, and the patient dies. 
 It may be worth while to fill up what is wanting in this brief sketch 
 of the disease, by the history of a case that displayed many of its most 
 characteristic features. 
 
186 ILLUSTRATIVE CASE. 
 
 A little boy, aged 7J years, after suffering for a few days from 
 general feverishness, with a constipated state of the bowels, was 
 attacked on the Hth of April with incessant short cough and hurried 
 breathing, for which symptoms he was ordered to be bled to six ounces, 
 although only two ounces of blood were obtained. TwerVe leeches were 
 applied to his chest, and powders containing two grains of calomel and 
 a quarter of a grain of antimony were given him every four hours. 
 The leech-bites bled profusely, and afforded some relief to the dyspnoea ; 
 but, notwithstanding this, the child passed a very restless night. The 
 next morning he was found lying on his back, with his knees drawn 
 up towards the abdomen, his face anxious, his eyes heavy, his skin 
 dry ; breathing at the rate of 78 inspirations in the minute, his respi- 
 ration being often interrupted by a short hacking cough. His pulse 
 was 138, and sharp. He complained of no pain, except when the 
 abdomen was pressed on ; but seemed then to suffer considerable 
 uneasiness about the epigastrium. Percussion of the front of the chest 
 occasioned so much pain that it could not be practised satisfactorily, 
 and behind it did not elicit any difference between the two sides. 
 Throughout the whole of both lungs sub-crepitant rale was heard ; it 
 was smallest in the inferior dorsal region, but was nowhere as small as 
 true pneumonic crepitus. He was ordered to be cupped to five ounces 
 between the shoulders, and tartar emetic was ordered in quarter of a 
 grain doses every ten minutes until free vomiting should be produced, 
 after which the powders were to be resumed. He took two grains of 
 the tartar emetic without the slightest effect being produced ; and on 
 the 8th his respiration ha^d risen to 98, and his pulse to 144. On the 
 9th his respiration had sunk to 72, but the pulse had risen to 156. 
 The cough was usually short and hacking, but attacks of it, which 
 resembled paroxysms of hooping-cough, now came on at intervals. 
 The tartar emetic was now given in doses of half a grain every two 
 hours, but no effect was produced by it beyond producing a feeling of 
 nausea, and occasioning very slight vomiting twice. For an hour or 
 two early on the morning of the 10th he seemed somewhat better ; but 
 this improvement soon passed away, and he began to complain of great 
 pain in the chest ; whereas his answer previously to all inquiries, had 
 been, " I am so stuffed." His cough was more severe, and the mucus 
 which he now and then expectorated with it was sometimes tinged with 
 blood. He passed another night of distressing restlessness, but on the 
 morning of the 11th grew quieter, and, when not disturbed, lay on his 
 right side dozing. If spoken to, he gave intelligent answers, and said, 
 "I am no better," though, if left alone, he made no complaint. He 
 continued drowsy all through the day. Towards evening he had a few 
 minutes of cheerfulness, and spoke of his own accord to his father. 
 Ilis mother lay down by his side : he slept, and seemed to breathe 
 "gently : she slept too ; and when she awoke at 4 a. M. on the 12th, her 
 boy was dead : life had fled so quietly, that, though her arm was round 
 him, she had not been disturbed. 
 
 I need not detail to you the appearances found on dissection of the 
 body, since they were such as have been mentioned as characteristic of 
 capillary bronchitis ; though the air-tubes, notwithstanding their intense 
 
KESULTS OF AUSCULTATION. 187 
 
 injection, contained neither pus nor false membrane, and very little 
 mucus. The case illustrates the remarks already made on the symp- 
 toms of the disease, and illustrates, too, the remarkable results which 
 percussion and auscultation yield in this affection, since sub-crepitant 
 rale continued to be heard to the last, unmixed with bronchial breath- 
 ing or pneumonic crepitus ; while, so long as percussion could be prac- 
 tised, it failed to elicit a dull sound anywhere. 
 
 Though the indications afforded by auscultation and percussion are 
 often sufficiently characteristic of this disease, yet there are some 
 circumstances which may occasionally render their information doubtful. 
 The child is sometimes so extremely alarmed, and the sensibility of its 
 surface so much increased, that we have much difficulty in percussing 
 the chest : but we shall usually be able to distinguish this from the 
 painfulness of the walls of the thorax which attends pleurisy, by find- 
 ing that it is not limited to one half of the chest, but that it is felt 
 equally on either side, and as much in front as behind. If we can 
 succeed in percussing the chest, however, it will be found to yield a 
 natural, sometimes even an increased, degree of resonance, while little 
 if any difference can be discovered between the sound afforded by the 
 upper, and that given out by the lower part of the chest ; or, should 
 such be perceived, it is generally due to pneumonia having supervened. 
 The ear detects a scanty transmission of air, attended at first with 
 rhonchus and sibilus, but soon with a universal sub-crepitant rale, 
 heard most distinctly on the child making a deep inspiration. By the 
 term sub-crepitant rale, it can hardly be necessary for me to say that 
 a sound is meant smaller in character than large mucous rale, but 
 larger than the true small crepitation of pneumonia. As the disease 
 advances, the only change that takes place consists in this sub-crepitant 
 rale being replaced by a larger mucous rale, the result not of any 
 improvement in the child's condition, but of the air scarcely penetrating 
 beyond the larger bronchi; for you will still hear the smaller sound 
 during the deep inspiration that follows an attack of cough. 
 
 This form of bronchitis is one not only very dangerous, but likewise 
 very rapid in its course to a fatal issue. One little girl in whom it 
 came on while convalescent from an attack of measles fourteen days 
 before, died within forty-eight hours ; and the boy whose case has been 
 just related, died in less than four days from the appearance of any 
 serious symptom. These, however, were instances of a rather unusual 
 rapidity in its course ; and from five to eight days, which is the estimate 
 of its duration formed by M. Fauvel, who has written a very valuable 
 essay on the disease, is probably not far from the true average. 1 
 
 But we may now pass to the treatment of bronchitis, in which you 
 will find those general rules applicable that have already been laid down 
 w T hen we were speaking of catarrh ; while, in exact proportion to the 
 severity of the symptoms, will be the care with which you must watch 
 against the supervention either of pneumonia or of that collapse of the 
 lung which is so grave an occurrence in early childhood. In the ordinary 
 
 1 Recherches sur la Bronchite Capillaire, etc. 4to. Paris, 1840; republished in a 
 more extended form in Vol. II. of the " Memoires de la SocieteMedicale d'Observation," 
 8vo. Paris, 1844. 
 
188 TREATMENT OE BRONCHITIS. 
 
 forms of bronchitis, general depletion is neither required nor well 
 borne, and even the local abstraction of blood must not be heedlessly 
 resorted to. Leeches may be applied at the commencement of 
 the attack, if the child be strong, and the febrile disturbance consider- 
 able, and they may be employed subsequently, if while the child's 
 powers are still undiminished, the cough should become shorter and 
 more hacking, and the crepitation either very general and abundant, 
 or smaller in the lower than in the upper lobes. They must not be 
 employed with the view of at once cutting short the attack, nor must 
 we be led by the relief afforded by their first application to repeat them 
 in the hope of subduing the disease by depletory measures. I usually 
 apply about four leeches to a robust child of two years old, and it is 
 very rarely that I repeat their application. The situation in which 
 they are applied is not altogether unimportant. I prefer applying 
 them beneath the scapulae ; partly because there may be some advan- 
 tage in drawing blood from the neighbourhood of that part of the lungs 
 which is most likely to become congested, but still more because the 
 child is not alarmed as it would be if they were put on in front of the 
 chest, where they are within its sight ; and because in this situation it is 
 unable to irritate the bites by picking them, as it is very apt to do when 
 they are beginning to heal. 
 
 There is in these cases the less excuse for over depletion, since we 
 are possessed in the tartar emetic of a most powerful means of subdu- 
 ing the disease. In a healthy child suffering from bronchitis of moderate 
 severity 1 sometimes give it in the form of James's powder, combined 
 with a small quantity of calomel and ipecacuanha, every four hours for 
 the first twenty-four or thirty-six hours. This combination usually 
 acts on the bowels slightly, as well as on the skin ; and if the child be 
 now relieved, the calomel may be suspended, and small doses of anti- 
 monial and ipecacuanha wine may be given instead, in a mixture. 
 
 A severe attack of the disease calls for the use of antimony in 
 larger doses, so as to obtain its emetic effect at first, and afterwards, by 
 the repetition of the remedy every hour or two hours, to keep the child 
 for one or two days under its influence. Even in cases where the 
 disease is not so severe as to require the energetic employment of 
 antimony, there is generally an exacerbation of fever and dyspnoea 
 towards evening, and this is often much relieved by an emetic of antimony 
 and ipecacuanha, which may also in many cases be repeated with 
 advantage in the morning, when the child having been asleep for some 
 hours, during which the mucus has been collecting in the bronchi, it 
 breathes with difficulty on awaking, until the air-tubes having been freely 
 emptied by an effort at vomiting, the air is once more enabled freely 
 to permeate the lungs. Even in those cases which at first required the 
 constant use of large doses of antimony, it is a matter of importance 
 to dispense with them as soon as we can with safety, and to substitute 
 the use of emetics at intervals, while we employ some milder expecto- 
 rant medicine between the doses of the emetic. It can scarcely be 
 necessary to remind you that there are few medicines which exert so 
 depressing an influence on the muscular powers as the tartar emetic. — 
 If therefore in a child whose air-tubes are already nearly filled with 
 
NERVOUS DYSrKCEA- 189 
 
 the abundant secretion, you carry the depressing effect of antimony too 
 far, the air will no longer be inspired with force sufficient to make it 
 reach the smaller bronchi, and collapse of the lung will consequently 
 take place. It follows, then, that we must not venture to carry the 
 depressing effects of antimony so far in the child as we may safely do 
 in the adult, but when the medicine has either ceased to vomit, or is 
 merely regurgitated without effort, we must either suspend it altogether 
 or greatly diminish its dose, or give it at distant intervals, so as to 
 obtain its emetic action, while we allow time between the doses sufficient 
 to permit the child perfectly to recover its powers. The effect of vomit- 
 ing, on the other hand, is useful in two ways, for it not only empties 
 the air-tubes of the mucus that obstructs them, but it also occasions 
 several deep inspirations to be made, by which the air is drawn into the 
 remotest parts of the lungs, and their tendency to collapse is thus 
 prevented. 
 
 Your attention has on more than one occasion been called to the 
 remarkable tendency of the nervous system in early life to sympathize 
 in the affections of other parts. This tendency is often very evident in 
 inflammation of the respiratory organs ; and, accordingly, you must not 
 always take the degree of dyspnoea in a case of infantile bronchitis as 
 a measure of the affection of the lungs, since it may be only an evi- 
 dence of the sympathy of the nervous system. If you treat this 
 symptom actively, without having first inquired into its import, you may 
 destroy your patient. When first taken ill, indeed, the child's respira- 
 tion was hurried and laborious ; you applied leeches to the chest, and 
 gave tartar emetic freely; and the breathing, which grew less hurried 
 and less oppressed, justified the wisdom of your treatment. But if the 
 respiration again rise in frequency, and you, in order to reduce it 
 redouble the activity of your treatment, you may be disappointed in 
 the effect you hoped to attain ; the respiration may grow more and 
 more frequent, and the child before long die in convulsions. If in such 
 a case, you had examined the patient with due care, you w T ould proba- 
 bly have discovered that the dyspnoea was not associated with increase 
 of the heat of the skin ; you would have learned that it had varied 
 much within a few hours, sometimes subsiding and then returning with- 
 out adequate cause ; you would not have detected any deterioration in 
 the results of auscultation, while you would probably have perceived in 
 the half-closed eyes, or the thumbs drawn into the palms, signs of the dis- 
 turbance of the nervous system. 
 
 This nervous dyspnoea sometimes occurs early in the disease, at a 
 time when active treatment is evidently indicated ; and while that plan 
 is continued, we shall best meet this symptom by applying a mustard 
 poultice to the chest, and by placing the child as high as the pelvis in a 
 hot-bath. The evening attacks of dyspnoea are often more effectively 
 controlled by this than by any other means. When these symptoms 
 come on at a more advanced period of the disease, or in a child previ- 
 ously debilitated, they indicate that active treatment must no longer 
 be persevered in. The antimony must be discontinued, or its dose 
 greatly reduced, and the vinum ipecacuanha, with small doses of nitrous 
 ether and of the compound tincture of camphor, should now be given, 1 
 1 Pee Formula No. 10, v. 171. 
 
190 TREATMENT OF NERVOUS DYSPNOEA. 
 
 or even small doses of Dover's powder. The general restlessness will 
 be much relieved by immersing the whole body in a warm bath, which 
 should not be employed at so high a temperature as when used for its 
 counter-irritant action. At the same time attention must be paid to 
 support the child's strength by veal-broth, arrow-root, or other nutritious 
 diet. 
 
 After the acute symptoms of bronchitis have been subdued, the sub- 
 sequent convalescence of the patient is often protracted by the continu- 
 ance of cough and wheezing respiration, — symptoms which on a very 
 slight cause are apt again to put on the more serious characters of the 
 acute disease. In this chronic stage, a general tonic plan of treatment 
 must be adopted while at the same time much benefit will often be 
 obtained by the employment of a stimulating liniment to the chest. 1 
 
 (No. 11.) 
 
 1 R Lin. Camph. co. ^j. 
 ' Tinct. Lyttse, gij. 
 
 Tinct. Opii, gij. M. Ft. Linimentum. 
 
 The pungency of liniments often compels us to employ them to the posterior part of 
 the chest only, or to rub the front of the chest with a much weaker liniment than that 
 which is used for the back. 
 
 The extract of bark is an extremely useful tonic, especially in cases 
 where there exists any tendency to diarrhoea ; while the wheezing is 
 often relieved by the administration of an emetic of ipecacuanha every 
 night. If the secretion in the bronchi be very abundant, the decoction 
 of senega with ammonia and tincture of squills, is often superior to any 
 other medicine. 2 If the bronchitis have supervened during dentition, 
 
 (No. 12.) 
 
 2 R Decoct. Senegae, ^ij. ^v. 
 
 Ammon. Sesquicarb. gr. viij. 
 Tinct. Scillee, TT^xvj. 
 
 Syr. Tolutan. ^iij. M. giij. 4tis horis e lacte. 
 For a child from two to three years old. 
 
 you must not be surprised at slight relapses occurring just as each tooth 
 approaches the gum. At other times, however, bronchitic symptoms 
 continue for a long period, and expectoration being copious and puri- 
 form, while the child loses flesh, and the relations become not unnatu- 
 rally apprehensive lest it should be phthisical. Their fears may be 
 well founded, but at the same time that you would recommend change 
 of climate to some warmer country in the winter, or to the sea-coast 
 during the summer, you would, as I shall hereafter point out to you 
 when speaking of phthisis, be warranted in taking a much more favour- 
 able view of such cases in a child than in the adult. 
 
 The general principles on which you must treat the more grave attacks 
 of capillary bronchitis have been laid down in what has been already 
 said. A greater degree of activity in your treatment is needed ; you 
 may even deplete generally, and follow up this depletion by local 
 
SYMPTOMS OF THE FIRST STAGE OF PNEUMONIA. 191 
 
 bleeding : but the caution already given against the repeated abstraction 
 of blood holds good here. With reference to antimony, too, it is while 
 the emetic action of the remedy continues that youmayhope for benefit 
 from its employment ; while you must be careful not to persevere in its 
 use when the livid face and faltering pulse show that the aeration of the 
 blood is nowhere duly carried on. A blister to the chest, and the stimu- 
 lant expectorants, — as ammonia and senega may now be given, while the 
 attempts may be made, by emetics of squills and ipecacuanha, to 
 unload the bronchi at intervals of four or six hours. These are the 
 cases, however, in which, if you do not get the better of the disease 
 at first, your subsequent remedies will probably be too tardy to over- 
 take it. 
 
 LECTUEE XVII. 
 
 Pneumonia, its Symptoms and Treatment. — Symptoms of pneumonia frequently present 
 a mixed character when it supervenes on bronchitis — Idiopathic pneumonia — approach 
 of first stage generally gradual — characteristic peculiarities of in mode of sucking and 
 of respiration— attack sometimes sudden. — Symptoms of second stage — results of 
 auscultation — reasons for rarity of true pneumonic crepitus. — Symptoms of third stage 
 — convulsions often precede death — their import — occasional imperfect recovery — 
 auscultatory phenomena of this stage. 
 
 Nature of modifications in symptoms produced by association with bronchitis. — Diag- 
 nosis from bronchitis — pleurisy — hydrocephalus — remittent fever — intestinal disorder 
 during dentition. 
 
 Treatment — Depletion, general and local ; rules for each — Tartar emetic — limitations 
 as to its use. — Mercury — its importance — danger of salivation very slight. — Diet- 
 antiphlogistic in the early stages — caution as to sucking — stimulants often needed in 
 advanced stage. — Blisters in general not desirable. 
 
 It was stated in the last lecture, that the supervention of inflammation 
 of the substance of the lungs constitutes one of the chief dangers of 
 infantile bronchitis. Pneumonia, however, is not to be regarded as 
 being invariably a secondary affection; for while the disease of the air- 
 tubes is in some cases but trivial, the pulmonary substance is the seat 
 of serious inflammation ; and in other instances the air-tubes are 
 altogether unaffected, or at least are involved only in common with the 
 other constituents of the lung. In either case, there are peculiarities 
 enough, both in the symptoms observed and in the treatment required, 
 to render the separate study of pneumonia indispensable. 
 
 When pneumonia supervenes, as it by no means seldom does, on 
 previous catarrhal symptoms, the disease often comes on insidiously, 
 and develops itself so gradually out of the preceding trivial ailments 
 that it is not possible to determine the exact date of its attack. At 
 other times indeed, there is a sudden and well-marked increase of the 
 fever and dyspnoea, and an aggravation of all the symptoms, sufficient 
 clearly to poi^il out the date of the supervention of the pneumonia. — 
 But, even though this should be the case, yet if there were much bron- 
 chitis previously, the affection of the air-tubes will often mask that of 
 the lung to some degree; and the case not presenting the symptoms 
 
192 SYMPTOMS OF THE FIRST STAGE OF PNEUMONIA. 
 
 either of bronchitis or of unmixed pneumonia, will assume some of the 
 characters of each, and merit, both by the phenomena attending it 
 during life, as well as by the appearances found after death, the name 
 of bronchio-pnewnonia. Cases of this mixed character occur most 
 frequently during the period of teething, when the mucous membranes 
 are especially susceptible. We will return to notice some of these 
 peculiarities hereafter, but will first examine the symptoms that attend a 
 case of idiopathic pneumonia, where the pulmonary substance has 
 been affected from the outset, and has not merely become involved by 
 the extension to it of mischief commencing in the bronchi. 
 
 In almost all of these unmixed cases, a condition of general feverish- 
 ness, exacerbated towards evening, with fretfulness and pain in the 
 head, precede the more marked symptoms. The child is either restless 
 at night, or if it sleep, its repose is unsound ; it talks in its sleep, or 
 wakes in a state of alarm. Sometimes from the very commencement, 
 at other times soon after the appearance of these febrile symptoms, 
 cough comes on ; at first, short and hacking, frequently not causing the 
 child any uneasiness, and so slight as scarcely to excite the notice, and 
 not at all to awaken the anxiety of the parents. Loss of appetite and 
 increase of thirst are early observable: the bowels are usually constipated, 
 and vomiting is not infrequent, especially in infants at the breast. The 
 tongue and lips are at the same time of a florid red ; the tongue is less 
 moist than usual, and is generally coated in the middle with a thickish 
 white fur. In these symptoms, indeed, there is but little to mark the 
 real nature of the case, or to point to the organ whose disease has 
 kindled the fever in the system ; for the slight cough, if not overlooked, 
 may yet be attributed to irritation of the bronchi, sympathetic with 
 derangement of the stomach or intestines. The respiration, too, is not 
 always much hurried at this early period ; while, in the young child, 
 both its frequency, and that of the pulse, is much modified by position ; 
 and the results of auscultation are not uniform, and may sometimes 
 afford no information at all. Even now, however, there are some signs 
 which to the attentive observer will convey much information, and 
 information all the more valuable from our being furnished with it 
 chiefly in those young infants in whom the diagnosis of this disease is 
 attended with most difficulty. The seat of the mischief is shown to be 
 in the respiratory organs by the child no longer breathing through the 
 nares, while the tongue is applied to the roof of the mouth, as it does 
 in health ; but by its breathing through the open mouth also, whence 
 the tongue early acquires an unusual degree of dryness. The same 
 inability to respire comfortably through the nares causes the child to 
 suck by starts : it seizes the breast eagerly, sucks for a few moments 
 with greediness, then suddenly drops the nipple, and in many instances 
 begins to cry. As the disease advances, these peculiarities in the mode 
 of sucking and of respiration often become more striking ; but it is at 
 its onset that they are most valuable, since then we have fewer indica- 
 tions to lead us right. 
 
 It is not, however, thus gradually that pneumonia always comes on ; 
 for sometimes a child who had gone to bed well, or merely a little poorly, 
 wakes in the night in a state of alarm, refusing to be pacified, with a 
 
RESULTS OF AUSCULTATION. 193 
 
 flushed face and burning skin, and hurried breathing and short cough. 
 This sudden supervention of pneumonia is not so often met with among 
 infants at the breast as among children from two to four years old. 
 Often, though not always, this severe onset of the disease has appeared 
 to depend on the pneumonia being associated with extensive inflammation 
 of the pleura ; but sometimes the symptoms w T hich at first seemed so 
 threatening, soon subside, and the affection, in its subsequent stages, 
 presents no peculiarity, and is not by any means remarkable for its 
 severity. 
 
 This first stage of pneumonia passes, for the most part, by degrees 
 into the second, in which the nature of the affection is generally obvious 
 to all. The momentary cheerfulness which before existed has now 
 passed away ; infants now no longer wish to be removed from the cradle, 
 or from the recumbent posture in their nurse's arms, and older children 
 have quite lost all interest in their play ; they become drowsy, ask to be 
 put to bed, and cry if taken up. The hurry of the respiration is now 
 abundantly evident ; the alse nasi are dilated with each inspiration, the 
 abdomincl muscles are brought into play to assist in its performance, 
 and any change of posture renders the breathing more laboured and 
 more hurried. The cough has become much more frequent ; it is still 
 hard, sometimes is evidently painful, so that the child cries with each 
 cough ; at other times it is an almost constant short hack. The bright 
 flush of the face, and the florid tint of the lips, have gone, but the heat 
 of skin continues; for the persistence of an almost unvarying high 
 temperature throughout its course, is, as M. Roger has shown, one of 
 the characteristics of the pneumonia of the child as well as of that of the 
 adult. It is a pungent heat, which becomes more sensible the longer 
 the hand is kept in contact with the surface ; and so great is the eleva- 
 tion of temperature, that M. Roger found it average almost 104° Fah. 
 in ninety-seven experiments, while in some cases it greatly exceeded this 
 degree. Though so intense, however, this heat is unequal at different 
 parts, — the extremities being cool, or even cold, while the body is hot ; 
 but there is no moisture on any part of the skin. The face now 
 assumes a puffed, heavy, but anxious appearance, and when the child is 
 very young, or the pneumonia very extensive, the lips put on a livid 
 hue, which is also very evident around the mouth, while the face 
 generally is pale. The thirst usually continues very urgent, but chil- 
 dren at the breast still vomit the milk. This is apparently owing to 
 their thirst being so urgent as to lead them to suck too greedily, and 
 thus overload their stomach, since while they generally vomit almost 
 immediately after leaving the breast, they do not reject small quantities 
 of fluid given them from a cup or spoon. The disease of the lungs 
 now betrays itself most strikingly in children at the breast, for as often 
 as they attempt to suck, the respiration becomes at once greatly hurried ; 
 they drop the nipple, panting, from their mouth, or, having seized it, 
 have not breath sufficient to make the vacuum necessary to bring the 
 flow of milk. 
 
 The results of auscultation, though variable, are now sufficiently 
 obvious. Crepitation is now heard, often in both lungs, and generally 
 in their lower and posterior parts — seldom, however, the minute crepitus 
 
 13 
 
194 SYMPTOMS OP THE THIRD STAGE OF PNEUMONIA. 
 
 such as we hear in the pneumonia of the adult, but that sound known as 
 the sub crepitant rale. The comparative rarity of true pneumonic 
 crepitus in inflammation of the lungs in infancy is a point not to be lost 
 sight of: often, however, if you keep your ear to an infant's chest, and 
 wait till it takes an unusually deep inspiration, you will hear the true 
 crepitus of pneumonia just for a moment when the air enters the pul- 
 monary vesicles ; and then again you will lose it when the child breathes 
 as it was doing before, and you will hear only the sub-crepitant rale. 
 If the inflammation have attacked only one lung, you will perhaps be 
 struck by the loud puerile breathing in the healthy organ, which is thus 
 compelled to perform a double function. If both be involved, you may 
 almost overlook the disease, since you have not the aid afforded by 
 contrast ; unless, as it sometimes happens, the mischief on the one side 
 is so far advanced as to cause bronchial breathing, while on the other 
 side crepitation alone is audible. This bronchial breathing is sometimes 
 heard associated with sub-crepitant rale, or with large crepitation, while 
 at other times the ear detects nothing but the whiff of air through the 
 larger air-tubes ; and often this alone is audible on an ordinary inspi- 
 ration, while on a deep breath being taken, the sub-crepitant rale will 
 be at once perceptible. In the child we lose all the information which, 
 in the adult, is afforded by the different modifications of the voice sound : 
 for the shrill or querulous tone of a suffering child, and the words often 
 uttered in very different keys, yield even when the child is old enough 
 to talk well, results far too uncertain to be trustworthy. 
 
 Percussion sometimes yields a very manifest dullness on the affected 
 side ; and this dulness is usually most evident in the infra-scapular 
 region. At other times, however, no such marked results are afforded, 
 but the lower parts of the chest yield a somewhat duller sound than the 
 upper, and the impression communicated to the finger is that of greater 
 solidity below than above the scapula. This last sign is often very 
 valuable, since it may be perceived at a time when the ear cannot 
 clearly detect actual dulness on percussion. 
 
 Death may take place in this, the second stage of pneumonia, if a very 
 extensive portion of lung have been involved in the disease, or if it be 
 associated with much inflammation of the pleura, or if the pneumonia 
 have been grafted on severe bronchitis. The pneumonia which super- 
 venes on measles, or which comes on in a child debilitated by previous 
 illness, sometimes terminates unexpectedly in this stage, and on an 
 examination of the body after death the lung is found scarcely to have 
 passed beyond the first stage of pneumonia, except in a few portions of 
 but limited extent: though still larger tracts will probably be found in 
 the state of carnification, and to the sudden supervention of this condition 
 the fatal event is probably in great measure due. It is important, too, 
 to bear in mind that in weakly children a pneumonia of even very small 
 extent will often prove fatal : hence the great importance of watching 
 most sedulously against all those intercurrent affections of the lungs 
 which come on in the course of diarrhoea, measles, remittent fever, &c. 
 
 But the pneumonia may be free from any of the above-named compli- 
 cations, and then, if unchecked by treatment, it will pass into the third 
 stage. The respiration now becomes more laboured, and though its fro- 
 
RESULTS OP AUSCULTATION. 195 
 
 quency is sometimes diminished it will be found to have become irregular ; 
 several short and hurried inspirations being followed by one or two deeper, 
 and at longer intervals, and these again by hurried breathing. The 
 cough sometimes ceases altogether, or if not, it is less frequent, and 
 looser, since it is now produced by the child's efforts to clear the larger 
 air-tubes from the accumulating secretions. The voice is often lost, the 
 patient speaking only in a hoarse whisper ; while children who were just 
 learning to talk will frequently maintain complete silence, as if conscious 
 that they have no breath to waste in words. The face looks sunken, the 
 extremities are cold, and though the trunk retains its high temperature 
 almost to the last, yet the skin often loses somewhat of its previous 
 dryness, and clammy sweats break out, especially about the head. The 
 pulse is extremely frequent and small, and the beats so run into each 
 other that it is almost impossible to count them. The child is sometimes 
 very restless at intervals, tossing about from side to side as much as its 
 reduced powers will permit ; but it usually lies in a state of half con- 
 sciousness, though sensible when spoken to, and fretful if disturbed. 
 If raised hastily from the recumbent posture, or if put to the breast, 
 the great increase of dyspnoea which is immediately produced shows 
 how seriously the respiratory organs are affected. In many cases, too, 
 the livid hue of the face and of the nails is a further proof of the great 
 impediment which exists to the decarbonization of the blood ; and once 
 I saw purpurous spots appear on the arms and hands thirty-six hours 
 before the death of a previously healthy child of a year old, in whom an 
 attack of idiopathic pneumonia terminated fatally on the seventeenth day. 
 This condition seldom lasts above two or three days ; for either life 
 becomes gradually extinct, without the supervention of any new symptom, 
 or convulsions occur, which are followed by fatal coma, or the child 
 recovers from it for a few hours only to suffer a second attack of con- 
 vulsions, and a return of coma, in which it dies. It can scarcely be 
 necessary to remind you of what was said some time since with reference 
 to the import of convulsions, and to their being in many cases merely 
 a token of disturbance of the function of the brain, such as delirium ia 
 the adult. The former symptom in the child, and the latter in the 
 adult, betoken in a case of pneumonia thatHhe brain is suffering from 
 the circulation through it of imperfectly aerated blood. 
 
 The third stage, however, does not always advance thus uninter- 
 ruptedly to a fatal issue, but a kind of imperfect recovery sometimes 
 takes place. A diminution is obvious in the more alarming symptoms ; 
 the patient begins to express some desire for food as well as for drink, 
 and even has occasional gleams of cheerfulness. The cough, which in 
 many instances had almost or altogether ceased, returns, but is short 
 and hacking, although there is sometimes a good deal of mucus in the 
 larger air-tubes. The dyspnoea is no longer urgent, though the breath 
 is habitually short. The skin is hot, dry, and harsh, and evening 
 exacerbations of fever often occur ; the tongue is red, dry, and some- 
 times chapped, or presents small aphthous ulcers at its edges ; diarrhoea 
 is not unfrequent ; the child wastes daily, and dies in the course of a 
 week or two, worn out and exceedingly emaciated. 
 
 The auscultatory signs of this third stage of pneumonia are in the 
 
196 BRONCHIO-PNEUMONIA. 
 
 main those of the second stage, except that the bronchial breathing 
 usually becomes both more distinct and more extensive, occupying situa- 
 tions where either the sub-crepitant rale, or even large crepitation, had 
 previously been heard. As it extends, too, it becomes audible in front 
 as well as behind, and both it, and dulness on percussion, may be per- 
 ceived in the infra-mammary as well as in the infra-scapular region, to 
 which, at first, they are almost always limited. This bronchial breathing 
 is generally much more extensive on one side than on the other, and 
 sometimes it is heard throughout the whole posterior part of one side 
 of the chest ; but I never found bronchial breathing confined to the 
 upper part of one lung, except in cases where there existed previous 
 tubercular disease of the organ, and then the pulmonary tissue may 
 become solidified under the influence of an amount of disease which 
 otherwise would be inadequate to produce this result. 
 
 The symptoms that attend the third stage of the disease usually are 
 the result of the lung having passed into the state of suppuration. I 
 say usually, for sometimes recovery eventually takes place even from a 
 condition apparently desperate, and in such cases the degree to which 
 disorganization of the lung had actually advanced must always remain 
 uncertain. 
 
 The results of auscultation do not help us, any more than in the 
 adult, to determine with certainty the amount of injury that the lung 
 has received, while we are deprived almost entirely of that information 
 which in the grown person is afforded us by the changes in the appear- 
 ance of the sputa. In some cases of rapidly fatal pneumonia I have 
 seen a frothy secretion collect about the mouth ; but this was evidently 
 not furnished by the air-tubes, but was merely the saliva which the 
 child was unable either to spit out or to swallow. The cough of pneu- 
 monia being generally short and not paroxysmal, we have not so much 
 chance of seeing the sputa as in the case of acute bronchitis, and chil- 
 dren even of five or six years old seldom spit out the matters that they 
 expectorate, but almost always swallow them. 
 
 When resolution of a hepatized lung takes place, the changes in the 
 physical signs of the disease are much the same as are perceived in the 
 adult. I have not, however, in any instance detected a return of true 
 pneumonic crepitation, but sub-crepitant rale in most cases became 
 audible, and in a few instances large crepitation. In either case 
 mucous rale was eventually heard, and it often continued for many days 
 after the lung had in other respects recovered its natural condition ; 
 apparently much as, in the pneumonia of the adult, prolonged expiration 
 often persists for a long time after all the other signs of disease have 
 disappeared. 
 
 At the commencement of this lecture reference was made to cases in 
 which the symptoms of pneumonia are modified by those of the bron- 
 chitis with which it is associated. In such cases there is from the very 
 outset a marked degree of dyspnoea and distress, and the face presents 
 from the first a livid hue. The cough is less short than in simple pneu- 
 monia, but it comes on in paroxysms which greatly distress the patient : 
 the respiration is more hurried and more irregular, and this irregularity 
 comes on at an earlier stage of the disease. Large crepitation and sub- 
 
DIAGNOSIS OF PNEUMONIA. 197 
 
 crepitant r&le are generally heard very extensively in both lungs, but 
 true pneumonic crepitation is unusual. A preponderating affection of 
 the lower lobes is seldom perceptible; and since these cases usually 
 tend to a rapid termination, death sometimes takes place before either 
 dulness on percussion, or bronchial breathing, has become distinctly 
 audible. 
 
 Such are the characters generally presented by pneumonia in early 
 life, and these are usually so well marked as to render it impossible 
 either to overlook the disease or to mistake its symptoms for those of 
 some other malady. This, however, is not invariably the case even 
 when the inflammation of the lungs occurs as an idiopathic affection, 
 while in those instances in which it comes on in the course of other dis- 
 eases, it very often remains latent, and much acuteness of perception, 
 as well as much patient observation, are necessary for its detection. 
 We will pass over for the present the consideration of secondary pneu- 
 monia, since to understand all the varieties that it presents would re- 
 quire a previous acquaintance with those diseases in the course of which 
 the inflammation of the lungs supervenes. "When we come to the study 
 of hooping-cough, croup, measles, remittent fever, &c, I will endeavour 
 to point out the period at which, in each of these maladies, pneumonia 
 is most to be apprehended, and the symptoms that indicate its attack ; 
 but to-day we will confine our notice to those cases in which the inflam- 
 mation of the respiratory organs occurs as an idiopathic affection. » 
 
 The points of difference between pneumonia and bronchitis have 
 already been dwelt on so fully as to render it unnecessary to recapitu- 
 late them. In many cases they are too obvious to admit of your 
 falling into error, but in others they are so shaded off that it is difficult 
 to determine whether the characters of one or of the other predomi- 
 nate ; and we are forced to conclude that the two exist together, the 
 one obscuring the otherwise well-marked features of the other. 
 
 In the child, as in the adult, some degree of pleurisy exists in a large 
 proportion of cases of pneumonia, though sometimes so slight as to be 
 scarcely noticed; whilst in other cases, though a little friction sound 
 may be heard for a short time, yet it is evident that the danger to life 
 is occasioned by the mischief in the lung, and not by the affection of 
 the pleura. Sometimes, however, inflammation of the pleura is the 
 chief, if not the sole, cause of the patient's danger, and hence it is 
 desirable to know, even at the outset, whether the lung or its investing 
 membrane is the part chiefly affected. 
 
 An attack of pleurisy is much oftener marked by complaint of severe 
 pain in the chest, than is an attack of pneumonia ; or if the child be 
 unable to express its feelings, the seizure is not infrequently announced 
 by violent and continued screaming. Sympathetic disturbance of the 
 brain is more frequent and more severe at the onset of an attack of 
 pleurisy than of pneumonia, and the attendant restlessness greater. 
 Auscultation, too, fails to discover the crepitant or sub-crepitant rale 
 which characterises pneumonia, but air enters the lung on the affected 
 side much less freely than on the other, and a friction sound may per- 
 haps be distinguished ; though this is by no means invariable, and even 
 when present it may easily be mistaken for rhonchus. It may be laid 
 
108 DIAGNOSIS OF PNEUMONIA. 
 
 down as a rule, subject to but few exceptions, that whenever a child is 
 suddenly seized with symptoms which, while they indicate some affec- 
 tion of the lungs, are yet unattended with the auscultatory signs of 
 pneumonia, the disease from which it is suffering is pleurisy ; and this 
 probability is rendered almost a certainty, if, while the child bears 
 percussion on one side of the chest, it cries and struggles on the 
 slightest attempt at percussion of the opposite side. 
 
 The error of taking a case of pneumonia for one of pleurisy, how- 
 ever, or the opposite, is of comparatively little moment : but there are 
 other diseases for which pneumonia may be taken, in which the error 
 of diagnosis will lead to serious, and perhaps fatal, mistakes in treat- 
 ment. 
 
 These mistakes, too, may be made at almost any stage of the disease. 
 At the commencement pneumonia may be taken for incipient hydroce- 
 phalus. The vomiting, the pain in the head, the restless nights, with 
 talking in the sleep, which attend the onset of almost all the acute 
 affections of childhood, the fever, and the constipated state of the 
 bowels common to both diseases, lead to this error. The cough in some 
 cases of pneumonia is so slight as scarcely to be noticed, while even if 
 present it may be taken for that sympathetic cough which is sometimes 
 present in the early stages of hydrocephalus ; and the child, if ques- 
 tioned, may complain of his head, and of nothing else. But still there 
 are circumstances which would lead the attentive observer, independ- 
 ently of auscultation, to detect the real nature of the case. The 
 vomiting that ushers in an attack of pneumonia, though sometimes 
 violent, seldom continues long, and is unattended with that permanent 
 nausea and irritability of the stomach which are so marked in the first 
 stage of hydrocephalus. The evacuations in pneumonia are natural ; 
 the tongue is of a much more vivid red than in hydrocephalus ; the 
 pulse is much more frequent, the heat of skin far greater, and more 
 remarkable on the trunk than about the head, and the thirst is gene- 
 rally urgent. If these indications, however, be overlooked at the com- 
 mencement of the attack, and if auscultation, by which the error might 
 still be set right, be neglected, it is probable that each subsequent 
 occurrence will be misinterpreted, and that the real nature of the 
 disease will not be understood until it is revealed by the post-mortem 
 examination. More or less sympathetic affection of the head is seldom 
 wanting in pneumonia to confirm the preconceived, erroneous, notion ; 
 while, as the child grows worse, the difficulties in the way of making a 
 careful auscultation increase. Convulsions sometimes occur even 
 several days before the patient's death, and the head symptoms may 
 appear, especially to a prejudiced observer, to be much more striking 
 than any which indicate affection of the lungs. 
 
 It sometimes happens that the sympathetic disturbance of the stomach 
 and bowels is so considerable as to obscure the chest symptoms, and the 
 case is taken for one of enteritis; or perhaps, if the heat of skin and 
 sensorial disturbance be considerable, for one of remittent fever. The 
 vomiting at the outset of the disease, the pain referred to the abdomen, 
 with the evident increase of discomfort on pressure, the red tongue, 
 with its disposition to dryness, and the diarrhoea that exists in these 
 
DIAGNOSIS OF PNEUMONIA — ITS TREATMENT. 199 
 
 rather exceptional cases of pneumonia, are the circumstances which 
 tend to lead into error ; and this error may be confirmed on the prac- 
 titioner finding that at least temporary relief follows the application of 
 leeches and poultices to the abdomen. With reference to the complaint 
 of pain in the belly, which seems often to have a large share in inducing 
 this error, it must be remembered that the statements of children with 
 reference to the seat of pain are very vague, and that they frequently 
 speak of the belly when they mean the chest; while the impediment to 
 the descent of the diaphragm occasioned by pressure on the abdomen, 
 especially if this pressure be either sudden or considerable, will almost 
 always excite expressions of uneasiness when the organs of respiration 
 are in any way aiFected. It is in careful auscultation that you will 
 find your chief safeguard against these mistakes ; but you will find 
 besides, that, by accustoming yourselves to look not at one or two 
 prominent symptoms only, but at the relation which each bears to the 
 other, many of the chief difficulties in the way of forming a correct 
 diagnosis will disappear. 
 
 It may perhaps seem to you that much of this is very dry and rather 
 needless detail ; but unfortunately my own case-books would enable me 
 to illustrate each of these errors of diagnosis, against which it is my 
 endeavour to guard you. One more caution I would offer you, and that 
 is, not to overlook the pneumonia which sometimes comesjon in children 
 ivhile teething. Unless you be on the watch for it, its early symptoms 
 will probably fail to excite your apprehension, since they will be 
 regarded as the result of that sympathetic irritation of the air-tubes, 
 which so often accompanies dentition, and the time for action will thus 
 be allowed to pass unemployed. The disease comes on most frequently 
 in weakly children, is unattended by much constitutional reaction, and 
 often runs a somewhat chronic course ; while its nature is further 
 obscured by the tendency to diarrhoea which exists during dentition, 
 and which is now excited by the thoracic affection. The purging often 
 becomes the most striking symptom, and all means are employed to 
 suppress it, and to check the vomiting which generally attends it. 
 These efforts, however, are unavailing ; the child wastes daily, and its 
 skin hangs in wrinkles about its attenuated limbs, while the abdomen 
 becomes tumid from the collection of flatus in the large intestines, and 
 tender on pressure, and the tongue grows red, dry, and chapped, or 
 covered with aphthous ulcers. The cough now perhaps attracts notice ; 
 but both it and the bronchial breathing in the lungs are probably looked 
 on as indications of phthisis, and the doctor consoles himself with the 
 belief that he has failed to cure the disease because it was irremediable. 
 At last the child is worn out, and dies, and great is the surprise to find 
 no tubercle in any part of the body, no disease in the intestines, 
 but pneumonia, with purulent infiltration in both lungs, — a disease 
 which ought to have been detected, and which probably might have 
 been cured. 
 
 We come now, in conclusion, to the consideration of the treatment 
 of pneumonia in children. The main principles that guide us are the 
 same as in inflammation of the lungs in the adult, and our chief reliance 
 
200 TREATMENT OF PNEUMONIA — DEPLETION — 
 
 is placed on the same remedies in both eases — namely, depletion, 
 calomel, and tartar emetic. 
 
 You will find that many of the continental writers on the diseases of 
 children are greatly opposed to the abstraction of blood in cases of 
 infantile pneumonia, and that some even assert that it invariably debili- 
 tates the system, and accelerates the patient's death. This opinion, 
 however, has been formed by the observation of those secondary pneu- 
 monias which are of such frequent occurrence among the inmates of the 
 Children's Hospital at Paris; and therapeutical conclusions deduced 
 from cases of so peculiar a kind as are there presented, cannot be 
 framed into rules for the general guidance of our conduct. But much 
 misapprehension has also arisen from confounding the condition of col- 
 lapse of the lung with that of its solidification from true inflammatory 
 action ; and the mistaken pathology has led to mistaken treatment. 
 In the management of cases of idiopathic pneumonia occurring in pre- 
 viously healthy children, whatever be their age, depletion is as impor- 
 tant a remedy as in the adult : nor will the most energetic employment 
 of any other antiphlogistic measures enable us safely to dispense with 
 its use. In a healthy child of two years old, a vein may be opened in 
 the arm, and ^iv. of blood may be allowed to flow, provided that faint- 
 ness be not earlier produced, without there being any reason for us to 
 apprehend that the plan we are adopting is too energetic. It often 
 happens that the child faints before this quantity of blood has been 
 drawn, while in other cases, not above one or two ounces of blood can 
 be obtained. Still, whenever the patient is seen at the commencement 
 of the attack, general depletion is desirable, even though it should be 
 necessary to follow it up by local bleeding ; for the immediate effect 
 which it produces is greater than that which follows local depletion, 
 and the quantity of blood abstracted by it is definite ; while, if both 
 the nurse and the medical attendant understand how to manage chil- 
 dren, it may be so conducted as to cause them but little excitement or 
 alarm. If but very little blood can be drawn from the arm, or if, as 
 is not seldom the case with infants under two years of age, it be not 
 possible to find a vein, depletion must be accomplished by means of 
 leeches, which, for reasons already stated, it is desirable to apply 
 beneath the scapulae. How great soever may have been the relief 
 which followed the first bleeding, it is not always permanent ; and 
 hence the child should be seen again in from six to eight hours ; and 
 if the symptoms appear to be returning with anything of their former 
 severity, depletion must be repeated ; though then local blood-letting 
 is to be preferred to venesection, even in cases in which bleeding from 
 the arm had been resorted to in the first instance. It must never be 
 forgotten, that in the child, as well as in the adult, no subsequent care 
 can make up for the inefficient treatment of the early stage of pneu- 
 monia : if the first twenty-four hours be allowed to pass while you are 
 employing inadequate remedies, the lung, which at first was merely 
 congested, will have become solid, and recovery, if it take place even- 
 tually, will be tardy, and perhaps imperfect. On the other hand, 
 cases that set in with the greatest severity sometimes appear to be at 
 once cut short by free depletion ; the violent symptoms being arrested, 
 
USE OF TARTAR EMETIC. 201 
 
 and recovery going on uninterruptedly, almost without the employment 
 of any other remedy. 
 
 In the treatment of the pneumonia of the adult we are accustomed 
 to follow up the advantages gained by depletion by the administration of 
 tartar emetic ; and, under proper restrictions, the remedy is no less 
 valuable in early life. Given in doses of one-eighth of a grain every 
 ten minutes till vomiting is produced in the case of a child of two years 
 old, and continued every hour or two hours afterwards for a period of 
 twenty-four or thirty-six hours, it subdues the fever and abates the 
 dyspnoea in a most remarkable manner ; often rendering a repetition 
 of depletion unnecessary, and sometimes speedily removing all signs of 
 the disease. It is not safe,, however, 1 in the great majority of cases, to 
 place our dependence entirely on the administration of antimony. In 
 cases of secondary pneumonia, especially if the affection of the paren- 
 chyma of the lungs were preceded by well-marked bronchitic symptoms, 
 antimony may sometimes be given at once without having recourse to the 
 abstraction of blood previously ; but, in pure idiopathic pneumonia, 
 depletion either general or local ought almost always to precede its use. 
 When antimony does good, it generally gives an earnest of that good 
 within a few hours from its first administration ; and the production of 
 some sensible effect, such as vomiting or very decided nausea, has 
 appeared to me to be a condition of its utility : unlike what we observe 
 in the adult, in whom the good results which it produces are sometimes 
 independent of any appreciable influence on the general condition of 
 the patient. When complete tolerance of the medicine has been 
 established, our subsequent conduct must be determined by the results 
 of auscultation. Should that inform us that the physical condition of 
 the lung has greatly improved, as well as the general state of the 
 patient, the use of the remedy may be persevered in at somewhat longer 
 intervals. If the signs of inflammation be advancing, and have 
 become perceptible in portions of. lung previously free from dis- 
 ease, mercury must be employed, which may be combined with small 
 doses of antimony, while large doses of that remedy may still be given 
 to combat any sudden increase of fever or dyspnoea that may chance 
 to supervene. If, notwithstanding a manifest diminution of the fever 
 and reduction of the dyspnoea, bronchial breathing should have 
 become distinctly audible, mercurials must at once be substituted for 
 the antimony ; and the existence in any case of extensive or well-marked 
 bronchial respiration should be regarded as of itself contraindicating 
 the antimonial plan of treatment. It is not my intention to say, that 
 after the supervention of bronchial respiration antimony ought never to 
 be given, but only that it should not be employed except in small doses, 
 and in combination with other remedies. 
 
 In cases where the symptoms do not set in with such violence as to 
 indicate the necessity for very large doses of antimony, or in which 
 the disease has passed that stage where antimony so given is likely to 
 be beneficial, mercurials may be used with great advantage. In cases 
 of the former kind, from two-thirds of a grain to a grain of calomel, 
 combined with two or three grains of James's powder, may be given 
 every six hours to a child two years old. If the case be of a graver 
 
202 EMPLOYMENT OF MERCURIALS — DIET — STIMULANTS. 
 
 kind, and bronchial breathing have become perceptible, notwithstanding 
 depletion and the administration of tartar emetic, the calomel must be 
 given more frequently, — as every four or three hours, combined with 
 small doses of Dover's powder and tartar emetic, if the child be not so 
 depressed as to render the use of the latter medicine inexpedient. 
 Sometimes the combination of antimony with the mercurial is at first 
 well borne, but afterwards it becomes desirable to discontinue it on 
 account of the sickness that it produces, or on account of the debility of 
 the patient. The diarrhoea which the calomel excites may usually be 
 checked by increasing the dose of the Dover's powder. There are 
 some troublesome cases, however, in which the stomach or bowels are 
 so irritable that scarcely any medicine can be borne ; and in them, as 
 well as in cases of neglected pneumonia in which the proper time for 
 active treatment has been allowed to pass by, and the child has become 
 exhausted, while a large extent of lung is impervious to air, much 
 benefit sometimes follows the persevering use of mercurial inunction. 
 In infants and children under five years of age, the gums hardly ever 
 become affected by mercury, even though most energetically employed ; 
 and it has never yet occurred to me to meet with an instance of profuse 
 salivation, or dangerous ulceration of the gums. Such accidents, how- 
 ever, do now and then occur, and have been known to terminate in 
 fatal gangrene of the cheek, or necrosis of the jaw. On this account, 
 therefore, you must watch the condition of the gums' in infants and 
 children to whom you are administering mercury, just as you would do 
 in the case of the adult, and diminish or discontinue the remedy on the 
 first indication of their being affected. 
 
 The diet of children in the early stages of pneumonia should be most 
 sparing ; and infants not weaned should have some less nutritious food 
 than the mother's milk, which their thirst will otherwise lead them to 
 take more abundantly even than when they are well. If the pneumonia 
 be severe, it is better to give even the mother's milk with a spoon, 
 rather than to allow the infant to suck, since the very act of sucking 
 is injurious, and taxes to the utmost the respiratory function, the organs 
 of which it is desirable to keep in as unexcited a state as possible. 
 
 But though the treatment of inflammation of the lungs requires a 
 most strict antiphlogistic regimen in the early stages of the disease, 
 yet in many cases there arrives a period in which a spare diet is no 
 longer suitable, — in which your main efforts must be directed to support 
 the constitutional powers, rather than to subdue the local inflammation. 
 If you forget this, it may happen to you to overcome the mischief in 
 the chest, but to lose your patient with head symptoms, brought on' by 
 carrying too far, or continuing too long, the very treatment which, 
 within proper limits, was most salutary. No point in the management 
 of the disease is more difficult than the seizing the exact moment when 
 the employment of stimulants becomes necessary ; and no general rule 
 can be laid down for regulating their use. If, however, the patient 
 were beginning to be much purged, if the respiration were growing 
 more laboured and irregular, though diminished in frequency, and if the 
 pulse were becoming more frequent, and above all smaller and smaller, 
 it is high time to resort to their use. Wine is as indispensable in such 
 
CEDEMA OF THE LUNGS. 203 
 
 cases in the pneumonia of the child as in that of the adult ; and it may 
 be necessary to give it even to infants at the breast. Ammonia may 
 also be advantageously administered in this stage of the disease, either 
 in a mixture with the decoction of senega, 1 or dissolved in milk, which 
 conceals its disagreeable pungency better than any other vehicle. If 
 diarrhoea do not exist, strong beef-tea or veal broth is the best form in 
 which nutriment can be given ; but if the bowels be relaxed, arrow- 
 root, or the decoction blayiche 2 of the French Hospitals, should be sub- 
 stituted for it. 
 
 In conclusion, it may be well to offer a caution with reference to the 
 employment of blisters, — a measure to which we often have recourse 
 with advantage during the resolution of pneumonia in the adult, but 
 which, as a general rule, is not advisable in young children whose lungs 
 have been solidified by the disease. Stimulating liniments 3 may be 
 employed with advantage; they produce very evident good, and are 
 unattended by the risk that always accompanies making a breach of 
 the surface in a young child exhausted by previous illness. The risk 
 of such sores taking on an unhealthy character, appears to be greater 
 after inflammation of the lungs than after almost any other disease ; 
 and it may be added, that the risk is still greater in those cases of 
 secondary pneumonia that supervene on measles. 
 
 LECTURE X VIII. 
 
 (Edema of tiie Lungs — occasionally comes on in the course of scarlatinal dropsy — 
 severity of the symptoms, and their sudden accession — Difference between the cha- 
 racters of cedematous and hepatized lung — treatment — importance of venesection 
 — occasional exceptions to its use. 
 
 Gangrene of the Lung — Case illustrative of the disease — is not the result of mere 
 intensity of inflammation — unattended by any pathognomonic symptom. 
 
 Pleurisy — its rarity in childhood as an acute uncomplicated idiopathic affection — 
 its symptoms and morbid appearances similar to those observed in the adult— it 
 occasionally stimulates other diseases, as affections of the head and of the abdomen 
 — Evidences of auscultation less conclusive than in the adult, and why. 
 
 Treatment — importance of early adoption of active measures — principles of treatment 
 same as in the adult. 
 
 Chronic pleurisy — rarely idiopathic — occurs oftener in connection with dropsy after 
 scarlatina — its symptoms frequently obscure. 
 
 Before we proceed to the examination of some other forms of inflam- 
 matory disease of the respiratory organs, it may be convenient to 
 notice two conditions of the pulmonary tissue, which, though not the 
 direct results of inflammation, yet are closely connected with it. One 
 of these conditions is acute oedema of the lung, the other is gangrene 
 of its substance. 
 
 It is unnecessary to occupy your time with any detailed account of 
 that anasarcous state of the lungs which is sometimes met with in 
 
 1 See Formula No. 12, p. 190. 2 See Note, p. 45. 3 See Formula No. 11, p. 190. 
 
204 (EDEMA OP THE LUNGS. 
 
 connection with general dropsy of long standing, or with some old 
 disease of the heart and great vessels. In such cases, which are very 
 rare in childhood, the oedema of the lungs is a secondary affection, and 
 has very little share in producing the patient's death. But it occa- 
 sionally happens that children are attacked with intense dyspnoea, and 
 other symptoms of disorder of the respiratory organs, which terminate 
 rapidly in death ; while it is discovered, on an examination of the body, 
 that the. thoracic viscera generally are free from disease, but that the 
 cellular tissue of the lungs is loaded with serous fluid. Laennec 1 refers 
 to such an accident as probably accounting for the occasional sudden 
 supervention of extreme dyspnoea in children recovering from measles ; 
 but a recent French writer, M. Legendre, 2 is, to the best of my know- 
 ledge, the first person who has clearly proved the connection between 
 the symptoms observed during life, and the state of extreme oedema of 
 the pulmonary tissue after death. 
 
 This oedema of the lungs, though it sometimes destroys life very speed- 
 ily, is seldom, if ever, a purely idiopathic affection, but occurs generally 
 as one of the complications of that acute anasarca which not infrequently 
 succeeds to scarlatina ; and even then it is not of common occurrence. 
 M. Legendre records only four cases, all of which were observed in 
 children who were suffering from anasarca after scarlatina ; and three 
 fatal instances of it have come under my own notice, in all of which it 
 supervened during scarlatinal dropsy. In two of these cases it came on 
 while the children were labouring under a great degree of anasarca ; on 
 the third occasion the dropsy had greatly abated before the thoracic 
 symptoms appeared. Indications of slight mischief in the chest, such 
 as frequent dry cough, some degree of dyspnoea, with rhonchus and 
 sibilus, or scanty crepitation, preceded the more serious symptoms for 
 two or three days. The patient, in short, had seemed to be suffering 
 from a bronchitis of moderate intensity, when suddenly extreme difficulty 
 of respiration supervened, attended with very hurried breathing, ortho- 
 pnoea, and most tumultuous and violent action of the heart, though with 
 a feeble pulse. The cough continued, being still short, and quite unac- 
 companied by expectoration. Auscultation under such circumstances 
 does not seem to give account of mischief sufficiently serious to explain 
 the alarming nature of the symptoms. It may be thought that air 
 enters the lungs less freely than it should do ; but the crepitation heard 
 is scanty, and neither bronchial respiration nor diminished resonance 
 on percussion of the chest is perceptible. Nevertheless, if relief be not 
 soon afforded, the child's sufferings in a few hours amount to perfect 
 agony ; the difficulty of respiration and the tumultuous action of the 
 heart continuing ; the lips and face becoming perfectly livid, but the 
 intellect remaining clear, and the child complaining of great distress ; 
 referred to the heart or epigastrium ; till at length death takes place 
 suddenly, which it sometimes does within twenty-four hours from the 
 appearance of these alarming symptoms. At other times the approach 
 of the disease is more gradual, the dyspnoea being augmented in parox- 
 
 1 On the Diseases of the Chest, translated by Dr. Forbes, 4th edition, p. 164. 
 London, 1834. 
 8 ltecherches sur quelques Maladies de l'Enfance, 8vo. p. 324-352. Paris, 1846. 
 
CHARACTERS OF (EDEMATOUS LUNG — TREATMENT. 205 
 
 ysms, but on the whole increasing with the increase of the general 
 anasarca, and proving fatal in the course of five or six days. 
 
 On examining after death the bodies of children who have died of this 
 acute oedema of the lungs, a little transparent serum is usually found in 
 the chest, and a few deposits of lymph on the surface of the lung some- 
 times betoken the existence of slight inflammation of the pleura. The 
 lungs themselves are of a deep red colour, firm, and destitute of air 
 through a great extent of their substance, not breaking down so easily 
 as lung in a state of true hepatization would do, but giving exit when 
 cut into to a most abundant quantity of reddish serum, mixed with very 
 few air-bubbles. The right auricle and ventricle are enormously dis- 
 tended with coagulated blood, — a token of the difficulty with which the 
 heart has discharged the functions to the performance of which it at 
 length became wholly unequal. To this description two importanfopar- 
 ticulars may be added from the account given by M. Legendre : the one, 
 that punctures of the lung will allow the fluid to drain out, and thus 
 restore to the organ much of its previous flaccidity ; the other, that by 
 the insufflation of air, the tissue of the lung may be made to resume its 
 natural suppleness and its light colour, and once more to crepitate as in 
 a state of health. From these facts M. Legendre concludes, and his 
 opinion is, I doubt not, quite correct, that the cellular tissue of the lung 
 is in these cases the chief seat of the serous effusion, and that dyspnoea 
 is produced by the consequent compression of the air-cells. 
 
 In the treatment of any case in which the symptoms just enumerated 
 come on, free venesection affords most remarkable and almost immedi- 
 ate relief, and, whenever it is practicable, is much to be preferred to the 
 most abundant depletion by means of leeches applied to the neighbourhood 
 of the heart. After depletion, large doses of tartar emetic should be 
 given, since there is no other remedy that so speedily or effectually 
 reduces the urgent dyspnoea. In the subsequent management of the 
 case just such remedies are required as would be best calculated to 
 relieve the general dropsy ; and as that decreases, the oedema of the 
 lungs will likewise diminish and disappear. 
 
 Sometimes you may meet with cases in which the coldness of the 
 extremities, and the great lividity of the surface, seem to forbid deple- 
 tion. Such an instance I once saw : the patient was a girl about nine 
 years old, in whom all the symptoms had come on very suddenly a few 
 hours before I saw her, and who appeared almost dying at the time of 
 my visit. I applied a large mustard-poultice over her chest, gave her 
 a draught containing a large dose of nitrous ether, and repeated it 
 every two hours. In the course of eight or ten hours, she was suffi- 
 ciently rallied to bear venesection, which was followed by a most 
 marked amendment, and in a few days her recovery was complete. 
 
 My experience of gangrene of the lung in childhood is still more 
 limited than that of the acute oedema of its tissue, for only one case of 
 it has come under my notice. The particulars of it, however, may be 
 worth relating, since they illustrate very well the symptoms which the 
 disease usually presents, and the circumstances under which it gene- 
 rally occurs. 
 
 A little girl, three years old, the child of healthy parents, who had 
 
206 GANGRENE OF THE LUNG. 
 
 previously had good health, with the exception of a severe attack of 
 inflammation of the lungs when two years old, began to droop in health, 
 to cough, and to have shortness of breath, on the 11th of February, 
 1843. No treatment was adopted until the child was brought to me 
 on the 15th. Her breathing was then more oppressed, her general 
 condition more cast down, and her strength more reduced than is usual 
 in so short a time from the commencement of an attack of pneumo- 
 nia, which had not set in with very severe symptoms. Four leeches 
 were applied beneath the right scapula, and half grain doses of calo- 
 mel and Dover's powder were given every three hours. Slight relief 
 succeeded to the bleeding, but this was of but short duration ; and the 
 child did not seem to be either better or seriously worse until the 19th, 
 when she appeared to be losing strength. The mercury was now dis- 
 continued, and ammonia and nourishing diet were freely given. On the 
 20th, the gums both of the upper and lower jaw began to swell ; by 
 the next day they were ulcerated ; the breath became very foetid, and 
 a discoloured, stinking fluid, ran from the mouth. The thoracic symp- 
 toms continued much the same, not at all increasing in intensity, and 
 the cough growing looser than before ; but the child became paler and 
 more exsanguine, and continued to lose power. The ulceration of the 
 gums extended to the fold of the lower lip, and three of the incisor 
 teeth fell out before the disease was finally checked, on Feb. 26th, by 
 the application of the pure nitric acid. The child did not appear to 
 suffer pain, but was very restless, and continually harassed by efforts 
 to vomit, during which she rejected nothing but an offensive mucus. — 
 She was extremely indisposed to take either wine or any nourishment 
 for four days before her death, which took place apparently from 
 exhaustion on the 1st of March, nineteen days after the commencement 
 of her illness. 
 
 On an examination of the body after death, the left lung was found 
 perfectly healthy, with the exception of some emphysema of its upper, 
 and considerable congestion of its lower lobe. 
 
 The right lung, which consisted of only two lobes, was universally 
 solid and non-crepitant, with the exception of about a fourth of the 
 upper and inner edge of the upper lobe which was emphysematous. 
 The two lobes were connected together by a layer of yellow lymph. — 
 The exterior of the lung generally was of a dark greyish red colour, 
 with irregular patches of yellow deposit beneath the pleura, some of 
 which were nearly half an inch in length and a quarter in breadth ; 
 besides which many small purulent deposits were contained within the 
 pulmonary veicles, as in vesicular bronchitis. The upper part of the 
 upper lobe, and a small portion near the diaphragmatic surface of the 
 lower lobe, felt soft and boggy to the touch. On cutting into the 
 upper lobe, a cavity was opened as large as a hen's egg, very irregular 
 in form, intersected in various directions by the tubes and vessels that 
 crossed it ; from which, as well as from the walls of the cavity, portions 
 of lung hung in shreds. The cavity contained a small quantity of 
 dirty, greyish yellow, putrilage, which exhaled a most foetid odour. The 
 substance of the lung in the immediate neighbourhood was in a far 
 advanced stage of purulent infiltration, and other parts of the lobe 
 
GANGRENE OF THE LUNG. 207 
 
 were in an earlier stage of the same condition ; besides which, small col- 
 lections of puriform fluid, not bigger than a split-pea, were found in 
 various parts of its substance. The state of the lower lobe on the whole 
 resembled that of the upper, but the cavity in its lower lobe was not 
 larger than a marble, and contained a small quantity of yellow pus of 
 a less foetid character than in the upper lobe. The bronchial glands 
 were swollen, soft, of a homogeneous aspect, and a grey colour ; but 
 neither in them, nor in either lung, nor in any organ of the body, was 
 there the least trace of tubercular deposit. 
 
 Although there was in this instance a larger amount of inflammatory 
 disorganization of the lung than is usually met with in connection with 
 gangrene of its substance, yet the symptoms noticed during the patient's 
 life-time were precisely such as are generally observed in cases of this 
 description. The child was attacked with symptoms of pneumonia 
 which, however, were far from being severe ; but nevertheless, by the 
 fifth day from their commencement, the greater part of the right lung 
 had become impervious to air, and percussion over the right side of the 
 chest, on the 15th of February, yielded an almost entirely dull sound. 
 Even then the child's strength seemed much reduced, and in the course 
 of a few days more she sank into a state of great weakness. Through- 
 out the whole course of the disease, there was the same absence of 
 striking indications of the extent to which the respiratory organs had 
 suffered, and this even after a large portion of the lung was completely 
 disorganized. The most remarkable phenomena were those which 
 betokened the general loss of power in the system, while the apearance 
 of gangrenous ulceration about the gums tended to prove the correctness 
 of the opinion which refers the disease to some peculiar alteration of 
 the circulating fluid, rather than to the violence of the inflammatory 
 action. Another circumstance which tends to support this opinion is, 
 that gangrene of the lung much more frequently supervenes on the 
 pneumonia that comes on in the course of the exanthematous fevers, 
 than on idiopathic inflammation of the lungs. The disease, too, occurs 
 far more rarely in children who are well fed, and who live in pure air, than 
 in those who are surrounded by unfavourable hygienic conditions. Hence 
 it results that this, as well as other forms of gangrene, are met with in 
 the Children's Hospital at Paris with far greater frequency than elsewhere, 
 and that they sometimes show a tendency to become epidemic in that 
 institution. 
 
 There is no symptom that can be mentioned as of constant occurrence 
 in gangrene of the lung in children, and as pathognomonic of the 
 disease. That peculiar fcetor of the breath on which so much reliance 
 is placed in cases of gangrene of the lung in the adult, sometimes loses 
 its value in the child, as it did in the case just related, by the coexistence 
 with it of gangrene of the mouth. It happens, too, not infrequently, 
 that the characteristic odour of the breath is altogether absent in cases 
 of gangrene of the lung, — a circumstance for which it is not easy to 
 account; though of the fact there can be no doubt, since it rests on the 
 authority of MM. Rilliet and Barthez. 
 
 Should you meet with any case in which you apprehend that this 
 condition of the lung is present, you would adopt a tonic and stimulant 
 
208 ACUTE PLEURISY. 
 
 plan of treatment, as affording the only chance, and that a very 
 slender one, of saving the patient's life. Dr. Stokes's suggestion, too, 
 for the administration of chlorine, should not be forgotten, since, if the 
 remedy did nothing else, it might diminish that foetor of the breath 
 which is a source of very great suffering to the patient. 
 
 We pass now from the examination of the inflammatory affections of 
 the substance of the lung, to the study of those to which its investing 
 membrane is liable. It will not, however, be necessary to occupy very 
 much of your time with the subject of pleurisy in childhood, since, 
 though it is a very important disease, yet neither its symptoms, course, 
 nor treatment, undergo such modifications from the early age of the 
 patient as we have observed in some other of those affections which we 
 have already passed in review. Some writers on the diseases of chil- 
 dren, indeed, have left pleurisy altogether unnoticed, on account of its 
 supposed extreme rarity in early life ; but this opinion is certainly 
 erroneous, so far as regards that secondary pleurisy which comes on 
 in the course of pneumonia, and which is almost, if not quite, as fre- 
 quent in childhood as in adult age. Acute idiopathic pleurisy, uncon- 
 nected with pneumonia, or in which the inflammation of the lung bears 
 but a very small proportion to that of the pleura, is certainly an 
 uncommon affection during the first years of childhood, and as a cause 
 of death, its rarity is extreme. It appears from the Reports of the 
 Registrar-General, that of 202 fatal cases of pleurisy that occurred in 
 London in the years 1842 and 1845, only 14, or 6.4 per cent, took place 
 in children under five years old, while you will not have forgotten that 
 63.2 per cent, of all fatal cases of pneumonia are alleged on the same 
 authority to have befallen children aged less than five years. Acute 
 idiopathic pleurisy has run a fatal course in children under five years 
 of age only on five occasions which I have had the opportunity of 
 observing, — a result that has seemed to be due at least as much to the 
 rarity of the disease as to its being seldom fatal. After five years 
 of age, however, the frequency of pleurisy manifestly increases, and 
 during the later years of childhood it is little, if at all less frequent, 
 than in the adult. 
 
 In fatal cases of pleurisy in childhood, the appearances found after 
 death are precisely the same as are met with in the adult. Adhesions 
 between the costal and pulmonary pleura, and between the different 
 lobes of one or other lung, associated sometimes with very intense red- 
 ness of parts of the membrane, are hardly ever wanting, and in con- 
 nection with them a small quantity of transparent serum, often of a 
 reddish tint, is sometimes effused into the cavity of the chest. In other 
 cases the effused matters are entirely solid, and both the surface of the 
 lung and the interior of the thorax are coated with a distinct investment 
 of lymph ; or, in addition to the deposit of lymph on the lung, fluid is 
 poured out into the chest, — no longer transparent serum, but either a 
 sero-purulent fluid, in which flakes of lymph are floating, or, more 
 rarely, healthy pus. The most frequent complication of pleurisy is 
 with inflammation of the lungs ; besides which it occasionally happens, 
 when the left pleura has been the seat of inflammation, that the disease 
 extends from it to the pericardium, which on two such occasions I have 
 
SYMPTOMS OF ACUTE PLEURISY. 209 
 
 found lined with lymph, partially adherent to the heart, and containing 
 a sero-purulent fluid. 
 
 The main symptoms that attend the disease, as well as the physical 
 signs of its existence, are the same at all ages. There are, however, 
 some circumstances peculiar to early life, which, unless you are on 
 your guard, may serve to obscure the real nature of the affection. The 
 history of a case of acute pleurisy in childhood is generally something 
 to this effect: — A child previously in perfect health, is suddenly 
 attacked with pain referred to the chest or upper part of the abdomen, 
 so severe as to occasion it to cry aloud ; perhaps attended at first 
 with vomiting of a greenish fluid, accompanied with fever, a rapid 
 pulse, and hurried respiration, interrupted by frequent short cough, 
 which evidently occasions pain, and w T hich the child labours, though in 
 vain, to suppress. After a few hours the severity of the pain subsides ; 
 but the fever, hurried respiration, and cough, continue, and the child, 
 though usually it looks heavy and seems drowsy, yet becomes extremely 
 restless at intervals, — cries and struggles as if in pain, and violently 
 resists any attempt to alter its position, since every movement brings 
 on an exacerbation of its sufferings. The posture which it selects 
 varies much : sometimes its breath seems disturbed in any other than 
 an upright position ; at other times it lies on its back, or on one side ; 
 but, whatever be the posture, any alteration of it appears to cause much 
 distress, and is sure to be resisted by the patient. 
 
 The probabilities are, that, if you auscultate the chest of a child 
 in whom these symptoms exist, you will hear good breathing through 
 the whole of one lung. On the other side, the air will be most likely 
 found to enter less freely, though unaccompanied by any moist sound, 
 perhaps unattended with any morbid sound at all ; or, a rough sound 
 like a rhonchus may be audible on this side, and for this you may very 
 likely at first take it, though with more attention it will be discovered 
 to be a friction sound. A day or two later you will probably detect a 
 sound like that of bronchial breathing, as you pass your ear from above 
 downwards along the posterior part of the chest, while the friction 
 sound will have disappeared ; and still lower there will be an utter 
 absence of all sound. The walls of this side of the chest, if their 
 tenderness do not prevent your trying percussion, will yield a much 
 less resonant sound than usual ; while, at the same time, a distinct 
 sense of solidity will be communicated to the finger. 
 
 I need hardly pursue the detail of other symptoms which are the 
 necessary result of pleurisy whatever be the age of the person in whom 
 it occurs. The diminished mobility of the affected side, the displace- 
 ment of the heart, the bulging of the intercostal spaces, and the enlarge- 
 ment of the chest on the diseased side, are phenomena that take place 
 under the influence of the same causes at every age, though their occur- 
 rence is less frequent in childhood than in adult age, since the effusion 
 of fluid is usually more scanty. The course of the disease, whether 
 towards recovery or to a fatal issue, presents nothing remarkable in 
 childhood ; but it is chiefly at the commencement of the disease that 
 you are likely to mistake its nature. 
 
 The symptoms by which an attack of acute pleurisy is ushered in 
 
 14 
 
210 DIAGNOSIS OF PLEURISY. 
 
 point sometimes rather to the head than to the chest. The child is 
 seized with vomiting, attended with fever and intense headache : it 
 either cries aloud, or is delirious at night, or screams much in its sleep, 
 and, when morning comes, complains much of its head, but denies 
 having any pain whatever in its chest, while the short cough and the 
 hurried breathing may be thought to be merely the result of the cere- 
 bral disturbance. Sometimes, too, the cough is altogether absent, and 
 the acceleration of the breathing so slight as not to suggest the idea 
 that serious mischief is going on in the chest. Under the impression 
 that the child is suffering from cerebral disease, auscultation is omitted, 
 or at least practised hastily and superficially, and consequently serves 
 but to confirm the erroneous diagnosis. It often happens, indeed, that 
 in these cases no friction sound is perceptible, and that you have no 
 other indication to guide you aright besides the feebleness of the respi- 
 ratory murmur on the affected side. The child, too, fearful of taking 
 a deep inspiration, fills neither lung completely, so that the information 
 usually gained by comparison of the breathing in one lung with that of 
 the other is in great measure lost. Still, the presence of feeble respi- 
 ratory murmur, at the lower part of one lung, when coupled with the 
 sudden access of acute febrile symptoms in a previously healthy child, 
 points almost invariably to the existence of acute pleurisy ; while a 
 careful consideration of the patient's history and general condition 
 will, even irrespective of the results of auscultation, go far towards pre- 
 venting you from falling into error. The onset of the illness has been 
 far too acute, attended with far too much febrile disturbance, for a case 
 of tubercular hydrocephalus, while many of the signs of cerebral mis- 
 chief which might be expected in a case of simple encephalitis have not 
 presented themselves. The heat of head is not greater than that of 
 the rest of the surface ; the cries with which the disease set in have not 
 ended in coma. It happens but seldom that convulsions mark the com- 
 mencement of the disease ; but, if they had occurred at the onset, they 
 have not since returned: neither twitching of the muscles, nor strabismus, 
 nor retraction of the head, is present; and, though the child may cry 
 (as children when ill and fretful often do) at the curtain being undrawn 
 and the candle brought near it, yet there is no real intolerance of light, 
 while, in spite of its fretfulness, the intelligence is not otherwise per- 
 verted. Error indeed is easy, but to avoid it, requires in this, as in 
 most instances, not so much great acuteness, as great care and great 
 patience. 
 
 The pain with which pleurisy sets in is sometimes referred not to the 
 chest, but to the abdomen; and its commencement maybe attended 
 with vomiting and purging. Pressure on the abdomen, too, often 
 causes a considerable increase of suffering ; and you may thus be led 
 to regard the case not as pleurisy, but as intestinal disorder, with fever. 
 In any such doubtful case it is well to bear in mind that children, long 
 after they can talk, describe the nature and seat of their sufferings 
 very inaccurately ; and if, as often happens in these cases, they refer 
 the pain to the right hypochondrium, you should not forget that pain 
 in that situation is at all ages much oftener connected with inflamma- 
 mation of the pleura than of the peritoneum; and, lastly, that tho 
 
DIAGNOSIS OF PLEURISY. 211 
 
 increase of discomfort produced by pressure on the abdomen, may be 
 due to the additional impediment thereby offered to the already labour- 
 ing respiration. 
 
 In most cases of pleurisy in childhood, careful auscultation will 
 preserve us from error. Still, the information that it yields is more 
 limited in the child than in adult age. The evidence afforded by the 
 various modifications of the voice sound, are much less marked, owing 
 to the feebleness of the voice in early life, while we cannot induce the 
 child to speak several sentences, or utter several words in the same 
 pitch of voice, in order that we may try how far the sound is altered. 
 For the same reason, too, we cannot test the difference between the two 
 lungs by the vibration of the voice perceived on applying the hands to 
 either side of the chest — a means by which, in the adult, we are often 
 assisted in determining between a solidification of the lung from pneu- 
 monia, and the dulness consequent on pleurisy with effusion. Another 
 circumstance which, in the child, increases the difficulty of distinguish- 
 ing between pleurisy and pneumonia, is, that, in the latter, children 
 sometimes inspire so slightly as not to produce any crepitation ; so that 
 in both cases we may have impaired resonance on percussion, with 
 scanty admission of air, and a bronchial character in the respiration, 
 but without any other morbid sound. In the child, too, we lose the 
 very valuable information which the presence of the expectoration in 
 the pneumonia of grown persons affords, when contrasted with the 
 absence of all expectoration as an attendant on the dry cough of 
 pleurisy. With the advance of the disease doubt as to its nature is 
 removed ; it is at its commencement only that mistake is possible. 
 But even then, and in spite of all the circumstances which have been 
 enumerated as tending to mislead, you will seldom be wrong if you 
 regard as an instance of pleurisy any case in which s}^mptoms like 
 those of pneumonia have set in suddenly and severely, auscultation 
 fails to detect the crepitus of pneumonia, and discovers only feebleness 
 of the respiratory murmur on one side, with or without a more or less 
 marked bronchial character in the breathing. 
 
 But we may pass now to the consideration of the treatment of acute 
 pleurisy in childhood; a subject which need not detain us long, since 
 the age of the patient in no respect alters the principles that must 
 guide our conduct. If seen sufficiently early, and treated with due 
 activity, cases of acute pleurisy in infancy and childhood nearly always 
 have a favourable termination, and in almost every instance that has 
 come under my observation in which the issue of the disease was unfor- 
 tunate, either all treatment had been neglected until the children were 
 past hope, or the nature of the complaint had been mistaken, or the 
 treatment followed had not been sufficiently active. This last error, 
 it is of great moment to avoid, for acute inflammation of the pleura in 
 childhood runs its course with greater rapidity to a fatal issue than in 
 the adult. Of seven fatal cases of acute pleurisy in childhood, of 
 which I have preserved a record, three ended in death on the 6th day, 
 one on the 9th, one within a fortnight; while one of the remaining 
 two terminated in thirty days, and the life of the child in the seventh 
 
212 ITS TREATMENT. 
 
 case was prolonged for several months, death eventually taking place 
 from the developement of phthisical disease in the lungs. 
 
 In almost every case, provided the symptoms be at all urgent, and 
 the child's previous health have been good, general depletion should 
 be resorted to, and you need not be afraid of carrying this first bleed- 
 ing to syncope, since children generally faint after the abstraction of 
 a comparatively small quantity of blood from the arm. It will be 
 almost always necessary to follow this up by local bleeding, but it is 
 desirable to wait for three or four hours in order that you may be 
 enabled to estimate the effect produced by the previous venesection. 
 A second bleeding from the arm is seldom needed, and may almost 
 always be avoided if local depletion be not too timorously practised. 
 In the acute stage of pleurisy, it is better to draw the blood by leeches 
 than by cupping, since the side is often so tender that the pressure of 
 cupping glasses would be unbearable. After depletion, our chief 
 reliance is to be placed on calomel, which should be freely given in 
 combination with opium or Dover's powder. Antimony, which often 
 renders us such good service in pneumonia, is here of little use ; and 
 though it may somewhat diminish the frequency of the breathing, it 
 exerts little or no influence upon the local mischief. A pleurisy treated 
 thus actively, is sometimes overcome in the course of 24 or 48 hours, 
 so that nothing remains of symptoms which had appeared so formida- 
 ble. Often, however, after the acute symptoms have subsided, the 
 affected side remains dull, and the respiration scanty, for several weeks 
 together ; and now is the time when the use of blisters, associated with 
 the exhibition of small doses of calomel, will be of most essential ser- 
 vice, and will generally effect the complete absorption of the fluid, and 
 the restoration of the patient to perfect health. 
 
 This, however, is not always the case ; but sometimes, in spite of 
 remedies perseveringly employed, one side of the chest continues full 
 of fluid ; and the question then comes before us, whether it will not be 
 expedient to let out that fluid by mechanical means. Many most 
 important considerations, are, as you know, involved in the question of 
 performing paracentesis of the chest ; but the indications for its per- 
 formance are the same in the child as in the adult : while my own 
 experience would lead me to conclude that cases in which the operation 
 is necessary, are of very rare occurrence in early life. 
 
 Pleurisy does not always present itself as an idiopathic affection. It 
 supervenes, as we have already noticed, in the course of pneumonia, 
 increasing the suffering of the patient, and, if severe, adding much to 
 his danger. It comes on sometimes during acute rheumatism, either 
 with or without pericarditis, and on two occasions I have observed 
 pleurisy, with effusion into one side of the chest, succeed to an attack 
 of peritonitis. But besides these cases in which the affection of the 
 pleura retains an acute character, the disease is likewise met with in a 
 chronic form, and manifesting its existence by comparatively few 
 symptoms. Attacks of chronic pleurisy are sometimes idiopathic, and 
 it is not always possible to trace them back to their commencement in 
 an acute seizure. The cough and dyspnoea in such cases are trouble- 
 
CHRONIC PLEURISY. 211 
 
 some rather than distressing, and nothing but examination of the chest 
 would lead to a suspicion of the serious nature of the affection. Cases 
 of this description usually do well under the employment of local 
 counter-irritation and the administration of mercury and diuretics, 
 though the absorption of the fluid is in general effected very gradually. 
 Chronic pleurisy, however, is a very rare occurrence as a purely idio- 
 pathic affection in early life ; but it is one of the most important, and 
 far from being one of the least common complications of the dropsy 
 which often succeeds to scarlatina. Under these circumstances, too, 
 it often needs much attention to detect it, since it may for a long 
 time give rise to but few symptoms that might betray its existence. 
 Some cough and some dyspnoea almost invariably attend the anasarca 
 that succeeds scarlatina, and often there is no complaint of pain, nor 
 increase of the cough, nor exaggeration of the dyspnoea, to betoken the 
 onset of this new and formidable disease. At length, perhaps, the 
 anasarca disappears, and now, when we notice the emaciated condition 
 of the child, we observe for the first time, that one half of the chest is 
 much larger than the other, that it remains immoveable during respi- 
 ration, and we discover that it is full of fluid. Or, our attention may 
 be suddenly called to the mischief that has been going on, by the 
 child becoming unable to breathe, except in one posture, and even then 
 with extreme difficulty : the fluid has been poured out so abundantly 
 as at length almost to prevent respiration, and when we find out the 
 evil, it is almost too late to effect its cure. 
 
 It is by the adoption of a vigorous antiphlogistic treatment in the 
 dropsy that follows scarlatina that you will be most likely to prevent 
 the supervention of this serious malady : it is only by the most atten- 
 tive daily auscultation that you will in many cases get notice of its 
 approach. 
 
 LECTUKE XIX. 
 
 Croup. — Reasons for not studying it earlier in the course — discrepancy of opinion with 
 reference to it, owing to modifications of its character by external circumstances. 
 
 Causes of the disease — its frequency in childhood, in the male subject, in northern 
 climates, in rural districts — its occasional epidemic prevalence. 
 
 Post-mortem appearances — variations in the extent of false membrane in the air- 
 passages — changes associated with it — affection of the fauces and soft palate. 
 
 Symptoms — occasional sudden onset — catarrhal stage, general course of a fatal case — 
 occasional delusive appearances of amendment. — Evidences of auscultation — changes 
 in tracheal sound. 
 
 Duration. Prognosis. 
 
 Treatment — importance of abstraction of blood — directions for its performance, and for 
 the administration of tartar-emetic — when and how mercurials are to be employed. 
 
 In strict propriety the very important disease which we are about to 
 investigate to-day ought to have engaged our attention immediately 
 after we had completed our study of infantile bronchitis. Two reasons, 
 however, independent of mere convenience, have led me to postpone 
 till now the consideration of the subject of croup. One of these 
 
214 croup. 
 
 reasons is that its gravity is often greatly increased by the association 
 with it of inflammation of the lungs, — a complication the importance of 
 which it was essential that you should thoroughly understand ; the 
 other is, that croup, though an inflammatory disease, is not without a 
 very evident spasmodic element in every case : so that it may very 
 appropriately form a sort of transition between the inflammatory and 
 the spasmodic diseases of the respiratory organs. 
 
 It can scarcely be necessary to tell any of you that croup is the 
 English name for the disease designated by scientific writers eynanche 
 trachealis, or eynanche laryngea. It consists in inflammation generally 
 of a highly acute character, of the larynx or trachea, or of both, which 
 terminates in the majority of cases in the exudation of false membrane 
 more or less abundantly upon the affected surface. 
 
 The formidable nature of the symptoms by which it is attended, and 
 the rapidity with which it tends to a fatal issue, have led many of the 
 ablest physicians to devote much time and attention to the study of 
 croup. It might therefore be anticipated that our knowledge of a 
 disease which betrays itself by very manifest and highly characteristic 
 symptoms, and which gives rise, when fatal, to changes easily 
 appreciable after death, should by this time, be very definite and 
 settled. With reference to many of the more important points in the 
 history of the malady, writers are now, indeed, pretty well agreed ; 
 but croup, like many other diseases that depend to a great degree on 
 atmospheric and telluric causes, is modified in many of its symptoms 
 by peculiarities of air, water, and situation. The affection assumes 
 one character among the poor of a crowded city and another among 
 the children of the labourer in some rural district. 1 
 
 1 I have preserved a record of 23 cases of croup that came under ray notice at the 
 lloyal Infirmary for Children between May 1839 and April 1849. Of these 23 cases, 11 
 were idiopathic, 12 secondary: five of the former and two of the latter recovered. In 
 two of the idiopathic cases that recovered, a scanty formation of false membrane was 
 observed upon the velum and tonsils, but no such appearance existed in the other 
 idiopathic cases. Three of the six fatal idiopathic cases were examined after death: 
 in two the false membrane was confined to the laryux ; and there was but little injec- 
 tion of the trachea or bronchi : in the third case there was great redness both of the 
 trachea and bronchi, and a large quantity of purulent secretion in both, and ulceration 
 of the mucous membrane of the larynx, but no false membrane. Of the 12 secondary 
 cases one supervened in the course of pneumonia ; in the other eleven, croup appeared 
 as the sequela or concomitant of measles, and ten of the twelve terminated fatally. 
 In the cases which recovered, and in three of those which terminated fatally, there was 
 no false membrane on the velum or fauces, but in the other seven, false membrane was 
 present in those situations as well as in the larynx, and twice this false membrane 
 extended into the oesophagus. Six of the fatal cases were examined after death ; in one 
 there was no false membrane anywhere, but intense redness of the larynx, trachea, and 
 bronchi, with an uneven granular appearance of the larynx, and ulceration about the 
 epiglottis. In the other five cases the larynx contained more or less false membrane, 
 and its surface was ulcerated ; and in four of the cases the palate and tonsils were 
 inflamed and coated with false membrane. In all these five cases pneumonia existed in 
 both lungs, and four times it was found to have reached in some parts the stage of 
 purulent infiltration. 
 
 These results, which differ in so many respects from the conclusions of many most 
 excellent observers in this country, approach much more nearly to those obtained in 
 the Hopital des Enfans Malades at Paris. The district in which my observations were 
 made is low, with defective sewerage, open drains running close to many of the houses ; 
 and most of the patients were the children of poor parents, who occupied only one 
 room, and who consequently were placed in most unfavourable hygienic conditions. 
 
CAUSES OP CROUP. 215 
 
 If, therefore, you find that my account of the disease varies in any 
 respect from the description given by some other writers, or from the 
 results of your own observation hereafter, do not too hastily assume 
 either that your teacher has been mistaken, or that your own obser- 
 vation has been incorrect. The difference may be nothing more than 
 a fresh exemplification of the old story of the shield, silver on the one 
 side, and golden on the other, about % which the knights in the fable 
 quarrelled. 
 
 Croup, in all the forms which it assumes in this country, is essentially 
 a disease of early life ; for it appears from the Fifth lleport of the 
 Registrar-General, that, while 1022 out of 98,391 deaths in the 
 metropolis, and twenty-four town districts, took place from croup, 1013, 
 or 99-9 per cent, of those deaths occurred before the age of fifteen ; 
 and 879, or 87'9 per cent, before the age of five years. Of twenty-six 
 cases of croup of which I have preserved a record, twenty-five occurred 
 in children under five years of age, and twelve in children under two. 
 It has been attempted to explain this great frequency of croup in early 
 life by the imperfect development of the organ of the voice before 
 puberty. This, however, can scarcely be admitted as a valid expla- 
 nation, since it does not at all account for the extreme rarity of the 
 disease after five years of age. The preponderance of male over 
 female children, among those who are attacked by croup, is another 
 fact which, though confirmed by the experience of all observers, has 
 never received any adequate explanation. 1 
 
 Croup appears to be influenced by peculiarities of climate and 
 locality much more than most diseases even of the respiratory organs. 
 Though not entirely confined to northern climates, it prevails but 
 seldom in the southern parts of Europe, and is even less frequent in the 
 southern than in the northern counties of England. In Kent, Surrey, 
 and Sussex, the deaths from croup are to the deaths from all causes in 
 the proportion of 9 per cent. ; while in the four northern counties, 
 Durham, Northumberland, Cumberland, and Westmoreland, which con- 
 tain an equal population, the deaths from this cause are in the 
 proportion of 1*6 per cent. It is endemic in particular localities; and 
 residence near the sea, proximity to the mouths of large rivers, a moist 
 soil and a damp atmosphere, have been enumerated as greatly predis- 
 posing to the disease. The influence of these local peculiarities has 
 probably, in some instances, been overrated ; but still it cannot be 
 denied, for a most striking illustration of it is afforded by the com- 
 parative rarity of croup in towns, and its frequency in rural districts. 
 In the county of Surrey, exclusive of the metropolitan districts, the 
 mortality, from all causes, under five years of age, is little more than a 
 third of the mortality, in Liverpool, and a little more than half the 
 mortality in London. But the total mortality, under five years of age, 
 
 1 From the Fifth Report of the Registrar-General, it appears that, while the deaths 
 of males under 15 from all causes, are to the deaths of females from all causes as 11 
 to 10, the deaths from croup are as 15 to 10. Of 249 cases that came under Golis' 
 observation at Vienna, 144 occurred in males, 105 in females; and at Geneva, under 
 J urine's observation, 51 males and 37 females died of croup, between the years 1791 
 and 1808. 
 
216 MORBID APPEARANCES. 
 
 from croup in the county of Surrey is to that in Liverpool nearly as 
 o to 2, and to that in London as 2 to 1 ; so that out of 100 children 
 dying under five years of age from all causes, more than four times 
 as many will have died from croup in Surrey as in Liverpool, and 
 exactly four times as many as in London. 
 
 Like other diseases that are much influenced by local and atmo- 
 spheric peculiarities, croup has i^ periods of epidemic prevalence. The 
 most remarkable epidemic of croup occurred in the years 1805, 6, and 
 T, when it extended over the greater part of central Europe. The 
 death of Napoleon's nephew, the Crown Prince of Holland, at this 
 time, gave occasion to the offer of a prize by the Emperor for the best 
 essay on this disease; to which we are indebted for many most valu- 
 able works on croup. Since then a sudden increase in its prevalence 
 has been noticed from time to time in certain towns or districts, 
 sufficient to show that the disease depends much on variations in the 
 atmosphere, though it has never again become so widely diffused over 
 large tracts of country as in the year 1807. In Paris, during the year 
 1840, twice as many deaths occurred from croup as had taken place in 
 1838; and there was a similar epidemic prevalence of the disease in 
 London during the years 1841 and 1842. 
 
 Variations in the condition of the atmosphere, and peculiarities of 
 situation, not only influence the frequency of the occurrence of croup, 
 but they likewise greatly modify its character, and determine to a 
 considerable extent the nature of the lesions which it produces. The 
 chief morbid appearances, however, are always discovered in the 
 larynx, trachea, and air tubes. They consist of redness of the mucous 
 membrane, which is often thickened, sometimes abraded or ulcerated, 
 and very generally covered with a more or less abundant exudation of 
 false membrane. This exudation, however, though so generally met 
 with as to have suggested to medical writers the terms angina poly- 
 posa, angina membranacea, as appropriate designations of croup, is 
 neither invariable in its occurrence, nor of a uniform extent in all 
 cases. It is found in the larynx oftener than in the trachea, and in 
 both more frequently than in the bronchi. There are nevertheless, 
 many instances on record in which the secretion of false membrane 
 was so extensive that it not only lined the larynx and trachea, but 
 reached into the minuter air-tubes, forming a complete cast of many of 
 their ramifications. There appears to be some connection between the 
 circumstances under which children become attacked by croup, and the 
 extent of false membrane in the air-passages, which a post-mortem 
 examination reveals. In rural districts, where the disease wears 
 throughout a sthenic character, false membrane is deposited in greater 
 abundance, and over a greater extent of surface, «than is usually 
 observed in the case of the poor in this metropolis : while, on the other 
 hand, we find in London a condition of unhealthy ulceration about the 
 larynx; ulceration, and the deposit of false membrane about the tonsils 
 and palate, in many instances: appearances which are seldom met with 
 in children placed under circumstances more favourable to health. 
 
 In cases of croup that have come under my own observation, the for- 
 mation of false membrane in the larynx has seemed almost invariably. 
 
MORBID APPEARANCES IN CROUP. 217 
 
 to precede its deposit in the trachea ; and not infrequently it has been 
 found constituting a tough, continuous, membrane, in the former situa- 
 tion, but growing less tenacious in the upper part of the trachea, and 
 passing gradually into a thick, puriform mucus, interspersed with 
 shreds of lymph. I have usually observed the false membrane lining 
 the whole of the larynx, and reaching down to the lower edge of the 
 thyroid cartilage, while the trachea contained nothing else than a 
 puriform matter, or glairy mucus, sometimes of a reddish colour. In 
 some instances the false membrane has been confined to the upper part 
 of the larynx, lining the lower surface of the epiglottis, blocking up 
 the opening of the sacculus laryngis, and covering the chordae vocales, 
 but not extending any further. When first secreted, the false mem- 
 brane is firmly adherent to the mucous lining of the air-passages, but 
 after a time a secretion of a puriform character is generally poured 
 out, which detaches the membrane from its connections ; and it is after 
 this occurrence has taken place that tubular pieces of false membrane 
 have sometimes been expectorated. This detachment of the false 
 membrane from the subjacent surface takes place more frequently and 
 more completely from the interior of the trachea than from that of the 
 larynx. On removing the false membrane from the trachea, the lining 
 of the tube is seldom found to present any change other than an 
 increase of its vascularity, which though sometimes very considerable, 
 does not bear any certain relation to the amount of false membrane 
 present. The greater difficulty in removing the false membrane from 
 the larynx depends upon the more extensive alterations which the 
 lining of that part of the air-tube is usually found to have undergone. 
 It is generally red and swollen, especially about the edges of the rima 
 glottidis and the arytenoid cartilages, and the openings of the sacculus 
 laryngis. Small aphthous ulcerations are also frequent in the two 
 former situations ; and occasionally, the ulcerations being more exten- 
 sive, the whole of the larynx, on detaching the false membrane that 
 lined it, presents a worm-eaten appearance. 
 
 It seldom happens that the bronchi are perfectly free from disease ; 
 but even though the trachea contain no false membrane, and present 
 but few signs of inflammation, they are almost always much congested, 
 and contain a muco-purulent or purulent secretion ; though false mem- 
 brane is seldom found in them, except when it is continuous with a 
 similar adventitious structure in the trachea. 
 
 Pneumonia, in all its stages, is far from being unusual, and is a com- 
 plication especially to be feared in those cases where croup occurs as a 
 secondary affection in the course of measles. 
 
 The cavity of the mouth, and the fauces, do not present any invari- 
 able alteration in cases of croup. Congestion about the fauces and 
 soft palate is of frequent occurrence, sometimes coupled with a scanty 
 deposit of false membrane in those situations, or the tonsils are found 
 in a state of sloughing ulceration. In that form of croup which suc- 
 ceeds to measles, there is moreover in many instances a condition of 
 unhealthy inflammation, and aphthous ulceration of the mouth and 
 gums : a slight speck of ash-coloured false membrane covering each 
 
218 SYMPTOMS OP THE FIRST STAGE. 
 
 little ulcer. In many of these cases I apprehend that the laryngeal 
 affection does not come on in consequence of extension to the air- 
 passages of disease beginning in the mouth, but that the disease is the 
 same in both situations; though the accident of the locality renders 
 that a serious disorder, when seated in the larynx, which is but a 
 trivial ailment when affecting the mouth. Cases of this last kind have 
 been called cases of ulcerative laryngitis : they have always come 
 under my notice associated with the effusion of false membrane, and 
 between them and croup I can discover no essential difference. 
 
 Whatever be the circumstances under which croup comes on, the 
 symptoms resulting from disease obstructing the channel of the larynx 
 and trachea by false membrane, or inducing a spasmodic closure of 
 their aperture, must always be to a great extent the same. The mode 
 of onset of the disease, however, is very variable. Sometimes, espe- 
 cially in those forms of croup that prevail among healthy children 
 living in the country, the disease is announced by few, if any, pre- 
 monitory symptoms ; but the affection of the larynx is apparent from 
 the very outset, and attains in the course of a few hours to a high 
 degree of intensity. Some years since I saw a little boy, about seven 
 years old, living at some distance from London. He had overheated 
 himself at play during the afternoon of a hot day in August, but went 
 to bed apparently well at eight o'clock, and soon fell asleep. At ten, 
 he began to breathe with the peculiar noise characteristic of croup, and 
 presented all the symptoms of the disease before midnight. 
 
 In his treatise on croup, Professor Golis, of Vienna, 1 relates the case 
 of a little boy four years old, previously in perfect health, who having 
 gone out of an overheated room into the open air, during an extremely 
 cold winter's day, was seized while walking with all the symptoms of 
 most violent croup, which proved fatal in fourteen hours. 
 
 This sudden onset and rapid course of the disease, however, are of 
 rare occurrence, and croup generally comes on gradually, attended in 
 its first stage with but few symptoms that could distinguish it from 
 ordinary catarrh. Slight fever, drowsiness, suffusion of the eyes, and 
 defluxion from the nares, attend it. The respiration is not perceptibly 
 disturbed, and the cough, though frequent, presents no peculiar cha- 
 racter. There is, besides, occasional complaint of slight sore throat,, or 
 of uneasy sensation about the larynx, but so slight as scarcely to 
 attract attention, and not sufficient to cause any alarm. 
 
 The duration of this stage is very variable : nor is there any regu- 
 larity in the mode of its transition into the second stage. In the 
 majority of cases, indeed, the transition takes place gradually ; but 
 thirty-six hours seldom pass without the supervention of some symptom 
 which, to the well-schooled observer, would betray the nature of the 
 coming danger. Most symptoms may continue unchanged, perhaps 
 scarcely aggravated, but a slight modification takes place in the cha- 
 racter of the cough, which now becomes attended with a peculiar ringing 
 sound, difficult to describe, but when once heard not easily forgotten. 
 
 1 De rite cognescenda et sananda Angina Membranacea, 8vo. Yiennae. Observ. iv. 
 p. 141. 
 

 SYMPTOMS OP THE SECOND STAGE OF CROUP. 219 
 
 This peculiarity in the cough very often precedes any change in the 
 respiration, and may sometimes be so slight as scarcely to attract the 
 parents' notice at the time, and to be remembered only when the lull 
 development of the disease leads to inquiries as to how the attack came 
 on. Soon after this modification of the cough has become perceptible, 
 or even simultaneously with it, the respiration undergoes a change no 
 less remarkable. The act of inspiration becomes prolonged, and 
 attended with a stridor as difficult to describe, but as characteristic of 
 the disease, as the tone of the cough. It often happens that these two 
 pathognomonic symptoms first come on, or at least first excite atten- 
 tion, in the night, and that a child who at bed-time was supposed to ail 
 nothing, or at most to have a slight cold, awakes suddenly with ringing 
 cough and stridulous breathing, frequently in a state of alarm and with 
 marked dyspnoea. Through the whole course of the disease, indeed, an 
 obvious tendency exists to nocturnal exacerbations, and to remissions 
 as the morning approaches. In whatever manner these symptoms may 
 have come on, they will not continue for many hours without being 
 attended by increase of fever, by acceleration, and soon by difficulty 
 of respiration. The skin becomes hot and dry, the face flushed, the 
 breathing hurried, the cough frequent, the pulse full and quick, the 
 child dull, fretful, and passionate. For a few minutes, indeed, it may 
 appear cheerful, may turn to its playthings, and breathe more natu- 
 rally, though the peculiar respiratory sound never ceases altogether. 
 Soon, however, the dyspnoea returns with increased intensity ; the 
 whole chest heaves with the inspiratory effort, which is more prolonged 
 and attended with greater stridor. During it, perspiration breaks out 
 at every pore, and the veins of the neck and face become greatly dis- 
 tended. Short and forcible expiration follows, and after this state of 
 dyspnoea has lasted for some minutes, an interval of comparative ease 
 succeeds. The child now often falls asleep exhausted: but during sleep, 
 the sound attending respiration is heard in an exaggerated degree. 
 Though the drowsiness is great, sleep is uneasy, and frequently inter- 
 rupted by violent startings, in spite of which the child may still sleep 
 on. After some minutes he awakes in a state of terror, to pass through, 
 another paroxysm similar to the preceding one, though more severe. 
 The cough does not increase in severity in proportion as the disease 
 advances ; it is unattended by expectoration, or at most a little mucus 
 is spit up, but without any relief. Although the paroxysms of dyspnoea 
 are not dependent on the cough, they are sometimes provoked by it, 
 and the two or three inspirations next following an effort of coughing 
 are often attended with increased stridor. From the first appearance 
 of the more marked symptoms, the voice is hoarse, cracked, and whis- 
 pering, or in young children is either totally suppressed, or, if their 
 voice be not actually extinct, at least their disinclination to speak is so 
 great, that they will reply to questions only by signs, and cannot be 
 induced by any persuasion to utter a w T ord. 
 
 There is almost always much eagerness for drink, and deglutition is 
 generally well performed. The fauces are often red, though their red- 
 ness bears no direct proportion to the intensity of the croupal symptoms ; 
 
220 OF ITS THIRD STAGE. 
 
 and there is frequently considerable tenderness of the larynx. The 
 tongue is red at the tip and edges, but coated in the centre and at the 
 back with thick white fur ; the bowels are rather constipated, and the 
 appetite for food is entirely lost. 
 
 As the disease advances, the paroxysms become less marked, or rather, 
 the intermissions grow less distinct, and the child is constantly engaged 
 with the effort to respire. The cough now sometimes ceases altogether, 
 and the breathing frequently becomes sibilant rather than stridulous. 
 The child throws its head back as far as possible, in order to increase the 
 capacity of the trachea, the chest is heaved violently at each effort to 
 inspire, and the larynx is depressed forcibly towards the sternum, while 
 the abdominal muscles co-operate energetically in expiration. The face 
 is heavy and anxious, the eyes are dull, the lips livid, the skin dry, and 
 the extremities cold ; or clammy sweats bedew the surface. The respi- 
 ration is hurried, unequal and irregular, and the pulse is very frequent 
 and very feeble. Though no remissions now occur, there are frequent 
 exacerbations, in which the child throws itself about, and puts its hand 
 to its throat, as though to tear away some obstacle to the admission of 
 air, while helpless, hopeless agony, is depicted on its countenance. In 
 the midst of these sufferings the patient dies, or coma or convulsions 
 come on, and close the scene. 
 
 It is not always, however, that the last stage of croup is attended by 
 such distressing symptoms. The treatment employed may seem to have 
 mitigated the severity of the disease ; the restlessness may give place 
 to ease, the burning skin may grow moist, the respiration may become 
 tranquil, the cough loose with but little clangor ; expectoration may be 
 easy, and a wheezing, attended with very slight croupy sound may be 
 the only indication of the dangerous disease under which the patient is 
 suffering. This apparent amendment may continue for a few hours, and 
 then be succeeded, without any assignable cause, by the return of all the 
 former symptoms, and soon be followed by death ; or, the mitigation of 
 the disease may be accompanied with great drowsiness, which, however, 
 does not excite alarm, since it is very naturally attributed to the exhaus- 
 tion produced partly by the disease, partly by the remedies. During 
 sleep, the respiration is deep and tranquil, like that of a person in a 
 sound slumber ; it is, indeed, attended by a kind of wheeze, but presents 
 little of the croupy stridor ; and when awake the child is quite sensible, 
 and even cheerful. After a time, however, it becomes difficult thoroughly 
 to rouse him; his pulse grows more rapid, the moisture on his skin 
 changes almost imperceptibly to a cold clammy sweat, and convulsive 
 twitchings of the angles of the mouth occasionally disturb the repose of 
 his features. Silently, but surely, the exudation has been making pro- 
 gress, and when the alarm is taken it is too late ; the stupor deepens, 
 and the child dies comatose, or rouses only to spend its last hours in the 
 vain struggle for breath, and embittered by all the painful circumstances 
 which ordinarily attend the suffocative stage of croup. 
 
 Auscultation yields us information in cases of croup with reference to 
 two important points ; namely, the amount of obstruction to the entrance 
 of air into the lungs, and the extent of disease of the air- tubes or sub 
 
RESULTS OF AUSCULTATION IN ITS DIFFERENT STAGES. 221 
 
 stance of the lungs which accompanies it. At first, air is heard entering 
 the chest freely, and unattended by any morbid sound other than that 
 stridor which is produced in the larynx. If the lungs should continue 
 unaffected, no other morbid sound will be heard ; but, as the disease 
 advances, the same negative results will be obtained from auscultation 
 as are yielded by it in cases of emphysema — a feeble respiratory murmur 
 belying the loud resonance on percussion. Often, however, respiration 
 is attended from the commencement with the sonorous rhonchus of the 
 first stage of bronchitis, though masked to some extent by the croupy 
 noise in the trachea. Even in cases where the disease is originally con- 
 fined to the larynx or trachea, inflammation almost always extends to 
 the bronchi ; often, also, to the substance of the lungs, so that mucous 
 or subcrepitant rale generally becomes perceptible during its course, 
 often attended by impaired resonance on percussion over the lower part 
 of the chest. Air, however, may enter so imperfectly as not to fill the 
 smaller bronchi ; and these sounds may be quite unperceived, unless 
 the auscultator listen at the moment when the child makes an unusually 
 deep inspiration, such as often follows a fit of coughing. The pneumonia, 
 too, in all cases that I have observed, was double, and the resonance 
 consequently nearly equally diminished on both sides of the chest. — 
 Hence the importance of comparing the sound elicited by percussion of 
 the upper with that given out by the lower part of the chest, — a point 
 to which you will remember that your attention has already been called 
 on several occasions. 
 
 The changes in the tracheal sound which attend the progress of the 
 disease may be traced with great distinctness by applying a stethoscope 
 to the larynx. Some writers have thought that they recognised in its 
 variations the indications of the formation of false membrane, and that 
 they also afford a means whereby to judge of its extent. I believe that 
 usually when false membrane has been extensively formed in the larynx, 
 the tracheal sound becomes less stridulous and more sibilant ; but I 
 noticed on one occasion those changes in the tracheal sound which are 
 supposed to indicate the presence of a very extensive deposit of false 
 membrane, although no false membrane was either expectorated during 
 the patient's lifetime, or discovered in the inflamed larynx and trachea 
 after her death. We must conclude, therefore, that the changes in the 
 tracheal sound do not afford absolutely certain evidence of the existence 
 of false membrane, and that still less can they be regarded as safe cri- 
 terions of its extent. 
 
 It is difficult to state with precision the duration of a disease such 
 as croup, since its premonitory symptoms vary greatly, and its fatal 
 termination is often in great measure due to the concomitant or consecu- 
 tive bronchitis or pneumonia. When the laryngeal affection goes on to 
 destroy life, it is seldom that more than forty-eight, or at the most 
 seventy-two, hours elapse from the full developement of the croupal 
 symptoms to the fatal event ; and, allowing the ordinary duration of the 
 premonitory stage to be about thirty-six hours, the disease will be found 
 to run its course in from four to six days. Once I knew death to take 
 place in the case of a little boy, aged 4 years, within thirty-six hours 
 
222 DURATION OF CROUP PROGNOSIS. 
 
 from the occurrence of the first croupal symptoms; but no other 
 instance of equal rapid termination of the disease has come under my 
 own observation. Treatment sometimes partially subdues it; but it 
 returns and the relapse, in the course of a few hours, proves fatal. — 
 Now and then the acute symptoms subside, and the disease assumes a 
 chronic character ; but this has only once come under my notice in 
 idiopathic croup, though it is more common in that form of the disease 
 which we shall have hereafter to notice as constituting a serious compli- 
 cation of measles. 
 
 The prognosis of croup must always be guarded, and is generally 
 unfavourable, since the disease is unquestionably one of the most dange- 
 rous to which childhood is liable. Much depends upon the patient 
 being seen at an early stage of the disease ; and the prospect of recovery 
 is generally very small if no treatment should have been adopted until 
 after the full developement of the symptoms. The presence of bronchitis 
 and, still more, of pneumonia, adds greatly to the dangers of the 
 affection, and would induce us to form a very unfavourable opinion of 
 the chances of recovery. A second attack of croup is generally less 
 serious than the first; and cases in which catarrhal symptoms have 
 preceded the seizure for several days are more amenable to treatment 
 than those in which the premonitory stage has been short, or altogether 
 absent. Diminution of the dyspnoea in the intervals of the cough, — 
 a louder and looser cough, attended with expectoration or vomiting of 
 muco-purulent matter, intermingled with shreds of false membrane, — 
 a less suppressed voice, less anxiety, and less restlessness, — all indicate 
 that the disease is abating. Much caution, however, must be exercised 
 in drawing a favourable conclusion from a diminution of the severity of 
 the symptoms, until such improvement has continued for twenty-four 
 hours at least. In all but the most acute cases of croup the remittent 
 character of the disease is very apparent ; and it is well to bear in mind 
 that the fatal termination usually takes place with extreme rapidity, 
 when an exacerbation of the symptoms follows soon after a manifest 
 remission of their intensity. 1 It can scarcely be necessary to remind 
 you that the extinction of the voice, suppression of the cough, the 
 change from stridulous to sibilant breathing, and increased difficulty of 
 respiration, all shew death to be surely and speedily approaching. 
 
 In no disease is the prompt employment of appropriate treatment 
 more important than in croup, since in none does the use of remedies 
 sooner become unavailing. Even in cases where the attack is merely 
 apprehended, but where catarrh exists, attended with a slight ringing 
 cough, such as often indicates the commencement of croup, the patient 
 should be watched most sedulously, and visited not merely by day-time, 
 but also late in the evening ; and attention should be particularly directed 
 to the character of the respiration during sleep as well as in the waking 
 state. The child should at once be placed in a warm bath, be confined 
 to bed, be placed on a spare diet, and should take an emetic of ipecacu- 
 anha and antimony, to be followed by some mild saline medicine, 
 
 1 "Mox post symptomatum remissioncni recidivantes, brevi ac certa morte dein- 
 untur."— Golis, lib. cit. p. 164. 
 
TREATMENT OF CROUP. 223 
 
 containing slightly nauseating doses of antimonial wine. 1 At the same 
 
 No. 13. 
 
 1 R Potassse Bicarbonatis, gr. xl. 
 Acidi Citrici, gr. xx. 
 Vin. Ant. Pot.-Tart. giss. 
 Vin. Ipecac. Tr^xx. 
 Syr. Limonum, ^iiss. 
 
 Aqua?, ^iiss. M. giij. 3tia vel 4ta quaque bora. 
 For a child two years old. 
 
 time the air which the child breathes should be both warm and moist, 
 the temperature of the room being steadily kept up at 65°, while the 
 moisture of the air is easily maintained, by a kettle boiling on the fire, 
 with a long roll of paper on its spout, which serves to direct the steam 
 into the apartment- These simple precautions, useful in diminishing 
 the irritability of the air-tubes when croup is merely threatened, are, I 
 need scarcely say, of still greater moment when the disease is fully 
 developed. By these precautions, which should be observed with 
 especial care if the premonitory symptoms of croup appear in a child 
 who has previously suffered from the disease, or in whose family a 
 liability to it exists, you may often succeed in warding off the attack. 
 A far more energetic plan must be resorted to if the disease set in 
 with violence, or if the indications of its approach having been either 
 overlooked or unchecked, the symptoms should have attained their full 
 development before the patient came under your notice. The abstrac- 
 tion of blood, and the administration of tartar emetic, are the two mea- 
 sures on which your main reliance must be placed ; and you must bleed 
 largely, and give tartar emetic freely, remembering that if relief do not 
 come soon it will not come at all, — that there is not danger only, but 
 death, in delay. I have never met with an exception to the rule which 
 prescribes the free abstraction of blood in every case of severe idio- 
 pathic croup, when seen at an early period, and before the purple lips 
 and livid countenance, and failing pulse, announce the long continu- 
 ance of a serious obstacle to the free admission of air into the lungs. 
 Even in very young children local depletion forms in these cases but a 
 poor substitute for general bleeding, for it is not merely the abstraction 
 of a certain quantity of blood that is needed, but its removal in such a 
 manner as most speedily to produce an effect on the system. Bleed- 
 ing from the jugular vein is preferable under these circumstances to 
 venesection in the arm, since the latter often fails in children under 
 three years old ; and the blood never flows so freely as when taken 
 from the jugular vein. It is not easy to state in figures the exact 
 quantity to be abstracted, since the child's previous health, the inten- 
 sity of the symptoms, and the effect produced by the flow of the blood, 
 must all be taken into account in determining when to stop. Dr. 
 Cheyne says " The removal of three ounces of blood from a child be- 
 tween one and two years of age, or of six ounces from a child from eight 
 till ten, generally appears to make a sufficient impression on the dis- 
 ease ;" and this is a sufficiently near approach to a correct estimate of 
 
224 DEPLETION. 
 
 what is usually needed. The effect of free venesection is often very 
 striking, and as the blood flows, the respiration may be seen to become 
 notably easier. But though the relief thus afforded is very great, it 
 proves but temporary ; and unless followed by other remedies, the 
 symptoms will often regain their former intensity in the course of four 
 or six hours. I have not seen any instance in which the repetition of 
 general bleeding appeared indicated, but many of you will probably 
 meet with such cases in the country. Local depletion I have occasionally 
 employed with advantage a few hours after the general bleeding ; but 
 if you follow up the first loss of blood by the free employment of tartar 
 emetic, you will often be spared the necessity for further depletion. It 
 has been recommended that leeches should be applied to the top of the 
 sternum rather than to the windpipe, since difficulty may be experienced 
 in arresting their bleeding if applied in the latter situation, as children 
 are very intolerant of pressure in that neighbourhood. The caution is 
 worth bearing in mind ; but if you superintend the application of the 
 leeches yourselves, which in such a case you certainly ought to do, the 
 advantage of drawing the blood as nearly as possible from the affected 
 part will more than make up for the risk of some slight difficulty in 
 stopping its flow. 
 
 To accomplish any real good by means of the tartar emetic it must 
 be given in doses of an eighth, a quarter, or half a grain every ten 
 minutes until vomiting is produced ; and the same doses should after- 
 wards be continued every half hour, until decided and permanent relief 
 has been afforded. The dose that at first caused vomiting, may, after 
 it has been repeated a few times, cease to excite it, in which case we 
 must increase it, and not rest satisfied with tolerance of the medicine 
 having been established, since its utility appears to be closely connected 
 with its emetic power. Nauseating doses of antimony have not seemed 
 to me to check the disease so surely, while they cause a greater de- 
 pression of the system, and thus mask the approach of the fatal event. 
 A striking illustration of the superiority of emetic over nauseating 
 doses of medicine is given by M. Valleix,* who states that in thirty-one 
 out of fifty-three cases of true croup, ipecacuanha and antimony were 
 employed in full doses as emetics, and of these thirty-one cases fifteen 
 recovered ; while of the twenty-two cases in which their use was but 
 sparingly resorted to, only one recovered. 
 
 If after antimony has been thus administered for four or six hours, 
 no satisfactory measure of improvement should have appeared, local 
 depletion may be resorted to ; or possibly a repetition of general 
 bleeding may in some cases be ventured on. If the croupal symptoms, 
 on the other hand, should have begun to abate, the antimony may be 
 given at longer intervals ; but you cannot be too much on your guard 
 against being misled by temporary improvement, and abandoning the 
 medicine too soon. Its use likewise is not to be relinquished by 
 gradually diminishing the dose and substituting a quantity sufficient 
 only to induce nausea for that which caused vomiting, but a full dose 
 should be given every hour or two hours, instead of every half hour, 
 
 1 Bulletin G6n6ra\e de Thdrapeutique, Oct, 1843, p. 246. 
 
ADMINISTRATION OF MERCURY. 2LO 
 
 and if amendment continue, the interval may be prolonged to three, 
 four, or six hours. It is now, after the severity of the disease has been 
 subdued by antimony, that the time has come for the administration of 
 calomel. From the very commencement of the attack, mercurial 
 inunction may be had recourse to every two or three hours : but the 
 action of mercurials is far too slow to overtake a disease which tends 
 so rapidly to a fatal issue. At this period, however, calomel seems to 
 have a two-fold utility ; it counteracts the tendency to the formation of 
 false membrane in the air-passages, and prevents or subdues that 
 inflammation of the lungs which is so frequent and so fatal a compli- 
 cation of the disease. I usually employ it in doses of half a grain or 
 a grain in children from two to five years old every hour or two hours, 
 in combination with minute doses of ipecacuanha, but interrupting its 
 use at intervals in order to give an antimonial emetic. The appearance 
 of any exacerbation of the croupal symptoms, however, would lead me 
 at once to discontinue the calomel, and to return to the emetic employ- 
 ment of antimony. 
 
 There is, however, one point which it is important to remember in 
 the management of the severer cases of croup, lest you fall into the 
 error of over-treating your patient ; an error not less hazardous than 
 the opposite one of too great inertness. The disease, as you know, 
 has a marked tendency to exacerbations and remissions, even inde- 
 pendently of any physical change in the condition of the respiratory 
 organs. You must not, therefore, allow 'the return of more difficult 
 breathing, after a period of comparative tranquillity, to lead you at 
 once to the inference that the child is worse, and that necessity exists 
 for renewed and increased activity of treatment. It is very possible 
 that the increased dyspnoea may be merely spasmodic ; that immersing 
 the child in a hot bath will give immediate and most signal relief; and 
 that if you auscultate the chest afterwards you will find the air entering 
 the lungs in as large a quantity as before, and unattended by any 
 increase of morbid sounds. 
 
 The administration of calomel is not necessary in every case of croup, 
 for when seen early and treated with due activity, its symptoms are 
 sometimes completely removed in the course of a few hours. But 
 though we may sometimes be warranted in suspending all active 
 treatment for a season, yet we must watch our patient with most 
 untiring care for some days after the decline of the acute croupal 
 symptoms, and at each visit, our attention must be directed to the 
 condition of the lungs, in order that we may at once put a stop at its 
 very commencement to that inflammation of the smaller bronchi and of 
 the pulmonary substance which so often disappoints the fairest pros- 
 pects of recovery. Its treatment does not differ from that of ordinary 
 bronchitis or pneumonia, except that depletion is not generally indi- 
 cated, and that it not infrequently becomes necessary to support the 
 patient's strength, even from a very early period. 
 
 Your own good sense will suggest to you the care and watching which 
 are required during convalescence from croup ; the necessity of with- 
 drawing your remedies cautiously, and of awaiting the complete 
 disappearance of all hoarseness and cessation of all cougb, before you 
 
 15 
 
226 TREATMENT OF CROUP. 
 
 allow the child to breathe the external air. In cases where the 
 peculiar croupal sound continues with slight cough, long after every 
 other sign of mischief about the larynx has subsided, you will often 
 find it of service to paint the neighbourhood of the windpipe every day 
 with the Tincture of Iodine ; a mild, but under the circumstances very 
 efficacious, form of counter-irritation. 
 
 It still remains for us to inquire into the treatment of cases in which 
 we have not the good fortune to encounter the disease at its outset, but 
 in which we have to combat it when it has already reached the 
 second stage. 
 
 This subject, however, must be reserved for our next lecture. 
 
 LECTURE XX. 
 
 Croup continued, — treatment of the more advanced stages of the disease — tracheotomy 
 — the difference between the results obtained by it in England and France, and 
 its probable cause — objections to its performance — reasons for not regarding them as 
 conclusive. 
 
 DiPHTHEEiTis, or Croup with affection of the fauces, — less frequent and less marked in 
 this country than in France — its symptoms when it occurs alone — oftener follows 
 some other disease, especially measles — its symptoms — treatment of both forms. 
 
 Laryngitis stridula, or Croup with predominance of spasmodic symptoms — not a 
 distinct disease, but results from constitutional peculiarity — illustrative case. 
 
 Instances of spasmodic cough and affection of larynx, from irritation in lungs — 
 intestines — brain. 
 
 In the last lecture we were occupied with the consideration of the 
 management of those cases of croup in which the patient is seen early, 
 and in which his condition warrants the employment of powerful anti- 
 phlogistic measures. He may, however, be seen too late for such means 
 to be allowable, or they may have been tried in vain. If antimony 
 cease to vomit, or if it be rejected immediately and without effort, the 
 fluid thrown up being unmixed with phlegm or false membrane, while 
 the temperature sinks, the lips grow more livid, the pulse becomes more 
 frequent and feeble, and the paroxysms of dyspnoea are undiminished 
 in severity ; or if the respiration, though less laborious, be attended 
 with a sibilant instead of a stridulous sound, it is evident that by con- 
 tinuing the medicine we may destroy the patient, but shall fail to cure 
 the disease. A totally different plan of treatment must at once be 
 adopted, though with but slender hope of success. 
 
 An attempt must be made to arouse the child from the state of col- 
 lapse into which it is sinking, by placing it for a few minutes in a hot 
 mustard bath, and emetics of the sulphate of copper should at once be 
 administered. The sulphate of copper has been considered by some 
 writers to be possessed of a specific influence over croup. I cannot, 
 however, take this view of its action. It has seemed to me to be nothing 
 more than an emetic of great power, and therefore especially applicable 
 in cases where considerable depression exists, where the stomach has 
 
TREATMENT OF THE ADVANCED STAGE OP CROUP. 227 
 
 consequently lost much of its irritability, and where tartar emetic would 
 probably not act at all, or if it did would be injurious from its depress- 
 ing action. Alum has been recommended under similar circumstances, 
 and I dare say would answer equally well, though perhaps there is 
 some advantage in the smaller bulk of the sulphate of copper. 1 I am 
 accustomed to give it dissolved in water in quarter or half-grain doses 
 every quarter of an hour till free vomiting has been produced, but have 
 never trusted to it alone, in the same way as in an earlier stage of the 
 disease I am used to rely on tartar emetic. I employ it with a two- 
 fold purpose: first, to obtain the stimulant action of an emetic; second, 
 to prevent if possible the accumulation of false membrane in the larynx. 
 Hence, if the child seem again sinking into a state of collapse, or if 
 coma appear coming on, or if the dyspnoea become much aggravated, 
 the sulphate of copper may again be employed to induce vomiting. If, 
 however, in these cases, or in others in which, though some degree of 
 improvement has followed the previous treatment, yet the child has 
 been much reduced by it, emetics should not act, I would not advise 
 you to attempt to compel vomiting by irritating the fauces or other 
 similar proceedings. On one occasion I saw these endeavours followed, 
 not by the vomiting, which they were intended to excite, but by general 
 convulsions, followed by a comatose condition, in which death took 
 place an hour and a half afterwards. Examination of the body dis- 
 covered some congestion of the brain, but shewed at the same time that 
 the affection of the air-passages had not reached such a degree as to 
 have precluded the possibility of recovery, and that the patient's death 
 had been caused not by the disease, but rather by the ill-judged 
 employment of a remedy. 
 
 In this stage of croup the decoction of senega is a medicine of great 
 value, and may be given in combination with the carbonate of ammonia 
 and tincture of squills, every two hours. 2 The pungency of the ammonia 
 is best concealed by sweetening the medicine with treacle or coarse 
 sugar, and mixing it with about a third of milk; and in this form 
 children will seldom refuse it. No other remedy or combination of 
 remedies has appeared to me to be so useful as a stimulant expectorant 
 in the advanced stages of croup or bronchitis. The patient's strength 
 must be supported by beef-tea, and a generally nutritious diet ; and 
 even wine may be indicated; though small, indeed, are the hopes that 
 remain when the vital powers have sunk so low as to require its employ- 
 ment. While by these means you try to keep your patient alive, there 
 is still one remedy that you may use, and use actively, though I fear 
 it must be admitted with no great prospect of success. You employ 
 mercury, or you increase the dose in which you have previously been 
 giving it. A grain of calomel may be given every hour to a child from 
 two to three years old, unless the existence of profuse diarrhoea should 
 
 1 Alum has been used and strenuously recommended under these circumstances by 
 Dr. Meigs of Philadelphia ; and the experience of his son, Dr. J F. Meigs, as recorded 
 in his work on Diseases of Children, seems fully to bear out his father's recommendation. 
 He gives a teaspoonful in honey or syrup, every 10 or 15 minutes, till free vomiting is 
 produced. 
 
 2 See Formula No. 12, p. 190. 
 
228 COUNTER-IRRITATION — BRONCHOTOMY. 
 
 contraindicate its use ; while, at the same time, a drachm of strong 
 mercurial ointment may be rubbed into the thighs every two hours. If 
 diarrhoea be present, the calomel must be given more sparingly, or 
 even altogether omitted. 
 
 Much difference of opinion prevails among writers of high repute as 
 to the proper time for employing counter-irritation in cases of croup, 
 and still more as to the part to which this counter-irritation should be 
 applied. I believe that when the disease has been checked by anti- 
 phlogistic measures, and the symptoms have lost something of their 
 severity, much good is done by the application of blisteis to the upper 
 part of the sternum. But, on the other hand, if croup have reached 
 an advanced stage, unchecked by previous remedies, blisters to the 
 sternum have seemed to me nearly, if not altogether, useless ; while, 
 from the application of a large blister to the throat, covering the larynx 
 and reaching down nearly to the sternum, I have often observed the 
 paroxysms of dyspnoea to be much alleviated, the respiration rendered' 
 far more easy, and expectoration for the first time accompanying the 
 cough. In any case, if very manifest relief were not observable within 
 six hours after the abstraction of blood and the administration of anti- 
 mony, while further depletion did not appear justifiable, I should apply 
 a blister to the throat. 1 
 
 It was to be expected that the probable utility of bronchotomy in cases 
 of croup should suggest itself to the earliest observers of the disease. 
 For many years, however, after it was first advocated on theoretical 
 grounds by Dr. Home, the value of the operation was not put to the test ; 
 and even for a long time after it had been tried, but one instance was 
 recorded of any other than an unsucccessful result. 2 In the year 1825, 
 M. Bretonneau, of Tours, saved the life of a little girl when in the last 
 stage of croup, by performing tracheotomy ; and the operation has since 
 then been performed more than 150 times, and rather more than a fourth 
 of the patients who underwent it recovered. By far the greater number 
 of these successful cases occurred in France, while in England the result 
 of almost every instance of the performance of tracheotomy in cases of 
 croup has been so unfavourable, that the operation is scarcely looked 
 on as a justifiable proceeding. The great discrepancy of opinion between 
 French and English practitioners, with reference to the value of tracheo- 
 tomy in croup, is without doubt, in a great measure due to the very 
 different character which the disease presents in the two countries. In 
 France, croupal symptoms are induced in the majority of cases by the 
 extension to the larynx of false membrane originally deposited on the 
 fauces and soft palate, while the windpipe itself is comparatively seldom 
 in a state of active inflammation, often altogether unaffected ; and the 
 
 1 This opinion being opposed to that of men such as Dr. Stokes and Mr. Porter, I 
 feel it necessary to appeal in support of it to the authority of Golis, lib. cit. p. 118, and 
 Albers, De Tracheitide Infantum, p. 127 ; and not to rest it solely on the results of my 
 own experience. 
 
 2 In this case, the operation was performed in the year 1782 by the late Mr. Andre, 
 of London, on a little girl live years old. The particulars are related in a dissertation, 
 published at Leyden in 1786, by Dr. T. White, whence they are extracted by Dr. Fai-re, 
 and appended as a note to a paper of his on Croup, at page o38 of vol. iii. of the 
 Medico-Chirurgical Transactions. 
 
TRACHEOTOMY IN CROUP. 229 
 
 bronchitis and pneumonia, which in this country so often and so seriously 
 complicate the disease, are there of less common occurrence. In esti- 
 mating the results of tracheotomy in France, it must likewise be borne 
 in mind that in many instances the operation was performed on patients 
 whose disease would probably have been amenable to other treatment, 
 and that in some cases the trachea was opened without the previous 
 adoption of any treatment whatever, and quite in the early stage of the 
 affection. 1 But though we cannot infer that all the patients on whom 
 tracheotomy was performed would have died if the operation had not 
 been resorted to, these cases of premature tracheotomy at least prove the 
 operation to be of itself unattended with very serious danger ; while it is 
 quite conceivable that the relief afforded by it to that spasmodic action 
 of the muscles of the glottis, which endangers the patient's life more 
 than the mere extent of false membrane in the air-passages, may contri- 
 bute, in a most important degree, to arrest the advances of the disease. 
 But whatever might be the result of the very early performance of 
 tracheotomy, such a proceeding would be practicable only in a hospital ; 
 and we must base our conclusions, with reference to the operation, on a 
 due consideration of the circumstances under which alone we are likely 
 to have the opportunity of performing it. " There is," as Dr. Stokes 2 
 has truly observed, " always that kind of feeling connected with a surgical 
 operation in acute diseases, which prevents its being proposed, assented 
 to, or performed, unless under nearly desperate circumstances, and when 
 all other means have failed. In the case before us, the operation is per- 
 formed at a time when the situation of the patient is the worst possible 
 for success; when the nervous system has been profoundly injured, and 
 the lungs, even though no primary complication may have existed, have 
 become extensively congested." Among my-patients at the Children's 
 Dispensary, I have never had recourse to the operation ; partly for the 
 reasons stated by Dr. Stokes, partly because it would have been impos- 
 sible in the houses of the poor to command that constant attention and 
 minute care which are absolutely essential to the success of tracheotomy, 
 even when everything in the patient's condition concurs to warrant its 
 performance. Recently, Mr. Arnott performed tracheotomy, at my 
 request, on a boy aged twenty-one months, who was admitted into the 
 Middlesex Hospital in the last stage of croup, which had succeeded to 
 measles, and which had been allowed to advance without any remedy 
 being employed to check it. In this instance life was prolonged for forty 
 hours after the operation, and the ingress and egress of air through the 
 canula continued free to the last ; but the child's pulse began to grow 
 more frequent and feeble after the lapse of little more than twelve hours, 
 and his respiration became at the same time hurried and laborious, 
 and continued increasingly so until death took place. This being the 
 only instance in which I have had the windpipe opened for the relief 
 of the symptoms of croup, it is not in my power to lay down any 
 
 1 In illustration of this fact two cases may be noticed, recorded in the Journal de la 
 Societe M6dicale d'Inde et Loire, extracted and commented on in the Bull. Gen. de 
 Tiierapeutique, October, 1842. 
 
 2 On Diseases of the Chest, 8vo. p. 220. Dublin, 1837. 
 
230 ARGUMENTS AGAINST THE OPERATION. 
 
 definite rules with reference to the time or manner of performing the 
 operation. 
 
 But though I have had almost no experience of tracheotomy in croup, 
 yet it is impossible to have closely watched many cases of that disease 
 without thinking much and anxiously upon the question of performing 
 an operation for its relief. Among the arguments against it, there are 
 two to which the chief importance has been attached. One of these is 
 founded on a statement of Dr. Cheyne's that three-eighths of the aper- 
 ture of the larynx have been found free in fatal cases of croup, and that 
 consequently there must have existed during life room enough for the 
 entrance of air. The other is derived from the condition of the bronchi, 
 which, while comparatively seldom free from disease before the operation, 
 generally, as is alleged, become the seat of increased and more rapidly 
 fatal inflammation after its performance. With reference to the former 
 of these arguments, however, I apprehend that bronchotomy is not per- 
 formed merely on the mechanical principle of removing from the windpipe 
 a quantity of matter which prevents the entrance of air into the lungs ; 
 but that it is done rather to obviate the dangers of that spasm of the 
 glottis which the inflammation occasions, and which will not cease until 
 either the inflammation is subdued, or the spasm relaxes with the 
 approach of death. Even the narrow opening made into the trachea — 
 often much narrower than the aperture of the larynx, though diminished 
 by swelling or encroached on by false membrane — suffices for a time, at 
 least, to admit all the air which the patient needs, and the dyspnoea is 
 relieved. The inflamed larynx is now at rest, while the air entering 
 continuously, and without effort, duly oxygenates the blood ; and the 
 child is thus placed in a condition in which all remedial agents would 
 seem much more likely to tell upon it, than when it was in a state of 
 impending suffocation. But then this promise of amendment too often 
 is but delusive : the relief is of only short duration ; the breathing once 
 more becomes difficult, and death takes place under symptoms of the 
 same kind as existed before the operation, though attended with rather less 
 distress. A measure of euthanasia, then, is all that in many cases is 
 obtained by tracheotomy ; while, in the opinion of many, the previous 
 bronchitis is much increased by its performance, and the patient's death 
 thus accelerated. Last year, however, when conversing with M. Trousseau, 
 at Paris, on the subject of tracheotomy, he suggested another reason for 
 the relapse which so generally follows even the most encouraging tem- 
 porary improvement. Tracheotomy fails, in his opinion, in great measure 
 because the opening made into the air passages is too small ; air is 
 admitted enough to afford temporary relief, but not enough for the 
 permanent discharge of the functions of the organism : the return of 
 hurried breathing, the reappearance of the livid hue of the surface, 
 betoken the imperfect depuration of the blood. Take a quill, and 
 closing your nostrils, endeavour to breathe entirely through it : at first 
 you breathe easily enough, but soon your respiration becomes laborious ; 
 and at length you are fain to throw away the quill, and with open mouth 
 once more to fill your lungs completely. Now, precisely this, says M. 
 Trousseau, is what happens when an opening of inadequate size is made 
 into the trachea ; air enters readily, and without the interruption which 
 
TRACHEOTOMY IN CROUP — ARGUMENTS AGAINST IT. 231 
 
 the spasm of the glottis occasioned; but it does not enter in sufficient 
 quantity, and hence the return of the symptoms, and the patient's death. 
 Acting on this principle, he always makes a much larger opening into 
 the trachea, and introduces a much larger canula, than the majority of 
 surgeons; and I mention his opinions and practice, because I think they 
 well deserve your consideration. 
 
 But, now, with reference to the second objection, — the uncertainty of 
 the extent to which inflammation of the air-tubes, with possible forma- 
 tion of false membrane, have already extended, and the dangers of 
 aggravating the already existing bronchitis. It is not possible, I believe, 
 to determine during life the extent to which false membrane may have 
 reached, nor at all easy to estimate the amount of bronchitis ; while, 
 against the risk of aggravating it, by tracheotomy, we must weigh on 
 the other hand the evils of spasm of the glottis, and the effects of 
 unaerated blood circulating through the vessels, if we leave the case 
 alone. Moreover, while M. Trousseau's explanation of the return of 
 dyspnoea after the operation may be received as accounting for a part 
 at least of what has generally been attributed altogether to the bronchi- 
 tis, it must not be forgotten that in the vast majority of cases the delicate 
 mucous membrane of the bronchi has been exposed to immediate contact 
 with the cold air of the ward of a hospital, or of a large chamber, — a 
 want of precaution to which it is probably not unfair to attribute a 
 large share in the excitement or aggravation of the secondary bronchial 
 inflammation. 
 
 It appears to me to be worth consideration, how far the careful 
 regulation of the temperature of the apartment, and of the condition as 
 to heat and moisture of the air respired by the patient — to the import- 
 ance of which, even in the early stages of the disease, I have already 
 referred — might diminish the hazard of bronchitis after the operation. 
 And, secondly, it may merit inquiry whether there be any difference to 
 be expected between the result of tracheotomy in cases of sthenic croup, 
 such as formed the basis of Dr. Cheyne's observations, in which false 
 membrane was very extensively deposited, — and in cases of a more 
 asthenic character, such as the chief of those were that came under my 
 notice among the poor in London, in which the deposit of false mem- 
 brane was very limited, and the larynx was the chief, sometimes the 
 exclusive, seat of the disease. 
 
 Perhaps, now, I have said too much upon this subject, seeing that I 
 have been dealing rather with theories than facts, — suggesting doubts 
 and propounding questions, rather than laying down positive rules; 
 but yet I thought it might not be useless if I stated to you the circum- 
 stances that make me hesitate in expressing a decided opinion against 
 tracheotomy, and that prevent me from joining at present in the un- 
 qualified condemnation of the operation in cases of croup, which has 
 been pronounced by the greater number and the most weighty of 
 English authorities. 
 
 I have endeavoured hitherto to direct your attention more especially 
 to that form of croup which is of most frequent occurrence in this 
 country, and in which the affection of the air-tubes is a primary idio- 
 pathic disease, calling for active antiphlogistic treatment. There is, 
 
232 DIPHTHERITIS. 
 
 however, another form of the disease, in which the laryngeal affection 
 is connected with inflammation of the tonsils, soft palate, and fauces, 
 and the deposit of false membrane upon them ; and in many of these 
 cases the affection of the air-passages is evidently a secondary occur- 
 rence. The symptoms attending this variety of croup generally present 
 more or less of an asthenic character ; and corresponding modifications 
 must he made in the treatment. In England this form of croup is com- 
 paratively rare ; when it does occur, it is in crowded cities much oftener 
 than in the country. 'The influence of unfavourable hygienic conditions 
 in predisposing to it is well illustrated by the statement of M. Guer- 
 sent, that the number of croup cases in the H6pital des Enfans Malades 
 has become greatly diminished since the wards have been less crowded 
 with patients, and since other means have been adopted calculated to 
 promote the health of the inmates. Another strong proof of the influ- 
 ence of causes unfavourable to health in inducing some varieties of 
 croup, is afforded by a further statement of the same writer, that the 
 greater number of cases of croup in the Parisian hospitals have super- 
 vened in patients who were already in those institutions for the cure of 
 other diseases. 
 
 In country districts, unfavourable influences of a different kind seem 
 to predispose to its occurrence. It is in those regions of France which 
 are damp and ill-drained that it presents itself in its most aggravated 
 forms, and there, has not infrequently assumed an epidemic character, 
 and proved extremely fatal. In several instances such epidemics have 
 broken out on the subsidence of an inundation ; but at other times it 
 has not been possible to assign any reason for the sudden appearance 
 of the disease in an epidemic form in neighbourhoods where for many 
 years it had been unknown. 
 
 In this country it seldom, if ever, assumes those formidable charac- 
 ters which have often marked it on the Continent, where the inflamma- 
 tion of the tonsils and pharynx have been very severe, and the forma- 
 tion of false membrane has not been limited to the fauces, but has 
 occupied a great part of the mouth, and reached far down into the 
 pharynx, as well as extending upwards into the nostrils. I cannot at 
 all account for this difference between the disease in the two countries ; 
 but the mere extent of the false membrane does not seem to me to 
 furnish any ground for supposing there be an essential difference 
 between the affection described under the name of diphtheritis by M. 
 Bretonneau, and other French writers, and that in which, with a much 
 more limited deposit of false membrane, there has yet seemed to be the 
 same connection between the disease of the throat and the air-passages. 
 
 This form of croup has come under my notice under two different 
 conditions, — either as an idiopathic affection, or as a complication of 
 some other malady ; the latter much more frequently than the former. 
 In those cases where it has appeared as an idiopathic affection, slight 
 febrile disturbance, and general disorder of the health, have usually 
 preceded the local symptoms for some days. By degrees, slight cough 
 comes on, often associated with catarrhal symptoms, and attended with 
 considerable drowsiness and heaviness of the head, and sometimes with 
 slight difficulty of deglutition. The cough next assumes the loud 
 
DIPIITnERITIS SOMETIMES AN IDIOPATHIC AFFECTION. 233 
 
 clangose character of croup, and stridor becomes perceptible with the 
 respiration. If the throat be examined, the fauces, soft palate, and 
 tonsils, will usually be found either universally red, or streaked and 
 spotted of a dark red colour. This condition is generally best marked 
 on the tonsils, the under part of the velum, and the uvula, and is in 
 most instances attended with but little tumefaction. Specks of false 
 membrane, of a dead white or greyish-white colour, next appear on the 
 inflamed surfaces. I have seldom seen these deposits of false mem- 
 brane become confluent, and never found them extend up into the 
 mouth, even though the life of the patient had been seriously endan- 
 gered by their extension to the larynx, while in many instances the 
 affection of the throat maybe altogether overlooked if care be not taken 
 to depress the root of the tongue sufficiently to obtain a thoroughly 
 good view of the fauces. When once the larynx has become affected, 
 the symptoms are in the main the same as attend on the other form of 
 croup, but there is less of that constitutional reaction which we observe 
 in acute inflammation of important organs. The fever generally pre- 
 sents throughout much of an adynamic character ; the drowsiness is 
 often very considerable ; and, if the case be neglected, the fatal termi- 
 nation may come on very speedily, without being ushered in by that 
 urgent dyspnoea and those violent efforts to obtain air which attend 
 most cases of cynanche trachealis. On the other hand, these cases 
 occasionally run a somewhat chronic course. The employment of 
 emetics having detached^ the false membrane, and the local application 
 of caustics having for a time prevented their reproduction, the croupal 
 symptoms diminish or altogether disappear; but a premature suspen- 
 sion of the treatment is soon succeeded by a return of the dangerous 
 symptoms of the disease ; and hence in this, not less than in the other 
 form of croup, it behooves us to be most sedulously on the watch for 
 any indications of returning mischief. 
 
 It is not as an idiopathic affection that this form of croup has come 
 most frequently under my notice, but as a most dangerous complication 
 of some other disease, almost always of measles. Under these circum- 
 stances it frequently disappoints the most well-founded hopes of our 
 patient's recovery ; sometimes running its course very rapidly, and at 
 other times so insidiously that nothing but the greatest care will secure 
 us against overlooking this most fatal malady. 
 
 This variety of croup seldom begins until the eruption of measles is 
 on the decline, or the process of desquamation has commenced. Its 
 occurrence is most frequent from the third to the sixth day from the 
 appearance of the eruption, but it often occurs at a later, than at an 
 earlier period. It is sometimes attended with well-marked svmptoms 
 from the very first, but it often happens that the character of the 
 disease is masked, and its course insidious, and that the degree of 
 suffering during life affords no correct index to the amount of mischief 
 which may be revealed by a dissection after death. Of itself, it is 
 highly dangerous, and its hazard is increased by the frequent coex- 
 istence with it of inflammation of the lungs, which serves moreover to 
 throw the symptoms of croup into the shade. When the laryngeal 
 affection comes on three or four days after the appearance of measles, 
 
234 DIPHTHERITIS AS A COMPLICATION OF MEASLES. 
 
 its presence is usually betokened by much more obvious symptoms than 
 when it occurs after the lapse of a longer period from the febrile attack. 
 Sometimes, however, it develops itself unnoticed, simultaneously with 
 the measles, and causes a fatal issue when the medical attendant is 
 least prepared to expect it. The child in such cases is evidently more 
 seriously ill than can be accounted for by the mere existence of 
 measles ; but he makes no definite complaint, neither are there any 
 obvious indications of the special suffering of any particular organ. 
 There are considerable drowsiness, disinclination to swallow, and reluc- 
 tance to speak ; but the cough may be very slight, and the respira- 
 tion free from distinct croupy stridor, while the child speaks in so low 
 a tone that it is almost impossible to appreciate any alteration of the 
 voice. Under such circumstances, the most careful observation is 
 needed to avoid error. The loss of voice should of itself direct atten- 
 tion to the state of the larynx ; the cry should be listened to atten- 
 tively ; pressure should be made on the larynx, to ascertain whether 
 much tenderness exists, and examination of the fauces should never be 
 neglected. 
 
 But little less obscure, and of much more frequent occurrence, are 
 those instances in which the laryngeal affection attends the process of 
 desquamation. Recovery up to a certain point had probably gone on 
 well, when, sometimes with, sometimes without an increase of the 
 cough and morbillous catarrh, the febrile symptoms become exacerbated, 
 and the child droops again, apparently without any adequate cause. 
 Sometimes a loud sonorous cough, succeeded or accompanied by altera- 
 tion of the respiratory sounds, betrays the nature of the disease ; but 
 at other times there are no symptoms besides unusual drowsiness, 
 reluctance to speak, or alteration in the tone of the voice, with disin- 
 clination to swallow, or difficulty in the act of deglutition. In many 
 instances deglutition is scarcely at all impeded ; and I remember only 
 one case in which the difficulty of swallowing was so great that the 
 fluids returned by the nose. But even though these symptoms be but 
 slight, it will usually be observed, on examining the mouth, that the 
 gums have a spongy appearance, or are actually ulcerated ; that the 
 tongue is preternaturally red and raw, and that small aphthous ulcers 
 have formed upon its edges, and on the lining membrane of the mouth. 
 The soft palate will usually be seen to be red and swollen, and specks 
 of false membrane will be observed on the velum or tonsils. In such 
 a case, if it terminate fatally, the duration of life is very variable ; 
 though the disease, for the most part, runs a somewhat chronic course. 
 The child's strength declines daily, and emaciation makes rapid pro- 
 gress ; yet no acute symptoms appear. There is great restlessness, 
 and no posture seems easy to the child ; or else it sits constantly 
 upright in bed, distress and dyspnoea following any attempt to place 
 it in the recumbent position. The alteration of the voice is succeeded 
 by complete aphonia, the frequent hacking cough which had previously 
 caused much annoyance, ceases altogether ; and although evidently 
 thirsty, the child often refuses drink, or swallows with difficulty. 
 Diarrhoea, or pneumonia, usually supervenes, and hastens death, though 
 in some instances exacerbation of the croupal symptoms, coupled with 
 
MORBID APPEARANCES — TREATMENT. 235 
 
 the increasing weakness of the child, are the only causes of the fatal 
 termination. 
 
 On examining after death the bodies of children who have died of 
 this affection, not only is the mucous membrane of the mouth found 
 inflamed and ulcerated, but the soft palate, fauces, epiglottis, and the 
 upper part of the pharynx, are seen to be more or less intensely con- 
 gested, and coated more or less extensively with false membrane. 
 Once I observed false membrane to have reached from the pharynx for 
 a short distance into the oesophagus ; and on another occasion I found 
 the oesophagus lined by a complete tube of false membrane, which had 
 extended to within an inch of the cardiac orifice of the stomach ; but 
 I have never seen the interior of that viscus occupied by a similar pro- 
 duction, though that would seem, according to the experience of French 
 writers, not to be a very unusual occurrence. The epiglottis is often 
 ulcerated on both its surfaces, and partially coated with false mem- 
 brane ; and the mucous membrane of the larynx is generally eroded by 
 numerous small ulcerations, as well as covered with a similar deposit. 
 I have in no instance observed false membrane extending below the 
 larynx ; and although the trachea is usually congested, sometimes 
 intensely so, yet this is by no means of invariable occurrence. Bron- 
 chitis and pneumonia, especially the latter, are frequent complications 
 of this affection. 
 
 Under whatever circumstances this form of croup may occur, — 
 whether as an idiopathic malady, or as a sequela of measles or of some 
 other disease, — it is generally attended with so great a depression of 
 the vital powers as to contraindicate the employment of active anti- 
 phlogistic treatment. When it occurs as an idiopathic affection, I have 
 occasionally applied leeches to the throat if there was much tenderness 
 about the larynx, or if the croupy symptoms had early acquired considera- 
 ble intensity ; but the two means on which I place my chief reliance are the 
 careful and repeated cauterization of the fauces, and the employment 
 of emetics. If the deposit of false membrane be extensive or the 
 ulcerations about the tonsils present anything of a sloughy character, 
 the strong hydrochloric acid, diluted with twice or thrice the quantity of 
 honey, is the best application to the fauces. In most instances, how- 
 ever, a solution of a scruple of nitrate of silver in an ounce of distilled 
 water, applied by means of a sponge or a piece of soft rag fastened on 
 a small portion of whalebone, answers every purpose. A probang 
 contrived by Dr. Horace Green, of New York, 1 the sponge attached to 
 which is sufficiently small to enter the glottis of the child, answers 
 extremely well for this purpose. By means of it he has applied a 
 solution of 9ij. of Argent. Nitrat. dissolved in an ounce of water, not 
 merely to the back of the throat and the neighbourhood of the glottis, as 
 many French physicians have done before him, but also carries the 
 sponge into the interior of the larynx itself. This proceeding, too, 
 
 1 Observations on the Pathology of Croup, &c., 12mo. New York, 1849. The 
 adoption of somewhat similar proceedings by MM. Bretonneau, Trousseau, and 
 Gerouard, does not seem to me sufficient to justify the very grave charge of plagiarism 
 brought against Dr. Green by one of his countrymen, in the American Journal of 
 Medical Science, Jan. 18-49. 
 
236 TREATMENT OP DIPHTHERITIS. 
 
 repeated every two to every six hours, according to the urgency of the 
 case, has been followed in some apparently desperate cases by the 
 patient's recovery. I have employed it but once, though that case 
 quite satisfied me of the possibility of cauterizing the interior of the 
 larynx, and even of the absence of any considerable difficulty in 
 accomplishing it. The case was in many respects an unfavourable one, 
 and I cannot say that the fatal termination which took place within 
 24 hours from the first well-marked croupal symptom was at all 
 retarded by it. It was practised twice ; the child having been very 
 freely depleted within six hours from the commencement of the disease, 
 but without any improvement. The first cauterization did not produce 
 much effect ; the second, two hours afterwards, was followed by marked 
 relief to the respiration, and by restoration of a clear instead of the 
 previously muffled voice, — an amendment which, however, was not of 
 long duration. I purpose trying it again in the next case of asthenic 
 croup, whether idiopathic or secondary, that comes under my notice. 
 
 At the same time that I adopt these local measures I employ the 
 tartar emetic in the same manner as in cases of simple cynanche tra- 
 chealis, except that it is not always desirable to give it in such fre- 
 quently repeated doses as in the other more active malady. If relief 
 be not speedily obtained, a mustard poultice or a blister should be 
 applied to the throat. In any case, however, where the vital depression 
 is very considerable, the mustard poultice only should be employed, 
 since, under such circumstances, a vesicated surface in the child often 
 does not heal favourably. The slower course which these cases often 
 run affords more time for the action of calomel than we generally have 
 in pure cynanche trachealis; and unless the presence of diarrhoea 
 contraindicate its employment, the remedy is one not to be omitted. 
 It should be given in doses of one grain every hour to a child of three 
 or four years old, combined with a quarter of a grain of ipecacuanha ; 
 — but if the symptoms be at all urgent, the emetic should be repeated 
 every four or six hours, to detach any false membrane that may have 
 been deposited on the fauces ; and cauterization should be practised 
 again, to prevent their renewal. As improvement advances these 
 remedies may be repeated at longer intervals, while expectoration may 
 be promoted by the employment of the decoction of senega, with squills 
 and ammonia, as has been already recommended. Care must be taken 
 throughout not to depress the child too much by over-active treatment ; 
 nourishment must be given from an early period, and even before it is 
 safe to discontinue the cauterization of the throat and the occasional 
 employment of emetics, the extract of bark in combination with its 
 tincture, or some other form of direct tonic, may be needed. 
 
 When consequent on measles, the same general plan of treatment must 
 be adopted, though with far slenderer prospects of cure. The cauterization 
 of the throat is in such cases especially necessary; and the ulcerated 
 condition of the mouth is often much benefitted by the frequent applicaion 
 to it of a solution of two scruples of borax in an ounce of water. The 
 tendency to diarrhoea often prevents the employment of calomel ; while, 
 owing to the weakened state of the system, we cannot always venture on 
 the use of antimony. In such a case, we may still have recourse to 
 
LARYNGITIS STRIDULA. 237 
 
 mercurial inunction ; and while the local cauterization is most seduously 
 attended to, emetics of ipecacuanha may be given two or three times a 
 day, or the sulphate of copper may be substituted for it if it cause 
 purging or fail to vomit. Here, however, more than in the idiopathic 
 form of the affection, we find in many instances a most urgent necessity 
 for supporting the child's strength, even from the very first. The occur- 
 rence of pneumonia is the accident most to be dreaded in the progress 
 of the case, and may require a modification of the treatment, though in 
 its management, the asthenic character of the affection must always be 
 borne in mind. Recovery is generally very slow, even in cases that 
 terminate favourably ; and it often happens that, after all alarming 
 symptoms have been removed, the voice is long in regaining its 
 proper character. 
 
 The peculiar sound that characterises the cough of the croup, the stridor 
 of the respiration, and the urgent dyspnoea, which attend the progress of 
 the disease, result, as I scarcely need remind you, almost entirely from 
 the spasmodic action of the muscles of the larynx, and not from the 
 mechanical obstacle which the presence of false membrane offers to the 
 free admission or exit of air. We have seen that these symptoms are, 
 on the whole, less marked in cases where the croup appears as a secondary 
 affection, and the larynx becomes involved by the extension to it of 
 disease beginning in the throat, than in those where the air-passages 
 themselves are primarily affected. Still, they vary much, both in the 
 period of their occurrence and the degree of their severity, even in those 
 cases that most resemble each other ; and they bear no certain relation 
 to the intensity of the inflammation anymore than to the amount of the 
 deposit of false membrane. The diversities in this respect depend on 
 constitutional peculiarity rather than on any essential difference in the 
 nature of the disease. 
 
 This view, indeed, is not taken by all writers, but some observers of 
 deservedly high repute, such, for instance, as M. Guersent, 1 have con- 
 ceived that there are differences sufficient to warrant our placing in a 
 separate category those cases of croup which are marked by the predo- 
 minance of spasmodic symptoms. They have proposed to designate this 
 form of the disease by the name of laryngitis stridula, to distinguish it 
 from ordinary croup, the laryngitis pseudomembranacea. It was 
 doubtless the observation of some cases of this kind, that led Dr. Millar, 2 
 more than eighty years ago, to describe, under the name of acute 
 asthma, a disease resembling croup in many respects, but presenting a 
 mixture of spasmodic and inflammatory symptoms ; the former predo- 
 minating at the commencement of the disease, the latter towards its 
 close. Dr. Millar appears, indeed, in some measure, to have confounded 
 two very different affections, — the true spasmodic croup, or laryngismus 
 stridulus, with the inflammatory croup, or cynanche trachealis, under the 
 idea that they constituted the two stages of one disease. But neverthe- 
 less, cases are sometimes observed that bear a very close resemblance 
 to Millar's description ; though no advantage seems to me likely to arise 
 
 1 In the article Croup, in vol. ix. of the 2d edition of the Dictionnaire de Medecine, 
 &c Paris, 1835. 
 
 2 Observations on the Asthma and on the Hooping-Cough, 8vo. London, 1709. 
 
238 LARYNGITIS STRIDULA — CASE ILLUSTRATIVE OF ITS SYMPTOMS. 
 
 from constituting a new species of croup out of a modification in its 
 symptoms produced by the idiosyncrasy of the patient. 
 
 In some children there is a greater tendency to spasmodic affections 
 than in others : in such the laryngeal nerves will take the alarm at the 
 very outset of the disease, and the paroxysms of dyspnoea will conse- 
 quently commence at an early stage, and will soon attain great intensity, 
 but may become masked by the permanent distress of breathing to 
 which the disease in its progress gives rise. In other instances, the 
 symptoms of inflammatory disease, and those of spasmodic disturbance, 
 may be so commingled, or may so alternate with each other, as to render 
 it hard to tell from which the child suffers most. This was the case 
 with a little boy ten months old, who some years since came under my 
 care, suffering from what seemed at first to be ordinary inflammatory 
 croup. The symptoms, though not very urgent, were plainly marked, 
 and the active employment of antimony soon dissipated them. During 
 the whole course of the disease, however, the child, who seemed highly 
 nervous and excitable, suffered from fits of dyspnoea far more severe 
 than could have been anticipated from the general mildness of the 
 attack, or than would have been supposed to exist by any one who had 
 seen the child, only in the intervals of the paroxysms. The cough and 
 respiration had for forty-eight hours entirely lost'all croupy character, and 
 nothing but catarrh seemed left behind, when the child was suddenly 
 seized with extreme difficulty of breathing, attended with slight croupy 
 noise, and lay stiff in his nurse's arms with his thumbs drawn into the 
 palms of his hands, and his great toe separated from the others. Four- 
 and-twenty hours had elapsed from the supervention of these new symp- 
 toms before I was able to visit the child. He was then extremely 
 restless : his face was flushed, his thumbs were drawn into the palms of his 
 hands, and his feet were forcibly extended ; his breathing was laboured, 
 and attended with a hoarse croupy sound, which became still more 
 distinct whenever the child coughed. The bowels had not acted for a 
 couple of days, but an hour after my visit, some purgative medicine, of 
 which large doses had been given during the previous six or eight hours 
 began to act, and produced three very copious evacuations, with perfect 
 relief to all his symptoms. The carpopedal contractions disappeared, 
 the respiration became easy, and the face ceased to be flushed or anxious. 
 The child slept well through the night, was cheerful on the following 
 day, and slight hoarseness attending his occasional cough was the only 
 remaining symptom. In a day or two that also disappeared, and the 
 child perfectly recovered. 
 
 The influence of that spasmodic element which enters so largely into 
 the production of the symptoms of cynanche trachealis, is seen in many 
 cases in the long persistence of a croupy sound with the cough, and in 
 its subsequent recurrence, when a patient who has once had croup 
 catches cold. In these cases the nerves have doubtless not thoroughly 
 recovered from the effects of the previous inflammation. 
 
 The spasmodic character of many of the symptoms of croup will 
 become still more evident when we observe, as we shall do in the next 
 lecture, the resemblance which they bear to those phenomena that 
 attend some of the more purely nervous affections of the respiratory 
 organs. 
 
SPASM OF THE GLOTTIS. 239 
 
 Even before closing this lecture, one or two illustrations may be 
 adduced of spasmodic affection of the larynx in connection with disease 
 seated elsewhere. 
 
 MM. Rilliet and Barthez have described a spasmodic cough that 
 returns in paroxysms, is loud, attended with an imperfect hoop, and 
 may. be easily taken for hooping-cough by the inattentive observer. 
 It is, however, a symptom of bronchial phthisis, due to the extension 
 to the larynx of irritation seated in a distant part of the respiratory 
 organs. 
 
 Intestinal irritation is a frequent cause of nervous cough in childhood. 
 It is sometimes a loud, solitary, ringing cough-^-the tussis ovilla, tussis 
 ferina of medical writers; at other times it is a short dry cough, 
 attended with no particular inconvenience, but teazing from its fre- 
 quency. Both of these forms appear to result in many instances from 
 the presence of worms, and speedily cease under the judicious employ- 
 ment of purgative medicines. 
 
 Lastly, I may once more remind you of the cough which is occasion- 
 ally heard in the early stage of inflammatory affections of the brain. 
 It is a very short, hoarse cough, which sometimes continues for a few 
 minutes almost incessantly, then ceases for a time, and then, after a 
 pause, returns again. The disturbance of the brain is sympathized in 
 by the larynx, and the depletion which relieves the former organ, 
 removes the irritation of the latter. 
 
 LECTURE XXI. 
 
 Spasm of the Glottis. — Its symptoms — description of the carpopedal contractions that 
 accompany it — impairment of general health — ways in which it proves fatal — Mode 
 of its production — its various exciting causes, dentition, gastric disorder, local irrita- 
 tion from enlarged glands — supposed to depend sometimes on enlargement of the 
 thymus gland — case in illustration. — Treatment — rules for diet and for the regulation 
 of the bowels — caution with respect to lancing the gums — occasional necessity for free 
 depletion — case in illustration. — Suggestions as to general management, and the 
 avoidance of circumstances likely to produce an attack. 
 
 We have often had occasion to notice the tendency to disorder of 
 the nervous system that characterizes early life, and have just now seen 
 to how great a degree the dangers of croup, and the sufferings that 
 attend it, are aggravated by the sympathetic disturbance of the nervous 
 system with which it is almost always associated. We have observed, 
 too, that the spasmodic symptoms of this disease are sometimes quite 
 out of proportion to the severity of the local mischief; and that in 
 many cases, long after the inflammation has subsided, slight stridor 
 with the respiration, and a degree of clangor with the cough, render it 
 probable that the laryngeal nerves have not yet regained their 
 accustomed tone. 
 
 Spasm of the glottis, however, is not always the result of inflammation 
 of the larynx, and a mere aggravation of danger that would even with- 
 
240 SPASM OP THE GLOTTIS. 
 
 out it be considerable. It sometimes constitutes an independent 
 disease, and one that may prove suddenly fatal, even though the larynx 
 be perfectly healthy, and though no other organ present changes 
 adequate to account for the patient's death. For a time it was 
 confounded with cynanche trachealis ; but the points of difference 
 between the two affections are now clearly recognized, and the terms 
 spasm of the glottis, cerebral croup, spasmodic croup, by which it is 
 designated, are more or less apt expressions of its connection with 
 disorder of the nervous system. 
 
 Spasm of the glottis, — which term I select as the simplest among 
 many appellations that the disorder has received, — usually comes on by 
 degrees, and it is but seldom that its early symptoms are such as to excite 
 the alarm of non-professional persons. It does not often occur in 
 perfectly healthy children ; but an infant who is attacked by it has usually 
 been observed to be drooping for some time previously, to have lost its 
 appetite, to have become fretful by day and restless at night, and to 
 present many of those ill-defined ailments which are popularly ascribed 
 to teething. At length, after these symptoms have continued for a 
 few days or weeks, a slight crowing sound is occasionally heard with 
 the child's respiration. The sound is something between the hoop of 
 hooping-cough and the stridor of true croup ; it must be heard to be 
 known, but when once heard will easily be recognized. Usually it is first 
 noticed on the child awaking out of sleep, but sometimes it is perceived 
 during a fit of crying, or comes on while the infant is sucking. Now 
 and then the first crow is very loud, and, by its resemblance to the 
 sound of croup, at once alarms the family : but this is not generally the 
 case ; and its loudness increases in proportion as its return becomes 
 more frequent. The spasm may have been excited by some temporary 
 cause, and the sound which is its token may in that case not be heard 
 again ; but generally it returns after the lapse of a few hours, or of a 
 day or two. It will soon be found, as its return becomes more frequent, 
 that certain conditions favour its occurrence ; that the child wakes 
 suddenly from sleep with an attack of it, that excitement induces it, or 
 deglutition, or the effort of sucking ; so that the child will suddenly 
 drop the nipple, make a croupy sound with its breathing, and then 
 return to the breast again. Throughout the whole course of the affection 
 its attacks will be found to be more frequent by night than by day ; 
 and to occur mostly either soon after the child has lain down to sleep, 
 or towards midnight, when the first sound sleep is drawing to a close. 
 
 At first the child seems, during the intervals of the attack in as 
 good health as before, — except, perhaps, that it is rather more pettish 
 and wilful; but it is not long before graver symptoms than the 
 occasional occurrence of an unusual sound with inspiration excite 
 attention, and give rise to alarm. Fits of difficult breathing occasionally 
 come on, in which the child throws its head back, while its face and 
 lips become livid, or an ashy paleness surrounds the mouth, slight 
 convulsive movements pass over the muscles of the face ; the chest 
 is motionless, and suffocation seems impending. But in a few 
 seconds the spasm yields, expiration is effected, and a long kud 
 crowing inspiration succeeds, or the child begins to cry. 
 
SPASM OF THE GLOTTIS. 241 
 
 Breathing now goes on naturally ; the crowing is not repeated, or the 
 crying ceases ; a look of apprehension dwells for a moment on the 
 infant's features, but then passes away ; it turns once more to its 
 playthings, or begins sucking again as if nothing were the matter. A few 
 hours, or even a few days, may pass before this alarming occurrence 
 is again observed ; but it does recur, and another symptom of the 
 disturbance of the nervous system is soon superadded, if it have not, 
 as is sometimes the case, existed from the very beginning. This 
 consists in a peculiar contraction of the hands and feet ; a state which 
 is likewise not infrequently observed during infancy, without any 
 spasmodic affection of the respiratory organs. It differs much in 
 degree : sometimes the thumb is drawn into the palm by the action 
 of its adductor muscles, while the fingers are unaffected; at other 
 times the fingers are closed more or less firmly, and the thumb is 
 shut into the palm ; or, coupled with this, the hand itself is forcibly 
 flexed on the wrist. In the slightest degree of affection of the foot 
 the great toe is drawn a little away from the other toes ; in severer 
 degrees of the affection this abduction of the great toe is very consider- 
 able, and the whole foot is forcibly bent upon the ankle, and its sole 
 directed a little inwards. Affection of the hand generally precedes the 
 affection of the foot, and may even exist without it ; but I have never 
 seen spasmodic contraction of the feet when the hands were unaffected. 
 At first this state is temporary, but it does not come on and cease 
 simultaneously with the attacks of crowing inspiration, though gene- 
 rally much aggravated during its paroxysms. Sometimes a child in 
 whom the crowing inspiration has been heard, will awake in the 
 morning with the hands and feet firmly flexed, although he may not 
 have had any attack of difficult breathing- during the night. At 
 other times, though but seldom, this state will subside during sleep ; 
 while very often it is impossible to assign any reason for its cessation 
 or return. The hands may often be unflexed by bending the fingers, 
 but they will resume their former position on the withdrawal of the 
 force ; and such attempts are painful to the child. When the contrac- 
 tion is but slight, children still use their hands ; but when considerable 
 they cannot employ them, and they sometimes cry, as if the contrac- 
 tion of the muscles were attended with pain. Coupled with these 
 carpopedal contractions, the back of the hand and the instep are 
 sometimes swollen, tense and livid; and occasionally there is slight 
 puffiness about the face. This condition is sometimes more general, 
 and on two successive years the same child was brought to me, in 
 whom these attacks of crowing inspiration were accompanied with a 
 state of tense anasarca of the whole body. 1 
 
 When the disease has reached this degree of intensity, a slight 
 crowing sound often attends each inspiration, and the paroxysms of 
 difficult breathing are much more severe ; they last longer, and 
 sometimes terminate in general convulsions. The breathing now does 
 not return at once to its natural frequency, but continues hurried for 
 
 1 This case presented a remarkable similarity to one described by Dr. M. Hall, at 
 p. 185 of his work on the Diseases and Derangements of the Nervous System. 8vo. 
 Lond. 1841. 
 
 16 
 
242 ITS SYMPTOMS. 
 
 a few minutes after the occurrence of each fit of dyspnoea ; and it is 
 sometimes attended with a little wheezing, from the accumulation of 
 mucus in the trachea and larger bronchi during the paroxysm. When 
 this wheezing is permanent, I do not apprehend that it constitutes any 
 essential part of the disease, but regard it either as due to an accidental 
 complication with catarrh, which is so frequent during the period of 
 dentition, or as the result of the affection being associated with tubercle 
 in the lungs or bronchial glands. The slightest cause is now sufficient 
 to bring on an attack of difficult breathing ; it may be produced by a 
 current of air, by a sudden change of temperature, by slight pressure 
 on the larynx, by the act of deglutition, or by momentary excitement. 
 The state of sleep seems particularly favourable to its occurrence, and the 
 short fitful dozes are interrupted by the return of impending suffocation. 
 
 The general condition of the child varies much during the existence 
 of these symptoms, but is always widely removed from a state of health. 
 The bowels are almost invariably disordered, constipation being more 
 frequent than diarrhoea. The mouth is sometimes hot, and the gums 
 are swollen, — the child evidently suffering from the process of teething; 
 and this is the state with which spasm of the glottis is perhaps most 
 frequently associated. Sometimes there is evident congestion of the 
 brain, and the face is flushed, the head hot, and the pulse frequent; 
 but these flushes of the face are usually temporary, and the skin is 
 generally pallid. When the affection has continued for some weeks, the 
 countenance often assumes a haggard, miserable aspect : and though it 
 may come on in children apparently in good health, I have never 
 known the health continue good, after the disease, even in a mild 
 form, has lasted for any time. 
 
 Death sometimes takes place during one of the paroxysms of 
 dyspnoea, the child being suffocated by the long continuance of the 
 spasm ; or at other times the often repeated difficulty of breathing 
 induces a state of permanent cerebral congestion : general convulsions 
 occur, and the child dies convulsed or comatose, serous effusion having 
 taken place into the ventricles of the brain. Should the child escape 
 both these dangers, and should no tubercular disease of the lungs or 
 bronchial glands exist, recovery is almost sure eventually to take place; 
 though the convalescence is often very protracted, and the attack is 
 apt to return under the influence of the same causes as originally 
 excited it. 
 
 Now, though for convenience sake I have spoken of this spasm of 
 the glottis as if it were an independent disease, yet the crowing 
 inspiration, and all the other phenomena that attend it, are merely a 
 collection of symptoms betokening disturbance of the nervous system 
 in general, and of the respiratory nerves in particular. The causes 
 that may. produce such disturbance are very various, and according to 
 them must our treatment be diversified. Many writers have over- 
 looked this fact, and fixing their attention on some one cause, have given 
 a defective, if not an erroneous explanation of the nature of the affec- 
 tion. But this is not the case with Dr. Marshall Hall, whose appli- 
 cation of the discovery of the reflex function of some* of the spinal 
 nerves, receives some of its most beautiful illustrations from this affection. 
 

 SPASM OF THE GLOTTIS. " 243 
 
 "It is," says this distinguished physiologist, 1 "excitation of the true 
 spinal or excito-motory system." It originates in — 
 
 I. 1. The trifacial, in teething. 
 
 2. The pneumogastric, in over- or improperly-fed infants. 
 
 3. The spinal nerves, in constipation, intestinal disorder, or 
 catharsis. These act through the medium of — 
 
 II. The spinal marrow, and 
 
 III. 1. The inferior or recurrent laryngeal, the constrictor of the 
 larynx. 
 
 2. The intercostals and diaphragmatic, the motors of res- 
 piration." 
 
 If we now bear in mind this theory of the disorder, the various 
 circumstances under ivhich it is met with will no longer be to us a 
 source of difficulty. The great share which dental irritation has in its 
 production is shewn by the age at which it generally occurs. Of 30 
 cases of which I have preserved some record, 24 occurred in children 
 between the age of six months and two years, or just at that period 
 when the process of dentition is proceeding most actively, and its 
 attendant diseases are most rife. I apprehend, however, that we 
 should err if we attributed this affection, or any of the other convulsive 
 disorders that occur at this time, entirely to the mechanical irritation 
 of the teeth, pressing on, and cutting through, the gums. The period 
 of teething, like that of puberty, constitutes one of the great epochs of 
 life: it is a time when general changes are going on in the whole 
 organism, — when, the animal machine being in a state of increased 
 activity, its parts are more than usually apt to get out of order. New 
 diseases appear, or such as were before of rare occurrence become 
 frequent ; catarrhal affections and disorders of the intestinal mucous 
 membrane are extremely prevalent, and the brain grows more than 
 ever liable to congestion of its vessels. Under these circumstances, 
 spasm of the glottis often occurs as the secondary rather than the 
 primary result of dentition. The child has cut some of its teeth with- 
 out any symptom of disorder of the nervous system making its appear- 
 ance; but at length it suffers an attack of diarrhoea, or the bowels are 
 allowed to become constipated, or signs of cerebral congestion shew 
 themselves. The crowing sound now becomes audible with the inspira- 
 tion, and it is not long before the whole train of symptoms make their 
 appearance which it has been my object to describe. It may be that 
 the gums were not swollen, nor any tooth near the surface, just at the 
 moment when the signs of disturbance of the nervous system made 
 their appearance ; but their connection with the process of dentition 
 is not the less undeniable. In many instances, too, though these 
 symptoms may subside as the health improves, yet they will return 
 when the child, cuts another tooth, and this even without a recurrence 
 of that impairment of the general health which attended tnem on the 
 former occasion. 
 
 The various sources of irritation that give rise to this affection, 
 however, are not limited to the period of teething; and hence it may 
 be met with before the commencement of that process, as well as after 
 
 1 Lib. cit. p. 71. 
 
244 ITS CAUSES. AND MODE OF Pr6dDCTION. 
 
 its termination. I have seen it in a child ten weeks old, as a conse- 
 quence of improper feeding ; in another, aged nineteen months, it 
 followed the sudden suppression of long continued diarrhoea ; in a third 
 aged two years and a half, it appeared to depend on a state of cere- 
 bral congestion which succeeded to habitual constipation ; in a fourth, 
 nine months old, it supervened in the course of chronic hydrocephalus ; 
 and in a fifth child, who died when two months old, it appeared as a 
 transitory symptom during a series of convulsive attacks, for which no 
 cause could be assigned during life, and which left no traces of disease 
 that could be detected after death. 
 
 But besides those cases in which spasm of the glottis is induced 
 by irritation set up in some distant part, there are others in which the 
 exciting cause of the affection is situated near to the larynx. The 
 late Dr. Hugh Ley observed several instances of this kind, in which 
 the attack appeared to be due to the presence of enlarged and 
 tuberculous cervical and bronchial glands ; and similar cases have 
 come under my own notice. Dr. Ley, indeed, based upon his dissec- 
 tions a theory of the disease which is now known to be erroneous; 
 but it will not excite your surprise that a mass of bronchial glands, 
 compressing and flattening the pneumo-gastric and recurrent nerves 
 (as you see represented in these plates 1 ), should in many instances 
 excite irritation of those nerves, and give rise to spasm in the parts to 
 which they are distributed. 
 
 Symptoms of a kind closely resembling those which we have been 
 studying, are now and then observed in infants in connection with a 
 hypertrophied state of the thymus gland ; and the affection has, in 
 such cases, received the name of thymic asthma. 
 
 The only instance of the kind that has come under my own notice 
 occurred in a little boy, who was brought to me at the age of six 
 months, suffering from symptoms which his mother said had existed, 
 though in a less aggravated degree, almost from the time of his birth ; 
 but which had not much alarmed her until they were followed by an 
 attack of general convulsions a day or two before I saw the child. — 
 These symptoms consisted in the occasional occurrence of great diffi- 
 culty in breathing attended with considerable livor of the surface, 
 continuing for a very short time and returning every two or three 
 weeks without any assignable cause. From the sixth month the 
 child seemed very liable to catch cold, and had frequent cough and 
 wheezing ; but a little rhonchus was all that was ever perceptible in 
 the lungs ; and febrile symptoms were at no time apparent. The 
 attacks of difficult breathing often occurred at night, the child waking 
 from sleep with them, or they were sometimes produced by deglutition, 
 which process always seemed to be attended with slight difficulty 
 whenever fhe child attempted, as it grew older, to swallow semi- solid 
 substances. It was remarkable that no distinct crowing sound ever 
 attended the inspiration ; but that the child having turned ex- 
 tremely livid during the paroxysm of dyspnoea, gradually recovered 
 its breath, and the livor and anxiety of the countenance disappeared by 
 
 1 Ley on the Laryngismus Stridulus, 8vo. Plates 1 and 2. London, 183C. 
 
THYMIC ASTHMA.- 245 
 
 degrees. Profuse perspiration about the head generally followed 
 these seizures ; and sometimes the child would pass into a state of 
 general convulsions, in which, however, it did not struggle much, but 
 continued to breathe hurriedly for some time after they had passed off*. 
 From about the ninth month, slight cough was almost constantly 
 present, though still unattended with any febrile disturbance ; the 
 head was sometimes very hot, and the difficulty of deglutition, the 
 dyspnoea, and the convulsions, increased both in severity and in the 
 frequency of their recurrence. The child now cut the two lower 
 incisors, but without any change taking place in his general condition. 
 Two or three weeks before his death, which took place when just a 
 twelvemonth old, he had an attack of coryza, with abundant puriform 
 discharge, which by its hardening blocked up the nostrils, and caused 
 a good deal of distress in breathing, though unattended by any really 
 grave symptom. He was recovering from this, when one morning 
 early a paroxysm of dyspnoea came on, which was followed by a 
 slight fit that left him pale and exhausted. About two hours afterwards 
 his breathing not having become as quiet and natural as before the 
 first paroxysm, another attack came on, in which he died. 
 
 On examining the body after death, the lividity of all the depending 
 parts was very remarkable. 
 
 The pericranium stripped off very easily from the bones of the 
 skull, which were exceedingly vascular. There was considerable 
 vascularity of the dura mater, the sinuses of which, and the cerebral 
 veins generally, were gorged with fluid blood. There was no injection 
 of the pia mater ; sections of the brain presented a rather greater 
 number of bloody points than natural, but its substance was firm, and 
 the lateral ventricles contained but little fluid. 
 
 The first object seen on opening the chest was the thymus gland, 
 which occupied the whole of the anterior mediastinum, and nearly 
 concealed the heart. Its structure was apparently natural ; its length 
 was 3f inches, and it weighed 328J grains. 
 
 The heart was extremely large, as large as the heart of a child of 
 three years old. Its auricles and the veins, both the cavae and the 
 pulmonary veins, were full of fluid blood. The organ was not well 
 contracted ; its structure was perfectly healthy, and the foetal openings 
 were closed. 
 
 There was a good deal of thick mucus in the trachea and bronchi, 
 but they were perfectly healthy : and the rest of the body presented no 
 remarkable appearance, except that a considerable extent of both lungs 
 was in a state of carnification. 
 
 Now, notwithstanding some points of difference between this case 
 and those in which spasm of the glottis has been induced by a different 
 cause, yet we recognise in it the grand symptoms of the affection. The 
 enlargement of the thymus appears to have induced permanent irrita- 
 tion about the windpipe, which betrayed itself by the frequent cough, 
 and the constant wheezing. To the same cause, too, must be referred 
 the difficult deglutition, while the convulsions were probably much 
 favoured by the enlarged gland pressing upon the superior cava and 
 
246 CASE ILLUSTRATIVE OF ITS SYMPTOMS. 
 
 right auricle, 1 and thus impeding the return of blood from the head : 
 nor must we forget, among the probable causes of the child's sudden 
 death, the remarkable degree of cardiac hypertrophy. The fatal event, 
 however, might possibly not have occurred but for the attack of coryza, 
 and the consequent impairment of the respiratory function, which 
 naturally tended to increase the congestion of the brain. 
 
 The treatment of spasm of the glottis must be regulated by the 
 nature of its exciting cause ; and this, as you have already seen, varies 
 much in different cases. In infants before the period of dentition, it is 
 usually induced by over-feeding, or by food of an improper kind. Our 
 inquiries, therefore, must at once be directed to ascertain how the 
 infant is fed ; and supposing it to be still suckled, it will be wise to 
 interdict any other food than the mother's milk, — or, at most, to allow 
 only a little barley-water. Spasm of the glottis, however, occurs much 
 oftener in infants who are brought up by hand, or in those who have 
 been weaned, than in children still at the breast. In such cases, much 
 pains are sometimes necessary in order to ascertain precisely the kind 
 of food that best suits the infant. Two parts of milk and one of 
 barley-water, sweetened with a little loaf sugar; or equal parts of milk 
 and of a solution of isinglass, made of the thickness of barley-water, 
 generally agfee very well ; but much caution must be used in the 
 introduction of farinaceous articles into the child's diet. Asses' milk, 
 which forms the nearest approach to its natural food, must sometimes 
 be given till the child has decidedly improved; while, if it be puny, 
 and do not appear to thrive, and the crowing inspiration continue 
 undiminished, it may become absolutely necessary to restore it to 
 the breast. 
 
 The state of the bowels requires no less attention than the regulation 
 of the diet. The tendency to constipation must be combated not by 
 drastic purgatives, but by mild aperients. Castor oil often answers 
 the purpose very well, but sometimes each dose of it nauseates a child 
 for several hours, and then it is not desirable to employ \t if a daily 
 aperient should be needed. Both senna and manna are apt to gripe ; 
 and if they be found on trial to produce this effect, their use must not 
 be persevered in. Few medicines act more mildly or more certainly 
 in children than aloes ; and the bitter of the compound decoction may 
 be much concealed by extract of liquorice. The bulk of a medicine, 
 however, often opposes a great difficulty to its employment in infancy ; 
 and if that be the case, the powder may be substituted for the decoction. 
 If slightly moistened, mixed with a little coarse sugar, and placed on 
 the tongue, it will often be swallowed very readily. The habitual use of 
 mercurials to overcome the constipation is not desirable : their employ- 
 ment is better limited to those cases in which the bowels are not only 
 sluggish, but the evacuations unnatural in character. 
 
 The action of the bowels may be encouraged by rubbing the abdomen 
 twice a day with a liniment composed of equal parts of soap liniment 
 and tincture of aloes ; or the bowels may sometimes be induced to act 
 
 1 Ha8se suggests in his (Specielle pathologische Anatomie, p. 519, Leip. 1841) that 
 this circumstance contributes to the production of the sudden death in thymic asthma, 
 —a supposition which the case recorded above certainly tends to bear out. 
 
TREATMENT OF SPASM OF THE GLOTTIS. 247 
 
 regularly in young infants, by the daily employment of a small soap 
 suppository. Enemata, consisting either of warm water, or gruel, may 
 also be given for the same purpose. 
 
 Sedulous attention to the diet and the state of the bowels will some- 
 times effect a cure ; but in many instances tonics may be employed 
 with advantage, and probably none with such decided benefit as the 
 preparations of iron. Removal to the pure air, however, or to the sea 
 coast, is often a tonic of greater power in these cases than all the con- 
 tents of the laboratory, and one which you will find in some instances 
 to be absolutely indispensable to the child's cure. 
 
 All these cares are not less needed in children in whom the process 
 of dentition has already commenced. In them, however, the irritation 
 of teething is often the exciting cause of the affection, and lancing the 
 gums is frequently needed in addition to the other treatment. The 
 relief thus afforded is sometimes very striking ; and the frequent 
 repetition of the process may be necessary to diminish the swelling 
 and tension, and to ease the pain of the congested gum. It is not, 
 however, a proceeding to be adopted, irrespective of all ether consid- 
 erations, simply because the child had begun to cut his teeth when the 
 attack of spasm of the glottis came on. Dentition does not go on 
 continuously from the time when the first tooth is cut until the com- 
 pletion of the whole set, but there are regular pauses in the process, 
 during which its advance is suspended for several weeks together. 
 Thus for instance, after the appearance of the incisors, there is a pause 
 of several weeks or months before the first molar teeth appear, and 
 then there is another cessation in the process before the child begins 
 to cut its canine teeth. The spasm of the glottis, therefore, may come 
 on during one of these pauses, and be excited by some cause quite 
 unconnected with dentition. Lancing the gums, too, is not well borne 
 in every case, even when it may have disappeared to be indicated; 
 and I have more than once been compelled to discontinue it, on account 
 of the pain and alarm which it excited bringing on a violent spasmodic 
 seizure, whenever I attempted to practise it. 
 
 In some instances the spasm of the glottis is associated with manifest 
 uneasiness in the head. It has been suggested, that in some of these 
 cases the brain is kept in a state of constant irritation, owing to the 
 deficiently ossified skull being too thin to defend it from injury, while 
 at the same time it affords no adequate counter-pressure to check the 
 over-distension of the cerebral vessels. I have seen one case that 
 seemed to lend decided support to this opinion, and many others have 
 come under my notice, in which the recommendation that a horse-hair 
 cushion should be made for the head to rest on, having a hole in its 
 centre, so as to relieve the occiput from all pressure, has been acted on 
 with manifest advantage. The supervention of attacks of spasm of the 
 glottis, in a case of well-marked chronic hydrocephalus, would call for 
 little change in the treatment, though it must evidently add much to 
 the danger of the patient. 
 
 Symptoms of cerebral congestion are sometimes associated with this 
 condition. They are seldom such as to call for active interference ; 
 
248 SPASM OF THE GLOTTIS ASSOCIATED WITH CEREBRAL CONGESTION. 
 
 but the tepid bath and neutral salines, with small doses of hyoscyamus, 1 
 are often of much service in quieting the general excitement of the 
 circulation, while the occasional application of a leech to the head may 
 be beneficial, especially if general convulsions are beginning to super- 
 vene on the attacks of dyspnoea. 
 
 It is possible that you may meet with a case in which active depletion 
 is indicated, and you must not allow the consciousness, that, as a general 
 rule, it is inappropriate, to prevent you from having recourse to it in 
 such exceptional instances as the following. In this case, indeed, it 
 was found necessary to carry depletion beyond that point which is in 
 general expedient in so young a child. 
 
 Some years since I saw a little boy, 2J years old, who had already 
 suffered from several attacks of spasm of the glottis. A return of the 
 affection had taken place about seven weeks before, though not attended 
 by any very alarming symptoms until after the lapse of a month, when 
 a general convulsive seizure occurred. From this he recovered, and he 
 had for some days appeared to be convalescent from the spasmodic 
 seizures, when his bowels became disordered, and a good deal purged, 
 and after they had been so for two or three days his mother noticed 
 one afternoon that his thumbs were forcibly drawn into the palm of his 
 hands. With the exception of this contraction of his thumbs, however, 
 he seemed as w r ell as usual, and had a tolerably good night ; but imme- 
 diately on awaking at six o'clock on the following morning he had a 
 paroxysm of stridulous breathing, in which he crowed so loudly as to be 
 heard over the w T hole house. His face at the same time became greatly 
 flushed, and his hands and feet contracted, as they were when I visited 
 him three hours afterwards. His face was then much flushed, his head 
 hot, his pupils rather dilated, his pulse full and bounding ; his thumbs 
 were drawn across the palm ; the fingers were not closed, but the hands 
 were forcibly flexed on the w r rist ; the great toe was drawn far apart 
 from the other toes, which were flexed, and the whole foot was stiffly 
 bent on the ankle. The child was then breathing quietly, and seemed 
 drowsy ; but he screamed out the moment he was touched, as if the 
 least disturbance of his limbs gave him pain. 
 
 Eight leeches were applied to his temples, and drew much blood, but 
 without producing any amelioration of his condition. A croupy sound 
 continued to attend his respiration, and he had a fit of urgent dyspnoea, 
 with loud stridulous breathing, between my first visit at 9 in the 
 morning, and my second at 5 in the evening. I now bled him from the 
 arm to 3vj. which subdued the fulness of the pulse, blanched his lips, 
 and diminished the flush of his face, though it did not cause actual 
 fainting. I ordered cold to be applied to the head, and saw him again 
 at 1\ P.M., when I found that he had been lying quiet ever since I left him, 
 and had had some tranquil sleep, without any crowing sound attending 
 the breathing. His pulse was less full, the flush of his face diminished, 
 the heat of the head was gone, and the contraction of the hands and 
 feet were both less, and less firm. 
 
 A powder with gr. j. of calomel and gr. viij. of rhubarb, which had 
 
 1 See Formula No. 2. p. 43. 
 
NECESSITY FOR DEPLETION — CURE. 249 
 
 been given in the morning, and had produced one evacuation, was now- 
 repeated. 
 
 The child had some sleep in the night, and no access of dyspnoea 
 returned, nor did the croupy sound again accompany the inspiration. 
 In the course of the day the spasmodic contractions of the hands and 
 feet greatly diminished, and the child became cheerful. In five days 
 from this formidable attack he was quite well, and continued so for a 
 year, when a slight return of spasm of the glottis took place, in the 
 course of a severe impetiginous eruption on the scalp. 
 
 Before concluding this lecture, I will suggest a few cautions, appli- 
 cable alike to all cases of spasm of the glottis. Sudden excitement, and 
 especially a fit of crying, are likely to bring on the attack, and since 
 there is a possibility of any one of these attacks proving fatal, the 
 greatest care must be taken in the management of the child to avoid 
 all unnecessary occasions of annoyance or distress. 
 
 Although the benefit that accrues from fresh air, or from a change 
 of air, is often very great, yet it is very important that the child should 
 not be exposed to the cold or wind, for I have seen such exposure fol- 
 lowed by a severe attack of dyspnoea, or by the occurrence of general 
 convulsions. The hazard of such an occurrence is greater in propor- 
 tion to the severity and long continuance of the affection ; and, in such 
 cases, the excitability of the spinal cord, and the irritability of the sur- 
 face, seem sometimes to become as great as they may be observed to 
 be in frogs when narcotized, whom you may then throw into convul- 
 sions by merely shaking the table on which they are placed. It is 
 possible that this condition in the infant may be due to a cause not 
 unlike that which produces it in the lower animal. In the latter, it is 
 manifestly due to the influence on the nervous system, of blood impreg- 
 nated with opium ; in the former, a similar influence may be exerted 
 by blood, the proper depuration of which has been prevented by the 
 frequent recurrence of spasm of the glottis. 
 
 There is also another reason for caution in exposing the child to cold 
 or wind, namely, that the occurrence of catarrh is almost sure to be 
 followed by an aggravation of the spasmodic affection. On more than 
 one occasion I have seen the supervention of catarrh convert a very 
 mild into a very serious attack; and once, the exacerbation of the 
 symptoms thus produced was the cause of the infant's death. 
 
 The parents should in every instance be made fully aware of the 
 uncertainty that attends this affection, — of the possibility of death 
 taking place very suddenly and unexpectedly. 
 
 In the paroxysm itself but little can be done. Cold water may be 
 dashed on the face, and the fauces may be irritated, or the finger passed 
 down into the pharynx, so as to bring on if possible the effort to vomit, 
 while at the same time the legs and lower part of the body may be 
 placed in a hot bath. 
 
 Lastly, 1 will observe that a plan of treatment different from that 
 just laid down has been suggested as applicable to those cases in which 
 spasm of the glottis is excited by hypertrophy of the thymus gland. 1 
 
 1 Dr. J. H. Kopp, Denkwiirdigkeiten in der arztlichen Praxis, 8vo. vol. i. pp. 77-107. 
 Frankfort, 1830. 
 
250 GENERAL MANAGEMENT OF CASES OF SPASM OF THE GLOTTIS. 
 
 A spare diet, the continued administration of small doses of calomel, 
 and the keeping a small blister open on the sternum for months toge- 
 ther, have been advised as means of promoting the absorption of the 
 gland. I cannot speak of the merits of this practice from experience, 
 but it is liable to two great objections ; since, not only have we no 
 means of distinguishing with certainty between cases of spasm of the 
 glottis that depend on hypertrophy of the thymus, and those much more 
 numerous instances of the affection in which the gland retains its 
 natural size, but also, the large thymus is probably, as suggested by 
 Dr. Schopf-Merei, 1 in the great majority of cases, a mere persistence 
 of a foetal condition connected with the generally backward development 
 of the child, rather than actual overgrowth of the organ. 
 
 LECTURE XXII. 
 
 Hooping-Cough — Course of the disease in its simplest form — subject to great variations 
 in its mode of onset and degree of severity. — Signification of the hoop. — Course of 
 the disease when declining — Its danger depends on its complications — Complication 
 with bronchitis — at its outset, or when it has continued for some time — Complication 
 with disorder of the nervous system — sometimes exists from the first and causes death 
 even before characters of disease are fully developed — but may come on at any 
 period — various forms assumed by disorder of nervous system — great danger when 
 paroxysms of cough terminate in convulsions — caution as to nervous character of 
 dyspnoea in many cases, and as to danger of overtreating it. — True hydrocephalus 
 rare as a complication. 
 
 We pass to-day to the study of one of the most common disorders 
 of childhood. Pew persons attain to adult age without having experi- 
 enced an attack of hooping-cough, and still fewer of those who escape 
 it when children suffer from it in after life. 
 
 Hooping-cough, then, claims our notice as being essentially a disease 
 of early life ; but as it is one which almost every old woman professes 
 to cure, we might fairly expect not to be detained long with its study. 
 We find, however, that in this metropolis it ranks fourth among the 
 causes of death under five years of age ; inflammation of the lungs, 
 convulsions, and hydrocephalus, being the only more fatal ailments. — 
 A cursory inquiry will not suffice to make us thoroughly acquainted 
 with all points of importance in the history of a disease that has so 
 many victims. 
 
 The aifection in its simplest form consists of a cough of spasmodic 
 character, that usually succeeds to catarrhal symptoms, and having 
 recurred at intervals for a few weeks, ceases without having occasioned 
 any serious disturbance of the general health, or required any active 
 medical treatment. In its graver forms it is one of the most fearful 
 diseases that we ever have to encounter, often keeping the life of the 
 patient for days or weeks together in almost constant jeopardy, liable 
 
 1 In his very interesting essay on Spasms and Convulsions of Children, in the Monthly 
 Journal of Medical Science, for 1850. 
 
SYMPTOMS OF HOOPING-COUGH. 251 
 
 to be exaggerated by the most trivial cause, or rendered fatal by the 
 slightest error in treatment ; while the highest effort of our art is 
 limited to mitigatir/g the severity and warding off the urgent danger 
 of symptoms which we are unable wholly to subdue, and which we 
 must trust to time and nature thoroughly to cure. 
 
 Such great differences in the course of the disease in different cases 
 have given rise to many ingenious theories as to its nature and seat, 
 framed with the view of explaining that which cannot but strike all 
 observers as so enigmatical in its character. None of these specu- 
 lations, however, have led to any useful practical result, and we shall 
 be better employed than in their study, if we confine ourselves to the 
 simple observation of the phenomena of the disease. In doing this, we 
 will begin with those cases in which it is most simple and least perilous, 
 and will then examine in succession the different modes in which its 
 course becomes complicated and dangerous. 
 
 An attack of hooping-cough usually begins with catarrh, and 
 presents at first little or nothing to distinguish it from a common cold, 
 except that sometimes the cough is attended almost from the outset 
 with a peculiar ringing sound. By degrees the catarrhal symptoms 
 abate, and the slight disturbance of the child's health altogether 
 ceases, but nevertheless the cough continues; it grows louder, and 
 lasts longer than before, and assumes something of a suffocative 
 character, in all of which respects a tendency to exacerbation towards 
 night becomes early apparent. As the cough grows severer, its pecu- 
 liarities become more and more manifest ; during each paroxysm the 
 child turns red in the face, and its whole frame is shaken with the 
 violence of the cough. Each fit of coughing is now made up of a 
 number of short, hurried expirations, so forcible, and succeeding each 
 other with such rapidity, that the lungs are emptied, to a great degree, 
 of air, and the child is brought by their continuance into a condition 
 of impending suffocation. At length, the child draws breath with a 
 long, loud sonorous inspiration, — the hoop from which the disease 
 derives its name, — and the attack sometimes terminates. More often, 
 however, the hoop is followed by but a momentary pause, and the 
 hurried expiratory efforts begin again, and are again arrested by the 
 loud inspiration ; perhaps only to recommence, until, after the abundant 
 expectoration of glairy mucus, or retchitig, or actual vomiting, free 
 inspiration takes place, and quiet breathing by degrees returns. If 
 you listen to the chest during a fit of hooping-cough, you will hear no 
 sound whatever in the lungs ; but when the hoop occurs, you will once 
 more perceive air entering, though not penetrating into the minuter 
 bronchi. It is not till the fit is over, and respiration once more goes 
 on quietly, that the air reaches the pulmonary cells again ; but then 
 you will hear vesicular murmur as clear as if nothing ailed the child 
 or at most interrupted only by a little rhonchus, or slight mucous 
 rale. If the cough be severe, quiet breathing does not return, nor the 
 vesicular breathing become audible, till some time after the paroxysm 
 is over ; and occasionally, short and laborious breathing ushers in each 
 fit of coughing. The child then seems to have a presentiment of the 
 coming seizure ; its face grows anxious, it looks up at its mother, and 
 
252 SYMPTOMS OF HOOPING-COUGH. 
 
 clings more closely to her, or if old enough to run about, you may 
 observe it even before its breathing has become manifestly affected, 
 throw down its playthings, and hasten to seize hold of a chair, or of 
 some article of furniture, for support during the approaching fit of 
 coughing. 
 
 If the case be uncomplicated, even though the attack be severe, the 
 child's health continues good, and little or nothing ails it during the 
 intervals of the cough. Its appetite is not impaired, but after throwing 
 up the contents of the stomach in a fit of coughing, it asks for food 
 almost immediately. It sleeps soundly, except when roused by the 
 cough ; the bowels act regularly, or are perhaps a little constipated, 
 and slight complaint of headache or languor, with loss of the usual 
 cheerfulness, are often all the permanent ill effects to be discerned 
 between the seizures. 
 
 After the hoop has been heard, the disease goes on for about a week 
 to increase in severity, the cough becoming more frequent, its paroxysms 
 severer and more suffocating, and attended with more frequent hoop. 
 After remaining stationary for ten days or a fortnight, it begins to 
 decline ; and one of the first indications of this is usually afforded by a 
 diminution in the severity of the nocturnal exacerbations. We next 
 find either that the fits of coughing are less frequent ; or, though they 
 should occur as often as before, yet they are less severe, and sometimes 
 cease without the occurrence of a hoop. When on the decline, how- 
 ever, exposure to the cold, neglect of the state of the bowels, or mental 
 excitement, will suffice in many cases to bring back the hoop, and to 
 increase the previously diminished severity of the attack. For the 
 most part, the cough loses its spasmodic character for many days before 
 it ceases altogether ; and you may even find a child, otherwise in good 
 health, who, some six weeks after an attack of hooping-cough, still has 
 occasional returns of cough, which a slight cause would once more con- 
 vert into an ailment with all the characters of fully developed pertussis. 
 
 Such is the ordinary course of the disease in those cases in which it 
 is unattended by any complication, and does not give rise to any for- 
 midable symptom, but issues in the complete recovery of the patient. 
 But even in favourable cases, its course is often variously modified, 
 while these modifications derive additional importance from frequently 
 betokening or accompanying some of those serious complications, to 
 which the danger of the disease is almost exclusively due. 
 
 The average duration of the catarrhal stage of hooping-cough, as 
 deduced from a comparison of fifty-five cases, in which the date of the 
 occurrence of the first distinct hoop was ascertained, was 12.7 days. 
 In nineteen of these cases the first hoop was heard within seven days 
 from the commencement of the catarrhal symptoms, and in nineteen 
 more cases during the succeeding seven days ; but the extreme limits 
 of the duration of the premonitory stage are very wide apart, since 
 on one occasion it lasted only two days, and on another, thirty-five days. 
 
 But there are many other respects in which the mode of onset of 
 hooping-cough varies, as is clearly shown by the following facts : — 
 
 In fifty-five cases the average duration of the catarrhal stage was 
 12.7 days : the extremes being 2 and 35 days. In eighteen cases the 
 
DURATION OF THE CATARRHAL STAGE OF HOOPING-COUGH. 253 
 
 catarrhal stage lasted on the average only 8.3 days, when the cough 
 assumed a distinctly paroxysmal character : but no hoop occurred till 
 the fifteenth day. In four cases, after the catarrhal stage had lasted 
 on the average 11.5 days, the cough became paroxysmal, but no hoop 
 occurred during the whole course of the affection. In one case the 
 cough had a distinctly paroxysmal character from the first, but no 
 hoop occurred during the whole course of the affection. In six cases 
 the cough was paroxysmal from the outset, and continued so on the 
 average 9.3 days, at the end of which time distinct hoop accompanied 
 it. In three cases a distinct hoop attended the cough from the very 
 commencement. 
 
 Some of these may be merely accidental differences, but I believe 
 that most of them are by no means unimportant, and that they depend 
 on causes with which a little observation will make you acquainted. 
 My excuse, indeed, for bringing before you such dry detail, with 
 reference to hooping-cough, is, that there is scarcely any other disease 
 of early life concerning which we are so much in want of definite facts. 
 Its general features are so obvious, that persons have not so carefully 
 observed those less striking characters which yet are of much moment, 
 as affording sure grounds for prognosis, and trustworthy indications 
 for the guidance of treatment. 
 
 Unusual protraction of the catarrhal stage of hooping-cough, is, I 
 believe, usually met with either at the commencement of an epidemic 
 of the disease, or towards its close. Epidemic hooping-cough very 
 frequently succeeds to epidemic catarrh ; the former disease becoming 
 gradually developed out of the latter, and the persistence of cough in 
 several cases long after the decline of all other indications of catarrh, 
 is often one of the first signs of the commencement of an epidemic of 
 hooping-cough. The characters of hooping-cough, like those of other 
 epidemic diseases, often become less marked towards the decline 
 of its prevalence, and we then meet with cases in which catarrhal 
 symptoms continue long, while the paroxysms of cough are slight, and 
 the hoop occurs very seldom and not severely. It may be laid down 
 as a general rule, that those cases in which the catarrhal stage is of 
 long continuance, seldom become severe during their subsequent pro- 
 gress, and the same holds good with reference to the majority of those 
 cases in which the hoop does not come on until after the cough has 
 for some time assumed a paroxysmal character. There are, however, 
 some instances, which we shall hereafter have to notice, where the 
 long duration of the paroxysmal and suffocative character of the cough, 
 unattended by any hoop, is a sign of the peculiar intensity of the 
 disease, rather than of its mildness : on the other hand, the preterna- 
 tural shortness of the catarrhal stage, or its total absence, is not of 
 itself any proof that the disease will be more than usually severe. It 
 is usually observed in very young children, who, as I have already told 
 you, are but little liable to catarrhal affections, and who are not so 
 often attacked by hooping-cough as older children. Sometimes, how- 
 ever, when other children in the same family are suffering from it, 
 they contract the disease apparently by contagion, and in that case it 
 frequently happens that no purely catarrhal symptoms precede it, but 
 
254 VARIATIONS IN THE MODE OF ONSET OP THE DISEASE. 
 
 that the cough from the first presents a paroxysmal character, and that 
 it very soon becomes attended with a distinct hoop. 
 
 Instead of coming on with catarrh of moderate intensity, hooping- 
 cough sometimes sets in with great fever, dyspnoea, and many symptoms 
 of severe bronchitis ; though the results of auscultation do not indicate 
 such 'serious disease as, judging from the amount of constitutional 
 disturbance, we should expect to discover. In such cases it is only on 
 the subsidence of the acute symptoms, which usually give way speedily 
 under treatment, that the real nature of the disease becomes apparent. 
 We then observe, however, that while the child in all other respects 
 improves, the cough continues unabated, that it soon grows more 
 severe, returning in paroxysms, and being attended before long by the 
 characteristic hoop. Besides these 'cases, there are others, though 
 much less common, in which, though the catarrhal symptoms are not 
 unusually severe, the child yet has paroxysms of dyspnoea, which gene- 
 rally come on at night, and may excite much apprehension on the 
 part of the parents. The attacks do not appear to be induced by any 
 previous fit of coughing, and after lasting from half an hour to an 
 hour, they pass off of their own accord, leaving the child free for many 
 hours together, and probably not returning until the following night. 
 While the child continues subject to them, auscultation discovers no 
 sign of serious mischief in the lungs ; but in proportion as the 
 paroxysms of the cough increase in distinctness, and the hoop becomes 
 established, the fits of dyspnoea diminish, and in the course of a few 
 days entirely disappear. 
 
 Some days usually elapse after the general characters of the disease 
 have become well marked, before it reaches its acme, and during this 
 time its nocturnal paroxysms generally increase in a greater ratio, 
 both as to frequency and severity, than those which occur by day. 
 Such, at leaft, was the course of the disease in thirty-eight out of 
 forty-seven cases in which this point was especially noticed. The noc- 
 turnal exacerbation is sometimes so marked, that the fits of coughing 
 are not only severer, but are actually more numerous by night-time 
 than by day. In very mild cases of hooping-cough there is but little 
 difference between the frequency and severity of the paroxysms at night- 
 time and by day ; and in other instances, while the child rests quietly 
 through the greater part of the night, there is yet a marked aggrava- 
 tion of the cough on first lying down at night, and on first waking in 
 the morning. When the exacerbations occur at these two periods, the 
 evening exacerbation is often induced by the child being removed to a 
 bed-room less warm than the apartment in which it spends the day, 
 while the morning attack results from the accumulation of mucus in 
 the bronchi during the hours of sleep. 
 
 Neither of these causes, however, is the sole occasion of the increased 
 severity of the disease at night, nor is the occurrence peculiar to hoop- 
 ing-cough, but is observed also in asthma, and in many other affections 
 of the respiratory organs in adults. The severity of the nocturnal 
 paroxysms is often a very good criterion of the general severity of the 
 disease ; and any exacerbation of the disease is usually attended with 
 special exacerbation of the nocturnal paroxysms, and not merely by 
 
CAUSE OP THE HOOP WHICH ATTENDS THE FITS OF COUGHING. 255 
 
 more frequent coughing and hooping, but likewise by a marked increase 
 of dyspnoea. On the other hand, a diminution of the nocturnal exacer- 
 bations is one of the most frequent indications that the disease has 
 begun to lose something of its previous severity, and the cough often 
 ceases entirely at night for some time before it disappears completely 
 during the day-time. 
 
 Cough, preceded by catarrhal symptoms, aggravated in paroxysms, 
 assuming a suffocative character, and attended with a peculiar sonorous 
 inspiration called a hoop, were said to be the characteristics of this 
 disease. The last two of these phenomena are the special results of 
 the nervous element which goes to make up the very compound charac- 
 ter of hooping-cough. Hence, in those cases which are very mild, 
 there is so little spasm of the glottis, that air enters freely when the 
 child draws breath after a fit of coughing, and the hoop is occasional 
 and faint, while it is still more seldom that the cough displays that 
 suffocative character which, when severe, constitutes one of its most 
 formidable peculiarities. 
 
 None of the phenomena of this disease call for such close observa- 
 tion as the hoop from which it derives its name. Its occurrence indi- 
 cates on the one hand the existence of spasm of the glottis ; and hence 
 in those cases which are very slight, it takes place but seldom, while 
 it hardly ever comes on until the disease has lasted a certain time, and 
 acquired a certain degree of intensity. It shows, however, on the 
 other hand, that air does enter, when the child endeavours to inspire, 
 and, therefore, in cases of severe hooping-cough, a loud, long-drawn, 
 sonorous hoop, instead of adding to our apprehension, tends rather to 
 quiet it, for it assures us that the spasm does not amount to actual 
 closure of the glottis, and that, for this time at least, the child will not 
 choke in the fit of coughing. I have already mentioned to you that the 
 nocturnal dyspnoea which excites anxiety in some cases while hooping- 
 cough is coming on, may disappear altogether when the disease has 
 asumed its regular type, and the hoop has become loud and distinct. 
 Just in the same w T ay, the violent, suffocative character of the paroxysm 
 often abates, the fits of coughing become fewer, and the dyspnoea grows 
 less urgent after the hoop has become developed. 
 
 But if the disease should increase in severity, cough comes on more 
 frequently, and the paroxysms are of longer continuance, so that the 
 face grows quite livid before they pass away. The pauses in the fit are 
 now no longer marked by the sonorous hoop, but, after a momentary 
 cessation, the cough recommences ; and though when at length the 
 attack passes off a hoop is heard, it is more stridulous than it used to 
 be, though not so loud. Each paroxysm of cough is now preceded and 
 followed by marked dyspnoea, and the child has scarcely recovered 
 from one attack before another comes on. The hoop now sometimes 
 disappears altogether, or is very occasional, very short, and suppressed ; 
 and then the cough itself loses its former character ; the child dreads 
 its approach much, and tries to suppress it, but in vain ; the whole 
 frame labours with the convulsive efforts, but no sound is produced: the 
 larynx is now completely closed ; violent, but fruitless, expiratory 
 efforts are made, as in some of the worst cases of spasmodic croup, till 
 
256 VARIATIONS IN ITS DISTINCTNESS, AND THEIR' IMPORT. 
 
 general convulsions come on ; or at length the spasmodic constriction 
 yields, and the effort at expiration is successful. The spasm over, the 
 child once more draws breath, but it seems quite exhausted bj the vio- 
 lence of the struggle; while sometimes, before it has recovered from 
 this seizure, another, and then another, succeed, till one at length 
 proves fatal. 
 
 When the disease has approached to this degree of intensity, we 
 should rejoice to hear the loud, long hoop again, which would be a sure 
 token of some diminution in the suffocative character of the cough. We 
 should next find that as the hoop regained its former character, those 
 more numerous but less distinct efforts, w r hich the child had made before, 
 would be merged in the single prolonged inspiration. The dyspnoea 
 would next diminish, and then the severity of each paroxysm would 
 grow less ; and then they would not recur so often, and the hoop would 
 be less loud, and the night attacks less frequent. If amendment were 
 to continue, the attacks would become more brief, and they would some- 
 times pass off without any hoop, while the mucous expectoration w T ould 
 become more copious; next the hoop would altogether cease, but the 
 cough would continue to recur in paroxysms, and to present something 
 of its old suffocative character; and then this too would cease, though 
 cough might still continue for a time longer. 
 
 The variations in the course of hooping-cough which I have now 
 described, depend for the most part either on the greater or less in- 
 tensity of the disease, or on some idiosyncrasy of the patient, or on 
 some peculiarity in the epidemic constitution of the year. There are, 
 however, other, and some of them much more important changes in its 
 symptoms and its course, which result from hooping-cough becoming 
 complicated with another disease. Of these complications, by far the 
 most frequent and most perilous are those which it presents with bron- 
 chitis and pneumonia, on the one hand; and with convulsions, conges- 
 tion of the brain, or hydrocephalus, on the other. Their importance, 
 too, is greatly increased by there being no period of the disease to which 
 we can look as bringing with it any immunity from either ; but, from 
 the commencement of the cough to its complete disappearance, we are 
 at any moment exposed to the risk of disease, either of the lungs or of 
 the brain, converting a trivial into a most formidable affection. 1 
 
 1 Of 27 children who died of hooping-cough under my care, 13 perished in conse- 
 quence of the supervention of bronchitis or pneumonia, 14 from congestion of the 
 brain, from convulsions coming on in a fit of coughing, or from hydrocephalus. 
 
 Reckoning the commencement of the disease from the first distinct hoop, or first 
 appearance of well-marked paroxysmal character of the cough, it appears that of 24 
 cases in which this point was noted — 
 Dying through the lungs. Dying through the brain. Total. Dying within 
 
 1 ., 1 7 days. 
 
 2 3 5 14 days. 
 
 1 2 3 21 days. 
 
 1 
 
 1 1 
 
 1 
 
 2 2 
 
 1 1 
 
 4 1 
 
 12 12 
 
 1 , 
 
 28 davs. 
 
 2 
 
 
 1 
 
 
 4 ....... 
 
 
 2 
 
 , 8 weeks. 
 
 5 
 
 24 
 
 from 8 
 
 weeks to 
 3 mcnths. 
 
BRONCHITIS. 257 
 
 The circumstances under which hooping-cough becomes associated 
 until other affections of the respiratory organs are very various. Some- 
 times, as I have already mentioned, rather severe bronchitic symptoms, 
 frequent, short cough, and considerable dyspnoea, precede the full de- 
 velopment of the disease. This occurrence is oftenest met with at the 
 commencement of epidemics of hooping-cough, or in children the mucous 
 membrane of whose air-tubes may be supposed to have acquired a pecu- 
 liar susceptibility from many previous bronchitic seizures. On the whole, 
 however, these are not the cases which need excite our greatest solici- 
 tude, for the constitutional symptoms, which are generally out of all 
 proportion to the amount of the local mischief, usually subside in the 
 course of a few days, just as we often observe to be the case with 
 epidemic influenza in the adult; and as the characteristic cough and 
 hoop come on, all cause for anxiety disappears. 
 
 Those cases are in general much more serious in which the symptoms 
 of bronchitis or pneumonia come on after the cough has assumed the 
 characters of hooping-cough. This complication sometimes occurs very 
 early in the course of the disease, and then the bronchitis and hooping- 
 cough appear to be developed almost simultaneously. For a day or two, 
 perhaps, a hoop has been heard accompanying the cough at intervals, 
 and nothing has appeared to indicate that the attack will be unusually 
 severe, when all the symptoms suddenly become very much aggravated ; 
 the skin grows hot ; the respiration and pulse become very much hur- 
 ried, and this increase in their frequency is permanent, though much 
 greater at one time than at another. The cough at the same time 
 becomes more frequent and more severe, and the hoop is more violent ; 
 but the cough is almost entirely unattended with expectoration, or if a 
 little mucus be spit up it is almost always streaked with blood. Though 
 very violent, the fits of coughing are not very long, and they seldom 
 or never end with vomiting. The ear detects mucous rale through nearly 
 the whole of both lungs : on a deep inspiration, still smaller sounds are 
 heard, for inflammation has attacked the minuter air-tubes ; and the 
 case is one of hooping-cough complicated with capillary bronchitis. 
 
 Supposing the disease to continue, the cough will often in a day or 
 two lose its characteristic hoop, an occurrence which you will likewise 
 observe in the course of many other intercurrent febrile or inflamma- 
 tory affections that may supervene during an attack of hooping-cough. 
 The cough, too, may become less frequent, or may lose its paroxysmal 
 character, though it will still appear to cause much suffering. The 
 respiration will increase in frequency, the child constantly labouring 
 for breath, and being distressed by the slightest movement, since that 
 adds to its dyspnoea. In one little child two years old, the inspirations 
 two days before her death were 130 in the minute, and then on the 
 following day they sank to 80; but her feet were now cold, her face 
 was livid, and her pulse very feeble. It was she, of whose lung I 
 showed the drawing some days since, illustrative of vesicular bronchitis ; 
 and her case might be taken as a type of those in which acute bron 
 chitis comes on at an early stage of hooping-cough. 
 
 Death takes place more speedily in cases of this kind than under any 
 other form of affection of the lungs which comes on in the course . 
 
 17 
 
258 COMPLICATION OF HOOPING-COUGH — BRONCHITIS — PNEUMONIA. 
 
 hooping-cough. I have seen a child die on the sixth day from the first 
 appearance of any indication that the disease was other than a very 
 mild attack of hooping-cough. It will not surprise you that the fatal 
 event should take place so speedily, if you bear in mind, that after 
 death we discover either intense injection, even of the smaller bronchi, 
 with copious effusion of pus into their cavities, or very extensive vesi- 
 cular bronchitis, or both conditions together. 
 
 But it is not only at the outset of an attack of hooping-cough that 
 we encounter the danger of its becoming complicated with other diseases 
 of the lungs. Exposure to cold, or damp, may at almost any period 
 induce an exacerbation of the cough, or a distinct attack of bronchitis. 
 If, however, the disease have already lasted for some ten days or a 
 fortnight, without having presented any grave features, such intercur- 
 rent bronchitic seizures are usually very tractable. 
 
 As a general rule, those cases have appeared to me to be far more 
 serious in which bronchitic symptoms become developed of their own 
 accord out of severe hooping-cough. In such cases there has usually 
 been a gradual increase in the child's sufferings ; the cough growing 
 more frequent, and, though not more violent, yet evidently occasioning 
 the child greater suffering; while the hoop is unchanged in its cha- 
 racter. At the same time the child seems overwhelmed by the disease ; 
 its face is anxious and puffed, the eyes are much suffused, the skin 
 usually dry and hot ; dyspnoea is no longer confined to the periods just 
 before and just after a fit of coughing, but the respiration is habitually 
 wheezing, hurried, and rather irregular. The- ear, at the same time, 
 detects mucous or subcrepitant rale through the whole of both lungs. 
 Such cases are seldom very rapid in their course. The symptoms, after 
 exciting our solicitude for a week, ten days, or a fortnight, may gradu- 
 ally abate in severity, and the disease may run the remainder of its 
 course slowly, but safely. If the case should have an unfavourable 
 issue, this sometimes takes place speedily, owing to the supervention of 
 cerebral symptoms; and the child then dies during a paroxysm of 
 coughing. Or the minute bronchi may become involved in the inflam- 
 matory mischief; the case may assume the characters of pneumonia, 
 and bronchial breathing and dulness on percussion may reveal during 
 the patient's lifetime the nature of the mischief which will be disclosed 
 on an examination after death. 
 
 In a still more numerous class of cases, the disease retains its chronic 
 character to the last, and presents little or no variation from day to day. 
 The violence of the cough, and the frequency of its return, sometimes 
 continue unabated, though often they undergo a marked diminution. 
 The respiration grows more hurried than before, the fever becomes 
 exacerbated, and the emaciation extreme ; while the child's strength is 
 still more enfeebled by the supervention of a troublesome diarrhoea, 
 which no remedies are adequate to restrain. Death at length takes 
 place, sometimes from pure exhaustion ; and the transition from sleep 
 to death is so gentle as to be almost imperceptible. At other times an 
 increase of the symptoms of bronchitis or pneumonia becomes apparent 
 for two or three days previously; or in other cases the child dies 
 exhausted in a fit of coughing, or convulsions take place a few hours 
 before death, and the patient dies convulsed, or comatose. 
 
CEREBRAL CONGESTION. 259 
 
 1 The complication of hooping-cough ivith serious disorder of the nervous 
 system is almost as frequent as its association with grave mischief in 
 the lungs and air-tubes, and even more dangerous and perplexing. 
 Hazard from this source attends alike the onset of the disease, its acme, 
 and decline ; and the mode in which the danger presents itself is no 
 less variable than are the seasons of its occurrence. The nervous 
 system sometimes suffers so severely from the very first, that death 
 takes place almost before the disease has had time to assume its usual 
 characters. At other times hooping-cough comes on naturally ; its two 
 elements, the bronchitic and the nervous (if I may be allowed the ex- 
 pression), increase daily in intensity, till all at once the symptoms of 
 the former recede, and are almost lost in those of the latter, which in 
 a day or two bring on the fatal termination of the case. Or lastly, no 
 symptoms referrible to the nervous system call for our solicitude until 
 after the hooping-cough has continued many weeks ; but then the long 
 continuance of the disease seems to excite mischief in the brain, and 
 death overtakes the patient when we had already begun to hope that 
 nothing more than time was needed to perfect his cure. 
 
 Danger from this cause sometimes assumes the form of simple con- 
 gestion of the brain : drowsiness is followed by convulsions, and these 
 are succeeded by fatal coma. In other instances the spinal system of 
 nerves becomes excited to more tumultuous reaction ; and carpopedal 
 contractions, and attacks of spasm of the glottis, become superadded to 
 frequently recurring general convulsions ; while in some cases the long 
 continuance of hooping-cough gives rise to the development of acute 
 hydrocephalus. The time will not be lost which we may spend in the 
 examination of each of these various modes in which hooping-cough 
 becomes complicated with disorder of the nervous system. 
 
 In very young children, and in those in whom the process of denti- 
 tion is still going on at the time of their becoming affected with hooping- 
 cough, the symptoms of disturbance of the nervous system are some- 
 times formidable even from the outset. In such cases the preliminary 
 catarrh is usually of short duration, and the cough, though not very 
 frequent, yet assumes a paroxysmal character almost from the first. 
 Each fit of coughing is extremely violent and suffocative ; it lasts for 
 several minutes, is not attended by any distinct hoop, nor followed by 
 vomiting, but ceases apparently from the child being too exhausted to 
 make any further effort. In the intervals of the cough the face is 
 flushed, the eyes are suffused, and the child is very drowsy, and averse 
 to being disturbed — a condition which is manifestly increased by each 
 paroxysm of coughing. When the cough comes on, the flush of the 
 face deepens to a livid hue, the pupils become dilated, convulsions seem 
 impending and at length come on, and though but of short continuance, 
 yet they often leave the child in a state of profound stupor. This state 
 seldom lasts long : sometimes the effort at coughing brings on a fatal 
 convulsive seizure, at other times the cough does not return, but con- 
 vulsions recur independently of it, and in twenty- four or thirty-six hours 
 from their first occurrence the child dies. 
 
 No cases of hooping cough run so surely or so speedily as these to a 
 fatal termination, which even the most judicious treatment will often 
 
260 HEAD SYMPTOMS SOMETIMES COME ON GRADUALLY. 
 
 fail to prevent. I have seen death take place in less than a week from 
 the commencement of the cough, and have known several instances of 
 its occurrence long before the lapse of a fortnight. 
 
 The circumstance of the cough having run its course naturally up to 
 a certain point, affords, however, no guarantee against the supervention 
 of a danger similar to that which we have just been contemplating. It 
 is, indeed, but seldom that any case which for the first ten. days or fort- 
 night has been mild in character, afterwards presents these alarming 
 symptoms of cerebral disturbance ; for in most instances the cough will 
 have been severe from the commencement, the paroxysms frequent and 
 of long continuance, the hoop loud, each attack terminating with vomit- 
 ing, and the return of each being much dreaded by the child. In all 
 this, however, there is nothing to direct special attention to the head, 
 and the approach of the new danger is not always very obvious. Some- 
 times the first indication that the head suffers is afforded by the in- 
 creased irritability of the stomach, which becomes almost unable to 
 retain food or drink. And here let me urge upon you the importance 
 of duly estimating the signification of this symptom. Vomiting, inde- 
 pendent of the fits of coughing, if it persist for above twenty-four hours, 
 and be not referrible to the remedies you are employing, nor connected 
 with obvious gastric disorder, should always excite your solicitude, and 
 direct your attention most anxiously to the head. 
 
 At other times, either in connection with this irritability of the 
 stomach, or even independently of it, the child is observed to become 
 daily more heavy and drowsy, and averse to movement ; complaining 
 of headache if able to talk, and appearing overwhelmed by the disease 
 to a greater degree than can be accounted for either by the severity of 
 the paroxysms or the frequency of their recurrence. This condition is 
 generally succeeded by aggravation of the dyspnoea both before and 
 after each fit of coughing, the respiration sometimes not regaining its 
 proper frequency during the interval between their return, though 
 auscultation fails to detect any adequate cause for this hurried breathing. 
 In some instances the hoop still continues as loud as before ; but if 
 that be the case, the cough grows harder, and hardly any mucus is 
 expectorated; while streaks of blood are seen in the matters rejected 
 by vomiting. It happens more frequently, however, that these symp- 
 toms are associated with a more or less complete suppression of the 
 hoop ; the cough losing something of its distinctly paroxysmal cha- 
 racter, but becoming more suffocative; the child, on each occasion of 
 its return, vainly striving to suppress it. A convulsive seizure- now, in 
 some cases, supervenes on an effort to cough, and in this the child 
 expires ; or the fatal convulsion may come on to all appearance cause- 
 lessly : or, more frequently, the first convulsion does not occasion death, 
 but it leaves the child in a comatose condition, which is interrupted by 
 the frequent return of convulsions, one of which at length proves fatal. 
 
 It happens sometimes that children who are labouring under severe 
 hooping-cough are suddenly seized, during a paroxysm of coughing, 
 with a fit of convulsions ; and they may die in this fit, even though they 
 had not previously seemed to suffer from any serious disorder of the 
 nervous system. Death in such cases takes place as the result of spas- 
 

 GREAT DANGER WHEN CONVULSIONS RETURN FREQUENTLY. 261 
 
 modic closure of the larynx, and consequent congestion of the brain : 
 you watch for a few moments the fruitless expiratory eiforts of the 
 child, and then all is over, just as in many fatal cases of spasmodic 
 croup. The relation between hooping-cough and spasmodic croup, 
 indeed, is sometimes very apparent; and you may observe, after some 
 unusually violent fit of coughing, the thumbs drawn into the palms, the 
 hand flexed upon the wrist, or the great toe drawn apart from the 
 others. At first, probably, the symptoms will be slight, and will soon 
 pass away ; but their import is most serious. You will expect soon to 
 see other and graver indications of the disturbance of the nervous sys- 
 tem, — if, indeed, they be not already present. It is especially in cases 
 of this sort that you will observe a degree of dyspnoea which you can- 
 not explain ; and that the child will seem to make the most violent 
 efforts to suppress the cough, — efforts which are really involuntary, and 
 are the result of the spasmodic closure of the glottis, which is sure, if 
 complete and long continued, to be followed by an attack of convul- 
 sions. If treatment fail, the carpopedal contractions will become per- 
 manent, the eyes will close but partially, the breathing will grow 
 extremely unequal and irregular, as well as hurried, the hoop will no 
 longer be heard, and the cough itself will yield only a kind of smothered 
 sound. The surface will grow quite livid, in consequence of the 
 extremely imperfect performance of the respiratory function ; the child 
 will sink^into a state of stupor, in which it will lie with dilated pupils 
 and constant twitching of the muscles of its face, till a great effort to 
 cough comes on, and passes almost at once into a convulsive paroxysm. 
 The fits at length come on independent of any attempt at coughing, 
 and once I saw a considerable degree of stiffness of the whole spinal 
 column precede for twelve hours the death of a little boy, who fell a 
 victim to hooping-cough thus sadly complicated with disorder of the 
 nervous system. 
 
 It would be only by the recital of cases that I could bring before 
 your notice each minute variation in the characters of these formidable 
 complications of hooping-cough v ; and for such details there remains no 
 time to-day. There are two points, however, bearing on this subject, 
 which I am most anxious to impress on your memory. One is, that 
 the supervention of dyspnoea, or the sudden aggravation of difficulty of 
 breathing which had existed previously, is often one of the earliest indi- 
 cations of serious affection of the nervous system. The other point, on 
 which I shall have to dwell at our next lecture, is, that if, mistaking 
 the import of this nervous dyspnoea, you direct your treatment to some 
 imagined mischief in the chest, and make free use of antimony and 
 other depressing medicines, you will aggravate, instead of relieving, 
 the difficulty of breathing ; and, — the irritability of the nervous system 
 increasing in proportion as the respiration becomes impaired, — you will 
 hasten the occurrence of convulsions, and of that formidable train of 
 symptoms which we have just been contemplating. 
 
 I mentioned that true tubercular hydrocephalus is now and then met 
 with as a complication of hooping-cough. Fortunately it is not of fre- 
 quent occurrence, though the danger of its supervention should never 
 be forgotten in the case of weakly children who have long suffered from 
 
262 ACUTE HYDROCEPHALUS. 
 
 severe hooping-cough. Two instances of it have come under my obser- 
 vation ; but in one of these cases the cerebral disease was associated 
 with such a large amount of mischief in the chest as would of itself 
 have sufficed to destroy the child. The other case was of much import- 
 ance, as shewing the insidious manner in which fatal disease may steal 
 on, presenting little to excite serious apprehension till long after the 
 possibility of doing good has passed away. The patient, a boy five 
 years old, of a phthisical family on his mother's side, was attacked by 
 hooping-cough, from which he suffered severely. The disease was 
 attended with great dyspnoea, with general oedema and great lividity 
 of the surface. No auscultatory signs of serious mischief in the lungs 
 existed at any time ; but the oppression of breathing was so consider- 
 able, and the child seemed so completely overwhelmed by the disorder, 
 that I feared he would not recover. After he had suffered from the 
 cough for about five weeks, and three weeks before his death, matters 
 seemed to take a more favourable turn ; his cough diminished greatly 
 both in frequency and severity, and his strength returned under a tonic 
 plan of treatment. He still, however, continued low-spirited, and very 
 much disposed to sleep ; and this condition of depression progressively 
 increased, until, about a week before his death, he sank into a state of 
 complete stupor ; but no convulsions occurred either as precursors of 
 the stupor or during its continuance. He lay on his back, either 
 sleeping, or in a state of stupor, from which, however, he could be par- 
 tially roused, when his pupils, before contracted, would become suddenly 
 dilated to the full, and he would stare wildly about for a few moments : 
 the pupils would then oscillate for a short time between dilatation and 
 contraction, but soon revert to their former contracted condition. The 
 bowels were not constipated at any time, neither did vomiting occur, 
 and the pulse continued frequent till within a day or two of his death. 
 Strabismus came on a day or two before he died, and two days before 
 his death deglutition became difficult, and he began to make slight 
 automatic movements with his hands and arms. Paroxysms of cough 
 continued to recur to the very last: they were suffocative in character, 
 but unattended by hoop. At the end of the eighth week from the com- 
 mencement of his cough, the child, who was extremely emaciated, died 
 quietly. 
 
 After death, the membranes of the brain were found much congested ; 
 there was a large quantity of fluid in the ventricles ; the central parts 
 of the brain were diffluent, and its lower parts were likewise considerably 
 softened. The membranes at the base of the brain presented an opales- 
 cent appearance, and were bestudded with numerous minute granules, 
 while about the optic nerves they were greatly thickened and infiltrated 
 with that hyaline matter to which I have often called your attention. 
 
 There was much congestion of the bronchi and pulmonary substance. 
 The lungs contained a good deal of tubercle, mostly in the state of grey 
 granulations, and a small cavity occupied the lower part of the left 
 upper lobe. 
 
 Many points of importance connected with the history of hooping- 
 cough remain for our examination before we can proceed to consider 
 its treatment ; but all of these must be reserved till our next meeting. 
 
 
HOOriNG-COUGH CONTINUED. 263 
 
 LECTURE XXIII. 
 
 Hooping-Cough, continued. — Complications with diarrhoea and intestinal disorder — 
 with great irritability of the stomach — with measles and varicella. — Duration of the 
 disease. — Relapses. — Influence of age, sex, season, &c. in its production. — Post- 
 mortem appearances. 
 
 Treatment. — No real specific for hooping-cough. — Treatment of first and second stages 
 — utility of hydrocyanic acid — of counter-irritation — of attention to the temperature 
 — danger of over-treating the bronchitis of hooping-cough. — Treatment of third stage 
 of disease. 
 
 It is a peculiarity of the affection which we are now studying, that 
 much of the suffering, and almost all the danger that attend it, are the 
 result, not of the disorder itself, but of some complication that super- 
 venes during its course. We have already examined the two most fre- 
 quent and most formidable sources of danger to patients labouring 
 under hooping-cough, but others remain, against which it behooves us 
 to be no less sedulously on our guard. 
 
 Some days ago I mentioned to you that a state of extreme irritability 
 of the lining of the air-tubes is one of the characteristics of early child- 
 hood. To this are due the attacks of catarrh which children often 
 experience while teething, and the cough which, wholly independent of 
 exposure to cold, comes on as the result of sympathy with irritation in 
 some distant viscus. This high degree of susceptibility, however, is 
 not confined to the bronchi, but is possessed in the young subject by 
 the whole tract of mucous membranes: diarrhoea often accompanies 
 catarrh, or alternates with it, and in the course of inflammation of the 
 lungs the patient's life is sometimes jeopardied, or his death hastened, 
 by the supervention of an intractable looseness of the bowels. 
 
 Diarrhoea, though comparatively seldom fatal, is frequently a very 
 troublesome complication of hooping-cough, and if it continue, it greatly 
 reduces the strength of a child, and interferes with the employment of 
 some of those means to which otherwise we might have, recourse. It 
 sometimes sets in with the preliminary catarrh, and abates as that sub- 
 sides, but in other cases it harasses the patient at intervals during the 
 whole course of the affection. It is, however, when it supervenes in 
 the course of an attack of hooping-cough which has already attained 
 considerable severity, that it should excite our chief solicitude. It does 
 not, indeed, in the majority of instances, betoken the supervention of 
 disease in the intestines, but is one of the forms of constitutional dis- 
 turbance that attend upon a congested state of the brain, or it indicates 
 the advance of serious mischief in the lungs. I have, indeed, seen 
 diarrhoea become the most prominent symptom in a case of severe 
 hooping-cough, the bowels being for days so irritable, that their action 
 was excited by the slightest article of food or drink, while the abdomen 
 was exquisitely tender; and yet, when death at length took place, 
 
264 COMPLICATIONS OF HOOPING-COUGH — DIARRHOZA, ETC. 
 
 unusual redness and prominence of the Peyerian glands were the only 
 morbid appearances in the intestines, while the signs of intense bron- 
 chitis, and inflammation, which in some parts had advanced to suppu- 
 ration, were discovered in the lungs. 
 
 An irritable state of the stomach, with occasional vomiting, are symp- 
 toms almost constantly observed at some period or other in the course 
 of hooping-cough. In cases of a mild character, they usually occur 
 only when the cough has reached its acme, and vomiting succeeds to 
 none but the severest fits of coughing, while it is one of the earliest 
 symptoms to cease as the severity of the disease declines. Sometimes, 
 however, very distressing nausea harasses the patient, and efforts to 
 vomit not only follow the paroxysms of coughing, but are excited by 
 food or by the blandest fluid. I have already warned you of the 
 serious import of this symptom in many instances, and have called 
 your attention to it as being frequently one of the earliest indications 
 of cerebral mischief. In some few instances I have observed it come 
 on very early in the disease, and subside by degrees as the cough 
 assumed a distinctly paroxysmal character; just as is the case some- 
 times with that nervous dyspnoea of which I spoke in my last lecture. 
 Sometimes it continues to be a troublesome though almost a solitary 
 symptom of disturbance of the nervous system, the cough not being 
 severe, nor the child's health at all seriously impaired ; and in two 
 instances that I met with it appeared to be the result of a state of ex- 
 treme irritability about the fauces, so that the cough, which hardly ever 
 occurred at other times, was immediately excited by any attempt at 
 deglutition, and the effort to cough terminated almost directly in vomit- 
 ing. Nausea and vomiting are sometimes associated with general 
 intestinal disorder and diarrhoea ; at other times there is equal evidence 
 of disorder of the digestive organs in a constipated state of the bowels, 
 a red tongue, with perhaps numerous small aphthous ulcers about the 
 mouth, or in the large quantity of frothy mucus rejected by the stomach 
 at each effort to vomit. 
 
 Before leaving the subject of the complications of hooping-cough, I 
 must notice the relation that appears to exist between it and two of the 
 eruptive fevers ; namely, measles and chicken-pox. It has been thought, 
 indeed, by some writers, that there is no connection between these 
 diseases other than that of their accidental association ; but my own 
 experience would lead me to incline to an opposite opinion, which is 
 likewise entertained by several high authorities. I am not, indeed, able 
 at this moment to adduce a number of observations bearing on this 
 point sufficient to establish the fact beyond doubt ; but my belief is, 
 that the occurrence of any one of these diseases during the epidemic 
 prevalence of another, increases the liability of the child to become 
 affected by that which is epidemic ; and that an exacerbation of the 
 fever of hooping-cough, and the appearance of more serious illness than 
 the local symptoms account for, is very likely to be due to the approach 
 either of measles or varicella. Like other intercurrent febrile and in- 
 flammatory affections, both measles and chicken-pox often produce some 
 temporary abatement of the paroxysms of hooping-cough, and some- 
 times cure the disease altogether. In this, however, there is nothing 
 
DURATION OF HOOPING-COUGH. 265 
 
 constant, for hooping-cough often appears not to be in the least modi- 
 fied in its character by the supervention of the other malady : while in 
 some cases the complication adds to the mischief in the chest, and 
 increases the patient's suffering and danger. 
 
 Although there are many important points of analogy between 
 hooping-cough and some of the exanthemata, yet in nothing is the 
 difference between these affections more apparent than in the uncertain 
 duration of the former, in the exacerbations which take place during its 
 course, either causelessly or -from very slight occasions, and in the 
 actual relapses that sometimes occur after apparent cure. It is a matter 
 of considerable difficulty, in the case of a disease so protracted in its 
 course as hooping-cough, to make even an approximation to a correct 
 estimate of its duration. In twenty-five cases, however, I had the 
 opportunity of watching the patients from the time when the cough first 
 assumed a paroxysmal character, or the hoop first became audible, until 
 the final cessation of all cough. From this small number of observa- 
 tions I should be disposed to estimate the average duration of hooping- 
 cough at ten weeks ; of whiqh period nearly two weeks 1 would be occu- 
 pied by the preliminary catarrh, for four weeks the cough would pre- 
 sent the characteristic hoop, and the cough would continue for about 
 the same period to occur occasionally, gradually losing its paroxysmal 
 character ; though exposure to cold, or any trivial cause, would suffice 
 to bring back the hoop, and to restore to the paroxysms of the cough 
 all their former intensity. So long as any cough continues, even though 
 very occasional in its occurrence, and though the hoop have entirely 
 ceased for many weeks, the patient cannot be regarded as well ; while 
 the neglect of proper hygienic precautions may protract the duration 
 of the cough for between three and four months, — an occurrence by no 
 means unusual among the poor. I have on several occasions treated 
 children for hooping-cough during the spring, in whom the hoop has 
 disappeared, and the cough almost ceased, in the warm months of sum- 
 mer ; but on the approach of autumn has returned with nearly its former 
 intensity. In other cases, hooping-cough contracted in the early part 
 of autumn has returned during the prevalence of cold March winds ; or 
 a casual catarrhal seizure has been followed by a recurrence of all the 
 signs of the disease in a severe form. These relapses of hooping-cough 
 frequently set in with considerable severity, the paroxysms of cough 
 being very frequent, and the hoop loud and often repeated ; but, if 
 treated judiciously, they are much more amenable to remedies than is 
 the first attack of the disease. 
 
 A true recurrence of hooping-cough, after the disease has been per- 
 fectly cured, is at least as unusual as the occurrence of measles or 
 small-pox twice in the same subject. Only one instance of hooping- 
 cough affecting the same patient more than once has come under my 
 notice. In that case the patient was a girl aged seven years, who, 
 
 1 The estimate of the duration of the catarrhal stage is deduced from the observations 
 of 55 cases, and the exact period of its continuance was 12-7 days. Of the 25 in which 
 the total duration of the cough from the occurrence of the tirst hoop was noted, 11, or 
 nearly half, showed a duration of eight weeks ; and the duration in the remaining 14 
 cases varied from four to twelve weeks. 
 
266 CAUSES INFLUENCING ITS PRODUCTION. 
 
 when three years old, had very severe hooping-cough, -which lasted for 
 several weeks, the paroxysms of cough being frequent, and the hoop 
 loud and often repeated. In March 1845, hooping-cough being then 
 epidemic, she experienced a return of the disease in a very severe form, 
 and continued to suffer from it until the end of June. 
 
 But little more remains to complete the history of the disease, except 
 that we notice briefly the circumstances under which it comes on. It 
 is essentially an affection of childhood, few children escaping from it, 
 while more than half of the cases»of it oicur before the completion of 
 the third year. After the age of five years its frequency rapidly 
 diminishes, and after ten it becomes so extremely rare, that out of 
 1367 cases in which I noticed the patient's age, I found but eleven in 
 which it exceeded ten years. 1 The occurrence of the disease appears 
 to be influenced to a considerable degree by sex as well as age; and, 
 as is the case with a larger number of the non-inflammatory disorders 
 of the nervous system, females suffer from it in a considerably larger 
 proportion than males. Of 100 cases of hooping-cough at the Children's 
 Infirmary, 55*3 per cent, occurred in females, only 44.7 per cent, in 
 males; although the total number of female children to the total 
 number of males among my patients at that institution was only as 
 50-2 to 49-8 
 
 Age and sex exert an evident influence on the mortality of the 
 disease as well as on its prevalence, both being greatest in early child- 
 hood, though hooping-cough does not seem to be so formidable before 
 the commencement of dentition as it is while that process is going on. 
 Female children are not only more liable to the affection, but it proves 
 more fatal to them than to boys in the proportion of about 3 to 2. 2 
 
 Hooping-cough is a disease of all climates, and though more frequent 
 in the cold than in the warm months of the year, yet its epidemics 
 
 1 Of the above 1367 cases — 
 
 41-2 per cent, occurred during the first 2 years of life. 
 i 50-7 « « « 3 
 
 82-9 " " " 5 " 
 
 98-4 " " " 10 " 
 
 The subjoined table shows the proportion borne by these hooping-cough cases to 
 14.440 cases of all diseases at the same ages, which occurred during the same period at 
 the Children's Infirmary. Cases of hooping-cough constituted— 
 
 8-4 per cent, of all cases occurring under the age of 6 months. 
 
 10-4 
 
 " 
 
 4t 
 
 ti 
 
 from 6 months to 12 months. 
 
 10-3 
 
 «« 
 
 «( 
 
 << 
 
 « 12 
 
 " 
 
 
 18 « 
 
 9-3 
 
 << 
 
 a 
 
 << 
 
 " 18 
 
 u 
 
 
 2 years. 
 
 122 
 
 M 
 
 «< 
 
 «< 
 
 " 2 years 
 
 to 
 
 3 " 
 
 14-6 
 
 ti 
 
 <( 
 
 <« 
 
 " 3 
 
 <« 
 
 
 4 " 
 
 13-2 
 
 a 
 
 <« 
 
 <( 
 
 " 4 
 
 ti 
 
 
 5 " 
 
 11-2 
 
 << 
 
 «( 
 
 «< 
 
 under 
 
 
 
 5 " 
 
 7-2 
 
 it 
 
 << 
 
 it 
 
 from 5 
 
 <( 
 
 
 10 »< 
 
 8 
 
 it 
 
 u 
 
 " 
 
 " 10 
 
 u 
 
 
 15 " 
 
 2 The subjoined table shows the 
 
 age 
 
 at which death took 
 
 place 
 
 in 
 
 27 fatal cases of 
 
 hooping-cough:— 
 
 
 
 
 
 
 
 
 under 6 months. 
 
 4 between months and 1 year. 
 6 " 1 year and 2 years. 
 
 5 " 2 3 " 
 2 " 3 " 4 " 
 
 5 between 4 years and 5 years. 
 
 1 « 5 G 
 
 2 " 6 "7 
 1 " 7 "8 
 1 « 10 " 11 
 
INFLUENCE OF VARIOUS CAUSES IN THE PRODUCTION OF 267 
 
 break out at almost all seasons. The epidemic of 1841-2 reached its 
 acme in the months of December and January; while in 1845, cases of 
 hooping-cough were by far more numerous in the months of June and 
 July than during any other part of the year. Though little influenced 
 by the season of the year, the outbreak of an epidemic of hooping- 
 cough seldom, if ever, takes place suddenly, and altogether without 
 warning. Sometimes, as already mentioned, it succeeds to an epidemic 
 of measles, but still more frequently it follows an unusual prevalence 
 of catarrh, which gradually assumes a paroxysmal character, and puts 
 on the characters of hooping-cough. In a similar way, epidemic 
 hooping-cough sometimes resolves itself into simple catarrh ; the signs 
 of disturbance of the nervous system by degrees disappearing, and the 
 cases presenting the indications of mere bronchial irritation. 
 
 The question whether hooping-cough is a contagious disease, has 
 long since been set at rest by a general answer in the affirmative. 
 How long it retains this character is an inquiry to which it is not 
 possible to return any very precise reply ; but so long as a child who 
 has suffered from hooping-cough continues to cough at all, even though 
 only once or twice a day, I should be unwilling to restore him to the 
 society of children who have not already had the disease. All children 
 are not equally susceptible of the contagion, and infants under six 
 months old appear to be especially indisposed to receive it, either by 
 association with other children, or as the result of atmospheric influence. 
 If carefully kept from contact with other children, infants of tender 
 age will very often escape during the general prevalence of hooping- 
 cough ; and in nearly half of the cases of hooping-cough that I have 
 met with in infants under six months old, other children in the family 
 had suffered from it for a week or ten days before the infants showed 
 any symptoms of it. 
 
 You may expect, perhaps, that before I pass to the consideration of 
 the treatment of hooping-cough, I should say something about the 
 morbid appearances to which it gives rise, and about the essential nature 
 of the affection. I know, however, of no morbid appearances peculiar 
 to this disease, nor do I think that much would be gained by a dis- 
 quisition on its seat, or on the occult cause of its symptoms. It is 
 through the medium of the lungs, or of the brain, that death takes 
 place in nearly every instance of fatal hooping-cough ; and almost all 
 the structural lesions of importance are found in one or other of those 
 organs. The vessels of the brain and its membranes are often found 
 over-filled with blood, though even in cases where death has taken 
 
 This result tallies very closely with that afforded by the Fifth Report of the Registrar- 
 Geueral, from which it appears, that the deaths from hooping-cough in London were 
 to the deaths from all causes in the proportion of — 
 
 5-0 per cent, between 5 and 10 years. 
 8 " " 10 " 15 " 
 
 5-6 per cent, under 1 year old. 
 10-6 " between 1 and 3 years. 
 10-2 " " 3 » 5 » 
 
 Of the 27 cases that came under my notice, 16 occurred in female, and only 11 in 
 male children, and the mortality under ten years of age from hooping-cough is to the 
 total mortality at that age in Loudon in the proportion of 8-9 per cent, among female, 
 and 6-1 per cent, among male children. 
 
268 HOOPING-COUGH — MORBID APPEARANCES. 
 
 place in convulsions, or has been preceded by a comatose condition, 
 these appearances are sometimes much less marked than might have 
 been expected, and occasionally are altogether absent. Softening of 
 the cerebral substance, or other indications of inflammatory action, are 
 very seldom met with ; increased vascularity of the organ, with perhaps 
 a small quantity of fluid in the ventricles, being almost the only morbid 
 appearances in the encephalon. 
 
 It is but seldom that the lungs are found free from disease, though 
 they present no structural changes that can be regarded as charac- 
 teristic of hooping-cough. The mucous membrane of the bronchi is 
 generally injected ; sometimes it is intensely red, while an abundant secre- 
 tion of thick mucus occupies the cavities of the air-tubes, and their calibre 
 is much increased. This dilatation of the bronchi, which sometimes is 
 very remarkable, arises from inflammation of the air-tubes, just as it 
 does in ordinary bronchitis, and is not due, as has been erroneously 
 supposed to the violence of the child's inspiratory efforts. The emphy- 
 sematous condition of the lung, which is likewise observed in some 
 cases of fatal hooping-cough, has been referred to the same forcible 
 attempts at inspiration. MM. Rilliet and Barthez, 1 however, have 
 observed, with great justice, that the supposed violence of the inspi- 
 ratory efforts during hooping-cough, is altogether a mistaken assumption ; 
 for the efforts made during the paroxysm of coughing are expiratory, 
 the lungs during a severe seizure being almost emptied of air ; while in 
 the inspiratory efforts that succeed, the air at first does not penetrate 
 beyond the larger bronchi, and is long before it again freely permeates 
 the pulmonary vesicles. My own experience fully confirms the 
 statement of these gentlemen, that emphysema is found only in those 
 cases cf hooping-cough in w T hich it has been complicated with bronchitis 
 or pneumonia, or, I may add, with extensive collapse of the lung ; so 
 that it is to these secondary affections rather than to the hooping-cough 
 itself that the dilatation of the pulmonary vesicles is to be attributed ; 
 and the amount of emphysema will be usually found proportionate to 
 the extent of those other lesions, and the rapidity with which they 
 supervene. But, although the direct tendency of the paroxysms of 
 hooping-cough is to prevent rather than to induce emphysema, the 
 forcible expiratory efforts which characterize them favour the occurrence 
 of that collapse of the lung to which on a former occasion I directed 
 your attention ; and few cases of hooping-cough terminate fatally in 
 which you will not find after death a more or less considerable portion 
 of lung in this condition. It may be simply collapsed, resuming, 
 its natural appearance readily when inflated, or the bronchial tubes 
 may have been the seat of inflammation, and be more or less filled with 
 puriform mucus, when the characters of vesicular bronchitis will be 
 superadded to those of mere collapse or carnification, and air will 
 permeate the organ very imperfectly, or not at all. It cannot be 
 necessary to describe again those other changes which may take place 
 in carnified lung, and which end in the infiltration of pus into its tissue, 
 
 i Lib. cit. vol. ii. p. 217. 
 
CONDITION OF THE PNEUMOGASTRIC NERVES. 269 
 
 or in the formation of vomicae, since I treated fully of this subject a 
 few days ago. 1 
 
 I do not dwell on other appearances in the chest, such as pleurisy 
 and lobar pneumonia, which are much less often met with, and which 
 have none other than a perfectly casual connection with hooping-cough ; 
 but I must notice one morbid condition alleged to have been frequently 
 observed, and which is of the more importance, since it has served as 
 the foundation of a theory of the disease. The pneumogastric nerve 
 has been discovered by various observers redder than natural, and in 
 some-cases swollen and softened — appearances which have been regarded 
 as indicating that it had been the seat of inflammation. Even those 
 observers, however, who have noticed this condition, appear to have 
 met with it but seldom, while others have sought for it in vain in a 
 large number of cases. Professor Albers of Bonn, 2 states, that, having 
 examined the bodies of 47 children who died of hooping-cough, he 
 found the nervi vagi perfectly healthy in 43. In 3 the vagus of the 
 right side, and in 1 that of the left side, were slightly reddened ; but 
 this redness corresponded to the side towards which the body had been 
 inclined, and in no respect differed from what is observed in the bodies 
 of plethoric persons, and of patients who have died of typhus fever. 
 Out of 18 examinations of the bodies of children who have died of 
 hooping-cough, it has only once happened to me to observe any altera- 
 tion in the appearance of the vagus, though my attention has been 
 directed to it on every occasion. In this instance both nerves seemed 
 to be of a decidedly redder colour than natural, although they were not 
 otherwise altered. We are, I think, warranted in concluding that an 
 appearance so frequently absent, cannot be one of much moment, that 
 it is probably a post-mortem alteration, and that certainly it is not a 
 phenomenon which can be adduced in support of any particular hypo- 
 thesis as to the nature of the affection. 
 
 1 It -would be unjust to leave this subject -without calling the reader's attention to the 
 excellent account of collapse or carnification of the lung contained in Dr. Alderson's 
 paper on the Pathology of Hooping-cough, published in the year 1830, in vol. xvi. of the 
 Medico-Chirurgical Transactions. In this paper he not only describes very correctly 
 the anatomical characters of this condition, which had merely been indicated by 
 previous observers, and speaks of it as a state different from pneumonia, which MM; 
 llufz and Gerhard did four years later, but he also suggests an explanation of its occur- 
 rence, which the recent researches of MM. Bailly and Legendre prove not to have been 
 far from the truth. 
 
 It may be well to quote two passages from this paper: — "In many other [cases] I 
 have invariably found the same appearances, uncomplicated with any evidence of 
 pleuritic inflammation. In the lower and posterior portions of the lungs, the structure 
 was rendered very firm and dense: the portions which were the subject of this change 
 exactly defined by the septa; of a dull-red colour, devoid of air, sinking instantly in 
 water, and thin slices undergoing no change by ablution. The individual lobules were 
 more dense than in hepatized lungs ; and the cellular membrane between them, retaining 
 its natural structure, conveyed to the touch the same sensation that is felt on touching 
 
 the pancreas I apprehend that the appearances detailed differ from those found in 
 
 peripneumony. In hooping-cough, the lung is always dense and contracted, as if the 
 air had been expelled, and from the throwing out of adhesive matter, the sides of the 
 air-sells had been agglutinated together; while in hepatization, the lung is less dense 
 than in hooping-cough, and is rendered more voluminous than in its natural state." 
 (pp. 90-91). 
 
 * Quoted by Aberle, De Tussi Convulsiva, 8vo. p. 45. Vindobonse, 1843. 
 
270 TREATMENT OF THE FIRST STAGE OF HOOPING-COUGH. 
 
 I have endeavoured to describe to you the symptoms of this affection, 
 to make you acquainted with the circumstances under which it occurs, 
 with the course that it usually follows, and with the chief dangers that 
 threaten a child while suffering from it. It now remains to examine 
 the treatment which may be best calculated to mitigate its severity, 
 and to ward off or overcome the dangers that attend it. 
 
 There are few diseases for the cure of which specifics have been more 
 eagerly sought after, or more earnestly recommended, than for that of 
 hooping-cough ; neither is there anything unreasonable in the expecta- 
 tion that a remedy may some day or other be discovered which shall 
 cut short its course with as much certainty as quinine arrests an inter- 
 mittent fever, or which shall render the constitution insusceptible of 
 its poison as infallibly as chicken-pox preserves from variola. At 
 present, however, no such remedy has been discovered ; and, though 
 the severity of an attack of hooping-cough, or its duration, varies 
 greatly in different individuals, during different epidemics, or at different 
 seasons of the year, yet we are unable by any medicinal agents to 
 produce effects such as in these cases flow from causes quite beyond 
 our control. 
 
 For the present, then, the treatment of hooping-cough must be con- 
 ducted in accordance with the ordinary principles of therapeutics, and 
 we shall study their application best by examining in succession the 
 course which, in each stage of the disease, it will be our duty to pursue. 
 The first stage of hooping-cough is distinguished, as you know, by 
 catarrhal symptoms, with some degree of febrile disturbance, and a 
 cough, which gradually assumes more and more of a paroxysmal 
 character, until at length it returns in well-marked fits, and is attended 
 by a distinct hoop. In the majority of cases the treatment of this first 
 stage of hooping-cough must be just that of an ordinary catarrh. The 
 child must remain in the house, and it is desirable that it should be 
 confined to its own apartments, both of which should be maintained at 
 a temperature of 60°, so that when it leaves the day for the night 
 nursery, it may not, as is too commonly the case, enter a colder 
 atmosphere, and thus have the irritability of the bronchi increased, 
 and the severity of the cough aggravated. If these precautions be 
 carefully observed, and the diet be light and unstimulating, but little 
 medicine is needed, beyond what may be required to keep the bowels 
 regularly open. If the cough be at all troublesome, a mixture may be 
 given, containing small doses of the Vinum Ipecacuanha and solution 
 of tartar emetic, with a few drops of laudanum, or of the compound 
 tincture of camphor, 1 — medicines that I should advise you always to 
 use in preference to the syrup of poppies, the strength of which is very 
 variable, and its action uncertain. If, as is sometimes the case, the 
 child should wheeze a good deal, this symptom will be much relieved 
 by the administration of an emetic of ipecacuanha every evening, or 
 more frequently if necessary. It is not always, indeed, that either 
 much care or much medicine is needed ; and if hooping-cough come on 
 in a perfectly healthy child, in whom the process of dentition is coin- 
 
 1 See Formula, No. 9, p. 171. 
 
OF ITS SECOND STAGE. 271 
 
 pleted, and during the warm months of summer, strict confinement to 
 the house may not be necessary. Usually, however, care in this stage 
 is very important, and will do much towards mitigating the severity of 
 the subsequent course of the disease, while no precautionary measure is 
 of so much moment as the preservation of the child from fluctuations of 
 temperature, and from damp as well as cold. 
 
 When the first stage of hooping-cough has passed into the second, in 
 which the disease assumes its characteristic features, the condition of 
 the patient must still determine whether any remedies are to be 
 employed, and must likewise influence their selection. It sometimes 
 happens that the cough and hoop are very slight, and the paroxysms 
 but few in the course of the day ; and, under such circumstances, 
 medicine can well be dispensed with. If the paroxysmal character of 
 the cough be well marked, and the fits of frequent occurrence, but the 
 child in other respects ails little, much benefit will accrue from the use 
 of the hydrocyanic acid. I usually begin with a dose of half a minim 
 of the acid of the London Pharmacopoeia every six hours for a child 
 nine months old ; gradually increasing the dose to one minim every 
 four hours, for a child of that age, and so on in proportion for older 
 children. 1 This remedy sometimes exerts an almost magical influence 
 
 (No. 14.) (No. 15.) 
 
 1 $ Acid. Hydrocy. dil. rr^iv. R Acid. Hydrocy. dil. TT^iv. 
 
 Sodse Sesquicarb. gr. x. Sodoe Sesquicarb. gr. x. 
 
 Syrupi simplicis, gj. Mist. Amygdalae, ^j. M. gj. 6tis 
 
 Aquas destill. gvij. M. gj. 6tis horis. 
 horis. 
 
 For a child 9 months old. 
 
 on the cough, diminishing the frequency and severity of its paroxysms 
 almost immediately ; while in other cases it seems perfectly inert; and 
 again, in others, without at all diminishing the severity of the cough, 
 it exerts its peculiar poisonous action on the system, so as to render its 
 discontinuance advisable. I have never but once, however, seen really 
 alarming symptoms follow its use, though I have employed it in many 
 hundreds of cases. In that instance I gave one minim of hydrocyanic 
 acid every four hours to a little boy two years and a half old. Be had 
 hooped for four days before he came under my care, and was then 
 suffering from rather severe cough, and considerable dyspnoea. He 
 took the acid for four days without any effect being produced either on 
 his system generally or on the cough ; but at the end of that time, after 
 taking each dose, he uttered a cry, became quite faint, and would have 
 fallen if not supported. This result having followed three or four 
 times, the child's mother discontinued the medicine, and, of course, I 
 did not resume its employment. Similar, though less severe symptoms 
 were produced by the same medicine in the sister of this child, a little 
 girl of five years of age ; but in neither instance was the severity of the 
 cough in the least mitigated by it. Though no other instances of the 
 kind have come under my notice, I always give a caution to the parents 
 to diminish the dose of the medicine, or even entirely to discontinue it, 
 
272 TREATMENT OF THE SECOND STAGE OF HOOPING-COUGH. 
 
 if the child appear faint or dizzy, or bewildered, after its administration ; 
 and I never persevere with the use of the acid if it do not give a very 
 decided earnest of good within three or four days after its first 
 exhibition. 
 
 In many instances, although the severity of the cough maybe greatly 
 relieved by the hydrocyanic acid, it yet does not enable us entirely to 
 dispense with all other remedies. If there be much wheezing at the 
 chest, an emetic of -ipecacuanha should be given once or twice a day, in 
 order to free the air-passages from the mucus which collects in them, 
 often in very considerable quantity, and thus tends, by the obstruction 
 it offers to the free admission of air, to favour the occurrence of collapse 
 of the lung. The degree to which the child suffers from the accumula- 
 tion of phlegm in the bronchi must determine whether the emetic be 
 given once. or oftener during the day. If it be given but once, the 
 evening should be the time selected for its administration ; and, after 
 the air-tubes have been thus relieved, the child will often rest well, 
 instead of passing, as it otherwise would do, a restless night, disturbed 
 by dyspnoea and frequent fits of coughing. In other instances the 
 cough is unattended by much secretion, the child scarcely wheezes at 
 all, and, even after a severe paroxysm, rarely vomits, and never rejects 
 more than a small quantity of phlegm ; but when night comes on, the 
 cough grows very distressing by its frequent return, even more than 
 by the severity of the paroxysms. When this is the case, a small dose 
 of Dover's powder, or of Dover's powder and the extract of hemlock, 1 
 
 (No. 16.) 
 
 1 R Pulv. Ipecac, co. gr. ss. 
 
 Pulv. Extracti Conii, gr. j. 
 Pulv. Cinnamomi, gr. ij. 
 
 Sacchari albi, gr. iv. M. Ft, pulvis hora somni capiendus. 
 For a child of two years old. 
 
 often seems to soothe this irritability of the air-tubes, and diminishes the 
 frequency of the cough. If there be a good deal of febrile disturbance, if 
 the cough be hard as well as violent, if it seem to occasion pain, and be 
 unattended with expectoration, while, in the intervals of the paroxysms, 
 a frequent, short, hacking, cough distresses the child, and generally 
 diffused rhonchus is heard throughout the lungs, the hydrocyanic acid 
 may be advantageously combined with small doses of tartar emetic or 
 of the Yinum Ipecacuanha. In other cases, if the existence of 
 drowsiness, with a flushed face, becoming livid during the fit of cough- 
 ing, and the suppression of the previously distinct hoop, betoken the 
 presence of cerebral congestion, the application of a few leeches to the 
 head will not only greatly relieve these symptoms, but will also diminish 
 both the frequency and severity of the cough, and prepare the way for 
 the more effective employment of the hydrocyanic acid. 
 
 Counter-irritation to the chest and spine is a popular remedy for 
 hooping-cough, in which many non-professional persons place great 
 confidence, while they employ it through all the stages of the disease. 
 I do not think that you will in general gain much by the employment 
 
USE OP NARCOTICS AND COUNTER-IRRITATION. 273 
 
 of counter-irritation until the disease has begun to decline, though it is 
 then often of much service. There are, however, some circumstances 
 under which counter-irritation may be advantageously resorted to, even 
 before the affection has attained its greatest degree of severity. The 
 attacks of dyspnoea which sometimes occur during the increase of the 
 disease, are often much relieved by a mustard-poultice to the chest; 
 and if, as occasionally happens, these attacks return, though with vary- 
 ing severity, almost every night for several nights together, the appli- 
 cation of a mustard poultice to the chest, and the immersion of the 
 lower part of the body in a hot bath, on three or four successive even- 
 ings, may be of service. In cases of this kind, too, the daily friction 
 of the chest and spine with an embrocation of soap liniment and the 
 Tinctura Lyttse, so as to keep up a slight degree of redness of the 
 surface, is often beneficial ; or that popular remedy, Roche's embroca- 
 tion, may be used, if the parents of the child fancy, as they often do, 
 that it is possessed of some specific virtue. 
 
 As a general rule, blisters to the chest are not desirable remedies in 
 young children ; but if the cough should be frequent, hard, and painful, 
 or if, in connection with the evidences of congestion of the brain, the 
 cough be suffocative and the hoop suppressed, much good often results 
 from their application. They must not, however, be allowed to remain 
 above four or six hours upon the skin ; neither is it desirable to attempt 
 to keep them discharging, on account of the very troublesome sores 
 which they sometimes produce. For the same reason, too, I do not 
 advise you to employ inunction of the tartar emetic ointment, although 
 this proceeding was once highly recommended, and very generally 
 adopted, as a remedy for hooping-cough. 
 
 Attention to maintain a warm and equable temperature around the 
 child, to prevent the stomach becoming disordered by unsuitable food, 
 and to avoid constipation, will in many instances suffice to conduct a 
 child in safety through the second stage of hooping-cough. If the 
 severity of the cough, or the condition of the child in other respects, 
 seem to call for more decided interference, your motto in the selection 
 and employment of remedies must be, u ne quid nimis ;" and especially 
 must this be your guide in the management of those complications 
 which often render hooping-cough so dangerous a disease. 
 
 In no case is it of more importance to bear in mind this caution as 
 to the danger of over-treating a patient who suffers from hooping- 
 cough, than when, at the commencement of the second stage of the 
 disease, a sudden increase of fever, and the supervention of a state of 
 permanent dyspnoea, seem to announce to you that active inflammation 
 has attacked the lungs or air-tubes. It is quite possible that such may 
 be the import of the symptoms, but it is at least as likely that they 
 result from disturbance of the nervous system. In such a case, then, I 
 would advise you to allow nothing but the positive evidence of ausculta- 
 tion to lead you to resort to free depletion and the use of large doses of 
 tartar emetic, — remedies to which you might feel disposed at once to 
 have recourse. If you feel in doubt, remain for some time with the 
 child, watch it carefully, auscultate it more than once during your visit, 
 
 ' 18 
 
274 DANGER OF OVER-TREATING HOOPING-COUGH. 
 
 and repeat your visit every two or three hours, 1 rather than resort at 
 once to measures which, powerful either for evil or for good, may, if 
 unwisely employed, destroy the life they were intended to save. 
 
 Example teaches louder than precept, and you may learn a useful 
 practical lesson from the following history : — 
 
 A little boy, about two years old, had had slight catarrh for a fort- 
 night, and towards the end of this time it was thought he had hooped 
 once or twice, though very slightly. He ailed but little, and had had 
 none other than domestic remedies during this period ; but one night, 
 without any apparent cause, he became very feverish, his cough grew 
 worse, and his respiration very hurried. On this account he was 
 depleted very freely by leeches, and calomel and antimony were given 
 in large doses for two days, though without any considerable diminution 
 of the dyspnoea. When this treatment was first adopted, it was thought 
 that air entered one lung but scantily ; but on the evening of the 
 second day both lungs admitted air equally well, although a good deal 
 of mucous rale attended the respiration. On the morning of the third 
 day, the child's face was flushed, and looked much oppressed ; his lips 
 were rather livid, his respiration was extremely hurried and irregular ; 
 he coughed little, but his cough had a suffocative character, and was 
 not attended by a distinct hoop. The hurried respiration was supposed 
 to indicate the continuance of graver mischief in the lungs than was 
 apparent on auscultation, and antimony was accordingly given in emetic 
 doses. It did not produce much sickness, and the respiration diminished 
 but little in frequency during its employment. On the fourth day the 
 child still breathed very hurriedly, and its inspirations varied from 40 
 to 60 in a minute, without there being any obvious cause for these great 
 changes in its frequency. On the fifth day the breathing increased in 
 rapidity, while the pulse began to lose power ; and not only had the 
 antimony ceased to exert any emetic action, but squills and ipecacuanha 
 failed to induce vomiting. Active measures were suspended towards 
 the evening of this day, and a grain of Dover's powder, given every six 
 hours, somewhat diminished the hurry of the breathing ; but it was 
 discontinued after the third dose, on account of the gradually deepening 
 drowsiness of the child. The child, however, still continued heavy and 
 oppressed, the cough became more frequent and more suffocative, the 
 breathing more rapid and more irregular. On the morning of the 
 seventh day, a fit of coughing terminated in convulsions ; and from 
 that time until the morning of the eighth day, when the child died, 
 they were extremely violent, frequent in their return, followed by 
 carpopedal contractions, which did not subside in the intervals between 
 them ; while after each convulsion the respiration became most distress- 
 ingly hurried and irregular. After a time the breathing grew con- 
 stantly laboured, the face became of a deep livid colour, the hands 
 
 I cannot refrain from directing the attention of junior practitioners to the anecdote 
 which Dr. Cheyne relates (at page xvii. of the Introduction to his work on Hydro- 
 cephalus), of the very different results that follow the practice of two Army surgeons, 
 one of whom visited his patients, during the prevalence of an epidemic disease, twice, 
 the other, four or five times daily. The moral which Dr. Cheyne .drew from the tale, 
 though obvious enough, is not sufficiently borne in mind by many who undertake the 
 treatment of children's diseases. 
 
ILLUSTRATIVE CASES. 275 
 
 were clenched, and the wrists bent upon the fore-arm ; the spine was 
 drawn slightly backwards, and sensation was quite abolished. At 
 length a slight convulsive movement passed across' the face, and the 
 limbs relaxed in death. Permission was not obtained to make a post- 
 mortem examination. 
 
 Other cases have come under my notice, in some of which I fell into 
 the error against which I have just tried to warn you : in some I saw* 
 the patient too late to rectify the mistake which others had committed, 
 while in some the right course of treatment adopted from the first was 
 followed by success. In a case such as I have related, the want of 
 correspondence between the general symptoms and the auscultatory 
 signs should have deterred from the copious depletion and the free use 
 cf calomel and antimony in the first instance, while it still further con- 
 tra-indicated the employment of antimony in emetic doses subsequently. 
 Two or three leeches to the head, when the serious symptoms first came 
 on, would probably have relieved the congested brain ; the tepid bath 
 would have soothed the irritability and diminished the fever; and hydro- 
 cyanic acid would, most likely, have been of service in quieting the 
 hurried breathing. If much febrile disturbance had still continued, 
 small doses of ipecacuanha, antimony, and hyoscyamus, might have 
 been tried, the antimonial not being given in such doses as to exert any 
 very considerable depressing influence on the system. A stimulating 
 liniment to the chest and spine should have been used several times in 
 the course of the day, and any sudden access of the hurried breathing 
 should have been met by the application of a mustard-poultice to the 
 chest. 
 
 The difficulties of diagnosis are sometimes rendered smaller, and the 
 right course of treatment more obvious, by the occurrence of occasional 
 carpopedal contractions, or of momentary strabismus from the very 
 commencement of this nervous dyspnoea ; or in other cases by the absence 
 of any auscultatory signs of mischief in the chest, such as could for a 
 moment lead you to refer the hurried breathing to disease going on in 
 the lungs. 
 
 Even when acute bronchitis really exists, you must not forget the 
 peculiar impress which hooping-cough stamps upon it. You must bear 
 in mind the impediment to the due aeration of the blood which each fit 
 of coughing occasions, and the influence on the nervous system gene- 
 rally of the imperfect decarbonization of the circulating fluid ; how it 
 heightens the irritability of the spinal system, thus exciting the hurried 
 and irregular breathing, and rendering the child peculiarly liable to 
 convulsive seizures. If active interference, therefore, be necessary, you 
 would abstract blood very cautiously, while you would employ nitre, 
 ipecacuanha, and James's powder in small doses, as a febrifuge and 
 expectorant, rather than attempt to bring the child rapidly under 
 the influence of antimony. At the same time, the peculiar tendency to 
 obstruction of the air-tubes, and consequent collapse of the lungs, which 
 characterizes hooping-cough, would lead you to endeavour to keep the 
 bronchi free, by the administration once or twice a day of an emetic of 
 ipecacuanha. You would employ liniments, mustard-poultices, or blis- 
 
276 TREATMENT OF THE NERVOUS SYMPTOMS OE BRONCHITIS. 
 
 ters to the chest, to combat any exacerbation of dyspnoea ; and if the 
 paroxysms of cough be severe, you would combine hydrocyanic acid 
 with your other remedies. If the powers appeared to be on the decline, 
 and the child neither expectorate with the cough, nor reject much phlegm 
 by vomiting, although the bronchi are loaded with mucus, you would at 
 once discontinue antiphlogistic measures, and have recourse to the 
 decoction of senega, with ammonia and squills, 1 while you endeavoured 
 by a nutritious diet to support your patient's strength. 
 
 The time allotted to this lecture will not enable me to do more than 
 just indicate the main points to which your attention should be directed ; 
 and I must now pass on to notice briefly your conduct in the third stage 
 of the disease. It is now that the cough diminishes in frequency and 
 severity, that the hoop grows less loud and less constant, and that any 
 signs of constitutional disturbance that had existed before by degrees 
 disappear. When the disorder runs this favourable course no medicine 
 is needed, and but few restrictions, beyond such as the avoidance of 
 damp and cold requires. Change of air generally expedites the cure; 
 and if the opportunity offer, and the season of the year be favourable, 
 it should never be neglected. There are many instances, however, in 
 which medical treatment in the decline of hooping-cough is of very con- 
 siderable service. It sometimes happens that the bronchi continue loaded 
 with secretion, which is either expectorated, or rejected by vomiting in 
 very considerable quantities after each fit of coughing, while the skin 
 is cold, the tongue moist, and the pulse soft and rather deficient in 
 power. In this condition, alum, 2 long a popular remedy in hooping- 
 
 (No. 17.) 
 
 2 R Alum. Sulphat. gr. xxiv. 
 Acid. Sulph. dil. lr^xy. 
 Syr. Rhoeados, giv. 
 Aquoe purse, ^iiss. M. giij. 6tis horis. 
 
 cough, is often of much service, diminishing the secretion, arresting the 
 sickness, and rendering the cough much less frequent. It may be given 
 in doses of three or four grains every four or six hours for a child of a 
 year and a half to two years old. This remedy, indeed, may sometimes 
 be used with advantage, even before the disorder has begun to decline, 
 if the condition be such as I have just referred to, namely, fever being 
 absent, and the bronchial secretion very abundant, even though the 
 cough is violent. In other cases, in which the cough continues violent 
 after the other symptoms have abated, and in which, though there is no 
 superabundance of secretion in the air-tubes, yet the attacks of cough 
 often end with the rejection of a considerable quantity of mucus from 
 the stomach, and loss of appetite and general dyspeptic symptoms are 
 present, the hydrochloric acid is often of much service. It has been 
 recommended as a specific agent against hooping-cough, in doses of 
 from two Ho six drachms daily ; but I have never employed it in other 
 
 1 See Formula No. 12, p. 190. 
 
TREATMENT OF THE THIRD STAGE OP HOOPING-COUGH. 277 
 
 than moderate doses, such as it would be administered in under other 
 circumstances. 1 
 
 (No. 18.) 
 
 1 R Acid. Hydrochlor. dil. TT^xxxij. 
 
 Tinct. Opii, r^iv. 
 
 Syr. Mori, giv. 
 
 Aquae puree, giiss. M. giij. ter die. 
 
 If the cough continue frequent, and the hoop loud, while the only 
 signs of constitutional disturbance are those of mere weakness, iron will 
 generally put a stop to it sooner than any other remedy. 2 If, however, 
 
 (No. 19.) 
 
 2 R Mist. Ferri co. giv. 
 
 Tinct. Scillae, TT^xvj. 
 
 Tinct. Conii, TT^xl. 
 
 Mist. Amygdalae, ^ij. £iij. M. giij. ter die. 
 
 there be a degree of feverishness, or of gastro-intestinal disorder, which 
 for the present contraindicates the use of iron, Battley's liquor cinchonae 
 may be given with great advantage, in combination with small doses of 
 hydrocyanic acid; 3 while every attention must of course be paid, by 
 
 (No. 20.) 
 
 3 R Acid. Hydrocy. dil. TTLviij. 
 
 Sodoe Sesquicarb. gr. xij. 
 Liq. Cinchonae, giss. 
 Syr. Aurantii, giss. 
 
 Aquae Flor. Aurant. giij. / 
 
 Aquae destil. ^vj. M. £pj. ter die. ( 
 
 All the above are suited for children of two years old. 
 
 mild alteratives, and other appropriate means, to improve the condition 
 of the digestive organs. 
 
 It is probably unnecessary to enter into further details, to specify 
 minutely the diet that a convalescent requires, or to refer to the utility 
 of liniments to the chest, or the occasional benefit of anodynes at night. 
 
 There still remain numerous remedies that have a more or less well- 
 merited reputation in cases of hooping-cough. I must content myself 
 with having pointed out to you the kind of weapons that, under diffe- 
 rent circumstances, must be employed ; and must leave to you the selec- 
 tion of the one, whose form and size may, on different occasions, seem 
 to you most fitting. The armoury is large enough to yield you an 
 ample choice. 
 
278 PULMONARY PHTHISIS. 
 
 LECTURE XXIV. 
 
 Pulmonary Phthisis — differences exist between the tuberculous cachexia in the child 
 and in the adult — Statistical table illustrating its peculiarities in early life. — Ana- 
 tomical characteristics of pulmonary phthisis in the child — frequency of miliary 
 tubercle and of grey granulations in the lung, independent of each other, and of other 
 forms of tubercle — frequency of tubercular infiltration — rarity of cavities — frequent 
 affection of bronchial glands — description of each of these peculiarities — changes in 
 tuberculous bronchial glands — perforation of bronchi, and elimination of tubercular 
 matter. 
 
 Symptoms of phthisis — their differences from those of the disease in the adult — danger 
 of overlooking its early stage, or of mistaking it for remittent fever, &c. — peculiarities 
 of its subsequent course. 
 
 Bronchial phthisis — its characteristics — remarkable fluctuations in its course — occa- 
 sional unexpected recovery — case of its occurrence, attended with expectoration of 
 tubercular matter — its fatal termination usually preceded by merging of its 
 symptoms in those of general pulmonary phthisis — occasional fatal haemoptysis, but 
 this accident not limited to cases of bronchial phthisis. 
 
 Phthisis in very early infancy — pulmonary symptoms often obscured by signs of 
 generally defective nutrition. 
 
 We enter to-day on the examination of one of the most painfully 
 interesting diseases with which we have to do. It is a disease that we 
 not only often see in hospitals, or in the dwellings of the poor, but 
 which has brought grief into the habitations of many among us, and 
 has robbed us of those whom we most dearly loved ; while the very men- 
 tion of its name gives rise to a feeling of utter hopelessness as to its 
 issue. I need hardly say that I propose to-day to call your attention 
 to Pulmonary Consumption or Phthisis, — a malady that attacks per- 
 sons of all ,ages, of both sexes, and of every rank, and which, under 
 every variety. of condition, medicine seems to be equally unable to cure. 
 
 It may, however, occur to some of you that, important though this 
 affection is, yet in speaking of it I am transgressing the bounds that I 
 set myself, when I proposed to treat only of those maladies which are 
 either limited in their occurrence to the period of childhood, or on which 
 the early years of the patient impress some well-marked peculiarity. 
 It is true, indeed, that at whatever age phthisis comes on, it presents 
 the same grand features, it works the same kind of changes, and tends 
 to the same fatal result. But yet the disease in the young subject dis- 
 plays differences from its character in the old, sufficient to attract the 
 notice of the observant ; nor are these differences merely curious, but 
 they influence our prognosis and modify our treatment, — and hence it 
 is fitting that we devote some time to their examination. 
 
 " That great constitutional malady, of which pulmonary consumption 
 is only a fragment, plays its part," in childhood as well as in adult age, 
 " most conspicuously in the lungs." In the adult, however, the lungs 
 are so almost invariably the seat of tubercular deposit, that out of 123 
 cases, M. Louis found but one exception to the rule, that if tubercle 
 exist in any viscus, it will be discovered also in the lungs. In the child, 
 though the lungs are still the most frequent seat of tubercle, yet M. 
 
DIFFERENCE BETWEEN PHTHISIS IN THE CHILD AND ADULT. 
 
 279 
 
 Louis' law no longer holds good, for MM. Rilliet and Barthez found 47 
 exceptions to it out of 312 instances in which tubercle was discovered 
 in some one or more organs of the body. 
 
 The first great difference, then, between the tubercular cachexia in 
 childhood and in adult age, consists in the same organs not being 
 equally liable to it at the two periods of life. 
 
 The following table will place this difference clearly before you. It 
 shows the proportion per cent, in which different viscera were the seat 
 of tubercle in children and in adults. The figures in the first column 
 are deduced from 312 cases which form the basis of MM. Rilliet and 
 Barthez' essay on the tuberculous cachexia ; those in the second, from 
 the 123 cases on which M. Louis' work on phthisis is founded ; and the 
 third contains the results arrived at by Lombard on an examination of 
 100 adults. 
 
 Of 100 instances in which tubercle was 
 
 in some 
 
 of the viscera, it was present in- 
 
 In the lungs 
 
 " bronchial glands 
 
 " mesenteric 
 
 11 small intestines 
 
 " spleen , 
 
 " pleura •. 
 
 " peritoneum 
 
 " liver 
 
 " large intestines 
 
 " membranes of the brain 
 
 " kidneys 
 
 " brain 
 
 " stomach 
 
 " heart and pericardium.. 
 
 Children from 
 1 to 15 years. 
 
 According to 
 
 Rilliet and 
 
 Barthez. 
 
 84 
 79 
 46 
 42 
 40 
 34 
 27 
 22 
 19 
 16 
 15 
 11 
 6 
 8 
 
 Adults from 20 years and 
 upwards. 
 
 According to 
 Louis. 
 
 100 
 28 
 33 
 33 
 13 
 
 2 
 
 
 
 
 10 
 
 
 
 2 
 
 0.8 
 
 
 
 
 
 According to 
 Lombard. 
 
 100 
 9 
 19 
 
 6 
 1 
 
 1 
 
 2 
 1 
 2 
 
 
 
 This table shows not only that the liability of certain organs to be- 
 come the seat of tubercle is different in childhood from what it is in the 
 adult, but also that tubercle is simultaneously deposited in a greater 
 number of organs' in the young than in the old. This greater intensity 
 of the tuberculous cachexia in early life is a fact of much importance. 
 It explains how it happens that death sometimes takes place in the 
 child, before tubercle has any where undergone those changes which 
 seem almost always to precede the fatal event in the adult. 1 
 
 1 1 have thrown together into the following note some details with reference to Phthisis 
 in early life, which, though far too few to warrant the deduction of any positive conclu- 
 sions, may not be without value as furnishing materials for comparison with the results 
 obtained by other observers. 
 
280 
 
 ANATOMICAL PECULIARITIES OF PHTHISIS IN THE CHILD. ' 
 
 These, however, are not the only peculiarities of the disease in early 
 life, but the anatomical characters of tubercle in the lungs, (and of this 
 I am now more particularly speaking) differ in some respects in the 
 child from those which are observed in the grown person. 
 
 The first of these peculiarities consists in the frequency with which 
 
 Table o/189 Cases, showing influence of Sex and Age in 
 
 ing to Pulmonary Phthisis. 
 
 Total Examinations 
 
 Under 
 1 year. 
 
 From 
 1-2. 
 
 From 
 2-3. 
 
 From 
 3-5. 
 
 From 
 5-10. 
 
 From 
 10-15. 
 
 Total. 
 
 M. F. 
 
 27 18 
 
 8 8 
 
 19 10 
 
 M. F. 
 
 23 23 
 
 7 7 
 
 16 16 
 
 M. F. 
 
 13 10 
 4 5 
 8 6 
 
 M. F. 
 
 17 19 
 
 6 11 
 
 11 8 
 
 M. F. 
 
 22 13 
 
 14 8 
 
 8 5 
 
 M. F. | M. F. 
 1 3 109 ft7 
 
 Tubercle present in chest, in... 
 Ditto, not present in chest, in.. 
 
 1 2 
 1 
 
 40 41 
 62 46 
 
 The degree of the tubercular degeneration was not the same in all cases ; but is stated 
 to have been slight in 22, moderate in 20, considerable in 39; proportions which were 
 thus distributed: — 
 
 Slight , 
 
 Moderate .... 
 Considerable 
 
 Under 
 
 From 
 
 From 
 
 From 
 
 From 
 
 From 
 
 Total. 
 
 1 year. 
 
 1-2. 
 
 2-3. 
 
 3-5. 
 
 5-10. 
 
 10-15. 
 
 M. F. 
 
 M. F. 
 
 M. F. 
 
 M. F. 
 
 M. F. 
 
 M. F. 
 
 M. F. 
 
 — 
 
 2 
 
 2 1 
 
 3 4 
 
 5 3 
 
 1 1 
 
 13 9 
 
 1 2 
 
 1 4 
 
 2 
 
 1 3 
 
 3 3 
 
 — 
 
 6 14 
 
 7 6 
 
 4 3 
 
 2 2 
 
 2 4 
 
 6 2 
 
 1 
 
 21 18 
 
 In the above 81 cases, the forms assumed by the tubercular deposit were as follows : — 
 
 Grey granulations 
 
 Yellow tubercle 
 
 " " softened 
 
 " " in cretaceous state... 
 
 Tubercular infiltration... 
 
 Small vomicae 
 
 Large cavities 
 
 Tubercle of bronchial glands 12 
 
 GO 
 
 a 
 o 
 
 S> S3 
 *\ 
 
 || 
 
 Iss 
 
 Yellow 
 
 ubercle in 
 
 retaceous 
 
 state. 
 
 .2.2 
 
 11 
 
 02 O 
 > 
 
 M 
 
 •H — 1 
 © '3 TO 
 
 I §1 
 
 O 
 
 
 
 fci « 
 
 EHm 
 
 
 
 H 
 
 29 
 
 16 
 
 5 
 
 
 7 
 
 3 
 
 3 
 
 12 
 
 15 
 
 40 
 
 7 
 
 — 
 
 16 
 
 8 
 
 2 
 
 38 
 
 5 
 
 1 
 7 
 
 7 
 
 9 
 
 1 
 
 3 
 
 7 
 
 — 
 
 9 
 
 16 
 
 3 
 
 20 
 
 7 
 
 6 
 
 20 
 
 3 
 
 8 
 
 7 
 
 — 
 
 7 
 
 13 
 
 3 
 
 13 
 
 3 
 
 2 
 
 — 
 
 — 
 
 6 
 
 3 
 
 8 
 
 3 
 
 12 
 
 38 
 
 9 
 
 — 
 
 20 
 
 13 
 
 8 
 
 72 
 
 In 16 of the 72 cases in which the bronchial glands were the seat of tubercle the pul- 
 monary tissue was unaifected; and this although thrice the deposit in the glands was 
 universal, and in one of the three cases had gone on to softening. 
 
 The tubercle of the glands was incipient in . . . .16 
 
 " " " general in . . . . .31 
 
 " " " had reached stage of softening in . . 18 
 
 " " " was in a firm, friable, cheesy state in . .2 
 
 u " " undergoing cretaceous change in . .6 
 
ANATOMICAL PECULIARITIES OP PHTHISIS IN THE CHILD. 281 
 
 grey granulations and crude miliary tubercles exist in the lungs inde- 
 pendent of each other, and of any other form of tubercular deposit. In 
 the adult, M. Louis 1 discovered miliary tubercles alone only in 2 out of 
 123 cases of phthisis ; and grey granulations alone only in 5 more. In 
 the child, MM. Billiet and Barthez, 2 found miliary tubercles alone in 
 107, and grey granulations alone in 36 out of 265 cases; and my own 
 observations, which are based on 81 cases, yield 18 instances of the 
 presence of miliary tubercles alone, and 13 of the presence of grey gra- 
 nulations alone in the tissue of the lungs. 
 
 The great rapidity with which the deposit and development of 
 tubercle often take place in early life, is doubtless one chief cause of this 
 peculiarity. If we examine the lungs of an adult aifected with the 
 tuberculous cachexia, we shall often observe their lower lobes containing 
 grey semi-transparent granulations ; as we advance higher, we shall pro- 
 bably find that the granulations have lost much of their transparency, 
 and that they present a yellowish spot in their centre, while near to the 
 apex of the lung the deposit exists in no other form than that of bodies 
 presenting the whitish yellow colour and friable texture characteristic 
 of crude tubercle. These appearances seem to betoken that the deposit 
 of tubercle has taken place slowly and at successive periods, so that those 
 tubercles which occupy the apex of the lung are already approaching 
 maturity at a time when the disease is just beginning to invade the 
 lower lobes. In the child, however, it not seldom happens that all the 
 lobes of both lungs present a nearly equal amount of tuberculous 
 deposit, and that this is seen to be nearly equally advanced in all. Thus 
 we may find the grey granulation diffused in about the same abundance 
 through all parts of the lungs, and all equally transparent ; or we may 
 observe each granulation presenting a yellow spot in its centre ; or the 
 change may be complete, and crude yellow tubercle may be everywhere 
 present. 
 
 Thi3 same fact, of the acute course of tuberculization of the lungs in 
 children, receives a further illustration from the second anatomical pecu- 
 liarity of the disease ; namely, the great frequency with which yellow 
 infiltration of tubercle is observed in early life ; MM. Rilliet and Bar- 
 thez having met with it in 88 out of 265 children, or in 33 per cent. ; 
 and I, in 20 out of 81, or in 25 per cent. It is a form of degeneration 
 of the lung which seldom exists alone, but is almost invariably asso- 
 ciated with grey granulations or yellow tubercle, and usually co-exists 
 with a state of very far advanced tuberculization of the bronchial 
 glands. It is often limited to one lobe, generally the upper : or some- 
 times the middle lobe, in those cases in which the right lung is the seat 
 of the disease. Those portions of the lung which are affected by it 
 become converted into a firm solid mass, having much both of the colour 
 and consistence of cheese, presenting a smooth surface when cut, and 
 by its solidity compressing the bronchial tubes which traverse it, so as 
 considerably to reduce their calibre. If the patient's life be prolonged, 
 a process of softening generally takes place, the tissue breaks down, 
 and a cavity is the result, the parietes of which are formed by solid 
 
 1 Reckerches sur la Phthisie, p. 3. 2 Op. cit., vol. iii., p. 221 and p. 227. 
 
282 FREQUENCY OF TUBERCULAR INFILTRATION. 
 
 tubercle. At other times, especially if the disease run its course with 
 great rapidity, the lung thus infiltrated seems to undergo a different 
 kind of softening, which does not lead to the formation of a central 
 cavity, but pervades its tissue throughout, which then presents a reddish 
 yellow, or rose-coloured tint, and breaks down easily into a kind of 
 putrilage, as if the changes produced were the result of a mixture of 
 true pneumonic hepatization, and of tubercular degeneration. Cases 
 of this sort go far towards substantiating the correctness of M. Roki- 
 tansky's theory, with reference to the nature of this tubercular 
 infiltration, as compared with the ordinary form of tubercular deposit. 
 He conceives that the deposit of tubercle in the form of grey or yellow 
 granulations takes place in the interstitial cellular tissue of the lung ; 
 while in the case of tubercular infiltration, the matter poured out into 
 the interior of the pulmonary vesicles during an attack of pneumonia 
 becomes converted into tubercle under the influence of the tubercular 
 cachexia. 
 
 A third peculiarity of "phthisis in the child, as contrasted with the 
 same disease in the adult, consists in the greater rarity of cavities in 
 the lungs during early life. Of 123 cases which form the basis of M. 
 Louis' work on phthisis, cavities were present in by far the majority of 
 instances ; and though the numbers are not exactly stated, the excep- 
 tions would seem to have been but very few. Out of 265 cases, 
 however, that came under the notice of MM. Rilliet and Barthez, only 
 76, or 28.6 per cent., presented cavities in the lungs; and they existed 
 in only 16 of the 81 cases which came under my own observation. 
 These cavities sometimes resemble those which we usually meet with 
 in the adult ; and this is especially the case with children above six 
 years of age, in whom, indeed, the general characters of phthisis 
 approximate closely to those of the same disease in the grown person. 
 In other instances, they are not so much caverns, as very small excava- 
 tions (vacuoles, as the French call them,) produced by the softening of 
 small tuberculous deposits. Such excavations communicate with the 
 bronchi and with each other, and are sometimes exceedingly numerous, 
 but do not occasion such a destruction of the pulmonary tissue as to 
 produce any where a cavity of considerable dimensions. This appear- 
 ance is one which MM. Rilliet and Barthez were the first to describe. 
 It is not frequent, and has only once or twice come under my notice. 
 Besides these two forms of cavity there is a third, to which I have 
 already referred, namely, that produced by softening of the yellow 
 tubercular infiltration, which is more commonly met with in very early 
 life than subsequently. Cavities of this kind sometimes form with great 
 rapidity, and attain a considerable size. The whole of one lobe of the 
 lung may even become converted into a sac, which is often almost or 
 quite empty, whilst its parietes are formed by little besides the pleura 
 and the fibrous capsule of the lung, with a very thin lining of dense 
 tubercular matter. It is far from unusual to meet with cavities of this 
 kind in the bodies of infants only a few months old, who have never 
 thriven, but have presented few signs of phthisis, with the excep- 
 tions of progressive loss of flesh and strength, and somewhat hurried 
 respiration. , 
 
COMPARATIVE RARITY OF CAVITIES IN THE LUNGS. 283 ' 
 
 The last anatomical peculiarity of phthisis in infancy and childhood 
 to which I shall direct your attention, consists in the abundant deposit 
 of tubercle in the bronchial glands, and the changes to which that 
 deposit gives rise. Even in the adult, tubercle is deposited in the 
 bronchial glands in about a fourth of all cases of phthisis, but the 
 deposit there is subsidiary to its deposit in the lungs. In the child, 
 however, this is far from being always the case ; but the disease in the 
 glands is often as important as that in the lungs, sometimes much more 
 considerable. 
 
 The tubercular deposit does not appear to begin simultaneously in 
 all the glands, nor to advance in all with the same rapidity; but those 
 about the bifurcation of the trachea, and close to the primary bronchi, 
 are usually the first affected ; and the disease in them often attains a 
 more advanced stage than elsewhere. The state in which the glands 
 are most frequently met with is one of tubercular infiltration, the 
 whole of their substance being converted into a firm, resistant matter, 
 resembling a portion of lung which has been the seat of tubercular infil- 
 tration ; and this even although the number of affected glands be but 
 small, and though the lungs be but little or not at all involved in the 
 disease. Sometimes, however, we may meet with the affection in an 
 incipient state, and it is then usual to find the glands which it has 
 attacked somewhat enlarged and injected, and their tissue infiltrated 
 with fluid, and less firm than natural. The tubercular deposit does not 
 proceed invariably from the centre to the circumference, but frequently 
 two or three small deposits may be discerned at different parts of the 
 same gland; or the tubercular matter may be accumulated entirely at 
 one end of the gland, while its other extremity is merely softened and 
 injected. Even when the disease starts from several points it is not 
 often that the deposit presents the distinctly circumscribed form of 
 miliary tubercle, and still less often" that of. grey granulation; but it 
 generally presents the character of tubercular infiltration which had 
 taken place at the same time in two or three different situations. 
 Sometimes it is impossible to distinguish any one spot as that from 
 which the disease started, but the whole tissue of the gland presents a 
 whitish hue, which appears due to the general infiltration of tuber- 
 culous matter. Whatever may have been the mode in which the 
 deposit of tubercle began, the tendency of the advance of the disease 
 is to convert the entire substance of the gland into firm tuberculous 
 matter, in which no trace of the original tissue can be detected. This 
 metamorphosis of the gland is attended with considerable increase of 
 its size ; the enlargement, however, being much greater in the case of 
 those glands which are situated externally to the lungs, than those 
 which are t imbedded in the pulmonary substance. The enlargement of 
 the glands is not attended, as might have been anticipated beforehand, 
 with a thinning of their original delicate cellular envelope, but this 
 increase in density and firmness, while at the same time it acquires a 
 very considerable thickness. Most of the glands which have become 
 converted into tubercle are enclosed within a cyst a line or more in 
 thickness, and extremely resistant ; its inner surface being smooth, of 
 a bright rose tint, and sometimes presenting a considerable degree of 
 vascularity. 
 
284 ANATOMICAL CHARACTERS OF BRONCHIAL PHTHISIS. 
 
 In a large proportion of cases in which tubercle is found in the bron- 
 chial glands, it has not passed beyond the crude stage ; but if life be 
 not cut shoi>t by the advance of phthisis in the lungs, a process of 
 softening next commences ; and the softening usually, though not 
 invariably, begins at the centre of the glands, and extends towards 
 their circumference. The softening is seldom found equally advanced 
 in all the glands ; but in some, a small central cavity containing liquid 
 tubercle is surrounded by a thick wall of solid matter ; while in others, 
 the whole substance has been softened, and the gland is no longer any 
 thing else than a cyst containing a quantity of puriform fluid. When 
 tubercle deposited in the lung has undergone*the process of softening, 
 an effort is made by nature to get rid of the morbid matter, which is 
 expectorated ; and the cavity, thus emptied of its contents, now and 
 then cicatrizes, and the patient is cured. The cases of cure, indeed, 
 bear but a very small proportion to those in which death takes place, 
 for in general, fresh deposits of tubercle successively undergo this 
 softening, until but a comparatively small portion of the lung remains 
 unaffected by the disease ; or the abundant secretion from the bronchial 
 tubes exhausts the patient, or death ensues from the degree to which 
 other organs are implicated in the tuberculous cachexia. When the 
 bronchial glands are the seat of the disease, a similar effort is made to 
 eliminate the morbid matter from the system ; and many circumstances 
 concur to render this a more hopeful task than it is when the pulmonary 
 substance itself is the seat of the disease. 
 
 The means by which this is effected deserve to be examined. When 
 tuberculization of the bronchial glands has attained an advanced stage, 
 we generally observe a process of thickening and infiltration to have 
 commenced in the cellular tissue around each gland, by no means unlike 
 that which takes place in the pia mater at the base of the brain in 
 cases of tubercular hydrocephalus. This cellular tissue often assumes 
 a greyish semi-transparent aspect, and presents a number of minute 
 granules of tubercle diffused through it. By a process of combined 
 inflammation and tuberculization, the connection between the gland 
 and the adjacent bronchial tube becomes extremely intimate. The cel- 
 lular tissue in the intervals between the bronchial rings becomes next 
 infiltrated with tubercle, and is then the first part of the wall of the 
 bronchial tube which disappears during a process of absorption that 
 advances from without inwards. The cellular tissue sometimes becomes 
 quite removed before the cartilages of the bronchi are much affected ; 
 but in process of time they too become absorbed, and the perforation 
 of the tube is then complete ; the tuberculated gland, however, block- 
 ing up the aperture in its walls, and projecting into its cavity. The 
 next step consists in the thinning of the envelope of the gjand, and 
 the next is the discharge of its contents into the tube ; and the cyst 
 then in all probability collapses and becomes applied to the outside of 
 the bronchus, so as to form a part of its parietes. But we are still in 
 want of some exact observations as to this last stage in the cure of 
 bronchial phthisis. 
 
 This process does not take place with equal frequency in all the bron- 
 chial glands ; for those which are situated around the trachea, and 
 
PERFORATION OF THE BRONCHIAL TUBES. 285 
 
 •wholly external to the lung, meeting with no obstacle to their increase 
 in size, often attain a great magnitude without at all compromising the 
 integrity of the trachea. Those, however, which are in contact with 
 the secondary and tertiary bronchi, and are imbedded in the pulmonary 
 substance (which prevents their attaining any considerable size), not 
 infrequently perforate the tube in the manner above described, — and 
 this not only after they have become softened, but even while the 
 tubercle they contain is still in the crude state. 
 
 Although the progress of the tubercular degeneration is most obvious 
 in those glands which are situated near to the larger air-tubes, yet it is 
 by no means limited to them, but is in many instances observed also in 
 the pulmonary glands which are imbedded in different parts of the sub- 
 stance of the lungs. They do not, however, become enclosed within a 
 cyst as dense and resisting as that which surrounds the tuberculous 
 bronchial glands ; while in a great number of instances the pulmonary 
 substance for a short distance around them presents a far more abundant 
 tubercular deposit than is apparent in any other part of the lungs. If 
 a tuberculous gland, thus imbedded in the tissue of the lung, should 
 become softened, the excavation thereby produced may easily be mis- 
 taken for a cavity in the lung itself. A pulmonary cavity of such small 
 dimensions, however, is hardly ever solitary, unless it proceeds from 
 the softening of tubercular infiltration ; but the deposit of tubercle 
 which takes place in the neighbourhood of a diseased pulmonary gland 
 is always in the form of distinct deposits — not of tubercular infil- 
 tration. 
 
 Tuberculization of the glands does not occasion perforation merely of 
 the bronchial tubes, but in some rare instances the oesophagus, trachea, 
 and pulmonary artery, have been perforated by the same process as is 
 usually limited to the air-tubes. 
 
 In some cases in which tuberculization has never advanced far, it 
 comes to a stand-still, and the tubercle itself undergoes the cretaceous 
 change. This, however, is a rare occurrence, for it has come under my 
 notice only in six out of seventy-two cases; though, on the other hand, 
 it is more frequent than in the lung, in which it has come under my 
 notice in the child only in one instance. In two other instances, the 
 contents of the bronchial glands, though not actually cretaceous, were 
 very dry and friable, as if the more fluid constituents of the tubercle 
 had been removed, and the cretaceous change were about to commence. 
 This change has never come under my notice as having taken place in 
 any gland which had attained considerable size in consequence of the 
 deposit of tubercle in it, nor have I ever seen it when the tuberculization 
 of the glands was general, or when the lungs showed evidence of general, 
 or advanced, phthisical disease. 
 
 The symptoms of 'phthisis in early life resemble in many respects 
 those which characterise the disease in adult age, while the points of 
 difference become fewer and fewer in proportion as the child grows older, 
 until they cease altogether at the period of puberty. During childhood, 
 however, even those cases which run a course most similar to that of 
 ordinary phthisis in the adult are in general distinguished by the absence 
 of haemoptysis at any stage of the affection, — the absence of expecto- 
 
286 SYMPTOMS OF PHTHISIS. 
 
 ration, or its very rare occurrence, — the comparative slightness of the 
 cough, and the rarity of those colliquative sweats which so much exhaust 
 the grown person. In many instances the child droops, loses its appetite, 
 and flesh, and strength, and complains of vague pains in the chest and 
 abdomen for many weeks before the occurrence of cough excites any 
 apprehension that the lungs are the seat of disease. When the cough 
 does come on, it is slight, short, and dry, and attracts attention by its 
 frequency, rather than by the discomfort which it occasions the child. 
 Its usual amusements cease to occupy the child, who sits about, listless 
 and fretful in the day-time, while the skin often grows hot and dry, and 
 the lips become parched as night approaches ; but there is so little that 
 is definite in these symptoms, that they are not infrequently supposed 
 to indicate the existence of remittent fever, or to be due to the presence 
 of worms in the intestines. 
 
 It is important to bear in mind, that strumous dyspepsia, as it has 
 been called by many writers, is of more frequent occurrence in child- 
 hood than in adult age, and that its symptoms may be all that marks 
 the advance of phthisis in the lungs until within a month or two of the 
 patient's death. A definite commencement can almost always be assigned 
 to an attack of remittent fever; and the great heat of the skin, the 
 very rapid pulse, the intense thirst, and the delirium at night, which 
 attend it even in its less severe forms, are symptoms which, if borne in 
 mind, would prevent our mistaking for it those slighter and more vague 
 ailments that are experienced during the first stage of phthisis. The 
 referring the symptoms of incipient consumption to the presence of 
 worms in the intestinal canal, is a mistake even less excusable ; the 
 natural temperature of the skin, and natural frequency of the respira- 
 tion, — the appetite at one time as ravenous as it is deficient at another, 
 — the tongue either clean and moist, or else thickly coated, — the con- 
 dition of the bowels, which is generally one of constipation, and the 
 marked relief that almost always follows the action of purgatives, — are 
 indications of the presence of worms sufficiently characteristic to guard 
 the attentive observer from error. 
 
 Fluctuations take place in the child's condition, and a casual attack 
 of bronchitis often seems to be the exciting cause of that aggravation 
 of the pulmonary symptoms which is observed before long. The respi- 
 ration now becomes habitually quicker than natural, instead of merely 
 being easily accelerated, and is often attended with considerable 
 wheezing : the cough grows more frequent and lasts longer, but is still 
 in most instances unattended with expectoration, owing to the circum- 
 stance that the child almost always swallows those matters which the 
 adult would spit up. The loss of flesh, and the decay of strength, 
 advance even more rapidly than the signs of pulmonary disease. Well- 
 marked hectic, however, is infrequent ; and if night sweats occur, they 
 are often limited to the head and face. Towards the elose of the disease 
 the mouth often becomes aphthous, especially in infants : but though 
 diarrhoea sometimes occurs, it does not often seem to contribute so 
 much to the exhaustion of the child as to that of the adult, and that 
 alternation of diarrhoea and hectic sweats, which is often observed in 
 the grown person, is seldom or never observed in the child. When 
 
PECULIARITIES IN THE SYMPTOMS OF BRONCHIAL PHTHISIS. 287 
 
 death at length takes place, it either occurs from exhaustion, or suc- 
 ceeds to some intercurrent attack of bronchitis or pneumonia. 
 
 In those cases in which tubercle has been deposited in great abun- 
 dance in the bronchial glands, constituting what is called bronchial 
 phthisis, the symptoms deviate still more from those which are usually 
 observed in the adult. Bronchial phthisis occurs in its best marked 
 form between the ages of two and six years, although, as it is scarcely 
 necessary to observe, tuberculization of the glands is by no means 
 limited to that age. Its symptoms in many instances first become dis- 
 tinctly evident after some severe bronchitic seizure, which either 
 accompanied measles or came on without any apparent exciting cause. 
 In other cases, although the commencement of the affection is not 
 clearly traceable to a single attack of severe bronchitis, yet the patients 
 in whom it occurs had in all probability been subject to frequent returns- 
 of catarrh or bronchitis, which, though not alarming in their symptoms, 
 yet left behind them a cough that never entirely subsided. By degrees 
 this cough becomes severer : it returns in paroxysms not unlike those 
 of pertussis : it sometimes induces efforts to vomit, and can scarcely be 
 distinguished from the cough of the earlier stages of hooping-cough. 
 The respiration grows habitually oppressed and wheezing, the face 
 becomes puffed and swollen, the veins of the neck distended, just as in 
 patients with heart disease, and the superficial vessels of the thorax 
 become enlarged, just as those of the abdomen do in cases of ascites, 
 or of mesenteric disease. 
 
 The great fluctuations which take place in the condition of the patient 
 constitute one of the most striking characteristics of this form of 
 phthisis. Attacks of bronchitis sometimes come on, during which the 
 respiration becomes painfully accelerated and oppressed, and the paroxys- 
 mal cough is merged for a time in a constant hacking, or in suppressed 
 attempts at coughing. These bronchitic symptoms, which often seem 
 to threaten life, and which sometimes actually destroy it, clear up by 
 degrees in the majority of cases, but leave the child with a severer 
 cough and a more hurried respiration than before, while it loses flesh 
 rapidly, and not infrequently sweats a good deal about the head and 
 upper part of the trunk. Accommodation of posture, too, in many 
 instances becomes necessary to the comfort of the little patient, who 
 perhaps can breathe only when supported in its mother's lap, or 
 when much propped up in bed. It is seldom, when the disease has 
 reached this degree of severity, that there is not also so large a 
 measure of tuberculous affection of the lungs and other viscera as to 
 render recovery quite hopeless, and the characteristic signs of bronchial 
 phthisis become lost by degrees in those of ordinary consumption. 
 Sometimes, however, a long pause takes place in the progress of the 
 disease, even though thus far advanced : the cough, which had acquired 
 fresh intensity, gradually abates, — the respiration is no longer habitually 
 wheezing — the patient can repose in any attitude, — the flesh lost is 
 regained, — and, were it not that cough still continues, though less 
 frequent and less severe, that the breathing is more hurried than 
 natural, and that auscultation contributes still further to undeceive us, 
 — we might fancy that all ground for anxiety was passing away, and 
 
288 SYMPTOMS OF BRONCHIAL PHTHISIS. 
 
 that the child was on the high road towards recovery. In some cases, 
 too, in which symptoms such as have been described are observed, 
 recovery does eventually take place. It is seldom possible to say in 
 any case by what means this recovery is brought about; sometimes, no 
 doubt, the tubercular matter makes its way into the air-tubes, and is 
 got rid of by expectoration. Once I observed the disappearance of 
 most well-marked general signs of consumption, in the case of a girl 
 eight years old, during the copious expectoration of a tenacious mucus, 
 in which were small quantities of a substance like broken-down cheese, 
 or grains of boiled rice, and which alternated with an expectoration of 
 thick, puriform matter, more or less tinged with blood. In the case of 
 this child an attack of measles, while in her seventh year, had been 
 succeeded by cough, the formation of abscesses in her neck, and a 
 frequent, puriform, and sanguineous discharge from her nose. These 
 abscesses had not been long healed when her mother's alarm was excited 
 by her expectorating blood mixed with the phlegm which she brought 
 up when coughing. Though not much emaciated, the child looked 
 unhealthy ; ber pulse was very feeble, and there were many small 
 petechias on her extremities. The lungs, however, were tolerably free 
 from disease ; for nothing more was heard during auscultation than a 
 good deal of rhonchus mixed with some moist sounds, which were most 
 evident at the. upper part of the chest. Expectoration such as I have 
 described continued for nearly three months, in the course of which 
 time the child by degrees lost her cough, and gained strength under 
 the use of steel and other tonics. Two years afterwards no ausculta- 
 tory signs of disease were perceptible, except a little creaking under 
 both clavicles ; and at the end of five years even this disappeared. 
 
 The fatal termination of bronchial phthisis usually takes place in 
 consequence of the lungs becoming seriously involved in the tubercular 
 disease, though life is sometimes suddenly cut off by haemoptysis, owing 
 to the perforation of one of the larger vessels of the thorax by a tuber- 
 culated bronchial gland. It must not, however, be supposed that this 
 is the only means by which fatal haemorrhage is produced, for it takes 
 place in other instances under precisely the same circumstances as in 
 the adult. Five cases of fatal haemoptysis have come under my notice 
 in children ; but in three, no examination was made after death. In 
 the fourth case, which was that of a boy between five and six years old, 
 who died at the end of nine months' illness, blood pouring in abundance 
 from his nose and mouth, the amount of disease, both of the lungs and 
 bronchial glands, was very considerable; but no large vessel had been 
 perforated, and it was not possible satisfactorily to determine the source 
 of the haemorrhage. In the fifth case, that of a little boy five years old, 
 in whom symptoms of pneumonia had supervened upon previous signs 
 of phthisis, the source of the bleeding in the single and fatal attack 
 of haemoptysis which took place at a time when he seemed recovering, 
 likewise eluded the most careful anatomical investigation. 
 
 A very considerable degree of tuberculization of the bronchial glands, 
 is by no means uncommon even in very early infancy ; but it then 
 generally forms only a part of such extensive tubercular disease, that 
 its special symptoms are lost in those of the general malady. In such 
 
PHTHISIS CONTINUED. 289 
 
 cases, too, it frequently occurs that the signs of thoracic disease are 
 almost entirely merged in those of generally defective nutrition. The 
 existence even of a large cavity in the lung may be announced in early 
 infancy by nothing more serious than some acceleration of the breathing 
 and an occasional short cough ; while the frequent vomiting, — the 
 irregular, often relaxed, condition of the bowels, — the unhealthy evacu- 
 ations, — the red tongue, and the aphthous state of the mouth, — may 
 direct the attention almost exclusively to the condition of the digestive 
 organs. 
 
 Many points still remain for our investigation, but we must postpone 
 their consideration, and the study of the auscultatory phenomena of 
 the disease, to the next lecture. 
 
 LECTUEE XXV. 
 
 Phthisis, continued. — Peculiarities of its auscultatory signs in early life — some of less 
 value than in the adult — influence of tuberculous bronchial glands in exaggerating the 
 signs of disease of the lung — difficulty in appreciating some signs which are "well 
 marked in the adult — sign peculiar to early life. 
 
 Different forms of phthisis — acute phthisis ; illustrative case— tuberculous pneumonia — 
 bronchitis grafted on phthisis may lead to an over-estimate of the tuberculous disease. 
 
 Duration of phthisis ; its course sometimes extremely chronic — cases in illustration. — 
 Modes of death in phthisis — head symptoms sometimes precede death, independent of 
 cerebral disease. 
 
 Prophylaxis, and treatment of phthisis. 
 
 It would be little better than a waste of your time to enter into a 
 minute description of all the modifications of the respiratory sounds 
 to which the presence of tubercle in the lungs of children may give 
 occasion : our time will be better spent than in such detail, if we direct 
 our attention to those respects in which the auscultatory signs of 
 phthisis in childhood differ from those which betoken its existence in 
 the adult, or in which the same auscultatory phenomena require a 
 different interpretation at the one period of life, from that which is 
 justly applied to them at the other. 
 
 The grand difference, indeed, is to be sought in the latter rather 
 than in the former of these respects. Tubercle, at whatever age it is 
 developed in the lungs, gives rise to much the same auscultatory 
 phenomena ; but many of those modifications of the respiratory sound 
 which would warrant us in pronouncing positively that phthisis existed 
 in the adult, cannot be relied on with the same certainty in the child : 
 still less can they be regarded as proving the existence of so large an 
 amount of disease in the latter case as in the former. It may be 
 stated, then, that 
 
 1st. Many of the auscultatory signs of phthisis deserve less reliance, or 
 have a less grave import, in the child than in the adult. 
 
 One of the earliest signs of tubercular deposit in the lungs of the 
 
 19 
 
290 
 
 AUSCULTATORY SIGNS OF PHTHISIS IN CHILDREN. 
 
 grown person is furnished by that peculiar modification of the respira- 
 tory sound, to which the name of coarse breathing has been applied ; 
 and this acquires still greater importance, when associated, as it often 
 is, with dry-rhonchus and creaking sounds. Much of the value of this 
 sign depends on its being limited to the infra-clavicular regions, or, at 
 least, heard there with much greater distinctness han elsewhere In 
 children, however, the deposit of tubercle in the lungs being more 
 uniform, and more generally diffused, the additional value which the 
 localization of these signs furnishes is lost ; and it becomes impossible 
 to determine whether the bronchial irritation which they betoken is 
 induced by the presence of tubercle in the lungs, or by some other 
 cause. 
 
 Prolongation of the expiratory sound beneath the clavicle, and inter- 
 rupted respiration, — the respiration saccadee of French authors, — 
 which are two of the earliest and most important indications of phthisis 
 in the grown person, are, on the whole, of less value in the child. 
 Their occurrence, indeed, should always excite suspicion as to the 
 existence of phthisis, but they are not infrequently very well marked 
 in cases where but slight disorder of the respiratory organs is present ; 
 and where the perfect recovery of the child, and its subsequent sound 
 health, prove that tubercular disease either was altogether absent or 
 at any rate was extremely slight. 
 
 The exaggeration of these two signs is probably, in some measure, 
 due to a cause which adds greatly to the intensity of some other of those 
 auscultatory phenomena that usually betoken far advanced phthisis. 
 MM. Rilliet and Barthez were, I believe, the first who pointed out the 
 fact that the bronchial glands, when enlarged by the deposit of tubercle, 
 and thus brought into contact with the walls of the chest, which they 
 do not touch in the healthy state, conduct to the ear of the auscultator 
 sounds that under other circumstances are inperceptible. The air 
 passing through the larger bronchi is now heard, on applying the 
 stethoscope to the walls of the chest, in the supra-scapular, and less 
 often in the infra-clavicular region, and can scarcely be distinguished 
 from bronchial breathing produced by solidification of the pulmonary 
 tissue itself. The sounds which are caused by the presence of mucus in 
 the larger air-tubes are in the same way conducted to the ear in other 
 situations than those, — such as the root of the lung, where alone they 
 would be heard if the glands were not enlarged. The auscultator may 
 thus be betrayed into the error of supposing that hopeless phthisis 
 exists, in cases where yet the amount of disease in the lungs is but 
 small, and where life may be prolonged for many years. Morbid 
 sounds, too, produced in one lung, may thus be conducted to the walls 
 of the chest on the opposite side, and the extent of disease may, in 
 consequence, be overrated ; or the sounds which, when perceived in the 
 front of the chest, may arise from real disease existing there, being 
 transmitted to the back through the medium of the glands, may thus 
 give rise to the conclusion that far more serious mischief exists than is 
 really the case. The means of avoiding error from this cause consist 
 in the careful comparisons of the results of auscultation with those of 
 percussion, and of those of auscultation on one day with those which it 
 
PECULIARITIES OF THE AUSCULTATORY SIGNS OF 291 
 
 yields a few days afterwards. If the sounds proceed from solidification 
 of the lung, or from cavities in its substance, the results of auscultation 
 will be as invariable as those of percussion ; but if they be merely 
 sounds transmitted from the larger air-tubes, they will be found to vary 
 much on different occasions ; while the dulness on percussion in certain 
 parts will continue unchanged, inasmuch as it proceeds from the 
 presence of the enlarged glands. This variability in the results of 
 auscultation is one of the most important indications of bronchial phthisis. 
 It depends not merely on the accidental variations in the sounds pro- 
 duced in the larger air-tubes, but also on the changes which the varying 
 degree of compression of the bronchi, produced by the increase or dimi- 
 nution in the size of the glands, may occasion, and on the variations in 
 the irritation of the air-tubes which this pressure produces. The risk 
 in cases of bronchial phthisis is not so much that of forming an alto- 
 gether erroneous diagnosis, as of expressing a prognosis far more 
 unfavourable than the nature of the case actually justifies. In cases 
 where a considerable measure of bronchitis is associated with tuber- 
 culization of the glands, we are especially likely to fall into this error, 
 and can avoid it only by much caution, and by frequently repeated 
 auscultation. 
 
 There are differences of another kind, however, between the results 
 of auscultation in cases of phthisis in the young and old, and which 
 depend 
 
 2d. On the absence, or difficult appreciation, of some auscultatory 'phe- 
 nomena in the child, to which much value is attached in the case of 
 the adult\ 
 
 To this head belong those differences which result from the loss in 
 the child of almost all that information which, in older persons, is 
 afforded by the different modifications of the vocal resonance. The shrill 
 voice of the child, the small power of modulating it which is possessed 
 in early life, and the consequent difficulty of inducing the patient to 
 utter a few sentences, or even a few words, in the same key, even when 
 fear does not reduce the voice to a mere whisper, take away almost all 
 value from the modifications of the voice-sound in young subjects. 
 
 The extreme excitability of children tends, as it does also in the 
 female subject, to reduce very low the value of mere inequality of breath- 
 ing between the two lungs ; for it is by no means a rare occurrence for 
 the lung which on one day seemed to admit but little air, to yield the 
 sounds of well-marked puerile respiration on the next day, and for the 
 feeble respiration to have changed sides. Before, therefore, any con- 
 clusion can be drawn from the feebleness of the respiration in either 
 lung, its situation, degree, and extent, must be confirmed by repeated 
 observation. 
 
 The finer variations in the sonoriety of the chest are not so easily 
 distinguished in childhood as in more advanced age. The main cause 
 of this appears to be furnished by the extreme resonance of the chest 
 in early childhood, which will admit of very considerable reduction 
 before percussion elicits a sound that the ear would recognise as at all 
 
292 PHTHISIS IN CHILDHOOD. 
 
 dull. Extremely gentle percussion is much more likely to elicit the 
 more delicate variations of sound, than those smart taps of the chest, 
 which, in the grown person, will often answer the purpose sufficiently 
 well. 
 
 A last source of difference may be mentioned as arising 
 
 Zd. From the occurrence of some physical signs peculiar to the form 
 which phthisis assumes in early life. 
 
 The only sign that comes with propriety under this category, is that 
 dulness between the scapulae which is not unfrequently produced by the 
 presence of tuberculous glands, and which, when it coexists with tolera- 
 ble resonance over the upper part of the lungs, and moderately good 
 respiration in these situations, may be regarded as pathognomonic of 
 bronchial phthisis. The absence of dulness in this situation, however, 
 does not of itself warrant the inference that the glands are free from 
 disease, but merely that they have not yet attained any very considerable 
 degree of enlargement. 
 
 It may perhaps be useful, before we proceed to the study of some 
 other peculiarities of phthisis in childhood, briefly to recapitulate the 
 general characteristics of the disease in early life. The chief of these 
 are — 
 
 1st. The frequent latency of the thoracic symptoms during its early 
 stages. 
 
 2d. That almost invariable absence of haemoptysis at the commence- 
 ment of the disease, and its comparatively rare occurrence during its 
 subsequent progress. 
 
 3rd. The partial or complete absence of expectoration. 
 
 4th. The rarity of profuse general sweats; and the ill-marked 
 character of the hectic symptoms. 
 
 5th. The frequency with which death takes place from intercurrent 
 bronchitis or pneumonia. 
 
 Bronchial phthisis is characterized by — 
 
 1st. The frequent development of its symptoms out of one or more 
 attacks of bronchitis. 
 
 2d. The peculiar paroxysmal cough which attends it, resembling 
 that of incipient pertussis. 
 
 3d. The great and frequent fluctuations in the patient's condition, 
 and the occasional, apparently causeless, aggravation, both of the 
 cough and dyspnoea. 
 
 In very early infancy, phthisis is remarkable for the very frequent 
 latency of the chest symptoms, which, through its entire course, are 
 often entirely merged in the signs of impaired nutrition. 
 
 The most important peculiarities in the auscultatory phenomena of 
 consumption in the child are — 
 
 1st. The smaller value of coarse respiration, prolonged expiration, 
 
COURSE OF THTHISIS SOMETIMES VERY RAPID. 293 
 
 and interrupted breathing, owing to their general diffusion over the 
 chest, and to their occasional existence independent of phthisis. 
 
 2d. The apparent, and to some extent the real, exaggeration of the 
 signs both of early and of far-advanced disease of the lungs, in some 
 cases of bronchial phthisis. 
 
 3d. The loss of that information which the phenomena of the voice 
 furnish in the case of the adult. 
 
 4th. The small value of inequality of breathing in the two lungs. 
 
 5th. The difficulty of detecting minute variations in the sonoriety of 
 the chest; and 
 
 6th. The existence of dulness in the interscapular region, together 
 with moderate resonance of the upper parts of the chest, and tolerably 
 good respiration there, which are characteristic of the presence of 
 enlarged bronchial glands. 
 
 Hitherto we have been occupied with the study of the more common 
 forms of phthisis in childhood; but deviations are occasionally met with 
 from the ordinary course of the disease, with which it behoves us to 
 .make ourselves acquainted. Phthisis occasionally runs a course so 
 extremely rapid that many of its most characteristic symptoms have 
 not time to manifest themselves. In such cases we are exposed to 
 considerable risk of error, for the history of the patient's indisposition 
 goes back only to a few weeks or days; the evidence of impaired 
 nutrition is almost or altogether wanting, and the symptoms appear to 
 be those of an acute malady coming on suddenly, rather than those of 
 a slow and wasting disease. 
 
 A remarkable instance of this came under my notice some years ago, 
 in the case of a little boy, nine months old, who was fat and ruddy, 
 and had always had perfectly good health until the 10th of April. 
 On that day he was taken with symptoms which his mother supposed to 
 be those of a bad cold. On account of this he was kept in the house, 
 and various domestic remedies were employed, though without any 
 improvement, and on April 24th he came under my notice. There did 
 not then appear to be any urgent symptom, though the child seemed 
 much oppressed at the chest. The case appeared to be one of rather 
 severe catarrh, occurring during the period of dentition. The gums 
 were lanced, and a mixture containing the vinum ipecacuanha was 
 ordered, to which, finding the symptoms did not abate, small doses of 
 antimonial wine were added on the 27th. On the 30th I was informed 
 that the child was much worse, that his dyspnoea was greatly increased, 
 and that his hands and feet had been swollen for the last forty-eight 
 hours. I found the little boy breathing fifty times in the minute, with 
 great oppression at the chest, the face much flushed, the skin dry, the 
 trunk hot, the limbs cool, and the hands and feet much swollen. Aus- 
 cultation detected generally diffused small crepitation through both 
 lungs, with indistinct bronchial breathing at the upper and back part 
 of the left side. Three hours after this visit, the child died without a 
 struggle, on being lifted out of bed for his mother to apply some leeches 
 to his chest. On examining the body after death, a very thick layer 
 of fat was found everywhere beneath the integuments. The lungs 
 
294 ILLUSTRATIVE CASE — TUBERCULOUS PNEUMONIA. 
 
 presented an extreme degree of tubercular degeneration, and many of 
 the bronchial glands were enlarged by the morbid deposit to the size of 
 a pigeon's egg. None of the tubercles in the lungs were softened, but 
 it existed both in the form of yellow miliary tubercle, of tubercular 
 infiltration, and of masses of crude tubercle, formed by the agglomera- 
 tion of many separate deposits. The pulmonary substance in the 
 intervals between the tubercular deposits was of a bright red colour, in 
 the first stage of pneumonia, and in many parts bordering on the second 
 stage, and there was very considerable injection of the bronchial tubes. 
 The various abdominal viscera contained tubercle, but it was > not far 
 advanced in the mesenteric glands. 
 
 This case represents a class in which there is much hazard of forming 
 an erroneous diagnosis. It shows the possibility of tubercular deposit 
 taking place to a very great extent without at all interfering with the 
 general nutrition of the body, and without giving rise to any symptom so 
 serious as to attract the notice of a very careful and affectionate mother. 
 It illustrates also the mode in which the fatal termination of many 
 cases of phthisis in children is brought about, and suggests the inquiry 
 whether there be any means of distinguishing between tuberculous pneu- 
 monia, and pneumonia which occurs uncomplicated with phthisical 
 disease of the lungs. 
 
 Pneumonia often complicates phthisis in early life, under circum- 
 stances in which no diagnostic difficulty occurs ; but it is of much 
 importance to detect the consumptive element in cases which to the 
 superficial observer present no other symptoms than those of acute 
 inflammation of the lungs. The existence of a considerable amount of 
 tubercular deposit in the lungs may be suspected in those cases in which 
 the degree of oppression of the chest has, from the very commence- 
 ment of the illness, been altogether out of proportion to the severity of 
 the catarrhal or bronchitic symptoms with which the disease set in. A 
 further evidence of its nature is afforded, if the skin, though very dry, 
 present a less considerable or a less pungent heat than attends simple 
 pneumonia, while the pulse from the very outset is less developed. 
 Suspicion would be strengthened if the frequency of respiration very 
 greatly exceeded the amount of mischief disclosed by auscultation, and 
 especially, if the rapidity of the breathing, though so great that it 
 would excite the most serious alarm if the case were one of pneumonia, 
 should yet continue the same for days together without marked dete- 
 rioration in the patient's condition. Auscultation also would throw 
 much light on the nature of the case, for the sounds detected in the 
 chest would be the subcrepitant and mucous rales, rather than the small 
 crepitation of pneumonia; while, though the smaller sounds would be 
 discovered at the lower part of the chest, the greatest dulness on per- 
 cussion would generally be detected at the upper part, and bronchial 
 breathing would very likely be perceived more or less distinctly in the 
 same situation. 
 
 The importance of distinguishing those cases in which inflammation 
 supervenes in a lung already the seat of tubercular deposit, from others 
 in which the organ had been previously healthy, is by no means confined 
 to cases of the severest kind, in which life is immediately threatened. 
 
DIFFERENCES BETWEEN SIMPLE AND TUBERCULOUS PNEUMONIA. 295 
 
 In every instance of pneumonia in early life, both your prognosis and 
 your treatment would be greatly modified if there were good ground for 
 believing that tubercular disease had for some time previously affected 
 the lungs. Hence follows the necessity for that very minute inquiry 
 as to the previous health of the patient, and of the other members of 
 the family, on which so much stress was laid at the commencement of 
 this course of lectures. If you learned that several children in the 
 family had already died of phthisis or of some other affection, — such as 
 acute hydrocephalus, which you knew to be most intimately associated 
 with the tuberculous diathesis, the possibility of the same complication 
 existing in the patient under your care would at once occur to you. 
 This complication would be rendered highly probable, if you were to 
 ascertain that the child had been peculiarly liable to catch cold, or had 
 for some months been seldom free from cough for many days together, 
 or had suffered from cough every winter, for two or three years, and 
 had already experienced two or three attacks similar to that you are 
 called on to treat, and which, though severe, had yet subsided by 
 degrees, without the employment of very active measures. The proba- 
 bility would be raised almost to certainty if there existed that want of 
 correspondence between the general symptoms and physical signs, or 
 between the results of auscultation and percussion, to which reference 
 has already been made ; or if the history of the present illness went 
 back to a period anterior to that which you would be disposed to 
 assign to it, if the affection had been simple pneumonia. 
 
 The case of tuberculous pneumonia you would deplete more spar- 
 ingly, and would subject to less rigorous antiphlogistic measures than 
 that of simple inflammation of the lung. Bearing in mind the influence 
 of enlarged bronchial glands in rendering parts of the chest dull on 
 percussion, and in exaggerating in some respects the morbid sounds, 
 you would not over-estimate the degree or extent of the inflammatory 
 mischief. At the same time you would not allow even a considerable 
 measure of improvement to lead you to speak too decidedly of the 
 ultimate recovery of your patient; since you would not forget that, if 
 inflammation do not originate tuberculous disease, it may yet communi- 
 cate increased activity to its progress. 
 
 The overlooking the more serious malady, owing to its symptoms 
 being thrown into the shade by those of the other more curable affec- 
 tion, is not the only error to which you are exposed in cases of infan- 
 tile phthisis. The degree of irritation of the bronchi that exists in 
 different instances, varies exceedingly; sometimes it is so considerable, 
 that when the child is placed under your care its respiration is wheez- 
 ing, difficult, and very hurried, its cough violent and exhausting; while 
 such is the general anxiety of the countenance, and so great is the de- 
 pression of the vital powers, that the struggle seems as if it could not 
 be long protracted. Percussion detects dulness at the upper part of 
 the chest ; the bronchi are so laden with phlegm, that air scarcely 
 penetrates beyond the larger tubes, and mucous rale is heard through- 
 out the whole of the lungs, while at their upper part it is so large as to 
 amount almost to gurgling. You regrrd the case as one of far ad- 
 vanced phthisis, and suppose that softened tubercle is diffused through 
 
296 COMPLICATION WITH BRONCHITIS EXAGGERATES THE SYMPTOMS. 
 
 the whole of both lungs, and that cavities exist at their apex. You form 
 the most gloomy prognosis, and entertain, very probably express the 
 conviction, that a few weeks at furthest will be the period of your 
 patient's life. By degrees, however, the most urgent symptoms sub- 
 side, and some signs of returning health appear; the respiration grows 
 slower and more tranquil, the cough abates, perhaps almost ceases. 
 The signs of a cavity grow less and less distinct, in proportion as the 
 secretion in the bronchi diminishes ; and after some months, while the 
 patient's general condition deviates but little from a state of health, a 
 little dulness at the upper and back part of the chest, unequal breath- 
 ing, prolonged expiration, or morbid sounds equally slight, are the only 
 auscultatory evidence that the most careful examination can discover 
 of pulmonary disease. 
 
 Non-professional persons are apt to imagine the mistake in cases of 
 this kind to have been greater than it really was. The error is one as 
 to the degree of the malady, rather than as to its kind. In cases that 
 present these symptoms, phthisis has in reality existed, but the chief 
 tubercular deposit has probably been seated in the bronchial glands, 
 and their enlargement gave rise to much of the dulness on percussion, 
 and exaggerated the morbid sounds at the upper part of the chest. 
 Erom some accidental cause, such as cold or damp, or from the mucous 
 membrane of the bronchi sympathizing with disorder of the digestive 
 organs, or from inappropriate treatment which aggravated the evil it 
 should have relieved, or even without any cause that we can assign, it 
 had come to pass that the air-tubes were in a state of great irritation. 
 The due regulation of temperature, generally appropriate treatment, 
 and nature's own healing power, improved the general health and 
 diminished the irritability of the bronchi ; while very probably the dis- 
 eased glands emptied themselves, at least in part, into the air-tubes, 
 and the tubercle was thus eliminated from the system. You should, 
 therefore, always express your opinion very guardedly with reference 
 to the condition of a child suffering from phthisis, until you have con- 
 firmed the results of auscultation by its frequent repetition, and till you 
 have had the opportunity of determining how large a portion of the 
 physical signs is due to the morbid deposit, and how much to that irri- 
 tation of the bronchi which you may fairly hope to mitigate, if not to 
 remove. 
 
 The average duration of phthisis in childhood, is estimated by MM. 
 Rilliet and Barthez at from three to seven months, though, as they 
 justly observe, its extreme limits vary from two months in unusually 
 rapid cases, to two years and upwards in other instances, in which the 
 course of the disease is very protracted. It is my impression, indeed, 
 that the ordinary duration of phthisis in childhood is less brief than the 
 observations of these gentlemen, made among the children in the 
 Hopital des Enfans at Paris, have led them to believe ; though the 
 number of observations on which this impression rests is too limited to 
 warrant my asserting it as a positive fact. Many cases, however, have 
 come under my notice in which the course of well-marked phthisis has 
 been extremely tardy, and some instances in which the disease has 
 continued for two, three, four, and nearly five years, before it termi- 
 nated fatally. 
 
CHRONIC PHTHISIS. 297 
 
 So little notice has been taken of this chronic form of phthisis in 
 children, that it may be "well to relate a few examples of it. In March, 
 1842, I saw a little girl, six years old, whose father had died of phthisis, 
 and who had had a cough ever since she suffered from measles two and 
 a half years before. Her mother's anxiety had been excited by the 
 increase of this cough, and by the child's losing flesh during the few 
 weeks previous to her coming to me. Auscultation at this time disco- 
 vered that air entered the lung in the left infra-clavicular region more 
 scantily than in the right, and that the respiration was coarse, and 
 attended with much creaking at the upper part of both lungs. In May, 
 the general symptoms were much improved, and the creaking sounds 
 were no longer heard. For many months the child continued to appear 
 tolerably well, though her cough never ceased entirely ; but in the 
 early part of the winter of 1844 her health completely failed. Exami- 
 nation of the chest in the beginning of December elicited great defi- 
 ciency of resonance at the upper part of the left lung, both in front 
 and behind. Bronchial breathing, intermixed with large mucous rale, 
 was heard in the left supra-scapular region, and abundant moist sounds 
 pervaded the lung posteriorly. In the left infra-clavicular and mam- 
 mary regions the respiration was very deficient, and accompanied with 
 distant moist sounds. Extreme coarseness of the respiration was the 
 only morbid sound heard at the upper part of the right lung, and the 
 breathing on that side was puerile in other parts. In January, 1845, 
 the child had slight hsemoptysis, which recurred occasionally at intervals 
 of a few weeks or months until her death, but was not profuse at any 
 time. In September, 1845, resonance was slightly impaired under the 
 right clavicle,; and also in a greater degree posteriorly, as far as the 
 angle of the scapula. ' There was absolute dulness of the left side, as 
 far as the nipple in front, and the angle of the scapula behind. There 
 was no natural breathing in the left lung, but the respiration was bron- 
 chial, and accompanied with large mucous rale as low as the nipple ; 
 the rale being smaller, and the admission of air scanty, below that 
 point. About the left scapula there were cavernous sounds and distinct 
 gurgling, smaller moist sounds lower down. In the right lung the 
 respiration was puerile in front, except quite at the upper part, where 
 the breathing was coarse, and attended with mucous rale ; and poste- 
 riorly the same characters were still more marked. 
 
 It cannot be necessary to detail the results of the subsequent exami- 
 nations of the chest, which showed that disease advanced slowly in the 
 right lung, though there was at no time proof of the existence of a 
 cavity there. The child's condition fluctuated : sometimes she seemed 
 almost dying under an aggravation of all the symptoms, and then again 
 she rallied, and was able to walk about, and seemed tolerably comforta- 
 ble. Life was prolonged until June 1st, 1847 ; and she had seemed 
 almost as well as usual until a very few days before her death. 
 Unfortunately, permission to examine the body could not be obtained ; 
 but the stethoscopic signs enable us to trace back the phthisical disease 
 for more than five years, while the evidence of a large cavity in the 
 left lung was distinct twenty-one months before death took place. 
 
 Nor is this a solitary case. In January, 1846, I saw a little boy, 
 
298 CASES IN ILLUSTRATION. 
 
 three years old, who had had cough ever since an attack of typhoid 
 fever in the previous July ; and for six weeks before he came under my 
 notice his cough had grown more severe. There was then very marked 
 flattening of the left side of the chest, which yielded a dull sound on 
 percussion in the infra-clavicular and mammary regions; and air 
 entered there very scantily. The same dulness existed on the left side 
 posteriorly ; and the scanty breathing was attended with a crumpling 
 sound. In April, moist sounds w r ere evident there ; and in May they 
 w T ere becoming larger about the left scapula ; and signs of incipient 
 disease were now perceptible in the right lung. In September, there 
 was absolute dulness in the left infra-clavicular region, slightly dimin- 
 ishing towards the nipple, and absolute dulness in the left scapular 
 region. Large gurgling was heard in this situation, most marked 
 behind, and rendered very striking during a fit of coughing, which w r as 
 followed by expectoration of about a teaspoonful of pus. From this 
 time to the present he has continued nearly stationary. The child is 
 considerably stouter than he was when he first came under my notice ; 
 but the cough and purulent expectoration continue. I auscultated his 
 chest on Sept. 26, 1847, and at that time loud blowing respiration was 
 heard over the whole of the left scapula, accompanied with gurgling ; 
 while, lower down, there were large moist sounds, though not amounting 
 to actual gurgling. From that time until August 1848, the child's 
 health continued tolerably good ; he coughed but little, but suffered 
 from occasional attacks of diarrhoea. The left side of his chest was 
 much shrunken, and yielded a dull sound every where except just under 
 the clavicle. Air entered but scantily ; moist sounds attended it, but 
 the evidences of a large cavity were growing less and less distinct. In 
 June 1849, I saw him for the last time ; the amount of air entering the 
 left lung was not increased, but the moist sounds had almost completely 
 disappeared. 
 
 How long the disease may continue, or what may be the ultimate 
 issue of the case, it would be useless to speculate on ; though it is by no 
 means unlikely that the child may live, with but little deterioration in 
 his condition, until measles or hooping-cough imparts a fresh stimulus 
 to the consumptive disease, or excites some fatal attack of bronchitis or 
 pneumonia. I used to see occasionally a little boy, who was aged only 
 three years when he first came under my notice, and whom 1 had the 
 opportunity of watching till he was eleven years old. When first brought 
 to me he had been suffering from cough ever since an attack of what 
 his mother called inflammation of the lungs, when he was sixteen 
 months old: his cervical glands had recently suppurated; he had 
 unusually well-marked hectic fever, and profuse night sweats ; and a 
 month before I saw him had spat blood once. His right side yielded 
 throughout a dull sound on percussion : breathing in that lung was 
 scanty, and attended with large moist sounds. The child went into 
 Devonshire to pass the winter, and, as I expected, to die there of 
 phthisis ; but he returned in better health ; he grew tall, and played 
 about like other children, though he seldom passed more than a few 
 months without attacks of a pleuritic character, the pain of which he 
 used to refer to his right side, and which usually subsided in the course 
 
CASE OF CHRONIC PHTHISIS. 299 
 
 of a few days, without any treatment more severe than a mustard 
 poultice, and some diaphoretic medicine. His cough never left him 
 entirely ; but both that and the quantity and character of his expecto- 
 ration varied, and sometimes he spat a little blood. In October, 1844, 
 the auscultatory signs were as follows : — The left lung yielded, as it had 
 constantly done, the sounds of puerile breathing in front ; posteriorly, 
 the breathing in that lung was also good, except that there were some 
 moist sounds in the infra-scapular region, and that the breathing had 
 a coarse and almost tubular character about the upper angle of the 
 scapula. In the right lung, in front, the respiration was puerile, with 
 now and then a little distant crepitus, as low clown as the lower edge of 
 the second rib, at which point the moist sounds became larger. Pos- 
 teriorly there were large moist sounds, intermixed with puerile breathing 
 in the supra-scapular region ; gurgling, cavernous breathing, and 
 bronchial voice about the scapula; and lower down there was very little 
 respiration, and that of a bronchial character, becoming quite inaudible 
 in the lateral region. In the axillary region the respiration was coarse, 
 accompanied with large mucous rales. In March, 1849, I saw him for 
 the last time. He had then continued for more than eighteen months 
 free from any serious pleuritic attack, and from haemoptysis. His 
 respiration was still hurried, but he had gained flesh, and sometimes 
 walked five or six miles in a day without inconvenience. Auscultation 
 showed, too, that his disease had been stationary for the previous five 
 years, — if, indeed, it had not actually improved. The moist sounds 
 about the left scapula were smaller, and heard over a smaller surface. 
 The indications of a cavity in the back part of the right lung continued 
 unchanged, but not increased ; while in other respects auscultation gave 
 exactly the same results as before. Other cases of a similar kind have 
 come under my observation, in which the history of phthisis went back 
 for several years, and in which the signs of caverns in the lungs were 
 unmistakable ; the children continuing to lead a sort of valetudinarian 
 existence, improving in health, and gaining flesh and strength in the 
 summer, but losing ground again with the return of winter. 
 
 In the present condition of our knowledge, it is not possible to state 
 with certainty either the anatomical characters of phthisical cavities of 
 long standing, or the signs which, during the patient's life-time, would 
 warrant the expectation that the disease will run a tardy course; but 
 it is well to bear in mind, that such cases are by no means very rare ; 
 that the powers of repair are far greater in the child than in the adult. 
 We must now, therefore, pass on to notice briefly the treatment of the 
 disease, after glancing for a moment at the different modes in which it 
 brings about a fatal issue. 
 
 In a very large proportion of cases of phthisis, the functions of all 
 the organs of the body become at length so much disturbed, and nutri- 
 tion generally so impaired, that the patient dies, because the whole 
 machine is worn out. But though this is the case in many instances, 
 yet it often happens, even when the powers have long seemed nearly 
 exhausted, and the body is wasted almost to a skeleton, that death is 
 far from tranquil, but is preceded by hours of severe agony, for which 
 it is not easy to account. In many cases, and especially in those where 
 
300 MODES OF DEATH IN PHTHISIS. 
 
 the disease runs a rapid course, the fatal termination is due to an 
 attack of intercurrent bronchitis or pneumonia, which is sometimes 
 supposed to have been the patient's only disease, until a post-mortem 
 examination reveals the tubercular degeneration of the lungs, to which 
 the inflammatory affection was but secondary. Death from haemoptysis 
 is rare, and still rarer is the perforation of the lung, by the walls of 
 the cavity giving way at some point, and thus producing pneumothorax. 
 The abdominal symptoms sometimes mask the thoracic, and the patient 
 dies of tuberculous peritonitis, who, had life been prolonged, would 
 have sunk eventually under pulmonary phthisis. Many children, in 
 whom the signs of incipient phthisis have appeared, die of acute hydro- 
 cephalus, excited by the membranes of the brain having become the 
 seat of tubercular deposit ; and some, in whom the disease has attained 
 a more advanced stage, are suddenly carried off by head symptoms, the 
 cause of which is explained by the discovery of large masses of tubercle 
 in the cerebral substance. Convulsions, however, sometimes precede 
 death for several hours, or head symptoms of greater or less intensity 
 constitute the most striking feature in the patient's history for some 
 days before death takes place; and yet, an examination of the body 
 throws no light upon the cause of their occurrence. Sometimes, too, 
 the symptoms that precede death are those of fever of a typhoid 
 character, rather than of serious mischief in the chest. They were so 
 in the case of a little boy, nearly seven years old at death, who had 
 shown the symptoms of phthisis for more than two years, and the right 
 side of whose chest had during that time presented the indications of 
 gradually increasing tubercular deposit. The disease had advanced 
 slowly, and with long intermissions, though, on the whole, very mani- 
 festly increasing. On Nov. 8 there was a manifest aggravation of his 
 chest symptoms, attended with much fever. On the night of the 12th 
 his mind wandered, and, when sensible, he complained of his head. On 
 the 14th he became delirious likewise during the day ; and until his 
 death, which did not take place before Dec. 1, his mind wandered 
 during many hours of every day, while at night he was quite light- 
 headed, extremely restless, and tried to get out of bed, or at other 
 times shrieked loudly, as if in violent pain. In the early part of his 
 illness he had a frequent, short, cough, which subsided as the febrile 
 symptoms increased in intensity ; but his respiration throughout con- 
 tinued at about 50 in the minute ; and this hurried breathing, coupled 
 with the auscultatory signs, afforded the only evidence of the mischief 
 that was going on within the chest. After death the only morbid 
 appearance of any importance was discovered in the upper lobe of the 
 right lung. Its anterior fourth was perfectly solid and non-crepitant, 
 of a yellowish red colour, owing to the infiltration of tubercle into it. 
 Its posterior three-fourths were of a reddish colour, and of a much 
 softer texture: while the slightest pressure with the finger reduced 
 their substance to a putrilage, from which there flowed a dirty reddish 
 liquid, which seemed like a mixture of blood, and pus, and serum. 
 Inflammatory softening of this lobe seems to have been the cause of 
 death, though manifesting itself less by local symptoms than by the 
 signs of most serious constitutional disturbance. 
 
PROPHYLACTIC TREATMENT OF PHTHISIS. 301 
 
 Though the study of phthisis, in its effects and its symptoms, has 
 occupied us during almost the whole of two lectures, yet there need be 
 but little said with reference to its treatment. The main principles by 
 which we are to be guided in its treatment are the same at every age; 
 nor do the differences in the patient's years bring with them many or 
 important modifications in the means by which these principles are to 
 be carried into action. 
 
 Among the prophylactic measures adapted to early life, none is of 
 more importance than the keeping the infant at the breast for the first 
 twelve or eighteen months of its existence, by which time it will have 
 passed through some at least of the dangers incidental to the period of 
 teething. The task of thus nursing the infant, however, ought not to 
 be undertaken by a mother who has shewn any tendency to consump- 
 tion, or in whose family consumptive disease has been prevalent, but 
 ought at once to be entrusted to a healthy wet-nurse. This rule does 
 not rest on mere theoretical grounds ; but actual observation has shown 
 that under some morbid states of the system the milk undergoes great 
 changes, and loses much of its nutritive properties. In the case of the 
 cow, these changes have been ascertained by Dr. Klencke of Leipzic to 
 be very remarkable ; and analogical reasoning would warrant the belief 
 that the scrofulous taint in the human subject may give rise to altera- 
 tions of a similar kind. Dr. Klencke confirmed the observation of 
 Dr. Carswell and others, that stall-fed cows are very liable to become 
 tuberculous ; and found, moreover, that under those circumstances their 
 milk loses much or the whole of its sugar ; that the butter and casein 
 diminish, while albumen is found sometimes in as high a proportion as 
 15 per cent.^and elain in the proportion of 1-4 per cent., and that in 
 some cases lactic acid is likewise present. Even if we set aside the 
 assumption of scrofulous disease being actually transmitted through 
 the medium of the milk, of which there is perhaps no clear evidence, 
 it is yet apparent that a very slight degree of such an alteration in its 
 constituents as has just been mentioned must render it very unfit for 
 the nutriment of a delicate infant. / 
 
 It is needless to dwell here on the general rules for feeding and 
 clothing children as they grow older, or to insist on the necessity for 
 the bed-rooms being airy and well ventilated. When the damp and cold 
 weather of winter approaches, removal to a warmer climate, in which 
 exercise in the open air may still be continued, is much to be preferred 
 to keeping the child for weeks together a prisoner to the house ; and as 
 a general rule more is gained by change of climate in early life than in 
 adult age. In children who are old enough to be taught to wear it, I 
 have sometimes seen the respirator of much service, in enabling them 
 to continue to take exercise in the open air at a season when, on pre- 
 vious years, exposure to the external air had always induced or greatly 
 aggravated the signs of bronchial irritation. Whenever catarrhal 
 symptoms appear, no care can be too great to bestow on the attempt 
 speedily to remove them. In doing so, however, and in the manage- 
 
 1 Ueber die Ansteckung und Verbreitung der crofelkrankeit bei Menschen durch den 
 Genuss der Kuhmilch, ltimo. Leipzig, 1846. 
 
302 TREATMENT OF PHTHISIS. 
 
 ment of all ailments that come on in children who have shown a dispo- 
 tion to consumptive disease, much caution must be used, in order to 
 avoid over-treating them. On this account it is of extreme importance 
 to encounter them at their very commencement, when mild measures 
 will suffice for their cure ; and, for the same reason, the child should 
 be defended with the most punctilious care from the contagion of hoop- 
 ing-cough and of the eruptive fevers — diseases in the course of which 
 serious thoracic complications are so apt to supervene, and to require 
 for their cure most active treatment. 
 
 In carrying out this plan of unwearied watchfulness, and of attention 
 to minute detail continued for months and years, you will have brighter 
 hopes with children for your patients, than if you were called on to 
 exercise similar precautions in the case of persons more advanced in 
 life. Without raising baseless expectations, too, you may communicate 
 something of hope to the parents, and thus lighten for them their 
 anxious task ; nor will the appearance even of decided physical signs 
 of tubercular deposit, nor the evidence that in some parts that tubercle 
 is softened, warrant an absolutely hopeless prognosis. Cases such as 
 have been related show how long life may be prolonged under circum- 
 stances the most inauspicious ; and, where speedy death has been 
 expected, an unlimited reprieve seems almost a pardon. 
 
 ^ It may suffice to have said thus much about the management of 
 phthisis in childhood ; for when the disease is actually developed, we 
 have the same indications as in the adult, and these must be met by 
 similar means. Iron, quinine, and the mineral acids, are the most 
 important of our tonic remedies ; and for these the extract of bark and 
 the extract of logwood may be substituted, if much tendency exist to a 
 relaxed state of the bowels. In cases where the glands of the neck are 
 affected, and where there seems to be reason for supposing that the 
 disease approximates to bronchial phthisis, the syrup of the iodide of 
 iron may be employed with advantage. Such cases, too, have seemed to 
 me to profit most by the cod-liver oil, though I must confess that my 
 own experience of it does not altogether bear out the high encomiums 
 which have been bestowed upon it by some practitioners. Sometimes I 
 have known it excite diarrhoea ; at other times it completely spoils the 
 appetite ; while, as a general rule, I think it is not borne well in cases 
 where dyspeptic symptoms are, as is so often the case, at all a prominent 
 feature in the disease. Sometimes, too, the child's repugnance to the 
 remedy is unconquerable, though this does not often occur. If given on 
 a little orange wine, or orange juice, sweetened with syrup of orange 
 peel if necessary, its taste is in general perfectly disguised ; while some- 
 times, nauseous though the oil is, children become really fond of its 
 flavour. The sickness and the paroxysmal cough are best relieved by 
 
 ' the hydrocyanic acid, with which the liquor cinchona of Mr. Battley 
 may be combined, 1 in cases where we are afraid to venture on any but 
 the mildest tonics. Among local measures, the use of stimulating lini- 
 ments to the chest are even more valuable in early life than in the adult ; 
 and sometimes the application of a blister about the size of a shilling, 
 
 i Sec Formula, No. 20, p. 277. 
 
DISEASES OF THE HEART. 303 
 
 under one or other clavicle, and its frequent repetition, are followed by 
 a very great amendment in the patient's condition, and by a marked 
 improvement in the physical signs furnished by the subjacent lung. 
 
 I have very rarely employed local depletion, except in the treatment 
 of the pneumonia which so often attacks the phthisical patient ; but it 
 has then seemed sometimes to be of great service; and it will probably 
 be safer to trust to a moderate abstraction of blood by leeches, followed 
 by smaller doses of antimonials, than to administer mercury, or to give 
 antimony in larger doses without previous depletion. The habitual 
 cough of phthisis requires small doses of ipecacuanha wine, combined 
 or not with antimony, and laudanum, or compound tincture of camphor, 
 in small doses — remedies which, on account of their strength being defi- 
 nite, are always to be preferred, in the management of the affections of 
 childhood, to a preparation so variable as the syrup of poppies. Opiates 
 in various forms, and for various purposes, may be needed to check 
 diarrhoea, or to relieve suffering ; and you must not allow any precon- 
 ceived notion of the danger of employing opium in infantile diseases to 
 prevent your having recourse to so valuable a medicine. 
 
 We must here leave this subject, so full of painful interest, and 
 proceed at our next lecture to the study of diseases of the heart in early 
 
 LECTURE XXVI. 
 
 Diseases op the Heart — reasons why much rarer in childhood than in the adult — but 
 often overlooked when present— Rarity probably exaggerated, as stiown by table — 
 rheumatic inflammation their most frequent cause — rheart sometimes affected when 
 rheumatic symptoms are very slight — both endocarditis and pericarditis may come on 
 independently of rheumatism — as sequelas of scarlatina — as complications of pleurisy 
 — or as purely idiopathic affections — illustrative cases. 
 
 Idiopathic endocarditis sometimes attended by very few symptoms — importance of its 
 early detection — tendency of valvular disease to grow worse and worse — power of the 
 growing heart to ward off the effects of disease — great rarity of anaemic bruits in 
 early life. 
 
 Congenital affections of the heart — reasons for not studying them here in detail— cases 
 illustrative of some of their symptoms. 
 
 Among the many causes of suffering and death to which persons in 
 adult or advancing years are exposed, diseases of the heart and great 
 vessels occupy a very prominent place. The frequency of these affec- 
 tions is, indeed, but very imperfectly shewn by our tables of mortality, 
 which represent them as occasioning less than one and a half percent, of 
 the total deaths at all ages in the metropolis ; but we know that in a 
 large proportion of cases of rheumatism, asthma, bronchitis, and dropsy, 
 the real cause of the fatal event is to be found in the cardiac mischief 
 with which those maladies are so often associated. 
 
 In childhood, however, many of the most influential causes of heart 
 disease are of comparatively rare occurrence ; rheumatism is popularly 
 regarded as an affection almost confined to youth and early manhood, as 
 
304: DISEASES OF THE HEART — ACUTE RHEUMATISM. 
 
 granular degeneration of the kidneys is to adult and declining age ; 
 while' all those forms of atheromatous deposit in the coats of arteries, 
 or in the substance of the valves of the heart, which are a fertile source 
 of suffering, and in their consequences a frequent cause of death, belong 
 essentially to the processes of decay which accompany the decline of life. 
 But though heart disease is confessedly less frequent in the child than 
 in the youth or in the adult, yet its rarity is not so great as, judging 
 from the silence concerning it of most writers on the diseases of child- 
 hood, you might naturally infer. On turning to my note-book, I find 
 that I have preserved a record of 38 cases of disease of the heart in 
 children under twelve years of age, and cannot doubt but that more 
 time for observing my patients, or more sedulous care in watching 
 their symptoms, would have disclosed to me its existence in other 
 instances. 
 
 If, then, organic disease of the heart be not very common in the 
 child, at least it is not so unusual as to warrant our passing it over 
 without notice ; while its importance is increased by the circumstance 
 that its symptoms are in many instances so slight at first, that its ex- 
 istence may be overlooked, until the evils which follow in its train force 
 themselves upon our attention. 
 
 Acute Rheumatism, as the accompanying Table 1 shows^you, is, both 
 before as well as after puberty, the most frequent cause of inflammation 
 of the external investment of the heart, or of its internal lining. The 
 symptoms of rheumatism are essentially the same at both periods of life, 
 nor is there any peculiarity required in their treatment in the case of 
 children, beyond that diminution in the doses of our remedies which is 
 called for by the tender years of our patients. It is of importance, 
 however, to bear in mind, that the risk of cardiac mischief supervening 
 in any case of acute rheumatism, increases in direct proportion to the 
 youth of the patient ; and that the mildness of the general symptoms, 
 the small amount of pain in the limbs, and the almost complete absence 
 of swelling of the joints, afford no guarantee that the heart may not 
 become the seat of serious disease. It happens, too, less rarely in the 
 case of children than of the adult, that the general indications of rheu- 
 matism follow, instead of preceding, the heart affection ; so that fever 
 with hurried circulation and distinct endocardial murmur may exist for 
 two or three days, or even longer, before the occurrence of pain, and 
 the appearance of swelling of the joints, show that the disease of the 
 heart is only a part of the great malady which has attacked the whole 
 system. 
 
 Every threatening of rheumatism, therefore, is to be watched with the 
 most anxious solicitude in the young subject, since so serious a compli- 
 cation as disease of the heart may accompany extremely slight general 
 symptoms. Nor must auscultation be neglected in cases of what may 
 seem to be simple fever, since rheumatic inflammation may attack the 
 heart before any other signs of rheumatism have manifested them- 
 selves. 
 
 1 The Table appended to this lecture shows the chief points of interest in the cases 
 referred to; thirty of which came under my notice at the Children's Infirmary, among a 
 total of 13,798 children under twelve years of age, suffering from all diseases. 
 
PERICARDITIS COiMPLICATING PLEURISY. 305 
 
 Rheumatism, however, is far from being the only exciting cause of 
 inflammation of the pericardium, or of the lining membrane of the heart. 
 It may supervene, as in the adult, upon some disease, such as scarlet 
 fever, in the course of which the composition of the circulating fluid 
 becomes altered, of which three instances have come under my own ob- 
 servation ; and in some epidemics of scarlet fever it would seem to have 
 been far from an unusual complication of the secondary anasarca. 1 
 
 The occurrence of acute pericarditis in connection with acute pleurisy 
 is an accident but rarely met with ; or perhaps it would be more correct 
 to say, but seldom ascertained to exist, except in cases where the disease 
 proves fatal ; for on examining the body of a boy eight years old, whom 
 I had treated two years before for pleurisy of the left side, I was sur- 
 prised to find a patch of old lymph on the left ventricle, near the apex 
 of the heart, and a good deal of old white lymph coating the right au- 
 ricle, and white spots at several points about the base of the heart, show- 
 ing that the pericardium had been the seat of extensive inflammation. 
 The affection of the pericardium in most of these cases is probably se- 
 condary to that of the pleura, since the products of a far more advanced 
 inflammation are in general found in the latter cavity than the former. 
 In some instances the two serous membranes would seem to have become 
 affected simultaneously, while in others the indications of pericarditis 
 are perceptible before those of pleurisy appear. In one of three cases 
 which terminated fatally, the patient, a little girl aged sixteen months, 
 was almost moribund when she came under my notice : convulsions came 
 on in two or three hours, and she died after they had continued for 
 twelve hours. In this instance the attack had commenced, eight days 
 previously, with violent sickness, followed by severe febrile disturbance 
 and great dyspnoea, though by but little cough. In the second case, 
 that of a little girl aged three and a half years, slight cough and febrile 
 symptoms had existed for nearly a fortnight, when they suddenly, and 
 without any obvious cause, became greatly aggravated ; the cough grew 
 constant, short, and hacking ; the respiration rose to 72, the pulse to 
 156 in the minute. The child became extremely restless, appeared to 
 suffer much, made frequent efforts to vomit, and often crammed her 
 hand down her throat, as though to pull something away which 
 obstructed her breathing. In neither of these cases was the existence 
 of pericarditis suspected. In the last-mentioned case the restlessness 
 of the child precluded careful auscultation ; but dulness on percussion, 
 and bronchial breathing, were perceived through the whole of the poste- 
 rior part of the left side of the chest, and small crepitation was heard 
 on the right side. 
 
 In the third case, the patient was a little girl five and a half years old, 
 who was reported to have had frequent attacks of inflammation of the 
 chest, but who was in good health at the time of her being seized with 
 vomiting, followed by pain in the head, stomach, and back ; and cough, 
 with great fever. These symptoms had continued for three days when 
 she came under my notice. Her face was then anxious, her skin very 
 
 1 As in the epidemic at Dresden in 1831, as described by Dr. v. Ammon in Analekten 
 f. Kinderkr, Heft. xi. p. 42. 
 
 20 
 
306 CASE IN ILLUSTRATION. 
 
 hot ; pulse frequent, quick, and wiry ; respiration hurried ; and she had 
 almost constant hard cough, which occasioned pain in the epigastrium. 
 She complained of pain in the left side, and across the chest. General 
 subcrepitant rale was heard through the whole chest. There was exten- 
 sive dulness in the precordial region : a loud, rough, bellows murmur 
 accompanied the first sound of the heart at the apex, and a similar 
 sound was distinguished at the base, where it was suspected to be the 
 commencement of a to-and-fro sound. The child was bled from the arm, 
 leeches were applied over the heart, and two grains of calomel, with one- 
 sixth of a grain of tartar emetic, were given every three hours ; but on 
 the following day her general condition was unchanged — the bruit with 
 the first sound of the heart continued at the apex ; and that at the base 
 was now a. distinct to-and-fro sound ; — in addition to which a loud, 
 pleural friction sound was heard over both sides of the chest posteriorly. 
 The remedies were continued, but by the next day the child's condition 
 had deteriorated. The results of auscultation were much the same as 
 before, but the pleural friction sound had almost completely disappeared, 
 and percussion yielded a dull sound in both infra-scapular regions. 
 Circumstances prevented my watching the child during the ensuing 
 forty-eight hours, at the end of which time she died — eight days after 
 the commencement of her illness. A post-mortem examination was not 
 made; but there can be no doubt but that it would have disclosed 
 appearances similar to those observed in the other two cases, except that 
 probably evidences of inflammation of the endocardium would have been 
 associated with those of pericarditis, and that the affection of the pleura 
 would have been found to be secondary to, and less extensive than, that 
 of the heart. 
 
 There is little danger, in cases which set in with symptoms so severe 
 as those just described, of our falling into serious error, either of diag- 
 nosis or treatment. Every thing would point to most serious mischief 
 in the chest ; and even should the tender age of the child, and its 
 extreme restlessness, prevent careful auscultation, or should the signs 
 of heart disease be masked by those of mischief in the lung or pleura, 
 enough will yet be discovered to show the necessity for immediate and 
 active interference ; while, if we bear in mind the possibility of such a 
 complication, that will go far towards preventing us from overlooking 
 its occurrence. 
 
 Inflammation of the pericardium, or of the lining membrane of the 
 heart, or both, sometimes comes on unaccompanied with any affection 
 of the lungs or pleura ; and in such cases the indications of disturbance 
 of the respiration are either altogether absent, or comparatively slight. 
 If auscultation be neglected, or but carelessly performed, disease may, 
 under such circumstances, go on unchecked till it has disorganized the 
 heart, and doomed the patient to a life of remediless suffering. 
 
 A striking instance of this idiopathic inflammation of the pericar- 
 dium and lining membrane of the heart came under my notice some 
 time since, in the person of a healthy boy, eleven years old, who, on 
 May 8, 1843, complained of feeling cold, and began to cough. The 
 chilliness was succeeded by fever, and he continued gradually getting 
 worse till the 13th, when I visited him for the first time. He had had 
 
IDIOPATHIC PERICARDITIS. 307 
 
 no other medicine than a purgative powder. On May 13th I found 
 him lying in bed; his face dusky and rather anxious; his eyes heavy, 
 and his respiration slightly accelerated; coughing frequently, but with- 
 out expectoration ; skin burning hot ; pulse frequent and hard. He 
 made no complaint, except of slight uneasiness about the left breast. 
 On examining the chest there was found to be very extended dulness 
 over the heart, with slight tenderness on pressure. A very loud and 
 prolonged rasping sound was heard in the place of the first sound, 
 loudest a little below the nipple, though very audible ever the whole 
 left side of the chest, and also distinguishable, though less clearly, for 
 a considerable distance to the right of the sternum. The second sound 
 was heard clearly just over the aortic valves, but was not distinct else- 
 where, being obscured by the loudness of the bruit. Respiration was 
 good in both lungs. 
 
 The child was cupped to six ounces between the left scapula and 
 the spine ; and a grain of calomel, with the same quantity of Dover's 
 powder, was given every four hours. 
 
 On the following day it was found that the sense of discomfort in the 
 chest had been relieved by the cupping, and that the child had slept 
 well in the night. He looked less anxious, though his eyes were still 
 heavy and suffused, and his skin was less hot and less dusky. His 
 pulse was 114, thrilling, but not full. There was now slight prominence 
 of the cardiac region, and the heart's sounds were obscurer and more 
 distant than on the previous day. The bruit was now manifestly a 
 friction sound, louder at the base than at the apex of the heart, and 
 altogether obscuring the first sound; while the second sound could be 
 heard over the aortic valves. Six more leeches were applied over the 
 heart, and the haemorrhage from their bites was so profuse as to occa- 
 sion some faintness. Mercurial inunction was now superadded to the 
 treatment previously employed; and the child's condition continued 
 through the 15th to be much the same as it had been on the previous 
 day. On May 16th there was some improvement in the general symp- 
 toms, and the pulse was softer. The friction sound was now no longer 
 audible, but a loud rasping sound was heard in place of the first 
 sound. The second sound was now distinguishable at the apex of the 
 heart, as well as over the aortic valves, and its characters were quite 
 natural. On the 19th the child's mouth was slightly sore, and the dose 
 of the remedies was diminished. On the 22d the soreness of the 
 mouth was considerable, and all active treatment was discontinued on 
 that day. The child gradually regained his strength, but the bruit 
 accompanying the first sound continued and was heard a month after- 
 wards, with no other change than being rather softer and more 
 prolonged. Four years afterwards I saw him again. He had con- 
 tinued well in the interval, and had never suffered from palpitation of 
 the heart, nor from any other ailment referrible to the chest ; but his 
 pulse was small, jerking, and not always equal in force; and the natural 
 character of the first sound was altogether lost in a loud prolonged 
 bruit. 
 
 In cases such as this the occurrence of the heart disease is not easy 
 of explanation. No sign of rheumatism appeared during the whole 
 
308 IDIOPATHIC PERICARDITIS. 
 
 course of the affection, nor was it associated with any other disorder, 
 such as scarlatina, which, by the alterations that it induces in the com- 
 position of the circulating fluid, could be supposed to favour the super- 
 vention of inflammation of the heart or other viscera. 1 The organs of 
 respiration were unaffected throughout, so that the case could not for a 
 moment be conceived to be one in which the heart disease was secondary, 
 and produced by the extension of the inflammation beyond the limits 
 by which it was originally circumscribed. But though the cardiac 
 affection came on independently of those conditions, which we regard, 
 and with justice, as usually essential to its production, it ran as acute a 
 course, and produced injury as extensive, as if it had been excited by 
 any of its ordinary causes ; and left, it is to be feared, as abiding a 
 disorganization of the heart. 
 
 Idiopathic pericarditis, uncomplicated with pleurisy, and sufficiently 
 severe to give rise to symptoms appreciable during the life-time of the 
 patient, is a very rare occurrence, and I have seen but one other instance 
 of it. Unfortunately, I cannot speak with accuracy as to the frequency 
 in early life of those slight inflammations of the pericardium which give 
 rise to the white spots upon its surface, shown by M. Bizot and Mr. 
 Paget 2 to be so common in the adult ; for I have not always recorded 
 their presence or absence in my notes of dissection. My impression, 
 indeed, is, that they are much rarer in early life than in the grown 
 person ; but I found extremely extensive old deposits of lymph on the 
 heart of a boy, who died at the age of eight months, of congestion of 
 the brain, and who was not known to have suffered from any chest 
 affection, beyond the catarrhal ailments of infancy ; while their presence 
 in an infant aged only four months, whose case is related at page 314, 
 shows that there is no age so early as to be exempt from pericardial 
 inflammation. 
 
 Idiopathic endocarditis is less uncommon, and appears to be governed 
 by the same laws, and to give rise to the same symptoms, as when it 
 complicates acute rheumatism. Uneasiness, or actual pain at the heart, 
 increase of its impulse, acceleration, perhaps irregularity, of its action, 
 dyspnoea, a livid countenance, and threatening suffocation, are the signs 
 by which it betrays itself to the observer. But, just as in rheumatic 
 endocarditis, these symptoms may vary in degree, and be in one case so 
 severe as to force themselves upon our notice, and in another so slight 
 as almost to elude our observation, so it is in cases where the endocar- 
 ditis is idiopathic. In cases of acute rheumatism you are aware of this 
 danger ; you do not wait till the patient's sufferings inform you that the 
 mischief has been done, but you are on the watch against the first threat- 
 enings of its approach, — and your sense of hearing gives you earlier 
 information, and surer information, concerning this than all the other 
 signs together. But if the same evil, against which you guard thus 
 sedulously in cases of rheumatism, may occur independently of it, and 
 
 1 As Bright's disease, for instance, in the adult favonrs the occurrence of pericarditis, 
 according to, the elaborate researches of Dr. Taylor, in vol. xxviii. of the Medico-Chi- 
 rurgical Transactions. 
 
 2 Me'moires de la Socict6 M6d. d'Observation, tome I p. 350 ; and Medico-Chirurgical 
 Transactions, vol. xxiii. 
 
IDIOPATHIC ENDOCARDITIS. 309 
 
 may scarcely give warning of its approach, until it is almost or altogether 
 too late to cure, a measure at least of the same precaution should be 
 observed at all times ; and in no instance of febrile disturbance in early 
 life, how simple soever the case may seem, should you consider the 
 examination of the patient complete until after auscultation. With all 
 your care, there will probably still be cases in which the commencement 
 of the heart affection will escape your notice ; in which you will acciden- 
 tally make the discovery of its existence when auscultating the chest for 
 some other purpose, or in which the gradual supervention of the signs 
 of valvular disease will call your attention to it long after the ailment 
 has become chronic. 
 
 The early detection of the disease is of the more importance, since its 
 gradual approach affords no assurance that it may not go on to ruin the 
 health, and at length destroy the life of the sufferer. Nothing could be 
 more gradual than the advance of the early stages of the disease of the 
 heart, in the case of a little girl, ten years old, who came under my 
 notice in the month of March, some years ago. Her mother stated, 
 that, though not robust, she had never had any definite illness, but that 
 for the last year she had been growing thinner, and had suffered from 
 palpitation of the heart, which had by degrees become more and more 
 distressing, and that for the past three months she had likewise suffered 
 from cough. The child when brought to me was greatly emaciated ; her 
 face was anxious and distressed; her breath short, so that it was with 
 difficulty that she walked even a short distance ; she had frequent short 
 cough, without expectoration, and she suffered much from palpitation of 
 the heart, and a sense of discomfort at the chest. The heart's action 
 was violent ; fulness in the precordial region was extended ; a very loud, 
 harsh, rasping sound accompanied the first sound of the heart, loudest 
 towards and to the left of the nipple, but heard over the whole of the 
 chest, both before and behind. Various remedies brought slight but 
 temporary relief to her sufferings, and she grew worse every month. 
 She became more and more emaciated; the distress at the chest, and 
 the palpitation of the heart, increased, her cough became more violent, 
 and once she had an attack of haemoptysis. For about a month before 
 her death the cough altogether ceased, but she was now unable to leave 
 her bed, from increasing weakness ; the palpitation continued unmiti- 
 gated, and her extremities became slightly anasarcous. During the 
 last week of her life her respiration was extremely difficult, and became 
 increasingly so, till she died on the 10th of October. The lungs were 
 very emphysematous, and much congested, but not otherwise diseased. 
 The heart was extremely large, but its right cavities did not exceed the 
 natural size ; the pulmonary valves were healthy ; the edges of the 
 tricuspid valve were slightly thickened ; the left auricle was enormously 
 dilated, but its walls were not at all attenuated ; the pulmonary veins 
 were much dilated ; the left ventricle was dilated, its walls were thick- 
 ened; the chordae tendineae of the mitral valve were greatly shortened, 
 so that the valve could not close ; the valve itself was shrunken, thick- 
 ened, and cartilaginous ; and there existed likewise slight thickening of 
 the edges of the semilunar valves of the aorta. 
 
 The symptoms in this case, from the earliest period to which the 
 
310 TENDENCY OF VALVULAR DISEASE TO INCREASE. 
 
 patient's history goes back, were those of chronic valvular disease with 
 hypertrophy and dilatation of the heart ; but no clue is afforded us by 
 which we can guess when the inflammation of the endocardium, the first 
 in this train of evils, attacked the heart. The constitutional distur- 
 bance which attended it was so slight as to escape the mother's notice, 
 and to call for no special complaint from the child : but it is probable 
 that more watchful care would have taken the alarm at some compara- 
 tively slight feverish seizure ; that auscultation would have discovered 
 the disease at its commencement ; and that treatment would have 
 diminished, though it might not have altogether prevented, the subse- 
 quent disorganization of the heart. 
 
 The general tendency of the disease in the child, as in the adult, 
 seems to be, to go on from bad to worse ; and the endocardium, once 
 inflamed, appears to have acquired an increased liability to become the 
 seat of renewed inflammatory action. Thus, a little boy, who came 
 under my notice a few years ago, with all the symptoms of acute endo- 
 carditis, with dyspnoea, inability to assume the recumbent posture, 
 palpitation of the heart, and irregularity of its pulsations, extended 
 dulness in the precordial region, and a loud bruit accompanying the 
 first sound, was reported to have had a similar attack two years before, 
 from which it was many weeks before he perfectly recovered. A little 
 girl was attacked, when three and a quarter years old, with slight 
 febrile symptoms, soon followed by uneasiness at the chest, shortness 
 of breath, and palpitation ; while a loud bruit, heard both at the base 
 and apex of the heart, showed that its lining membrane had become 
 the seat of disease. The general symptoms were relieved, but the child 
 remained short-breathed and liable to palpitation, and the physical 
 signs of injury to the valves continued unchanged when she was five 
 years old. At the age of seven I saw her again, and learned that she 
 had during the previous two years complained frequently of shortness 
 of breath, and pain in her chest ; that she had become unable to walk 
 more than a short distance ; while under any unusual exertion her lips 
 and face became quite livid. She was brought to me, however, at this 
 time, in consequence of a sudden aggravation of these symptoms having 
 followed exposure to cold ; which, moreover, had occasioned a very 
 violent cough, and severe pain in the left side. The dulness in the 
 precordial region now extended over a somewhat larger space than 
 natural, and the first sound of the heart was completely masked at the 
 apex by a loud, harsh$ murmur, which was heard in a still harsher key 
 over the aortic valves, and was likewise continued for some distance 
 along the aorta. 
 
 The increase of the child's sufferings was but temporary, and when 
 she had regained her usual health, I again lost sight of her for some 
 years. In May, 1848, however, I had the opportunity of seeing her, 
 and of again examining her chest. She was then ten years and a half 
 old ; tall for her age, and tolerably well nourished, but there was a 
 livid flush constantly on her face ; her extremities were cold ; her pulse 
 108, small, and unequal in power. Her mother stated that she was 
 unable to walk a couple of hundred yards without suffering from violent 
 palpitation, and from pain about and across the epigastrium, and that 
 
CASES OF VALVULAR DISEASE — 311 
 
 during these attacks she turned quite blue,— symptoms all. of which 
 had become much more marked during the preceding twelve months. 
 The dulness in the precordial region was now very extended; the 
 results of auscultation continued the same, but the hand distinguished 
 a slight fremissement when placed over the heart. 
 
 It is easy, in this case, to infer from the past what will be the future 
 history of this poor child. The valvular disease, and the heart's efforts 
 to overcome its consequences, have already led to a considerable degree 
 of hypertrophy of the organ ; the danger of each acute attack will be 
 aggravated by the old disease, and every fresh inflammatory seizure will 
 add to the chronic mischief, until in course of time the disorganization 
 of the heart will have advanced so far as to render it unable to perform 
 its office sufficiently well to maintain existence any longer, and a life 
 of suffering will then be closed by a painful death. 
 
 Such was her condition, and such seemed to be her prospects, three 
 years ago. I have seen her again in June of the present year, and 
 slowly, but surely, these sad prophecies are in course of fulfilment. 
 The livid flush, the feeble pulse, and the dyspnoea, continue ; even the 
 sitting posture is now a source of discomfort to her, and she cannot 
 bear it long, for her heart is so damaged that it can do its work reason- 
 ably well only when reclining, and in a state of absolute repose. 
 
 But, you may ask, is a prognosis so gloomy to be formed with refer- 
 ence to every case in which our ear informs us there is something wrong 
 about the heart ? Dr. Latham, — whose name I cannot mention without 
 the expression of respect and gratitude due to one to whose instructions 
 I owe so much, — mentions the case of two young ladies, in whom the 
 auscultatory, signs of valvular imperfection have existed from early 
 childhood, but who have never suffered any important disturbance of 
 the general health that could be attributed to it. With reference to 
 these and other similar cases, he says, "Do not these facts give intima- 
 tion of a certain protective power, possibly inherent in the growing 
 heart, whereby it can accommodate its form and manner of increase 
 to material accidents, and so repress or counteract their evil tenden- 
 cies : a 
 
 Cases that seem to show the existence of such a power have come 
 under my own notice, and some time since I watched a striking illus- 
 tration of it with much interest. A little girl, six years old, whose 
 health had never been robust, and who had suffered much from measles 
 and scarlatina, the latter of which left her liable to attacks of what 
 was said to be inflammation of the chest, came under my notice at the 
 end of April, 1846. She was then labouring under urgent dyspnoea, 
 with symptoms of acute bronchitis, and, in the course of auscultation, a 
 systolic murmur was heard at the apex of the heart. The bronchitic 
 symptoms by degrees subsided, but dyspnoea continued ; the child was 
 wholly unable to rest, except when propped nearly upright ; she was 
 distressed by palpitation ; her cough was frequent, and when worse 
 than usual, she expectorated with it small quantities of florid blood. 
 Her face was pale, but with a livid flush on either cheek ; the carotids 
 
 1 On Diseases of the Heart, vol. i. p. 241-3. 
 
312 TENDENCY OF THE DISEASE TO INCREASE. 
 
 pulsated visibly, and the jugular veins were distended, while her heart 
 beat at the rate of 150 in a minute. The heart's impulse was increased, 
 and dulness in the precordial region extended far beyond its proper 
 limits/ It was next noted that the smallness of the pulse corresponded 
 ill with the labouring of the heart; and a distinct sense of J remiss em ent, 
 when the hand was laid upon the precordial region, completed the 
 signs of great contraction of the mitral orifice, with hypertrophy and 
 dilatation of the heart. From time to time the child suffered much since 
 then with a return of her old symptoms ; and, after the lapse of twenty 
 months, the bruit still continued: the hand placed upon the cardiac 
 region Was still sensible of a distinct purring tremor, and the pulse was 
 exceedingly small and feeble. But the heart no longer laboured as it 
 used to do ; its pulsations did not exceed 110 in the minute ; and though 
 the child was still unable to lie flat in the bed, the distressing orthopncea 
 had ceased for many months. Her eyelids were no longer puffy, nor 
 her limbs anasarcous, as they were before ; her cough troubled her but 
 little, and haemoptysis was very rare. She had gained flesh, was 
 cheerful, and played, though not so boisterously as other children might 
 do, yet with such heartiness, that I could scarcely believe her to be the 
 little suffering thing for whom, a year before, one would have chosen 
 speedy death as the happiest lot that could befal her. 
 
 But though this case made a great impression on me, as seeming to 
 shew how large a power the growing organ possesses to adapt itself 
 to a diseased condition, yet I should fear that the state of almost com- 
 plete immunity from evil consequences which was the good fortune of 
 the young ladies mentioned by Dr. Latham, must be confined to cases 
 in which nothing existed more serious than some slight congenital 
 imperfection ; and that we cannot hope for so happy a result in any 
 instance in which the heart has been damaged by inflammation. The 
 subject is one on which I would speak with great diffidence ; but it has 
 seemed to me that, how slight soever the mischief may have been which 
 a first attack of endocarditis inflicted, a second attack is almost sure to 
 be excited by some most trivial cause, and then a third, until the injury 
 becomes irremediable, and its consequences such as nature, though she 
 may alleviate, is yet unable to remove. If the evil be congenital, the 
 heart may perhaps accommodate itself so completely to it as to do 
 away with all that made it serious ; but if the damage be produced by 
 disease, the chances of that disease returning and aggravating it are 
 so great as to forbid our entertaining sanguine hopes with reference to 
 what nature may be able to effect ; and even in the case of the little 
 girl whose history I have just related the improvement has probably 
 reached its limit ; for though she remained tolerably free from suffer- 
 ing, yet at the age of 9 years all the physical signs of her disease were 
 increased rather than diminished : she was still unable to lie down in 
 bed ; and the least cold brought back all her former symptoms. 
 
 There is one more point to which, before quitting this subject, I must 
 advert, since it tends to give a graver character in every instance to the 
 auscultatory signs of cardiac disease in early life, than belongs to them 
 invariably in the adult. It is unnecessary to describe to you the peculiar 
 murmur heard in the heart and large vessels in the adult, in many cases 
 
RARITY OF ANAEMIC BRUITS IN THE CHILD. 313 
 
 in which no heart disease exists ; but which is associated with a general 
 condition of angemia, and ceases to be audible when tonic remedies or 
 abundant nutriment have reinvigorated the patient's frame. I have 
 often sought for, but have never heard, those endocardial, arterial, or 
 venous murmurs which are produced by an impoverished state of the 
 blood in children under seven years old ; and even at a later period 
 they are exceedingly rare, until that age is attained at which the 
 changes that take place as puberty approaches have already commenced, 
 or are on the eve of beginning, though in three 1 of the cases enumerated 
 in the table, in which an endocardial murmur was heard in conjunction 
 with acute febrile symptoms, it afterwards became so faint as to warrant 
 the hope that it was due merely to functional disorder, and would even- 
 tually disappear. Of the rarity of such murmurs I think that I may 
 speak with certainty, but I will not venture to assign a reason for it, 
 since the very slight difference between the composition of the blood in 
 early childhood and in after life can scarcely be regarded as affording 
 a sufficient explanation of it. 
 
 It might perhaps seem to you that I had been guilty of a serious 
 omission, if I were to conclude this lecture on the affections of the heart, 
 without some mention of those symptoms which are observed in cases 
 w T here the heart has been malformed from birth. From one of the 
 most striking of these symptoms — a peculiar lividity of the surface, 
 produced by the circulation through the body of imperfectly aerated 
 blood — the term cyanosis has been applied to this morbid condition. 
 It was once supposed that the admixture of venous with arterial blood, 
 owing to the imperfect closure of some of the foetal passages of com- 
 munication between the two sides of the heart, was sufficient to produce 
 this livid colour of the surface, and must invariably give rise to it. 
 This, however, is by no means the case, and we are now aware that 
 something more than the mere patescence of the foetal openings is in 
 general necessary to produce the cyanosis, the cold surface, the 
 occasional attacks of suffocation, and those other symptoms which used 
 to be regarded as characteristic of this defect of development. Cases 
 are on record in which such defects have not manifested themselves by 
 any symptoms until the patient had grown up to childhood, or had even 
 attained to adult age ; while even then their consequences have some- 
 times been slight and of short duration, and have shewn themselves but 
 seldom ; or, on the other hand, having manifested themselves a few 
 weeks before death, they have recurred with ever increasing intensity, 
 until they destroyed life. Nor are these the only circumstances which 
 render the study of congenital malformations of the heart difficult and 
 intricate ; but diseases acquired in after life sometimes give rise to 
 similar symptoms; and aneurism in the grown person, or valvular 
 disease in the young, occasionally assumes many of the characters that 
 commonly belong to defects in the original structure of the heart. To 
 do justice to the subject, therefore, would require that we should enter 
 upon a field of pathological inquiry, interesting indeed, but in which 
 we should be drawn aside from that special investigation of the diseases 
 of childhood which is our business now. 
 
 1 Nos. 2, 10, and 25 in the Table. 
 
314 MALFORMATIONS OF THE HEART. 
 
 I shall, therefore, merely lay before you my personal experience of 
 cases of cyanosis, which is but small, since it includes only two cases in 
 which the nature of the affection was demonstrated by examination after 
 death ; and a third, in which, though the patient still lives, yet her 
 symptoms are so well marked as to preclude much doubt as to their 
 cause. 
 
 The first of these cases is interesting, not merely as an instance of 
 congenital malformation of the heart, but as affording a striking illus- 
 tration of the influence which malformation exerts in predisposing to 
 other diseases of the organ. The patient, a little boy, who was four 
 months old when he died, did not come under my notice until the day 
 of his death. The history which I heard of him was, that he was very 
 livid at birth, that respiration was established with difficulty, and that 
 the dark hue of his surface never went off completely. At times he 
 seemed cheerful, and used to breathe pretty well, but at other times he 
 was seized, without apparent cause, with difficult respiration, during 
 which he became very cold and quite purple, made a grunting noise, 
 and frothed at the mouth. These attacks never came on while he was 
 sucking ; they were preceded by crying, though usually he was very 
 quiet. 
 
 On October 19, 1848., an attack came on, similar to the previous 
 seizures, though more severe, lasting between one and two hours, and 
 not being preceded by crying. On the 20th, a similar attack came on, 
 and lasted from 4 to 7} P. M., and another returned on the morning of 
 the 24th, at noon of which day he was brought to me. His surface 
 was then generally very pale, but with a marked livid hue of the lips 
 and fingers, and around the mouth. His skin was cool, almost cold ; 
 his respiration, irregular and very frequent, and his pulse extremely 
 feeble. Auscultation detected no unnatural sound with the heart's 
 action. 
 
 As he was being carried home a fresh seizure came on, and proved 
 fatal in half an hour. 
 
 The lungs and pleurae generally were healthy. 
 
 The pleura, where it is in contact with the pericardium, and that 
 membrane itself, were of a bright red colour, with the vessels minutely 
 injected. This sac of the pericardium contained 5J. of a dirty, 
 yellowish, sero-purulent fluid, in which little granules of lymph, like 
 minute grains of rice, were floating. It did not any where adhere to 
 the heart, but its parietal layer, which was intensely red, and beset 
 with numerous little ecchymoses, was lined through a great extent by 
 a thin layer of lymph. This layer was thicker on the right than on 
 the left half of the pericardium, and especially so about the right 
 auricle. Lymph was also deposited between the left auricle and the 
 root of the pulmonary artery. 
 
 The pericardium investing the heart was intensely red, and numerous 
 small flocculi of lymph covered its surface. Besides this, there was an 
 old white spot, half an inch long by a quarter of an inch broad, at the 
 apex of the left ventricle, having just the character of the white spots 
 of old pericarditis; and there was another small spot on the posterior 
 surface of the right auricle. 
 
ILLUSTRATIVE CASES. 315 
 
 The foramen ovale was wide open, so as to admit the finger with ease ; 
 the pulmonary artery was very small : the ductus arteriosus wide open, 
 and the septum of the ventricles very imperfect : the ductus venosus 
 was closed. 
 
 In the second case the patient was a little girl, whom I saw when she 
 was three months old. She was stated to have been healthy when born, 
 and to have continued so till two months old, when an eruption, appa- 
 rently of a syphilitic character, broke out upon her body, and her 
 health since then had failed. The condition in which she was when 
 brought to me had been coming on gradually for three weeks. She 
 was small, but not emaciated ; her skin was pale as marble, and rather 
 cold; her buttocks were covered with the scars of a syphilitic eruption, 
 which had nearly faded. A large purpurous spot on the abdomen, near 
 the umbilicus, surrounded the ill-formed scab of a vesicle which had 
 been situated there. A large ecchymosis had formed in the left hypo- 
 chondriac region, and another similar one on the left wrist, and the 
 legs were covered with petechia. The child seemed feeble, and its cry 
 was very faint. Two days afterwards a slight fit occurred, in which 
 the child died. 
 
 The upper lobe of the right lung, and many isolated lobules in the 
 left, were in a state of carnification. The foramen ovale, though not 
 closed, was yet not widely open, while no attempt whatever seemed to 
 have been made to close the ductus arteriosus. 
 
 In this case, the livid colour of the surface, often observed when the 
 two sides of the heart communicate freely, was altogether absent, and 
 nutrition seems for a time to have gone on well. At this early period 
 in infantile life a child's movements are but few and slight ; and, as no 
 cause arose to disturb the equability of the heart's action, there were 
 no paroxysms of difficult breathing, and no symptoms of threatening 
 suffocation. The temperature, however, was but ill maintained; and 
 when the poison of syphilis had contaminated the blood, nutrition lan- 
 guished; for the circulating fluid was not only imperfectly aerated, but 
 tainted with disease ; the strength failed, the inspiratory effort was no 
 longer adequate to expand the lungs, and the patient died. 
 
 The third case was that of a puny, weakly, backward little girl, who 
 came under my notice at three years old, when she was suffering from 
 a severe attack of measles, with bronchitis. It was many months before 
 she regained her health, and it was during her convalescence that the 
 indications of disease of the heart first attracted my attention. She 
 had always been ailing from her birth, and her extremities had habi- 
 tually presented a deep blue colour, which at some times was much more 
 striking than at others. When four years old, she had become strong 
 and hearty, and very fat ; but even then her finger nails had a deep 
 blue tinge ; and the same colour was evident, though in a less degree, 
 about her feet, while she always suffered much from cold. Occasionally 
 she had sudden attacks of uneasiness^ which lasted for various periods, 
 were accompanied by complaints of great weariness, and of pain at the 
 epigastrium ; and during their continuance the hands, feet, lips, and 
 inside of the mouth, turned of a deep blue colour. At this time a loud 
 bruit accompanied the first sound of the heart, being louder at the base 
 
316 MALFORMATIONS OF THE HEART. 
 
 than the apex, continued along the aorta, and heard over the whole of 
 the chest, both in front and behind. The child grew up, and passed 
 through a very severe attack of scarlatina, though she nearly sank 
 under the exhaustion which followed it. At nine years old her health 
 was very good, but she was exceedingly fat, and quite unequal to any 
 exertion. In going up stairs she laboured for her breath, and her face 
 and hands turned blue, while the natural colour of her lips and ex- 
 tremities was very livid, and her surface very chilly. When quite quiet, 
 her respiration was easy, and the sound of puerile breathing was heard 
 throughout both lungs. Her pulse was about 90, small and feeble, and 
 the heart's impulse weak. The results of former auscultations were 
 confirmed, and the bruit was ascertained to be continued along the 
 course of the pulmonary artery, as well as along the aorta. The child 
 is now fifteen years old. I often see her ; and her condition, which 
 continues just the same, seems to render it probable that, with care, she 
 may reach the ordinary term of human existence. 
 
 And now, gentlemen, in bringing this lecture of details to a close, let 
 me make my excuse, in better language than my own, for having to- 
 day brought before you mere isolated facts, rather than a complete 
 description of those diseases with the study of which we have been 
 occupied. 
 
 " The subjects of our profession," says Dr. Latham, " require to be 
 treated summarily or in detail, according to the degree of light that is 
 brought to bear upon them from a general pathological principle. If 
 you enter a spacious room with a small taper, you must carry it about 
 and pick your way with it into corners and recesses, and round pillars 
 and projections ; and, after all, you will hardly know where you are, 
 and will be lucky if you escape without accidents. But if you enter 
 the same with a bright burning lamp, you have only to place it on a 
 pedestal, and then stand in the midst and look around, and then you 
 will find all things, great and small, near and remote, brought out 
 equally to view, and will at once understand and admire the beauty and 
 proportions of the whole apartment. 
 
 " So it is with our clinical inquiries. We must deaf much in detail ; 
 we must note cases one by one, while we yet want a great pathological 
 principle which can show their natural relations, and reconcile them 
 together. But once establish such a principle, and it will compass and 
 illustrate perhaps a hundred particulars at once, and render their 
 minuter examination needless and superfluous." 
 
CASES OF DISEASE OF THE HEART. 
 
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DISEASES OF THE ORGANS OF DIGESTION AND ASSIMILATION. 323 
 
 LECTURE XXVII. 
 
 Diseases of the Organs of Digestion and Assimilation. — Peculiarities of the digestive 
 organs — they require a peculiar kind of food, the milk — composition of that fluid, its 
 adaptation for the nutriment of the infant — changes in the digestive organs as the 
 child grows older — these changes take place more slowly in the human subject than 
 in animals. 
 
 Evils of giving other food than the mother's milk until the infant is old enough to bear 
 it — shown by the increased mortality it produces — different modes in which such food 
 acts injuriously — appearances found in bodies of children who have died from imper- 
 fect nutrition. , 
 
 Great importance of infants being suckled, even for a short time — rules for management 
 of children whose mothers are unable to suckle them — substitutes for mother's milk 
 — caution with reference to occasional unhealthy condition of cows' milk. 
 
 We prefaced our investigation of the diseases of the nervous and 
 respiratory systems with an inquiry into the peculiarities of structure 
 and of function which characterize those organs in early life. A similar 
 inquiry will not be out of place now, as preliminary to the study of the 
 diseases of the organs of digestion and assimilation, and their depen- 
 dencies. 
 
 Man, when he has attained to maturity, is able to support his life, 
 and to preserve his health, upon food of various kinds ; and the structure 
 of his organs is such as to enable him to live upon an exclusively animal 
 diet, or upon food furnished entirely by the vegetable kingdom. We 
 know that iri either case the ultimate elements from which the body is 
 nourished are the same; but that while in the former instance they are 
 furnished as it were ready to hand, they have in the latter to be elimi- 
 nated by nature's chemistry, through a process which occupies much 
 time, and which requires considerable complexity in the apparatus that 
 effects it. 
 
 Those powers, however, of which the adult is possessed, belong in but 
 comparatively small measure to the infant. The growing animal, indeed, 
 needs proportionably more food than the adult; for not merely is the 
 daily waste to be repaired, and that constant reproduction of the tissues 
 to be provided for which is essential to the maintenance of vitality in all 
 parts of the body, but each day is to bring with it an increase in size and 
 stature. But though in early life an ample supply of food is so neces- 
 sary, yet the organs by which it is to be assimilated, like those which 
 have other offices to perform, are at that time frail and delicate, and 
 must not be overworked. Their development is incomplete, not in 
 strength only, but also in form. 1 The peculiarities which characterize 
 the digestive process in ruminants, do not begin till some time after 
 birth : the fourth stomach is the only one called into use ; the others are 
 little more than indicated in the new-born animal. In the infant, too, 
 
 1 Many of the facts mentioned concerning the peculiarities of the digestive organs in 
 early life, are to be found iu Burdach's Physiologic, vol. iii. \ 512 to 540 ; and in Schultz's 
 Essay, Ueber den Akt des Erbrechens, &c. in the Analekten ueber Kinderkrankheiten, 
 vol. ii. Heft. vi. p. G2. 
 
324 PECULIARITIES OF THE DIGESTIVE ORGANS IN INFANCY. 
 
 the form of the digestive organs, as well as their feeble muscularity, 
 shows them to be unsuited for food, which needs to pass through a long 
 process of preparation within the body before it becomes fitted to nourish 
 it. The shape of the human stomach in the first month of existence 
 approaches that which it retains through life in the carnivora, in whom 
 the process of digestion is more simple than in any other mammalia. 
 It is long, but little curved, growing narrower toward either end, where 
 it passes into the oesophagus on the one hand, and into the intestine on 
 the other. Its small curvature is but little arched, and approaches 
 nearly to a straight line ; the large curvature is but slightly developed, 
 and runs almost parallel with the other, — characteristics which are all 
 found in the stomach of carnivorous animals. Compare with this the 
 form of the stomach in the adult. It is altogether more rounded : the 
 oesophagus no longer enters at its left extremity, but nearly midway 
 between that point and the pylorus. The pylorus itself is drawn back 
 towards the cardia, and the two orifices are thus brought near to each 
 other : hence the small curvature is very short ; the great curvature of 
 considerable extent, forming not merely the whole under part of the 
 circumference of the stomach, but likewise bounding the whole of that 
 pouch which is situated beyond its cardiac orifice. Besides this, too, 
 the transition from the pylorus to the intestine is gradual in the child, 
 while in the adult the demarcation between stomach and intestine is well 
 marked. The result of all this is, that in the adult, who is an omnivo- 
 rous animal, the stomach presents a form not unlike that which it has 
 in some of the rodents — as the rat and the rabbit; and that the food, in 
 the course of digestion, undergoes somewhat of a rotatory motion, not 
 the simple onward movement which is communicated to it in the stomach 
 of the carnivora. The stomach of the adult, then, is framed to act upon 
 substances which may require some time for their digestion, while that 
 of the infant is ill suited to retain matters long within it, and its small 
 size unfits it for receiving much at once. If, therefore, the food given 
 to an infant be such as it can digest with facility, it soon passes out of 
 the stomach, and the infant speedily seeks for more. Nor are these 
 arrangements calculated for the rapid digestion of easily assimilated 
 food, confined to the stomach of the infant, but the form and proportions 
 of the intestines correspond thereto : the small intestine is of relatively 
 shorter length than in the adult ; the large intestine of smaller calibre ; 
 the caecum less developed ; whilst the peristaltic action of the bowels is 
 more rapid than in later life ; excrementitious matters are quickly 
 expelled, and the healthy infant passes three or four evacuations in the 
 twenty-four hours. 
 
 But while the digestive organs of the young of all mammiferous 
 animals are thus adapted to ensure the rapid performance of their func- 
 tions, and to provide for the quick as well as for the complete nutrition 
 of the body, the question naturally suggests itself, where shall that food 
 be found, which, while it yields the necessary sustenance, is yet so easily 
 assimilated as not to require powers of which the delicate organs of the 
 young are destitute ? We should search in vain through the animal and 
 vegetable kingdom for any substance completely fulfilling these condi- 
 
MILK THE PROPER ALIMENT FOR THE YOUNG. 325 
 
 tions, had not nature supplied the want, and given to every mother the 
 means of herself nourishing her young. 
 
 Milk, the proper aliment of the young, expressly prepared for it within 
 its mother's organism, contains, ready combined, all those elements 
 which are necessary, whether for its growth or for the maintenance of 
 its proper temperature, by serving as materials for respiration. The 
 mean of 14 analyses of human milk, by the late Professor Simon, of 
 Berlin, 1 yields the following result: — It is composed of 
 
 Water . . . 883-6 
 Solid matters . . 1164 
 
 100 parts of these solid constituents are made up of 
 
 Casein . . . 31-2 
 
 Butter . ... 23-0 
 
 Sugar of milk, and extractive 
 
 matter . . . 43*8 
 
 Incombustible salts . 3-0 
 
 100-0 
 
 How small must be the effort needed to effect the assimilation of this 
 fluid ! The chief of its solid constituents, the casein, differs little, if at 
 all, from the albumen of the blood, while in combination with it is a 
 considerable quantity of the phosphate of lime — a salt that enters largely 
 into the cornposition of the bones. Among its other components we 
 find butter and sugar, the former of which probably in part contributes 
 to the formation of the fat which is so abundantly deposited in the 
 healthy infant, while the remainder of it supplies materials for the 
 generation of heat, by being resolved, together with the saccharine 
 matter, into its ultimate elements of carbonic acid and water. This 
 food, too, is not merely suitable for the infant soon after birth, but it 
 continues to be the aliment most proper for it for many months ; the 
 casein increasing in quantity as the infant grows older, and the demand 
 for materials to maintain its growth increases. 
 
 By degrees the stomach alters in form : its muscularity increases ; 
 the powers of the digestive organs become greater, and the child becomes 
 able to derive support from food in which the nutritive principles are 
 not presented in so simple a form as in the milk. At the ninth month 
 teeth begin to appear ; the first clear evidence of those changes which 
 nature is working in the organism, and the indication that before very 
 long the child will be able entirely to dispense with that elaborately 
 prepared nourishment which it has hitherto derived from its mother. 
 In the human subject the process of dentition not only begins late, but 
 it goes on slowly ; the first molar tooth is seldom cut before the com- 
 mencement of the second year : dentition is not concluded till its end. 
 Nature's object in the laws by which she governs the brute creation, 
 
 1 The statements with reference to the chemistry of the milk are taken from Sherer's 
 article " Milch," in Wagner's Handworteerbuch der Physiologie, Part 10. 
 
826 CHANGES IN THE DIGESTIVE ORGANS VERY GRADUAL. 
 
 appears to be, to fit the young animals as soon as possible to provide 
 for themselves, and to shorten the period during which they must 
 depend for sustenance on their mother ; and, therefore, they begin to 
 cut their teeth much sooner, and the process is completed within a 
 much shorter time, than in the infant. Young rabbits are always 
 provided with two teeth when born, and the others make their appear- 
 ance within ten days ; in the different ruminants, the teeth have either 
 begun to appear before birth, or they show themselves a few days 
 afterwards, and in either case dentition is completed within the fiist 
 month ; and in dogs and cats during the first ten weeks of existence. 
 
 For the difference in this respect between the lower animals and 
 man, it seems to me that a moral reason, not altogether visionary, may 
 be assigned. The young animal has to learn nothing more than how 
 to apply those instincts with which Almighty power has endowed it for 
 its own support and the perpetuation of its species. But the infant is 
 to be trained to become a man : its moral as well as its physical nature 
 is to be cultivated : parental influence is to be the means of doing this ; 
 and Providence may have wisely determined that the infant shall for 
 months be dependent on its mother for support, in order that her 
 instinctive feelings may lay the firm foundation of that love which 
 causes her to cling to her little one with a fondness that surpasses all 
 other affection, and which gives her the patience, the gentleness, the 
 untiring energy, that make her the child's best guardian, friend, and 
 teacher, during its early years. 
 
 But whether it is right or wrong to seek in something higher than 
 the material, for the reasons of this physical law, it yet is a law, and 
 one which cannot be violated with impunity. The infant whose mother 
 refuses to perform towards it a mother's part, or who, by accident, 
 disease, or death, is deprived of the food that nature destined for it, 
 too often languishes and dies. Such children you may often see, with 
 no fat to give plumpness to their limbs, — no red particles in their blood 
 to impart a healthy hue to their skin, — their face wearing in infancy 
 the lineaments of age, — their voice a constant wail, — their whole aspect 
 an embodiment of woe. But give to such children the food that nature 
 destined for them, and if the remedy do not come all too late to save 
 them, the mournful cry will cease, the face will assume a look of con- 
 tent, by degrees the features of infancy will disclose themselves, the 
 limbs will grow round, the skin pure red and white ; and when, at 
 length, we hear the merry laugh of babyhood, it seems almost as if the 
 little sufferer of some weeks before must have been a changeling, and 
 this the real child brought back from fairy-land. 
 
 Much care, much patience, judicious management in all respects, 
 may, indeed, counteract the otherwise inevitable evils that result from 
 the attempt to bring up infants by hand. The statement, however, . 
 just made with reference to the hazard of such an experiment, and to 
 the evil consequences that almost of necessity attend it, is by no means t 
 overcharged. M. Villerme, one of the most distinguished statisticians 
 of France, has compared the results of the two systems as followed in 
 three of the principal foundling hospitals in that country. 1 At Lyons, 
 
 1 De la Mortality des Enfans Trouve's, in the Annalcs d' Hygiene, vol. xix. p. 47. Fur- 
 
EVILS OF OTHER FOOD THAN THE MOTHER'S MILK. 327 
 
 each infant, on its reception, is given into the charge of a wet nurse, 
 and its stay in the hospice does not exceed a very few days, after which 
 it is sent to he nursed in the country. At Rheims, the stay of the 
 infant in the hospice is equally short ; hut neither while there, nor 
 afterwards when at nurse in the country, is it brought up at the breast. 
 At Paris, the stay of the children in the hospice is often very much 
 longer ; but they are usually, though not invariably, suckled by wet 
 nurses. The mortality under 1 year of the children admitted into these 
 institutions is — 
 
 At Lyons. 33*7 per cent. 
 
 „ Paris 50*3 „ 
 
 „ Rheims 63*9 „ 
 
 These results need no comment, and render it almost unnecessary to 
 adduce any farther evidence of the dangers that are inseparable from 
 the attempt to bring up infants on artificial food. One more illustra- 
 tion of the fact, however, may be adduced from the work of a benevolent 
 ecclesiastic, M. Gaillard, on the foundling hospitals of France. He 
 observes — 
 
 "At Parthenay, in the department of Deux-Sevres, of 153 found- 
 lings, 54 died between the ages of one day and twelve months, or 35 
 per cent., which is a higher proportion than that presented at Poitiers. 
 
 At X , of 244 new-born infants, 197, or 80 per cent., had died by 
 
 the end of the first year. Struck by the enormous difference between 
 this rate of mortality and that afforded by the hospices at Poitiers and 
 Parthenay, I determined to investigate its cause. I ascertained that 
 in this hospice as much attention is paid to the children, and the nurses 
 are under as strict oversight, as at Poitiers and Parthenay. But at 
 
 X none of the children are suckled, but all are fed ; and the reason 
 
 assigned for so doing is the fear of infecting the nurses with syphilis. 
 Be this as it may, I have been assured by many persons connected with 
 the institution, that the fearful mortality just mentioned can be attri- 
 buted to no other cause than the practice of not suckling the children. 
 The officers of the hospice have tried all means to remedy this evil, but 
 neither their own efforts, nor those of some most excellent female 
 assistants, have been of the slightest service ; and the only measure by 
 which they could reduce the mortality, was the having recourse to suck- 
 ling the children by wet nurses." 1 
 
 It can hardly be necessary to say, that these statements are not to 
 be taken as representing the ordinary mortality among infants brought 
 up by hand, since many causes will suggest themselves to you as con- 
 curring to render the life of foundlings especially precarious. Neither, 
 indeed, is the whole of the mortality among other children who have 
 been deprived of the mother's milk to be attributed to the food which 
 
 ther information on this and other allied subjects will be found in a review of the works 
 of Terme, Monfalcon, and others, on the Foundling Hospitals of France, published by 
 the author in the British and Foreign Medical Preview for April, 1842. 
 
 1 Recherches surles Enfans Trouvds, &c. parl'Abb^ A. H. Gaillard, 8vo. p. 166. Paris, 
 1337. 
 
328 INFANTILE MORTALITY FROM ARTIFICIAL FEEDING. 
 
 is substituted for it ; but in many cases, if the mother do not suckle 
 her infant, she delegates to another the performance of her other 
 maternal duties, and the baby is left to languish in the house of a 
 stranger. That this cause is very influential in producing a high rate 
 of mortality among infants, appears from the fact mentioned by M. 
 Benoiston de Chateauneuf, 1 that while among children suckled by their 
 mothers only 18.36 per cent, die within a year after their birth, 29 per 
 cent, of those put out to wet-nurse die during the same period. 
 
 It is not enough, however, for us to know that food other than the 
 mother's milk is injurious to the young infant ; but it behoves us, both 
 as physiologists and as physicians, to push our inquiries further, to 
 ascertain as far as possible the means by which this injurious effect is 
 produced, and to determine what organs of the body suffer most 
 severely, and the mode in which they are affected. Unfortunately, the 
 information which I am able to give you on these points is much less 
 definite than I could wish ; for the evils that result from improper food 
 in infancy do not, like some diseases, arrest attention by their alarming 
 symptoms, or by their rapidly fatal result, and hence they have received 
 less than their due share of notice. 
 
 If improper food be given to an infant, the contractions of the 
 stomach are in general speedily excited, and the food is rejected. 
 Owing to the form of the stomach in infancy, and the position which it 
 occupies in the abdomen — approaching to the perpendicular rather 
 than the transverse — vomiting is then attended with little distress : the 
 child eructates the food almost without effort, and in a few minutes 
 seems well again. This eructation of a portion of its food may indeed 
 be noticed even in infants at the breast, who have either sucked more 
 than their stomach can conveniently hold, or whose digestive powers 
 are temporarily weakened by some trivial ailment. But the hint which 
 nature gives is too often thrown away on those who have the charge of 
 the infant. Food of the same kind is given again, perhaps in smaller 
 quantity, or with some slight difference in its mode of preparation, and 
 part, or the whole of it, is now retained. The shape of the organ, how- 
 ever, does not allow of substances remaining long within it ; and hence 
 those which need much time for their digestion, if not rejected by 
 vomiting, pass the pylorus while that process is but half completed. 
 Unfortunately the farinaceous articles of food which are so often 
 selected, on account of their supposed lightness, as fit to form the 
 almost exclusive diet of infants, belong to the class of substances that 
 are assimilated with difficulty ; so that a large proportion of the con- 
 tents of the stomach, in the young child brought up by hand, enter the 
 duodenum in a state wholly unfit to be acted on by the bile. The 
 intestines become irritated by these undigested matters ; and, in the 
 effort to get rid of them, diarrhoea is excited ; while, if not speedily 
 expelled, they pass into a state of fermentation or putrefaction, and 
 thus produce those horribly offensive evacuations which are frequently 
 voided by children under these circumstances. 
 
 It would be natural to expect that a child should lose flesh and 
 strength, even if the food given to it were no otherwise objectionable 
 
 1 Considerations sur les Enfans Trouvds, 8vo. p. 57. Paris, 1824. 
 
INJURIOUS EFFECTS OF ARTIFICIAL FEEDING EXPLAINED. 329 
 
 than as being difficultly digested. The stomach, indeed, becomes in 
 time more accustomed to it ; and it has been stated 1 that its form some- 
 times undergoes a change by which it approximates to that of the 
 stomach in the adult, or even in the herbivorous quadruped, and thus 
 becomes able to retain food within it for a longer time. But even 
 though this change took place to a much greater degree than there 
 seems reason for believing to be the case, the evil of such a diet would 
 not be half remedied ; for not only are the sago, arrow-root, or gruel, 
 with which the child is fed, in themselves less easy of digestion than 
 the milk, which is its proper aliment ; but, when reduced to their ulti- 
 mate elements, they present essential differences from it, and differ- 
 ences by which they are rendered so much the more inapt to nourish 
 the body during the period of its most active development and growth. 
 It would be out of place to enter here into minute details with reference 
 to the physiology of digestion, or the composition of different articles 
 of food, in order to illustrate this subject ; neither, indeed, is it neces- 
 sary to do so. You are aware that physiological and chemical research 
 has proved that food has to answer two distinct purposes in the 
 organism : the one to furnish materials for the growth of the body ; the 
 other to afford matter for the maintenance of its temperature ; and 
 that life cannot long be supported, except on a diet in which the 
 elements of nutrition and the elements of respiration bear a certain 
 proportion to each other. Now in milk, the proper food of infants, the 
 elements of the former are to those of the latter, according to the 
 approximative estimate of an English chemist, 3 in the proportion of 1 
 to 2 ; while in arrow-root, sago, and tapioca, they are only as 1 to 26, 
 and even in wiieaten flour only as 1 to 7. If to this we add the absence 
 in these substances of the oleaginous matters which the milk contributes 
 to supply the body with fat (and which can be eliminated from farina- 
 ceous substances only by a conversion of their elements, to which the 
 feeble powers of digestion in early life are not equal,) and the smaller 
 quantity, and, to a certain extent, the different kind of the salts which 
 they contain, it becomes at once apparent that by such a diet the 
 health, if not the life, of the infant must inevitably be sacrificed. The 
 body wastes most rapidly ; for it is forced from its own tissues to supply 
 the nitrogenous elements essential to the maintenance of life, and 
 which its food contains in far too scanty a proportion. Every organ in 
 the body contributes to the general support, and life is thus prolonged, 
 if no kind disease curtail it, until each member has furnished all that it 
 can spare, and then death takes place from starvation ; its approach, 
 indeed, having been slower, but the suffering which preceded it not 
 therefore less, than if all food had been withheld. 
 
 I have dwelt at length upon this, which is the most frequent cause of 
 the atrophy of new-born children : but similar effects are produced 
 when, from any other reason, an infant is imperfectly nourished, 
 whether, as sometimes occurs, the mother's milk is so deteriorated as 
 to be unsuitable for its support; or whether, as often happens, the 
 
 1 Schultz, loc. cit. p. 74-5. 
 
 2 Dr. R. D. Thomson, On the Relation between the Constituents of the Food and the 
 Systems of Animals, in vol. xxix. of the Medico-Chirurgical Transactions. 
 
330 IMPERFECT NUTRITION OF INFANTS. 
 
 child having been weaned prematurely, its digestive organs are unequal 
 to the task of assimilating the food that has been substituted for the 
 mother's milk. In both cases the abdominal viscera become disordered, 
 nutrition is ill performed, and the child falls into a state of atrophy. 
 
 On examining after death the bodies of children who have died under 
 these circumstances, the complete absorption of all the fat, and the 
 removal of much even of the cellular tissue, is the point that first 
 attracts our notice. The thoracic viscera present no unnatural appear- 
 ance, unless it be that large portions of the lungs are sometimes found 
 in a state of collapse. There is also seldom anything unnatural in the 
 condition of the liver, except the congested state of the organ, the 
 vessels of which, being often loaded with venous blood, form a marked 
 contrast to the generally anaemic appearance of the other viscera. 
 The gall-bladder is usually full of bile, probably because, as in the case 
 of persons who have died of inanition, the empty stomach has long 
 ceased to stimulate it to contraction by its movements. The stomach 
 and small intestines are in general nearly empty ; the fundus of the 
 stomach is sometimes found more or less softened, — a condition, the 
 occurrence of which after death is probably favoured by the tendency 
 of those kinds of food that are usually given in early life, to pass into 
 a state of fermentation, in the course of which an acid is produced 
 which is capable of dissolving the animal tissues. In some instances in 
 which children have been fed on an exclusively farinaceous diet, the 
 mucous membrane even low down in the intestines, has been found 
 covered with a thin coating of starch, which presented the characteristic 
 blue colour when tested with iodine. 1 The intestines are generally 
 pale, though with patches intermingled of a red or dark grey colour ; 
 besides which small circumscribed spots of bright vascularity are some- 
 times interspersed through the small intestines, being especially evident 
 at their upper part. Peyer's glands usually appear much more promi- 
 nent than is natural ; sometimes they are of a brighter red than the 
 surrounding intestine, and somewhat swollen, and sometimes they are 
 of a large grey tint, and present a singular punctated appearance. In 
 the large intestines there is also sometimes a remarkable development 
 of the solitary glands, the dark orifice of which renders them very 
 evident; and in a few instances they become still more apparent, from 
 the mucous membrane immediately around each presenting a dark grey 
 colour. The appearances in short, are those of general inanition, 
 coupled with the signs of irritation or inflammation of the whole 
 secreting apparatus of the intestinal canal. 2 
 
 The full consideration of every question connected with the imperfect 
 nutrition of infants would require little else than a complete treatise on 
 
 1 According to some experiments by M. Guillot, of Paris, referred to by Dr. Stewart, 
 of New York, in a paper republished from an American Journal in the Dublin Medical 
 Journal, March, 1845. 
 
 2 This account of the post-mortem appearances observed in infants who have been im- 
 perfectly nourished, is not merely borne out by the very interesting paper of MM. Fried- 
 leben and Fleisch, in Vol. v. of the Zeitschvift fiir rationelle Medicin, Heidelberg, 1846; 
 but receives a remarkable illustration in the recent work of M. Bednar, physician to the 
 Foundling Hospital at Vienna. The observations of the former gentlemen are founded 
 on the examination of lilteen infants, all of whom were under one year old, who were 
 
SUCKLING IMPORTANT, EVEN THOUGH ONLY FOR A SHORT TIME. 331 
 
 the dietetics of early life. In these lectures I can aim at nothing 
 more than to bring before your notice a few points of the greatest 
 importance. 
 
 Although it is very desirable that for the first six months of their 
 existence children should derive their support entirely from their 
 mother, and that until they are a year, or at least nine months old, 
 their mother's milk should form the chief part of their food, yet many 
 circumstances may occur to render the full adoption of this plan im- 
 practicable. In some women the supply of milk, although at first 
 abundant, yet in the course of a few weeks undergoes so considerable a 
 diminution as to become altogether insufficient for the child's support ; 
 while in other cases, although its quantity continues undiminished, yet 
 from some defect in its quality it does not furnish the infant with 
 proper nutriment. Cases of the former kind are not unusual in young, 
 tolerably healthy, but not robust women ; while instances of the latter 
 are met with chiefly among those who have given birth to several 
 children, whose health is bad, or whose powers are enfeebled by hard 
 living or hard work. The children in the former case thrive well 
 enough for the first six weeks or two months ; but then, obtaining the 
 milk in too small a quantity to meet the demands of their rapidly 
 growing organism, they pine and fret, they lose both flesh and strength, 
 and unless the food given to supply their wants be judiciously selected, 
 their stomach and bowels become disordered, and nutrition, instead of 
 being aided, is more seriously impaired. If, however, a healthy wet 
 nurse be employed to supply the mother's inability to nourish her child, 
 its health will soon return ; and by the sacrifice of the infant of the 
 poor woman, the offspring of the wealthy will be preserved. But many 
 circumstances besides those moral considerations which should never be 
 forgotten before the determination is formed to employ a wet nurse, 
 may put this expedient out of the question ; and it becomes, therefore, 
 our duty to inquire what course a mother should pursue, who has learnt 
 by experience that she is unable to suckle her child for more than a 
 very short period. 
 
 Knowing the attempt to rear her child entirely at the breast to be 
 vain, the mother may in such a case naturally be tempted to bring it up 
 by hand from the very first. But, how short soever the period may be 
 
 brought up either exclusively, or in great measure, on artificial food, and who died, after 
 long-continued illness, in a state of atrophy, or else sank rapidly under profuse watery 
 diarrhoea. In cases of the former class, a state regarded by the writers as the result or 
 chronic inflammation of Peyer's glands was the chief morbid appearance ; while in those 
 instances where death took place rapidly, a swollen and congested condition of the same 
 bodies, betokening, as they believe, their recent inflammation, was almost always pre- 
 sent. They found, too, that in all these cases the disease of the colon was comparatively 
 slight, and evidently secondary to the more serious changes in the small intestine. Dr. 
 Bednar's patients were all under three months, — many only a few days old, — partly 
 suckled by women, each of whom had several nurslings, partly fed on artificial food. 
 As might be anticipated, the mortality is high, and of such almost uniform occurrence 
 is a swollen condition of the mesenteric and Peyerian glands, and even of the solitary 
 glands of the lai'ge intestines, that, when treating of diarrhoea, he speaks of them as 
 conditions of no sort of importance ; and concerning the last expresses the opinion that 
 it is to be regarded as a physiological rather than a pathological occurrence. No more 
 striking comment could be written on the mischiefs and the dangers of artificial feeding 
 of infants. See pp. 37 and 88 of Bednar's Krankheiten der Neugebornen, &c. 8vo. Wien., 
 1850. 
 
332 
 
 SUBSTITUTE FOR THE MOTHER S MILK. 
 
 during which the mother is ahle to suckle her child, it is very desirable 
 that she should nurse it during that period, and also, that her milk 
 should then constitute its only food. For the first four or five days 
 after the infant's birth the milk possesses peculiar qualities, and not 
 merely abounds in fatty and saccharine matters, but presents its casein 
 in a more easily assimilable form than subsequently. 1 It afterwards 
 loses these characteristics ; but still, during the first few weeks of life, 
 it contains casein in smaller quantities than enter into its composition 
 at a later period. The secretion, in short, is especially adapted to the 
 feeble powers of the digestive organs soon after birth : and hence the 
 difficulty of providing any good substitute for it is greater in proportion 
 to the tender age of the infant, while art often imitates but ill that 
 gradual increase of the casein, by which the main element of the 
 infant's sustenance is made to bear a constant proportion to the de- 
 mands of its daily growth. 
 
 The same course of conduct would be proper in the case of women 
 whose milk is of so poor a quality that their infants do not thrive upon 
 it, since, though its deficiency in casein may render it unfit for the per- 
 manent support of the child, yet that circumstance will not prove pre- 
 judicial to it during the first few weeks of its existence. 
 
 In both of these cases, however, it is only for a season, and usually 
 a very brief season, that the mother is able to suckle her infant with 
 advantage ; while instances are by no means rare in which the import- 
 ant question of the best substitute for the mother s milk has to be 
 answered within a few hours after the infant's birth. It is obvious that 
 the more nearly the substitute that we select approaches to the cha- 
 racter of the mother's milk, the greater will be the prospect of the 
 attempt to rear the infant upon it proving successful. Discarding, 
 therefore, all those preparations of arrow-root, flour, or biscuit powder, 
 in which the vulgar repose such confidence, we shall not need any 
 laboured argument to convince us, that in the milk of some other animal 
 we shall be likely to find the infant's most appropriate food. You will 
 perceive, however, by the subjoined table, that there are many important 
 
 Table shewing the Composition of the Milk in Man and in various Animals. 
 
 In Man 
 
 100 parts contain — 
 
 100 parts of the solid constituents contain — 
 
 Fluid. 
 
 Solids. 
 
 Casein. 
 
 Butter. 
 
 Sugar and 
 Extractive 
 Matters. 
 
 Salts. 
 
 883.6 
 842.0 
 
 907.0 
 865.0 
 856.2 
 
 116.4 
 158.0 
 
 93.0 
 134.0 
 143.8 
 
 31.2 
 42.1 
 
 18.0 
 41.1 
 31.2 
 
 23.0 
 28.1 
 
 13.2 
 
 28.0 
 29.2 
 
 43.8 
 23.9 
 
 2.0 
 5.7 
 
 " the Cow 
 
 " " Ass 
 
 " " Goat 
 
 68.5 
 
 30.0 
 
 34.7 4.7 
 
 " " Ewe 
 
 
 
 
 1 See on this subject a very interesting paper by Mr. Moore of Dublin, On the Coa- 
 gulability of Human Milk, in Dublin Journal of Medical Sciences, May, 1849. 
 
SUBSTITUTE FOR THE MOTHER'S MILK. * 333 
 
 differences between the milk of all the domestic animals and of the 
 human female ; while the infant who is fed upon the milk of any of 
 them, loses those advantages which, when it is suckled by its mother, 
 result from the gradual change that takes place in the proportion of its 
 constituents as the infant advances in age. 
 
 The expense of asses' milk, which, from the small quantity of casein 
 that it contains, is especially fitted for young or delicate infants, unfor- 
 tunately prevents it being generally employed ; and in the majority 
 of instances in which children are brought up by hand, cows' milk is 
 used, as being the most easily procured. For the first month or five 
 weeks, however, it is very desirable that the asses' milk should be given, 
 and that cows' milk should not be substituted for it, until the first dan- 
 gers of the experiment of bringing an infant up by hand have been 
 surmounted. In order to make up for the deficiency of oily matter in 
 the asses' milk, the suggestion has been made of adding to it a twen- 
 tieth part of cream j 1 and Sir Henry Marsh tells us, that the laxative 
 property which asses' milk possesses, and which sometimes interferes 
 with our employing it, is effectually destroyed by heating it to 212°. 
 If, as sometimes will happen, even when this best substitute for the 
 mother's milk is given, the infant's bowels should still be relaxed, the 
 addition of about a fourth part of lime water will generally control this 
 diarrhoea. 
 
 When cows r milk is given, it must be borne in mind that it contains 
 more casein than human milk, and less sugar ; and that it is therefore 
 necessary that it should be given in a diluted state, and slightly 
 sweetened. The degree of dilution must vary according to the infant's 
 age : at first, ^the milk may be mixed with an equal quantity of water, 
 but as the child grows older, the proportion of water may be reduced 
 to one-third. Attention must be paid to the temperature of the food 
 when given to the infant, which ought to be as nearly as possible the 
 same as that of the mother's milk, namely, from 90° to 95° Fahrenheit; 
 and in all cases in which care is needed, a thermometer should be em- 
 ployed, in order to ensure the food being always given at the same 
 temperature. Human milk is alkaline ; and even if kept for a consi- 
 derable time, it shows but little tendency to become sour. The milk of 
 animals in perfect health likewise invariably presents an alkaline reac- 
 tion, and that of cows when at grass forms no exception to this rule. 
 Comparatively slight causes, however, exert a marked influence upon 
 the milk of the cow in this respect ; and if the animal be shut up and 
 stall-fed, its milk almost constantly assumes a strongly acid property 2 
 — a fact which of itself is sufficient to account for the symptoms of 
 gastric and intestinal disorder so often produced by it in the case of 
 children brought up in large towns. Whenever, therefore, the attempt 
 is made to rear an infant by hand, under circumstances which render 
 it impossible to obtain the milk of cows which are at pasture, it is 
 desirable that the milk should be daily tested, and that any acidity 
 
 1 By Mr. Moore, of Dublin, in his paper already referred to. 
 
 2 See the results of Dr. Mayer's observations on cows in Berlin and its neighbourhood, 
 in a valuable paper on the Artificial Feeding of Infants, in the first volume of the Ver- 
 handlungen der Gesellschaft fur Geburtshulfe in Berlin, 8vo. p. 56, Berlin, 1846 ; and 
 also two papers by Dr. Peddie in the London a nd Edinburgh Monthly Journal for 1848. 
 
334 CHARACTERISTICS OF UNHEALTHY MILK. 
 
 should be neutralized by the addition of lime water, or of prepared 
 chalk, in quantity just sufficient to impart to it a slightly alkaline reac- 
 tion. If the bowels be disposed to be constipated, carbonate of mag- 
 nesia may be substituted for the chalk. Unfortunately, there seem, as 
 I stated a day or two ago, to be good reasons for believing that the 
 milk of stall-fed cows often undergoes a deterioration much more serious 
 than the merely becoming ascescent ; and that changes not infrequently 
 take place in it such as must render it wholly unfit for an infant's food, 
 and calculated only to promote disease. The possibility of their occur- 
 rence shews the necessity, when an infant who is brought up by hand 
 fails in health, for making a careful inquiry into the source of the milk 
 with which it is fed; and for examining the fluid, both chemically and 
 under the microscope, before proceeding to prescribe remedies for 
 ailments which may be caused entirely by the unwholesome nature of 
 its food. 
 
 It can scarcely be necessary to add, that such examination of the 
 milk as is necessary for practical purposes is extremely simple ; since 
 unhealthy milk is characterized not only by the weakening or complete 
 loss of its alkaline reaction, but also by the agglutination of the oil 
 globules, which in health float about perfectly free in the colourless 
 serum, by the presence of numerous large granular bodies similar to 
 those which have been termed colostrum corpuscules, and even in some 
 instances of epithelium scales from the lactiferous tubes. Similar 
 changes, too, take place in the human milk ; and the use of the micro- 
 scope will therefore often help you to solve the question of whether a 
 woman should wean her infant, or whether she may safely continue to 
 suckle it longer. 
 
 It may suffice, for to-day, thus to have brought before you the main 
 principles by which you must be guided in the attempt to rear a young 
 infant by hand. Details as to the general dietetic management of 
 infancy or childhood would not only carry us beyond the period allotted 
 for this lecture, but would be a departure from our special object of 
 investigating the diseases of early life. 
 
 LECTURE XXVIII. 
 
 Atrophy of Young Children — not a special disease, but a condition that may be induced 
 by various causes. 
 
 Thrush, a peculiar affection of the mouth often associated with impaired nutrition — 
 its different names of aphthae and inuguet apply to different degrees of same affection 
 — conflicting opinions as to nature of the deposit — treatment. 
 
 Dentition — high rate of mortality while it is going on — erroneous views "with reference 
 to the cause of this, and to the nature of the process — physiology of dentition — order 
 of appearance of the teeth — pauses in their evolution frequently attended with local 
 suffering — various morbid conditions of mucous membrane of the mouth excited by it. 
 
 Management of children when teething — circumstances under which lancing the gums is 
 likely to be useful — dietetic and medical management — treatment of affections of the 
 mouth — caution with reference to cure of cutaneous eruptions during the time of 
 teething. 
 
 At our last meeting we were occupied with various preliminary 
 inquiries, of importance to the thorough understanding of the diseases 
 
ATROPHY OF YOUNG CHILDREN. 335 
 
 of the digestive organs in early life, on the study of which we now 
 are about to enter. We examined the structural and functional pecu- 
 liarities of those organs in the young, and endeavoured to ascertain 
 wherein consists the special fitness of the mother's milk for the 
 nutriment of her infant. We further tried to discover the mode in 
 which other food acts injuriously on the infant, and sought from the 
 knowledge thus acquired to deduce rules for our guidance, whenever it 
 should become necessary to provide a young child with a substitute 
 for that sustenance which nature intended that it should receive. 
 
 These considerations naturally brought under our notice the symp- 
 toms which betoken that the process of nutrition is imperfectly carried 
 on, and the appearances which, when death takes place from this 
 cause, are revealed on an examination of the body. It may seem to 
 you, however, that the atrophy of young children calls for a more 
 elaborate study than ours of yesterday, and for a minute account of its 
 symptoms. But to attempt this would be to enter upon almost endless 
 details, whi6h would leave upon your memory no clear' impression. 
 Whether all food is withheld from an infant, or whether it is suppled 
 with food which it cannot assimilate, or whether disease prevent it from 
 digesting food on which a healthy infant would thrive, the main result 
 is the same, and the child dies of inanition. Various accidents may 
 abridge the infant's life, or make it sink, in one case, under circum- 
 stances somewhat different from those which precede its death in 
 another. Sometimes the vital powers grow so feeble, that the inspi- 
 ratory efforts no longer suffice to fill the lungs with air ; sometimes the 
 irritable stomach rejects all food, while at other times diarrhoea comes on 
 which no medicine can check. But in these symptoms there is nothing 
 characteristic of one special cause, — they may occur alike in the 
 infant who, though healthy when born, was early deprived of its 
 mother's milk, or in the child who is the subject of general tuberculous 
 disease, or whose strength has been exhausted and its digestive powers 
 impaired by dysentery. The symptoms, then, that accompany the 
 atrophy of new-born children, must be expected to vary much in 
 different cases ; while the considerations brought before you in the last 
 lecture will, I think, furnish you with a clue to the complete under- 
 standing of them all. 
 
 Before we pass, however, to the special study of the diseases of the 
 digestive organs and its appendages, I would beg to call your attention 
 to that peculiar condition of the mucous memhrane of the mouth popu- 
 larly known as the thrush, which is so frequently met with in connection 
 with the artificial feeding of young infants, — so almost invariably asso- 
 ciated with the evidences of their impaired nutrition, that the present 
 seems to be the best time for noticing it. 
 
 If you examine the mouth of a young infant on whom the attempt is 
 being made to bring it up without the mother's milk, you will often 
 observe its mucous membrane to be beset with numerous small white 
 spots, which look like little bits of curd lying upon its surface, but 
 which on a more attentive examination are found to be so firmly adhe- 
 rent to it as not to be removed without some difficulty, when the 
 subjacent membrane is left of a deep red colour, and often bleeding 
 
336 INFANTILE ATROPHY NOT A SPECIAL DISEASE. 
 
 slightly. These specks appear upon the inner surface of the lips, espe- 
 cially near the angles of the mouth or the inside of the cheeks ; and 
 upon the tongue, where they are more numerous at the tip and edges 
 than towards the centre. They are likewise seen upon the gums, 
 though less frequently, and in smaller number. When they first appear, 
 they are in general of a circular form, scarcely larger than a small 
 pin's head ; but after these aphthce, as they are called, have existed for 
 a day or two, some of the spots became three or four times as large, 
 while at the same time they in general lose something of their circular 
 form. By degrees these small white crusts fall off of their own accord, 
 usually leaving the mucous membrane where they were seated redder 
 than before — a colour which gradually subsides as the mouth returns 
 to its natural condition ; or the white specks are reproduced, and again 
 detached, several times before the membrane resumes its healthy aspect. 
 In 'some cases these specks coalesce, or the deposit, from its first 
 appearance, presents more of the character of a false membrane ; and 
 the mouth is then seen to be extensively coated with it. Under these 
 circumstances, the deposit generally loses something of the dead white 
 colour characteristic of the smaller spots, and presents a slightly yel- 
 lowish tint. On the continent, where the severer form of the affection 
 is not infrequently seen, it was supposed, though the opinion is now 
 generally abandoned, to be an essentially different ailment from the 
 slighter "forms of the disease, in which the points of deposit are distinct. 
 Accordingly, the term aphthoe has been restricted by many French 
 writers to the milder variety, while they have applied the name cf 
 muguet to designate its severer form. I use the English word thrush 1 
 to denote both forms, regarding them merely as degrees of the same 
 malady. 
 
 Children in whom either form of this deposit exists in any consider- 
 able degree, usually appear out of health ; and it will generally be 
 found on inquiry that this indisposition had preceded for some days the 
 eruption in the mouth. For the most part such children are emaciated, 
 and present those symptoms that attend upon imperfect nutrition, 
 while the bowels are in general relaxed, and the evacuations of a green 
 colour, and very sour. The acridity of the motions sometimes irritates 
 and inflames the margins of the anus, and a blush of erythematous 
 redness not infrequently extends over the nates and buttocks, while in 
 some instances a deposit of a similar kind to that in the mouth occupies 
 the edges of the intestine. The deposit in the mouth sometimes ren- 
 ders sucking very difficult, and may even impair deglutition, while the 
 child, thus obtaining but little food, lies in a state of torpor and drow- 
 siness, the result of its debility. 
 
 In its more serious form this affection was said to prove fatal to a 
 large number of the inmates of the different foundling hospitals on the 
 continent. Observation has shown, however, that although the deposit 
 exists in the mouth of very many children who die in those institutions, 
 yet their death is due not to the local affection, but to the constitutional 
 disease, of which that is only one out of many evidences. 
 
 1 A word the etymology of which is uncertain ; as is that of its Swedish synonym 
 Torsk, and the Danish and Norwegian Trodske. 
 
INTIMATE NATURE OF THE DEPOSIT. 337 
 
 At the time when the local affection was regarded as in itself of such 
 grave import, every inquiry into its nature presented a degree of prac- 
 tical importance which no longer attaches to it. The differences between 
 that slight ailment, in which the deposit appears in the form of a 
 number of isolated specks, and the more serious affection, in which it 
 completely lines the mouth, were thought to be differences of kind, not 
 merely of degree. This opinion is now, however, ascertained to be 
 erroneous ; and though observers are not yet quite agreed as to the 
 intimate nature of the deposit, yet its identity in both cases is no 
 longer matter of dispute. The microscope has not yet cleared up all 
 doubts with reference to its nature ; and while some persons are dis- 
 posed to regard the deposit as being a parasitic growth, like the mus- 
 cardine which attacks the silk-worm, or the confervse found on other 
 living animals, other observers look upon it as a false membrane similar 
 to that of diphtheritis or croup, and consider that the development- of 
 confervae in its substance is an accidental occurrence, and one which is 
 frequently absent. 1 According to the former opinion, the white deposit 
 is made up of epithelium thickened by swelling of its cells, in the midst 
 of which a parasitic growth is developed in greater or less abundance, 
 so that the aphthous mass is composed partly of it, partly of epithelial 
 cells. The relation of the two elements to each other varies according 
 to the duration of the disease and the age and constitution of the 
 patient ; but the development of the aphthophytes, as this growth has 
 been termed, is regarded as essential to the production of the affection. 
 
 On the other hand, the existence of the vegetable parasite has been 
 considered to be purely accidental, the disease consisting according to 
 this view oi\ its nature, essentially in the formation of a false 
 membrane beneath the epithelium ; this adventitious production serving 
 as a nidus for the parasitic growth which, under favourable circum- 
 stances, may be developed in it. The fibrils observed in the deposit, 
 which by some persons have been regarded as proving it to be in 
 reality a vegetable parasite, are stated by the opponents of that view 
 to be nothing more than very delicate fibres, having a parallel 
 arrangement, and owing the branched appearance which they 
 sometimes seem to present entirely to an optical illusion. 
 
 I cannot pretend to decide from personal observation, the point at 
 issue between the supporters of these two conflicting theories ; but my 
 opinion decidedly leans to the adoption, as generally correct, of that 
 view which sees in the deposit the result of an inflammatory process 
 ending in the formation of false membrane, wherein a parasitic growth 
 may become developed. The endemic prevalence of thrush in 
 foundling hospitals, and other similar institutions, may be accounted 
 
 1 Not to encumber this lecture with the citation of authorities, it may suffice to refer 
 to the valuable essay of Dr. Berg, of Stockholm, analyzed in the Journal fur Kinderkrank- 
 heiten for September and October, 1847, and since translated into German, as a most 
 able defence of the first-mentioned opinion ; and to the papers by Dr. Kronenberg, of 
 Moscow, in that Journal for February and September of the same year, for observa- 
 tions and arguments tending to support the opposite view. With reference to the pro- 
 duction of confervee on the mucous surfaces of the human body in disease, the fullest 
 account is given by Hannover, in Miiller's Archiv for 1842, p. 281. 
 
 22 
 
I 
 
 338 TREATMENT OF THE AFFECTIONS OF THE MOUTH. 
 
 for by the noxious influences to which infants are there subjected ; 
 and which, as we have already seen, in the case of diphtheritis and of 
 malignant coryza, are favourable to the formation of false membranes 
 upon the different mucous surfaces. The frequency of the parasitic 
 growth in the false membrane is possibly dependent on the actual 
 transplantation of its sporules from one patient to another by means 
 of the cups, spoons, &c. used by them in common, and generally 
 without sufficient attention being paid to ensure their perfect 
 cleanliness. Such at least, is the conclusion to which Dr. Berg, 
 of Stockholm, 1 was led by his observation, while his experiments seem 
 further to prove the possibility of exciting the disease by the deposit 
 of these sporules upon the surface of the healthy mucous membrane, 
 which, in all the four instances where it was tried, was followed by 
 the developement of the confervae and the alteration of the epithelium 
 of the mouth. 
 
 In the treatment of this affection, the removal of the constitutional 
 disturbance is of at least as much importance as the ministering to 
 the local malady. It is, however, only the local treatment that it 
 will be expedient to dwell on here, since the general management of 
 the case must vary as widely as the causes to which the affection of 
 the mouth is due. One point of considerable moment, and to which 
 less care than it deserves is usually paid, is the removing from 
 the mouth, after each time that the infant is fed, all remains of the 
 milk, or other food that it has taken. For this purpose, whenever the 
 least sign of thrush appears in the infant, the mouth should be carefully 
 wiped out with a piece of soft rag, dipped in a little warm water, every 
 time after food has been given. Supposing the attack to be but slight, 
 this precaution will of itself suffice in many instances to remove all 
 traces of the affection in two or three days. If, however, there be 
 much redness of the mucous membrane of the mouth, or if the aphthous 
 spots be numerous, some medicated topical application is useful. — 
 Various detergents have been recommended, among which the mel 
 boracis, and a mixture of the Armenian bole with honey, are very 
 frequently employed. An objection, however, has been raised, and 
 I think on good grounds, to any application into the composition 
 of which honey or other saccharine matters enter, on the ground that 
 the tendency of those substances to pass into a state of fermentation 
 will make them favour rather than prevent the formation of conferva? 
 in the interior of the mouth. It is my custom to dissolve a scruple or 
 half a drachm of borax in an ounce of water, and to direct that after 
 the mouth has been carefully cleansed with warm water, this lotion 
 should be applied to it on a piece of lint or soft linen. In the milder 
 forms of the affection, the borax lotion usually answers every purpose. 
 Should it, however, appear insufficient, a solution of five grains of the 
 nitrate of silver in an ounce of distilled water may be employed in 
 the same way twice a day, while at other times the solution of borax 
 may be used in the manner just directed. 
 
 The close connection that subsists between this local affection and 
 
 p 
 i Ueber die Schwiimmchen der Kinder, 8vo. Bremen, 1 848, pp. 76-80. 
 
MORTALITY DURING DENTITION. 339 
 
 -the condition of generally impaired nutrition, which engaged our atten- 
 tion yesterday, induced me to br^ng the subject now under your notice. 
 I do not know, however, that any better plan can be adopted, in 
 studying the diseases of the organs of digestion and assimilation, than 
 closely to follow an anatomical arrangement, and to consider, first, the 
 diseases of the mouth, then those of the stomach, then those of the 
 intestines, and lastly those of the other abdominal viscera. 
 
 It may, perchance, seem to you that, according to this plan, it is not 
 proposed to assign any place of importance to the disorders of dentition, 
 though in our tables of mortality we find teething registered as having 
 occasioned the death of nearly 5 (4.8) percent, of all children who died 
 in this metropolis under one year old, and of 7.3 per cent, of those who 
 died between the age of twelve months and three years. Many other 
 circumstances, too, tend to increase the impression which this fact natu- 
 rally makes ; for not only do nurses attribute to teething the most 
 varied forms of constitutional disturbance, and mothers express serious 
 apprehensions as the period of dentition approaches, but medical men 
 hold forth to anxious parents the expectation that their child will have 
 better health when it has cut all its teeth. The time of teething, too, 
 is in reality one of more than ordinary peril to the child ; though why 
 it should be so is not always rightly, understood. It is a time of most 
 active development of the organism — a time of transition from one 
 mode of being to another, in respect of all those important functions 
 by whose due performance the body is nourished and built up. Sta- 
 tistics, 1 embracing the largest numbers, prove the dangers of this 
 period, and warrant us in regarding the completion of the process of 
 teething as a Xair subject for congratulation. 
 
 The error which has been committed with reference to this matter, 
 not merely by the vulgar but by members of our own profession also, 
 consists, not in overrating the hazards of the time when changes 4 so 
 important are being accomplished, but in regarding only one of the 
 manifestations — though that, indeed, is the most striking one — of the 
 many important ends which nature is then labouring to bring about. 
 A child in perfect health usually cuts its teeth at a certain time and in 
 a certain order, just as a girl at a certain age presents the various 
 signs of approaching puberty, and at length begins to menstruate. In 
 her case we do not fix our attention solely on the menstrual flux ; nor, 
 if it fail to appear, do we have recourse to the empirical employment 
 of emmenagogue medicines. We examine into the cause of its absence ; 
 try to ascertain whether it depends on the state of the health in 
 general, or of the uterine system in particular, and regulate accord- 
 ingly our attempts at cure. The epoch of dentition is to be looked at 
 just in the same way as that in which we regard the epoch of puberty. 
 Constitutional disturbance is more common, and serious disease more 
 frequent, at these times than at others; but their causes lie deeper than 
 the tooth which irritates the gum that it has not yet pierced in the one 
 case, or than the womb which has not yielded the due discharge of 
 
 l See, for instance, the table of mortality at different months, at p. 36 of MM. Quetelet 
 et Smits, Recherches surla Reproduction et la Mortality, &c. 8vo. Bruxelles, 1842. 
 
340 ORDER IN WHICH THE TEETH APPEAR. 
 
 blood in the other. .You might produce haemorrhage from the uterine* 
 vessels in the latter instance, or might cut through the gum which 
 enclosed the teeth in the former, with no other effect than that of 
 aggravating the condition of your patient. 
 
 In speaking of the diseases of the nervous and respiratory systems, 
 your attention has on several occasions been drawn to the greater 
 frequency of some of those affections just at the time when the process 
 of teething is going on ; and you will have to remark a similar fact 
 with reference to some of the disorders of the abdominal viscera. 
 These maladies, however, are not peculiar to the time of teething, nor, 
 when they occur at that period, do they present symptoms different 
 from those which characterise them under other circumstances, while 
 it often happens that the changes which mark the transition from 
 infancy to childhood are accomplished so quietly as to be attended with 
 no notable disturbance of the general health. 
 
 The great changes which nature is constantly bringing about around 
 us and within us, are the result of laws operating silently but unceas- 
 ingly ; and hence it is that in her works we see little of the failure 
 which often disappoints human endeavours, or of the dangers which 
 often attend on their accomplishment. Thus, when nature's object is to 
 render the child no longer dependent on the mother for its food, she 
 begins to prepare for this long beforehand. The first indication of it 
 is^furnished by the greatly increased activity of the salivary glands. 
 If you look into the mouth of a young infant, you will be struck by the 
 very small amount of saliva that moistens its surface — a circumstance 
 which explains in great measure the tendency to dryness which the 
 tongue then presents under the influence of very trivial ailments. 
 About the fourth or fifth month, however, this condition undergoes a 
 marked alteration : the mouth is now found constantly full of saliva, and 
 the child is continually drivelling ; but no other indication appears of the 
 approach of the teeth to the surface, except that the ridge of the gums 
 sometimes becomes broader than it was before. No further change 
 may take place for many weeks : and it is generally near the end of 
 the seventh month, oftener later than earlier, before the first teeth 
 make their appearance. The middle incisors of the lower jaw are 
 generally the first to pierce the gum ; next in order appear the middle 
 incisors of the upper jaw, then the lateral incisors of the upper jaw, 
 and next the lateral incisors of the lower. The first four molars next 
 succeed, and often without any very definite order as to whether those of 
 the upper or of the lower jaw are first visible, though, in the majority 
 of cases, the lower molars are the first to appear. The four canine 
 teeth succeed ; and, lastly, the four posterior molars — making, in all, 
 the number of twenty deciduous teeth. 
 
 We must not, however, picture to ourselves this process as going on 
 uninterruptedly until completed — a mistake into which parents often 
 fall, whose anxiety respecting their children is consequently excited by 
 observing, that, after several teeth have appeared in rapid succession, 
 dentition appears to come to a standstill. Nature has so ordered it, 
 that the process of dentition, beginning at the seventh or eighth month, 
 shall not be completed until the twenty-fourth or thirtieth ; and has 
 
AFFECTIONS OF THE MOUTH DURING TEETHING. 841 
 
 doubtless done so in some measure with the view of diminishing the risk 
 of constitutional disturbance which might be incurred if the evolution 
 of the teeth went on without a pause. A little observation will show 
 you, that, while the irruption of the lower central incisors is generally 
 completed in a week, an interval of six weeks or two months often takes 
 place before the upper incisors make their appearance, which then are 
 Quickly followed by the lower lateral incisors. A pause of three or 
 four months now frequently occurs before we see the first molar teeth, 
 another of equal length previous to the appearance of the canine teeth, 
 and then another still longer before the last molars are cut. 
 
 Though a perfectly natural process, dentition is yet almost always 
 attended with some degree of suffering. Many of us, no doubt, can 
 remember feeling much pain when we cut our wisdom teeth, and chil- 
 dren probably experience the same kind of annoyance. This, however, 
 is not always the case ; for sometimes we discover that an infant has 
 cut a tooth, who had yet no sign of discomfort, nor any indication that 
 dentition was commencing, with the exception of an increased flow of 
 saliva. More frequently, indeed, the mouth becomes hot, and the gums 
 look tumid, tense, and shining, while the exact position of each tooth is 
 marked, for some time before its appearance, by the prominence of the 
 gum : or the irruption of the teeth is preceded or accompanied by a 
 somewhat different condition of the mouth, in which there are much 
 heat, and intense redness of the mucous membrane, an extremely 
 copious flow of thin saliva, and a disposition to the formation of small 
 aphthous ulcerations on the tongue, at the outer surface of the alveolae, 
 or at the duplicature of the lip, though the gums themselves may not 
 be particularly swollen or painful. Either of these states is usually 
 attended with some degree of febrile disturbance, and apparently with 
 considerable suffering to the infant, who is constantly fretful and pee- 
 vish, or cries out occasionally as if in pain. A third morbid condition 
 of the mouth is sometimes seen, which is usually ushered in or attended 
 by very considerable fever and disorder of the chylopoietic viscera. 
 The gums then become extremely hot and swollen, and usually tender, 
 especially over some tooth or other in particular, and in that situation 
 we find the gum swollen up into a kind of little tumor. Small unhealthy 
 ulcerations, with a sloughy appearance, often form upon the summit of 
 the gum, and especially around any tooth which has partly pierced 
 through it. To this affection, which is often very painful, and often 
 difficult of cure, the name of Odontitis Infantum has been applied by 
 some continental writers. 
 
 In considering the rules by which you must direct the management 
 of children ichen teething, it can scarcely be necessary to caution you 
 against regarding all diseases that may come on during dentition as of 
 necessity connected with that process, or with the general changes then 
 going on in the organism : still less need'I warn you against looking 
 upon all ailments at that time as symptomatic of the local uneasiness 
 which the child suffers in its mouth. Some persons, indeed, act as if 
 they held both these notions in their fullest extent ; and, following up 
 in practice this coarsely mechanical theory, they lance the gums of 
 every child who has not yet cut all its teeth, almost or altogether irre- 
 
342 RULES FOR THE USE OF THE GUM-LANCET. 
 
 spective of the nature of the affection from which it suffers. Such a 
 proceeding is nothing better than a piece of barbarous empiricism, 
 which causes the infant much pain, and is useless or mischievous in a 
 dozen instances, for one in which it affords relief. Still less is the gum- 
 lancet to be applied, merely with the view of expediting the process 
 that nature is engaged in. The gradual protrusion of the teeth occa- 
 sions the slow absorption of the superjacent gum, and for this process 
 the division of the gum by a scalpel forms at best but a clumsy sub- 
 stitute. 
 
 The circumstances under which the use of the gum-lancet is really 
 indicated are comparatively few. You may employ it when a tooth is 
 so nearly through that you can feel sure it will burst the gum in a day 
 or two at latest , for then, by making an incision through the very thin 
 gum, you may certainly spare the infant some suffering. Or, you may 
 lance the gums if they be red, and swollen, and tense, and injected ; but 
 then you scarify them in order that they may bleed, and that their 
 congested vessels may be thus relieved : you do not divide them to let 
 out the imprisoned tooth. Under such circumstances it may be neces- 
 sary to repeat your scarification several times with the same object ; 
 and it is therefore well to explain beforehand to the mother the reasons 
 of your proceeding, lest she should expect to see the tooth at once make 
 its appearance. There are, besides, cases in which the general consti- 
 tutional disturbance that often attends dentition continues for several 
 days, or even weeks, while yet the condition of the swollen gum remains 
 unaltered, and the tooth does not seem to approach nearer to the surface. 
 In such a case you may try the experiment of lancing the gums, or you 
 may try it in the case of a child in whom you have already observed that 
 catarrh, or fever, or diarrhoea, has been excited by the approach of each 
 tooth to the surface, and has ceased immediately that the tooth has 
 pierced the gum. Lastly, in the cases of sudden, and apparently cause- 
 less convulsions, which are occasionally met with in children, you will be 
 justified in lancing the gums if you find that the process of dentition is 
 going on with activity ; but you would do no good if you lanced the 
 gums during one of those periods of repose which you will remember 
 interrupt from time to time the evolution of the teeth. You must 
 therefore inquire not merely what teeth the child has cut, but also when 
 the last made their appearance ; and must seek for some evidence either 
 that the process is still going on, or that its activity is once more 
 recommencing, before you would have ground for supposing the source 
 of irritation of the nervous system to be such as your gum-lancet would 
 relieve. 
 
 If the process of teething be going on perfectly naturally, no 
 interference, medical or other, is either necessary or proper. The 
 special liability of children to illness at that time must indeed be borne 
 in mind, and care must betaken not to make any alteration in the 
 infant's food while it is actually cutting its teeth, but rather to choose 
 the opportunity of some one of those pauses to which reference has 
 been made, as occurring between the dates of irruption of the successive 
 teeth, for any such change. Should the child at any time appear very 
 feverish, some simple febrifuge medicine may be given ; as for instance, 
 
GENERAL MANAGEMENT OF TEETHING CHILDREN. 343 
 
 a mixture of the bicarbonite of potash not quite neutralized with citric 
 acid, to each dose of which two or three minims of the tincture of 
 hyoscyamus may be added, if the child be very restless and fretful. 1 
 The diet must be carefully regulated ; and as the heat of the mouth may 
 induce the child to suck too often, in order to obtain the grateful relief 
 of moisture, and by so doing to overload its stomach, water or barley- 
 water should be freely given to it; and the mother should be cautious 
 not to put it too frequently to the breast. If the child have been 
 weaned, still greater care will be required, for it will often be found 
 that it is no longer able to digest its ordinary food, which either is at 
 once rejected by the stomach, or else passes through the intestines 
 undigested. Very thin arrow-root made with water, with the addition 
 of one third of milk, will suit in many cases; or you may occasionally 
 substitute for this, equal parts of milk and water thickened by 
 dissolving isinglass in it till its consistence equals that of thick barley- 
 water ; or may employ the white decoction of Sydenham with the 
 addition of one part of milk. If the bowels be disordered, half a 
 grain of Dover's powder night and morning will often restrain their 
 over action ; while the child may take during the day a mucilaginous 
 mixture, 2 containing small doses of the vinum ipecacuanha and of 
 
 (No. 21.) 
 2 R Misturae Acaciae, ^vj. 
 
 Liquoris Potassae, n^xxx. 
 Vin. Ipecacuanha, nvxxiv. 
 Syrupi Altheae, %'w. 
 
 Aquas purae, gxiij. M. giij. 6tis horis. 
 \ For a child from 12 to 18 months old. 
 
 some alkali, as the bicarbonate of potash or the liquor potassae. The 
 dysuria from which infants sometimes suffer when teething is relieved 
 by a similar plan of treatment, with the addition of small doses of 
 castor oil if the bowels do not act regularly ; while the tepid bath is 
 often extremely serviceable in diminishing that great heat of skin which 
 exists in many of these cases. 
 
 That state of the mouth in which small aphthous ulcers appear upon 
 the tongue and about the alveolae is usually connected with disorder of 
 the digestive organs, to the relief of which our treatment must be chiefly 
 directed. It is seldom necessary to do more locally, than to pay great 
 attention to cleanse the mouth every time after the child has sucked or 
 taken food, and afterwards to apply to it a solution of borax, in the 
 manner I pointed out to you at the commencement of this lecture. 
 Now and then the submaxillary glands become swollen and tender 
 while the infant is cutting some of its teeth ; but this condition 
 generally subsides of its own accord. Sometimes, however, the 
 irritation extends to some of the absorbent glands beneath the jaw 
 or near its angle; and in scrofulous subjects they occasionally inflame 
 and suppurate. In such children, too, strumous ophthalmia and 
 otorrhcea are not infrequently excited by dentition. 
 
 1 See Formula No. 2, p. 43. 
 
344 TREATMENT OF THE AFFECTIONS OF THE MOUTH. 
 
 That severe form of inflammation of the gums to which the name of 
 Odontitis has been given sometimes occasions great suffering, and may- 
 even endanger the child's life, though no instance has come under my 
 own notice in which it proved actually fatal. The gum-lancet will here 
 do no good whatever ; its employment would be intensely painful, and 
 that unhealthy ulceration which attends the inflammation of the gums 
 would attack the edges of the cut, and thus aggravate instead of 
 relieving the child's sufferings. Local depletion by leeches, however, 
 is extremely useful in such cases. Some writers have suggested that 
 the leeches should be applied to the gum itself; but I have always 
 contented myself with the much easier plan of applying them to the 
 angle of the jaw, and have seldom been disappointed in obtaining very 
 marked relief 01 all the symptoms. The diet must be most carefully 
 regulated, the state of the bowels attended to, and a mildly antiphlogistic 
 plan of treatment adopted, while the borax lotion may be used locally 
 with advantage. There is, however, one remedy which acts in the 
 various forms of stomatitis almost like a charm, and which proves 
 exceedingly useful even when inflammation of the mouth is associated 
 with the process of teething. This remedy, for the introduction of 
 which into practice in cases of stomatitis, the profession is indebted 
 to Dr. Hunt, 1 is the chlorate of potash, which may be given dissolved 
 in water and sweetened, in the dose of one grain every four hours to 
 a child a year old, with almost a certainty of effecting a cure in the 
 course of four or five days. 
 
 In conclusion, I may just refer to those eezematous and impetiginous 
 eruptions of the face and scalp which often occur in teething children. 
 The old prejudice which regards diseases of the skin appearing at this 
 time as having in them something salutary, and that consequently it is 
 not desirable to attempt their cure, is not destitute of a certain founda- 
 tion in fact. Instances of the sudden disappearance of eruptions on 
 the scalp during the period of dentition, being followed by serious 
 impairment of the general health, by convulsions, or by other signs of 
 mischief in the brain, are far from uncommon. Their removal, there- 
 fore, must never be attempted except by the gentlest means, while every 
 threatening of the supervention of cerebral congestion, or of more 
 serious disease of the brain, must be most closely watched for and most 
 vigorously combated. Sometimes, too, it will be found that whenever 
 the cutaneous affection has made a certain advance towards cure, the 
 signs of other disease invariably appear. In such a case it is wiser to 
 content yourselves with keeping the local ailment in check, rather than, 
 by persevering in the attempt to cure it, to endanger in far more serious 
 respects the welfare of the child. 
 
 1 Medico-Chirurgical Transactions, vol. xxvi. p. 142. 
 
INFLAMMATION OF THE MOUTH. 
 
 LECTURE XXIX. 
 
 Inflammation or the Mouth, or Stomatitis— its three varieties. 
 
 Follicular stomatitis — often a secondary affection — most frequent before dentition is 
 completed — its symptoms — character of the ulceration of the mouth — not a serious 
 disorder. — Its treatment. 
 
 Ulcerative stomatitis — principally affects the gums — its course usually chronic — has very 
 little tendency to degenerate into gangrene — Its treatment — the chlorate of potash 
 almost a specific for it. 
 
 Gangrenous stomatitis — extremely rare, but very fatal— essential differences between it 
 and the other forms of stomatitis — dependent on alterations of the blood, such as occur 
 in fevers — its mode of commencement, symptoms, and course — state of the gangrenous 
 parts on dissection. 
 
 Treatment — importance of efficient cauterization — what caustics are to be used, and how 
 they are to be applied. 
 
 The disease does not depend on the administration of mercury. 
 
 Cynanche Tonsillaris — unusual in young children — its symptoms not peculiar. 
 
 Hypertrophy of the Tonsils — its frequency and importance in childhood — its symp- 
 toms — extreme dyspnoea sometimes produced by it — modifications it produces in form 
 of mouth and nose— deformity of chest resulting from it, how produced. — Treatment 
 — necessity for excision of tonsils. 
 
 Cynanche Parotidea — most common near period of puberty — epidemic and contagious 
 — its symptoms — metastasis of inflammation rare — Treatment. 
 
 Among the local accidents which complicate dentition, we noticed a 
 condition of the mucous membrane of the mouth, which, though not 
 attended by serious danger, is often the source of much suffering to the 
 patient. \ 
 
 Inflammation of the mouth, however, is an occurrence by no means 
 confined to the period of teething, but it comes on in children of all 
 ages, assumes very different forms, and leads to very different results in 
 one case from those which characterize it in another. The mucous fol- 
 licles of the mouth 'are the chief seat of the disease in one case, the 
 substance of the gum in another, that of the cheek in a third. In the 
 first, the affection issues in the formation of several small ulcers, which 
 heal eventually of their own accord ; in the second, an unhealthy pro- 
 cess of ulceration destroys the gums and denudes the teeth, but it is 
 tardy in its advance, and tends to a spontaneous cure ; while, in the 
 last, mortification involves all the tissues of the cheek, and spreads with 
 a rapidity which remedies generally fail to check, and which is arrested 
 at last only by the patient's death. 
 
 Each of these varieties of stomatitis requires from us more than a 
 passing notice. 
 
 The first — the follicular stomatitis of some writers, the aphthous 
 stomatitis of others, is met with either as a concomitant or sequela of 
 measles, or as an idiopathic affection. In the former case it depends 
 on the extension to the mouth of a state of inflammation similar to that 
 which gives rise to the eruption on the skin ; in the latter, it is often 
 associated with obvious gastric or intestinal disorder. Under either of 
 these conditions it is rare after five years of age ; and though it often 
 depends on causes quite independent of dentition, yet from the period 
 
346 symptoms or follicular^stomatitis. 
 
 when teething has commenced, to the end of the third year, is the time 
 of its most common occurrence. When it constitutes an idiopathic 
 affection, more or less fever, and restlessness, loss of appetite, and 
 unhealthy state of the evacuations, and frequently a relaxed condition 
 of the bowels, precede the local ailment for several days. Attention 
 is generally called to the state of the mouth by the child being observed 
 to suck, or to take food, with manifest pain and difficulty ; while at the 
 same time the secretion of saliva is greatly increased, and the submax- 
 illary glands are swollen and tender. The mouth is hot, its mucous 
 membrane generally of a livid red, while a coat of thin mucus covers 
 the centre of the tongue. On the surface of the tongue, especially near 
 its tip, on the inside of the lips, particularly on the lower lip and about 
 its fold, on the inside of the cheek, near the angles of the mouth, and 
 less often in other situations also, may be seen several small isolated 
 transparent vesicles, or the ulcers which, after bursting, they leave 
 behind. The ulcers are small, of a rounded or oval form, not very 
 deep, but having sharply-cut edges ; and their surface is covered by a 
 yellowish-white, firmly-adherent slough. When attention is first 
 directed to the mouth, several of these small ulcerations usually exist, 
 for the vesicular stage of the affection appears to be generally very short, 
 while the ulcers are indolent, and sometimes continue for many days 
 without shewing any disposition to heal or to increase in size. The 
 eruption of a single crop of vesicles, and the change of these vesicles 
 into minute ulcerations, that heal in the course of time, do not complete 
 the history of this affection, for while the mucous membrane in the 
 situation of some of these ulcers at length resumes its natural condition, 
 other vesicles appear, which again degenerate into little ulcers, and 
 thus keep up the ailment, sometimes for weeks together. In some 
 cases, not above five or six of these little ulcers exist at once, or they 
 may even be less numerous, while it is very seldom that more than 
 fifteen or twenty of them are observable at one time. By the successive 
 appearance of fresh ulcerations, and the coalescence of several, an 
 ulcerated strip of considerable extent sometimes forms, especially at the 
 tip of the tongue, or on the lower lip. When the ulcers are healing no 
 change in their aspect is observable, and they continue to the last 
 covered by the same yellow slough, but by degrees they diminish in 
 size ; and seldom or never is any cicatrix observable in the situation 
 which they occupied. In some cases the affection is complicated with 
 a herpetic eruption about the edges of the lips, the vesicles of which 
 degenerate into ulcerations similar to those observed in the interior of 
 the mouth, and by their soreness add very much to the sufferings of 
 the patient. 
 
 Even though no remedies be employed, this affection shows no ten- 
 dency to rapid increase, neither is it, in general, associated with any 
 disposition to the formation of false membrane in the mouth, still less 
 with any tendency to gangrene. It is sometimes a source of much 
 annoyance to the child, but need never excite any serious solicitude, 
 except when it occurs as a sequela of measles. In that case, however, 
 as was observed some days ago, it occasionally becomes associated with 
 diphtheritic deposits on the fauces, and with ulcerative inflammation of 
 
ULCERATIVE STOMATITIS, OR NOMA. 347 
 
 the larynx, though our anxiety is then excited less by the affection 
 itself than by its concomitants. 
 
 In the treatment of this affection, our attention must be chiefly 
 directed to correcting the gastric and intestinal disorder by which it is 
 accompanied ; and when this object has been attained, the local ailment 
 in many cases speedily subsides. The borax lotion mentioned in the 
 last lecture is one of the best local applications that can be used ; but 
 if the ulcerations shew no tendency to heal, it may be desirable to 
 touch them once or twice a day with a solution of five grains of nitrate 
 of silver in an ounce of distilled water. 
 
 Between the mild affection we have just been studying, and the second 
 form of stomatitis, to the examination of which we are now about to 
 pass, there are comparatively few points of resemblance. This variety 
 of the disease attacks the gums, and sometimes destroys them exten- 
 sively, unlike the former ailment, which, even though it should continue 
 long, seldom occasions any actual loss of substance. The process, 
 however, by which the destruction of the gums is accomplished is one 
 of ulceration, not of mortification — a fact which it is of importance to 
 bear in mind, lest we should fall into the error of some observers, who 
 have confounded together under the name of Cancrum Oris, both this 
 affection and that more formidable malady, true gangrene of the mouth. 
 To preserve the distinction between the two diseases, it may be well, 
 following the example of some writers, to apply to the former the 
 designation of Ulcerative Stomatitis, or Noma, 1 and to the latter that 
 of gangrenous stomatitis, or gangrene of the mouth. 
 
 It is by no means a constant occurrence for any special derangement 
 of the general health to precede the attack of ulcerative stomatitis, 
 though the children who are affected by it are seldom robust, and in 
 many instances are such as have suffered from deficient food, or a damp 
 unhealthy lodging, or both. In children who are not very carefully 
 tended, the ulceration has sometimes made considerable progress before 
 its existence is suspected, and the profuse flow of the saliva, or the 
 offensive smell of the breath, is the circumstance which at length excites 
 attention. Coupled with these symptoms, too, there is often considera- 
 ble swelling of the upper lip, and the submaxillary glands are frequently 
 swollen and painful. On opening the mouth, the gums are seen to be 
 red, and swollen and spongy, and their edge is covered with a dirty 
 white, or greyish, pultaceous deposit, on removing which their surface 
 is exposed, raw, and bleeding. At first, only the front of the gum is 
 thus affected; but as the disease advances, it creeps round between the 
 teeth to their posterior surface, and then, destroying the gum both in 
 front and behind them, leaves them denuded, and very loose in their 
 sockets ; but it is not often that they actually fall out. The gums of the 
 incisor teeth are usually first affected : those of the lower jaw more 
 frequently and more extensively than those of the upper; but if the 
 disease be severe, the gums at the side of the mouth become likewise 
 involved, though it is seldom that the two sides suffer equally. Some- 
 
 1 From voftcu ? used by Hippocrates with reference to putrid and eroding ulcers. See 
 Foesius, (Economia Hippocratis, p. 432. 
 
348 ITS SYMPTOMS. 
 
 times aphthous ulcers, like those of follicular stomatitis, are seen on the 
 inside of the mouth in connection with this state of the gums ; but 
 oftener it exists alone. On those parts of the lips and cheeks, however, 
 which are opposite to, and consequently in contact with, the ulcerated 
 gums, irregular ulcerations form, which are covered with a pultaceous 
 pseudo-membranous deposit, similar to that which exists on the gums 
 themselves. Sometimes, too, deposits of false membrane take place on 
 other parts of the inside of the mouth, the surface beneath being red, 
 spongy, and bleeding, though not distinctly ulcerated. If the disease 
 be severe and long-continued, the tongue assumes a sodden appearance, 
 and is indented by the teeth, and the cheek, on one or other side, is 
 somewhat swollen, while the saliva, though rather less abundantly secreted 
 than at the commencement of the affection, continues horribly foetid, 
 a x nd is often streaked with blood, the gums themselves bleeding on the 
 slightest touch. But even if left alone, the affection usually subsides 
 in the course of time, though it may continue almost stationary for days 
 or weeks together, and this notwithstanding that the general health is 
 tolerably good. It would be too much to say that this unhealthy 
 ulceration never degenerates into gangrene : but though a very large 
 number of cases of ulcerative stomatitis have come under my notice, I 
 have seen only one instance in which it was succeeded by true gangrene 
 of the mouth. When recovery has commenced, the disease ceases to 
 spread ; the drivelling of foetid saliva diminishes ; the white pultaceous 
 deposit on the gums, or on the ulcerations of the cheek or lips, becomes 
 less abundant ; the ulcers themselves grow smaller ; and, finally, the 
 gums become firm, and their edges of a bright red, though still for a 
 long time shewing a disposition to become once more the seat of the 
 ulcerative process, and continuing for a still longer time to cover the 
 teeth but very imperfectly. 
 
 Various internal remedies and local applications have been at different 
 times recommended for the cure of this affection. Tonics have been 
 much employed, and the supposed analogy between this state of the 
 gums and that which exists in scurvy, has led practitioners to give the 
 preference to remedies reputed to be possessed of antiscorbutic proper- 
 ties. Lotions of alum, or the burnt alum in substance, or the chloride 
 of lime in powder, have all been used locally with more or less benefit. 
 It was my custom also to prescribe these remedies in cases of ulcerative 
 stomatitis; but since I became acquainted with the virtues of the chlo- 
 rate of potash, I have learnt to rely upon it almost exclusively. It 
 appears, indeed, almost to deserve the name of a specific in this affec- 
 tion ; for a marked improvement seldom fails to be observed in the 
 patient's condition after it has been administered for two or three days ; 
 and in a week or ten days the cure is generally complete. Three grains 
 every four hours, dissolved in water, and sweetened, is a sufficient dose 
 for a child three years old ; and five grains every four hours is the 
 largest quantity that I have administered to a child of eight or nine. 
 If the bowels be constipated, a purgative should be previously adminis- 
 tered ; but there seems to be no form, nor any stage of the affection, in 
 which the chlorate of potash is not useful. The diet should be light 
 but nutritious, and quinine or other tonics are sometimes serviceable if 
 
GANGRENOUS STOMATITIS. 349 
 
 the child's health should continue feeble after the local malady has 
 been cured. 
 
 Ulcerative stomatitis is an affection of such frequent occurrence, that 
 many instances of it come under my notice every year, especially during 
 the damp autumnal months ; while it is attended with so little danger, 
 that the only case which I have known to prove fa'al was one in which 
 gangrene of the mouth supervened upon it. Gangrenous stomatitis, 
 on the other hand, is a disease so rare, that I have only six times had 
 the opportunity of witnessing it ; but so fatal, that in five out of those 
 six cases the patients died. The larger experience of other observers 
 shows an almost equally unfavourable result, since twenty out of twenty- 
 one cases that came under the notice of MM. Rilliet and Barthez had 
 a fatal termination ; and a recent French writer, 1 who has collected 
 from different sources 239 cases, which did not all occur in children, 
 states that 176 of the number, or 75 per cent, terminated fatally. The 
 formidable nature of the disease requires that we study it more closely, 
 than, considering the rarity of its occurrence, would otherwise be neces- 
 sary ; and it is the more important to do so, in order that we may 
 avoid the not very uncommon error which confounds this dangerous 
 affection with that comparatively trifling ailment — ulcerative stoma- 
 titis. 
 
 The constitutional disturbance which often precedes the other two 
 affections of the mouth that we have just been studying, was seen to be 
 generally of a trivial nature, and never so severe as to excite serious 
 anxiety. Gangrene of the mouth, on the other hand, seldom comes on, 
 except in children whose health has been already much impaired by 
 previous disease, and especially by such diseases as are connected with 
 important changes in the circulating fluid. In strict propriety, indeed, 
 I doubt whether we ought not to remove both this and those other 
 allied affections, in which the skin or the genital organs become the 
 seat of gangrene, from among the class of local ailments, and refer 
 them to the category of blood diseases. Of twenty-nine cases of gan- 
 grene of the mouth, which MM. Rilliet and Barthez either observed 
 themselves, or of which they found mention in the writings of other 
 physicians, only one appeared to be an instance of the disease in an 
 idiopathic form ; while in twelve cases it followed an attack of measles. 
 Of the six cases which I have observed, and three of which I examined 
 after death, two succeeded to typhoid fever, two to measles, one came 
 on in a child whose health had been completely broken down by ague, 
 and one supervened in a tuberculous child, who had been affected for 
 many weeks with ulcerative stomatitis in a severe form. Though not 
 confined to any one period of childhood, gangrene of the mouth is more 
 frequent between the ages of two and five than either earlier or later. 
 Of the six cases that came under my own observation, two were in 
 children between two and three years old, one in a child aged three, 
 one between four and five, one at six and a quarter, and one at eight 
 years of age. Of the twenty-nine cases mentioned by MM. Rilliet and 
 Barthez, nineteen occurred between two and five ; ten between six and 
 
 1 Tourdes, Du Noma, &c. 4to. Thfese de Strasbourg, 1848. 
 
850 ITS SYMPTOMS. 
 
 twelve ; and M. Tourdes' 1 comparison of 102 cases between one and a 
 half and twelve years, likewise yields the greatest number during the 
 third and fourth years. 
 
 Although all the tissues of the cheek become involved in the course 
 of this affection, yet difference of opinion has existed with reference to 
 the part in which it commences ; some observers conceiving that it 
 usually begins in the substance of the cheek, while others regard the 
 mucous membrane as being the part which is invariably the first 
 attacked. So far as my own observation enables me to judge, I am 
 disposed to regard this latter view, which is that of MM. Rilliet and 
 Barthez, and of M. Baron, and which is moreover supported by the 
 recent minute researches of Professor Albers, 2 of Bonn, as generally cor- 
 rect. At the same time, however, I must admit that I have had no very re- 
 cent opportunity of personally investigating this subject, while a very com- 
 petent observer, Dr. Loschner, 3 physician to the Children's Hospital at 
 Prague, while he admits the occasional commencement of the affection 
 in either way, believes the former to be the more common. According 
 to his observations, the appearance of a swelling, having a hard central 
 spot or nucleus, surrounded by tense, elastic, but less firm tissue, 
 gradually passing off into the texture of the adjacent parts, is the first 
 step in the process ; ulceration of the mucous membrane being secondary 
 to this peculiar infiltration of the cellular tissue of the cheek. It is, 
 indeed, very probable that the gangrene sometimes begins in the one 
 way and sometimes in the other ; while any dispute concerning it 
 loses almost all its practical moment, if we regard this and other forms 
 of gangrene as resulting from merely accidental differences in the 
 mode in which the graver deterioration of the circulating fluid manifests 
 itself. 
 
 The early stages of the affection are attended by scarcely any suffer- 
 ing, owing to which, as well as to the circumstance that the children in 
 whom it supervenes are almost always labouring under some other dis- 
 ease, or in the course of convalescence from it, it is probably due that 
 the malady is often not discovered until after it has made considerable 
 progress. There may for a day or two have been an unusual foetor of 
 the breath, and a profuse secretion of offensive saliva ; but the appear- 
 ance of swelling of the cheek is frequently the first symptom that leads 
 to a careful examination of the state of the mouth. The characters of 
 the swelling of the cheek are almost pathognomonic of gangrene of the 
 mouth. It is not a mere puffiness of the integument, unaccompanied 
 with any change of its colour, such as is sometimes observed in ulcera- 
 tive stomatitis; but the cheek is tense, and red, and shining, — it looks 
 as if its surface had been besmeared with oil, and in the centre of the 
 swollen part there is generally a spot of a brighter red than that around. 
 The cheek feels hard, and is often so unyielding, that the mouth cannot 
 be opened wide enough to get a good view of its interior. The disease 
 is almost always limited to one side, and generally to one cheek. Some- 
 
 1 Op. cit. p. 31. 
 
 2 Archiv f. physiol. Heilkunde, ix. 7-8, 1850 ; and Schmidt's Jahrb. 1851, No. 2, p. 195. 
 
 3 Der Brand ?ui Kindesalter, in the Viertejahrschrift fiir die praxt. Heilkunde, Vol. 
 xv. p. 85. 
 
SYMPTOMS OF GANGRENOUS STOMATITIS. 351 
 
 times, however, it extends to the lower lip ; and occasionally it begins 
 in that situation. The upper lip is now and then reached by the pro- 
 gress of the disease, but is never its primary seat. Whatever be the 
 situation of the- external swelling, there will generally be found within 
 the mouth, at a point corresponding to the bright red central spot, a 
 deep excavated ulcer, with irregular jagged edges, and a surface covered 
 by a dark brown shreddy slough. The gums opposite to the ulcer are 
 of a dark colour, covered with the putrilage from its surface, and in 
 part destroyed, leaving the teeth loose, and the alveolae denuded. 
 Sometimes, especially if the disease be further advanced, no single spot 
 of ulceration is recognizable, but the whole inside of the cheek is occu- 
 pied by a dirty putrilage, in the midst of which large shreds of dead 
 mucous membrane hang down. As the disease extends within the 
 cheek, a similar process of destruction goes on upon the gum ; the 
 loosened teeth drop out one by one, and the alveolar process of the jaw 
 loses its vitality for a more or less considerable extent; while some- 
 times, though of this I have not seen any instance, a portion of the 
 ramus of the jaw itself becomes necrosed. The saliva continues to be 
 secreted profusely, but shows by the changes which take place "in its 
 characters the progress of the disease. At first, though remarkable for 
 its fcetor, it is otherwise unaltered ; but afterwards it loses its trans- 
 parency, and receives from the putrefying tissues over which it passes, 
 a dirty, greenish, or brownish colour, and at the same time acquires a 
 still more repulsive odour. 
 
 While the gangrene is thus going on inside the mouth, changes no 
 less remarkable are taking place on the exterior of the face. The red- 
 ness and swelKng of the cheek extend, and the deep red, central spot, 
 grows larger. A black point appears in its midst; at first it is but a 
 speck, but it increases rapidly, still retaining a circular form ; it attains 
 the bigness of a sixpence, a shilling, a half crown, or even a larger size. 
 A ring of intense redness now encircles it, the gangrene ceases to 
 extend, and the slough begins to separate. Death often takes place 
 before the detachment of the eschar is complete, and it is fortunate 
 when it does so, for sloughing usually commences in the parts left behind. 
 The interior of the mouth is now exposed ; its mucous membrane and 
 the substance of the cheek hang down in shreds from amidst a blacken- 
 ing mass, and form one of the most loathsome spectacles that can be 
 conceived; while the horrible stench which the mortified parts spread 
 around, makes the task of watching the poor child as repulsive as it is 
 distressing. 
 
 Happily it is not often that acute suffering of the child occurs to 
 heighten the distress of the sad scene. Usually the patient has but 
 little pain from the very first, but is generally more drowsy than natural, 
 though sometimes the nights are restless ; and in those cases in which 
 gangrene of the mouth supervened in the course of typhoid fever, the 
 delirium which existed before continued unmodified. The pulse grows 
 feebler as the disease advances; but gleams of cheerfulness may some- 
 times be perceived, even long after the appearance of the black eschar 
 on the cheek has shown the case to be all but hopeless ; and the desire 
 for food often continues unabated, till within a few hours of the child's 
 
852 SYMPTOMS OF GANGRENOUS STOMATITIS. 
 
 death, which generally takes place quietly, though sometimes- it is pre- 
 ceded by convulsions. 
 
 Since gangrene of the mouth occurs in the course of a great variety 
 of diseases, the only morbid appearances characteristic of it are those 
 which result from the local mischief. On two occasions I dissected the 
 gangrenous parts very carefully, and the alterations which presented 
 themselves to my notice were precisely the same as have been described 
 by MM. Rilliet and Barthez. The absorbent glands, both superficial 
 and deep-seated, on the affected side, are enlarged, and the cellular 
 tissue of the cheek is infiltrated with serum, which is more abundant the 
 nearer one approaches to the slough. In the substance of the eschar 
 the distinction of parts is no longer easy, but with care the vessels and 
 nerves may still be traced ; and the reason why fatal haemorrhage so 
 seldom cuts short the life of patients suffering from this affection, is 
 at once explained by the clot which plugs up the vessels for some dis- 
 tance on either side of the gangrenous mass. On one occasion I found 
 the root of the tongue, the tonsils, pharynx, both surfaces of the epi- 
 glottis, and about an inch of the oesophagus, completely coated with a 
 moderately firm, yellow false membrane, about a line in thickness, easily 
 detached, and leaving the subjacent mucous membrane only a little 
 redder than natural. A few patches of a similar deposit existed in the 
 larynx, but not continuous with that in the pharynx. In this case, 
 great difficulty of deglutition had existed for three days before the 
 death of the child. The association of diphtheritis with gangrene of 
 the mouth, is, however, an accidental complication, and one of not very 
 frequent occurrence. 
 
 The arrest of the sloughing is the one point to which in the treatment 
 of this affection the attention of all practitioners has been directed. The 
 small amount of success which has attended their efforts is partly attri- 
 butable to the circumstance that the affection has frequently been over- 
 looked until it has already made considerable progress ; in part also to 
 the fact that when recognised, the local remedies employed in-order to 
 check the gangrene have either been too mild, or have been applied with 
 too timorous a hand. Unfortunately, too, there is considerable difficulty 
 in applying any caustic effectually to the interior of the mouth; for not 
 only does the tense and swollen condition of the cheek prevent our 
 obtaining easy access to the gangrenous parts, but the child naturally 
 resists an operation which cannot but occasion it most severe pain. 
 Ineffectual cauterization, however, is useless, or worse than useless ; and 
 though every endeavour should be made to prevent the needless destruc- 
 tion of healthy parts, yet of the two evils, that of doing too much is 
 unquestionably less than that of doing too little. It is of importance, 
 moreover, not only that the cauterization should be done effectually, but 
 also that it should be practised early. M. Baron, indeed, speaks of 
 incising the slough in the cheek, and then applying the actual cautery 
 to the part ; but I am not aware of any instance in which this suggestion 
 has been acted on with a good result. When once the mortification has 
 extended through the substance of the cheek, the chances of arresting 
 its progress must be very few. As the sloughing advances from within 
 outwards, it is to the interior of the mouth that our remedies must be 
 
TREATMENT OF GANGRENOUS STOMATITIS. 853 
 
 applied ; and since the advance of the disease is too rapid to allow of 
 our trying mild means at first, and afterwards resorting, if necessary, 
 to such as are more powerful, we must employ an agent sufficiently 
 energetic at once to arrest its progress. "Various caustics have been 
 recommended for this purpose, but none appear to be so well fitted to 
 accomplish it as the strong hydrochloric or nitric acid. I am accus- 
 tomed to employ the latter, applying it by means of a bit of sponge, or 
 of soft lint or tow, fastened to a quill, while I endeavour, by means of 
 a spoon or spatula, to guard the tongue, and other healthy parts, as far 
 as possible, from the action of the acid. In the only case that I saw 
 recover, the arrest of the disease appeared to be entirely owing to this 
 agent ; and though the alveolar processes of the left side of the lower 
 jaw, from the first molar tooth backwards, died, and exfoliated, appa- 
 rently from having been destroyed by the acid, yet it must be owned 
 that life was cheaply saved even at that cost. Some increase of the 
 swelling of the cheek almost invariably follows the application of this 
 agent — a circumstance which may at first occasion unfounded apprehen- 
 sion lest the disease be worse. Twelve hours, however, must not be 
 allowed to elapse, without the mouth being carefully examined, in order 
 to ascertain whether the disease has really been checked, or whether 
 there is any appearance of mortification in the parts beyond the yellow 
 eschar left by the first application of the acid. The cauterization may 
 now be repeated, if it appear necessary, and even though the disease 
 had seemed completely checked; yet reliance must not be placed on the 
 improvement continuing, but the mouth must be examined every twelve 
 hours, for fear the mortification should spread unobserved. During the 
 whole progress of the case the mouth must be syringed frequently with 
 warm water, or with camomile tea mixed with a small quantity of the 
 solution of chloride of lime, in order to free it from the putrid matters 
 that collect within it, and to diminish as much as possible their offensive 
 odour. Should the case go on well, the frequent repetition of the strong 
 acid will be unnecessary ; but the surface may still require its applica- 
 tion in a diluted form, or it may suffice to syringe the mouth frequently 
 with a chloride of lime lotion, or to apply the chloride in powder onca 
 or twice a day, according to the suggestion of MM. Billiet and Barthez. 
 In the last two cases of this affection that came under my notice, I like- 
 wise employed the chloride of potash internally, but it did not appear 
 to exert any influence over it: and valuable though the remedy is in 
 ulcerative stomatitis, yet I should scarcely feel disposed to rely upon it, 
 to the exclusion of local treatment, in true gangrene of the mouth. Two 
 cases, however, of cancrum oris succeeding to fever, in children of twelve 
 and thirteen years of age, were recently treated with most complete 
 success by Dr. Burrows, in St. Bartholomew's Hospital, without the 
 employment of any other local measures than a chloride of soda gargle; 
 but with good diet, wine, and chlorate of potash, in doses of ten grains 
 every four hours. 
 
 During the whole course of treatment you have another indication to 
 fulfil — namely, to support your patient's strength by nutritious diet, 
 and by the employment of wine and other stimulants, and by the 
 administration of quinine, or of the extract or tincture of bark, or 
 
 23 
 
354 MERCURY SELDOM CAUSES GANGRENE OF THE MOUTH. 
 
 whatever form of tonic may seem best suited to the peculiarities of the 
 case. 
 
 In conclusion, let me remind you that during the whole progress of 
 the case your prognosis must be regulated by the state of the local 
 disease, rather than by the urgency of the general symptoms. So long 
 as the sloughing is unchecked, the affection is tending rapidly to a fatal 
 issue, and this even though the pulse be not very feeble, though the 
 appetite be good, and the child still retain some show of cheerfulness. 
 
 It might seem to you to be an omission on my part, if I left the 
 subject of inflammation and gangrene of the mouth, without some 
 notice of the supposed influence of mercury in its production. There 
 can be no doubt but that this preparation, even when given in small 
 doses, has in a few instances produced severe ptyalism, inflammation of 
 the mouth, loss of the teeth, and necrosis, more or less extensive, of 
 the lower jaw. In some cases, too, the inflammation has terminated in 
 gangrene of the cheek which has presented many of the characters that 
 we have just been noticing ; and under such circumstances inquests 
 have sometimes been held, and blame has been attached to the medical 
 attendant for alleged want of caution in the administration of so pow- 
 erful an agent as mercury. Now, although mercury should never be 
 given without necessity, nor its administration continued without 
 watching its effects most carefully, yet I cannot but regard the super- 
 vention of gangrene of the mouth during its use as merely an accidental 
 coincidence, or else as the result of some peculiar idiosyncrasy of the 
 patient, such as has been observed in the adult as well as in the child. 
 More than 16,000 children, of all ages, came under my care during the 
 period of my connection with the Children's Infirmary, and I adminis- 
 tered mercury to any of them who seemed to require it, but hardly ever 
 saw salivation follow its employment before the completion of the first 
 dentition ; and never observed that medicine, at any age, produce an 
 affection of the mouth sufficiently serious to cause me a moment's 
 anxiety. 
 
 An inconvenience, — I do not know that it deserves a more serious 
 designation, — inseparable from the arrangement of subjects which I 
 have adopted, is that we pass at once from diseases that are very 
 hazardous, to others which are of a comparatively trifling character, or 
 are the sources of discomfort rather than of severe suffering. Of this 
 some of the ailments which remain for our consideration to-day are no 
 inapt illustrations. 
 
 Inflammation of the soft palate, tonsils, and fauces, constituting 
 Cynanche Tonsillar es, is not strictly limited to any age, nor attended 
 with any special symptoms when it occurs in the child. It is, however, 
 comparatively rare under 12 years of age, and is almost always less 
 severe than at or after puberty, while I scarcely remember to have met 
 with it under 5 years of age, — a circumstance which attaches special 
 importance to sore-throat in young children, since it will usually be 
 found to betoken the approach of scarlet fever rather than the exist- 
 ence of simple inflammation of the tonsils. 
 
 But, though acute inflammation of the tonsils is unusual in early 
 childhood, a sort of chronic inflammation of those glands, which leads to 
 
HYPERTROPHY OF THE TONSILS. 355 
 
 their very considerable enlargement, is far from uncommon ; and this 
 hypertrophy of the tonsils, which, in the adult, is little more than an 
 inconvenience, is, in the child, not infrequently the cause of more serious 
 evils. It is seldom traceable to any acute attack of angina, but usually 
 comes on in children who are out of health, feeble and strumous; or 
 takes places slowly during the latter stages of the first dentition, the 
 irritation of which appears in some cases to be its only exciting cause. 
 
 Unless accidentally discovered, the enlargement of the tonsils has 
 usually become very considerable before it attracts much notice, and 
 hence it is comparatively seldom observed in children under 3 years old, 
 though M. Robert, a French surgeon, 1 who has written a very excellent 
 paper on the subject, speaks of having noticed it as early as the sixth 
 month. 
 
 One of the first symptoms that attracts attention is the habitually 
 loud snoring of the child during sleep, owing to the enlarged tonsils 
 pressing up the velum, and thus obstructing the passage of air through 
 the posterior nares, while at the same time the voice becomes thick ; 
 and both of these symptoms are remarkably aggravated during, and for 
 some time after, even sligbt attacks of catarrh. An amount of enlarge- 
 ment of the tonsils sufficient to cause these symptoms is by no means 
 uncommon, and if it do not exceed this extent the inconvenience to 
 which it gives rise will in general disappear altogether with the develop- 
 ment of the mouth and vocal organs at the period of puberty. Often, 
 however, it is more considerable, and then the tonsils produce a degree 
 of deafness, partly by actual pressure on the Eustachian tubes, partly 
 by the state of habitual congestion which they occasion in the parts 
 in their neighbourhood ; the respiration, moreover, becomes rather 
 laboured, and the child has a constant hacking cough, occasionally 
 aggravated and paroxysmal, — two symptoms which I have known to 
 raise on more than one occasion an unfounded apprehension of 
 phthisis; and to lead in others, where some phthisical disease actually 
 existed, to the expression of a more gloomy prognosis than was war- 
 ranted by the amount of mischief in the lungs. Now and then the 
 difficulty of respiration from mere enlargement of the tonsils has been 
 so considerable as to threaten life. No instance of this, indeed, has 
 come under my own observation, but my friend and former colleague, 
 Mr. Shaw, once had a little boy under his care, who, in addition to 
 constant dyspnoea, suffered from occasional fits of suffocation arising 
 from this cause; and one of these fits was so severe that in order to 
 preserve the child's life it was necessary to perform laryngotomy. 
 
 The long existence of considerable enlargement of the tonsils, and the 
 consequent almost complete obstruction to the passage of air through 
 the nostrils, give rise to a peculiar alteration in the form of the parts 
 thus thrown out of use. The nostrils become extremely small, narrow, 
 and compressed ; and the peculiar character which the physiognomy 
 thus acquires is further increased by the accompanying modification in 
 the development of the upper jaw. The superior dental arch remains 
 very narrow, so as not to allow adequate room for the teeth, which con- 
 
 1 In the Bulletin Ge'ndrale de Thdrapeutique, May and July, 1843. 
 
356 HYPERTROPHY OF THE TONSILS. 
 
 sequently overlap each other very much, while at the same time the 
 palate becomes unusually high and arched. Nor is this the only mode 
 in which due development is interfered with ; but it was noticed five- 
 and-twenty years ago by Dupuytren that enlargement of the tonsils and 
 the pigeon-breast very usually go together. The fact was confirmed by 
 others, but I believe that Mr. Shaw 1 was the first person to offer an 
 explanation of it. He pointed out how the obstacle to the free entrance 
 of air into the lungs prevents their being filled at each inspiratory 
 effort ; so that a vacuum would be formed between them and the walls 
 of the chest, were it not that the pressure of the external air on the 
 yielding parietes of the thorax forces them inwards to occupy the vacant 
 space ; and doing so most readily where their resistance is least, namely, 
 at the commencement of the costal cartilages, produces the well-known 
 lateral flattening of the thorax, and prominence of the sternum. The 
 little boy whose case I have just mentioned as necessitating the opera- 
 tion of laryngotomy, gave in his own person a striking illustration of 
 the correctness of the explanation which I have just given you. " On 
 his admission into the hospital," says Mr. Shaw, u and for several 
 weeks afterwards, it was observed that he had the pigeon-breast form of 
 chest ; but after his tonsils were excised, and his breathing had been 
 perfectly free for some time, the sternum subsided to its proper level, 
 and the thorax recovered its natural shape." 
 
 Enlargement of the tonsils, then, though at first sight it may appear 
 a trivial ailment, is yet one which you must by no means neglect. A 
 weakly child, whose tonsils are but slightly enlarged, will often get 
 rid of his ailment as he gains health and strength, or at puberty will 
 completely outgrow it. Any slight attack of cold, indeed, is apt to be 
 followed by the increase or the return of the enlargement ; but this 
 may often be kept in check by the application of powdered alum once 
 or twice a day to the tonsils, or by touching them every day or two 
 with the solid nitrate of silver. In no case, however, in which the 
 hypertrophy of the tonsils was considerable, or of long standing, have 
 I found these measures, or the painting the exterior of the throat just 
 above the angle of the jaw with tincture of iodine, of much service, 
 and excision of the tonsils is then the only remedy. Whether this be 
 had recourse to at once, or whether you will wait a few years till the 
 child is older and better capable of that slight amount of self-control 
 which is desirable for the performance of the operation, must depend 
 on the size of the tonsils, on the amount of inconvenience which they 
 occasion, and on the presence or absence of any marked deformity of 
 the chest. If after the tonsils have been removed, the chest is long in 
 regaining its natural form, the use of dumb-bells, and the careful 
 practice of gymnastic exercises, are often of much service Dupuy- 
 tren's recommendation, too, to stand the child with its back, against a 
 wall, and then placing the hand upon the most prominent part of the 
 sternum, to press firmly upon it during each expiratory effort, remitting 
 the pressure during inspiration, in order that the child may fill its chest 
 
 1 Medical Gazette, Oct. 23, 1841. See also his remarks in the article Thorax, in the 
 Cyclopaedia of Anatomy and Physiology, p. 1039 ; and also those of M. Robert, in his 
 paper already referred to. 
 
CYNANCHE PAROTIDEA. 357 
 
 as completely as possible, I have found to be, in spite of its seeming 
 roughness, extremely valuable as an additional means of removing the 
 deformity of the pigeon-breast. 
 
 Inflammation of the parotid gland, — the CynancJie parotidea of 
 scientific writers, called mumps by the vulgar, — is an affection met with 
 among children and young persons, concerning which a few words only 
 need be said ; and I know of no more suitable place than the present 
 for introducing them. It attacks young persons near the period of 
 puberty, especially boys, much oftener, and with much greater severity, 
 than infants, or children under seven years old. Though it sometimes 
 occurs as a sporadic affection, it is more commonly met with as an epi- 
 demic ; and being likewise propagated by contagion, it not infrequently 
 attacks most of the inmates of a boarding-school, or of any other public 
 institution in which large numbers of the youth of either sex are col- 
 lected together. The seat of the disease is in one or both parotid 
 glands and in the adjoining cellular tissue ; but if the attack be at all 
 severe, the submaxillary and other salivary glands generally become 
 involved during its progress. It generally sets in with the ordinary 
 symptoms of slight fever or catarrh, which are followed in about 
 twenty-four hours by stiffness of the neck and pain about the lower 
 jaw, any movement of which, either for the purpose of speaking or of 
 mastication, is obviously attended with considerable suffering. At the 
 same time, too, a swelling makes its appearance about the angle of the 
 lower jaw, sometimes on one side only, and at other times on both; and 
 this swelling increasing rapidly in size, occasions great disfigurement 
 of the face. The swelling is usually very tense, but the colour of the 
 skin is in general unaltered, except in some cases, in which the glands 
 on both sides, being swollen, and pressing much upon the veins, the 
 return of blood from the head is impeded, and the face assumes a 
 flushed appearance. If the swelling be very considerable, deglutition 
 for a short time is rendered so difficult as to be almost impossible, and 
 the tongue becomes dry from the child breathing with its mouth open ; 
 but the secretion of saliva is neither morbidly increased or diminished. 
 If the disease be severe, the child suffers much, is very feverish, and 
 may even be light-headed ; but in the course of forty-eight hours from 
 the appearance of the swelling it reaches its height, and the fever 
 begins to subside and the swelling to diminish. The time of the final 
 disappearance of the swelling is very variable, being five or six days in 
 some cases, ten days or a fortnight in others ; while in some instances 
 the glands on one side are affected first, and when the attack is subsi- 
 ding there, those of the opposite side become affected in a similar way, 
 and the duration of the ailment is thus protracted. The occurrence of 
 suppuration in the neighbourhood of the gland is a rare termination of 
 the inflammation ; but is, 1 believe, oftener met with in infants and 
 young children than in those who are approaching the period of puberty. 
 On the other hand, metastasis of the disease from the parotid to 
 the mamma, the testicle, or tli£ brain, of all of which instances are 
 recorded by different writers, appears to be rare in proportion to the 
 tender age of the patient. The most formidable of these metastases, 
 indeed — that to the brain, would seem to be an accident very seldom 
 
358 DISEASES OF THE STOMACH. 
 
 met with ; and neither of it, nor of the translation of the disease to the 
 mamma or the testicle, can I say any thing from personal experience. 
 
 The treatment of this affection is in general very simple, and requires 
 the judicious selection of precautionary measures rather than active 
 interference. Mild antiphlogistic medicines, with the application of 
 warmth locally, are all that is usually needed ; and local depletion is 
 neither necessary nor useful. The period during which much distress 
 and much difficulty of deglutition exist is generally very short ; so that 
 even in severe cases it will be our wisest course to await the sponta- 
 neous subsidence of the swelling. If suppuration should take place in 
 the cellular tissue about the gland, a warm poultice must be substituted 
 for the fomentations previously employed. Even when the gland 
 remains enlarged, as it sometimes does for some time after the subsi- 
 dence of the febrile symptoms, it is yet in general the best plan to let 
 it alone, since the swelling is sure eventually to disappear of its own 
 accord. 
 
 With reference to the management of the metastases of the disease, 
 I have no observations to make, further than that inflammation of the 
 brain, however induced, is not an affection with which we can safely 
 temporize; while a mild and palliative treatment will generally answer 
 every purpose, when either the mamma or the testicle has become the 
 seat of the affection. 
 
 LECTURE XXX. 
 
 Diseases of the Stomach. — Vomiting often symptomatic of disease elsewhere — occa- 
 sionally occurs suddenly in a previously healthy infant without signs of general illness 
 its treatment — is often one out of many symptoms of indigestion. — Infantile dyspepsia 
 — sometimes connected with general debility of the system ; at others, dependent on 
 special disorder of the stomach — its symptoms and treatment. 
 
 Softening of the Stomach — discovered after death in various degrees — different theo- 
 ries as to its nature — great frequency in early infancy — J)r. Elsasser's explanation of 
 this fact — probably not correct to the full extent. 
 
 H^matemesis and Meljena — very rare — sometimes connected with injury to the child 
 during labour — its occurrence often difficult of explanation — illustrative cases. — 
 Spurious hsematemesis. 
 
 The diseases to which the stomach is liable in early life are neither 
 numerous nor important, although its functions are more or less 
 disordered in the course of most of the affections of childhood. 
 Vomiting, indeed, is more frequent in the infant than in the adult, 
 and this not merely because the delicate structure of the organ renders 
 its irritability greater, but because the form of the viscus, and its 
 position in the abdomen during early life, are such as greatly to 
 facilitate the discharge of its contents. Even when the first few months 
 of existence kave been passed, vomiting is still an occurrence often met 
 with. It is sometimes one of the first symptoms of inflammation of the 
 lungs or pleura : it frequently ushers in the eruptive fevers, and marks 
 the early stages of cerebral disease. Causes more purely local 
 
VOMITING IN EARLY INFANCY. 359 
 
 produce a similar effect, and vomiting often attends upon infantile 
 diarrhoea, and is associated with signs of intestinal disorder, especially 
 when such disorder has been excited by improper food. But besides 
 these cases, in which the disorder of the stomach is either the result of 
 disease seated elsewhere, or in which the disturbance of its function is 
 sufficiently explained by the nature of the ingesta, instances are some- 
 times observed in which the stomach becomes so irritable as almost 
 always to reject its contents, or in which, though the food taken be not 
 brought up again, yet the organ is unable to effect its digestion. 
 
 It sometimes happens that young infants are suddenly seized with 
 vomiting, which, though violent, and frequently repeated, is attended 
 with few or no indications of general intestinal disorder. The child in 
 such cases seems still anxious for the breast ; but so great is the 
 irritability of the stomach, that the milk is either thrown up unchanged, 
 immediately after it has been swallowed, or it is retained only for a 
 very few minutes, and is then rejected in a curdled state; while each 
 application of the child to the breast is followed by the same result. 
 It will generally be found, when this accident takes place in the 
 previously healthy child of a healthy mother, that it has been occa- 
 sioned by some act of indiscretion on the part of its mother or nurse. 
 She perhaps has been absent from her nursling longer than usual, and, 
 returning tired from a long walk, or from some fatiguing occupation, 
 has at once offered it the breast, and allowed it to suck abundantly ; or 
 the infant has been roused from sleep before its customary hour, or it 
 has been over-excited or over-wearied at play, or, in hot weather, has 
 been carried about in the sun without proper protection from its rays. 
 
 The infant^n whom, from any of these causes, vomiting has come on, 
 must at once be taken from the breast, and, for a couple of hours, 
 neither food nor medicine should be given to it. It may then be offered 
 a teaspoonful of cold water ; and, should the stomach retain this, one 
 or two more spoonfuls may be given in the course of the next half 
 hour. If this be not rejected, a little isinglass may be dissolved in the 
 water, which must still be given by a teaspoonful at a time, frequently 
 repeated ; or cold barley-water may be given in the same manner. In 
 eight or ten hours, if no return of vomiting take place, the experiment 
 may be tried of giving the child its mother's milk, or cow's milk diluted 
 with water, in small quantities, and from a teaspoon. If the food 
 thus given do not occasion sickness, the infant may in from twelve to 
 twenty-four hours be restored to the breast ; with the precaution, how- 
 ever, of allowing it to suck only very small quantities at a time, lest, 
 the stomach being overloaded, the vomiting should again be produced. 
 
 In many instances where the sickness has arisen from some accidental 
 cause, such as those above referred to, the adoption of these precautions 
 will suffice to restore the child to health. If, however, other indications 
 of gastric or intestinal disorder have preceded the sickness, or be asso- 
 ciated with it, medicine cannot be wholly dispensed with. According to 
 the age of the child, a quarter, half, or a whole grain of calomel may 
 be laid upon the tongue, while sucking is forbidden, and the plan 
 already recommended is in other respects strictly carried out. If the 
 vomiting have already continued for several hours before the adoption 
 
360 INFANTILE DYSPEPSIA. 
 
 of any treatment, a small mustard poultice may likewise be applied to 
 the epigastrium. In about a couple of hours after the calomel has 
 been given, the child may have a teaspoonful of a mixture containing 
 small doses of the bicarbonate of potash and of hydrocyanic acid ; and 
 this may be continued every three or four hours so long as any unu- 
 sual irritability of the stomach remains. 
 
 Sickness, however, is not always a solitary symptom, unattended with 
 other indications of gastric disorder, but it is sometimes associated with 
 the signs of general impairment of the digestive powers. In its graver 
 forms, indigestion is associated with greatly impaired nutrition, and 
 with all those serious results which are characteristic of the atrophy of 
 young children. But it sometimes happens that, though the child does 
 not lose much flesh, yet digestion is ill performed, and various dyspeptic 
 symptoms appear, which would be troublesome rather than alarming, 
 if it were not that they are often connected with the strumous dia- 
 thesis, and are the first indications of a state of constitution in which, 
 after the lapse of a few months, pulmonary phthisis is very apt to 
 supervene. 
 
 In some of these cases there is complete anorexia, the infant caring 
 neither for the breast nor for any other food that may be offered it. It 
 loses the look of health, and grows pale and languid, although it may 
 not have any especial disorder either of the stomach or bowels. It 
 sucks but seldom, and is soon satisfied ; and even of the small quantity 
 taken, a portion is often regurgitated almost immediately. This state 
 of things is sometimes brought on by a mother's over-anxious care, 
 w T ho, fearful of her infant taking cold, keeps it in a room too hot or 
 too imperfectly ventilated. It follows also, in delicate infants, on 
 attacks of catarrh or diarrhoea, but is then for the most part a passing 
 evil, which time will cure. In the majority of cases, however, the loss 
 of appetite is associated with evidence of the stomach's inability to 
 digest even the small quantity of food taken, and there exists more or 
 less marked gastric or intestinal disorder. Anorexia, too, is far from 
 being a constant attendant upon infantile dyspepsia ; but in still more 
 numerous instances, although the power of assimilating the food is in 
 a great measure lost, yet there is an unnatural craving for it, and the 
 infant never seems so comfortable as when sucking. But though it 
 sucks much, the milk evidently does not sit well upon the stomach ; for 
 soon after sucking, the child begins to cry, and appears to be in much 
 pain until it has vomited. The milk thrown up is curdled, and its 
 rejection is followed by immediate relief, but at the same time by the 
 desire for more food, and the child can often be pacified only by allow- 
 ing it to suck again. In other cases, vomiting is of much less frequent 
 occurrence, and there is neither a craving desire for food, nor much 
 pain after sucking, but the infant is distressed by frequent acid or 
 offensive eructations : its breath has a sour or nauseous smell, and its 
 evacuations have a most foetid odour. The condition of the bowels 
 that exists in connection with these different forms of dyspepsia is 
 variable. In cases of simple anorexia, the debility of the stomach is 
 participated in by the intestines ; their peristaltic action is feeble, and 
 constipation is of frequent occurrence, though the evacuations do not 
 
TREATMENT OF DYSPEPSIA FROM DEBILITY. 361 
 
 always present any marked deviation from their character in health. 
 Constipation, however, though a frequent, is not an invariable atten- 
 dant on indigestion, but the bowels in some cases act with due 
 regularity. If the infant be brought up entirely at the breast, the 
 evacuations are usually liquid, of a very pale yellow colour, often 
 extremely offensive, and contain shreds of curdled milk, which, having 
 escaped through the pylorus, pass unchanged along the whole tract of 
 the intestines. In many instances, however, the infant having been 
 observed not to thrive at the breast, arrow-root or other farinaceous 
 food is given to it, which the digestive powers are quite unable to assi- 
 milate, and which gives to the motions the appearance of putty or pipe- 
 clay, besmeared more or less abundantly with intestinal mucus. The 
 evacuations are often party-coloured, and sometimes one or two 
 unhealthy motions are followed by others which appear perfectly natu- 
 ral; while attacks of diarrhoea often come on, and the matters 
 discharged are then watery, of a dark, dirty green colour, and exceed- 
 ingly offensive odour. 
 
 Dyspeptic infants, like dyspeptic adults, often continue to keep up 
 their flesh much better than could be expected, and in many cases even- 
 tually grow up to be strong and healthy children. Still, the condition 
 is one that not merely entails considerable suffering upon the child, 
 but, by its continuance, seriously impairs the health, renders the child 
 but little able to bear up against any intercurrent disease, and develops 
 the seeds of latent phthisis. 
 
 Within the space that can be allotted to each subject in these 
 lectures, it is not possible to do more than just glance at some of the 
 main points to\be borne in mind in the treatment of infantile dyspepsia. 
 Those cases, the chief symptom of which consists in the loss of appetite, 
 usually require, and are much benefited by, a generally tonic plan of 
 treatment. All causes unfavourable to health must be examined into, 
 and, as far as possible, removed. It must be seen that the nursery is 
 well ventilated, and that its temperature is not too high ; while it will 
 be found that no remedy is half so efficacious as change of air. Next, 
 it must not be forgotten that the regurgitation of the food is due in 
 a great measure to the weakness and consequent irritability of the 
 stomach ; and care must therefore be taken not to overload it. If 
 these two points be attended to, benefit may then be looked for from 
 the administration of tonics. These tonics may either be such as the 
 infusion of orange-peel with a few drops of sulphuric acid and of some 
 tincture ;* or should any disposition to diarrhoea have appeared, the 
 
 (No. 22.) 
 1 R Ac id- Sulph. dil. TT^xvj. 
 Tinct. Aurantii Co. gj. 
 Syrupi, £j. 
 Inf. Aurantii, ^j. 
 
 Aq. Cinnamomi, gij. M. 3J. ter die. 
 For a child a year old. 
 
 extract with the compound tincture of bark will be preferable f or if 
 2 See Formula No. 3, p. 45. 
 
362 TREATMENT OP DYSPEPSIA PROM GASTRIC DISORDER. 
 
 the stomach be very irritable, the liquor cinchonse in combination with 
 small doses of hydrocyanic acid 1 may be given with advantage, when 
 any other medicine would be rejected. As the general health improves, 
 the constipated condition of the bowels so usual in these cases will by 
 degrees disappear. Even if the symptoms should call for medical inter- 
 ference, it is not by drastic purgatives that its cure must be attempted. 
 A soap suppository will sometimes excite the bowels to daily action ; or 
 friction of the abdomen twice a day with warm oil, or with a liniment 
 composed of one part of Linimentum Saponis, one of olive oil, and two 
 of tincture of aloes, will sometimes have the same effect. Should it 
 become necessary to give aperients internally, the decoction of aloes 
 sweetened with liquorice, and mixed with caraway or aniseed water, 
 generally answers the purpose very well ; 2 while the employment of 
 
 (No. 23.) 
 2 R Decoct. Aloes Co. gvj. 
 Extr. Glycyrrhizee, ^j. 
 Aquse Anisi, spj. M. gj. vel. gij. p. r. n. 
 For a child a year old. 
 
 mercurials must be restricted to cases in which there is very evident , 
 deficiency in the biliary secretion. 
 
 A different plan must be adopted in those forms of indigestion which 
 depend on some cause other than mere debility of the system. The 
 rule, indeed, which limits the quantity of food to be taken at one time 
 is no less applicable here, for the rejection of the curdled milk may be 
 the result of nothing more than of an effort which nature makes to reduce 
 the work that the stomach has to do within the powers of that organ. 
 But when, notwithstanding that due attention is paid to this important 
 point, uneasiness is always produced by taking food, and is not relieved 
 till after the lapse of twenty minutes or half an hour, when vomiting 
 takes place, or when the infant suffers much from flatulence and from 
 frequent acid or nauseous eructations, it is clear that the symptoms are 
 due to something more than the mere feebleness of the system. 
 
 It is not, however, in these cases the mere fact of the infant vomiting 
 its food, or of the milk so vomited being rejected in a coagulated state, 
 which indicates the stomach to be disordered, but it is the circumstance 
 of firmly-coagulated milk being rejected with much pain, and after the 
 lapse of a considerable interval from the time of taking food, which 
 warrants this conclusion. 3 The coagulation of its case in is the first 
 change which the milk of any animal undergoes when introduced into 
 the stomach, though the coagulum formed by human milk is soft, floc- 
 culent, and not so thoroughly separated from the other elements of the 
 fluid as the firm hard curd of cow's milk is from the whey in which it 
 floats. In a state of health, the abundantly secreted gastric juice 
 speedily re-dissolves the chief part of the casein, while the subsequent 
 
 1 See Formula No. 20, p. 277. 
 
 3 The physiology and chemistry of the digestion of the milk -will be found fully treated 
 in the article Milch, in Wagner's Handworterbuch der Physiologie ; and in ElsJisser's 
 essay, Ueber die Magenerweichung der Stiuglinge, 8vo. Stuttgart, 1846. They arc the 
 authorities for the statements in the text. 
 
DIET OF DYSPEPTIC INFANTS. 363 
 
 addition to it of the alkaline bile converts it into an albuminate of soda ; 
 and being thus assimilated as nearly as possible to the characters of 
 one of the chief elements of the blood, it is easily absorbed by the 
 lacteals, and passes into the mass of the circulating fluid. 
 
 Milk tends, however, to undergo changes spontaneously, which 
 produce its coagulation, and the occurrence of these changes is greatly 
 favoured by a moderately high temperature, such as that which exists 
 in the stomach. But the alterations in the fluid which attend upon 
 this spontaneous coagulation are very different from those which are 
 brought about in it by the vital processes of digestion. A free acid 
 becomes developed abundantly within it, and the acid thus generated 
 shews none of the solvent power of gastric juice, but by its presence 
 impedes rather than favours, digestion. Every nurse is aware that a 
 very slight acidity of the milk with which the infant is fed will 
 suffice to occasion vomiting, stomach-ache, and diarrhoea; and the 
 result, as far as the child is concerned, must be much the same whether 
 the acetous fermentation had begun in the milk before it was swallowed, 
 or whether it commences afterwards, in consequence of the disordered 
 condition of the stomach, and the absence of a healthy secretion of 
 gastric juice. 
 
 The nature of the food is the first point that requires attention in 
 the management of these cases of infantile dyspepsia. If the child 
 had been fed on cow's milk, the symptoms may have been produced by 
 the gastric juice being unable to re-dissolve the hard curd formed by 
 the coagulation of its casein. In this case the infant may sometimes 
 be restored to health without the employment of any medicine, by 
 diluting the rn^lk, by substituting asses' milk, or even by giving whey 
 for a day or two, until the stomach recovers its powers of digesting 
 casein. The addition of a small quantity of some alkali — as the 
 carbonate of potash, or prepared chalk — to the milk, is another precau- 
 tion which should not be omitted, since while it does not at all interfere 
 with digestion, it tends to prevent the matters taken into the stomach 
 so readily undergoing the acetous fermentation. The indiscriminate 
 employment of alkalies as medicine, is, however, not to be recom- 
 mended; — they are of service combined either with minute doses of 
 hydrocyanic acid, or of laudanum, when the irritability of the stomach 
 is extreme, as in those cases which we referred to at the commencement 
 of this lecture ; — they are also useful in cases of a more chronic kind, 
 where the sour smell of the evacuations, and the frequent occurrence 
 of acid eructations, indicate the presence of an excess of acid in the 
 primse vise. I do not give them by themselves, but in combination 
 with some tonic, as the infusion of calumba, to which the extract of 
 dandelion and the tincture of rhubarb may be added if as some- 
 times happens, 1 the functions of the liver appear to be but ill performed. 
 
 (No. 24.) 
 1 R Sodae Sesquicarb. gr. xxiv. 
 Extr. Taraxaci, ^ij. 
 Tinct. Rhei, 3J. 
 Inf. Calumbse, 3XJ. 
 Aquoe Carui, giv. M. 31J. bis die. 
 For a child a year old 
 
361 TREATMENT Off INFANTILE DYSPEPSIA. 
 
 Vomiting of the milk in a coagulated state is no proof of the presence 
 of an excess of acid in the stomach. It may indicate a condition in 
 which the secretion of the gastric juice is either disordered or 
 insufficient, and in which the acetous fermentation is set up in the 
 contents of the stomach, because the organ is inadequate to the proper 
 discharge of those vital functions which would prevent its occurrence. 
 Such cases, and they are many — and among them may be classed all 
 those in which the breath is offensive and the infant is distressed by 
 nauseous eructations — are benefitted by the mineral acids in combi- 
 nation with some bitter infusion ; as for instance, the infusion of 
 cascarilla with hydrochloric acid. 1 I have often observed the action of 
 the bowels become regular and the appearance of the evacuations 
 healthy, during its administration. The use of mercurials, indeed, so 
 generally resorted to in order to correct some real or fancied disorder 
 of the liver, has become too indiscriminate a practice. The diarrhoea, 
 with very pale light yellow evacuations, that comes on in some of these 
 cases, is often arrested by a spare diet and by the administration of 
 very small doses of sulphate of magnesia and tincture of rhubarb ; 
 such as five grains of the former and ten minims of the latter three 
 times a day to a child a year old. 3 In cases where diarrhoea has been 
 
 (No. 25.) (No. 26.) 
 
 ! R Acid. Hydrochlor. dil. TTLxvj. 2 R Magnesise Sulphatis, 33. 
 
 Syr. Aurantii, 3J. Tinct. Rhei, gj. 
 
 Tinct. Aurantii, 3J. Syr. Zinziberis, spj. 
 
 Inf. Cascarilloe, £x. M. gj. ter die. Aquae Carui, gix. M.- ^j. ter die. 
 
 For children a year old. 
 
 long continued, or where the evacuations are very white, and resemble 
 putty, mercurials are generally needed ; as they are, also, in those cases 
 where the horribly offensive odour of the evacuations proves that the 
 contents of the intestines have been undergoing a process akin to 
 putrefaction. The mercury and chalk powder in small doses night and 
 morning, is the mildest preparation that can be given. Sometimes, 
 however, it causes nausea or vomiting, and very small doses of calomel 
 must then be substituted for it ; while, if the mercurial should excite 
 the bowels to over-action, this tendency may generally be checked by 
 combining it with Dover's powder. 
 
 The same rules must guide us in the management of children whom, 
 though they be still at the breast, the symptoms of dyspepsia make 
 their appearance. Disorder of the digestive function is, however, much 
 less common before weaning than afterwards. It may depend on the 
 mother's milk being from some cause or other ill adapted to the support 
 of tbe child; and hence the condition of the parent's health must in all 
 these cases engage our attention. 
 
 With these general rules I must dismiss the subject of indigestion, 
 content to have pointed out the principles that should guide you. It 
 must be left to your own experience in future years to supply the 
 details. I have touched on the subject, too, only with reference to the 
 infant, for as the child grows older and its food becomes the same as 
 
SOFTENING OF THE STOMACH. 365 
 
 that of the adult, the symptoms of disorder of its digestive organs 
 become the same too, and require a similar treatment. 
 
 In many works on the diseases of childhood we meet with an enume- 
 ration of rather obscure symptoms, which are stated to indicate the 
 existence of gastritis or gastro-enteritis, and to be followed by more or 
 less considerable softening of the stomach or intestines, or of both. A 
 similar condition of the stomach was observed by John Hunter in the 
 adult, and was conceived by him to be the result of the action of the 
 gastric juice upon the tissues after death. The carefully conducted 
 experiments of Dr. Carswell have completely confirmed the opinion of 
 Mr. Hunter with reference to the agent by which this softening is 
 effected; while they have further shown that it is independent of the 
 person's previous health. Some writers, among whom may be men- 
 tioned those eminent authorities M. Cruveilhier and Professor Roki- 
 tansky, have, however, dissented in a measure from these views, and 
 have endeavoured to distinguish between two kinds of softening, one of 
 which they regard as a post-mortem occurrence ; the other, which is that 
 chiefly observed in infancy, they consider to be the result of disease. 
 
 Softening of the stomach varies in degree from a slight diminution 
 in the consistence of the mucous membrane, to a state of complete 
 diffluence of all the tissues of the organ, in which it breaks down under 
 the finger on the slightest touch, or even gives way of its own accord, 
 and allows of the escape of its contents into the abdomen. When the 
 change is not far advanced, the exterior of the stomach presents a per- 
 fectly natural appearance, but on laying it open, a colourless, or slightly 
 brownish, tenacious mucus, like the mucilage of quince seeds, is found 
 closely adhering to its interior, over a more or less considerable space 
 at the great end of the organ, and extending along the edges of its 
 rugae. This mucus is easily washed away, and the muscular coat of 
 the stomach in those parts to which it had adhered is then left almost 
 or altogether bare, and denuded of its mucous membrane. When the 
 change has gone further, the stomach at its great end presents a semi- 
 transparent appearance, though not uniformly so, but in streaks running 
 in the direction of the rugae ; the destruction of the tissues having in 
 those situations reached deeper than elsewhere, and involved a portion 
 of the muscular as well as the mucous coat of the organ. If roughly 
 handled, the stomach in many cases gives way, an irregular rent taking 
 place at its great end, where the coats of the organ are found to be soft 
 and pulpy, and to breaK down easily under the finger. In the next 
 degree, the coats of the stomach are found to have been already dis- 
 solved in some parts, so that the contents of the organ have escaped 
 into the abdominal cavity. The whole of. the great end of the stomach, 
 and a considerable extent of the posterior wall, are now reduced to a 
 gelatinous condition, in which no distinction of tissues is apparent ; and 
 the parts thus altered are either transparent and colourless, or else of 
 a pale, rose-red, hue. The interior of the organ sometimes presents a 
 similar tinge, even beyond the limits to which the softening of its tissue 
 has extended. This, however, is by no means constantly observed, while 
 in no case is there any injection of the vessels of the stomach, or any 
 evidence of its having been the seat of real inflammatory action. The 
 
366 SOFTENING OF THE STOMACH AND INTESTINES. 
 
 opaque and brownish appearance of the tissues — characteristic of pulpy 
 softening — is but seldom met with in infancy. 
 
 Softening of the intestines, though much less frequent than softening 
 of the stomach, is observed under similar circumstances, and presents 
 much the same characters. The exterior of the intestines is generally 
 anaemic, and the softened parts present no trace of increased vascularity, 
 but are either colourless, or of a pale rose hue. The mucous membrane 
 in their interior is neither ulcerated nor abraded, but is found in some 
 parts to be much softened, or even altogether absent in small patches. 
 The muscular coat, too, is sometimes destroyed, though no abrupt edge 
 marks the limits of its destruction, but there is a gradual attenuation 
 of the tissue down to the spot where the peritoneum is laid completely 
 bare. Several of these softened patches are generally met with in the 
 same subject, and at some of them the bowel is often found to have 
 given way, or it breaks down in the attempt to lay open its cavity. 
 
 The allegation, that softening of the stomach in the adult occurs with 
 greater frequency in persons who have died from some diseases, 1 than 
 in those who have died from others, has led to the hypothesis that, in 
 the former case, a diseased and superabundant secretion of gastric juice 
 during the life of the individual had caused the softening of his stomach 
 after death. The same hypothesis has been applied to account for its 
 peculiar frequency in infancy, since at no period of life is gastric dis- 
 order so common as then. Some writers have advanced still further, 
 and have endeavoured to connect the existence of a softened state of 
 the stomach after death, with certain well-marked symptoms of disorder 
 of its functions ; for my own part, however, I have not been able to 
 discover any peculiarity in the character of such symptoms, nor even 
 any constancy in their occurrence. 
 
 The much greater frequency of softening of the stomach and intes- 
 tines in infancy and early childhood than in adult age, and the greater 
 amount and wider extent of the alterations, have received considerable 
 elucidation from the recent researches of Dr. Elsasser. 2 He found that 
 a much more rapid action upon animal tissues than that exerted by the 
 gastric juice, was put forth by any substance capable of undergoing the 
 acetous fermentation, combined with pepsin. Such substances are fur- 
 nished by the milk as well as by the various farinaceous and saccharine 
 matters on which infants almost exclusively subsist. The tendency of 
 these substances to undergo the acetous fermentation is checked by the 
 presence of healthy gastric juice, while, as we know by experience, it 
 takes place very readily in infants who are dyspeptic, and to a very 
 remarkable degree in many cases of infantile diarrhoea. Facts bear out 
 
 1 The recently published very elaborate work of MM. Herrich andPopp, Der plotzliche 
 Tod aus inneren (Jrsachen, 8vo. Regensburg, 1848, contains at page 330, a table of 104 
 cases in which softening of the stomach was found after death from different causes, and 
 at various ages. In no instance were symptoms observed that would have enabled any 
 one to pronounce beforehand that softening of the stomach would be discovered after 
 death. In by far the greater number of cases the stomach was empty, showing that the 
 occurrence very often did not depend on digestion going on at the time of death ; while 
 the period of childhood, the rapid course of the fatal disease, and death from cerebral 
 affections, were the only circumstances which appeared to have any clearly appreciable 
 influence in favoring its production. 
 
 2 Die Magenerweichung der Siiuglinge, 8vo. Stuttgart, 1846. 
 
OCCURS AFTER ITS DEATH — THEORIES AS TO ITS CAUSE. 367 
 
 to a very great extent the opinion of M. Elsasser. Out of 104 cases of 
 softening of the stomach that came under the notice of two very emi- 
 nent German physicians, MM. Herrich and Popp, 72 were met with in 
 the period of infancy or early childhood. My own notes on this point, 
 though too few to be of any weight, yet point to a similar conclusion ; 
 for of 14 cases of softening of the stomach or intestines, or of both, ob- 
 served out of a total of 61 cases in which the condition of those viscera 
 was carefully recorded, 11 were met with in children under two years 
 of age ; while out of a total of 889 examinations of infants under the 
 age of three months in the Foundling Hospital at Vienna, M. Bednar 1 
 met with 100 instances of softening of the stomach or intestines ; in 61 
 of which death had taken place from diarrhoea. I need scarcely add 
 this theory of M. Elsasser's is only supplementary to Mr. Hunter's, 
 and is perfectly reconcilable with the correctness of his observations, 
 and of those of Dr. Carswell. 
 
 Among those rare diseases, too seldom met with for any person to 
 have what can be called real experience about them, may be mentioned 
 the vomiting and purging of blood occasionally observed in infants and 
 young children. In the greater number of cases the occurrence has 
 taken place within a few days 2 after birth, sometimes within a few 
 hours, and in some instances has followed a tedious or difficult labour, 
 in which the head of the child has been much compressed, or its abdo- 
 men has been pressed on, or otherwise injured, during attempts at its 
 extraction; while in other cases the difficult establishment of respira- 
 tion has seemed to be the predisposing cause of the haemorrhage. Very 
 often, however, no reason can be assigned for it ; and the vomiting of 
 blood, sometimes associated with its discharge per anum, has been 
 unattended with other indications of disorder of the abdominal viscera. 
 In most cases the haematemesis has not recurred above two or three 
 times in any quantity ; and the children, though at first very much 
 exhausted by the loss of blood, have, in about half the cases, eventually 
 recovered. In a few instances, however, recovery has been but partial, 
 and the children have sunk into a cachectic condition, in which they 
 died. When death has taken place from the immediate effects of the 
 haemorrhage, the liver and the abdominal veins have sometimes been 
 found gorged with blood, and blood has been found within the intes- 
 tines, or extravasated between their coats, constituting what has been 
 termed abdominal apoplexy, — appearances which have been supposed 
 to indicate that some impediment to the establishment of the new 
 course of the circulation which the blood should follow after birth, had 
 given rise to the accident. 
 
 1 have nothing to say about the treatment of an accident which in 
 general occurs too causelessly to furnish indications for its prevention, 
 and too suddenly to allow of the employment of measures for its arrest ; 
 but I will give you the result of my scanty experience concerning it, 
 which amounts to three cases. In one of these cases the haemorrhage 
 
 i Die Krankheiten der Neugebornen, &c 8vo. p. 76. Wien, 1850. 
 
 2 Within 6 days in 17 ; and within 86 hours in 9 out of 20 cases collected by M. Rilliet, 
 in his essay Surles He"morrhagies Intestiniales chez les Nouveau ne"s, published in Gaz. 
 Med. de Paris, No. 53, 1848. 
 
368 H^EMATEMESIS AND HELENA. 
 
 occurred, without apparent cause, soon after birth, and ceased sponta- 
 neously ; while in the other two it took place at a later period, and 
 approached in its characters more nearly to similar occurrences in 
 adult age. 
 
 The subject of the first observation was a male child, who was born 
 of a healthy mother, after a short and easy labour, at 11 A. M. on Sept. 
 23, 1845. The infant was well grown, and apparently strong and 
 healthy, and continued so till 2J a. m. on the 24th, when, without any 
 previous sickness, or other indications of illness, he vomited nearly half 
 a teacupful of blood. This vomiting was not attended with any pain, 
 nor was any large quantity of blood rejected afterwards, but the child 
 continued at intervals of not more than an hour to throw up small quan- 
 tities of dark greenish matter, resembling meconium, and mixed with 
 mucus ; and on the morning of the 25th he vomited a small portion of 
 coagulated blood, as big as the top of the little finger. Between the 
 time of the child's birth and the morning of the 25th, the bowels acted 
 seven times ; the motions were rather scanty, and consisted entirely of 
 meconium. The child sucked well, did not appear in distress ; its sur- 
 face was warm, and its abdomen neither full nor tender. The matters 
 vomited did not decompose, although they were kept for some days ; 
 and when examined under the microscope, they were seen to be made 
 up of a great number of granular globules, with which were intermixed 
 some scales of tesselated epithelium. 
 
 The 27th of September was the last day on which the dark solid 
 matter like mecomium was vomited ; but the child continued to be sick 
 occasionally until October 7, although the attacks of sickness did not 
 seem to be excited by sucking, but occurred in general when the 
 stomach was empty, and ended with the rejection of a small quantity 
 of mucus, occasionally of a greenish colour. The bowels were rather 
 constipated, and the evacuations for the first week after the child's 
 birth continued very dark-coloured : they afterwards assumed a more 
 natural colour ; but the bowels remained very constipated during the 
 whole of the child's life. The child never throve ; it lost flesh, occa- 
 sionally vomited the milk, had a frequent and troublesome cough ; its 
 strength decayed, and it died exhausted on April 28, 1846, at the age 
 of seven months. On examining the body, nothing was found to 
 explain the child's illness : there was no tubercle in any organ ; the 
 viscera were anaemic ; no trace of inflammatory action was visible any- 
 where. A few lobules in both lungs were in a collapsed condition ; the 
 small intestine presented several recent intussusceptions ; and the 
 stomach was remarkably small, and undeveloped in form as well as in 
 size ; but no other morbid appearance existed in any part of the body. 
 In the second case, the child, likewise a boy, had perfectly good 
 health, till he was two months old, when he began to appear stuffed at 
 his chest, and had frequent, though not severe cough. At the age of 
 ten weeks, he brought up a small quantity of dark blood while cough- 
 ing, and afterwards had frequent attacks of retching and vomiting, 
 independent of cough. During these attacks he brought up a dark red 
 fluid, like blood, sometimes in as large a quantity as two-thirds of a 
 teacupful. On Feb. 17th, 1844, after these symptoms had continued 
 
H^EMATEMESIS AND MELvENA. 369 
 
 for four days, I saw the child, whose face was slightly flushed, and the 
 expression of his countenance dull. His abdomen was full and rather 
 tender, especially in the right hypochondriac region; his urine was 
 very high coloured, and his evacuations were quite white. From Feb. 
 17th to April 13th, the child remained under my care, and during 
 this time the above-mentioned symptoms continued, although with a 
 gradual amelioration in the child's condition. Within a week after I 
 first saw him, he had a severe convulsive seizure, and attacks of a 
 similar kind occurred a great many times afterwards, independent of 
 any obvious cause. The bowels were always constipated ; the evacua- 
 tions usually very white, though occasionally almost black, sometimes 
 accompanied with a slight discharge of blood ; and blood was now and 
 then voided unmixed with faecal matter. The stomach became very 
 irritable, and the child suffered from frequent vomiting ; the matters 
 rejected being untinged with blood for days together, and then, without 
 any apparent reason, blood was abundantly mingled with them. Some- 
 times the infant cried much, and appeared in very great pain, and 
 these attacks often terminated in the rejection of a considerable quan- 
 tity of nearly pure blood. The face soon lost its flush, and became 
 pale ; but the puffiness continued, and was evidently due to a slight 
 degree of anasarca. From the tender age of the child, I was unable 
 to obtain any of his urine, in order to ascertain whether or not it con- 
 tained albumen. The treatment followed was directed to diminish the 
 abdominal tenderness, by the application of a couple of leeches over 
 the right hypochondrium, and to overcome the constipated state of the 
 bowels, and induce the healthy action of the liver, by the employment 
 of small doses of mercurials, and of the sulphate of magnesia, to 
 which it became sometimes necessary to add the administration of an 
 active purgative. In May, 1844, the child was sent to Margate, 
 where the convulsive attacks, and the other symptoms, altogether 
 ceased. On his return to London, after a stay of six months at the 
 sea-side, his health failed, — partly, as it seemed, in consequence of his 
 mother's poverty preventing her from supplying him with proper food. 
 In Nov. 1846, when much out of health, and suffering from diarrhoea, 
 he came again under my care, but died suddenly of haemorrhage into 
 the arachnoid. 1 There was no appearance in the abdominal viscera 
 after death which threw any light on the cause of the haematemesis 
 and melaena, from which the child had suffered for so many months 
 during his early infancy. 
 
 The subject of the third observation was a little boy, the child of a 
 healthy father but strumous mother, who had thriven well at the 
 breast till he was four months old, when he cut some of his incisor 
 teeth; and his health had seemed less good since that period. There 
 was, however, no marked ailment until he was weaned, at nine and a 
 half months ; but after that he drooped, became much less cheerful, and 
 his evacuations were seen to be white and unhealthy. He was in this 
 condition when ten months and a week old ; his abdomen, though 
 large, was generally soft ; but pressure in the left hypochondrium 
 
 1 The particulars of his last illness are given in Lecture IV. p. 53. 
 24 
 
370 ILLUSTRATIVE CASES. 
 
 seemed to give pain ; and careful examination detected a tumor there 
 of the size of a small apple. On the evening of the same day on which 
 he was first seen, the bowels having acted spontaneously in the morn- 
 ing, the child suddenly, and without any effort or straining, voided 
 between three or four ounces of pure blood, partly fluid, partly coagu- 
 lated. The discharge of blood occasioned faintness, and left the child 
 very pallid, but apparently not suffering. He slept tolerably well 
 during the night, but the ensuing morning, at 7 A. M., voided nearly 
 the same quantity of blood as on the previous evening, unmixed with 
 faeces, but apparently somewhat diluted with intestinal mucus. Some 
 warm water thrown up the bowel returned, stained with blood, but 
 unmixed with faecal matter; as did a second enema administered six 
 hours afterwards. In the course of the same day he had two scanty 
 evacuations, both composed almost entirely of bloody mucus, and with 
 such slight admixture of adhesive, white, faecal matter, almost like 
 putty in appearance, that I did not feel my anxiety lest the case should 
 turn out to be one of intussusception of the intestines entirely removed 
 until nearly twenty-four hours afterwards, when, after a dose of castor 
 oil, two tolerably healthy evacuations were passed. The tenderness of 
 the abdomen had now completely subsided, the swelling in the left 
 hypochondrium (possibly the enlarged and congested spleen) had 
 entirely disappeared ; and the child, in spite pf the quantity of blood 
 it had lost, appeared much better than before the haemorrhage occurred. 
 This amendment, however, was not of long duration ; no haemorrhage, 
 indeed, returned, but the child had an attack of very severe diarrhceal 
 attended with great emaciation and much abdominal pain, which lasted 
 for nearly six weeks. After the diarrhoea ceased, the child still con- 
 tinued weak, and thin, and suffering, and died convulsed in the middle 
 of June, after vague head symptoms of two days' duration. 
 
 In this last case no post-mortem examination could be made, so that 
 we are uncertain what connection, if any, subsisted between the 
 haemorrhages at the outset of the child's illness, and the obstinate 
 diarrhoea which came on soon after, and had so large a share in 
 occasioning its death. One thing, at any rate, these cases illustrate, 
 and one worth bearing in mind, — viz. that formidable as the occurrence 
 is, and large as the quantity of blood which is lost may be, still the 
 immediate danger to life is far less than, but for this evidence to the 
 contrary, we should most naturally apprehend. 
 
 It will not be necessary to do more than allude to cases of what has 
 been called spurious hoematemesis, in which an infant vomits blood 
 drawn from some crack or ulceration of its mother's nipple, or which 
 has been furnished by some little vessel cut in dividing the fraenum 
 linguae, or in performing some other operation on its mouth. You 
 would at once suspect the source of the blood vomited after the opera- 
 tion on the infant's mouth ; and an examination of the mother's nipple, 
 in a case of haematemesis will guard you against the other possible 
 source of error. 
 
ICTERUS OF NEW BORN CHILDREN. 371 
 
 LECTUER XXXI. 
 
 Icterus of New born Children — generally a trivial affection — not usually dependent 
 on intestinal disorder, but on imperfect performance of function of skin and respiratory 
 organs — sometimes results from absence or closure of hepatic or cystic ducts — is then 
 associated with great tendency to haemorrhage, and proves speedily fatal. It occa- 
 sionally occurs in children under the same circumstances as in the adult. 
 
 Constipation sometimes results from mechanical obstruction of intestines — which may 
 be congenital — as from imperforate anus, or impervious rectum. — Varieties of these 
 malformations — their general symptoms — special signs of each — their comparative 
 danger, and appropriate treatment. 
 
 Obstruction of intestines from causes not congenital — strangulated hernia very rare in 
 infancy — intussusception of intestines — its symptoms — usually more characteristic 
 than in the adult — its generally fatal result — but occasional spontaneous cure. 
 
 It often happens, that, some two or three days after birth, the skin 
 of a new-born infant assumes more or less of a yellow colour, — that 
 this colour gradually deepens, and becomes apparent in the conjunctiva 
 as well as over the whole surface of the body ; but after a day or two 
 the yellow tinge diminishes, and in the course of a week or ten days 
 completely disappears — little if any indisposition having attended any 
 stage of the affection. The general resemblance of its symptoms to 
 those of jaundice in the adult, has led some persons to attribute this 
 icterus neonatorum to retention of the meconium, or to gastric or intes- 
 tinal disorder produced by unsuitable food. On the other hand, the 
 slightness of the constitutional disturbance which attends it, and the 
 occasional absence of all signs of disorder of the general health, have 
 given rise to a different opinion, according to which the occurrence is 
 attributed to physiological rather than to pathological causes. With 
 reference to the first of these views, it may be observed that infantile 
 icterus is often unattended either with retention of the meconium, or 
 with any other form of intestinal disorder ; while very serious distur- 
 bance of the digestive organs, or even complete retention of the meco- 
 nium, from an impervious condition of the rectum, may exist without 
 being associated with a yellow tinge of the skin. The assumption that 
 it is a perfectly natural state, in which the skin and other secreting 
 organs are called on for a few days to assist in disposing of the bile, 
 until the demand for it to minister to the digestive functions becomes 
 equal to its abundant supply, is shown to be erroneous, by the circum- 
 stance that jaundice does not affect perfectly healthy children, who 
 have been born at the full time, have been nourished exclusively at the 
 mother's breast, and been sheltered from cold without being overbur- 
 thened with clothing or confined in a vitiated atmosphere. In the 
 Dublin Lying-in-Hospital, where the children are defended by the most 
 watchful care from the evils either of cold or of a vitiated atmosphere, 
 the occurrence of infantile jaundice is rare ; while in the Foundling 
 Hospital at Paris jaundice is so common, that comparatively few 
 infants escape it. Almost all the children at the Foundling Hospital 
 have been exposed to the action of cold while being brought to the 
 
372 INFANTILE JAUNDICE GENERALLY OF LITTLE MOMENT. 
 
 institution, and suffer from the combined influences of cold and bad air 
 while inmates of it, — causes which interfere very seriously with the 
 due performance of the functions of the skin and of the respiratory 
 organs. 
 
 The children in whom jaundice is most frequent and most intense, 
 are the immature and the feeble ; while in none is it so often met with, 
 or in such an intense degree, as in infants affected with induration of 
 the cellular tissue, in whom the yellow colour is often so deep as to be 
 manifest in the serum infiltrated into their cellular tissue, or poured 
 out into the cavities of their chest or abdomen. Interruption of the 
 function of the skin, and great impairment of that of the lungs, are, 
 as you know, the grand characteristics of that affection ; while in many 
 instances of it the foetal passages are still pervious, and the blood 
 circulates in part through channels which ought to have been closed 
 from the time of birth. These facts seem to substantiate the opinions 
 entertained by many writers of high authority, that the jaundice of 
 young children is not due to any cause 'primarily seated in the liver, 
 but rather to the defective respiration and the impaired performance 
 of the function of the skin, of which the hepatic disorder and conse- 
 quent jaundice are but the effects. 
 
 As the respiratory function, and that of the skin, increase in activity 
 — which they will do if the cause of their imperfect performance be 
 but slight or temporary — the jaundice disappears of its own accord. 
 Great attention must be paid during its continuance to avoid exposure 
 of the child to cold ; while no other food than the mother's milk should 
 be given. If the bowels be at all constipated, a grain of Hyd. c. 
 Creta may be given, followed by a small dose of castor oil ; and the 
 aperient will often seem to hasten the disappearance of the jaundice ; 
 but in a large number of cases even this amount of medical inter- 
 ference is not needed. 
 
 Besides these cases, however, in which the jaundice is at most but a 
 very trivial ailment, instances are sometimes met with where it is a very 
 serious affection, dependent on congenital absence of the hepatic or 
 cystic biliary ducts, or on the obstruction of those ducts by inspissated 
 bile. Under these circumstances death takes place sooner or later, 
 though now and then not for several months ; and, as might be 
 expected, the evacuations continue during the whole period destitute of 
 bile. One remarkable phenomenon attending these cases is the ten- 
 dency to haemorrhage by which they are characterized ; this haemor- 
 rhage taking place for the most part from the umbilicus, either before 
 or soon after the separation of the funis. In some instances the recur- 
 rence of this bleeding proves fatal, while in others the infant sinks into 
 a state of coma, which continues for a day or two before death takes 
 place. It is unusual for the infant to survive its birth longer 
 than a fortnight ; and, if its life should be prolonged, a condition of 
 general atrophy comes on, attended with enlargement of the abdomen 
 in both hypochondriac regions ; and some* intercurrent attack of diar- 
 rhoea generally exhausts the feeble powers when only a few months 
 have passed. It may suffice just to have referred to the main features 
 of these unfortunate cases. Happily they are very rare ; no instance 
 
OCCASIONALLY A DANGEROUS AFFECTION. 373 
 
 of them has come under my own notice, but you will find a very inte- 
 resting history of three cases of this fatal icterus in a paper published 
 by Dr. A. B. Campbell, in the Northern Journal of Medicine for 
 August, 1844. 1 
 
 Jaundice may also occur in older children under the same circum- 
 stances as in adults, and associated with similar symptoms ; the evacua- 
 tions being white, the urine high coloured, and more or less pain and 
 tenderness being experienced in the hypochondriac region. Such cases 
 are most frequently met with during the summer or autumn, especially 
 at times when diarrhoea is prevalent ; the skin sometimes assuming a 
 generally yellow tinge as the purging subsides ; while in other instances 
 the jaundice occurs as an idiopathic aifection, though apparently due to 
 the same causes as have produced diarrhoea in other children. 
 
 In the instances that have come under my notice the skin has never 
 assumed a very deep yellow tinge, and the constitutional symptoms 
 have seldom been severe. Now and then, however, considerable febrile 
 disturbance precedes the appearance of the jaundice for two or three 
 days : the skin is dry, though not very hot ; vomiting occurs ; and the 
 child complains much of headache and dizziness, and rests ill at night, 
 or awakes in a state of alarm. The resemblance between these symp- 
 toms and some of those which occur in cases of real cerebral disease is 
 almost sure to excite much apprehension in the mind of the parents ; 
 and may even render it a difficult task for you to form a correct diag- 
 nosis. The following circumstances will, however, usually suffice to 
 preserve you from error : — The attack has not, in most instances, been 
 preceded by those indications of generally failing health which so often 
 occur during many days before the symptoms of hydrocephalus mani- 
 fest themselves ; and it is not attended either by the anxious expression 
 of countenance, the heat of head, or the intolerance of light, by which 
 cerebral disease is accompanied. Though the sleep may be disturbed, 
 it is usually less so than in hydrocephalus ; the pulse is less frequent ; 
 and though the child vomits occasionally, it does not suffer from con- 
 stant nausea. When to these symptoms tenderness on pressure in the 
 hypochondriac region is superadded, with the appearance in a day or 
 two of high-coloured urine and of white evacuations, and lastly, of the 
 yellow tinge of the skin, no further possibility of error remains. 
 
 The treatment of jaundice in the child calls for but very simple 
 remedies. If it be accompanied with much tenderness in the hypo- 
 chondriac region, a few leeches may be applied in that situation with 
 much advantage. If, however, this be not the case, the employment of 
 small doses of the sulphate of magnesia, in combination with the tinc- 
 ture of rhubarb, every four or every six hours, with three grains of the 
 Hyd. c. Creta" for a child of five years old, at bed-time, will generally 
 suffice to restore the patient to health in the course of four or five days. 
 Should the appetite continue bad, and the child fretful and languid, 
 after the subsidence of the jaundice, and the return of the evacuations 
 
 1 The valuable paper of Mr. Ray, in Med. Gazette for March, 1849 ; that of Dr. Manley 
 in the same journal for May, 1850; and the essay of M. E. Dubois, in the Arch. Gen. de 
 Medicine for October, 1849, furnish a very complete account of umbilical haemorrhage 
 in the infant. 
 
374 CONSTIPATION — 
 
 to a more healthy character, the compound infusion of roses, either 
 alone or in combination with small doses of sulphate of magnesia, will 
 be found of much service. In some cases, however, removal to the 
 country, or to the sea-side, appears to be absolutely necessary to the 
 child's complete recovery. 
 
 I have nothing to add to what has already been said on the subject 
 of constipation, — which is to be regarded as a symptom of various 
 diseases rather than as a special idiopathic affection. To this rule, 
 however, an exception must be made in those cases in which the due 
 action of the bowels is prevented by some mechanical impediment. 
 Such an impediment is, in some rare instances, presented by congenital 
 malformation of the intestines, whose calibre has been found greatly 
 diminished, or their canal completely obstructed, or even their conti- 
 nuity altogether interrupted. These occurrences, although of great 
 interest and importance, from their relation to the laws that regulate 
 foetal development, yet for the most part afford no scope for the inter- 
 ference of medical or surgical skill. But while we pass over, as foreign 
 to our purpose, the general study of these malformations, we must take 
 some notice of one variety of them, in which the obstacle to the escape 
 of the faeces is situated low down in the large intestine, since their 
 diagnosis is often easy, and their cure not always beyond the resources 
 of our art. 
 
 The cause of the obstruction in these cases is not always of the same 
 kind, nor is the patient in every instance exposed to the same amount 
 of danger. But three different classes of the malformation may be 
 recognized, in each of which our prognosis must somewhat differ, 
 although in almost all it must be doubtful, and in many extremely 
 unfavourable. 
 
 To the first class may be referred all those cases in which the rectum 
 is perfect, but the canal is closed either by a false membrane obstruct- 
 ing its orifice, or situated higher up in the intestine ; or by the cohesion 
 of the opposite sides of the gut. 
 
 The second class includes cases in which, although the natural aper- 
 ture is absent, yet the intestine terminates by opening into the urethra, 
 bladder, or vagina. 
 
 To the third class belong those instances in which the intestinal 
 canal is not merely occluded, but also malformed, or altogether absent 
 for a more or less considerable extent. 
 
 The affection in any form is so rare, as to render a correct estimate 
 of the comparative frequency of its varieties by no means easy. Dr. 
 Collins observed only one instance of it out of 16,654 children born in 
 the Dublin Lying-in Hospital during his mastership ;* and Dr. Zohrer, 
 of Vienna, 2 mentions that he met with it only twice out of 50,000 new- 
 born children. A comparison of 74 cases derived from different sources 
 yields 17 belonging to the first class, 29 to the second, and 28 to the 
 third ; but it is probable that many instances of simple closure of the 
 anus have passed unrecorded, while all the instances of more serious 
 malformation have been described. 
 
 1 System of Midwifery, p. 509. 
 
 2 Oesterr. med. Wochenschr. ; and Canstatt's Jahresber. fur 1842, Bd. i. S. 456. 
 
FROM MALFORMATION OF THE INTESTINES. 375 
 
 Whatever be the seat of the obstruction, its existence is betrayed by 
 much the same train of symptoms in all cases. Attention is first 
 excited by the infant not having voided any meconium, although from 
 twelve to twenty-four hours may have elapsed since its birth. A dose 
 of castor oil, or of some other aperient, given with the view of exciting 
 the bowels to action, fails of producing this effect, while it is either 
 returned by vomiting, or, if not actually rejected, it causes nausea and 
 retching. Before long, the child shows indications of uneasiness, and 
 has attacks of pain, in which it cries, and seems to suffer much. In 
 some cases it remains quiet in the intervals between these attacks, and 
 seems drowsy ; but in other cases it appears to be in a state of constant 
 discomfort, which it betrays by a whimpering cry. The attempt to 
 suck is almost always followed by retching, frequently by actual vomit- 
 ing ; and attacks both of retching and vomiting often come on when 
 the stomach is quite empty. In some cases nothing more is thrown up 
 than a little mucus, which is sometimes of a greenish colour; while in 
 other instances vomiting of meconium takes place ; but this occurrence 
 is by no means constant. The abdomen becomes distended and 
 tympanitic, and grows larger and more tense the longer that life con- 
 tinues, while at the same time the child's discomfort is much aggravated 
 by any pressure upon it. The restlessness increases, and the attacks 
 of pain grow more severe, the child often making violent straining 
 efforts during their continuance ; but as the powers of life decline these 
 efforts become more feeble, though the retching and vomiting often 
 continue to the last. The period at which death takes place varies 
 much ; for though, in the majority of instances, the child dies within a 
 week from its^birth, yet cases are on record in which it has survived 
 for several weeks ; and an instance has been mentioned to me by Mr. 
 Arnott, in which he saw a child live for seven weeks and three days, 
 although the colon terminated in a blind pouch, and the rectum was 
 entirely absent. Death usually occurs under a gradual aggravation of 
 the previous symptoms ; but now and then it is ushered in by the 
 sudden supervention of a state of collapse, owing to the over-distended 
 intestine having given way. This is, however, a rare occurrence ; for 
 I find mention of it having happened only in three out of the seventy- 
 four cases to which I have referred. 
 
 Coupled with the general signs of intestinal obstruction, there are in 
 each case some special indications of the peculiar form of malformation 
 to which the obstruction is due. If the anus be merely closed by a 
 membrane, or by the cohesion of its edges, the collection of the meco- 
 nium above may give rise to the formation of a distinct tumor between 
 the buttocks ; while sometimes the dark colour of the meconium shows 
 through the thin integument by which its escape is prevented. In other 
 cases the anus itself is well formed, but the introduction of the finger 
 or of a bougie into the rectum detects the existence of some obstruction 
 within the gut. Again, in other instances, there is no trace of an anus, 
 or a small depression is all that marks the situation which it should 
 occupy ; the rectum either ending in a blind pouch, or communicating 
 with the vagina, urethra, or bladder. 
 
 Although the diagnosis in all cases is sufficiently easy, yet the carry- 
 
376 VARIETIES OF THEIR MALFORMATIONS, 
 
 ing out the very obvious indication of relieving the patient by providing 
 for the escape of the contents of the intestines, is often very difficult ; 
 and, even when accomplished, its result is in many instances extremely 
 uncertain. If the obstruction be situated at the orifice of the anus, a 
 crucial incision through the membrane which closes it, or the introduc- 
 tion of a trocar, will afford immediate relief. Our prognosis also may, 
 under these circumstances, be very favourable ; for of fifteen cases of 
 this kind, all but one had a favourable issue. After the opening has 
 been established, however, some attention must be paid to prevent its 
 becoming closed, or much contracted. For this purpose it has been 
 recommended that a tent should be kept in the anus for some days ; 
 though to this it has been objected that a constant straining effort is 
 thereby produced, and the frequent introduction of the finger or of a 
 bougie into the passage is therefore recommended, as preferable to 
 leaving any body constantly within it. 
 
 If the obstacle be occasioned by a membrane seated higher up in 
 the rectum, w T e may still hope to succeed, though our prognosis must 
 be more guarded, since two out of four cases of this description had a 
 fatal result. In one of the fatal cases, it appeared that rupture of the 
 intestine had already taken place before any operation was performed ; 
 in the other, the death of the child was accounted for by the discovery 
 of a second septum higher up in the rectum than that which had been 
 divided. 
 
 The existence of an anus, and a small extent of gut above it, although 
 a decidedly favourable feature in a case, does not warrant quite so 
 hopeful a prognosis as we might in the first instance feel disposed to 
 adopt. The probabilities, indeed, are, that the distance is not great 
 between the end of the rectum and the cul-de-sac in which the anus 
 terminates ; yet a considerable space may intervene between the two, 
 or, as in a case which Mr. Arnott was so good as to communicate to 
 me, the rectum may be found altogether absent, the colon terminating 
 in a blind extremity, and floating loose in the abdominal cavity. In 
 the majority of instances, the two blind pouches are connected 
 together by the intervention of an eighth or a quarter of an inch of 
 dense cellular tissue, which sometimes presents an almost ligamentous 
 character ; and in some cases the end of the large intestine is situated 
 anterior to the extremity of the cul-de-sac that leads from the anus. — 
 Owing to this latter circumstance, the operation for the relief of this 
 condition has sometimes failed ; the instrument, although introduced 
 deep enough, yet passing behind the distended bowel. Out of nine 
 cases of this kind, eight had a fatal termination ; the bowel on four 
 occasions not having been reached at all, while once the opening made 
 in it was too small to allow the free escape of the meconium. It may 
 be added, that in three of the fatal cases there existed such contraction 
 of the calibre of different parts of the large intestine as would of itself 
 have opposed a serious obstacle to the child's recovery. 
 
 In twelve cases the anus was absent, and in some of these instances 
 no trace of it existed, while the rectum terminated in a cul-de-sac at 
 from one to two inches from the surface. In five of these cases the 
 attempt to open the intestine was successful, and the child eventually 
 
AND THEIR COMPARATI\ h DANGER. 377 
 
 did well ; while in two other cases, although temporary relief followed 
 the operation, yet symptoms of inflammation of the bowels came on, 
 which terminated fatally in the course of a few days. In three 
 instances it was not found possible to reach the bowel ; and in two 
 others, although an opening was made, yet its size was insufficient to 
 afford a free vent to the accumulated meconium ; and the fatal issue, 
 though deferred, was not prevented. Failure to reach the intestine 
 seems to have depended either on the trocar not having been intro- 
 duced sufficiently deep, or on its having been directed too far backwards. 
 The danger of haemorrhage, or of wounding the bladder, of which some 
 operators seem to have been apprehensive, is not much to be feared ; 
 for I find but one instance on record in which the bladder was acciden- 
 tally wounded, and not one of fatal or even of serious haemorrhage. — 
 Better success also appears to have been obtained in those cases in which 
 a sufficiently deep and free incision was made with a bistoury in the 
 direction of the rectum, than in those in which a trochar was at once 
 introduced. The suggestion of M. Amussat, that in these cases the 
 blind sac of the intestine should be drawn down, and its cut edges 
 attached by sutures to the margin of the external skin, in order to 
 prevent the infiltration of faecal matter between the end of the rectum 
 and the wound in the integuments, and to diminish the danger of the 
 aperture closing, is worth bearing in mind. It was adopted with 
 apparent advantage by Mr. Waters in a case of this kind recorded by 
 him in the Dublin Journal for May 1842, on which he operated with 
 success ; and I was a witness to its advantages in a little boy on whom 
 Mr. Shaw operated successfully a few years since at the Middlesex 
 Hospital. \ 
 
 Besides these cases in which the malformation was confined to the 
 rectum, I find mention of three others in which the rectum was entirely 
 absent, and the intestine terminated in a cul-de-sac as high up as the 
 colon. In two other cases in which the attempts to discover the 
 rectum failed, the life of the child was preserved by the establishment 
 of an artificial anus. M. Amussat has of late recommended that in 
 all cases in which fluctuation cannot be detected through the skin, an 
 artificial anus should at once be formed in the left lumbar region, as 
 being a safer proceeding than the attempt to open the bowel from the 
 perineum. When we consider, however, the loathsome nature of the 
 infirmity to which a person is condemned in whom an artificial anus 
 exists, we shall probably be disposed still to regard the operation for its 
 formation as a last recourse, to be employed only in the event of 
 our failing to discover the rectum by an operation instituted on the 
 perineum. 
 
 In some cases, although the anus is absent, yet the intestine is not 
 imperforate, but opens either into the vagina in the female, or into the 
 bladder or uretha in the male subject. In either case the malfor- 
 mation is due to a similar cause — namely an arrest of development, 
 whereby the separation between the bowel and the sinus uro-genitalis 
 has never been completed. The malformation in the female subject 
 is not attended with immediate danger to life, and fortunately it admits 
 of cure in the great majority of instances. I find, indeed, that in 
 
378 OPERATIONS FOR CURE OF IMPERFORATE RECTUM. 
 
 seven out of ten cases of this description, an operation was attempted, 
 and that in every instance it proved successful. In some cases the 
 mere establishment of the natural opening of the anus, with the 
 introduction of a tube in the rectum, was sufficient to effect a cure ; 
 but a more complex operation was in general necessary, the principle 
 of which consisted in dividing all the parts from the vagina into the 
 rectum ; though the details of the proceeding, and the means whereby 
 a re-union of the two canals was prevented, varied in different cases. 
 
 The result is very much more unfavourable when a communication 
 subsists between the intestine, and the bladder or urethra in the male; 
 for eight out of ten cases of the former kind, and the same number out 
 of nine of the latter kind, ended in the death of the infant. The con- 
 nection with the bladder is generally established by means of a very 
 slender canal which enters that viscus at or near its neck ; but in one 
 instance in which the rectum was wanting, the colon terminated by 
 opening with a wide aperture into the upper part of the bladder. A 
 slender duct is likewise the usual channel of communication between the 
 rectum and the urethra, and this duct generally enters the membranous 
 portion of the urethra just in front of the prostate. Cruveilhier, how- 
 ever, met with an instance in which the rectum opened under the glans 
 penis, and a somewhat similar case, in which there was a small aperture 
 through which meconium passed in front of the scrotum, came under 
 the notice of Mr. South, and is mentioned by him in his edition, of 
 Chelius's Surgery. 
 
 The existence of a communication between the rectum and the urethra, 
 or bladder, is generally indicated by the urine voided being tinged with 
 meconium ; but it seldom happens that the contents of the intestines are 
 discharged by the urethra with freedom sufficient to preserve the child 
 from the suffering and danger that attend upon an imperforate state of 
 the rectum. Even when life has been prolonged for some time, yet the 
 infant's death is merely deferred, for the symptoms of obstruction 
 appear, and at length prove fatal, after the fasces have acquired a firmer 
 consistence than they possessed during the first few months of existence. 
 These cases, too, do not appear to be favourable for an operation, since 
 the rectum usually terminates high up, and in five out of ten cases in 
 which it is stated that the attempt was made to puncture the intestine, 
 this attempt was unsuccessful. In Mr. South's case the rectum was 
 punctured by a trocar introduced an inch deep, and though much diffi- 
 culty was experienced in keeping the passage free, yet the child survived 
 and grew up to manhood. Of the other two successful cases, one of 
 which is recorded by Mr. Miller, 1 and the other by Mr. Fergusson, 2 both 
 were cured only with much trouble and difficulty. For a full account 
 of the difficulties these gentlemen had to contend with, and the means 
 by which they overcame them, I must refer you to the history of the 
 cases in the Edinburgh Medical Journal. 
 
 An insuperable obstacle to the action of the bowels may occur in 
 children, just as it sometimes does in older persons, either from the 
 
 1 Edinburgh Medical and Surgical Journal, No. 98, p. 61. 
 
 2 Ibid. vol. xxxvi. p. 363. 
 
INTUSSUSCEPTION OP THE INTESTINES. 379 
 
 strangulation of an external hernia, or from the invagination of a por- 
 tion of intestine. Although hernia is by no means an uncommon affec- 
 tion in early life, yet it is, I believe, a very rare occurrence for the 
 intestine to become strangulated. Such an accident, however, may take 
 place, even in very young infants, of which the case related by Mr. 
 Fergusson, in which he operated for strangulated inguinal hernia on an 
 infant only seventeen days old, may be mentioned as a striking illustra- 
 tion. Bearing in mind its possibility, therefore, you would examine any 
 infant or child, in whom abdominal pain, vomiting, and obstinate consti- 
 pation came on, just as carefully as you would an adult under similar 
 circumstances, lest it should be found out, when too late, that the symp- 
 toms had been due to some unsuspected external hernia. 
 
 The strangulation of an external rupture is probably a rarer accident 
 in early life, than the occurrence of intussusception of one or more 
 portions of the intestines. This condition, indeed, is frequently met 
 with in the bodies of children who have died of various diseases, and 
 wholly independent of any symptoms of disorder of the bowels during 
 the patient's life-time. Sometimes a single intussusception exists, but 
 oftener there are several ; ten, twelve, and even more, have occasionally 
 been observed in the same subject. They are most numerous in the 
 ileum, and though seldom involving more than three or four inches, have 
 been found to include more than double that extent of intestine. Their 
 great frequency, the absence of any symptom of them during life, and 
 of any indication of inflammation about the intestines after death, all 
 confirm the general opinion that they take place during the act of dying. 
 
 It happens, however, now and then, that an infant previously well is 
 suddenly, and^pparently causelessly, seized with abdominal pain, vomit- 
 ing, and obstinate constipation, attended with tenesmus, and the dis- 
 charge by the anus of small quantities of blood or bloody mucus, and 
 that death having taken place under an aggravation of these symptoms, 
 an intussusception of some portion of the intestine is discovered on 
 making a post-mortem examination. In other cases, after these symp- 
 toms have continued for some hours, and after medicine has seemed 
 altogether unable to relieve them, the pain and the vomiting cease, the 
 child has one or more faecal evacuations, and regains its usual health 
 without the recurrence of any accident calculated to renew our anxiety. 
 It has been suggested, and with great probability, that in cases of this 
 kind an invagination had existed, which nature had succeeded in 
 removing, and had thus preserved the infant's life. Be this as it may, 
 neither occurrence is at all frequent, for it has never happened to me 
 to meet with a case of fatal intussusception, and the cases recorded in 
 medical journals are not numerous ; whilst I have observed only one 
 instance in which the symptoms of intussusception having existed in a 
 marked degree, at length spontaneously ceased, and were followed by 
 the restoration of the infant to perfect health. 
 
 Children in whom intussusception takes place are generally infants 
 under a year, often under six months old. Their previous history does 
 not in general display any liability either to constipation or to diarrhoea ; 
 nor, in the greater number of instances, has the manifestation of the 
 symptoms followed the administration of any aperient medicine. Sud- 
 
380 ITS SYMPTOMS. 
 
 den and violent vomiting, followed by loud cries, and other indications 
 of uneasiness, which, ceasing for a time, return at uncertain intervals, 
 and are accompanied by violent straining, and efforts to empty the 
 bowels, are the earliest symptoms of the accident. At first some fasces 
 are voided during these efforts, but afterwards the matters discharged 
 from the bowels are either mucus tinged with blood, 1 or else pure blood, 
 and that sometimes in considerable quantities. If an enema be given, 
 the fluid thrown up is immediately returned, it appearing not properly 
 to enter the intestine ; while on one or two occasions, the existence of 
 an obstruction has been discovered on introducing the finger into the 
 rectum. The vomiting is almost immediately renewed whenever either 
 food or medicine is given, but faecal matters are seldom if ever discharged 
 by the mouth. The child has intervals of quiet, from which it is roused 
 by the returns of pain ; it is often thirsty, and though the sickness con- 
 tinues unabated, yet it seems eager for the breast, and sucks frequently. 
 The condition of the abdomen is variable ; and though a distinct tumor 
 is said to have been detected in some. cases, at a spot which was found 
 afterwards to correspond to the situation of the intussusception, yet it 
 has happened, in at least as large a number of instances, that the most 
 careful examination has failed to detect anything unnatural in its state, 
 and that it has continued uniformly soft up to the time of the patient's 
 death. The continuance of the intussusception leads to the exhaustion 
 of the infant's strength ; its pulse grows more and more feeble, its face 
 becomes anxious and sunken, and it falls in the intervals between its 
 attacks of pain into a quiet, half-comatose condition. In the majority 
 of cases convulsions come on a few hours before death, which always 
 takes place within a week, oftener in from forty-eight to seventy-two 
 hours. 
 
 A portion of the ileum, the caecum, and sometimes a portion of the 
 ascending colon, are the parts usually invaginated. In many, though 
 not in all instances, these parts display more or less evidence of inflam- 
 mation, which sometimes is found to have extended to the peritoneum. 
 The presence of inflammation, and its amount, are, as might be expected, 
 mainly dependent on the duration of the infant's life. 
 
 On comparing the history of several cases of this affection, there 
 appears to be such an uniformity in their symptoms as would, I should 
 imagine, render it in general tolerably easy to form a correct diagnosis. 
 I do not dwell upon the treatment, for that must be the same in the 
 infant as in the adult ; and my own experience does not enable me to 
 say any thing that could be of use in diminishing the difficulties by 
 which the subject is attended. I would only observe, that as the symp- 
 toms enable you in the infant earlier than in the adult to arrive at a 
 tolerably certain knowledge of the nature of the case, you will have 
 absolutely no excuse for persevering in the use of active purgatives, in 
 order to overcome the constipation. It was during the suspension of 
 the active remedies which had been previously employed, that the case 
 
 1 The credit of drawing attention to the value of the intestinal haemorrhage in these 
 cases as a sign of intussusception, belongs to Mr. Gorham, whose essay on this affection, 
 in No. 7 of the Guy's Hospital Reports, may be consulted with profit. 
 
DIARRHC3A. 381 
 
 which I saw took a favourable turn ; and I should regard the use of 
 powerful cathartics as less warrantable in the child than in the grown 
 person. The same objection could not attach to the use of large 
 enemata, nor to the inflation of the intestine with air, which has once 
 or twice been followed by the subsidence of the symptoms, and which I 
 had proposed employing in the case above referred to, had I not had the 
 pleasure of finding that nature had effected the patient's cure. 
 
 LECTURE XXXII. 
 
 Diarrhcea — its two forms, the simple and inflammatory — causes of the affection — in- 
 fluence of age — of process of dentition — of temperature, and season of the year. 
 
 Symptoms of simple diarrhoea — not usually a dangerous affection — occasional^ hazard 
 from great exhaustion that it produces — cessation of purging sometimes independent 
 of real amendment — danger of secondary diarrhoea. 
 
 Inflammatory diarrhoea — occasional want of correspondence between the symptoms and 
 morbid appearances — latter observed chiefly in large intestine — very similar to those 
 discovered in dysentery of the adult. 
 
 Symptoms of inflammatory diarrhoea — occasional disturbance of nervous system at the 
 outset — progress of the disease — its tendency to a chronic course. Life sometimes cut 
 short by intercurrent bronchitis — by head symptoms — by relapse after temporary 
 amendment. 
 
 In a systematic course of lectures like the present, subjects of very 
 various interest and importance come successively before us. We were 
 engaged yesterday in the study of some affections, which fortunately 
 are of very rare occurrence ; but to-day we pass to the examination of 
 one of the most common, and at the same time one of the most serious, 
 disorders of infancy and childhood. The importance of diarrhoea in 
 early life, indeed, is not to be estimated merely by the number of deaths 
 which our tables of mortality represent it to have occasioned ; for the 
 figures that they display would warrant our dismissing it with a 
 comparativly short notice. 1 But we shall come to a very different 
 conclusion, if we consider the frequency of the affection, and the slight 
 causes which often suffice to induce it ; the dangers to health which 
 result from its long continuance ; and the greatly increased hazard to 
 which its supervention in the course of some other disease exposes the 
 patient. 
 
 Under the common name of diarrhoea, many of the older writers on 
 the diseases of children have included all cases, without distinction, in 
 which there is an unnatural increase in the alvine discharges. On the 
 other hand, some among the moderns, rejecting the word diarrhcea 
 from their medical nomenclature, have treated only of certain inflam- 
 matory affections of the intestines of which they believe the flux to be 
 
 i According to the Fifth Report of the Registrar-General, the deaths in London from 
 diarrhcea, dysentery, and cholera, as compared with the total deaths from all ascertained 
 causes, were, in children under one year old, in the proportion of 3-9 per cent. ; between 
 one and three, 2-3 per cent. ; from three to five, *6 per cent. ; from five to ten, 1-1 per 
 cent. ; and from ten to fifteen, 1 • per cent. 
 
382 DIARRHCEA — ITS TWO FORMS — THE SIMPLE AND INFLAMMATORY. 
 
 symptomatic. Neither of these arrangements, however, is free from 
 objection, for while the former draws no adequate distinction between 
 cases in which the disorder of the functions of the bowels is the result 
 of some accidental and temporary cause, and others in which it is the 
 consequence of organic disease, the latter involves an attempt to 
 distinguish, on purely anatomical grounds, between affections which 
 present the same symptoms and require the same treatment. 
 
 In the present state of our knowledge, it will perhaps be the safer 
 way to attempt no. further subdivision than into the two grand classes 
 of simple diarrhoea, or catarrhal diarrhoea, as it has been termed by 
 some writers, and inflammatory diarrhoea or dysentery. Even in this 
 arrangement it must be confessed that there is something arbitrary, 
 for the two affections are closely allied to each other. In the child, as 
 in the adult, they often prevail at the same time, — they are to a 
 considerable degree dependent on the same causes, and are in a measure 
 amenable to the same remedies ; while the milder complaint not infre- 
 quently passes into the more severe. Before we proceed, therefore, to 
 the study of the spcial charactres of either affection, it may be well to 
 examineunto some of those conditions which are alike favourable to the 
 production of both. 
 
 The following table, deduced from 2129 cases of diarrhoea or 
 dysentery that came under my notice at the Children's Infirmary, 
 shows that the age of the child has much to do with the occurrence of 
 the affection: — 
 
 of diarrhoea in children at the 
 following ages : — 
 
 Under 6 months 
 
 Between 6 " and 12 months 
 
 12 
 
 18 " 
 
 2 years 
 
 3 
 
 5 
 10 
 
 18 '< 
 2 years 
 
 10 
 15 
 
 Were to all cases of diarrhoea 
 
 in children under 15 in 
 
 the proportion of 
 
 9*7 per cent. 
 15-7 
 20-9 
 13-9 
 121 
 11-2 
 11-5 
 
 4-7 
 
 Were to all diseases at 
 
 the same age in the 
 
 proportion of 
 
 16-1 percent. 
 
 20-0 
 
 26-8 
 
 25-4 
 
 150 
 
 9-3 
 
 7-9 
 
 7-7 
 
 You will observe that the period of the greatest prevalence of 
 diarrhoea coincides exactly with that time during which the process of 
 dentition is going on most actively, and that exactly half of all cases 
 of diarrhoea occurred in children between the ages of six months and 
 two years. So close, indeed, is the connection between teething and 
 diarrhoea, that a French physician, M. Bouchut, 1 found that only 26 
 out of 110 children entirely escaped its attack during the period of 
 their first dentition, while 46 suffered from it very severely. The older 
 writers on medicine, whose notice this fact did not escape, attributed 
 the disturbance of the bowels to a sort of sympathy between the 
 
 1 Manuel Pratique des Maladies des Nouveaux-Nes, 12mo. p. 19G. Paris, 1845. 
 
CAUSES PREDISPOSING TO DIARRHOEA. 383 
 
 intestinal canal and the gums, swollen and irritated by the approach of 
 the teeth to their surface. The frequent observation of cases in which an 
 attack of diarrhoea attends the irruption of each fresh tooth, and ceases 
 when it has cut through the gum, shows that such a hypothesis is not 
 altogether without foundation. But besides the influence of nervous 
 irritation in quickening for a time the peristaltic action of the bowels, 
 and thus inducing diarrhoea, it must be borne in mind that there exists 
 during the period of teething a more abiding cause, which strongly 
 predisposes to its occurrence. All parts of the digestive canal, and of 
 its dependencies, are now undergoing an active evolution to fit them 
 for the proper assimilation of the varied food on which the young being 
 will soon have to subsist. Just as the salivary glands are now deve- 
 loped, and pour out saliva in abundance, so the whole glandular system 
 of the intestines assumes a rapidity of growth, and an activity of func- 
 tion, which, under the influence of comparatively slight exciting causes, 
 may pass the just limits of health. In too many instances, causes fully 
 adequate to excite diarrhoea are abundantly supplied in the excessive 
 quantity or unsuitable quality of the food with which the infant is fur- 
 nished; for it is forgotten that its condition is one of transition, in 
 which something more than ordinary care is needed, while in accordance 
 with that mistaken humoral pathology so popular among the vulgar, 
 the profuse secretion from the irritated glands is regarded as the result 
 of a kind of safety-valve arrangement, whereby nature seeks to mode- 
 rate the constitutional excitement attendant upon teething. 
 
 But, besides those conditions seated within the organism which pre- 
 dispose to diarrhoea, and those occasions furnished from without by the 
 food with which the child is supplied, atmospheric influences constitute 
 a third, and a Very important class of causes, which at one time render 
 diarrhoea very frequent, and at another greatly check its prevalence. 
 
 On a comparison of the results of eight years' observation at the 
 Children's Infirmary, I find that 
 
 In the 3 months, Nov., Dec, and Jan., diarrhoea formed 7.9 per cent, of all cases of disease. 
 " Feb., March, and April, " 9.5 " " 
 
 " May, June, and July, " 15.3 «• " 
 
 " Aug., Sept., and Oct., * 28.0 " " 
 
 The above mentioned causes dispose alike to diarrhoea and dysentery ; 
 but among the dwellings of the poor in this metropolis, and especially 
 in that district of it where most of my observations have been made, 
 conditions abound which often stamp on the disease the characters of 
 the more serious malady. Before investigating them, however, we may 
 first study the symptoms of the milder affection, which, though much 
 the more frequent, yet, if uncomplicated, is seldom or never fatal. 
 
 When the attack comes on in perfectly healthy children, it often sets 
 in quite suddenly, with vomiting of the contents of the stomach, and 
 afterwards of mucus, which sometimes has a yellow or greenish colour. 
 The sickness does not in general continue, though exceptions are met 
 with in some of the more severe cases, in which the stomach remains 
 very irritable during the whole period that the affection lasts. In either 
 case, the vomiting is almost immediately succeeded by increased action 
 
384 SYMPTOMS OF SIMPLE DIARRH03A. 
 
 of the bowels, the matters discharged being at first the healthy faeces ; 
 but they soon assume a bright yellow colour, like that of the yolk of 
 egg, and are often intermixed with slime ; or in other cases they present 
 a frothy appearance. The bright yellow colour of the evacuations, 
 often, though by no means always, changes to green under exposure to 
 the air : while, if the diarrhoea should continue, the faeces present in 
 many instances a green colour when voided, similar to that which is 
 frequently produced by the administration of mercury. In other cases 
 the green and yellow colours appear intermixed in the evacuations, 
 while the presence in them of numerous white specks, the casein of the 
 undigested milk, shows that the function of the stomach is interfered 
 with by the same cause as produces the over-action of the bowels. The 
 source of the green colour of the evacuations has not yet been quite 
 satisfactorily determined. In some cases it probably depends on the 
 action of the acids of the alimentary canal upon the colouring matter 
 of the bile ; but Dr. Golding Bird's investigations have proved it not 
 to be always due to this cause, and have rendered it probable that, in 
 many instances, it results from the presence of altered blood in the 
 evacuations. As the child returns to health, the faeces become less 
 watery, and then resume their yellow colour; or stools of a natural 
 character alternate with others of a green colour and unhealthy aspect, 
 or in which a very large quantity of mucus is present. The action of the 
 bowels, too, becomes less frequent, and the child often regains its usual 
 health in four or five days, though sometimes a disposition to diarrhoea 
 is left behind, and the disorder is liable to be re-excited by very slight 
 causes. 
 
 In the majority of cases this over-action of the bowels is not attended 
 with much fever or constitutional disturbance, though, if it should come 
 on during teething, the general feverishness of the child is often some- 
 what aggravated. The appetite is, usually much impaired, while the 
 thirst is often considerably increased, and the child seems very desirous 
 of cold water. The tongue is moist, in general thinly covered with 
 mucus, through which the papillae appear of a brighter red than natural ; 
 but the tongue is neither very red, nor much coated. The abdomen is 
 soft, seldom either full or painful ; and the pain which attends the 
 diarrhoea is very variable — sometimes it is completely absent, the stools 
 being expelled without either effort or suffering ; while in other cases 
 pain comes on severely at intervals, and then ceases so soon as the 
 bowels have acted. Although there is seldom much tenesmus, yet a 
 slight degree of it attends upon simple diarrhoea in the child much 
 more frequently than in the adult. There is, as might be anticipated, 
 a loss of the natural look of health — the face grows pale, the eyes 
 appear sunken, and the child become fretful and languid, — while, if the 
 attack set in severely, a day or two sometimes suffices to reduce the 
 child to a state of extreme weakness and exhaustion ; and in young 
 infants, I have now and then observed all the symptoms of spurious 
 hydrocephalus make their appearance. 
 
 The diarrhoea that occurs in connection with the irritation occasioned 
 by teething is in general more gradual in its onset, and slower in its 
 progress, than that which depends on some more transient cause. It 
 
SOURCES OF DANGER IN ITS COURSE. 385 
 
 is likewise often associated with catarrhal symptoms ; and both the 
 catarrh and diarrhoea freequently continue, until the tooth, having 
 pierced the gum, the irritation of the mucous membranes subsides ; but 
 to be renewed when a fresh tooth approaches the surface. 
 • Although the dangers attendant on simple diarrhoea, especially when 
 it occurs in healthy children, are not considerable, yet the affection is 
 one which it is never wise to make light of. On more than one occa- 
 sion I have seen an infant reduced by it to a state of such extreme 
 exhaustion as seriously to endanger life. Diarrhoea, indeed, is the 
 exciting cause of the greater number of cases of that spurious hydro- 
 cephalus, 1 in which cerebral disturbance from debility simulates real 
 inflammatory disease of the brain. Under such circumstances, too, the 
 diarrhoea has not infrequently ceased for some time before the other 
 more alarming symptoms made their appearance. The cessation of 
 diarrhoea may be due, not so much to the quieting of irritation, as to 
 the exhaustion of the nervous energy which is essential to the per- 
 formance of their secretory function by the glands of the intestines, or 
 to the due maintenance of the peristaltic movements of the bowels. In 
 infants prematurely weaned, or improperly fed after being taken from 
 the breast, we often see this fact exemplified in the cessation some 
 twelve or twenty-four hours before death, of the diarrhoea, from which 
 they have been suffering for weeks together. Nor must we ever make 
 too sure that, because purging has ceased, therefore danger is over ; or 
 venture to relax our watchful care, until the continuance of amendment, 
 for twenty-four hours or more, shows that there is indeed no longer 
 anything to fear. 
 
 This, however, is not the only danger to which previously healthy 
 children are exposed by an attack of simple diarrhoea ; for if not quickly 
 checked, it sometimes assumes the more serious characters of dysentery, 
 and occasions severe and long-continued suffering. When diarrhoea 
 supervenes in children who are recovering from some disease, such as 
 measles, in which a tendency to relaxation of the bowels often marks 
 the period of convalescence, or who have been suffering from a pro- 
 tracted ailment, such as hooping-cough, it sometimes occasions the 
 patient's death, although it may leave behind in the intestinal canal no 
 traces of serious mischief. Still more frequently is this the case with 
 infants who have been brought up by hand, or who have thriven badly 
 at the breast. A troublesome purging, continuing for weeks together, 
 exhausts the strength of such infants, and at length occasions their 
 death ; but yet the intestinal canal in many instances presents no trace 
 of more serious mischief than an unusual degree of distinctness of the 
 follicles of the small intestines, and of the solitary glands of the colon 
 and rectum. 
 
 In proposing at the commencement of this lecture, to distinguish 
 between simple and inflammatory diarrhcea, I yet was forced to 
 acknowledge that the distinction was one rather of degree than of 
 kind ; or, perhaps it would be more correct to say, that our observation 
 has not hitherto been minute enough to enable us to draw the line of 
 
 1 See Lecture X. p. 111. 
 25 
 
386 INFLAMMATORY DIARRHOEA, OR DYSENTERY. 
 
 demarcation strictly between the two affections. Even MM. Hilliet 
 and Barthez, 1 whose opportunities have been so extensive, and whose 
 industry is so untiring, confess their inability to refer the symptoms 
 that attend upon the different varieties of diarrhoea to any distinct and 
 invariable anatomical lesions. They remark, that not merely are exceed- 
 ingly different appearances discovered after death in cases where the 
 same symptoms have been observed during life, but that likewise there is 
 often no proportion between the intensity of the two ; and that some- 
 times no morbid appearances are found, even where well-marked symp- 
 toms had existed. Usually, indeed, in cases where the morbid appear- 
 ances are slight, the symptoms during life have not been severe. Occa- 
 sionally, however, the reverse has occurred ; and the diarrhoea has been 
 intense, the pain considerable, and the abdomen tense and tympanitic. 
 MM. Rilliet and Barthez state, that out of 127 children who had died 
 of different diseases, 84 had presented the symptoms of inflammatory 
 diarrhoea, or entero-colitis, and the characteristic appearances of that 
 affection were manifest on an examination of their intestines after death ; 
 in 24, though no symptoms had existed during life, similar changes were 
 discovered; while in 19, the signs of disease were present during life, 
 but its morbid appearances were absent. It is true that these observa- 
 tions refer to children above two years of age, and to cases in which 
 diarrhoea had occurred as a secondary affection ; but my own observation 
 would lead me to believe that a similar statement might be made with 
 reference to younger children, and to cases of idiopathic diarrhoea. 
 
 These circumstances prevent our deducing from the results of anato- 
 mical investigation those practical conclusions which we should other- 
 wise be inclined to draw from them; but they do not warrant us in 
 altogether omitting to inquire what changes we shall be most likely 
 to meet with in cases of fatal diarrhoea. 
 
 These changes will be found chiefly, though not exclusively, in the 
 larger intestine; and though usually much less serious than those 
 which are observed in cases of fatal dysentery in the adult, they yet 
 present very similar characters. In those cases in which the structural 
 alterations have been least considerable, the attention is arrested less 
 by any great increase of vascularity in the intestine, than by the 
 remarkable distinctness of the orifices of the solitary glands which 
 appear like almost innumerable dark spots upon the surface of the 
 mucous membrane. In many cases, and especially in those in which 
 the diarrhoea was profuse at the time of the patient's death, not 
 merely are the openings of these follicles unusually distinct, but the 
 glands themselves are enlarged, and project like small millet-seeds, or 
 small pin's heads, beyond the level of the surrounding tissue. This 
 enlargement of the solitary glands is usually associated with increased 
 vascularity of the mucous membrane ; which does not however, assume 
 the characters of a general erythematous redness, but it is confined to 
 that part of the membrane which covers each gland, or which surrounds 
 its base. If the disease advance further, ulceration succeeds to this 
 inflammation of the glands. A small, circular, or slightly oval spot, 
 
 1 Op. cit. tome i. p. 509-12. 
 
MORBID APPEARANCES IN THE LARGE INTESTINE. 387 
 
 appears upon their summit and increases in size and depth, until it has 
 destroyed the glandular structure and the mucous membrane, and Has 
 produced a deep cup-like depression or ulceration, the base of which 
 is formed by the muscular coat of the intestine. On one occasion I 
 observed, in the midst of enlarged and ulcerated glands, some others 
 equally large, but on which the excavated ulcer had not yet formed ; 
 their summit presenting a small round or oval spot, of a yellowish 
 colour — most probably a minute slough not yet detached from the 
 surface. Besides that loss of substance which results from the 
 ulceration or sloughing of the glands themselves, a process of thinning 
 and destruction likewise affects other parts of the mucous membrane, 
 especially in those situations which correspond to the edges of the 
 intestinal rugae. In some parts the membrane appears to be merely 
 attenuated, while in others it seems to have entirely disappeared, 
 though the limits of its destruction are not marked by the same well- 
 defined edges as circumscribe the ulcers of the glands ; nor is the loss 
 of substance so deep. On the inner surface of an intestine thus 
 affected may be seen a number of narrow, white, lines, enclosing 
 between them islets of mucous membrane ; and often having such an 
 arrangement as to give to those portions of membrane the form of 
 irregular parallelograms. This superficial destruction of the mucous 
 coat of the intestine is often much more complete in the rectum, and 
 in the sigmoid flexure of the colon, than elsewhere ; and when this 
 is the case the surface of the bowel presents an uniformly rcugh 
 appearance. It is also in the lower part of the large intestine that 
 the ulcerative process is most frequent and most extensive ; and if 
 care be not taken to examine the last few inches of the rectum, we 
 may come to the mistaken conclusion that ulceration is altogether 
 absent, in cases where more careful investigation would have easily 
 convinced us of its existence. On one occasion, I found the disease 
 in the lower part of the large intestine to be so far advanced that 
 the interior of the sigmoid flexure of the colon and of the rectum 
 presented an irregular tuberculated surface, of an ash-grey colour, 
 which appeared eaten into holes by a number of small, circular pits, 
 or ulcers, with sharply cut edges. Besides these changes in the 
 interior of the large intestine, a thickening of its submucous coat is 
 almost always observable, whenever the diarrhoea has continued for 
 any considerable length of time. It is in the rectum and sigmoid 
 flexure of the colon that this thickening is most perceptible ; and in 
 this situation a gelatinous-looking matter is sometimes deposited in 
 such abundance beneath the mucous membrane as to prevent the 
 intestine from becoming collapsed when it is divided. 
 
 But it is not merely in the morbid appearances presented by the 
 large intestines, but also in the subsidiary changes observed in other 
 parts of the intestinal canal, that the close relation is manifested 
 between the diarrhoea of the infant and the dysentery in the adult. 
 The changes in the small intestine are almost always confined to the 
 lower part of the ileum, and become more striking the nearer we 
 approach to the ileo-ccecal valve. They consist in a more or less 
 intense redness of the mucous membrane, which sometimes appears 
 
388 MORBID APPEARANCES IN INFANTILE DYSENTERY. 
 
 thickened, and presents something of a velvety appearance, studded 
 over with numerous dark spots — the orifices of the solitary glands. 
 In other instances, the surface of the reddened mucous membrane 
 appears slightly roughened, as if sprinkled over with fine sand ; while 
 near to the caecum this roughening is often greater, the membrane 
 appearing elevated into rough, orange-coloured prominences, separated 
 by narrow lines of a dead white colour, which marks the situations 
 where, by the destruction of the mucous membrane, the subjacent 
 tissue is exposed. Both of these changes are well represented in this 
 drawing of the intestine of an infant six months old, who died of a 
 relapse of diarrhoea, from which she had seemed to be in course of reco- 
 very. Besides this affection of the mucous membrane of the ileum, 
 Peyer's glands are not unfrequently very well marked in the lower part 
 of the small intestine ; and their surface presents a punctuated appear- 
 rance, due to the unusual distinctness of the orifices. of the sacculi 
 whieh compose each gland. Occasionally a few of them are congested 
 and swollen ; and once or twice I have observed one or two spots of 
 ulceration on that cluster of Peyer's glands which is situated close to 
 the ileo-coecal valve ; but in every instance, the affection of the small 
 intestine has appeared to be secondary, and quite subsidiary, to the 
 disease in the colon. Lastly, I may observe, that the mesenteric 
 glands, even in the vicinity of the diseased large intestine, deviate but 
 little from a state of health, being at most a little larger, and of a 
 somewhat redder colour, than usual — a condition which contrasts 
 remarkably with their serious affection in cases of typhoid fever in 
 childhood, while yet the intestinal lesion is often much less considerable. 
 The symptoms of inflammatory diarrhwa sometimes become deve- 
 loped very gradually out of what had seemed at first to be nothing 
 more than a simple looseness of the bowels ; but, in the majority of 
 cases, they present, almost from the outset, a graver character than 
 those of simple diarrhoea, and are associated with more serious consti- 
 tutional disturbance. When the attack comes on suddenly, it often 
 commences with vomiting ; and though in many instances the sickness 
 does not recur frequently, yet sometimes the irritability of the stomach 
 continues, for twenty-four or forty-eight hours, to be so extreme, that 
 every drop of fluid taken is immediately rejected ; and that frequent 
 efforts at vomiting are made even when the stomach is empty. Violent 
 relaxation of the bowels occurs almost simultaneously with the vomit- 
 ing ; and the child sometimes has as many as twenty or thirty evacu- 
 ations, or even more, in the course of twenty-four hours. The motions 
 are at first faecal ; but they soon lose their natural character, and 
 become intermixed with slime, often streaked with blood. At first 
 they are abundant, and are often expelled with violence ; but before 
 long they become scanty, though sometimes they still gush out without 
 much effort on the part of the child. The character of the evacuations 
 again changes : in the severest cases they not only lose their fgecal 
 appearance, but become like dirty-green water, with which neither 
 blood nor intestinal mucus is intermingled. Usually, however, when 
 the first violence of the purging has a little abated, although some 
 serious stools may still be voided, yet the evacuations consist chiefly of 
 
SYMPTOMS OP THE AFFECTION. 389 
 
 intestinal mucus, intermixed with a little feces, and more or less 
 streaked with blood. These scanty mucous stools are generally expelled 
 with much straining and difficulty ; a few drops of blood sometimes 
 follow them ; and once or twice, at an early period of the attack, I 
 have known an infant void as much as a table-spoonful of pure blood. 
 
 The constitutional symptoms which accompany an attack of this 
 description are usually very severe : the skin becomes dry and very 
 hot, though unequally so ; the pulse is quickened, often very much so ; 
 the head is heavy ; the child fretful and irritable if disturbed, though 
 otherwise it lies drowsily in its nurse's lap, with its eyes half open, and 
 scarcely closing the lids even when they are touched with the finger. 
 Now and then, too, the disturbance of the nervous system at the com- 
 mencement of one of these attacks of diarrhoea is so considerable, that 
 a state of excitement alternates with one of stupor, that convulsions 
 seem impending, and that there are distinct carpo-pedal contractions, 
 or startings of the tendons of the wrist or fore-arm. The abdomen is 
 usually full, and rather tympanitic, but seldom very tender ; nor does 
 the child seem to suffer much pain, though sometimes a degree of tor- 
 mina appears to precede each action of the bowels. The tongue at 
 first is moist, coated slightly with mucous fur ; its papillae are often of 
 a bright red, as are also its tip and edges ; while, if the disease con- 
 tinue, the redness becomes more general, and the tongue grows dry, 
 though it is not often much coated. The thirst is generally intense, 
 the child craving for cold water, and crying out for more the moment 
 that the cup is taken from its lips ; and the thirst is quite as urgent 
 even in those cases where the stomach is so irritable that it immedi- 
 ately rejects whatever is swallowed. 
 
 There is scarcely any affection in which the loss of health and of 
 flesh is so rapid as in the severer forms of diarrhoea ; and a period of 
 twenty-four hours will in some cases suffice to reduce a previously 
 healthy infant to a condition in which its eyes are sunken, its features 
 sharp, its limbs shrunken, and its strength so impaired, that, though I 
 have never seen an instance of it myself, I can yet well understand 
 that death may sometimes take place in the course of a few hours from 
 the commencement of the attack. This rapidly fatal termination is 
 far from unusual in some of the Southern States of America, where 
 diarrhoea, under the various names of Cholera Infantum, the Summer 
 Complaint, or Gastro-follicular Enteritis, annually destroys many thou- 
 sands of children. 
 
 A rapidly fatal termination, however, is not that which is in general 
 observed in this country ; but, how urgent soever the symptoms may 
 have been, there is in most instances a spontaneous subsidence of them 
 in the course of forty-eight hours at furthest ; or a measure of abate- 
 ment of their severity follows the use of remedies. The sickness 
 entirely ceases ; the bowels act much less frequently, probably not 
 above ten or twelve times in the twenty-four hours ; but they act irre- 
 gularly, five or six evacuations being passed within an hour or two, and 
 then no action of the bowels occurring for four or five hours together. 
 The appearance of the motions likewise varies, and apparently without 
 cause, being mucous, green, watery, intermingled with blood, all in 
 
390 OF ITS CHRONIC STAGE. 
 
 the course of a single clay, and with no accompanying modification in, 
 the infant's symptoms. The tenesmus in general continues ; and in 
 weakly children, or in those who have previously suffered from diarrhoea, 
 prolapsus ani not infrequently occurs ; though this accident happens 
 less commonly in infants than in children of two or three years old. 
 
 There is much uncertainty in the further course of the affection, and 
 in the way in which it tends in one instance towards recovery, and in 
 another to a fatal issue. Many fluctuations generally interrupt the 
 progress of those cases which terminate favourably ; while, when it 
 eventually proves fatal, the affection often assumes a chronic character, 
 and does not end in death until after the lapse of several weeks. 
 
 In such chronic cases, the patient's condition, through progressively 
 tending from bad to worse, presents but little difference from day to 
 day. The loss of flesh goes on until the child is reduced to a degree of 
 emaciation as great as is ever witnessed even in the most advanced 
 stage of mesenteric disease or pulmonary consumption, though its 
 extreme attenuation is sometimes concealed by the anasarcous swelling 
 of its face and hands. The appetite fails completely, or becomes very 
 capricious ; and the child refuses to-day the food which yesterday it 
 took with eagerness. In course of time, the desire for drink is lost 
 too ; for though there may be no return of vomiting, yet nausea is 
 excited by everything which the child takes. The tongue grows red 
 and dry, coated with brown or yellow fur towards its root, or aphthae 
 appears upon its tip and edges, or the whole inside of the mouth 
 becomes coated with muguet. The diarrhoea continues much as it was 
 before, except that the action of the bowels is now almost immediately 
 excited by either food or drink. The evacuations are usually of a 
 green colour, ? often particoloured, and though generally watery, yet 
 they vary both in their consistence and in their other characters, with- 
 out apparent cause. Slime, blood, and pus, are sometimes present in 
 the stools, at other times absent ; and it does not often happen that 
 purulent matter is present in large quantity in the evacuations, or for 
 many days together, though I have observed this in some cases that 
 recovered, as well as in others which had a fatal termination. The 
 body is no longer able to maintain its proper temperature, but the 
 extremities are almost invariably cold ; small indolent abscesses occa- 
 sionally form about the buttocks ; and on one occasion I saw an erup- 
 tion of large vesicles, like those of pemphigus, make their appearance 
 on the hands, arms, and neck of an infant eight months old, about ten 
 days before her death. In the condition of weakness to which the 
 child is now reduced, a slight aggravation of the diarrhoea, or a return 
 of vomiting, suffices to put out its feeble life ; or, even should no such 
 accident occur, death takes place from pure exhaustion. 
 
 But various causes may abridge this protracted course of the affec- 
 tion ; and hence it results that death not infrequently takes place before 
 the mischief in the intestines has become so serious as it is usually 
 found to be in cases of fatal dysentery in the adult. Bronchitis is one 
 of the most frequent of these intercurrent maladies, while the symp- 
 toms that attend it are often so slight, that danger to the patient from 
 this source is very frequently overlooked. It happens, indeed, in many 
 
VARIOUS CAUSES OF DEATH. 391 
 
 cases, that almost from the outset of an attack of diarrhoea, the mucous 
 membrane of the respiratory organs sympathises with the irritation of 
 the intestinal canal, and from the very commencement of its illness the 
 child has slight cough, the continuance or even the aggravation of 
 which attracts but little notice. Unless, therefore, auscultation is 
 carefully practised, and often repeated, there is little in such cases to 
 call attention to the state of the respiratory organs until the accu- 
 mulated secretions in the bronchi have already seriously interfered 
 with the entrance of air into the pulmonary vesicles, and have 
 occasioned the collapse of a considerable extent of the substance of 
 the lungs. 
 
 Life is sometimes cut short by other causes in the course of infantile 
 diarrhoea. The disturbance of the nervous system that attends the 
 attack issues now and then in convulsions, and these convulsions end in 
 a state of stupor which terminates in death — an occurrence fortunately 
 rare, but of which instances may be observed during those hot seasons 
 of the year when bowel complaints are usually epidemic. Less rare 
 than a fatal termination of this kind is the infant's death under symp- 
 toms of a gradually deepening coma, which may have supervened on 
 the suppression of the diarrhoea, or on its great mitigation. Many of 
 the symptoms by which this condition is accompanied are such as to 
 indicate the exhaustion of the infant's powers ; but it happens in many 
 instances that there is an occasional flush of the face, or a temporary 
 heat of skin, or some other passing sign of an attempt at reaction, just 
 sufficient to mislead the practitioner, and to betray him into a vacil- 
 lating line of practice that proves fatal to his patient. 
 
 Lastly, the^e are cases, and those by no means few, in which the 
 onset of a severe attack of diarrhoea has been promptly met and judi- 
 ciously treated, in which the symptoms have yielded, and the child has 
 appeared convalescent. Some slight error in diet, however, a variation 
 in the temperature, or the too early withdrawal of medicine, is followed 
 by a return of the vomiting and purging ; or the relapse may take place 
 without our being able to assign for it any adequate cause. The active 
 symptoms which attended the original seizure are absent now; the 
 evacuations, though very watery, generally contain neither blood nor 
 slime; but medicine is often wholly unable to check them. The vital 
 powers fail speedily, and death often takes place in three or four days 
 from this exacerbation of the symptoms ; while an examination of the 
 body after death shows no evidence of recent mischief in the intestines, 
 but only the traces left by the first attack, and these manifestly in 
 course of disappearance. 
 
 We must postpone until the next lecture the very important subject 
 of the treatment appropriate to all the varieties of diarrhoea and its 
 different complications. 
 
392 DIARaH(EA CONTINUED. 
 
 LECTURE XXXIII. 
 
 Diaerh(ea, continued. — Close resemblance between inflammatory diarrhoea and tbe 
 dysentery of the adult — local conditions favouring its occurrence, as damp, want of 
 drainage, &c. 
 
 Treatment of simple diarrhoea — of diarrhoea in connection with teething — use of astrin- 
 gents. 
 
 Treatment of inflammatory diarrhoea — in its acute stage — treatment of certain symptoms 
 — as the irritability of the stomach, the cerebral symptoms — indications for the use 
 of stimulants — of astringents — management of the chronic stage — use of enemata — 
 diet in this stage. 
 
 Management of intertrigo excited by diarrhoea — and of prolapsus ani. 
 
 Those of you who were present at yesterday's lecture could hardly 
 fail to be struck by the close resemblance which exists between the 
 severer forms of infantile diarrhoea and the true dysentery of the adult. 
 In both cases similar morbid appearances are discovered, occupying the 
 same parts of the intestinal canal ; in both the symptoms during life 
 are almost identical, their resemblance being disturbed mainly by the 
 greater excitability of the nervous system in early life; whence it 
 arises that convulsions and other signs of serious cerebral disturbance 
 are often observed in the infant affected with diarrhoea, while they are 
 but seldom noticed in the adult suffering even from severe dysentery. 
 But this difference is one of degree rather than of kind, since the 
 morbid poison, whateverbe its nature, to which dvsentery is due in the 
 adult, produces under favourable circumstances disorders of the nervous 
 system analogous to those which we may have frequent opportunities 
 of observing in the infant. If dysentery, for instance, break out epi- 
 demically in a large prison, the inmates of which have had the excita- 
 bility of their nervous system increased by the debilitating influence of 
 long confinement, tremors, cramps, spasms, convulsions or stupor, may 
 attend upon the affection, and death may take place under symptoms 
 that betoken disorder of the brain or spinal cord. You will find ample 
 proof of this in Dr. Latham's account of the Disease at the Peniten- 
 tiary in the year 1823 ; and in Dr. Baly's Gulstonian Lectures on 
 Dysentery, which are based on observations at the same establishment. 
 Among the striking examples of this complication related by those 
 writers, some are recorded in which, though death took place, neither 
 the brain nor the spinal cord presented any sign of disease. Just of 
 the same kind, and equally independent of any appreciable change of 
 structure, are the nervous symptoms that often come on in the course 
 of infantile diarrhoea. I shall have presently to refer to the important 
 practical bearings of this fact, when we come to consider the treatment 
 of diarrhoea and its complications. 
 
 Before we pass to that subject, however, we must inquire whether 
 there are any special conditions that tend to engender the severer forms 
 of bowel complaint in childhood, over and above those general causes of 
 diarrhoea to which your attention was directed in the last lecture. I 
 
INFANTILE DYSENTERY INDEPENDENT OF LOCAL CAUSES. 393 
 
 believe that such special conditions do exist — that they abound in the 
 locality where most of my observations have been made — and that they 
 are precisely the same as prevailed far more extensively in this metro- 
 polis at the time that the bloody flux annually carried off large numbers 
 of its inhabitants. 
 
 In almost every country and climate, and under circumstances in 
 many respects very different, dysentery has been known to occur, but 
 in each instance it has been possible to connect the prevalence of the 
 disease with some source or other of malaria. Although, while I was 
 physician to the Finsbury Dispensary, a large amount of disease among 
 children as well as among adults came under my notice, yet my acquaint- 
 ance with those severer forms of infantile diarrhoea which approach to 
 the characters of dysentery, and which give rise to similar lesions, has 
 been derived almost exclusively from observations made in Lambeth and 
 the adjoining parishes. The children in both districts are alike sub- 
 jected to the evils of improper and insufficient food, and of close and 
 ill-ventilated dwellings; but in the latter there are superadded certain 
 very important influences of a local character. A considerable portion 
 of the district on the Surrey side of the Thames lies below high-water 
 mark ; and the kitchens and cellars of some of the houses near the river 
 become flooded at unusually high tides. The sewerage throughout is 
 very defective ; in many parts it is effected entirely by open drains, 
 while in some places there are mere cesspools, which have no communi- 
 cation with any drain whatever. Cases of infantile dysentery do not 
 occur with the same frequency in all parts of this district, but they are 
 most numerous and most severe wherever these noxious influences are 
 most abundant. Proof, too, of the intimate connection that subsists 
 between these conditions and the occurrence of infantile dysentery is 
 afforded by cases such as the following : — 
 
 With the return of every spring, a poor woman brought to me her 
 younger children suffering from diarrhoea, which they seemed to outgrow 
 when about three years old. This diarrhoea was always obstinate, very 
 apt to assume a dysenteric character, and was almost sure to return if 
 medicines were discontinued before the return of the cold season. On 
 one occasion, her infant, aged about fifteen months, who had had diar- 
 rhoea severely in the previous autumn, suffered a return of it with the 
 returning warmth of spring. The infant's symptoms were very alarming, 
 and the child had frequent convulsions; on which account I visited her 
 at home. I then found that the infant spent the whole of the day in a 
 back room on the ground floor which looked out upon a little yard, at 
 the bottom of which there was a large cesspool, whence there came a 
 most offensive smell during the whole of the warm weather. I urged 
 the mother to remove her infant from this room, and to occupy instead 
 a front room on the first floor in the same house, which looked upon the 
 street. When this had been done, the convulsions ceased almost at 
 once, and the diarrhoea was not long before it disappeared. I have 
 attended this woman's children since for other affections, but they have 
 now for nearly eighteen months occupied the more wholesome room, 
 and during this time I have heard nothing of their suffering from diar- 
 rhoea. I may just add, that under similar circumstances, I have met 
 
894 MALARIA A CAUSE OF DYSENTERY. 
 
 with a few instances of the sudden and apparently causeless occurrence 
 of convulsions, in two or three children of the same family. It is not 
 long since a little girl, five years old, was seized with convulsions, which 
 recurred frequently for between two and three days, leaving her in a 
 state of stupor. By degrees the symptoms of very severe typhoid fever 
 developed themselves out of this disturbance of the nervous system. 
 The disease during the whole of its course presented an adynamic cha- 
 racter, and required the free employment of wine and stimulants. 
 While she was convalescent, the health of her elder sister, who was 
 eight years old, began to fail, and before long she experienced convul- 
 sive attacks of an anomalous character not unlike fits of hysteria, which 
 returned at intervals of two or three days for several weeks together, 
 three or four fits sometimes occurring in the course of a single day. 
 These seizures were accompanied with much debility, and they disap- 
 peared by degrees under the use of preparations of iron, and a generally 
 tonic plan of treatment. 
 
 In studying the treatment of diarrhoea and dysentery in early life, we 
 will pass successively in review the different forms of the disease ; begin- 
 ning with the simplest and least dangerous, and passing to the more 
 formidable varieties of the affection, and to those complications which 
 add so greatly to its hazard. 
 
 In a large proportion of cases of simple infantile diarrhoea, the 
 ailment tends to subside in a day or two, and finally to cease of its own 
 accord. While, -therefore, in consideration of the tender years of the 
 patient, no such case can be regarded as altogether trivial, yet in many 
 instances but little medical interference is needed. Great care, how- 
 ever is required in this, as well as in the more serious forms of diarrhoea, 
 to prevent the affection being aggravated by any error of diet, or even 
 by the infant being allowed to partake too freely of food otherwise suit- 
 able for it. If, therefore, the sickness with which the attack sets in 
 have not altogether subsided, the child should be taken completely from 
 the breast for a few hours, and should have nothing more than a few 
 spoonfuls of water or barley-water, till the irritability of the stomach 
 has abated. If the disposition to vomit have completely ceased, it will 
 yet be right to put the infant less frequently to the breast ; while it is 
 supplied, if thirsty, with water, or barley-water, in small quantities at a 
 time. In children already weaned, a similar plan must be carried out ; 
 solid food being for a time withdrawn, and thin arrow-root, or barley- 
 water and milk, in equal parts, being substituted for it. If the attack 
 be clearly traceable to some improper article of food, a dose of castor- 
 oil will sometimes get rid of the irritant cause and of the diarrhoea 
 together. Unless this be the case, however, it is better not to give the 
 aperient, since its action, under these circumstances, is somewhat uncer- 
 tain ; and instead of relieving, it may aggravate the diarrhoea. Provided 
 there be neither much pain nor much tenesmus, and the evacuations, 
 though watery, are faecal, and contain little mucus and no blood, very 
 small doses of the sulphate of magnesia and tincture of rhubarb have 
 seemed to me more useful than any other remedy j 1 and I seldom fail 
 
 1 See Formula, No. 26, p. 3G4. 
 
TREATMENT OF SIMPLE DIARRHOEA. 395 
 
 to observe from it a speedy diminution in the frequency of the action 
 of the bowels, and a return of the natural character of the evacuations. 
 
 In the diarrhoea that comes on in connection with teething ', it has 
 seemed to be better to pursue a somewhat different plan. It is usually 
 attended by a greater amount of constitutional disturbance than is 
 observed in the diarrhoea of younger infants, and by some degree of 
 febrile excitement. There is likewise, in many instances, a considerable 
 disposition to catarrhal affection of the respiratory mucous membrane, 
 which needs to be carefully watched, lest by its increase it should 
 become a source of serious danger to the child. The diarrhoea in the 
 majority of these cases comes on gradually, and its subsidence takes 
 place gradually too. Now and then the gum may appear at one spot 
 so tense and swollen, as to induce us to scarify it ; and if the tooth be 
 very near the surface, this proceeding may sometimes greatly diminish 
 the diarrhoea, by relieving the irritation which excited it. Any such 
 marked benefit, however, is quite an exceptionable occurrence ; and 
 unless the state of the gums be such as of itself to indicate the pro- 
 priety of scarifying them, it would be a cruel and useless piece of 
 empiricism to subject the child to the distress of the operation. Instead 
 of the saline and rhubarb mixture w T hich I have just mentioned, I usually 
 employ in these cases small doses of ipecacuanha in combination with 
 an alkali ; and think that I have found great benefit from this plan. 
 Three or four drops of liquor potassas, and the same quantity of vinum 
 ipecacuanha, mixed with mucilage, 1 and given in a little milk about 
 every four hours, is a suitable dose for an infant a twelvemonth old. 
 At the same time the child should be placed in a tepid bath every night ; 
 and a powder\of one grain of Dover's powder, and one of mercury with 
 chalk, given to it afterwards, will often be found to procure for the little 
 patient, previously restless and fretful, some hours of quiet repose. If 
 the child should appear much exhausted, a slight stimulant, such as four 
 or five drops of the spirit of nitrous ether, may be advantageously com- 
 bined with each dose of the mixture ; and in all cases of simple diarrhoea 
 it behoves us to watch most carefully against the powers becoming too 
 much depressed, either by the profuseness of the purging or by its con- 
 tinuance. 
 
 Supposing in any case that a considerable degree of looseness of the 
 bowels should continue after the lapse of two or three days, astringents 
 must be resorted to ; and I know of none better than the extract of 
 ogwood, in combination with tincture of catechu 2 . The logwood 
 
 (No. 27.) 
 2 R Extr. Hsematoxyli, gj. 
 Tinct. Catechu, gij. 
 Syrupi, gj. 
 
 Aquae Carui. gix. M. gj. ter die. 
 For a child a year old. 
 
 moreover, is something besides a mere astringent ; it is a very valuable 
 tonic in all cases where gastro-intestinal disorder has existed ; and it is 
 one which children take readily. It is, however, not very popular in 
 the nursery, because it imparts to the evacuations a deep pink colour, 
 1 See Formula No. 21, p. 843. 
 
396 OF INFLAMMATORY DIARRHOEA. 
 
 "which leaves an indelible stain upon the napkins: a circumstance which 
 it is as well to mention when you prescribe the medicine. The mercury 
 and chalk and Dover's powder may be still continued at bed-time, if 
 the evacuations, though less frequent, be still slimy and unhealthy. If 
 either the evacuations or the infant's breath have a sour smell, three 
 grains of the sesquicarbonate of soda may be added to each dose of the 
 mixture ; or, if the child be not wholly fed at the breast, a drachm of 
 prepared chalk may be stirred up with each pint of milk given to it ; 
 and after the powder has been allowed to settle, enough will still remain 
 suspended in the fluid to counteract any slight acidity in the alimentary 
 canal. If, after the bowels have become quite regular, some tonic should 
 still be required, the extract of bark, with small doses of the tincture, 1 
 will be onerof the. best that can be given. You will observe that all 
 the remedies mentioned occupy but a very small compass, — a point the 
 importance of which is never to be forgotten in prescribing for children. 
 
 But there are cases which wear a much more serious aspect than those 
 the treatment of which we have hitherto considered. Even in true 
 inflammatory diarrhma, however, depletion is but seldom needed ; for 
 either the abdominal tenderness is inconsiderable, or, if the attack set 
 in with great severity, it will be generally found to have occasioned so 
 much depression as to contra-indicate the abstraction of blood. Still, 
 in cases of recent date, if the abdominal tenderness be considerable, and 
 if it be associated with much heat of skin and febrile disturbance, a few 
 leeches may be applied in either iliac region. The child should be care- 
 fully watched for some hours afterwards, in order to prevent any exces- 
 sive loss of blood ; since considerable haemorrhage not unfrequently 
 follows the application of leeches to the abdomen, and it is not always 
 very easily arrested. On this account, I think you may find it the 
 better plan to apply the leeches to the margin of the anus, in which 
 situation they will relieve the bowels at least as much, while the bleed- 
 ing from them will be completely under your control. In the majority 
 of instances the pain and tenderness of the abdomen are much relieved 
 by the application of a large hot bran poultice; the frequent renewal of 
 which often affords great comfort to the child. 
 
 If the irritability of the stomach be not so great as to prevent its 
 administration, no medicine is of such general application, or of such 
 essential service, in these cases, as a mixture containing a small quantity 
 of castor oil diffused in mucilage, with the addition of a few drops of 
 tincture of opium ; which I was led to use in the inflammatory diarrhcea 
 of children from observing the great benefit which followed its employ- 
 ment by my friend Dr. Baly, in the treatment of dysentery among the 
 prisoners in Milbank Penitentiary. 3 
 
 (No. 28.) 
 2 R 01. Bicini, 3J. 
 Pulv. Acacise, £ss. 
 Sacchari, albi, %ss. 
 Tinct. Opii, TT^iv. 
 Aquae Flor. Aurant. gvij. M. 3J. 4tis horis. 
 
 For a child a year old. 
 1 See Formula No. 3, p. 45. 
 
TREATMENT OF THE NERVOUS SYMPTOMS. 397 
 
 Although this medicine may relieve all the symptoms considerably, 
 and although the general state of the child may be much improved, yet 
 it sometimes happens that a considerable degree both of tenesmus and 
 of purging continue. These symptoms will now be more effectually 
 relieved by an opiate enema than by any other means. Three minims 
 of laudanum will form, an enema of sufficient strength for an infant a 
 year old ; and this should be given suspended in half an ounce of muci- 
 lage, since a more bulky injection is almost sure to be immediately 
 expelled. Supposing the symptoms not to yield to these means, or that 
 the case presented from the first a great degree of severity, small doses 
 of Hyd. c. Creta, and Dover's powder may be given every four hours, 
 in addition to the castor oil mixture; which, however, should now be 
 given without the laudanum. 
 
 In some cases the irritability of the stomach is so great, that almost 
 every thing taken is speedily rejected; and when this condition is 
 present, none of the medicines already mentioned can be borne. Under 
 these circumstances a small mustard poultice should at once be applied 
 to the epigastrium, the child should be taken from the breast, a tea- 
 spoonful of cold water, or cold barley-water, should be given at inter- 
 vals, and a powder of a third of a grain of calomel, and a twelfth of a 
 grain of opium, should be laid upon its tongue every three hours. The 
 sickness will generally subside in four or five hours, though the stomach 
 often remains too irritable to bear any change in the remedies, and the 
 greatest caution will be needed in restoring the infant to the breast. 
 It may be necessary, indeed, to confine the child for twenty-four or 
 thirty-six hours to cold barley-water, cold water thickened with isinglass, 
 the white decoction of Sydenham, or equal parts of cold milk and water ; 
 and when the \mild has been seen early in the disease, I have never 
 observed any evil to follow the perseverance for this short period in a 
 rigorous diet. 
 
 The tepid bath employed twice a day, or even more frequently, will 
 be found of great service in soothing that general irritability of the 
 nervous system which often continues through the whole course of the 
 affection, and which sometimes issues in convulsive seizures, or in other 
 symptoms that are occasionally mistaken for the indications of real cere- 
 bral disease. It cannot be necessary to reiterate here the often- 
 repeated caution against regarding the symptoms of disturbance of the 
 nervous system as being always the signs of active cerebral disorder, 
 calling for depletion to relieve the congestion of the vessels of the brain, 
 and for antiphlogistic measures to moderate the excited state of the 
 circulation. At the very commencement of this course of lectures 1 I 
 endeavoured to set before you the various circumstances under which 
 convulsions came on in early life ; and some days ago 2 I tried to deli- 
 neate the characteristic features of spurious hydrocephalus. On that 
 occasion I related the history of two children, both of whom had been 
 attacked by severe diarrhoea. In one case, the child passed every few 
 minutes from a state of listless drowsiness to a condition of extreme 
 restlessness and alarm ; the tendons of the forearm were in a state of 
 
 1 Lecture II. p. 31. , 2 Lecture X. p. 111. 
 
398 USE OF STIMULANTS. 
 
 subsultus, and general convulsions seemed impending. In the other 
 case, the irritability of the nervous system was rapidly subsiding under 
 the general exhaustion of the vital powers, and probably in a few hours 
 more the infant would have sunk into a profound coma, from which no 
 means would have been adequate to rouse it. The tepid bath and an 
 opiate enema in the first-mentioned case, and the free employment of 
 stimulants in combination with small doses of Dover's powder in the 
 second, speedily averted dangers that had seemed so threatening. I 
 need not, however, tread again over all the ground w r e have already 
 passed, but will content myself with repeating the remark I then made, 
 — that if, in cases of this kind, you fall into the error of regarding the 
 cerebral symptoms as the signs of active disease, and withhold the 
 Dover's powder or the opiate enema, that might have checked the diar- 
 rhoea and soothed the irritability, while you apply cold lotions to the 
 head, and give the child nothing more nutritious than barley-water in 
 small quantities, because the irritability of the stomach, which results 
 from weakness, seems to you to be the indication of disease of the brain, 
 the restlessness will before long alternate with coma, and the child will 
 die either comatose or in convulsions. 
 
 As to the time when stimulants are to be given, or the quantity in 
 which they are to be employed, no definite rule can be laid down. Each 
 case must be treated for itself; and to be treated successfully it must 
 be watched most closely. The necessity for stimulants may arise sud- 
 denly, or the need of their administration may be but temporary ; while 
 the infant's state in the morning affords, in cases of severe diarrhoea, 
 no sure criterion by w T hich to judge what its condition will be at night. 
 In general, it is not until the active symptoms have begun to decline 
 that stimulants are needed, nor even then are they required in a large 
 number of instances. I have, however, met with some instances in 
 which they were absolutely necessary as early as the second or third 
 day of the disease. This has occurred in cases in which there was 
 great irritability of the stomach, as well as violent action of the bowels ; 
 in which no medicine could be borne except the calomel and opium 
 powders, nor any drinks except such as were given cold. Under such 
 circumstances a state of extreme debility is sometimes very rapidly 
 induced, and the vomiting, w T hich at first was a sign of the gastric dis- 
 order, continues, when it is nothing else than an effect of the general 
 exhaustion. About half a drachm of brandy given every two or three 
 hours to a child of a year old, in a quantity of a few drops at a time, 
 mixed with the cold milk and water, or the thin arrow-root with which 
 it is fed, will often have the effect of arresting the sickness, as well as 
 of rallying the sunken energies of the system. No stimulant has 
 appeared to answer the required ends better than brandy : and, when 
 sufficiently diluted, children take it very readily. Sometimes, however, 
 when it has been necessary to continue it for some time, it has seemed 
 to occasion pain in the stomach, and even to nauseate the child ; and in 
 this case the compound tincture of bark, or the aromatic spirits of 
 ammonia, or the two together, may be substituted for it; and there is 
 seldom much difficulty in administering them, if they be mixed with 
 milk and sufficiently sweetened. 
 
TREATMENT OF CHRONIC DIARRHEA. 399 
 
 The proper time for the employment of aromatics and astringents is 
 not during the acute stage of the affection : but when the disease has 
 already begun to decline, these remedies will be found of most essential 
 service in checking that looseness of the bowels which otherwise is very 
 apt to degenerate into a state of chronic diarrhoea. Under these cir- 
 cumstances the logwood and catechu mixture, mentioned at an early 
 part of this lecture, is a very valuable medicine. If, notwithstanding 
 its employment, the bowels still continue to act with excessive frequency, 
 small doses of the compound pow T der of chalk and opium may be given 
 twice a day, 1 or the use of the opiate enema may be continued if there 
 
 (No. 29.) 
 \ R Pulv. Crete Co. c. Opio, ^j. 
 
 Inf. Catechu Co. 3iss. M. gj. bis vel ter die. 
 For a child a year old. 
 
 be much tenesmus. By these means, coupled with the most sedulous 
 attention to the child's diet, and the greatest care in allowing either 
 animal broths or meat or other solid food, a complete cure will usually 
 be brought about in the course of two, or at the latest, of three weeks. 
 There are some cases in which, after the disease has passed its acute 
 stage, it still retains much of its dysenteric character ; the bowels not 
 merely acting with undue frequency, but the evacuations containing 
 mucus, pus, or blood, and their expulsion being attended with very con- 
 siderable tenesmus. The strength in such chronic cases is very greatly 
 reduced, and emaciation goes on to a greater degree than in almost any 
 other affection, with the exception of phthisis and mesenteric disease ; 
 while the bowels are excited to almost immediate action by even the 
 simplest foodA The treatment of these cases is attended with con- 
 siderable difficulty ; recovery, when it does take place (and it is con- 
 solatory to know that it often does, even from a condition apparently 
 desperate), is brought about very slowly, and each remedy employed 
 seems speedily to become ineffectual. Throughout their course two 
 objects are to be borne in mind, — one being to check the diarrhoea ; the 
 other to support the child's strength during the time required for nature 
 to effect the cicatrization of the ulcerated mucous membrane, and to 
 restore it to a state of health. The utility of mercurial preparations 
 has appeared to me to be almost exclusively confined to the early stage 
 of dysentery, and to cease when the disease has passed into the chronic 
 form. On the other hand, astringents may now be employed with the 
 most marked benefit, and, when one fails, another may be substituted for 
 it. In cases where the stomach has been very irritable, so that almost 
 everything has been speedily rejected, I have sometimes employed the 
 gallic acid in combination with laudanum, 2 and have seen much benefit 
 
 (No. 30.) 
 2 R Acidi Gallici, gr. viij. 
 
 Tinct. Cinnamomi co. gj. 
 
 Tinct. Opii, TT^viij. 
 
 Syrupi, gij. 
 
 Aquoe Cinnamomi, gv. 
 
 Aquce pur. ^j. M. gij. 6tis horis. 
 
400 TREATMENT OF CHRONIC DIARRH(EA. 
 
 from its use. At other times I have given the acetate of lead with 
 
 m opium 1 — a combination which retains its efficacy, when given in the 
 
 form of mixture, notwithstanding the decomposition that takes place. 
 
 The sulphate of iron combined with opium 2 is another highly useful 
 
 (No. 31.) (No. 32.) 
 
 1 U Plumbi Acetat. gr. vj. z J£ Ferri Sulphatis, gr. iv. 
 
 Aceti destillati, n^xx. Tinct. Opii, TT^vj. 
 
 Tinct. Opii, TTLviij. Syrupi Aurantii, gij. 
 
 Muc. Acaciae, sjij. Aquae Carui, ^x. M. gij. 6tis horis. 
 Syrupi Zingib. sjj. 
 
 Aquae purae, gxiij. M. gij. 6tis horis. 
 
 The above are all suited for children 1 year old. 
 
 remedy in these cases, and appears to have the advantage over the 
 sulphate of zinc, w T hich has likewise been used in similar cases, of not 
 exciting the irritability of the stomach. 
 
 Our remedies are not to be confined to those administered by the 
 mouth ; for much may be done towards relieving the symptoms and 
 curing the disease by suitable enemata. In some cases of unmanageable 
 diarrhoea, M. Trousseau employs an enema of nitrate of silver in the 
 proportion of a grain to an ounce of distilled water, which I have some- 
 times tried in conbination with a few drops of laudanum, with very 
 good effect. I have employed the gallic acid in enema in a similar 
 manner ; and throughout any case of chronic diarrhoea, occasion will 
 often arise for altering our remedies in various ways, not so much to 
 meet any changes in the character of the symptoms, as because all 
 medicines, even the most appropriate, after having been employed for 
 a time seem to lose their power. In the majority of instances I have 
 begun with the administration of clysters of laudanum diffused in 
 mucilage, or in a small quantity of starch, while occasionally, in pro- 
 tracted cases, where the tenesmus was very distressing, I have used the 
 black wash as a vehicle for the laudanum ; and, on one occasion, in 
 which a copious discharge of pus continued for several days in a little 
 boy two years old, this symptom was greatly relieved by the adminis- 
 tration, twice a day, of an enema containing two grains of sulphate of 
 zinc. 
 
 The support of the child's strength is a matter of no less importance 
 in chronic dysentery than the suppression of the diarrhoea. The great 
 weakness of the patient, and the manifest distaste for nourishment of 
 all kinds, often render it necessary to continue the use of brandy for 
 several days, or even for several weeks. For an infant not weaned, 
 there can be no better food than that which is furnished by the breast 
 of a healthy nurse. In the majority of cases, however, the child has 
 been either in great measure or altogether weaned before the affection 
 came on, and, consequently, it is a less easy matter to supply it with 
 suitable food. Farinaceous articles, such as arrow-root, sago, &c, are 
 less easily assimilated in early life than in adult age, and in cases of 
 this kind they not infrequently pass through the alimentary canal 
 unchanged. Milk, too, does not always agree, and is sometimes 
 
DIET IN CHRONIC DIARRHCEA, — TREATMENT OF INTERTRIGO. 401 
 
 rejected almost at once, unless it be given in a state of extreme 
 dilution. Under these circumstances we must not hesitate to give 
 strong beef or veal tea in small quantities, but at short intervals, to the 
 patient ; for though it be true that the bowels are often excited to 
 increased action, in cases of chronic diarrhoea or dysentery by animal 
 broths, yet this is a smaller hazard than that of the child dying for 
 want of sufficient nutriment. I may add, that, when prepared with 
 care, and quite free from salt or any seasoning, and when given cold, 
 I have seldom observed any serious increase of the diarrhoea to follow 
 their use under these circumstances. 
 
 Two accidents are occasionally met with in connection with pro- 
 tracted diarrhoea in infants and young children, concerning each of 
 which a few words must be said. It is not unusual to observe a general 
 erythematous redness of the buttocks and nates in infants suffering 
 from severe diarrhoea, and sometimes the irritation of the acrid faeces 
 produces an attach of intertrigo, and a serous fluid exudes abundantly 
 from the inflamed skin. This condition, which is the occasion of very 
 considerable suffering to the child, almost always depends upon a 
 neglect of that most scrupulous cleanliness which is of such essential 
 importance in early life. In order to prevent its occurrence, the nates 
 and buttocks must be sponged with warm water immediately after each 
 evacuation ; the surface may afterwards be smeared with a little zinc 
 ointment, while any part at which the skin seems disposed to crack 
 should be dusted over with the oxide of zinc in powder. These simple 
 precautions will usually suffice to prevent a condition which, in some of 
 the hospitals \pf Paris, where such sedulous care is almost impossible, 
 degenerates into a state of unhealthy ulceration that exhausts the 
 infant's powers, and sometimes contributes to its destruction quite as 
 much as the diarrhoea in the course of which it came on. 
 
 Prolapsus of the anus is another troublesome accident which some- 
 times takes place in the course of protracted diarrhoea. It abates, 
 however, almost always, as the diarrhoea diminishes, and generally ceases 
 altogether as the child regains its strength. When there is a disposi- 
 tion to it during the acute stage of the affection, this may often be 
 controlled if the nurse be instructed to support the margin of the anus 
 during each evacuation, and thus to prevent the descent of the bowel, 
 while the opiate enema which relieves the tenesmus is of most essential 
 service, by thus removing the cause of the prolapse. The child's 
 attendant should also be taught how to return the bowel if it should 
 come down ; and this is best effected by means of gentle pressure with 
 a napkin wrung out of cold water. If, as the diarrhoea abates, the 
 prolapse should still continue, and especially if the gut should come 
 down independent of efforts at defaecation, it may be necessary to make 
 the child wear a compress and bandage to prevent its descent. In such 
 cases, too, an enema consisting of a small quantity of some astringent, 
 such as the decoction of tormentilla, should be administered cold once 
 or twice a day; and no instance has come under my notice in which 
 these measures, persevered in for a few weeks, have not sufficed to 
 remove this troublesome ailment. 
 
 26 
 
402 PERITONITIS. 
 
 LECTURE XXXIV. 
 
 Peritonitis — sometimes occurs during foetal existence, or in very early infancy — is 
 then possibly dependent on syphilitic taint — when epidemic in large institutions is 
 often connected with infantile erysipelas. 
 
 Peritonitis in after-childhood — a rare occurrence — generally secondary to some febrile 
 attack — case illustrative of its symptoms, which are much the same as in the adult — 
 occasional escape of the fluids effused, through the abdominal walls, and recovery of 
 the patient. — Inflammation sometimes circumscribed, especially in connection with 
 disease about the appendix caeci — illustrative case. — Treatment of peritonitis. 
 
 Chronic peritonitis — almost always a tubercular disease. — Morbid appearances — symp- 
 toms — their vagueness — pauses in the advance of the disease — various and often 
 obscure forms which it assumes — close analogy between its symptoms and those 
 referred to tubercular disease of the mesenteric glands. 
 
 Tabes Mesenterica — rarity of extensive disease of the glands — slightness of its symptoms 
 when uncomplicated. — Treatment of it, and of tubercular peritonitis. 
 
 From the study of the affections of the mucous lining of the intestinal 
 canal, we pass by a natural transition to that of the diseases of its 
 serous investment. Peritonitis, however, which is not very common as 
 an idiopathic affection at any period of life, is still more rare during 
 the greater number of the years of childhood ; while its symptoms do 
 not deviate in any important respect from those which characterise it in 
 the adult. It would be idle to spend our time in speculating on the 
 reasons for the rarity of inflammation of the peritoneum in early life. 
 The tendency of inflammatory disease in childhood appears, indeed, to 
 be to attack the mucous rather than the serous membranes; a fact of 
 which we have another illustration in the comparative rarity of acute 
 pleurisy in the child. Some connection may perhaps be thought to 
 subsist between the great irritability of the intestinal mucous membrane, 
 and its proneness to disease during the greater part of childhood on the 
 one hand; and the immunity from disease which the peritoneum exhibits 
 during the same period. At any rate, it is certain that in the new-born 
 infant, in whom the former peculiarity has not yet become developed, 
 inflammation of the peritoneum is of more common occurrence than in 
 subsequent childhood. 
 
 Inflammation of the peritoneum, giving rise to adhesions between the 
 intestines, and to the effusion of lymph and serum into the cavity of 
 the abdomen, occurs sometimes even during intra-uterine life, and occa- 
 sions the death of the foetus. It is not possible to say with certainty 
 to what cause the disease should be attributed, at a time when the being 
 is sheltered from all those influences from without which may excite 
 inflammation after birth ; but it is worthy of notice that in many 
 instances of peritonitis in the foetus, traces of syphilitic disease are 
 observed upon it; or there is clear evidence of the existence of venereal 
 taint in the mother. In such cases, the inflammation of the serous lining 
 of the abdomen is probably due to the altered state of the circulating 
 fluid — a cause to which, in after life, inflammation of the serous mem- 
 branes is frequently owing. In the only instances of non-congenital 
 
PERITONITIS IN EARLY INFANCY. 403 
 
 peritoneal inflammation that has come under my notice in early infancy, 
 there was no other cause than this to which it could be attributed. 
 
 In this case, a little boy, five weeks old (whose mother had twice 
 before been confined prematurely with still-born children), began to have 
 snuffles at the age of three weeks. In the course of the next week a few 
 copper-coloured spots appeared about his face; his scrotum next grew 
 sore, then his voice became hoarse and his lips cracked ; and at the end 
 of the fourth week he grew sick, and his abdomen enlarged and became 
 tender. When brought to me the child was extremely small; he was 
 greatly emaciated; the skin of his face wrinkled; his appearance dis- 
 tressed ; his chin covered with copper-coloured blotches ; the angles of 
 his mouth were ulcerated ; his lips cracked ; and small sores beset his 
 scrotum. His abdomen likewise was very large : it was remarkably 
 prominent about the umbilicus, and its superficial veins were much 
 enlarged. It was extremely tense ; somewhat tympanitic ; and though 
 dull in places, it yet did not yield the impression of distinct fluctuation 
 anywhere. The abdomen was exceedingly tender to the touch, but the 
 child seemed in pain also at other times ; he had been very sick for 
 nearly a week, and vomited almost immediately after sucking, besides 
 which he threw up a yellow fluid at other times. His bowels were 
 purged several times a day. His mother, who did not suffer at that time 
 from any syphilitic symptom, was put upon a mild mercurial course, 
 with iodide of potassium and sarsaparilla ; and the mercury with chalk 
 was likewise administered to the child. By degrees, as the syphilitic 
 spots faded, the abdomen grew less tender and less swollen, — it became 
 soft ; and in the course of time the infant regained perfect health. 
 
 The symptohjs in this case ran a chronic course ; but peritonitis of an 
 acute character, and tending to a rapidly fatal termination, is sometimes 
 observed to occur among very young infants when collected together in 
 large numbers, and under conditions unfavourable to health. A French 
 physician, M. Thore, 1 during a year's observation at the Hospice des 
 Enfans Trouve*s at Paris, found that acute peritonitis existed in about 
 six per cent, of the infants who died at that institution. The disease, 
 such as he observed it, seems to be exclusively, an affection of early 
 infancy, since, though the hospice contains children of all ages, yet no 
 child above the age of ten weeks was attacked by it, while thirty-five 
 out of fifty-nine were less than a fortnight old. The previous health of 
 the children had in some instances been good, but in many cases the 
 peritonitis appeared as a consequence or complication of some other 
 affection. A sudden tympanitic swelling of the abdomen was often the 
 first symptom of the disease, and was soon associated with vomiting of 
 a greenish matter ; which phenomenon, however, was seldom of long 
 continuance. The bowels were generally constipated throughout, the 
 respiration and pulse soon became accelerated, and the heat of skin 
 increased, while the child evidently suffered pain in the abdomen. 
 With the advance of the disease the countenance altered, the skin grew 
 cold, and the pulse feeble ; and in the majority of cases the child died 
 
 1 De la Pe'ritonite chez les Nouveau-ne's, in the Archives Ge*n. de Med. for August an 
 September, 184(5. 
 
404 PERITONITIS SOMETIMES EPIDEMIC IN HOSPITALS. 
 
 within twenty-four hours, while life was not in any instance prolonged 
 beyond the third day. 
 
 The appearances found after death were much the same as those 
 which characterise peritonitis in the foetus. In none of the sixty-three 
 cases which were examined was there any puriform matter in the abdo- 
 minal cavity, but only a dirty serous fluid, in which flocculi of lymph 
 were often floating ; while the intestines were more or less coated with 
 false membrane, which was especially abundant about the spleen and 
 liver. Pleurisy was found associated with the peritonitis in a third of 
 the cases ; and the frequency of this complication is another point of 
 resemblance between the disease as it occurs during foetal life and in 
 early infancy. Its causes, too, appear to be such as act through the 
 medium of the circulating fluid ; for in seventeen out of sixty-three cases 
 the peritonitis followed on erysipelas, and in four on phlebitis of the 
 umbilical vein — affections which, it is known, are immediately dependent 
 on epidemic causes, and are excited by the same atmospheric conditions 
 as induce puerperal fever in lying-in women. The influence of such 
 agencies is still farther shown by the fact that forty-two per cent, of 
 the cases of peritonitis recorded by M. Thore occurred during the months 
 of April and May, while the others were somewhat unequally distributed 
 over the remainder of the year. 
 
 When the child grows older it is no longer so susceptible of noxious 
 influences as before ; and when they come into play, the mucous mem- 
 brane of the bowels suffers, rather than their serous investment. Hence, 
 acute idiopathic peritonitis becomes a very rare disease in childhood : 
 and peritoneal inflammation usually occurs as a sequela of some affection 
 which has been attended with considerable alteration in the circulating 
 fluid. It sometimes succeeds to an attack of scarlatina ; and the possi- 
 bility of its occurrence should lead us to look with great suspicion upon 
 any complaint of pain in the abdomen made by children during their 
 convalescence from that disease ; while, though the danger of its super- 
 vention after other febrile affections is less considerable, the risk is by 
 no means to be forgotten. 
 
 The symptoms and course of the disease appear to be much the same 
 whether it occurs as a primary or as a secondary affection ; but there 
 is a great difference between the severity of the symptoms and the 
 amount of danger to which the patient is exposed, in different cases. 
 
 I do not recollect ever to have witnessed more intense suffering than 
 was endured by a little boy, nine years old, who, after recovering from 
 fever, yet seemed to regain his health by but slow degrees, and had 
 almost habitual constipation. He came under my notice on May 25, 
 and was much benefited by alterative and slightly aperient medicines ; 
 when he was suddenly, and without any known cause, seized on the 3d 
 of June with profuse diarrhoea, and severe pain in the abdomen. On 
 the following day, when I saw him, his face was haggard and anxious, 
 and his abdomen excessively tender ; while the diarrhoea continued even 
 more profusely than before. Some leeches were applied to the abdo- 
 men, and calomel and Dover's powder were given every four hours ; but 
 the leeches drew but little blood, and though the purging ceased, the 
 pain iii the abdomen increased in severity. On the 5th of June I found 
 
SYMPTOMS OF ACUTE PERITONITIS IN CHILDREN. 405 
 
 the boy lying on his back, with his legs stretched straight out ; while 
 the slightest movement, or any attempt to sit up, produced excruciating 
 pain. The abdomen was tympanitic, very tender to the touch, and 
 especially so just below the umbilicus. The pulse was frequent and 
 sharp ; the tongue moist, and uniformly coated with yellow fur. Leeches 
 were again applied, in greater numbers than before : and the mercurial 
 was given every three instead of every four hours. Towards evening 
 he was rather better, but the pain, which was referred especially to the 
 neighbourhood of the umbilicus, came on severely during the night, and 
 was aggravated in paroxysms. He had passed no urine for many 
 hours ; but only half a pint was drawn off by the catheter, and this 
 was dark coloured, and had a very strong smell. The bowels had acted 
 only once, and then scantily. The same remedies were continued, but 
 the child's condition continued to grow worse ; and during the night he 
 was in such pain that he frequently shrieked aloud so as to alarm the 
 neighbours. On the morning of the 7th he had turned round upon his 
 right side, and lay with his knees drawn up towards his abdomen, his 
 head supported in his mother's lap ; his face expressed the most intense 
 suffering, and he shrieked frequently with pain. The abdomen was 
 much distended, and so tender that it could not endure the slightest 
 touch. The pulse had become frequent and thready. He had made 
 water twice of his own accord. The abdomen was now covered with a 
 large blister: beef-tea and brandy were given to support the vital 
 powers ; and while the mercurial was continued, an endeavour was 
 made, by a full dose of opium, to procure a temporary abatement of 
 the child's sufferings. When seen at 6 P. M. he had vomited frequently 
 a dark-green fluid, and had passed three natural liquid evacuations. 
 He was lying in the same attitude as before, dozing with half-closed 
 eyes, his forehead wrinkled, the corners of his mouth drawn down, 
 terror and pain stamped on his countenance, — seeming as if dying, till 
 roused by a return of pain, when he called with loud and piteous cries 
 on his mother for help. His pulse was now smaller, and more thready. 
 During the night his sufferings were unceasing ; towards morning he 
 became quieter, and died quietly at 9 A. M., on June the 8th. 
 
 On opening the abdomen, thin pus, unmixed with lymph, poured 
 forth in great abundance. It quite concealed the intestines from view, 
 and must have amounted to at least a quart. The peritoneal lining of 
 the abdominal walls was highly vascular, especially in the hypogastric 
 region ; that covering the intestines had lost its natural transparency, 
 was softer, and seemed thicker, but was not much injected. There was 
 no lymph effused on any part of the parietal peritoneum, nor were there 
 any adhesions between the intestines ; but the spleen and liver, the latter 
 especially on its convex surface, were coated with lymph. The whole 
 tract of the intestines was examined with great care, and was found to 
 be quite healthy ; the mucous membrane being rather pale. There was 
 . some crude tuberculous matter in the mesenteric glands. The right 
 side of the chest contained a pint of pus, similar to that in the abdo- 
 men ; the right pleura was intensely vascular, and this condition was 
 especially remarkable in that part of it which lined the diaphragm : a 
 patch of lymph, of small extent, formed a connection between the two 
 
406 CASE OF ACUTE PERITONITIS. 
 
 surfaces of the lung, while the right lung generally had a rather thick 
 coating of false membrane. Some tubercles in the bronchial glands, 
 and a compressed state of the substance of the right lung, formed the 
 rest of the morbid appearances. 
 
 There can be no doubt but that, in the early stages of this case, a 
 more active plan of treatment ought to have been adopted. It is related, 
 however, not as an illustration of the therapeutical principles by which 
 you should be guided, but as affording a remarkably good specimen of 
 the symptoms of acute peritonitis. The inflammation of the pleura was 
 doubtless secondary to that of the peritoneum, and the effusion into the 
 cavity of the chest probably coincided with the time when the child 
 assumed the position on his right side. We learn from this case, that 
 pain, coming on suddenly, referred particularly to one part of the 
 abdomen, but extending over the w T hole, greatly aggravated on pres- 
 sure, or on the slightest movement, so as to compel the patient to 
 remain in the recumbent posture, with the legs extended and motionless, 
 characterize the disease. The abdomen before long becomes tympanitic, 
 and this tympanitis, if considerable, greatly aggravates the patient's 
 sufferings. The state of the bowels varies : frequently they are relaxed 
 at the outset of the illness ; sometimes they continue so throughout, 
 while they are but rarely constipated. Vomiting is not ,a constant 
 symptom ; and when it does occur, the irritability of the stomach 
 varies, both in its degree as well as in the time at which it appears. 
 The symptoms sometimes continue to increase in severity until death 
 takes place ; at other times they undergo a sudden diminution, or even 
 cease altogether; though this seeming amendment is attended, or 
 rapidly followed, by sinking of the vital powers, and soon afterwards 
 by the patient's death. 
 
 Acute general peritonitis is fortunately very rare in childhood — only 
 three other instances of it have come under my notice ; and still rarer 
 is its termination by the effusion of pus into the cavity of the abdomen. 
 Even under these apparently hopeless circumstances, however, nature 
 does sometimes make an effort at cure. The active symptoms diminish 
 in intensity ; the abdominal parietes grow thin at some spot, where a 
 passage at length is formed through which the pus is discharged, and 
 recovery sometimes slowly follows ; the result of a process precisely 
 analogous to that which nature has recourse to in pleurisy, when she 
 brings about the evacuation of the fluid through an opening sponta- 
 neously formed in the parietes of the thorax. An instance of this 
 mode of cure of peritonitis, in a child seven years old, was related 
 by Dr. Aldis, at a meeting of the Medico-Chirurgical Society, in 
 November, 1846. 1 A few similar cases may be found in medical 
 journals ; 2 and one has come under my own observation, in the person 
 of a little girl, whose history I formerly related, 3 as affording an illus- 
 tration of that rare affection, inflammation of the sinuses of the dura 
 mater. 
 
 1 Reported in the London Medical Gazette, November, 1846. 
 
 2 For instance, Bernhardi, in Preuss. Med. Zeitung, 1842, No. 10; and Beyer, Casper's 
 Wochenschr. 1842, No. 5. 
 
 3 See Lecture VII. p. 88. 
 
SYMPTOMS OF ACUTE GENERAL PERITONITIS. 407 
 
 The peritoneal inflammation which comes on during scarlatinal dropsy- 
 is not in general of a very active character, and seldom produces any 
 morbid appearance of greater gravity than numerous slight adhesions 
 between the intestines. It generally succeeds to ascites ; and the 
 abdominal affection seldom exists alone, but is usually associated with 
 pleurisy, and abundant serous effusion into the chest'; and the symptoms 
 of disease of the respiratory organs very often mask those of the abdo- 
 minal inflammation, which latter, indeed, seem in many instances to 
 have but a very subsidiary share in bringing about the patient's death. 
 
 Besides those cases in which the peritonitis is general, there are 
 others in which the inflammation is circumscribed to a 'part, and some- 
 times but a small part, of the peritoneum. Now and then, peritonitis 
 affecting only a very small extent of surface proves rapidly fatal, 
 (though no such instance has come under my own notice) ; but usually 
 there is a correspondence between the severity of the symptoms, 
 and the extent of the disease. I imagine the inflammation to have 
 been circumscribed in some cases, in which the principal pain was 
 referred to one part of the abdomen, while the tenderness was almost 
 limited to that situation, in which, moreover, the abdomen did not 
 become generally tense or tympanitic, and all the symptoms yielded 
 with tolerable readiness to the employment of remedies, though the 
 disposition to pain and tenderness in one spot was, some time before it 
 wholly disappeared. 
 
 Lastly, some notice must be taken of a highly dangerous form of 
 peritonitis, circumscribed in some cases, but general in others, which 
 succeeds to inflammation of the csecum, or of its vermiform appendix. 
 This affection\ however, is not so common in early life as in adult age, 
 while the same symptoms characterise it in either case ; so that no 
 lengthened description of it will be necessary. It has only once come 
 under my observation, and, in that instance, although the inflammation 
 had produced gangrene of the mucous membrane of the appendix, and 
 a sloughing opening of communication between it and an abscess in the 
 cellular tissue behind the caecum, yet no intestinal concretion or other 
 foreign body was discovered, to the lodgment of which, in the appendix, 
 the disease could be attributed. All the viscera in the right half of 
 the abdomen were thickly coated with lymph, but the inflammation 
 had not at all involved the parietal peritoneum, nor extended to the 
 intestines on the left of the mesial line. Acute pleurisy, however, 
 existed on the right side, and had given rise to the effusion of nearly 
 three pints of milky serum. The patient was a little boy, only seven 
 years old, whose health had been habitually good, till he began to 
 complain, on the 5th of July, of pain in the abdomen, and was attacked 
 at the same time with violent purging and vomiting. The purging 
 ceased in the course of a few hours, but the vomiting continued at the 
 time of my seeing him on July 8, when he likewise complained of great 
 pain, and of exquisite tenderness in the right hypochondriac region. 
 Leeches were twice applied in that situation, with manifest relief, and 
 calomel and opium were given every three hours. In the night of the 
 10th, an aggravation of the symptoms took place, and auscultation 
 detected a friction sound in the right side of the chest. Cupping 
 
408 PERITONITIS CONSEQUENT ON INFLAMMATION OF THE CAECUM. 
 
 beneath the right scapula was followed by a very marked improvement: 
 he rested well on the night of the 11th ; and on the 12th, he not only 
 breathed without difficulty, but was free from pain in the hypochon- 
 drium, except on pressure, and the sickness had completely ceased. 
 An aggravation of his symptoms, however, occurred during the night : 
 on the 13th, he changed his attitude, and lay on his right side instead 
 of on his back, and retained this posture till his death. A marked 
 fulness was now apparent on the right side, extending from the crest of 
 the ilium to the ribs. On the ensuing day this part was not merely 
 full and tender, but exceedingly firm to the touch, — a condition which 
 existed throughout the whole lumbar region, and extended forward to 
 about two inches to the right of the linea alba. The bowels were at no 
 time much constipated, and after the administration of an aperient on 
 the 12th, they acted several times each day, the motions being relaxed, 
 but otherwise natural. Sickness returned on the 13th, and during the 
 last two days of the child's life it was almost constant ; while the great 
 thirst that existed during the whole course of the illness rendered this 
 symptom the more distressing. On the 12th, there were physical signs 
 of some effusion into the chest, which had increased so much before 
 death that the right half of the chest was manifestly enlarged, and the 
 intercostal spaces on that side were very prominent. Auscultation of 
 the back of the chest was however impossible for some days, owing 
 to the acute pain produced by any movement. The breath grew very 
 short ; the flesh wasted rapidly ; the face was habitually expressive of 
 distress, and at night delirium came on. On the 16th, after a most 
 wretched night, his pulse became very feeble, and his extremities cold, 
 while the vomiting was incessant. Convulsions came on, and lasted 
 for six hours, when they ceased, and two hours afterwards the child 
 died tranquilly, on the 11th day from the first sign of indisposition. 
 The mercurial treatment had been continued all along, the opium being 
 increased as the intensity of the child's sufferings seemed to require, 
 and four days before death the inunction of a drachm of strong 
 mercurial ointment every four hours was begun ; but no effect seemed 
 to be produced by the remedies. 
 
 The indications for treatment, in cases of acute peritonitis, are so 
 clear that it would be superfluous to occupy much time in laying down 
 rules for your guidance. You have to deal with the active inflamma- 
 tion of parts in which acute disease cannot goon long without destroying 
 life. Depletion, both general and local, and the employment of mer- 
 cury, combined with opium or Dover's powder, in order to mitigate 
 the suffering which attends on the disease, are the remedies to which 
 you must have recourse, and which you must employ with an unsparing 
 hand. When the abdominal tenderness has been mitigated by bleed- 
 ing, a warm poultice, frequently renewed, will often afford considerable 
 comfort ; and in some cases of local peritonitis I have seen the warm 
 hip-bath give much relief. The error into which you are likely to fall 
 in the management of these cases is not that of pursuing a wrong 
 course, but of following the right one with too little vigour. 
 
 In the peritonitis that follows scarlatina, the symptoms are often less 
 urgent than under other circumstances ; but you will bear in mind, 
 
TUBERCULAR PERITONITIS. 409 
 
 that when the function of the kidneys is disturbed, and urea is circu- 
 lating in the blood, the serous membranes are very apt to become 
 inflamed, and you will, therefore, keep on the look-out for any indica- 
 tion of their suffering. I shall hereafter have to point out to you, that 
 in this, as well as in so many other cases, prevention is not only better, 
 but easier than cure ; and that if on the first appearance of the dropsy 
 consecutive on scarlet fever, you have recourse to active antiphlo- 
 gistic measures, you will, in the large majority of cases, escape the risk 
 of these secondary inflammations. 
 
 Acute peritonitis, like the acute inflammation of any other tissue, 
 may subside, but not altogether cease ; it may pass into a chronic 
 state, and the patient may suffer from the consequences of the disease 
 long after the disease in its original form has disappeared. But it is 
 not to an affection of this kind that I wish to call your attention in 
 speaking of chronic peritonitis; but to a disease, the progress of which 
 is slow from its commencement, which is weeks or months in running 
 its course, but which yet demands our closest attention, since in a very 
 large number of cases that course is to a fatal issue. 
 
 It is not, however, its tardy progress which alone distinguishes the 
 chronic from the acute inflammation of the peritoneum, but the former 
 is almost invariably associated with the tuberculous cachexia, and, 
 indeed, generally succeeds to the deposit of tubercle upon the serous 
 membrane of the abdomen. The occasional recovery of a child in 
 whom the symptoms of chronic peritonitis have existed, by no means 
 disproves that connection between it and phthisical disease, of which 
 dissection in fatal cases affords such convincing proof. 
 
 The bodies®/ children who have died of this affection are usually 
 found to be exceedingly emaciated ; and their face retains after death 
 the suffering expression which it had worn during their protracted ill- 
 ness. The lungs and bronchial glands contain tubercle in greater or 
 less abundance, and the pulmonary disease is sometimes so far advanced 
 as to have obviously had no small share in bringing about the fatal 
 event. On dividing the abdominal parietes, long, slender, cellular, 
 adhesions, are often found connecting the peritoneum to the subjacent 
 viscera. The intestines, too, are connected by adhesions, some of 
 which are very easily broken down, while others are so firm that the 
 coats of the bowels give way in the attempt to separate them. This 
 difference does not depend on the age of the adhesions (although in 
 this respect they vary greatly, some being apparently of very recent 
 date, others of long standing), so much as on their nature. Those 
 connections which are formed by the mere effusion of lymph, even 
 when from age they have acquired considerable firmness, can gene- 
 rally be broken down without much difficulty ; and at any rate the 
 attempt will not produce rupture of the intestines. When, however, 
 different portions of the bowel are matted together so inseparably that 
 it is easier to lacerate than to detach them from each other, it will be 
 found that something more than the mere effusion of lymph has pro- 
 duced this union. It will be seen to have been effected by means of a 
 yellow, granular matter, like that which connects the opposite surfaces 
 of the arachnoid in a case of tubercular hydrocephalus, and made up 
 
410 MORBID APPEARANCES. 
 
 like it in part of lymph, in part of tubercular deposits. Adhesions 
 are thus formed between the opposite surfaces of peritoneum, at first 
 of small extent, but fresh deposits of tubercle soon take place in the 
 vicinity, and the attendant inflammatory process unites together a still 
 greater extent of intestine. Nor is this all ; but in time, the tubercle 
 thus deposited undergoes a process of softening, in the course of which 
 the muscular tissue of the intestines becomes destroyed, and their 
 mucous membrane may thus eventually be perforated, so that distant 
 parts of the intestinal canal, which at first were merely adherent 
 together, are sometimes brought by this means into direct communica- 
 tion with each other. The abdomen generally contains a small quantity 
 of transparent serum ; but if, as sometimes happens, life should have 
 been cut short by the supervention of acute peritonitis upon the old 
 disease, the effusion may be of a puriform or sero-purulent character ; 
 though this is seldom abundant. 
 
 In addition to the evidences of inflammatory action presented by 
 the peritoneum, that membrane and the various abdominal viscera are 
 the seat of a more or less generally diffused tubercular deposit. The 
 surface of the peritoneum lining the abdominal walls is sometimes 
 abundantly beset with small, grey, semi-transparent granulations ; but 
 in the majority of cases the tuberculization is less general, and the 
 parietal peritoneum is less affected than other parts of the membrane. 
 That part of the peritoneum which lines the diaphragm, or the abdom- 
 inal walls in the immediate vicinity of the spleen, is one of the favourite 
 seats of tubercular deposit, which in these situations generally put on 
 the form of small, yellow, miliary tubercles, not that of grey granula- 
 tions. In some instances the omentum is the seat of the chief tuber- 
 cular deposit ; and though it usually assumes the miliary form, yet 
 now and then masses of crude tubercle of considerable size are met 
 with in this situation. The peritoneum covering the liver and spleen 
 seldom fails to shew an abundant deposit of tubercle ; and tubercles 
 usually abound in the substance of the latter organ. The mesenteric 
 glands likewise are tuberculous, though the degree of their degenera- 
 tion, and the size which they have in consequence attained, vary much 
 in different cases. The same remark holds good with reference to the 
 amount of tubercular disease in the interior of the intestines, which, 
 though in many cases very considerable, yet bears no invariable rela- 
 tion either to the degree of the affection of the peritoneum, or to that 
 of the mesenteric glands. 
 
 In cases of this affection, those vague indications of decaying health 
 which characterise the early stages of the tuberculous cachexia often 
 precede any symptom of special disorder of the abdominal viscera. 
 But this is not always the case ; for in some instances the child begins, 
 without any previous indisposition, to complain of occasional pains in 
 the abdomen, which last but for a moment, and which cause the less 
 anxiety, from the appetite being good, the bowels regular, and the 
 general cheerfulness undisturbed. In the course of a short time, how- 
 ever, the appetite fails, or becomes capricious; the bowels begin to act 
 irregularly, being alternately constipated and relaxed , while the 
 motions, always abundant, are usually unnatural in character, — dark, 
 
 r 
 
SYxMPTOMS AND COURSE OP TUBERCULAR PERITONITIS. 411 
 
 loose, and slimy. The child now grows restless and feverish at night, 
 its thirst is considerable, and the abdominal pain becomes both more 
 severe and more frequent in its recurrence. Sometimes the stomach 
 grows very irritable, and the food taken is occasionally vomited ; but this 
 symptom is often absent ; while the tongue, throughout the early stages 
 of the affection, continues for the most part clean and moist, and deviates 
 but little from its appearance in health. The symptoms just enume- 
 rated seldom continue long without being accompanied with a marked 
 change in the size of the abdomen ; and sometimes the alteration in 
 the abdomen takes place rather suddenly, and is one of the earliest 
 signs of the affection from which the child is suffering. The abdomen 
 becomes large, tense, and tympanitic, while its parietes often seem 
 glued to the subjacent viscera ; and that manipulation which causes no 
 discomfort, even when practised somewhat roughly on the big abdomen 
 of a rickety child, is sure to occasion uneasiness, often even considerable 
 pain, when tried with ever so much gentleness in the child suffering 
 from chronic peritonitis. 
 
 In this, as in other forms of tubercular disease, the progress from 
 bad to worse seldom goes on uninterruptedly. Pauses take place in 
 its course, though each time they become shorter ; and signs of amend- 
 ment now and then appear, — but they, too, promise less and less with 
 each return. The child loses flesh; the face grows pale, and sallow, and 
 anxious ; the skin becomes habitually dry, and hotter than natural, and 
 the pulse is permanently accelerated. The abdomen does not grow 
 progressively larger, but it becomes more and more tense, although this 
 tension varies without any evident cause, and sometimes disappears for 
 a day or two,\to return again as causelessly as it disappeared. When 
 the tension is diminished, the abdomen yields a solid and doughy sen- 
 sation, and the union between the contents of the abdomen and the 
 abdominal walls becomes very perceptible. The superficial abdominal 
 veins now become enlarged in many instances, and the skin grows 
 rough, desquamates, and looks as if it were dirty. The pain in the 
 bowels retains the same colicky character as before, but it returns very 
 frequently, and is sometimes exceedingly severe, while the child is 
 never free from a sense of uneasiness. The tenderness of the abdomen, 
 however, but seldom increases in proportion to the increase of pain. 
 The bowels are in general habitually relaxed, though the degree of the 
 diarrhoea, as well as the severity of the abdominal pain, vary much in 
 different cases. As the disease advances, the child becomes confined 
 to bed, and is at length reduced to a state of extreme weakness and 
 emaciation. Death is often hastened by the concomitant affection of 
 the lungs ; but should this not be the case, the patient may continue 
 for many weeks in the same condition, till life is destroyed, after a day 
 or two of increased suffering, by some renewed attack of peritoneal 
 inflammation. 
 
 Such, now, is the ordinary course of tubercular peritonitis ; but just 
 as it would not be possible to draw a picture of pulmonary phthisis 
 which should represent with perfect accuracy every case of the disease, 
 so it is with our attempt to delineate the features of this malady. Its 
 main diversities, of which the differences in the appearances found after 
 
412 COURSE OF TUBERCULAR PERITONITIS. 
 
 death are far from affording a satisfactory explanation, consist in the 
 various degrees in which pain is experienced, in the rapidity in the 
 course of the affection, and in the alternation of constipation with diar- 
 rhoea, or sometimes in the complete substitution of the one condition for 
 the other. One form of tubercular peritonitis, in which its early stages 
 are very likely to be unnoticed, is that which it assumes when it super- 
 venes upon one of the eruptive fevers — usually upon measles : the diar- 
 rhoea, the feverishness, the loss of flesh, are regarded merely as attend- 
 ants upon a tardy convalescence; the abdominal pain, probably by no 
 means severe, is supposed to be of little moment ; and the abiding ten- 
 derness is altogether overlooked. The chief safeguard against this error 
 is found in our being fully alive to the possibility of the danger, and in 
 the most sedulous watching of every child whose convalescence is tedious. 
 In other instances the disease sets in with a degree of febrile disturbance 
 which throws the abdominal affection into the background, and the case 
 is put down as one of remittent fever ; a mistake from which, however, 
 any one may be preserved by noting that the pulse is less frequent, the 
 heat of skin less intense ; that delirium is absent, that the abdominal 
 tenderness is more general, the pain usually more severe, and the abdo- 
 men more tense. Another class of symptoms which should excite our 
 suspicion are those which are sometimes presented by children who, 
 having suffered from dyspepsia, become liable to occasional attacks of 
 colic and constipation, the severity of the pain being out of proportion 
 to the duration of the previous constipation ; the effect of purgatives in 
 inducing action of the bowels being uncertain, and the relief which fol- 
 lows their operation neither immediate nor complete. Lastly, the disease 
 is sometimes observed attended by scarcely any pain : the child grows 
 pale and thin, and has occasional diarrhoea, but makes no complaint of 
 pain, or at most of nothing beyond a sense of stuffing and fulness of 
 the belly; but emaciation goes on, perhaps, rapidly; the diarrhoea 
 becomes habitual, and medicine loses much of its control over it ; the 
 strength fails, and the little one dies, worn out and weary, but quietly 
 and without pain. It would be easy, but I do not think it necessary, 
 to relate a history illustrative of each of these varieties of the disease; 
 they would each point to the same moral — that, under all modifications 
 of symptoms, when a child loses flesh, and has in conjunction with that 
 emaciation, abiding, even though but slight, tenderness of the abdomen 
 on pressure, you are to suspect the existence of tubercular peritonitis. 
 Some of you have probably been struck by the many points of resem- 
 blance between the symptoms that have just been described, and those 
 which are often enumerated as characteristic of mesenteric disease. 
 Nor is it at all surprising that a very close analogy should subsist 
 between chronic peritonitis and tabes mesenterial, since not only are 
 both affections -the results of the tubercular cachexia, but in both the 
 abdominal viscera are chiefly involved in the disease, and both are in 
 consequence characterised by a remarkable impairment of the functions 
 of nutrition. It was natural, too, that in former times, when morbid 
 anatomy was less carefully cultivated than at present, the attention of 
 the observer should have been chiefly drawn to the increased size and 
 altered structure of the mesenteric glands — appearances which must 
 
TABES MESENTERICA — A RARE AFFECTION — V 413 
 
 have been often discovered on an examination of the bodies of children 
 who had died after a slow wasting of their flesh, attended with more or 
 less enlargement of the abdomen and disturbance of the bowels. The 
 physiology of those days, too, knew of no means whereby the absorption 
 of the chyle could be effected except through the medium of the mesen- 
 teric glands; and the coarse appliances which then subserved the pur- 
 poses of anatomical investigation did not suffice to show that, even when 
 these glands outwardly present a considerable degree of tuberculization, 
 their lymphatics in many instances are still pervious. 
 
 We know that the nutrition of children is often much impaired from 
 other causes besides tubercular disease ; and that, when the digestive 
 organs perform their functions ill, nothing is more common than for the 
 abdomen greatly to exceed its natural size. Our predecessors had 
 observed similar facts ; but, from the imperfection of their physiological 
 knowledge, they drew from them erroneous conclusions. Disease of the 
 mesenteric glands was in their eyes the almost exclusive cause of the 
 atrophy of children, and a preternatural enlargement of the belly was 
 looked upon by them as an almost infallible sign that such disease had 
 already begun. Tabes mesenterica was consequently regarded as a very 
 common affection ; and though its frequency is now well known to have 
 been much overrated, yet the appearance of those symptoms that were 
 once supposed to be characteristic of it, still excites much needless 
 alarm among non-professional persons. 
 
 The mere presence of tubercle in the mesentery is, it must be owned, 
 of very common occurrence, since MM. Rilliet and Barthez met with it 
 in nearly half of all the children in whom that morbid deposit existed 
 in some or o^ier of the viscera. But though the existence of tubercle 
 in the glands be thus frequent, its presence in any considerable quantity 
 is extremely rare, since, according to the same authorities, it was found 
 in abundance, only in one out of every sixteen children, some of whose 
 organs contained tubercle. 
 
 The general character of tuberculous mesenteric glands is much the 
 same with that of tuberculous bronchial glands,, but the former are 
 usually surrounded by a more delicate cyst ; and although their size 
 seldom exceeds that of a chesnut, yet they occasionally undergo a 
 degree of development which far exceeds that of tuberculous bronchial 
 glands, and three or four of them coalescing together, sometimes form 
 a mass as big as the fist, or even bigger. 
 
 The effects produced even by an advanced degree of tuberculization 
 of the mesenteric glands are smaller than might be anticipated, and 
 much smaller than those which result from a considerably less amount 
 of disease of the bronchial glands. Nor will this at all surprise us, if 
 we bear in mind the difference between their anatomical relations. 
 The bronchial glands are not merely situated in a cavity which is 
 bounded by comparatively unyielding parietes, but the viscera with 
 which they are in contact are solid and resisting, and they are, more- 
 over, adherent to the trachea and the larger air-tubes, so that any 
 increase of their size is sure to' produce compression of parts whose 
 functions are of vital importance. The mesenteric glands, on the con- 
 trary, are contained in a cavity whose yielding walls allow them to 
 
414 ITS SYMPTOMS. 
 
 increase readily in size, while the loose attachments of the mesentery 
 still further permit them to attain even to considerable dimensions, 
 "without pressing upon any viscus ; so that it is an exceedingly unusual 
 occurrence for them to cause the perforation of any part of the intes- 
 tines, or even for them to contract adhesions to their exterior. 
 
 To these causes it must be attributed that there is no symptom 
 pathognomonic of tubercle of the mesenteric glands, except their being 
 perceptible through the abdominal parietes. This, however, they never 
 are during the early stage of the affection ; and though on one or two 
 occasions I have felt a tumor in the abdomen, which, from its being 
 associated with the evidences of tuberculous disease in other organs, I 
 have been led to attribute to the enlarged mesenteric glands, yet in 
 these cases, I have not had the opportunity of confirming the diagnosis 
 by an examination after death. There can, however, be no doubt but 
 that they do become perceptible through the abdominal walls, though 
 at a season when, their cure being hopeless, little practical use can be 
 made of the certainty of our diagnosis. In its earlier stages no 
 symptoms at all are present, or only the indications of that general 
 tuberculous disease of which the affection of the mesentery is usually 
 but a subordinate part. At a later period, when the disorder of the 
 digestive organs attracts attention, the symptoms are generally much 
 the same with those of chronic peritonitis, save that if the peritoneum 
 be free from disease, the abdomen is in most cases both less tense and 
 less tender. 
 
 I the less regret that so little time remains for the consideration of 
 the treatment of chronic peritonitis and of tabes mesenterica, since the 
 subject may be dismissed in a few words. In each of these affections 
 two periods may be distinguished. During the first, while our diagnosis 
 is still uncertain, general principles guide our conduct, and lead us to 
 subject the child to the same dietetic and hygienic management as we 
 should adopt if we feared the approach of any other form of phthisis. 
 In the second, the advancing mischief has removed all doubt from our 
 minds, but at the same time has chased all hope from our spirits ; and 
 we now minister to symptoms as they arise, and try to mitigate sufferings 
 which we cannot cure. 
 
 The dyspeptic symptoms, the unhealthy appearance of the evacua- 
 tions, and the frequency with which diarrhoea occurs, enforce the 
 necessity for the diet being as mild and unstimulating as possible. The 
 abdominal pain which is experienced in tubercular peritonitis is almost 
 always relieved by the application of a few leeches; but even local 
 depletion must not be practised without absolute necessity ; and in 
 many instances a large poultice to the abdomen, frequently renewed, 
 will remove pain, the severity of which had at first seemed to call for 
 the abstraction of blood. Now and then, however, symptoms of acute 
 peritonitis come on in children who have manifested previously unmis- 
 takeable signs of tubercular disease, and nevertheless yield to free local 
 depletion, and the administration of mercury. I would therefore 
 advise you not to allow any notion, how well founded soever, of the 
 probable connection of the symptoms with tubercular disease, to betray 
 you during the presence of acute symptoms into an inert course of 
 
TREATMENT OF TUBERCULAR PERITONITIS. 415 
 
 treatment ; nor, I may add, into the too positive expression of a 
 gloomy prognosis. Still these are exceptional cases ; and our treat- 
 ment in the majority of instances is confined to relieving the more 
 urgent symptoms. Next in importance to the pain, or sometimes even 
 more important, is the diarrhoea, which we must try by all means to 
 keep in check ; for which purpose few astringents are better than the 
 logwood and catechu mixture mentioned in the last lecture. Sulphate 
 of iron and opium, in the form either of pills or mixture, may be used 
 if the diarrhoea be very obstinate, though we may be compelled to 
 abandon their use, from finding that they add to the fever, and thus 
 aggravate the patient's symptoms ; but I have not observed the mere 
 suppression of the diarrhoea by astringents to be followed by any 
 exacerbation of the other abdominal symptoms. Astringents, however, 
 are far from being the only remedies to be employed ; but mercurials 
 in a mild form, and continued for a long period, have often seemed to 
 be of much service. When the tenderness of the abdomen has been 
 sufficiently relieved to admit of it, I generally direct the use of a lini- 
 ment twice a day, consisting of the Linimentum Hydrargyri, soap 
 liniment, and olive oil, in equal parts, which has seemed useful as a 
 counter-irritant even independent of the mercury which enters into its 
 composition. Besides this I usually give equal parts of the Hydr. c. 
 Creta and Dover's powder once or twice a day. The Dover's powder 
 prevents the mercurial from irritating the bowels, and also allays the 
 restlessness and feverishness at night — an end to which the use of the 
 tepid bath every evening likewise conduces, often in an eminent degree. 
 The comfort of the child is frequently much promoted by wearing a well- 
 adapted flaniicl bandage over the abdomen both by night as well as by 
 day ; and the support this affords may be increased with advantage by 
 a piece of thin whalebone at either side. 
 
 If diarrhoea be absent, or if, though it be present in a slight degree, 
 the skin be very hot and dry, and the child very thirsty and feverish, 
 the tepid bath, the mercurial with Dover's powder, and small doses of 
 liquor potassae and ipecacuanha, are the remedies on which I chiefly 
 rely, and to this the extract of dandelion may often be added with 
 advantage. If it seem likely that a mild tonic will be borne, a mixture 
 containing the extract of dandelion, extract of sarsaparilla, and sesqui- 
 carbonate of soda, 1 may be given ; or the liquor cinchonae or the infu- 
 
 (No. 33.) 
 1 R Extracti Taraxaci, ^ij. 
 Sodse Sesquicarbonatis, gj. 
 Extr. Sarzse, giv. 
 Syr. Aurantii, ^iv. 
 
 Decoct. Sarzse Co. ^vss. M. gvj. ter die e lacte. 
 For a child four years old. 
 
 sion of calumba may be employed for the same purpose. It is only 
 with much caution that we can administer chalybeates in these cases, 
 and after having found that the milder vegetable tonics are well borne. 
 The ferro-citrate of quinine, or the citrate of iron, are the preparations 
 
416 INTESTINAL WORMS. 
 
 which it will generally be desirable to employ in the first instance, and 
 even their effect should be watched attentively. When well borne, the 
 cod-liver oil is, I think, more useful in this than in any other form of 
 the tuberculous cachexia in early life. The cases in which it causes 
 nausea or diarrhoea are comparatively few, and its effects in fattening 
 children who were greatly emaciated are sometimes very remarkable. 
 In conclusion, I need hardly mention the importance of change of air, 
 and the benefits likely to result from a sojourn on the sea-coast; for 
 you know how much more powerful nature's remedies are in diseases of 
 this kind than the remedies of man's devising. 
 
 LECTUKE XXXV. 
 
 Intestinal Worms — their varieties, symptoms, and treatment. 
 
 Diseases of the Urinary Organs — Inflammation of the kidneys — Albuminous nephritis 
 — generally follows one of the eruptive fevers, oftenest scarlatina — its symptoms — 
 condition of the urine — appearances after death — essential nature of the changes in 
 the kidneys. — Treatment. 
 
 Calculous disorders — frequent in early life — deposits in the urine in childhood almost 
 always consist of the lithates. — Other causes of dysuria besides gravel and calculus. — 
 Treatment of dysuria in early life — Lithic acid deposits connected with chronic rheu- 
 matism in children — symptoms of ill health associated with them — importance of not 
 overlooking them. 
 
 Diabetes — true saccharine diabetes very rare in early life — simple diuresis less uncom- 
 mon — symptoms of disordered health that attend both affections. — Treatment. 
 
 Incontinence of urine — circumstances under which it occurs. — Treatment. 
 
 Our study of the diseases of the digestive organs would be incom- 
 plete if we took no notice of those parasitic animals which frequently 
 inhabit the alimentary canal in children. It will not, indeed, be neces- 
 sary to say much respecting them; for we know that the older medical 
 writers greatly overrated their frequency and importance, when they 
 saw the proofs of their existence in almost every variety of gastric and 
 intestinal disorder, and even attributed to their presence many forms 
 of serious disturbance of the nervous system. Still, they are in many 
 instances the occasion of considerable discomfort ; they often aggravate, 
 and sometimes even give rise to, disorder of the digestive organs, while 
 now and then the irritation excited by their presence being propagated 
 to the spinal cord, produces convulsions or other formidable nervous 
 symptoms. 
 
 Although intestinal worms are much more common in early life than 
 in adult age, yet no species of them is peculiar to the child, but they 
 belong to one or other of the five sorts ordinarily met with in the grown 
 person. 
 
 The ascaris vermicularis, or small thread-worm, which lives princi- 
 pally in the rectum, is by far the most common of all these entozoa, 
 and is very troublesome, from the local irritation which it excites. The 
 long thread-worm, the tricocephalus dispar, appears much less fre- 
 quently in the evacuations: it inhabits the upper ends of the large 
 
SYMPTOMS OF INTESTINAL WORMS. 417 
 
 intestines, and in some cases coexists with the presence of ascarides in 
 the rectum. When it is present alone, I am not aware that it gives rise 
 to any unpleasant symptoms. The ascaris lumbricoides is of much less 
 common occurrence than the small thread-worm, though observed more 
 frequently than the tricocephalus : it dwells in the small intestines, and 
 sometimes, entering the stomach, is rejected by vomiting. Occasionally 
 only one of these worms is present, and though there are oftener several, 
 yet it is but seldom that they exist in the child in very considerable 
 numbers. The tape-worm, of which there are two kinds, the taenia 
 solium and taenia lata, is much the rarest of these entozoa in early life, 
 and is seldom met with in children under seven years of age, though 
 once or twice I have known it to exist in infants who were still in part 
 nourished at the breast. 
 
 Various symptoms have been said to indicate the presence of worms 
 in the intestines, but most of them are of small value : and nothing short 
 of actually seeing the worms can be regarded as affording conclusive 
 evidence of their existence. No one who is at all familiar with 
 the disorders of early life will be disposed to attach much weight to 
 symptoms, such as the altered hue of the face, the appearance of a livid 
 circle around the eyes, the loss of appetite, or its becoming irregular or 
 capricious. Many causes besides the presence of worms give rise to a 
 tumid state of the abdomen, to colicky pains, and to occasional sickness 
 and vomiting ; and itching of the nose or anus, though often present 
 when the intestinal canal is infested with worms, yet is sometimes the 
 occasion of much annoyance independently of their existence. An 
 irregular or intermittent pulse, widely dilated pupils, occasional drowsi- 
 ness, with uneasy rest at night, and starting during sleep, are evidences 
 of disturbance of the nervous system, but do not specially indicate the 
 presence of w r orms as the cause of such irritation. 
 
 In any case however, where symptoms such as those above mentioned 
 make their appearance, and, though fluctuating in severity, continue for 
 weeks together, there exists, in the absence of any obvious cause of 
 nervous irritation, reasonable grounds for suspecting the presence of 
 worms ; and the evacuations should be examined, in order to ascertain 
 whether or no that suspicion is well founded. Even though for a season 
 none should be discovered, yet fortunately the treatment which the 
 general symptoms would lead us to adopt will be in great measure such 
 as, if worms exist, will prove most efficacious in producing their expul- 
 sion. The capricious appetite will induce us to regulate the diet with 
 care ; the disordered and generally constipated state of the bowels will 
 lead to the employment of alteratives, and to the occasional administra- 
 tion of brisk cathartics ; while the absence of febrile symptoms will 
 probably seem to warrant the employment of some of the preparations 
 of iron. These remedies will in many instances not have been continued 
 long before the appearance of worms in the motions encourages us to 
 persevere in the same treatment. The combination of ferruginous 
 preparations with active purgatives is a plan especially effective in cases 
 where the lumbricoid entozoa are present, and is likewise of much ser- 
 vice in getting rid of the ascarides which inhabit the rectum, and in 
 preventing their reproduction. The latter worms, however, need to be 
 
 27 
 
418 TREATMENT OF INTESTINAL WORMS. 
 
 assailed in their habitation ; and, from the circumstance of their living in 
 the lower end of the rectum, this is a sufficiently easy task. Enemata of 
 lime-water usually answer the purpose of destroying them ; hut, should 
 they fail, the addition of some two drachms of the muriated tincture 
 of iron to the clyster is tolerably sure to make it effective. In young 
 children these ascarides sometimes not merely occasion much itching 
 and distressing irritation about the anus, but even produce a trouble- 
 some diarrhoea, attended with considerable tenesmus. Under such 
 circumstances, the lime-water should be administered daily for two or 
 three days together ; while, at the same time, small doses of the castor- 
 oil mixture every six or eight hours will soothe the irritation of the 
 bowels. In female children these ascarides sometimes creep up the 
 vulva, and not merely cause much irritation there, but excite a leucor- 
 rhoeal discharge, which ceases on the expulsion of the worms. 
 
 The alarming symptoms of cerebral disturbance which are occasion- 
 ally produced by worms jn the intestinal canal, result more frequently 
 from the presence of the round worm than of other varieties of these 
 entozoa. This, however, is not always the case ; and is the only 
 instance that has come under my observation in which the occurrence 
 of serious convulsions seemed clearly traceable to the presence of 
 worms in the intestines, the small thread-worms were the cause of the 
 symptoms. Apart from the knowledge which we have in many of these 
 cases that the child had been previously afflicted with worms, there is 
 nothing in the symptoms which could enable us at once to distinguish 
 between convulsions from this cause and those which result from some 
 other source of irritation of the nervous system. In most instances, 
 however, the child has passed worms frequently before the cerebral 
 symptoms made their appearance, and not improbably was under treat- 
 ment for the destruction of those parasites at the time when the 
 nervous symptoms supervened. Even though this be not the case, the 
 constipated state of the bowels which is almost sure to have preceded the 
 occurrence of the convulsions, indicates the employment of active pur- 
 gatives — remedies which in most instances remove together these 
 symptoms and their cause, although convulsions apparently induced 
 by the presence of worms have sometimes had a fatal termination. 
 
 The tsenia is, as was stated, much less common in childhood than 
 after puberty ; and in the few cases in which I have met with it during 
 early life, I have been reluctant to try, until after the fruitless employ- 
 ment of other medicines, that heroic remedy, turpentine and castor-oil, 
 which is so serviceable in procuring the expulsion of tape-worm in the 
 adult. When I have used it in the child, it has always proved effica- 
 cious in bringing away large quantities of the worm, but one seldom 
 has dispensary patients sufficiently long under observation to feel sure 
 that the apparent cure of such a disease has been permanent. I have 
 been accustomed to employ the decoction of the bark of the pomegranate 
 root in doses of an ounce three times a day for a child of seven years 
 old, interrupting its administration twice in the week, in order to give 
 a purgative of scammony and calomel. Under this plan, pursued for 
 several weeks together, large quantities of the worm have been voided, 
 and the children have appeared entirely freed from this very trouble- 
 
DISEASES OF THE URINARY ORGANS. — NEPHRITIS. 419 
 
 some parasite. It is undoubtedly more certainly and speedily effica- 
 cious when given every hour for four or five successive hours, as 
 recommended by Mr. Breton, 1 who first brought the remedy into notice 
 in this country ; but I have found an unavoidable difficulty in any 
 attempt so to administer it, from the natural repugnance of children 
 to take medicine, especially when in a bulky form, or when its taste 
 is unpleasant. I have had no opportunity of employing the new remedy 
 Kousso, but testimony appears to be unanimous in its favour, as more 
 efficacious than any other anthelmintic which we possess. 
 
 Closely connected with the disorders of the digestive organs are 
 those affections to which the urinary apparatus is liable. Unfortu- 
 nately, special difficulties attend their investigation in early life, and 
 difficulties which it is least easy to overcome in dispensary practice : 
 hence the information which it is in my power to give you with refe- 
 rence to these diseases is less complete than I could have desired. 
 
 Nephritis, or acute inflammation of the substance of the kidney, is 
 exceedingly rare, as an idiopathic affection, in early life. MM. Rilliet 
 and Barthez, 2 decline attempting to give any description of its symp- 
 toms, on account of the very few instances of it that have come under 
 their observation, although they refer to some cases in which the con- 
 gested, swollen, and indurated state of the kidneys after death seemed 
 to indicate that those organs had been the seat of acute inflammatory 
 action. M. Bayer 3 relates an instance or two where the presence of 
 purulent deposits in the kidneys of infants a few clays old gave positive 
 evidence of their inflammation ; but no symptoms observed during the 
 lifetime of these children had called attention to their urinary organs. 
 He mentions it,\ moreover, as a disease of very unusual occurrence in 
 early life, and adds, that though he has seen cystitis follow the appli- 
 cation of a blister in early life, yet in those cases there was no sign of 
 the irritation having extended to the kidneys. 
 
 Albuminous nephritis, or that form of inflammation of the kidney 
 which is usually met with in connection with general dropsy, is rather 
 less uncommon as a primary disease, though in by far the greater 
 number of cases it is met with as a sequela of one of the eruptive 
 fevers, generally of scarlatina. It is under these latter circumstances 
 only that it has presented itself to my notice, and the description 
 which I will endeavour to give you of it applies to the characters that 
 it then assumes. It sometimes sets in with symptoms of considerable 
 severity, but even then it has a great tendency to pass into a chronic 
 state, while in by far the majority of cases its attack is gradual, and its 
 advance is slow. The dropsical symptoms by which it is almost 
 always attended, generally show themselves within a fortnight or three 
 weeks from the appearance of the rash ; the face, hands, and feet, 
 being affected in succession, and fluid being likewise sometimes effused 
 into the cavity of the abdomen. The dropsical symptoms are generally 
 preceded for a day or two by the indications of constitutional distur 
 
 1 Medico Chirurgical Transactions, vol. xi. p. 301. 
 
 2 Op. cit. vol. i. chap. xvi. 
 
 3 Traite des Maladies des Reins, 8to. vol. i. p. 417. Paris, 1839. 
 
420 SYMPTOMS OF ALBUMINOUS NEPHRITIS AND SCARLATINA. 
 
 bance. The child who had passed through the attack of fever perhaps 
 with less than the average amount of suffering, and who for a few days 
 had seemed rapidly advancing to convalescence, begins to droop, grows 
 languid, feverish, and restless. The skin becomes dry and hot ; the 
 process of desquamation is arrested while still incomplete ; the appe- 
 tite is lost, though the thirst is often considerable ; the bowels become 
 constipated, and the urine diminished in quantity, although the desire 
 for voiding it is very frequent. After these signs of interrupted con- 
 valescence have continued for two or three days, or even longer, the 
 face becomes slightly swollen, a puffiness appearing about the eyelids 
 in the morning, which probably disappears later in the day ; so that 
 in many instances the attention of the parents is not particularly 
 directed to the child's condition until oedema has extended to the hands 
 and feet. The degree of anasarca varies much in different cases, and 
 likewise fluctuates at different periods in the same patient. Usually, 
 though not invariably, there is a distinct relation between the degree 
 of swelling and the severity of the general symptoms ; and few cases 
 terminate fatally in which there is not considerable serous effusion 
 into the different cavities of the body. In very mild cases the febrile 
 disturbance is inconsiderable, the anasarca slight, and confined to the 
 face ; and after a few days of poorliness, the kidneys resume their 
 proper functions, the anasarca disappears, and the child's health returns. 
 In severe cases the symptoms persist for a longer time, and complaints 
 of pain in the back, and evident tenderness in the lumbar region, are 
 usually associated with them, while the swelling extends to the cellular 
 tissue of most parts of the body ; but unless some complication should 
 exist, improvement generally becomes apparent in the course of a 
 week or ten days, and recovery takes place slowly. In the worst 
 cases, the swelling, after having undergone many apparently cause- 
 less fluctuations, becomes extreme, as well as universal; the features 
 are disfigured by the dropsy, the legs greatly swollen, and the abdo- 
 minal parietes much infiltrated, while the skin remains dry and hot. 
 The quantity of water voided is very small indeed, and the pain in 
 the back is often very severe. The chief suffering, however, is referred 
 to the chest ; the respiration is laboured and accelerated, and the child 
 is frequently unable to assume the recumbent posture, and is moreover 
 distressed by a frequent, short, hacking cough. Under these circum- 
 stances, life is sometimes prolonged for several days, though in a state 
 of extreme suffering, remedies proving unable either to increase the 
 action of the kidneys, or to relieve the dropsy. Death is sometimes 
 preceded by a sudden aggravation of the signs of disorder of the respi- 
 ratory organs, which assumes all the painful characteristics of oedema 
 of the lungs ; and in other cases a comatose condition comes on, such 
 as often precedes death from Bright's disease in the adult. Sometimes 
 a temporary improvement takes place, the anasarca abates, and the 
 kidneys resume their functions, but the patient dies not long afterwards 
 from the effects of the pleurisy or pericarditis, which had come on 
 almost unnoticed during the acute stage of the affection. 
 
 These symptoms of constitutional disturbance, which you recognize 
 as the characteristics of inflammatory dropsy, are associated with 
 
CHANGES IN THE URINE. 421 
 
 changes in the composition of the urine, as well as with a diminution 
 in the quantity of the secretion. In the milder cases it is transparent 
 when passed, though of a deeper colour than natural, and becomes turbid 
 on cooling, when it deposites a more or less abundant precipitate. It 
 has a strong acid reaction, somewhat exceeds the usual specific gravity 
 of healthy urine, is at first rendered clear by the application of heat, but 
 again becomes cloudy as the albumen which it contains is coagulated, 
 and falls down in a flocculent precipitate. If the attack be more 
 severe, the urine, which is very scanty, is of a brown or smoke colour, 
 deep red, or coffee-coloured, and throws down a deposit chiefly of a 
 reddish-brown colour ; which, however, does not entirely disappear when 
 heated, while albumen is present in it in extreme abundance. An exa- 
 mination under the microscope of the deposit that takes place sponta- 
 neously in the urine in these cases, discovers not merely crystals of the 
 lithate of ammonia, but blood globules, often very little altered, mucus 
 corpuscles, and epithelium scales. These matters, however, disappear 
 by degrees as the urine regains its natural appearance, even though it 
 may still be shown by chemical reagents not to be entirely free from 
 albumen. 
 
 In cases where death takes place during the progress of this disease, 
 if the dropsical symptoms had not been very severe, and the child had 
 been carried off less by them than by some sudden cerebral symptoms, 
 or some intercurrent serous inflammation, the kidneys appear to the 
 naked eye no otherwise altered than in being generally darker and 
 more congested than natural. In severer cases, however, in which 
 death has resulted from the disease itself, and not from any casual com- 
 plication, the capsule of the kidneys strips off more easily than natural, 
 and their surface presents a pale colour and a mottled appearance. 
 On a section being made, a marked contrast is observable between the 
 pale, fawn-coloured, cortical structure of the organs, and their deeply 
 injected tubular part, coupled with which their pelvis and infundibula 
 generally display a greatly increased vascularity. 
 
 The use of the microscope has of late enabled us to advance a step 
 further than we otherwise could have done towards understanding the 
 pathology of this disease. 1 It has shown us that the morbid process 
 begins in the cortical parts of the inflamed kidney, the urinary tubules 
 of which are stimulated to an increased production of their epithelial 
 lining, or even to a pouring out of solid fibrinous matter into their cavi- 
 ties. The urine carries away with it some of these matters, and thus 
 frees the tubules for a time ; but as their contents are reproduced in 
 quantities too large to be thus eliminated, some of the tubules become 
 plugged and impervious, sometimes even so over-distended that they 
 give way, and are completely destroyed. Nor is this all, but the capil- 
 laries of the organ necessarily bear a part in the mischief. At first, 
 from over congestion, they become dilated and varicose, and afterwards 
 
 1 On this subject it is almost needless to refer to the papers of Dr. Johnson, Mr. 
 Busk, and Mr. Toynbee, in vol. xxix. of the Medico Chirurgical Transactions, or to 
 those by Dr. Johnson and Mr. Simon, in vol. xxx. ; together with the note appended to 
 the latter volume by the editors, respecting the labours of continental observers in this 
 field of inquiry. 
 
422 CHANGES IN THE KIDNEYS — PATHOLOGY OP THE DISEASE. 
 
 (in part probably from the formation of fibrinous clots within them, in 
 part as the result of a process of adhesive inflammation), they become 
 obstructed or even obliterated. Supposing this morbid process to have 
 gone on to any considerable extent, the kidney must be left by it per- 
 manently and irreparably injured ; while even in its slighter degrees it 
 must for a time seriously disturb the functions of the organ. In the 
 earlier stages of the disease, the presence of albumen in the urine is in 
 part due to the actual escape of blood from the over-loaded capillaries 
 of the kidney, in part to the temporary suspension of its functions. If 
 at a later period, when the urine has lost its preternaturally deep colour, 
 and has regained much of its healthy appearance, albumen should still 
 exist in any quantity, there will be reason for apprehending that some 
 abiding injury has been inflicted on the organ. 
 
 In the case of the dropsy that succeeds to scarlatina, although the 
 convalescence is often very tedious, there fortunately does not appear 
 to be much tendency to the production of any serious permanent injury 
 to the kidney. The danger to the patient in the acute stage of the 
 affection is, however, often very considerable, if the attack be severe ; 
 for the function of the kidney is almost entirely suspended, while at the 
 same time the action of the skin, that other great emunctory of the 
 system, is completely arrested. Chemical reagents shew that the blood 
 which circulates through the vessels is laden with urea, which the sys- 
 tem, unable to eliminate by its natural outlets, tries to get rid of by 
 pouring it out abundantly in the serous effusions that take place into 
 tne different cavities of the body. These efforts of nature to relieve 
 herself not only prove unsuccessful, but the effused fluid often seriously 
 interferes with the due performance of their functions by the different 
 viscera ; and I have seen several instances of sudden death from hydro- 
 thorax under these circumstances. In other cases inflammation attacks 
 the pleura, or pericardium, or less frequently the peritoneum ; while, 
 even though these secondary affections should not be very severe, still 
 the continuance of life is not compatible with the circulation through 
 the body of blood loaded with urea. 
 
 When this affection occurs as a sequela of scarlatina, it may very often 
 be traced to exposure to cold while the process of desquamation was 
 going on, whereby the activity of the skin has been checked or alto- 
 gether suppressed, or to the injudicious adoption of a tonic or stimu- 
 lant plan of treatment, at a very early period of the patient's convales- 
 cence. The opinion, that it more frequently follows a mild than a 
 severe attack of scarlatina, does not appear to have any better founda- 
 tion than the circumstances that premature exposure to the air, and 
 errors of diet, are exciting causes much more likely to occur after slight 
 than after severe cases. Something, moreover, is unquestionably due 
 to the epidemic constitution of the year, as Sydenham calls it, since 
 the occurrence of the consecutive dropsy is common after the scarlet 
 fever of one year, comparatively rare after the same disease in another 
 year. 
 
 The treatment of this affection is on the whole that of inflammatory 
 dropsy, from what cause soever it may arise. If it have set in with 
 severity, the urine being very high coloured, extremely scanty and 
 
TREATMENT OP ALBUMINOUS NEPHRITIS. 423 
 
 loaded with albumen, the abstraction of blood is almost indispensable, 
 and from four to six ounces may be taken from the arm of a child of 
 five or six years old. It will, I believe, seldom, if ever, be necessary 
 to repeat the general depletion, though if no improvement follow, and 
 especially if there be pain or tenderness in the loins, cupping, or the 
 application of leeches in that situation, should be resorted to. At the 
 same time, the child must be put on a low diet : he must be kept in bed, 
 and must be placed in a hot bath every night, in order, if possible, to 
 excite the skin to action. The bowels must be kept freely open ; but I 
 have not found as much advantage from the employment of cathartics 
 as from the use of diaphoretic medicines. The tartar emetic is in these 
 cases a very valuable remedy, and may be given in nauseating doses 
 every three or four hours combined with the solution of the acetate of 
 ammonia. If, as sometimes happens, the child complain of headache, 
 or appear heavy and drowsy, or if the bowels be constipated, Dover's 
 powder is inadmissible, though otherwise it may be advantageously 
 combined with the medicine, or be given in a rather larger dose at bed- 
 time. When by the employment of these means the skin has been ex- 
 cited to action, and the swelling, if not actually diminished, has at least 
 ceased to increase, some of the milder diuretics may be combined with 
 the mixture — as the acetate of potash, the extract of taraxacum, or the 
 spirits of nitrous ether, while at the same time the dose of the tartar 
 emetic may be reduced : but the change of the urine to a darker colour, 
 or the increase of albumen in it, should be regarded as indicating the 
 propriety of discontinuing their use, and of returning to the previous 
 strictly antiphlogistic treatment. 
 
 In cases where little or no fever is present, and where the urine, 
 though still albuminous, is neither so scanty nor so high coloured as in 
 the instances just referred to, while the oedema is comparatively slight, 
 a less vigorous plan of treatment may be adopted^ The child should 
 still be kept on low diet, and confined at first to bed, and for a consi- 
 derable time afterwards to its nursery, while the warm bath should still 
 be employed every night. Bleeding, however, is unnecessary ; the tartar 
 emetic need not be administered, but saline aperients, so given as to 
 keep up a somewhat free action of the bowels for several days, will 
 generally suffice to effect a cure. When, after the nearly complete 
 disappearance of the oedema, and the return of the urine almost or 
 altogether to a healthy state, the child still continues pale, and languid 
 and feeble, the tincture of the sesquichloride of iron is the best tonic 
 that can be administered, and under its use any traces of albumen that 
 previously existed in the urine will be altogether removed. Much care 
 is required in restoring the child to its usual diet, and it should not be 
 allowed to go abroad without wearing flannel next its skin : but no case 
 has come under my observation in which the continuance of a morbid 
 state of the urine after apparent convalescence from this affection has 
 warranted the apprehension that actual degeneration of the kidney had 
 been produced. 
 
 Before leaving this subject, I must just observe, that a slight degree 
 of anasarca occasionally follows an attack of scarlet fever in a weakly 
 child as a mere effect and indication of its feebleness ; and also that an 
 
424 TREATMENT OF ALBUMINOUS NEPHRITIS. 
 
 affection is now and then met with having all the characters of inflam- 
 matory dropsy, except that the urine is free from albumen. This was 
 observed in the dropsy which followed a recent epidemic of scarlatina 
 at Berlin, 1 anc^ is likewise mentioned by Dr. Henry Kennedy as having 
 been the case in some instances of the secondary dropsy which occurred 
 during the Dublin epidemic of the disease. 3 With few exceptions, how- 
 ever, it has been found that the affection is slight, when there is no 
 albumen ; its absence being probably due to the congestion of the 
 kidney not having been so considerable as to lead to the rupture of its 
 capillaries and the admixture of blood with the urine. 
 
 Although most diseases of the urinary organs are less common in 
 children than in grown persons, yet calculous disorders are far more 
 frequent in early life than in adult age. It appears, indeed, from some 
 statistical data furnished by Dr. Prout, that out of 1256 patients 
 received into the Bristol, Leeds, and Norwich hospitals, for the purpose 
 of being operated on for stone, 500, or nearly 40 per cent., were under 
 ten years of age. If we bear in mind the intimate connection that 
 subsists between the assimilative and the excretory functions, it will 
 not surprise us that in early life, when the former, though so active, 
 are so readily disturbed, the latter should be often thrown into disorder. 
 
 Very slight and very temporary causes often suffice to occasion 
 deposits in the urine of children ; and these deposits almost always 
 consist either of the amorphous lithate of ammonia, or of the small 
 reddish brown crystals of lithic acid. These deposits, indeed, are not 
 of much moment, and one might perhaps say that the younger the 
 infant the less is their importance, since the presence of lithic acid in 
 considerable quontity in the kidneys of new-born children seems to be 
 almost a physiological condition. Its frequency was first noticed some 
 years ago, by Professor Schlossberger ; and his original statements 
 have been confirmed both by his own subsequent researches, as well as 
 by those of Professor Martin, of Jena. 3 Dr. Schlossberger on an 
 examination of 199 children who died within thirty days from birth, 
 found lithic acid gravel in the tubuli uriniferi of 32 per cent, of the 
 number ; in many, but not all of which, some degree of icterus had 
 existed. The frequency of this condition is probably connected with 
 the peculiar changes in the processes of assimilation which take place 
 after birth ; and any interruption to their performance, or any disturb- 
 ance of the cutaneous function, increases, as in the case of infantile 
 icterus, the probability of its occurrence. The same causes exert a 
 similar influence both in infancy, and also to a considerable degree 
 even in subsequent childhood. A trifling cold, slight gastric disorder, 
 or the feverishness and general irritation which sometimes attend upon 
 dentition, not infrequently produce these deposits, while they disappear 
 as soon as the brief constitutional disturbance subsides. In many cases 
 no local symptom indicates their presence, but sometimes the condition 
 of the child is one of very considerable suffering. 
 
 1 Described by Dr. Philip, in Casper's Wochenschr. August 29, 1840. 
 
 2 In his excellent Account of the Epidemic of Scarlatina in Dublin, from 1834 to 1842. 
 12mo. Dublin, 1842. 
 
 3 Archiv f. physiol. Heilkunde, vol. ix. ; also Schmidt's Jahrbiicher, Dec. 1850, p. 333. 
 
THEIR SYMPTOMS, 425 
 
 Very slight, and very temporary causes indeed, often suffice to occa- 
 sion abundant deposits in the urine of children, and these deposits 
 almost always consist either of the amorphous lithate of ammonia, or of 
 the small reddish brown crystals of lithic acid. A trifling cold, or the 
 slight feverishness and general irritation which sometimes attend upon 
 dentition, not infrequently produce them, while they disappear as soon 
 as the brief constitutional disturbance subsides. While it lasts, however, 
 the condition of the child is often one of very considerable suffering, 
 each attempt to make water being attended with much pain, the patient 
 crying and drawing up its legs towards its abdomen ; while frequently 
 a few drops only of urine are voided at each time. Now and then, the 
 suppression of urine is complete for twelve,, eighteen, or twenty-four 
 hours ; but this seldom happens, except in children previously much out 
 of health, and in whom, under these circumstances, the febrile symp- 
 toms and the constitutional disturbance are very severe, the bowels 
 usually constipated, and the evacuations very unnatural in appearance. 
 But besides cases of this acute kind, which occur almost exclusively in 
 infants in whom the process of dentition is not yet complete, similar 
 symptoms are often observed in older children ; and though at first of a 
 much less urgent character, they are yet of more serious import, since 
 they frequently indicate the existence of a calculus in the bladder, 
 instead of betokening a merely temporary excess of lithic acid deposits 
 in the urine. 
 
 In many instances, the formation of lithic acid in the kidneys goes 
 on without giving rise to any very obvious symptoms ; and I have but 
 rarely seen a, child suffer from pain of that severe character which in 
 the adult not infrequently accompanies the descent of a calculus from 
 the kidney to the bladder. Sometimes, however, after frequent attacks 
 resembling seizures of ordinary colic, a child begins to manifest the 
 symptoms of stone in the bladder ; and, under these circumstances, it is 
 probable that the previous attacks of abdominal pain were due to the 
 disordered function of the kidneys, rather than to any primary affection 
 of the intestinal canal. The occurrence of colic in children of three or 
 four years old, indeed, should always direct our most sedulous attention 
 to the state of the urine, which will very often be found to deviate 
 widely from a healthy condition, — frequently to abound in lithic acid 
 gravel. 
 
 The symptoms of stone in the bladder are much the same at all ages : 
 the pain in voiding urine, and immediately afterwards, the frequent 
 desire to pass water, the occasional abrupt stoppage of the stream of 
 urine, and the irritation about the penis, owing to which the child keeps 
 its hand almost constantly on its genitals, can hardly fail to awaken 
 suspicion as to the nature of the case. Before subjecting the child, 
 however, to the fright and pain which the introduction of a sound into 
 its bladder is sure to occasion, it should be first ascertained that the 
 patient's sufferings are not due to the prepuce being extremely long and 
 its orifice very narrow. The existence of that malformation sometimes 
 prevents the ready escape of the urine ; while the edges of the foreskin 
 becoming irritated and sore, any attempt to make water is rendered 
 exceedingly painful, and the symptoms present a most deceptive resem- 
 
426 TREATMENT OF DYSURIA. 
 
 blance to those of stone in the bladder. The presence of ascarides in 
 the rectum likewise sometimes produces a degree of irritation about the 
 bladder, which is by no means unlike that produced by calculus ; and 
 against this possible source of error it behooves us to be likewise on the 
 watch. 
 
 The treatment of dysuria in early life, connected, as the affection 
 almost always is, with an excess of lithic acid in the urine, is sufficiently 
 simple. Those acute attacks which come on during infancy, and for 
 the most part during the period of teething, and which are attended 
 with much fever, with a constipated or otherwise disordered condition 
 of the bowels, and with severe suffering, obviously call for antiphlogistic 
 and soothing measures. The warm bath is often very serviceable in 
 these cases in relieving the febrile symptoms ; besides which, the occa- 
 sional immersion of the child in hot water, as high as the hips, soothes 
 the pain which is so apt to attend upon every attempt to empty the 
 bladder. The bowels should be acted on freely by castor oil ; and after- 
 wards, no medicine has appeared to me to afford so much relief to pain, 
 or so effectually to excite the kidneys to action, as the castor-oil mix- 
 ture which I have already mentioned to you, in combination with small 
 doses of liquor potassse, laudanum, and nitrous ether. Barley-water, 
 milk and water, and thin arrow-root, should constitute the child's nou- 
 rishment during the severity of its attack ; and even when the symptoms 
 are on the decline, much prudence must still be exercised in keeping to 
 a very mild and unstimulating diet. It is generally wise to continue 
 the use of alkalies for some time after the active symptoms have sub- 
 sided ; and small doses of liquor potassae, either alone or in combination 
 with the vinum ipecacuanhas, may be given three or four times a day in 
 a little milk. Once or twice, I have seen a sudden suppression of urine, 
 attended with great aggravation of the child's sufferings, follow after the 
 existence of severe dysuria for two or three days ; and have found this 
 occurrence to be due to the mechanical obstruction of the urethra by a 
 small calculus which had become impacted in its canal. The dysuria 
 which is produced by the excessive length of the prepuce can be relieved 
 only by the removal of a portion of the superfluous foreskin ; while, 
 when it is excited by ascarides, an enema of liquor calcis, with a dose 
 or two of castor oil, will often produce an immediate cure of symptoms 
 which had been very troublesome. 
 
 The treatment of calculus in the. bladder hardly requires special 
 notice here ; but you will bear in mind that the calculi which form in 
 childhood are just of that kind on which medicinal agents are best cal- 
 culated to act ; and that we have but little reason for dreading those 
 changes in the precipitate thrown down from the urine which take place 
 in later life. The deposits that take place, and the calculi that form 
 in childhood, consist almost invariably of the lithates, and hence we 
 may employ the alkaline carbonates without apprehension ; and under 
 their continued use I have seen very copious sediments completely and 
 permanently disappear from the urine. Their action, however, is far 
 too slow to be relied on in any case where unequivocal signs are pre- 
 sent of the existence of a stone of considerable dimensions ; while, for- 
 tunately, the anaesthetic agents which we now possess, by depriving 
 
EXCESS OF LITHATES IN THE URINE. 427 
 
 the operation of lithotomy of the pain that once attended it, have 
 robbed it of many of its terrors. 
 
 The importance of lithic acid deposits in the urine, is, however, by no 
 means dependent on the temporary suffering associated with its elimi- 
 nation, in some instances ; or the dangers of the formation of vesical 
 calculus, in others. Deposits of lithic acid are observed in the urine 
 of children, as the consequence and the indication of a state of general 
 constitutional disorder, which manifests itself by dyspeptic symptoms 
 and imperfect nutrition, is often associated with chronic cutaneous affec- 
 tions, and not infrequently succeeds to some attack of rheumatism. I 
 have already told you that rheumatism in the child runs its course 
 frequently with a much smaller amount of local pain, and with less 
 swelling of the joints, than generally attends it in the adult. Its remote 
 effects also very seldom shew themselves in those abiding pains which 
 characterise chronic rheumatism in the grown person, but in a state of 
 general ill health such as that to which I have just referred. A child 
 is brought to you with a vague history of failing health ; of loss of flesh, 
 of variable appetite, sluggish bowels, and occasional night perspira- 
 tions. On further enquiry you learn that he is nervous and excitable 
 to the highest degree ; sometimes depressed and sullen, at other times 
 so high spirited as to be almost uncontrollable ; each of these fluctua- 
 tions in his condition, whether for better or worse, is found to be more 
 marked at some seasons of the year than at others ; and often also 
 modified by change of residence, his health being manifestly worse in 
 cold weather, and in exposed situations, than in a sheltered spot, and 
 during the summer season. Anxiety lest consumptive disease should 
 be impending^ often needlessly entertained in these cases ; but if you 
 examine the urine ycu will at once find the clue that will help you to 
 their thorough understanding. The urine will be found acid, of a very 
 high specific gravity, 1025° or upwards, depositing on cooling abundant 
 red crystals of lithic acid, and on the addition of nitric acid giving evi- 
 dence, by the speedy crystallization that takes place, of the presence of 
 an excess of urea. On close inquiry you will probably learn that some 
 months previously the child had had an attack of rheumatism, not 
 necessarily very severe, and that since then his health had never been 
 so good as before ; or, if not, you will almost certainly find that rheu- 
 matism is a disease from which, in some or other of its numerous forms, 
 members of his parent's family have suffered. It is to cases such as 
 these that the term of the lithic acid diathesis 1 is applicable. 
 
 The treatment of this condition does not require much notice. A 
 residence in a sheltered and warm situation and the habitual wearing 
 of flannel next the skin, are two points of much importance. A third, 
 of at least equal moment, is the careful regulation of the diet, which 
 should be simple, unstimulating, and moderate in quantity. With refe- 
 rence to medicine, the alkalies and alkaline carbonates may be given 
 with a vegetable bitter if some decided tonic appears necessary ; but 
 you must bear in mind, and clearly explain to your patient's friends, 
 
 1 It is almost superfluous to remind the reader of Dr. Todd's remarks on this subject 
 in his Croonian Lectures — On Gout, Rheumatism, &c. 
 
428 x INFANTILE DIABETES. 
 
 that the condition is not one to be overcome in a short time by a few 
 potent remedies, but one which will require watching and care, and a 
 well-considered system of diet and regimen, to be carried on for months 
 and years, and from which it is scarcely safe to depart before the time 
 of puberty has been passed in safety. I referred to it not because I 
 had any special cautions to give you about its treatment, but to call 
 your attention to a set of symptoms, the real signification of which may 
 be readily overlooked. 
 
 An unnaturally profuse flow of urine occurs at all ages as a tem- 
 porary symptom in the course of many disorders. Its permanent increase, 
 when associated with certain changes in the composition of the fluid, 
 and the presence of saccharine matters among its elements, constitutes 
 diabetes. This disease, although not common at any period of life, yet 
 occurs in the adult sufficiently often for us to become familiar with its 
 characters, and to dread it as one of the most formidable results of dis- 
 order of the assimilative processes. In the child, however, it would 
 seem to be an exceedingly rare affection, for not only has no instance 
 of it come under my notice at the Children's Infirmary, but Dr. Prout, 
 out of his immense experience in diseases of the urinary organs, states 
 that he has seen but one instance of it in a child of five years old, and 
 only twelve in young persons between the ages of eight and twenty 
 years, out of a total of 700 cases of diabetes. 1 Simple diuresis, indeed, 
 is less rare than true saccharine diabetes ; and I have seen some in- 
 stances in which, coupled with serious gastric and intestinal disturbance 
 there was so considerable an increase in the secretion of urine as to 
 constitute a prominent symptom of the disease. In these cases, how- 
 ever, considerable disorder of the digestive organs had for some time 
 preceded the excessive flow of urine; and Dr. Prout states, that in the 
 earlier stages of infantile diuresis, the urine is loaded with lithates and 
 diminished in quantity, though as the disease advances the quantity of 
 urine becomes considerably increased ; and it sometimes contains albu- 
 men, or in rarer cases yields signs of sugar. So far as my observation 
 goes, indeed, the disturbance of the functions of the kidney is in these 
 cases purely secondary, and subsidiary to the gastric and intestinal dis- 
 order. The quantity of urine has either been speedily diminished under 
 a due attention to diet and the regulation of the digestive organs, or 
 the symptoms have become merged by degrees in those of phthisis, 
 which has gradually developed itself. My experience concerning these 
 affections amounts, in short, to this — that whenever the processes of 
 digestion and assimilation are seriously disturbed for any considerable 
 time in early life, the functions of the kidney are very apt to become 
 excessive in degree as well as disordered in kind. Further, such dis- 
 order is especially likely to occur just at that period when the simple 
 but highly animalized food of the suckling is exchanged for the more 
 varied diet of the infant after weaning. And, lastly, its existence may 
 be suspected, whenever, coupled with more or less marked indications 
 of gastro-intestinal disorder, there is a rapidly increasing emaciation, 
 for which no adequate cause appears. It will, however, often happen, 
 
 1 On Stomach and Renal Diseases, 5th edit. 8vo. p. 36, note. 
 
ITS CAUSES AND TREATMENT. 429 
 
 even when the amount of urine greatly exceeds the healthy average, 
 that the parents of an infant take no notice of the circumstance, imagin- 
 ing it to be either an accidental and unimportant occurrence, or ac- 
 counting for it as the natural result of the thirst, which induces the 
 child to drink very abundantly. Hence, unless you make special 
 inquiries with reference to this point, you may remain in ignorance of 
 a very important symptom. 
 
 "When once you have become aware of the existence of this affection, 
 its treatment is attended by no particular difficulty, and, if undertaken 
 sufficiently early, will often prove successful. The state of the bowels 
 requires most careful attention : mild alteratives are frequently ser- 
 viceable, but drastic purgatives are very unsuitable. The Hydr. c. Creta;, 
 in combination with Dover's powder, is often very useful in promoting 
 a healthy condition of the evacuations ; while the Dover's powder alone 
 is also beneficial in calming the child's excessive irritability, as well as 
 in diminishing the amount of urine secreted. Dr. Prout adds a caution, 
 however, with reference to the use of opiates in these cases, as well as 
 to the sudden withdrawal of fluids, since a suppression of urine may 
 follow the incautious adoption of these measures, and that condition is 
 almost sure to end in coma and death. Change of air to a dry and 
 temperate situation, especially on the sea-coast, is of much importance, 
 and the tepid or warm sea-water bath is often beneficial ; while tonics 
 of various kinds are generally of service. The different preparations 
 of iron appear to have advantages over other medicines ; and Dr. 
 Venables, who was the first to call the attention of the profession to this 
 affection, bestows high commendation on the phosphate of iron. Dr. 
 Prout insists^moreover, on the importance of a suitable diet, into which 
 albuminous matters should enter freely, in preference, though not to 
 the entire exclusion, of those which contain gelatine. Milk should 
 form a chief element in the diet ; while of farinaceous matters, those 
 are to be preferred which have undergone the fermentative process. 
 These precautions, too, must be observed, not for a short period only, 
 but until the child has for some time regained its health, since a slight 
 error is very likely to be followed by a serious relapse. 
 
 Incontinence of urine is a very distressing infirmity from which 
 children sometimes suffer, and which, in many instances, it is found 
 very difficult to cure. In most cases this inability to command the flow 
 of urine exists only in the night-time, but sometimes it is present also 
 by day ; and both forms of the affection are met with in children of 
 both sexes and of all ages, even up to the period of puberty. The 
 nocturnal incontinence of urine is often associated with the presence of 
 an excess of lithic acid in the secretion ; and in such cases the first step 
 towards remedying the infirmity consists in correcting the morbid state 
 of the fluid. Now and then it appears to be dependent upon the irri^ 
 tation produced by ascarides in the rectum, while in the majority of 
 cases, so long as the affection is recent, a connection may be clearly 
 traced between it and gastro-intestinal disorder. If not remedied, how- 
 ever, all the other functions of the body may return to a healthy state, 
 while yet the incontinence is perpetuated by a kind of habit, which it 
 is found very difficult to break through. 
 
430 INCONTINENCE OF URINE. — ITS TREATMENT. 
 
 The involuntary discharge of urine by day-time as well as at night is 
 a still more troublesome affection. Sometimes there is an absolute 
 ■want of control over the bladder ; so that the urine is almost constantly 
 dribbling away; while in other cases the desire to pass water is dis- 
 tinctly felt at certain short intervals ; but the patient is unable to resist 
 this desire even for a minute. This affection, too, is sometimes asso- 
 ciated with a morbid condition of the urine ; in other instances it seems 
 to depend on a state of general weakness; while in some cases there is 
 no apparent cause, either general or local, to which it is possible to 
 ascribe it. Cases of this last kind are of all the most troublesome ; 
 they are sometimes met with in several members of the same family, 
 especially in girls, though, according to my experience, the other more 
 curable forms of incontinence are much more common in male children. 
 
 In the cure of nocturnal incontinence of urine which may often be 
 gained by attention to certain precautionary measures; such as limiting 
 the quantity of drink taken at the last meal, preventing the child from 
 lying on his back when in bed (a position which seems greatly to favour 
 the occurrence of the accident), and rousing him from bed to empty his 
 bladder two or three times in the night. If the urine be loaded with 
 lithates, the diet must be most carefully regulated, and medicines must 
 be given to restore the urine to a healthy state, and to ensure the due 
 performance of the functions of the digestive organs. Tonics are often 
 extremely useful afterwards, and there is none from which I have seen 
 so much benefit as from the tincture of the sesquichloride of iron. At 
 the same time, cold sponging to the back and loins is often decidedly 
 serviceable ; and if the case resist these milder measures, the frequent 
 application of a blister to the sacrum seldom fails to do great good. In 
 very obstinate cases the tincture of cantharides is of service ; and once 
 or. twice I have employed with advantage large doses of the nitrate of 
 potash, according to the recommendation of Dr. Young, of Chester ; 
 but, as a general rule, the employment of these stimulant diuretics is 
 not desirable. 
 
 LECTUKE XXXYI. 
 
 Abdominal Tumors.— Enlargement of abdomen not always the result of actual disease — 
 causes to which it may be due. — Abdominal tumors — from enlargement of the liver, 
 by simple hypertrophy, by hydatid growths, by malignant disease — from malignant 
 disease of the kidney — from enlargement of the spleen — from psoas abscess. — Cases 
 in illustration. 
 
 Infantile Syphilis — its symptoms — characters of the syphilitic cachexia — tendency of 
 the symptoms to return after apparent cure. — Treatment. 
 
 Discharges from the vulva and vagina of female children — how to be distinguished from 
 gonorrhoea — associated with debility and strumous habit — difficult of cure. — Treatment. 
 
 Among the anatomical peculiarities of early life, none is more 
 remarkable than the great size of the abdomen, as contrasted with the 
 undeveloped state of the thorax, on the one hand, and of the lower 
 extremities, on the other. Though most striking in the new-born 
 infant, it still continues to a great degree during the whole of the first 
 
ABDOMINAL TUMORS. 431 
 
 years of childhood; nor does it altogether disappear until, with 
 advancing age, the pelvis enlarges, the spinal column acquires its 
 proper curvature, the limbs gain their due development, and the chest 
 expands in a measure commensurate with the demands made upon the 
 thoracic viscera for the vigorous performance of their functions. 
 
 The anxiety of non-professional persons is often needlessly excited 
 by the large size of the abdomen in childhood, while those even who 
 are conversant with medicine do not always bear in mind the very 
 different causes to which an increase of its bulk may be due. It will, 
 therefore, I think, be no waste of time to notice briefly the circum- 
 stances under which enlargement of the abdomen may occur in child- 
 hood, and to give you what little information I may be able to furnish 
 with reference to those diseases which occasion distinct abdominal 
 tumors. 
 
 The abdomen sometimes appears preternaturally large, wholly inde- 
 pendent of any disorder of the general health, but as the result of the 
 child's growth and development having gone on slowly, so that its 
 body retains its infantile proportions but little altered at the age of 
 two or three years. If, as often happens, this tardy development 
 should be associated with feeble health, with a somewhat impaired per- 
 formance of the digestive functions, and with a constipated condition 
 of the bowels, flatus is almost sure to collect in the intestines, and 
 the enlargement of the abdomen is thus rendered still more consider- 
 able. With such a state of health, too, some of the minor degrees of 
 rickets are often associated ; and even though no serious deformity 
 mark the existence of the disorder, yet to its influence are due the 
 undeveloped chest and the small pelvis ; while the contracted and mis- 
 shapen thorax, which is produced by the advance of the disease, makes 
 the abdominal enlargement appear more striking, and causes the child, 
 according to MM. Rilliet and Barthez' apt comparison, to resemble the 
 toy tumblers which Italian image boys sell about the streets. 
 
 In cases such as have been referred to, you will save yourselves and 
 your patient's friends much needless anxiety, if you bear in mind that 
 tabes mesenterica is exceedingly rare before five years of age, while 
 this condition of general abdominal enlargement is met with chiefly 
 between the commencement and the end of the first dentition. Further, 
 you will find that, under these circumstances, the abdomen is perfectly 
 soft and painless ; you will learn that no symptom of tubercle has 
 shown itself; while, if you strip the child, which in doubtful cases you 
 ought to do, you will probably see more or less distinct indications of 
 the action of rickets, either in deforming the skeleton, or in disordering 
 its proportions. 
 
 Enlargement of the abdomen is a much more frequent attendant on 
 tubercular peritonitis than on mesenteric disease. The tense, and 
 tympanitic, and painful, state of the abdomen, the sensation of adhesion 
 between the abdominal walls and the subjacent viscera, the loss of flesh, 
 the frequently recurring diarrhoea, the febrile symptoms, and the more 
 or less well-marked indications of tubercular disease which attend it, 
 usually stamp the nature of that affection too clearly for the attentive 
 observer to fall into error. 
 
432 ABDOMINAL TUMORS. 
 
 But besides these cases, in which there is a general enlargement of 
 the abdomen, there are others in which its increase of size is mainly 
 due to the presence of a distinct and well-defined tumor. A good many 
 instances of this sort have come under my notice at different times, 
 though, as often happens in Dispensary practice, the number of those 
 is but small in which I have had the opportunity of watching the affec- 
 tion to its close, and of confirming or correcting by an examination 
 after death the diagnosis formed during the life-time of the patient. 
 
 One not very uncommon cause of abdominal tumor is enlargement of 
 the liver, which sometimes undergoes a very great increase of its bulk, 
 without any obvious reason, and even unattended with any serious 
 disturbance of the general health. I remember a little girl, about ten 
 years old, who was received into St. Bartholomew's Hospital on account 
 of the very great enlargement of her abdomen. She looked very pale, 
 and the distension of the superficial veins of her chest and abdomen, 
 and the livid congestion of her face, shewed that there existed some 
 serious obstacle to the circulation. Her abdomen had been gradually 
 enlarging for many months, and at the time of her admission into the 
 hospital the margin of the liver was distinctly traceable below the 
 umbilicus ; her bowels were habitually constipated, but the evacuations 
 were natural in appearance, and the child was well-nourished, cheerful, 
 and active, being but little annoyed by her great size. I saw her again 
 two years afterwards, and her condition was then quite unaltered. 
 Similar cases, of what I believe to have been simple hypertrophy of 
 the liver, have since come under my notice. For the most part they 
 were associated with very obvious indications of a scrofulous habit, but 
 on one occasion only was there any serious disturbance of the general 
 health ; the child in that instance suffering from very severe diarrhoea, 
 which had succeeded to a state of somewhat obstinate constipation. 
 
 I once met with a hydatid tumor of the liver in a girl aged 13 J 
 years, in whom, two years and a half previously, a swelling had begun 
 to form at her right side, without any sign of general indisposition, 
 though the subsequent increase of the growth had been attended with 
 occasional attacks of severe pain. At the time of my seeing her she 
 had gone through a variety of treatment, which consisted chiefly in 
 leeching and the inunction of iodine ointment, without any benefit ; but 
 her general health was good, although she was small for her age. On 
 removing her dress, the lower part of her chest and the upper part of 
 her abdomen were seen to be much enlarged by a growth the lower 
 margin of which could be felt a little above the umbilicus, and which 
 seemed larger on the right than on the left side. At this time the 
 circumference of her chest, on a level with the nipple was 25J inches, 
 and 25 inches,. four inches lower down; but three years and a half 
 later, and a short time before her death, she measured 32 inches at the 
 former, and 33 at the latter point. Even when I first saw her, the 
 respiratory murmur ceased to be audible on a level with the nipple, and 
 the cavity of the chest became still more encroached on with the 
 advance of the disease. Fluctuation was distinctly perceptible over 
 nearly the whole of the tumor in the chest as well as in the abdomen, 
 and continued so during the whole of the patient's life. It was in May 
 
EXAMINATION AFTER DEATH. 433 
 
 1840 that the patient first came under my notice, and no change what- 
 ever took place in her condition until February 1842. At that time, 
 after severe pain in the tumor had been experienced for several days, a 
 fresh growth made its appearance, of about the size of a breakfast-cup, 
 to the left of the umbilicus, and a little above it. In July following, 
 the patient began to lose flesh, her appetite failed, and she began to 
 suffer frequent attacks of palpitation. At this time, and often subse- 
 quently, the child complained of pain and numbness, extending down 
 the right arm. Notwithstanding the progressive increase of the tumor, 
 the patient's health continued tolerably good for the succeeding seven- 
 teen months, though she grew but little, and no signs of approaching 
 puberty appeared. In the middle of December 1843, symptoms of 
 gastric disorder showed themselves: the child suffered much from 
 flatulence, had occasional diarrhoea, severe pain in her abdomen, great 
 feverishness, and her mind wandered a little at night. The skin grew 
 jaundiced, and her water became very high coloured ; while the attacks 
 of pain, chiefly referred to the epigastrium, sometimes were so severe 
 that the patient fainted from their intensity. Slight cough came 
 on, and for three weeks before death she was unable for a moment to 
 assume the recumbent posture. Her strength gradually failed, and 
 she died on Jan. 28, 1844, during an unusually severe attack of pain. 
 
 On opening the abdomen, from which a gallon and a half of transpa- 
 rent yellow scum escaped, the enormously large liver was brought into 
 view. It reached down to somewhat below the false ribs on the left 
 side, not quite so low on the right, and extended upwards on the left, 
 pushing thexdiaphragm before it to rather above the upper margin of 
 the second rib\and on the right side to a little above the level of the 
 third. This enlargement seemed made up of the left lobe, for the right 
 lobe, rather dark but otherwise healthy, was found pushed downward by 
 it into the right flank. The surface of the enormously enlarged left 
 lobe was of a pale colour : on making an incision into it, it was found 
 to have formed a sac, the parietes of which were about a third of an 
 inch thick, containing a gallon of viscid yellow fluid, and a number of 
 hydatids of large size. The sac itself appeared to be formed by the 
 parent hydatid, the parietes of which were firmly adherent to the sub- 
 stance of the liver. At the anterior edge of the right lobe of the liver, 
 just to the right of the gall-bladder, was a yellowish white tumor of the 
 size of a walnut, which, on being cut into, was seen to be composed of 
 dead and shrivelled hydatids ; they were folded together, one within the 
 other, like the coats of an onion, except that, in order to reduce the 
 space they occupied as much as possible, they were plicated. The two 
 or three outer layers had begun to be the seat of cretaceous deposits. 
 The gall-bladder contained a little pale, fluid, bile. 
 
 The lungs were healthy, though much compressed. The valves of the 
 heart were quite healthy, but the pericardium was universally, and in 
 some parts very firmly, adherent to its substance ; the result, doubtless, 
 of inflammation, which most likely came on at the time when the child 
 began to complain of palpitation of the heart. The other viscera were 
 quite healthy. 
 
 I have once seen the liver in the child the seat of malignant disease 
 
 28 
 
434 FUNGOID DISEASE OF THE LIVER — OF THE KIDNEYS. 
 
 of the fungoid kind, in the progress of which the organ acquired a very- 
 large size. The affection was attended by vague indications of abdo- 
 minal disease, in which there was nothing that pointed especially to any 
 one viscus, while the morbid growth, having originated from the under 
 surface of the right lobe of the liver, was supposed, from the relations 
 which it presented, to be due to enlargement of the mesenteric glands. 
 The patient was a little boy, who was eight months old when the first 
 indications of disordered health appeared, in diarrhoea, fretfulness, and 
 loss of flesh and appetite ; and at the age of nine months his mother 
 noticed some solid masses in the abdomen, though from the commence- 
 ment of his illness his belly had been hard and rather tender. The 
 child lived to the age of one year ; and for the last six weeks of his life, 
 during tvhich time I had the opportunity of watching him, he suffered 
 from diarrhoea, which was occasionally very profuse. He became ex- 
 tremely emaciated, and his skin assumed an exceedingly sallow colour ; 
 but the evacuations, though relaxed, were otherwise natural. No 
 hasmorhage took place from the intestines, and the urine was found to 
 be perfectly natural whenever it was tested. During the last month of 
 his life he had a slight cough and wheezing respiration ; but death 
 seemed due to the constant diarrhoea and the severe pain which the child 
 suffered ; his exhaustion being doubtless in great measure the conse- 
 quence of the blood which should have nourished his body being diverted 
 to supply the enormous mass of fungoid disease of the liver. 
 
 During the six weeks that the child was under my observation, his 
 abdomen increased from twenty-one to twenty-five inches in circum- 
 ference, and the tumor, the surface of which was uneven, was always 
 much larger on the left than on the right side. It turned out, however, 
 on an examination after death, that the left lobe of the liver was almost 
 completely healthy, but that it had been driven up under the ribs by 
 the enlarged right lobe ; which part of the organ was converted into a 
 soft, white, brain-like matter, intermingled with which were portions of 
 a firmer, highly vascular, fibro-cellular substance. The disease, in 
 short, consted of a mixture of carcinoma medullare, and carcinoma 
 fasciculatum. A few deposits of medullary cancer, one of them as big 
 as a walnut, existed also in the right lung, but the other viscera were 
 healthy. 
 
 Malignant disease of the kidney is another occasional cause of abdo- 
 minal tumor in children, and of this I have met with two instances. 
 The first occurred in a boy, who died at the age of two years and ten 
 months ; and the second in a girl, who was fourteen months old at death. 
 In the former case, at the same time that the child became languid and 
 fretful his abdomen was observed to be enlarging. For a few days in 
 the early part of his illness he was reported to have passed bloody 
 urine ; but this symptom did not recur during the subsequent progress 
 of the disease. In proportion as his abdomen increased in size, he be- 
 came more and more emaciated : he had occasional attacks of diarrhoea, 
 but nevertheless his appetite continued craving ; and it was not till ten 
 months after the first symptom had been noticed that the child died, 
 exhausted. In the case of the girl, the disease ran a much more rapid 
 course, and death took place in ten weeks from the appearance of the 
 
TUMOR FROM PSOAS ABSCESS. 435 
 
 first symptom. She was attacked with feverishness, gastric disorder, 
 and occasional vomiting, which had not continued more than a week 
 when her mother noticed a tumor in the abdomen. When these symp- 
 toms came on, the child was well nourished, but she lost flesh rapidly 
 in proportion as her abdomen increased in size ; her evacuations were 
 often very unnatural, but at no time was there either diarrhoea or hema- 
 turia. Towards the end of her life she became very fretful, and seemed 
 occasionally to suffer severe pain in the abdomen ; but her death took 
 place suddenly, and without any sign of her health being worse than it 
 had appeared to be for some days before. In one case the left, in the 
 other the right kidney, was the seat of the disease : the local symptoms 
 were very similar in both instances, and consisted in the presence of 
 a solid tumor occupying the lumbar region, and extending from the 
 spine across the abdomen towards the opposite side, and reaching up- 
 wards beneath the ribs, and downwards towards, and in the first case 
 even into, the pelvis. On examining the body after death, the nature 
 of the disease was seen in both instances to be precisely the same, being 
 a mixture of cerebriform matter and of the peculiar structure of fungus 
 nematodes, while in both the kidney was considerably bigger than the 
 head of an adult. 
 
 In connection with this subject, I must warn you of the possibility of 
 mistaking the swelling formed by a psoas abscess for that produced by 
 enlargement of the kidney. When psoas abscess occurs in young 
 children, its early stages may readily be overlooked, partly because the 
 patient is unable to describe those vague sensations of uneasiness in 
 the loins byxwhich it is attended, — partly because impairment or loss of 
 the power of walking is so common a result of indisposition of any kind 
 in early life that it seems scarcely necessary to seek for any special 
 cause to explain its occurrence. The gradual failure of the health, the 
 loss of flesh and the occasional disturbance of the bowels, are symp- 
 toms that attend upon various disorders of the abdominal viscera, and 
 that present nothing pathognomonic of any. The tumor, like that 
 formed by enlargement of the kidney, occupies the lumbar region, pro- 
 jecting forwards into the abdomen ; while fluctuation in the abscess is 
 often so obscure, as to be scarcely, if at all, perceptible. The tumor 
 of psoas abscess, however, reaches less high up in the abdomen than 
 that formed by enlargement of the kidney : its contour is usually more 
 circular, less oval, and the tenderness over it is in general greater, 
 than in cases of malignant disease of the kidney. As the affection 
 advances, and the matter gravitates into the thigh, or points in the 
 lumbar region, its nature becomes clearly manifest; but though, as far 
 as the final issue of the case is concerned, an error of diagnosis is of 
 but little import, it is yet very desirable for your own reputation that 
 you should not, at any period, have fallen into a mistake as to its 
 nature. 
 
 In this country, and especially in the neighbourhood of London, 
 where the severer forms of intermittent fever seldom occur, we do 
 not often meet with instances of that enlargement of the spleen which 
 is common enough even among children in malarious districts, and 
 usually, though not invariably, succeeds to previous attack of ague. 
 
436 ENLARGEMENT OF THE SPLEEN. 
 
 The only instance of it which I have had the opportunity of observing 
 was presented by a little girl, six years and a half old, who had lived 
 at Fernando Po from the age of two years and a half, having had 
 dysentery at three years old, and frequent attacks of fever subse- 
 quently. The enlargement of her spleen had first become apparent at 
 five years of age ; and when I first saw her, a few weeks after her 
 return from Africa, it had attained so considerable a size that her 
 abdomen measured twenty-one inches and a half in circumference. 
 The spleen in this case reached from under the ribs quite down into 
 the pelvis, and forwards as far as the mesial line of the abdomen. 
 Independently of the patient's history, which in a case of this kind 
 would be of itself sufficient to prevent an erroneous diagnosis, the 
 relations of the swelling were characteristic ; for, although situated at 
 the side of the abdomen, it did not extend backwards into the lumbar 
 region so as to fill it up completely, as an enlarged kidney would do, 
 but a considerable interval existed between the posterior margin of 
 the tumor and the vertebral column. 
 
 Though, in the cases which I have just related to you, the enlarge- 
 ment of the abdomen was in general due to malignant disease, yet I 
 would not have you too ready to pronounce an unfavourable prognosis 
 .concerning cases in which you find some increase in the size of the 
 abdomen, and that increase apparently associated with the presence of 
 a definite tumor. A decided opinion can seldom be formed after seeing 
 such cases only once ; for, in addition to the usual sources of fallacy, 
 there are those special difficulties which arise from the child's unwil- 
 lingness to submit to any protracted examination, and which compel 
 us to acquire our knowledge by instalments. Moreover, the rate of 
 increase of the tumor, the changes in its contour, and in its relations 
 to the abdominal viscera, often require to be carefully noticed, before 
 you can venture to pronounce upon it with any certainty. I have 
 indeed known some instances, where the complete disappearance of 
 manifest abdominal tumor, and the eventual recovery of perfect health, 
 have belied the unfavourable opinion which I had expressed. I wish 
 that I could give you some criterion for distinguishing the hopeful 
 cases from those which are hopeless ; but even this caution as to the 
 possibility of error may not be without its use. 
 
 According to the plan which we proposed to follow in this course of 
 lectures, it remains for us now to study, in conclusion, the febrile dis- 
 eases of infancy and childhood. There is one affection, however, too 
 important to be passed over in silence, although it cannot be assigned 
 to any of those classes into which, for convenience sake, we distributed 
 the diseases of early life. I propose, therefore, to devote the remaining 
 half hour of to-day to the study of infantile syphilis, and to defer till 
 to-morrow the consideration of the fevers and exanthemata. 
 
 Syphilis, as it occurs in the infant, presents many important dif- 
 ferences from the characters which it assumes in the adult ; nor is there 
 in this any thing to excite our surprise, if we bear in mind the very 
 different circumstances under which, in the two cases, the poison infects 
 the organism. In the adult, the manifestations of the disease are 
 almost always the result of the direct inoculation of the system with 
 
INFANTILE SYPHILIS. 437 
 
 the venereal virus. In the child, infection by that mode seldom occurs. 
 The supposition, once generally entertained, that an infant becomes 
 affected with syphilis in consequence of its body being brought, during 
 the time of its birth, into contact with venereal sores upon the mother's 
 genitals, is now deservedly regarded as altogether erroneous. The 
 infection of a child by sucking the breast of a syphilitic nurse, is, to say 
 the least, a very unusual occurrence ; and the weight of evidence is 
 dacidedly against its ever taking place. In by far the greater number 
 of cases the infant has, without doubt, contracted the disease in the 
 womb, although its indications comparatively seldom shew themselves 
 until at least fourteen days after birth. In many of these cases the 
 mother has, during her pregnancy, been the subject of primary syphilis, 
 or if not, has presented well-marked secondary symptoms; and under 
 either of these conditions we can understand that her infected blood 
 may deteriorate that of her infant, and give rise to consequences more 
 or less analogous to those from which she has recently suffered herself. 
 Cases, however, are now and then met with, in which the venereal taint 
 appears to have been derived entirely from the father ; the mother, as 
 far as can be ascertained, not having suffered at any time either from 
 primary or secondary symptoms, although she has given birth to an 
 infant affected with all the characteristic marks of syphilitic disease. 
 
 Through whichever of these media the infant becomes infected with 
 syphilis, symptoms of the same kind appear, though there is no inva- 
 riable order in which they shew themselves ; and coryza is its earliest 
 indication in one case, a cutaneous eruption in a second, ulceration 
 about the corners of the mouth in a third. When we consider the fre- 
 quency with wjiich abortion or premature labour appears to be due to 
 the influence of the syphilitic poison, it might naturally be expected 
 that cases should be by no means unusual in which infants at the moment 
 of their birth should present evidences of the venereal taint. This, 
 however, is very seldom the case, — so seldom, indeed, that I do not 
 remember to have met with an instance of it; neither has any case 
 come under the notice of M. Trousseau, of Paris, 1 whose appointment at 
 the Hopital Necker in that city gave him most ample opportunities for 
 observing the diseases of early infancy. Children, although infected 
 with syphilis, and in whom the signs of the disease speedily shew them- 
 selves, are yet generally well nourished, and apparently in good health, 
 at the time of birth. This, too, is observed to be the case even where 
 the mother has suffered severely from secondary symptoms, — has 
 already aborted frequently, or has given birth prematurely to dead 
 children whose cuticle was peeling off, — a condition generally regarded, 
 though far from being satisfactorily proved, to be an effect of the venereal 
 poison. When she at length produces a living child, there is nothing for 
 the first two or three weeks after its birth to distinguish it from the 
 offspring of the most healthy parents. After the lapse of that time the 
 first symptom of disease shows itself; and most commonly this is 
 nothing more than the occurrence of a degree of snuffling with the 
 
 1 See his very valuable memoir on Infantile Syphilis, in the Archives Gen. de M6decine 
 for October, 1847. 
 
438 SYMPTOMS OP INFANTILE SYPHILIS. 
 
 child's breathing, and slight difficulty in sucking, — the signs, in short, 
 of ordinary coryza. Now and then, as I stated some days ago, 1 no 
 other indication of syphilis appears ; but nevertheless the coryza does 
 not yield until after the child has been brought under the influence of 
 mercurial remedies, — a fact which would seem to shew that, although 
 unaccompanied with other signs of venereal taint, the snuffles of young 
 infants are sometimes produced by that cause. In the majority of 
 instances, however, the coryza does not continue long without charac- 
 teristic signs of disease appearing about the nostrils themselves, and 
 without syphilitic eruptions breaking out upon the surface of the body. 
 The mucous membrane of the nostrils secretes a yellow ichorous matter, 
 sometimes slightly streaked with blood, which drying, obstructs the 
 opening of the nostrils, and renders breathing and sucking very dis- 
 tressing to the child. The voice, too, before long becomes affected, and 
 assumes a peculiar hoarse tone, which has been not inaptly compared 
 to the sound of a child's penny trumpet, and which, when you once 
 have heard, you will at once recognize as almost pathognomonic of 
 syphilis. This change of voice depends no doubt on the affection of the 
 throat, which you will often see, in common with the interior of the 
 mouth, to be red and shining, and to present many superficial ulcera- 
 tions. The skin of the upper lip, over which the discharge from the 
 nostrils runs, often becomes exoriated, or if not, it assumes a peculiar, 
 yellowish brown, colour, like the hue of a faded leaf. Should the dis- 
 ease be unchecked, large patches of the skin upon the face and forehead 
 put on this appearance, which seems due to a kind of staining of the 
 part, and is unaccompanied with any alteration of its texture. Both 
 lips before long become affected : a number of minute perpendicular 
 fissures take place in them, which bleed whenever the infant sucks ; and 
 small ulcerations appear at either angle of the mouth. It generally 
 happens, however, before these effects of the disease have become very 
 obvious about the mouth, that the skin in various parts presents ap- 
 pearances equally characteristic. Though not limited to any situation, 
 the eruption of syphilis usually makes its appearance about the buttocks 
 and nates, in the form of small, circular, shining spots of a coppery red 
 colour, having a slightly shining surface, and disposed to become some- 
 what rough at their centre from the desquamation of the epidermis in 
 that situation. The spots in the neighbourhood of the anus often 
 degenerate into small, soft, spongy ulcerations, with a slightly elevated 
 base ; the margins of the anus become fissured; and the skin about the 
 scrotum and along the inside of the thighs grows red, sore, cracked, 
 shining, and denuded of its epidermis. The eyes grow weak, the mar- 
 gins of the eye-lids sore, and a scanty, adhesive, puriform secretion is 
 poured out from the Meibomian glands, attended with but little redness 
 of the conjunctiva. Sometimes, too, the hair of the head drops off, as 
 small, red, sometimes slightly elevated spots, extend over the scalp. 
 
 The child is generally by this time reduced to the last stage of weak- 
 ness and attenuation, but even when the disease proves fatal, it does 
 not, as in the adult, affect the bones. I have chanced, indeed, to see one 
 
 i In Lecture XV. p. 169. 
 
PROGRESS OF THE DISEASE. 4S9 
 
 instance of destruction of the bony palate from this cause in an infant 
 of a few months old, but so rare is the occurrence that the late Mr. 
 Colles of Dublin, 1 notwithstanding his immense experience, states that 
 he had never observed it. Should life be prolonged after the disease 
 has reached an advanced stage, its further manifestations consist in the 
 formation of small pustules about the mouth, especially upon the lower 
 lip and chin, which destroy the cutis, and leave the surface after they 
 have healed much scarred by their cicatrices. The epidermis, too, in 
 some bad cases peels off the hands and feet : it generally becomes thick- 
 ened to a kind of crust, like that which forms on the hands in psoriasis 
 palmaria, and then, cracking, falls off in patches, leaving the skin 
 fissured and sometimes deeply ulcerated at the bend of the wrist, or at 
 the flexures of the fingers and toes. The new and delicate epidermis 
 in its turn undergoes a similar thickening, and becomes detached in 
 the same manner, or else it continues white and thin, but shrivelled, 
 and looking like the sodden and wrinkled skin of a washerwoman's 
 hand, and peeling off in little fragments, leaves the cutis, especially at 
 the tips of the fingers and toes, red, and bleeding slightly, even on the 
 gentlest touch. 
 
 Although such are the effects that may flow from infantile syphilis 
 when it runs its course unchecked, it yet happens but rarely that we 
 meet in any case with all the symptoms that have just been described. 
 Most serious constitutional disturbance is associated with the local 
 mischief, and the child often falls a victim to the former, when the out- 
 ward signs of syphilitic disease are yet comparatively slight. It wastes 
 rapidly, it suffers from sickness, or its bowels become much purged ; it 
 is constantly fretful and uneasy ; the advance of ossification is arrested ; 
 the head feels soft, and the anterior fontanelle is large ; — circumstances 
 which sometimes lead to the suspicion that chronic hydrocephalus has 
 come on, though, if the poison of syphilis should be eradicated from the 
 system, the completeness of the patient's recovery shows that no serious 
 cerebral disease had existed. In children affected by this syphilitic 
 cachexia, not only are the loss of flesh, and that withered aspect which 
 gives to infancy the appearance of old age, very remarkable, but also 
 the bloodless state of the conjunctiva, and the yellow waxen hue of t^he 
 skin, like that of a person who has been reduced to the most extreme 
 degree of anaemia. Even in children who have survived their earliest 
 infancy, and in whom the disease, though not completely eradicated, 
 has yet been kept in check, this colour of -the skin continues, and seems, 
 indeed, to be an almost pathognomonic sign of the affection from which 
 they are suffering. 
 
 When imperfectly cured, other indications of the disease remain 
 besides the impairment of the general health, the loss of flesh, and the 
 peculiar colour of the skin, or at least, if not constantly present, they 
 show themselves from time to time, reappearing at uncertain intervals, 
 without there being any fresh cause for their manifestation. Such 
 symptoms are the return of the small copper-coloured spots, which, 
 however, seldom reappear in considerable numbers ; the general loss of 
 
 1 Practical Observations on the Venereal Disease, 8vo. p. 271. London, 1837. 
 
440 CHARACTERS OF THE SYPHILITIC CACHEXIA. 
 
 hair ; the existence of a slight degree of coryza ; the appearance of one 
 or two soft tubercular elevations, with ulcerated summits, about the 
 organs of generation, or the outbreak of a very severe and unmanage- 
 able intertrigo. In other instances, there are few local signs of the 
 disease beyond the occurrence of small ulcerations at each angle of the 
 mouth, or the development of large soft condylomata at the verge of 
 the anus, or in a few instances the formation of exceedingly trouble- 
 some ulcerations, having a slightly elevated base, between the fingers 
 and toes, which last appearances seem to belong to the tertiary rather 
 than to the secondary consequences of syphilitic disease. 
 
 The duration of the disease, and the mode in which it proves fatal, 
 vary in different cases ; for while death sometimes takes place speedily 
 under the first outbreak of its symptoms, life is in other instances pro- 
 longed for several months. In cases of this kind the more marked 
 signs of the disease recede for a time either spontaneously or under 
 medical treatment, but the evidences of the syphilitic cachexia continue, 
 the child never regains its health, glandular enlargements take place, 
 and it either dies phthisical, or else drags out a miserable existence until 
 some intercurrent disease, as pneumonia or diarrhoea, supervenes and 
 destroys it. 
 
 But though the consequences of infantile syphilis are so serious, if it 
 be either let alone or inefficiently treated, a fatal result seldom takes 
 place if remedies be employed before the syphilitic cachexia has become 
 fully established, and if treatment, when once begun, be perseveringly 
 continued for some time after the complete disappearance of every 
 symptom. This, indeed, sometimes implies the continuance of treat- 
 ment for two or even three months ; for so long as any symptom remains, 
 be it only a slight spot of eruption, or a small condyloma about the anus, 
 the suspension of remedies will be certainly followed by the reappear- 
 ance of the whole train of symptoms. Even after the apparent cure of 
 the affection, it is not wise hastily to omit all medicines, since, just as 
 in the adult, the symptoms have a great tendency to recur. 
 
 Mercury in some form or other appears to be indispensable to the 
 cure of this affection. It has been recommended by some writers not 
 to administer it directly to the child, but to content ourselves with 
 bringing the mother's system gently under the mercurial influence, and 
 to cure the infant through her medium. In some slight cases this may 
 suffice, and in almost all, the cure of the infant is materially expedited 
 by the administration of the remedy to its mother ; but I think that, as 
 a general rule, it is expedient to give mercury likewise to the child. 
 For internal administration I prefer the hydrargyrum cum creta, to any 
 other form of the remedy, and give it in doses of a grain twice a day to 
 a child of six weeks old, combining it with two or three grains of chalk 
 if the bowels be disturbed at the time of commencing the treatment, or 
 if they become so during its continuance. I have never found it 
 seriously disagree, though sometimes it causes sickness, in which case 
 small doses of calomel, or of the solution of corrosive sublimate, may be 
 substituted for it. In some cases, whatever be the form of mercurial 
 employed, its protracted use occasions such great irritability of the sto- 
 mach, that we are compelled to discontinue the remedy. Usually, the 
 
TREATMENT OF INFANTILE SYPHILIS. 441 
 
 child becomes able to take it again, after a pause of two or three days ; 
 but if this should not be the case, we must leave it oif, and content our- 
 selves with ordering a scruple of mercurial ointment to be rubbed into 
 the thighs or the axilla twice a day ; or with letting the child wear the 
 mercurial belt. This simple contrivance, which consists in nothing else 
 than swathing a piece of flannel, the inner surface of which is smeared 
 daily with the Unguentum Hydrargyri, around the abdomen of the 
 infant, is spoken of by those who have employed it most as being an 
 exceedingly efficacious method of bringing the system under the influence 
 of mercury, and as free from all the risks of disordering the child's 
 health which attend upon the internal administration of that remedy. 
 In Dispensary practice I confess that I have scarcely tried its merits ; 
 for I found that while I could give powders without suspicion, the mer- 
 curial ointment was known; and inconvenience arose from the remedy 
 betraying the nature of the disease. This objection might probably 
 have been got rid of by colouring the ointment with cinnabar ; but my 
 experience of the grey powder was on the whole so satisfactory, that I 
 felt the less anxious to try a new plan of treatment. 
 
 As a local application to the sores, the black wash usually agrees 
 better than anything else, but the large soft condylomata, which form 
 about the anus, often require to be touched with the solid nitrate of 
 silver. It very often happens that as the syphilitic symptoms disappear, 
 the health of the child becomes perfectly restored under the use of no 
 other remedy than mercury. If this be not the case, however, some 
 tonic medicine or other must be given. If the bowels be disordered, 
 the liquor cinchonse, or the extract of sarsaparilla, will be found very 
 useful. If there be no gastric or intestinal irritation, minute doses of 
 iodide of potass may be given in combination with the extract of sarsa- 
 parilla ; but if the syphilitic cachexia be w T ell marked, and the child have 
 suffered long from the disease, or have had frequent returns of its symp- 
 toms, no remedy has appeared to be so serviceable as the iodide of iron, 
 which may be given in the form of syrup, and is in most cases taken by 
 the child very readily, while it is seldom found to disagree. 
 
 I may here conclude my remarks about an affection which, perhaps, 
 in strict propriety, scarcely comes within my province; but before 
 closing to-day's lecture I should wish to say a few words about those 
 muco -purulent discharges from the vagina and vulva, in young girls, 
 which were once erroneously supposed to be due to some impure cause ; 
 an opinion which, though now justly abandoned by the profession, still 
 retains its hold among the vulgar. 
 
 Discharges of pus, or of mucus mingled with it, take place in female 
 children of all ages, from the time when dentition commences down to 
 the period of puberty, but are most frequent between the ages of two 
 and seven years. They are almost always essentially chronic in their 
 character, being associated in general w r ith very little swelling of the 
 sexual organs, and with little or no pain ; but proving extremely annoy- 
 ing from their disposition to continue for a long time, from their obsti- 
 nate resistance to remedies, and their great tendency to recur under 
 very slight exciting causes. Even when the discharge is very profuse, 
 there is no great redness of the parts from which it is poured out ; while 
 
442 TREATMENT OF INFANTILE SYPHILIS. I 
 
 it will be seen to be furnished almost entirely by the inner surface of 
 the labia, by the nymphee and the vulva generally, but to come scarcely 
 at all from the canal of the vagina. The slight degree of swelling of 
 the parts ; the source of the discharge almost exclusively from the parts 
 anterior to the hymen ; and the absence of dysuria, or the very slight 
 degree in which it has attended the onset of the affection, coupled with 
 the integrity of the hymen, and the absence of all appearances of 
 injury, are sufficient to distinguish this affection from gonorrhoea. 
 Sometimes, indeed, when this discharge has come on during teething, 
 it has been preceded by considerable dysuria ; but older children rarely 
 suffer more than a degree of itching and smarting of the parts, which is 
 troublesome from its persistence rather than from its severity. When 
 it occurs during dentition, the discharge is not in general abundant, and 
 ceases so soon as the tooth has cut through the gum, though probably 
 returning with a renewal of the irritation. Sometimes it occurs in 
 children who are much troubled by ascarides, when it is kept up in many 
 instances not merely by the irritation excited by their presence in the 
 rectum, but in a measure also by their creeping about the vulva. In 
 some instances it takes place as a sequela of the eruptive fevers, espe- 
 cially of scarlatina; and though I have never met with it under these 
 circumstances, except as a chronic ailment, accompanied by great gene- 
 ral debility, cases have been related, 1 in which it came on with acute 
 symptoms on the decline of the eruption. Generally, however, it 
 neither succeeds to any previous fever, nor is dependant on any local 
 cause, but occurs in strumous children in connection with general 
 impairment of health, or following some considerable fatigue. Where 
 no special cause can be assigned for its occurrence, its appearance is 
 yet, in general, preceded for a day or two by some slight increase of 
 indisposition; such as an attack of feverishness, or catarrh, or diarrhoea. 
 Be the cause what it may, our great difficulty in almost every 
 instance is to effect a permanent cure, so that the suspension of our 
 remedies may not be followed by a return of the discharge. When it 
 is connected with teething, or with the presence of worms, the indica- 
 tions are plain enough, and cure is in general comparatively easy. 
 Simple but abundant ablution with tepid water, repeated every hour or 
 two on the first appearance of the discharge, will, in conjunction with 
 appropriate general treatment, not infrequently suffice for its complete 
 arrest. If the discharge, however, continue for more than one or two 
 days, astringents must be had recourse to, such as the Liquor Plumbi 
 Dilutus, or lotions of sulphate of zinc, or of alum, each of which may 
 be employed for a few days, and then changed for another. At the 
 same time frequent cold sponging of the nates and vulva should be 
 employed ; and it must be impressed on the child's attendants that no 
 lotion whatever can supply the place of frequent ablution. Now and 
 then, when at the onset of the discharge there has been more dysuria 
 than common, I have given small doses of copaiba and liquor potassae ; 
 and have obtained from their administration just the same kind of 
 relief as those remedies afford in acute vaginitis in the adult. Such 
 
 1 By Dr. Cormack, in the London Journal of Medicine, Sept. 1850. 
 
' FEVERS. 443 
 
 cases, however, are quite exceptional ; and usually, tonics, and expe- 
 cially preparations of iron, are the only internal remedies which are 
 required, while it is in general necessary to begin their administration 
 early. These medicines, especially if associated with change to the 
 sea-side, and sea-bathing, usually suffice, even in the most obstinate 
 cases, to effect a cure. It is, however, in general a wise precaution to 
 continue the employment of frequent ablution, and, in addition, to 
 sponge the parts twice a day with alum lotion, even for weeks after 
 the discharge has completely ceased; while once I found the employ- 
 ment of a lotion of a scruple of nitrate of silver to an ounce of 
 water necessary to arrest a discharge which had bid defiance to all 
 other remedies. 
 
 LEC TUEE XXXVII . 
 
 Fevers — chiefly belong to the class of the Exanthemata. Mistakes with reference to 
 
 simple fever in childhood— its identity with fever in the adult. 
 Simple or remittent fever occurs in two degrees — symptoms of its milder form — of its 
 
 severer form— signs of convalescence — modes of death. — Diagnosis. — Treatment. 
 
 We come now to the last part of this course of lectures ; namely, 
 to the study of the febrile diseases incidental to infancy and childhood. 
 They belong, for the most part, to the class of the Exanthemata, — 
 diseases characterized, as you know, by very well-marked symptoms, 
 by a very definite course, and by usually occurring only once in a 
 person's life. These peculiarities have always obtained from them the 
 notice of practitioners of medicine, and few of the affections of early 
 life have been watched so closely, or described with so much accuracy, 
 as small pox, measles, and scarlatina. Hence it will be unnecessary to 
 occupy so much of your time with their investigation as we have 
 devoted to the study of other diseases which, though not so important, 
 have yet been less carefully or less completely described. 
 
 While the well-marked and unvarying features of the eruptive fevers, 
 however, have forced those diseases on the attention of all observers, 
 the more fluctuating characters of simple continued fever have been so 
 masked by the differences between youth and age, that the affection as 
 it occurs in early life was long almost entirely overlooked, and its nature 
 was, in many respects, still longer misapprehended. Many, indeed, 
 even of the older writers on medicine, have spoken of fevers as occurring 
 among children at all ages ; but under this name they confounded 
 together several diseases in which febrile disturbance was merely the 
 effect of the constitution sympathizing with some local disorder. This 
 mistake was committed with especial frequency in the case of various 
 affections of the abdominal viscera; many of which are attended by a 
 considerable degree of sympathetic fever, while their symptoms, in other 
 respects, are often so obscure that the perfect diagnosis of former days 
 failed to discover their exact nature. As medical knowledge increased, 
 many of these disorders were referred to their proper place ; but, never- 
 
444 INFANTILE REMITTENT FEVER. 
 
 theless, the descriptions given of the so-called remittent fever, worm 
 fever, and hectic fever of children, present little of a definite character, 
 and are evidently the result of a blending together of the symptoms of 
 various affections. The disease described under these different names 
 was supposed to be a symptomatic fever, excited by gastric or intestinal 
 disorder, and limited in the period of its occurrence to early life ; while 
 the absence of the well-marked shivering which usually attends the 
 onset of fever in the adult, the rarity of any efflorescence on the surface 
 of the body, and the comparatively low rate of mortality which it occa- 
 sions, led persons altogether to overlook the close connection between 
 it, and the continued fever of the adult. 
 
 If, however, we look attentively at the characters of this disease, 
 and compare them, as has been done by MM. Rilliet and Barthez, 
 with those presented by the simple continued fever of the adult, we 
 shall, I think, see so close a correspondence between the two affections 
 as to remove all doubt with reference to their identity. Both diseases 
 occur independently of any cause which we are able to detect ; and 
 both, though generally affecting isolated individuals, yet have also their 
 seasons of epidemic prevalence. Though varying in severity, so that 
 in some cases confinement to bed for a few days is scarcely necessary, 
 while in other cases the patient hardly escapes with his life, yet 
 medicine has not been able to cut short the course even of their mildest 
 forms. And, lastly, though the local affections associated with both 
 vary much in different cases, yet in every instance we meet with that 
 assemblage of symptoms which make up our idea of fever. Or if, from 
 the examination of the symptoms during life, we pass to the inquiry 
 into the traces left by the disease on the bodies of those to whom it 
 proves fatal, we shall find still further evidence of the close relation 
 that subsists between the fever of the child and that of the adult. 
 Enlargement, tumefaction, and ulceration of Peyer's glands, constitute 
 one of the most frequent morbid appearances m both diseases, and in 
 both, the changes that these glands are found to have undergone are 
 more advanced and more extensive in proportion to their nearness to 
 the ileo-caecal valve. In both, too, the mesenteric glands are enlarged, 
 swollen, of a more or less deep red colour, and manifestly increased 
 in vascularity; while the softened state of the spleen, the gorged con- 
 dition of the lungs, and the congestion of the membranes of the brain, 
 are appearances common to both diseases. There is, however, no 
 more relation between the severity of the intestinal lesion and the 
 intensity of the symptoms in the fever of the child, than in that of 
 the adult ; and there is no ground for regarding the disease as the 
 mere effect of the constitution sympathizing with a certain local mis- 
 chief in the former case, which may not be equally alleged with refe- 
 rence to the latter. The symptoms in both " are the expression of 
 the influence of the disease on the whole economy, of the disorder, 
 which it occasions in the principal functions of the body, and are an 
 essential part of the disease itself, rather than the secondary effects of 
 certain lesions of the bowels." 1 
 
 J Chomel, Legonsde Clinique Medicalo : Fi£vre Typhoide, p. 231, 8vo. Paris, 1834. 
 
SYMPTOMS OP ITS MILDER FORMS. 445 
 
 There are still many questions that might be proposed with reference 
 to the remittent fever of children, but on which I do not enter now, 
 because I am at present unable to give you what would be, even to my 
 own mind, a thoroughly satisfactory solution of them. We will, there- 
 fore, pass at once to a safer and more profitable field for inquiry, and 
 will examine into the symptoms that characterize this aifection. 
 
 The different degrees of severity which a disease may present in dif- 
 ferent cases do not in general form a good basis on which to found any 
 classification of its varieties ; but in the case of the remittent fever of 
 children the differences are so great between its milder and its severer 
 form, as to warrant our adopting them as a ground for a subdivision of 
 the disease into two classes. In cases of the first or milder kind, the 
 disease usually comes on very gradually, often so much so that the 
 parents of a child who is attacked by it are unable to name any fixed 
 time as that at which the illness began. The child loses its cheerful- 
 ness, the appearance of health leaves it, the appetite fails, and the 
 thirst becomes troublesome; by day-time it is listless and fretful, and 
 drowsy towards evening> but the nights are often restless, or the slumber 
 broken and unrefreshing; while all these symptoms come on without 
 any evident cause, and are not accompanied by any definite illness. 
 When once the attention of the parents has been excited to the condi- 
 tion of the child, it is soon ascertained that the skin is often hotter, and 
 almost always drier than natural, though now and then rather profuse 
 sweats break out causelessly on the surface, and continuing for an hour 
 or two, leave the patient in no respect relieved by their occurrence. 
 The bowels are sometimes loose even at the onset of the disease, or if 
 not, they are\in general readily disturbed by medicine; a very mild 
 aperient being not infrequently followed by three or four actions of the 
 bowels daily for the next two or three days. In a few instances there 
 is a condition of rather obstinate constipation at the onset of the dis- 
 ease, requiring active measures to overcome it ; but this is not often 
 the case, and when it does occur, it is, I think, more frequently in the 
 severer than in the milder form of the disease. The appearance of the 
 evacuations is almost always unhealthy, and they are usually relaxed 
 and very offensive. The tongue is generally rather deficient in mois- 
 ture, red at the tip and edges, thinly coated on the dorsum with white 
 mucus, through which the papillae appear of a deep red colour. The 
 abdomen is soft, though there is some flatus in the intestines, and pres- 
 sure is usually borne without pain. These characters often continue 
 through the whole course of the affection, though sometimes, after the 
 second week, pressure in either iliac region, especially the right, ap- 
 pears to cause suffering. The pulse is generally accelerated from the 
 very commencement of the illness; sometimes it is very much so, but 
 there is by no means a constant relation between the heat of the skin and 
 the rapidity of the pulse. Occasionally there is slight cough, but this 
 symptom is very frequently absent in the milder cases of the disease. 
 As the symptoms which constitute this affection come on very gradually, 
 so they often continue for several days with little, if any, change from 
 day to day, though the patient is far from seeming equally ill at all 
 times of the day ; and this periodical exacerbation and remission of the 
 
446 SYMPTOMS OF THE MILDER FORM OF REMITTENT FEVER. 
 
 symptoms has obtained for the disorder the name of remittent fever. 
 In some instances two distinct exacerbations and remissions may be 
 observed in the course of every twenty-four hours, but in the majority 
 of cases only one is well marked. The child, who during the day has 
 been listless and poorly, but yet not incapable of being amused, and 
 has had the appearance of a patient convalescent from illness, rather 
 than of one still suffering from disease, becomes flushed and uneasy, 
 and feverish, as evening approaches; and sometimes slight horripilation 
 ushers in the evening exacerbation of fever. The child seems drowsy, 
 and begs to be put to bed, where sometimes he sleeps, though seldom 
 tranquilly, till morning. In the second week, the nights generally 
 become worse than they were at an earlier stage of the disease ; the 
 child's skin is very dry and hot, he sleeps with his eyes half open, talks 
 in his sleep, wakes often to ask for drink, and occasionally has slight 
 delirium. Early in the morning he wakes pale and unrefreshed, but 
 about 9 or 10 o'clock seems to have recovered something of his cheer- 
 fulness, and for the succeeding three or four hours appears tolerably 
 well ; but as evening approaches he seems weary and drowsy, again 
 the febrile paroxysm occurs, and the succeeding night closely resem- 
 bles the night before. Sometimes, in addition to the evening exacer- 
 bation, there is a second one, though less severe, at about 11 o'clock in 
 the morning ; from which the child has hardly recovered before the 
 severe evening attack comes on. As the case advances towards reco- 
 very, the morning attack disappears long before the evening paroxysm 
 ceases to recur ; and it happens not infrequently that a slight threaten- 
 ing of the evening exacerbation continues to return for some time after 
 the child has seemed in other respects well. It is during the second 
 week of the disease that the typhoid eruption generally makes its 
 appearance, if it appear at all. In the milder cases, it is, I believe, 
 much oftener absent than present, and even in cases of a severe kind, 
 it is, if I may judge from my own experience, much less common in 
 this country than in France. Towards the end of the second, or the 
 beginning of the third week, the symptoms begin to abate, the bowels 
 act more regularly, the appearance of the evacuations becomes more 
 natural, the tongue grows cleaner and uniformly moist, the thirst dimi- 
 nishes, and the evening exacerbations of fever become shorter and less 
 severe ; while the child's cheerfulness by day returns, and its face 
 assumes the aspect of health. Still, after even a mild attack of this 
 disease, the child is in general left extremely weak, and greatly emaci- 
 ated ; the loss of flesh and strength being quite out of proportion to the 
 severity of the illness, and the progress to complete recovery being 
 generally very slow. 
 
 It sometimes happens, that, having set in with comparatively mild 
 symptoms, the infantile remittent fever assumes a serious character in 
 the course of the second week. In the majority of instances, however, 
 the severer form of the disease gives some earnest of its severity at a 
 very early period. It commonly sets in with vomiting, accompanied, 
 in many cases, by headache, or by a remarkable degree of drowsiness 
 and heaviness of the head. Coupled with these symptoms, there are 
 those indications of fever which attend the milder forms of the disease, 
 
OF ITS SEVERER FORxMS. 447 
 
 though in this case with a proportionable increase in their severity : and 
 sometimes distinct rigors may be observed alternating with the heat of 
 the surface, or preceding the evening exacerbations of the fever. In 
 the greater number of instances, the vomiting with which the illness 
 sets in does not return after the second or third day of the patient's 
 illness ; but to this there are occasional exceptions ; and as the sickness 
 is usually more severe in cases in which constipation is present, there is 
 some risk of mistaking the real nature of the affection, and of regard- 
 ing the irritability of the stomach as a sign of approaching cerebral 
 disease. Now and then, too, the drowsiness at the onset of the disease 
 is so overwhelming that I have known a child fall asleep two or three 
 times during breakfast, while its dizziness, and inability to walk steadily, 
 still further strengthened the impression that he was suffering from 
 some affection of the brain. Either of these occurrences, however, is 
 unusual; and, though listless and drowsy, the child is in general unwill- 
 ing to keep his bed, while by night he is commonly very restless,, waking 
 often in a state of alarm, or talking much in his sleep. The counte- 
 nance before long begins to wear the peculiar heavy appearance of a 
 fever patient, and by the end of the first or the beginning of the second 
 week the child is usually found to have sunk into a state of stupor, from 
 which he seems unwilling to be roused. The skin of the trunk is now 
 almost constantly hot as well as dry ; the temperature being often 
 higher than in any other disease, with the exception of scarlatina, and 
 in a few instances ranging as high as 105° Fah. My own observations 
 w T ith reference to the date of the appearance of any eruption on the 
 surface are neither sufficiently numerous nor sufficiently accurate for 
 me to rely on\their authority. MM. Rilliet and Barthez observe that 
 it very seldom appears so early as the fourth day, from the sixth to the 
 tenth being the most common date of its appearance; while both the 
 period during which it remains visible, and the number of spots, are 
 liable to great variation. In by far the greater number of cases, the 
 eruption, according to their experience, is extremely scanty ; it often 
 remains visible for only two or three days, and in not a few instances is 
 absent altogether. In a few cases of severe remittent fever, profuse 
 sweats take place, but they do not seem to have anything of a critical 
 character. The pulse is very frequent, and I have known it to con- 
 tinue at nearly 140 in the minute, for several days together, during the 
 increase of the fever in a child eight years old. A frequent, short, 
 hacking cough often occurs during the first week ; and rhonchus, sibilus, 
 and occasional large crepitation, are heard, in many cases, in both 
 lungs. Now and then, too, the respiration continues much accelerated 
 for several days, without any other sign of serious pulmonary disease 
 being present, and gradually regains its proper frequency as the febrile 
 symptoms subside. Tenderness of the abdomen is generally very evi- 
 dent before the first week is passed, but frequently there is no com- 
 plaint of pain, even in severe cases, except on pressure. Diarrhoea is 
 usually present, though it is not in general severe, the bowels not acting 
 above four or five times in the twenty-four hours. The tongue is 
 usually more thickly coated at the commencement than in the milder 
 forms of the disease ; a dry streak soon appears down the centre, and 
 
448 SYMPTOMS OP SEVERE REMITTENT FEVER. 
 
 by degrees the tongue becomes uniformly dry, red, and glazed ; or less 
 often it is partially covered with sordes. In the course of the second 
 week the patient generally sinks into a more profound stupor, a condi- 
 tion which alternates in many cases with delirum. Sometimes the mind 
 wanders occasionally almost from the commencement of the disease, in 
 other cases delirum is a very temporary symptom, occurring only at 
 night, or when the child, during the day-time, wakes from sleep. Now 
 and then, though not generally, the delirium is of a noisy kind, but the 
 child iiot infrequently tries to get out of bed ; and both the restlessness 
 and delirium, though generally present in bad cases during the daytime, 
 are aggravated in a marked degree at night. Once or twice I have 
 known violent delirium come on towards evening, the child crying and 
 shouting aloud during nearly the whole night, and sinking into a state 
 of stupor by day. The child now seems nearly or quite unconscious of 
 all that goes on around it ; its evacuations are passed unconsciously, 
 and it often seems dead to the sensation of thirst, by which, in the 
 early stages of the disease, it was so much distressed ; but this stupor 
 of fever is so different from the coma which supervenes in affections of 
 the brain, and the insensibility which characterises it is so much less 
 profound, that one can hardly be mistaken for the other. Even when 
 the disease is most severe, neither subsultus nor floccitation is frequent, 
 though it often happens that during the tedious and fluctuating conva- 
 lescence the child picks its nose till it bleeds, or makes the tips of its 
 fingers, or different parts of its body, sore by picking them. The pa- 
 tient is by the end of the second week, sometimes earlier, reduced by 
 the continuance of these symptoms to the most extreme degree of ema- 
 ciation, and to a condition apparently hopeless ; but there is no disease 
 from which recovery so often takes place, in spite of even the most 
 unfavourable systems, as from remittent fever. The signs of recovery 
 are, in the main, the same as betoken the recovery of an adult suffer- 
 ing from fever, but the amendment has seemed to me always to be 
 gradual, and in no case the result of any critical occurrence. Moisture 
 begins to reappear upon the edges of the tongue, the pulse loses its 
 frequency, the delirium ceases by degrees, more quiet rest is enjoyed at 
 night. Such signs of improvement may in general be looked for about 
 the end of the second week, but often the patient's progress is inter- 
 rupted by many fluctuations ; the convalescence is almost always slow, 
 and relapses occur from very slight causes. 
 
 In the few cases, and according to my experience they are but few, 
 in which remittent fever terminates fatally, death is seldom the result 
 of complications such as not infrequently supervene in the course of 
 fever in the adult, but the vital powers give way under the severity of 
 the constitutional affection, the symptoms of which assume more and 
 more of a typhoid character. It is towards the end of the second, or at 
 the beginning of the third week, that death under these circumstances 
 is most likely to occur ; I have seen it take place as late as the twenty- 
 ninth day in one instance, and at the end of the fifth week in another, 
 but in both of these instances gangrene of the mouth came on after the 
 more alarming general symptoms had begun to subside ; and to this the 
 death of the child was chieily due. Now and then a fatal termination 
 
DIAGNOSIS OF THE DISEASE. 449 
 
 takes place after the lapse of little more than a week from the com- 
 mencement of the illness, under signs of cerebral disturbance which 
 throw the general febrile symptoms into the shade ; great restlessness 
 and agitation, with loud cries, being succeeded by convulsions, and 
 they, in their turn, being followed by coma, in which the child dies ; 
 while an examination after death discovers nothing more serious than 
 a somewhat greater vascularity than natural of the brain and its 
 membranes. 
 
 The diagnosis of remittent fever, has been rendered needlessly diffi- 
 cult by the loose manner in which the name has been applied to a 
 variety of affections ; still it must be confessed that there are several 
 diseases, between which, and remittent fever, there are, in some parts 
 of their course, points of similarity that may easily deceive the unwary. 
 The resemblance is often very close between the milder varieties of the 
 fever and some of those cases of gastro-intestinal disorder, by no means 
 unusual in young children, which are excited by errors of diet, and are 
 either associated with diarrhoea or preceded by it. Even in such cases, 
 however, the loss of strength, the dry heat of the skin, and its intensity 
 at the time of the exacerbations of the fever, the marked disturbance 
 of the sensorium, and the delirium at night, which is almost always 
 present in children sufficiently old for this symptom to be apparent, are 
 characters by which remittent fever may generally be known. General 
 tubercular disease, running an acute course, may now and then be 
 taken for a short time for remittent fever ; but the observation of the 
 case for a few days will usually suffice to correct the error. In most 
 instances ofxthe former affection, indeed, the possibility of mistake is 
 altogether prevented by the skin being less hot, the sensorium not dis- 
 turbed, and the abdominal symptoms slighter than they might be 
 expected to be in a case of remittent fever of the same degree of 
 severity. Independently of this, too, auscultation will often shew good 
 reason for suspecting the real nature of the case, or the previous history 
 of the child will afford some clue with reference to it. There are two 
 other affections between which and remittent fever it is often far from 
 easy to distinguish, while, unfortunately, the practical evils that follow 
 from a wrong diagnosis are of a very serious nature. When speaking, 
 however, of hydrocephalus and of pneumonia, 1 I dwelt so fully upon 
 the circumstances that might lead you to mistake either of those 
 diseases for remittent fever, and of the characteristics which belong to 
 the last-named affection, that it can scarcely be necessary to do more 
 than refer you to the observations made on those occasions. 
 
 I am anxious, however, before we pass to the treatment of the disease, 
 to guard against an error which may possibly arise, from my having 
 pointed out certain well-marked distinctions between the cerebral 
 symptoms of hydrocephalus and those which accompany remittent fever. 
 Now, although it is perfectly true that the disturbance of the brain in 
 the latter case is the result of mere functional disorder, which, with the 
 abatement of the fever, will, in general, by degrees pass away, still it 
 is not to be forgotten that serious, and even fatal, cerebral affection 
 
 1 See Lecture YI. p. 72 ; and Lecture XVII. p. 198. 
 29 
 
450 DIAGNOSIS OP REMITTENT FEVER. 
 
 occasionally attends it. It is not indeed, commonly at an early stage 
 of the fever that we need be anxious on this account, for dangerous 
 cerebral complications seldom occur before the middle of the second 
 week, sometimes even later ; while now and then they succeed to a sort 
 of imperfect convalescence, from the signs of which we had already 
 begun to hope that the most anxious period was passed. The indica- 
 tions of their supervention are various, and often of such a kind as, 
 considering the character of the child's previous illness, may fail to 
 excite that attention which otherwise they would attract. The more 
 than ordinary excitability of the patient, the peculiar noisiness of his 
 delirium, and the ungovernableness of his temper, should arouse our 
 suspicions, even in the case of an ill-managed and wayward child, in 
 w T hom these symptoms may in part be due to mere petulance. Some- 
 times, however, the mode of approach of serious head mischief is even 
 more treacherous. The fever has already abated, the tongue has 
 grown somewhat moister, the delirium is less constant, the restlessness 
 less distressing, and the child even has some quiet sleep ; but he lies often 
 grinding his teeth, or there is frequent machonnement, or slight 
 twitchings of the facial muscles occur occasionally. The eyes grow 
 less intolerant of light, and as the child opens them once more, the 
 parents please themselves with its fancied improvement, fondly imagining 
 that it looks around and notices again. The pupils, however, are more 
 dilated than natural, and act more sluggishly; the pulse presents a 
 slight irregularity or intermission ; sensibility to external objects lessens ; 
 and coma steals on almost imperceptibly, though death is sometimes 
 preceded by convulsions, while in other cases all the symptoms of 
 hydrocephalus by degrees develop themselves. 
 
 The unobserved supervention of pneumonia is guarded against by 
 daily careful auscultation : the existence of diarrhoea tells too plainly of 
 the abdominal complication for that to be overlooked ; but when so 
 much disturbance of the nervous system is part and parcel of the affec- 
 tion, some excess of it may readily pass without due importance being 
 attached to it. When, then, you may ask, are we to become anxious 
 about the head ? I should say,, whenever delirium is present, not merely 
 during the night, or on waking from slumber in the day-time, but 
 whenever it also continues during the day, or when there is during the 
 day an extremely excitable and unmanageable condition, though not 
 amounting to actual delirium. Or, secondly, whenever, with the 
 abatement of the fever, the cerebral symptoms do not diminish in 
 proportion ; or some new, even though very slight, indication of disor- 
 der of the nervous system appears, although the excitement manifest 
 in the earlier stages of the affection may have almost or altogether 
 passed away. These symptoms may, indeed, speedily subside, or they 
 may yield, and probably will, to judicious treament, but they indicate 
 a source of danger against which tyou cannot be too carefully or too 
 unceasingly on the watch. at* 
 
 Thus much concerning the disease ; now, in conclusion, as to its 
 treatment. In the management of remittent fever in the child, just as 
 of fever in the adult, the grand object to which our attention ought to 
 be turned is to carry the patient through an affection which we cannot 
 
ITS TREATMENT. 451 
 
 cut short, with as small an amount of suffering or danger as possible. 
 " Medieus curat, natura sanat morhum" says an old Latin adage; and 
 in no disease is it of so much importance as in fever, that we should 
 assign to our art its proper position as the handmaid of nature. The 
 gradual approach of the disorder, in the great majority of instances, 
 of itself points out the propriety of that expectant mode of treatment 
 which is generally the most appropriate during the first week of the 
 child's illness. The languid and listless state of the little patient, his 
 headache and drowsiness, often lead him to wish to remain in bed all 
 day long ; but there is no reason for confining him to bed, if, during 
 the period of remission of the fever, he should prefer to sit up. The 
 impaired appetite often renders any other directions about the diet 
 unnecessary, than a caution to the parents or nurse not to coax or 
 tempt the child to take food, which it is, and will probably for some 
 days continue to be, entirely unable to digest. The heat of skin 
 and the craving thirst are the two most urgent symptoms in the early 
 stages of the affection. The first of these is generally relieved by the 
 tepid bath at 90° or 92° every morninpr, and by sponging the surface 
 of the body several times a day with lukewarm water. The desire for 
 cold drinks is often very urgent, and no beverage is half so grateful as 
 cold water to the child. Of this it would, if permitted, take abundant 
 draughts ; but it should be explained to the attendants that the thirst 
 is not more effectually relieved by them than by small quantities of 
 fluid, while pain in the abdomen is very likely to be caused by the over- 
 distention of the stomach. The cup given to the child should therefore 
 only have a\dessert or table-spoonful of water in it, for it irritates the 
 little patientX to remove the vessel from its lips unemptied. In the 
 milder forms of the disease, and during the first week, medicine is little 
 needed; but a simple saline may be given, such as the citrate of potass 
 in a mixture to which small doses of vinum ipecacuanha may be added, 
 if, as sometimes happens, the cough be troublesome. If the bowels act 
 with due frequency, and the appearance of the evacuations be not 
 extremely unhealthy, it is well to abstain from the employment of any 
 remedy which might act upon them, for fear of occasioning diarrhoea, 
 which is so apt to supervene in the course of this affection. For the 
 same reason, if an aperient be indicated, drastic purgatives are not to 
 be given, but a moderate dose of castor oil should be administered. 
 Now and then, however, cases are met with in which the bowels remain 
 confined during a great part of the affection, and in which such purga- 
 tives as senna are not only borne, but absolutely necessary. They 
 however, are purely exceptional cases ; and it will generally suffice, if 
 there exists any tendency to constipation, to give a small dose of the 
 mercury and chalk night and morning, and during the day-time a small 
 quantity of the tartrate of soda or sulphate of magnesia, dissolved in 
 some simple saline mixture, every six or eight hours. 
 
 The unhealthy state of the evacuations that exists in a large number 
 of cases is generally associated with a disposition to diarrhoea, which 
 becomes a more prominent symptom in the second than it was in the 
 first week of the disorder. Equal parts of the hydrargyrum cum cret& 
 
452 OF HEAD SYMPTOMS BY ANTIMONY AND OPIUM. 
 
 and Dover's powder are the best means of relieving both these morbid 
 conditions ; the remedy being given either once or twice a day, or more 
 frequently, according to the urgency of the symptoms. The amount of 
 abdominal pain and tenderness must be ascertained every day ; and a 
 few leeches must be applied to either iliac region if the tenderness seem 
 considerable, or if the child appear to suffer much from pain in the 
 abdomen, or if the diarrhoea be severe. If depletion be needed, the 
 application of but a small number of leeches will generally meet the 
 requirements of the case, while copious bleeding is neither useful nor 
 well borne. Even in children of ten years old I never apply above four 
 or six leeches, and it is very seldom that any occasion arises for a 
 repetition of the bleeding. The application of poultices of linseed meal 
 or scalded bran to the abdomen, and their frequent repetition, is a very 
 valuable means of relieving the griping pain which often distresses 
 children ; and in most cases it is desirable to make trial of them before 
 having recourse to depletion. 
 
 There is but one other class of symptoms likely to occur during the 
 first week of the fever, to the management of which I have not yet 
 referred ; namely, those signs of cerebral disturbance which are some- 
 times so serious as to call for treatment. The early occurrence of 
 delirium, though it generally implies that the disease will assume a 
 rather serious character, yet does not of itself indicate the necessity for 
 taking blood from the head ; but if the child be quiet and generally 
 rational during the day-time, and though dull yet not in a state of 
 stupor, while the delirium at night is of a tranquil kind, and inter- 
 rupted by frequent and tolerably quiet slumber, it will generally suffice to 
 apply cold to the head, and to keep the apartment cool and absolutely 
 quiet. The irritability, excitability, and restlessness at night, accom- 
 panied by loud and noisy delirium, from which the child gets scarcely 
 any respite all night long, are frequently arrested at once by an opiate. 
 Unless some abdominal complication should forbid its employment, the 
 tartar emetic is in these cases a most valuable adjunct to the opium. 1 
 A draught containing five minims of laudanum, and a quarter or a 
 third of a grain of tartar emetic, will be a suitable anodyne for a child 
 of five years old, and may be repeated night after night with almost 
 magical effect. When the delirium at night is succeeded during the day- 
 time by an almost equally distressing condition of excitement, accom- 
 panied with a burning skin, and a very frequent though feeble pulse, 
 the continuing the tartar emetic in slightly nauseating doses, combined 
 with smaller quantities of laudanum, every four hours, will often be of 
 essential service. If, however, there be any injection of the conjunc- 
 tivae, or if the head be in a marked degree hotter than the surface 
 generally, or if any other indication of disorder of the brain be present 
 besides the delirium and excitement, leeches should be applied to the 
 head, — though depletion should in these cases be used sparingly ; and 
 after the abstraction of blood by the application of half a dozen leeches, 
 
 1 The remarks of Dr. Graves, in his Lectures on Clinical Medicine, vol. i. p. 207, on 
 the use of Tartar Emetic and Opium in Fever, are little less applicable to its manage- 
 ment in the child than in the adult. 
 
TREATMENT 03T HEAD SYMPTOMS — DEPLETION. 453 
 
 we should return to the.tart.ar emetic and opium, remembering that 
 we have no active inflammation to combat, nor even that intense 
 cerebral congestion which we occasionally meet with under other cir- 
 cumstances, and safety from which is found only in very active 
 depletory measures. 
 
 Depletion is also called for in cases, not very commonly met with, in 
 which even at an early period of the disease there is a great degree of 
 stupor, and apathy, with a dilated and sluggish pupil, but little com- 
 plaint of thirst, and none of headache or local suffering. By the cautious 
 abstraction of blood we may here sometimes anticipate the development 
 of the more alarming head symptoms, which, if we leave the patient 
 alone, lulled into a false security by the absence of any signs of active 
 mischief, will not fail before long to manifest themselves. As a general 
 rule, indeed, it must be our object in the management of this fever to 
 anticipate the head symptoms as far as possible, to keep down the 
 excitement and quiet the delirium by tartar emetic and opium, or by 
 the local abstraction of blood : a purely expectant course of practice is 
 neither wise nor safe. The head symptoms, which come on slowly and 
 almost imperceptibly at a more advanced stage of the disease, are some- 
 times very unmanageable. Depletion is no longer of service, but blisters 
 may be applied to the occiput and nape of the neck with advantage ; 
 they should, however, not be kept on so long as to produce complete 
 vesication, but only for a time sufficient to obtain their counter-irritant 
 effect, and to allow of their reapplication in the same neighbourhood, if 
 not upon exactly the same spot, on the next day. The unfavourable 
 termination^ of the disease in this stage is, I apprehend, due, in the 
 great majority of cases, to the development of some previously latent 
 tendency to tubercular hydrocephalus; while the more active head 
 symptoms, which are met with at an earlier period, are often merely 
 the result of functional disturbance, and therefore often yield to well- 
 considered treatment. 
 
 In mild cases of the disease, the expectant treatment, usually appro- 
 priate during its early stages, may be continued throughout its course ; 
 great caution being exercised, as the child begins to improve, to prevent 
 its committing any error in diet. When severe, however, the second 
 week often brings with it a train of symptoms that require many 
 modifications in the plan of treatment. The vital powers need to be 
 supported, and the nervous system requires to be tranquillized ; and this 
 is to be attempted by means similar to those which we should employ 
 in the management of fever in the adult. The mere diluents which 
 were given during the previous course of the fever must now be 
 exchanged for beef or veal tea or chicken broth, unless the existence 
 of severe diarrhoea contraindicate their administration ; in which case 
 we must substitute arrow root, milk, and isinglass, for animal broths. 
 In a large proportion of cases nutritious food is all that will be required; 
 but wine is sometimes as essential as in the fevers of the adult ; and 
 the indications for giving it are much the same in patients of all ages. 
 Even though wine be not necessary, I generally give some form of 
 stimulant during the second and third weeks of the affection. The 
 
454 TREATMENT OP REMITTENT FEVER. 
 
 prescription 1 which I usually follow is one inuch praised under such 
 
 (No. 34.) 
 1 J& Acid. Hydrochlor. dil. ttl^xxxij. 
 Spt. iEth. Sulpb. co. 3J. tt^xx. 
 Syr. Rhseados, giv. 
 
 Mist. Camph. ^iiiss. M. giv. 6tis horis. 
 For a child five years old. 
 
 circumstances by Dr. Stieglitz, of St. Petersburgh, the chief ingre- 
 dients of which are ether and hydrochloric acid. It seldom disorders 
 the bowels if they be not much disturbed at the time of commencing 
 its administration ; while, if this be the case, a small dose of Dover's 
 powder, as a grain or a grain and a half at bed-time, will be doubly 
 useful, both in checking the tendency to diarrhoea, and in procuring 
 sleep for the child, who, without it, would probably be watchful and 
 delirious all night long. While any severe abdominal symptoms are 
 present, I abstain from the use of the acid mixture, but give the mer- 
 cury with chalk, and Dover's powder, every four or six hours, to which 
 I occasionally add an opiate enema at bed-time, and support the 
 strength by food and wine as may be necessary. 
 
 The only complication that is apt to be troublesome is the bronchitis. 
 Usually, however, the cough to which this gives rise is an annoying 
 rather than a dangerous symptom ; and it is in general more harassing 
 at the commencement of the affection, and again when convalescence 
 is beginning, than during that time when the graver symptoms are pre- 
 sent. A little ipecacuanha wine, nitrous ether, and compound tincture 
 of camphor, will usually relieve it, to which it may occasionally be 
 expedient to add the application of a mustard poultice to the chest. 
 
 The convalescence is often extremely tedious ; the child is left by the 
 disease not only extremely weak and emaciated, but with its digestive 
 powers greatly impaired. It is often many days before the stomach is 
 able to digest any solid food ; even a piece of bread will sometimes 
 irritate the intestines, and bring on a return of diarrhoea. The appe- 
 tite seems sometimes quite lost; tonics either do no good, or are actu- 
 ally injurious by rekindling the fever ; or symptoms supervene which 
 seem to threaten the development of tubercular disease, a consequence 
 that not very seldom follows severe attacks of remittent fever. Under 
 such circumstances, change of air, and the removal, if possible, to the 
 sea-side, are often the only means of restoring the child to health ; a 
 means which you may recommend with the more confidence since it 
 hardly ever fails to be successful. 
 
SMALL-POX. 455 
 
 LECTUEE XXXVIII. 
 
 Small pox — checked but not extirpated by vaccination — its chief mortality among chil- 
 dren — rate of mortality in cases of the disease undiminished during the last fifty 
 years. — Its symptoms — their early differences from those of the other exanthemata — 
 characters and progress of the eruption — peculiarities of confluent small-pox — dangers 
 attending the maturation of the pustules, and the secondary fever. — Treatment. 
 
 Modified small pox — its low rate of mortality — its peculiarities. 
 
 Chicken-pox — its symptoms, and differences from small-pox. 
 
 Until the commencement of this century, the disease to which I 
 •wish to-day briefly to call your attention possessed a degree of impor- 
 tance far greater than that which attaches to it at present. Before the 
 introduction of vaccination, the small-pox was a disease of almost uni- 
 versal prevalence, causing at the least eight per cent, of the total mor- 
 tality of this metropolis, and disfiguring for life thousands whom it did 
 not destroy. Its loathsome character, and its formidable symptoms 
 when it attacked the constitution at unawares, led to the adoption of 
 variolous inoculation, by which the disease was communicated in a mild 
 form, and under favourable conditions ; and persons having undergone 
 comparatively little suffering, and having been exposed to still less 
 danger, enjoyed by this means almost complete immunity from subse- 
 quent attacks of small-pox. But, great as its benefits were, variolous 
 inoculation perpetuated at all times, and in all places, a disease which 
 would otherwise have obeyed the general law of epidemics, and would 
 have had its periods of rare occurrence as well as those of wide-spread 
 prevalence. Thus, as has been well observed, while the advantages of 
 the practice were great and obvious to the individual, to the community 
 at large they were very doubtful. 
 
 No such drawback exists to detract from the benefits of vaccination, 
 though unfortunately our present experience does not altogether justify 
 the sanguine expectations entertained concerning it by its first promo- 
 ters. Peculiarities of climate oppose a serious barrier to its successful 
 introduction into some countries, 1 and even in our own land individuals 
 are occasionally met with in whom vaccination altogether fails, or over 
 whom it seems to extend but a partial or a temporary protective power. 
 
 But I will not enter on the question of the merits of vaccination, nor 
 of the circumstances that impair its preservative power, or call for its 
 repetition : for though the subject is one important alike to the physi- 
 cian and the philanthropist, I have had no opportunities of forming a 
 judgment concerning it which are not alike open to you all. In the 
 writings of Dr. Gregory, physician to the Small-Pox Hospital, and in 
 the treatise on vaccination by Dr. Steinbrenner, to which the Institute 
 
 1 Dr Duncan Stewart's valuable Report on Small-Pox in Calcutta, and Vaccination in 
 Bengal, 8vo., Calcutta, 1844, shews conclusively that the peculiarities of the Indian 
 climate present obstacles to vaccination such as greatly to detract from its value ; while 
 it is to be feared that they are of a nature which the greatest care will never wholly 
 overcome. 
 
456 SMALL-POX. 
 
 of France adjudged a prize in 1835, you will find everything that either 
 large experience or unwearied research can bring to its elucidation. 
 
 One fact which it behoves us always to bear in mind, is, that albeit 
 the prevalence of the disease has been greatly checked by vaccination, 
 small-pox is still one of the most fatal maladies of this country ; and 
 further, that it selects its victims, as heretofore, chiefly from among 
 children and young persons, — nearly three-fourths of the fatal cases of 
 this affection occurring before the age of five, and more than nine- 
 tenths before the age of fifteen years. In spite, too, of the increase 
 of medical knowledge during the past fifty years, the proportion of 
 small-pox cases that terminate fatally has been estimated by the best 
 authorities to be as great now as it was half a century ago; To some 
 extent, perhaps, the very diminution in the frequency of the disease 
 may have had an unfavourable influence on its issue in individual cases ; 
 for practitioners, meeting with it now less often than medical men in 
 former days were wont to do, are not so familiar with the meaning of 
 those minuter variations in its symptoms, from which important practi- 
 cal conclusions might be drawn, by those who knew how to interpret 
 them aright. 
 
 Let me therefore urge you to watch every case of this formidable 
 disease that may come under your observation with most minute care, 
 lest you misinterpret the symptoms, or mistake the treatment of some 
 patient affected with it, whose w T ell-being may be dependent on your 
 skill. For my own part, I cannot pretend to give you more than an 
 outline sketch of its characters, and must refer you to the writings of 
 others who have had greater opportunities of watching it than have 
 fallen to my share, to fill up the portrait. 
 
 The early symptoms of small-pox are those of approaching fever, and 
 if any other febrile disorder be prevalent at the time of their occurrence 
 they may possibly be taken for the indications of an approaching attack 
 of the prevailing epidemic. There are, however, some peculiarities in 
 the mode of onset of small-pox which are sufficiently characteristic of 
 it even in the child, and which generally distinguish it from either of 
 the other eruptive fevers. The sickness with which it sets in is in gen- 
 eral severe, and the disorder of the stomach often continues for forty- 
 eight hours, during which time vomiting recurs frequently. In measles 
 there is comparatively little gastric disorder ; and the vomiting that 
 often ushers in scarlatina, though frequently severe, is not of such long 
 continuance. In young children we lose those complaints of intense 
 pain in the back which in the case of older patients often awaken our 
 suspicion ; but on the other hand, the severity of the cerebral distur- 
 bance is an important feature in the early stage of the disease. At the 
 commencement of measles, the brain is in general but little disturbed ; 
 in scarlatina, delirium often occurs very early ; but in small-pox the 
 condition is one rather of stupor than of delirum, while convulsions 
 sometimes take place, and continue alternating with coma for as long a 
 period as "twenty-four or thirty-six hours. Lastly, though the skin in 
 small-pox is hot, it is neither so hot nor so dry as in scarlet fever ; the 
 tongue does not present the peculiar redness, nor the prominence of its 
 papillge, which are observable in scarlatina ; neither is there any of the 
 
ITS SYMPTOMS. 457 
 
 sore-throat which forms so characteristic a symptom of that disease. 
 The early stages of small-pox are not attended with the catarrhal 
 symptoms which accompany measles ; the eruption of measles usually 
 appears later, that of scarlet fever always sooner, than the eruption of 
 small-pox; while its papular character is in general sufficiently well 
 marked to distinguish it from the rash of either of those diseases. It 
 never appears in less than forty-eight hours from the first sign of in- 
 disposition, often not till after a somewhat longer time. It shews itself 
 in the form of small papulae, which are first discernible on the face, 
 forehead, and wrists, whence they extend to the trunk and arms, and 
 lastly to the lower extremities. These papulae are at first slightly red, 
 somewhat acuminated elevations, so minute that they may be easily 
 overlooked on a hasty examination, but yet conveying a distinct sense 
 of irregularity to the finger when passed over the surface. They 
 increase in size, and in the course of forty-eight hours assume a vesi- 
 cular character, and contain a whey-like fluid ; while, instead of a coni- 
 cal form, they now present a central depression. During another period 
 of forty-eight hours, or thereabouts, these vesicles go on enlarging, 
 their central depression grows more and more apparent, and their con- 
 tents become white and opaque ; they are no longer vesicles, but have 
 become converted into pustules, each of which, if they be distinct, has 
 an areola of a red hue around its base. As the pustules enlarge, the 
 face, hands, and feet become swollen, and a general redness of the 
 surface succeeds to the more circumscribed areola which had previously 
 surrounded each separate pustule. As the size of the pustules increases, 
 they lose that central depression which they had presented while vesi- 
 cles ; they assume a spheroidal form, or even become slightly conical. 
 The next change observable in them is an alteration of their color from 
 a white to a dirty yellow tint, which they continue to retain until the 
 desiccation of the eruption commences. This token of the decline of 
 the disease is first apparent on the face, where, as you will remember, 
 the eruption is earliest observable ; while on the hands and feet, pro- 
 bably owing to the thickness of the epidermis in those situations, this 
 change is longest delayed, and the pustules there attain a greater size 
 than in any other situation. The maturation of the pustules usually 
 occupies from the commencement of the fifth to the commencement of 
 the eighth day of the eruption, or from the eighth to the eleventh day 
 of the disease ; when the process of desiccation begins. A few of 
 the smaller pustules dry up and become converted into crusts, which 
 afterwards drop off ; but the greater number of them burst, and the 
 pus which they discharge, together with a very adhesive matter which 
 they continue to secrete for two or three days contribute to form the 
 scab, which incrusts, more or less extensively, the surface of a small- 
 pox patient during the decline of the disease. When this scab falls off, 
 which it does in from three to five or six days, the skin appears stained 
 of a reddish-brown colour, which often does not disappear for several 
 weeks ; but it is only in cases where the pustule has gone so deep as to 
 destroy a portion of the true skin, that permanent disfigurement, the 
 so-called pitting of the small-pox, is produced. 
 
 It is only in cases of discrete small-pox, in which the eruption is but 
 
458 PROGRESS OF THE ERUPTIONS. 
 
 moderately abundant, and the pustules consequently run their course 
 "without coalescing with each other, that the above-mentioned changes 
 can be distinctly traced. In the confluent variety of the disease, in 
 which the pustules are so numerous that they run together as they 
 increase in size, the characteristic alterations in the individual pustules 
 cannot be followed. In those situations where the eruption is confluent, 
 the pustules never attain the size which separate pustules often reach ; 
 they do not become so prominent, nor do their contents in general 
 assume the same yellowish colour, but several of them coalesce to form 
 a slightly irregular surface of a whitish hue ; while, when the stage of 
 desiccation comes on., each of these patches becomes converted into a 
 moist brown scab, which is many days before it is detached. Nor is it 
 merely at those parts, such as the face, where the eruption is actually 
 confluent, that its character is modified, but, even where the pustules 
 are distinct, their advance goes on more slowly, and the maturative 
 stage is longer in being completed, than in less severe cases of the 
 disease. It is, moreover, in cases of confluent small-pox that the ulce- 
 ration of the pustules most commonly invades the true skin, and that 
 serious disfigurement is most likely to take place ; while further, the 
 degree of danger to life is in almost direct proportion, in every case of 
 small-pox, to the amount of confluence of the eruption. 
 
 The appearance of the eruption of small-pox is attended with a great 
 abatement, sometimes with the almost complete disappearance, of those 
 signs of constitutional disturbance with which the disease set in ; and in 
 mild cases the child shews few other signs of illness than are furnished 
 by the eruption on the skin. But, with the maturation of the pustules, 
 the secondary fever, as it is called, is excited, and the period of the 
 greatest danger to the patient now comes on. The skin once more 
 grows hot ; the pulse rises in frequency ; restlessness, thirst, and all the 
 phenomena of inflammatory fever, develope themselves, and continue 
 with more or less intensity for about three days. These symptoms 
 afterwards diminish, and finally disappear as the pustules burst, and the 
 stage of desiccation is accomplished. It is, however, only in cases of a 
 favourable kind that the secondary fever runs so mild a course. In 
 confluent small-pox, the secondary fever is always more severe than in 
 the discrete form of the disease, though it comes on later, in consequence 
 of the more tardy maturation of the pustules. Often, indeed, it assumes 
 a typhoid character ; the pulse becomes extremely frequent and feeble ; 
 the tongue dry and brown ; and the patient lies delirious. In other 
 instances the maturation of the pustules goes on for a day or two with 
 very slight reaction ; and were it not that this extreme mildness of the 
 secondary fever, in cases where the eruption has been abundant, is itself 
 a suspicious circumstance, we should be disposed to express, without 
 hesitation, a most favourable opinion as to the patient's condition. 
 Suddenly, however, the pulse begins to falter; the pustules, which 
 before seemed full, collapse ; the extremities grow cold ; and in a few 
 hours the patient dies. This fatal change is sometimes ushered in by a 
 fit of convulsions ; at other times it is preceded by a condition of extreme 
 restlessness, which contrasts remarkably with the quietude of the child's 
 manner for the two or three previous days ; and it is well to bear in 
 
DANGERS ATTENDING THE MATURATIVE STAGE. 459 
 
 mind that the supervention of either of these two symptoms during the 
 maturative stage of small-pox is the almost certain herald of speedily 
 approaching death. One other not infrequent source of danger during 
 this period arises from the pustules which have formed on the mucous 
 membrane of the mouth, fauces, and air-passages. In almost every case 
 of small-pox, a few spots of the eruption may be seen upon the tongue 
 and on the interior of the mouth ; while an inspection of the bodies of 
 patients to whom it has proved fatal has shown that the pustules form 
 likewise on the interior of the larynx and trachea — sometimes in consi- 
 derable numbers. It is to the presence of pustules in these s situations 
 that the hoarse or altered voice, and the difficulty of deglutition, which 
 are observed in most cases of severe small-pox, are due ; as well as that 
 short hacking cough which sometimes proves a very troublesome symp- 
 tom. The ptyalism, too, which occurs in many instances, is apparently 
 owing to the salivary glands sympathising with the irritated and 
 inflamed state of the mucous membrane of the mouth. In cases which 
 run a fortunate course, these symptoms, having come on about the third 
 or fourth day of the eruption, and having increased in severity until the 
 eighth or ninth, then progressively decline. Under less favourable cir- 
 cumstances, however, they continue to grow worse : the voice becomes 
 perfectly extinct, and deglutition almost impossible ; and the patient 
 dies from the obstacle which the inflammation and swelling of the lining 
 membrane of the larynx present to the free access of air to the lungs ; 
 though the symptoms are seldom or never those of active inflammatory 
 croup. 
 
 You will fimi in the writings of those whose opportunities of observing 
 small-pox have\been considerable, the description of many other modes 
 in which it occasionally proves fatal. Thus, it is sometimes associated 
 with a great tendency to haemorrhage ; petechia appearing on the sur- 
 face of the body, and the pustules assuming a black colour, from the 
 extravasation of blood into them. In other instances, gangrene attacks 
 the feet or some other part of the body. But these are occurrences 
 which it has not been my lot to witness, and I will not therefore take 
 up your time by detailing them at second-hand. 
 
 Let us now glance for a few minutes at the treatment to be pursued 
 in this disease. You know that before the time of Sydenham, physicians 
 adopted a heating regimen in cases of small-pox; excluding fresh air 
 from the chamber, covering the patient with blankets, and administering 
 stimulating medicines and cordial drinks. To this practice the preva- 
 lent theory of fermentation, and of nature's efforts in disease being 
 directed to eliminate the peccant matter from the blood, had given occa- 
 sion. In accordance with these notions it was assumed that the more 
 abundant the eruption, the more complete would be the separation of 
 these noxious matters, and consequently the better the chance of the 
 patient's well-doing. The observation of nature, however, taught Syden- 
 ham that the very reverse was the case ; — that the more abundant the 
 eruption, the greater the danger, — the fewer the pustules, the more 
 favourable the prospect of the patient's recovery. A cooling regimen, 
 therefore, is now universally adopted in the early stage of the disease, 
 and fresh air is freely admitted into the chamber, in order to prevent, 
 
4G0 TREATMENT OF SMALL-POX. 
 
 if possible, a copious eruption, while the same end is sought to be still 
 further promoted by keeping the bowels gently open, by a spare diet, 
 and by mild antiphlogistic medicines. Depletion, which even in the 
 adult is not to be practised merely with the hope of thereby diminishing 
 the quantity of the eruption, is still less to be resorted to in the child, 
 unless evidently called for by symptoms of severe cerebral disturbance ; 
 such as convulsions frequently recurring, or ending in coma. Such' 
 occurrences as those, however, demand not merely the abstraction of 
 blood, but its removal with an unsparing hand ; for, as I told you at 
 the commencement of these lectures, the cerebral congestion which 
 attends the onset of the eruptive fevers, if not speedily relieved, may 
 prove very quickly fatal. Cases of an opposite kind are sometimes met 
 with in w T hich the patient before the appearance of the eruption is in a 
 state of depression so great as to call for warmth to the surface, or for 
 the hot bath, for diaphoretic medicines, and sometimes even for stimu- 
 lants. In this, however, there is nothing more than we may occasionally 
 witness in a patient completely prostrated during the first stage of 
 typhus fever, and needing perhaps the free administration of wine and 
 ammonia to preserve him from death. 
 
 With the outbreak of the eruption there ensues a lull in the symp- 
 toms, and a period now succeeds during which we have nothing else to 
 do than to leave nature to her workings undisturbed. Even in cases of 
 confluent small-pox, there is in many instances not a single symptom 
 just at this time which could either excite solicitude or call for treatment, 
 and you must therefore take care not to allow yourself at this moment 
 to be betrayed into the hasty expression of a very favourable prognosis, 
 which the supervention of the secondary fever may perhaps in a day or 
 two most grievously belie. If, however, the number of pustules should 
 be but small, the secondary fever will be slight: our favourable opinion 
 may, under these circumstances, be expressed with some confidence, 
 and most probably no deviation from our previous expectant plan, of 
 treatment will be required during the subsequent progress of the 
 disease. If the eruption be more abundant, and the accompanying 
 secondary fever consequently severe, an antiphlogistic plan of treatment 
 must be carried out more strictly, while in all cases the restlessness 
 which is so common a symptom during the maturative stage of small- 
 pox must be controlled by the administration of Dover's powder, or of 
 some other form of opiate, once or twice a day. In cases of confluent 
 small-pox, the patient needs to be very closely watched during the 
 maturation of the pustules, for on the second or third day of this 
 process the vital powers sometimes suddenly fail. The first indications 
 of any such occurrence, which would be furnished by a great aggrava- 
 tion of the previous restlessness, by the subsidence of the swelling of 
 the face and hands, the paleness of the skin in the interval between the 
 pustules, and the collapse of the pustules themselves, attended with a 
 sinking in the temperature of the surface, and a great diminution in the 
 power of the pulse, call at once for the energetic employment of stimu- 
 lants, for the administration of wine, and the substitution of nutritious 
 food for the previous meagre diet. A similar course must also be 
 pursued whenever the secondary fever shows any disposition to assume 
 
TREATMENT OF THE SECONDARY FEVER. 461 
 
 a typhoid character, while, irrespective of any unfavourable symptoms, 
 it is not infrequently expedient, if the eruption be abundant, to give 
 beef-tea, and to adopt other means for supporting the strength from 
 the fifth or sixth day of the eruption — a period corresponding, as I 
 hardly need remind you, with the eighth or ninth day of the disease. 
 
 Various local means have been recommended to be adopted at an 
 early stage of the disease, with the view of preventing the full develop- 
 ment of the pustules, and consequently of preserving the patient from 
 the disfigurement produced by the pitting of the eruption. The 
 cauterization of each individual pock with the nitrate of silver is a 
 process impracticable from its tediousness, while there is some discrep- 
 ancy in the results which different persons allege that they have obtained 
 by applying mercurial ointment or plaster, or by washing the surface 
 which it is wished to defend with a solution of corrosive sublimate. 
 The weight of evidence appears to me, however, to be in favour of 
 some proceeding of this kind; and that which seems to have been the 
 most successful, is the application of the mercurial plaster at a period 
 not later than the third day from the outbreak of the eruption. 
 
 Attention must be paid to the state of the eyes, which often suffer . 
 much during attacks of the small-pox, though Dr. Gregory states that 
 the conjunctiva never becomes the seat of the pustules. From the time 
 when the swelling of the face begins, during the maturation of the 
 eruption, the eyelids are often so much swollen as completely to close 
 the eyes, while their edges are glued together by a tenacious secretion 
 from the Meibomian glands. The patient will be much relieved by 
 bathing the Vyes frequently with warm water, and any pustules that 
 occupy the margins of the palpebrse should be carefully cauterized with 
 the nitrate of silver. 
 
 The condition of the mouth and throat must not be neglected. If 
 old enough, the child may be made to gargle with a little infusion of 
 roses, while, should it be too young to do this, the endeavour must be 
 made to keep the mouth and throat free from the secretions which 
 collect there, by washing or syringing them frequently with warm water, 
 and by applying a weak solution of chloride of lime to the fauces. If 
 difficult respiration should come on, in consequence of the affection 
 seriously involving the larynx and trachea, the patient's condition, 
 according to the testimony of almost all writers, is rendered nearly 
 hopeless. 
 
 The intense itching of the eruption during the latter part of the 
 period of maturation, and the stage of desiccation, not only distresses 
 the patient exceedingly, but is often the occasion of subsequent dis- 
 figurement, in consequence of the desire to scratch being irresistible, 
 and the pustules being converted by abrasion of their heads into 
 troublesome ulcerations. The application of sweet oil, cold cream, or 
 spermaceti ointment, will do something towards allaying the irritation ; 
 but you will often find it necessary to muffle the hands of children, in 
 order to prevent their producing troublesome sores by scratching 
 themselves. 
 
 The convalescence from small-pox is often very tedious ; the patient's 
 recovery is frequently interrupted by various intercurrent affections, 
 
462 SMALL-POX AFTER VACCINATION. 
 
 and the latent seeds of scrofulous disorder are in many instances called 
 into activity by its attack. These, however, are occurrences which 
 present nothing of a special character, and it is therefore unnecessary 
 to make any observation with reference to their treatment. 
 
 Although previous vaccination usually confers upon the system a 
 complete immunity from subsequent attacks of small-pox, yet to this 
 rule there are occasional exceptions. In many instances, indeed, the 
 occurrence of small-pox after alleged successful vaccination may be 
 accounted for by the careless performance of that operation, by the use 
 of lymph taken from the arm at too late a period, or by the production 
 in some way of a spurious instead of a genuine vaccine vesicle. It 
 must be confessed, however, that when every allowance has been made 
 for these casualties, the number of cases of small-pox occurring after 
 successful vaccination is proportionably much greater than the number 
 in which a second attack of small-pox is experienced by those who 
 have either had, that disease casually, or in whom it has been produced 
 by^ variolous inoculation. It would occupy far more time than we have 
 at our command, if we were to attempt to enter upon the inquiry as 
 to the causes of the failure in the protective power of vaccination. 
 Different views have been taken by very high authorities upon this 
 subject ; but there is one important fact concerning which nearly all 
 are agreed — namely, that the liability to a subsequent attack of small- 
 pox is almost incalculably diminished by revaccination. Considering, 
 then, how simple the operation is, and how nearly painless its perform- 
 ance, while the benefit to be obtained by it is so inestimable, I would 
 strongly urge you to revaccinate all persons turned twelve years old, 
 even though they had been vaccinated with the most complete success 
 in their infancy. 1 
 
 But although we should take a comparatively low estimate of the 
 value of vaccination, and confess to the fullest extent the failure in 
 its complete preservative virtue, we shall yet find, in the modifying 
 and mitigating influence which it exerts over small-pox, more than 
 enough to make us value it as a priceless boon. Twenty years ago, 
 small-pox raged epidemically at Marseilles, where it attacked almost 
 exclusively persons under 30 years of age. M. Favart, 3 who sent an 
 account of this epidemic to the Academy of Medicine at Marseilles, 
 estimated the number of the inhabitants of that city under 30 years 
 of age at 40,000. Of these, about 30,000 had been vaccinated, 2,000 
 had had small-pox casually or by inoculation, and 8,000 had had 
 neither variola nor cow-pox. Of this last class, 4,000, or 1 in 2, were 
 attacked by small-pox, and 1,000 of them, or 1 in 4, died. Of those 
 who had had small-pox previously, only 20, or 1 in 1,000, were again 
 affected ; but 4 of these, or 1 in 5, died ; while of the vaccinated, 
 although 2,000, or 1 in 15, had it, yet it proved fatal only to 20, or 1 
 per cent. 
 
 The influence of vaccination in rendering attacks of small-pox which 
 may succeed to it, so much less severe, and so much less dangerous, 
 
 1 For facts shewing the preservative influence of re-vaccination, see Steinbrenner, 
 Trnit6 sur la Vaccine, 8vo. pp. 688-734. Paris, 1846. 
 
 2 As reported by Steinbrenner, op. cit. p. 166. 
 
CHICKEN-POX. 463 
 
 than the unmodified disease, does not in many instances manifest itself 
 in any diminution of the intensity of the primary fever. The symp- 
 toms with w hih modified small-pox sets in are often as severe as those 
 of the unmodified disease, and are also in general of the same duration. 
 So soon as the eruption begins to make its appearance, however, the 
 difference between the two diseases usually becomes apparent. In many 
 instances, notwithstanding the sharp onset of the patient's illness, the 
 eruption is exceedingly scanty, not more than from twenty to a hundred 
 pustules appearing over the whole body. In other instances, the erup- 
 tion is much more abundant, and in a few exceptional cases the pustules 
 are actually confluent. But even when they are most numerous, the 
 postules seldom fail to follow a different course from that which they 
 pursue inordinary variola, and run through their different stages within 
 little more than half the period required by the eruption of unmodified 
 small-pox. The small size of the pocks, — the frequent absence of the 
 central depression, — their imperfect suppuration, — and their speedy 
 desiccation, are the chief local characters of this affection ; while the 
 almost complete absence of the secondary fever is both its grand con- 
 stitutional peculiarity and the main source of the patient's safety. 
 
 Besides the modified small-pox to which reference has just been made, 
 there is another and still milder affection often observed in children, to 
 which, from the extreme lightness of the symptoms that usually attend 
 it, the diminutive appellation of varicella or chicken-pox has been given. 
 Much difference of opinion has existed with reference to the relations 
 bornby this disease to small-pox; and even at the present day writers 
 are not quite agreed whether to regard it as an extremely mild form of 
 variola, or as\an affection altogether distinct from it. The weight of 
 evidence, however, is decidedly in favour of the opinion that varicella is 
 an affection distinct from, and wholly independent of small-pox, not 
 being produced by any modification of the poison of that disorder, nor 
 affording any kind of protection from its attacks. 
 
 Varicella is almost exclusively a disease of childhood, and in the 
 great majority of cases it occurs prior to the completion of the first 
 dentition. Its initiatory fever, which is scarcely ever severe, is some- 
 times altogether wanting, so that the appearance of the eruption on 
 the surface is the first occurrence that calls attention to the child's con- 
 dition. Now and then, however, exceptions occur to this mildness in 
 the onset of the disease ; and I have occasionally seen children 
 (chiefly those in whom the process of dentition was going on with 
 activity at the time of the attack) suffer for twenty-four or thirty-six 
 hours from febrile symptoms quite as severe as those which precede the 
 attack of measles, or as accompany a sharp attack of influenza. The 
 duration of this premonitory stage of chicken-pox is somewhat uncer- 
 tain ; the vesicles which characterize it making their appearance after 
 twenty-four hours in some cases, — not for thirty-six or forty-eight hours 
 in others ; while, as already mentioned, the eruption is occasionally the 
 first symptom of the existence of the disease. 
 
 The eruption usually consists of more or less numerous, minute, 
 circular vesicles, containing a transparent serum, irregularly distributed 
 over the face, head, shoulders, and trunk, but rarely appearing on the 
 
464 MEASLES. 
 
 lower extremities ; and, even. when present in considerable abundance, 
 being very seldom confluent at any part. For two or three days they 
 increase somewhat in size, but their contents then become turbid and 
 milky ; about the fourth or fifth day they shrivel, and then dry up into 
 a light, pulverulent scab, which falls off on the eighth or ninth day of 
 the disease. It very seldom happens that any cicatrix is left after the 
 detachment of the scab of varicella, unless the skin has been irritated by 
 the patient scratching it in order to relieve the itching, which is some- 
 times very troublesome. Besides these differences between the eruption 
 of chicken-pox and that of variola, another, and still more striking 
 peculiarity of the former disease consists in the appearance of two or 
 three successive crops of vesicles, so that after the third day of the 
 affection vesicles may be observed close to each other in all stages of 
 their progress. 
 
 The disease is one so void of danger, that it requires hardly any 
 treatment beyond the adoption of a mild antiphlogistic regimen ; and 
 no complications occur during its course, nor sequelas remain after its 
 . disappearance, concerning which any thing more need be added. 
 
 LECTUEE XXXIX. 
 
 Measles — once confounded with scarlatina, though essentially different diseases. — 
 Symptoms of measles — their chief danger due to the supervention of bronchitis or 
 pneumonia. — Treatment. 
 
 Scarlatina — great differences in its severity in different cases — symptoms of each of 
 its three varieties— sequelse of the disease — diagnosis from measles. — Treatment. 
 
 When the short-lived prejudices which at first were entertained 
 against vaccination had been removed, men passed, as they not seldom 
 do, to the opposite extreme, and over-estimated the worth of that 
 discovery which they had before undervalued. Physicians rejoiced in 
 it, as a means of getting rid for ever of a disease which might well be 
 counted among the opprobria of their art, — philanthropists exulted in 
 the probable extermination of one of the most fearful scourges of the 
 human race, and statisticians counted the increase brought to the 
 population, and drew up elaborate tables to illustrate their bright 
 anticipations of the future. 1 In these over-sanguine calculations, how- 
 ever, they almost entirely lost sight of the fact, that not all who were 
 preserved from small-pox would be added to the useful population of 
 the country, but that the life of many would be prolonged only for a 
 short season, to be cut off soon by some other disease, against which 
 neither science nor fortunate accident has hitherto discovered a talis- 
 man. Experience has proved the truth of what calm reflection might 
 have suggested, and with the diminution in the frequency of small-pox 
 there has been an increase, though not to an equal extent, in the 
 prevalence of measles and scarlatina. 
 
 It is not easy to state with exactness the amount of mortality which 
 these two diseases occasion, for though they are never altogether absent 
 
 1 As an instance of which may be mentioned the work of Duvillard, De l'lnfluence de 
 la petite verole sur la Mortalite, 4to. Paris, i806. 
 
MEASLES AND SCARLET FEVER NOT THE SAME DISEASE. 465 
 
 from a large city like London, yet their frequency and their fatality 
 vary much in different years. At one time they occur sporadically, 
 and are then in most instances mild in their character, and readily 
 amenable to treatment ; while at another time they prevail as epidemics, 
 and are attended with alarming symptoms, which it is often not in the 
 power of medicine to control. Dr. Gregory, who, in his work on the 
 Eruptive Fevers, has collected together with much labour the statistics 
 of these diseases, presents us with a table, from which it appears that, 
 on an average of five years, very nearly six per cent, of the mortality 
 of London is due to measles and scarlatina. This number, indeed, is 
 not so great as at once to impress us with the formidable nature of 
 these two affections ; but it should not be forgotten, that (according to 
 the Fifth Report of the Register-General), 81 per cent, of this mortality 
 occurs in children under five ; and 97 per cent, in children under ten 
 years old ; while no figures can accurately represent the instances in 
 which death is occasioned by their complications or sequelae. 
 
 These two diseases present many points of resemblance, — so many, 
 indeed, that they were long supposed to be but varieties of the same 
 malady ; and the essential differences between them were not recog- 
 nized till within the last seventy years. It is, however, on many 
 accounts important to distinguish between them, — for not only are they 
 not attended by the same degree of danger, but this danger arising 
 from dissimilar causes, the treatment which they require is in many 
 respects different. We shall presently examine into some of those 
 peculiarities in their symptoms on which we chiefly rely in forming our 
 diagnosis beWeen the two affections, but I may even now state some of 
 the broad distinctions between them. 
 
 Measles is still more eminently than scarlet fever a disease of early 
 childhood, — for of 1298 deaths which it occasioned in London in 1842, 
 93-8 per cent, occurred in children under five years old, and 99 per 
 cent, in those under the age of ten ; while of 1224 deaths from scar- 
 latina 31 per cent, occurred after five, and 10 per cent, after ten years 
 of age. Though there are great fluctuations both in its prevalence and 
 in the mortality which it occasions, yet its variations in these respects 
 are less considerable than those of scarlet fever ; while the number of 
 persons who pass through life without having experienced its attack is 
 smaller than of those who die without ever having been affected with 
 scarlatina. Though a more universally prevalent disease, however, it 
 is fortunately less dangerous, its mortality not exceeding 3 per cent, 
 of the patients attacked by it ; while the medium rate of mortality 
 from scarlet fever is estimated as at least double that amount. When 
 measles proves fatal, too, it is very seldom the fever itself which occa- 
 sions the patient's death, but generally its complication with inflam- 
 matory disease of the respiratory organs. Scarlet fever, on the con- 
 trary, destroys its victims in all stages of the disease : and in many of 
 the worst cases, in which death takes place early, no organic change is 
 left behind which the scrutiny of the anatomist can discover. 
 
 The symptoms that attend the onset of measles present little besides 
 their greater severity to distinguish them from those of ordinary catarrh. 
 A child previously in perfect health, becomes suddenly restless, thirsty, 
 
 30 
 
466 SYMPTOMS OP MEASLES. 
 
 and feverish, and, if able to talk, generally complains of head-ache. 
 The eyes grow red, weak and wattery, and are unable to bear the 
 light ; the child sneezes very frequently, sometimes almost every five 
 minutes, and is troubled by a constant, short, dry cough. On the fourth 
 day from the commencement of these symptoms, a rash makes its ap- 
 pearance on the face, whence it extends in the course of about forty- 
 eight hours to the rest of the body and the extremities, travelling in a 
 direction from above downwards. The rash is made up of a number of 
 minute, deep red, circular stigmata, not unlike flea-bites, slightly 
 elevated, especially on the face, and though close together, yet usually 
 distinct from each other ; the skin in the interspaces between them 
 retaining its natural colour. On the cheeks, the spots sometimes become 
 confluent, and then form irregular blo:ches, about a third of an inch 
 long by half that breadth ; while the spots elsewhere often present an 
 indistinctly crescentic arrangement. The eruption fades in the same 
 order as that in which it appeared, and after the lapse of forty-eight 
 hours from its appearance, at which time it is at its height on the trunk, 
 it is beginning to disappear from the face. On the seventh day of the 
 disease the rash grows faint on the body generally, and on the eighth, 
 or at latest the ninth day, it has entirely vanished, leaving behind either 
 a little general redness of the surface, or a few yellowish red spots, 
 corresponding to some of the situations which the eruption itself had 
 occupied. In some cases a partial desquamation of the cuticle takes 
 place after the rash has disappeared ; but this is by no means constant, 
 while, when it occurs, the epidermis separates in minute branny scales, 
 never in large portions, as it often does after scarlatina. 
 
 Unlike small-pox, in which the appearance of the eruption is imme- 
 diately followed by the subsidence of all the previous symptoms, the 
 constitutional disturbance of measles is in many instances not at all 
 alleviated on the outbreak of the rash. The reverse, indeed, is fre- 
 quently the case ; and in many instances, for twenty-four or forty- eight 
 hours afterwards, the fever is aggravated, and the cough more trouble- 
 some than before, while the voice often becomes hoarser, and the throat 
 is somewhat sore in consequence of the inflammation of the palate and 
 fauces, which may be seen to be the seat of a punctated redness, re- 
 sembling that produced by the eruption on the skin. 
 
 The aggravation of the symptoms, however, when it does occur, is 
 only temporary ; and on the sixth day of the disease, if not sooner, an 
 amelioration in the patient's condition becomes apparent; the fever 
 diminishing, the cough growing looser and less frequent, and moist 
 sounds becoming audible in the lungs, where previously nothing was 
 heard but rhonchus or sibilus. In cases, however, in which the disease 
 takes a less favourable turn, this is the period when the supervention of 
 serious thoracic complication is most to be feared* It happens, indeed, 
 occasionally, that the disorder of the respiratory organs is severe from 
 the very commencement of the child's illness, and that it merely becomes 
 aggravated with the progress of the disease. But in the majority of 
 cases, it is not until the eruption has already reached its acme, or is 
 just beginning to fade, that serious inflammation of the larynx or 
 bronchi, or of the substance of the lungs, is set up, while the symptoms 
 of any such occurrence need to be watched all the more carefully at 
 
COMPLICATIONS OF MEASLES. 467 
 
 this period, from the rapidity with which they tend to a fatal issue. 
 Still although the danger from mischief in the chest is most imminent 
 at this stage of the disease, yet the same symptoms may come on at a 
 later period, when the eruption has already faded for one or two days ; 
 or even later, and at a time when a sort of incomplete convalescence is 
 already established. I need not now do more than remind you of the 
 croupal symptoms which sometimes come on at the decline of measles, 
 and which, as I mentioned some days ago, 1 are so dangerous and intract- 
 able. At this period, too, inflammation of the substance of the lungs is 
 to be dreaded, and all the more from its coming on almost impercep- 
 tibly, unattended with much cough or dyspnoea, and associated with 
 such considerable sympathetic disturbance of the stomach and bowels, 
 as very readily to lead into error with reference to the seat of the dis- 
 ease. The course of the affection of the lungs in this case is usually 
 chronic; the child loses flesh, — becomes the subject of an irregular 
 hectic fever ; and when the thoracic symptoms at length become more 
 apparent than at first they had been, and the cough grows more frequent 
 and attended with more expectoration, the case so strongly resembles 
 one of tubercular phthisis that it is exceedingly difficult to avoid an 
 erroneous diagnosis. 
 
 The treatment of measles is usually very simple : in mild cases, in- 
 deed, little is needed beyond confinement to a warm chamber, a spare 
 diet, and gentle antiphlogistic remedies. The cuugh, which is the most 
 troublesome symptom, — frequently, indeed, the only one that calls for 
 much attention, — is often very much relieved by the application for 
 three or four^ hours, of a small blister, no bigger than a shilling, to the 
 trachea, at the point just above the sternum ; and this slight counter- 
 irritation, which seldom produces any vesication of the surface, may be 
 repeated during the course of the affection. If more than this be needed, 
 small doses of antimonial and ipecacuanha wine, with laudanum or the 
 compound tincture of camphor, may be given every few hours. The 
 imperfect desquamation that sometimes takes place as the eruption 
 declines, is often attended with very distressing itching of the whole 
 surface ; while the cough is sometimes frequent and troublesome at 
 night, and the child is thus prevented from sleeping. To relieve these 
 troublesome symptoms, as well as to check that tendency to diarrhoea 
 which often comes on at the decline of measles, it is desirable to follow 
 the plan pursued by Sydenham, and to give an opiate every night, — a 
 small dose of Dover's powder being the best form in which it can be 
 administered. 
 
 But though these simple measures are amply sufficient in the great 
 majority of cases, we yet must not allow ourselves to be betrayed into 
 inertness when any indications of mischief in the chest make their 
 appearance. Such symptoms sometimes come on early in the disease, 
 and before the eruption has well appeared, the child seeming much 
 oppressed, and experiencing considerable dyspnoea, although the auscul- 
 tatory evidences of disease in the chest may be but small. This nervous 
 dyspnoea is often relieved by the application of a mustard poultice to 
 the chest, and by placing the child in a hot bath — a proceeding which 
 will very frequently be followed by the appearance of the rash abund- 
 1 See Lecture XX. p. 233. 
 
468 TREATMENT OP MEASLES. 
 
 antly over the whole surface. Should these measures, however, fail to 
 produce relief, or should the symptoms from the first be alarming, the 
 distress and dyspnoea very considerable, and the rash not merely scanty, 
 but of a dark or livid hue wherever it has appeared, the abstraction of 
 blood is urgently required ; and general depletion should, under such 
 "circumstances, be employed in preference to merely local bleeding. If 
 bronchitis or pneumonia should come on at a later period of the disease, 
 when the rash has already fully appeared, or is beginning to decline, 
 the question of bleeding, as well as of the mode in which the depletion 
 shall be practised, must be determined entirely by the severity of the 
 chest symptoms, and is little if at all modified by any considerations 
 drawn from the circumstance of their supervening during the course of 
 another disease. The unfavourable condition under which infants are 
 placed in the H6pital des Enfans at Paris, has induced, on the part of 
 French physicians, a dread of depletion in the course of measles which 
 is certainly not justified by the characters that the disease presents in 
 this country. A repetition of depletion is, however, not generally 
 either necessary or useful, especially if the first abstraction of blood be 
 followed up, as it ought to be, by the free employment of tartar emetic. 
 The dyspnoea, which is frequently exacerbated towards evening in the 
 course of the pneumonia and bronchitis that accompany measles, is 
 generally much relieved by mustard poultices ; but the application of 
 blisters under these circumstances is hazardous, since the sores which 
 they produce are often very intractable ; and the irritation and suffering 
 they occasion prove, in many instances, seriously prejudicial to the 
 children. It is important, too, to bear in mind that little reliance can 
 be placed on mercurial remedies in the treatment of active rubeolous 
 pneumonia, though small doses of the Hydr. c. Cretai, with Dover's 
 powder, are often exceedingly useful in cases where a hepatized state 
 of the lung is left behind after the subsidence of the fever, and of the 
 more acute inflammatory symptoms. I spoke so fully some days since 
 concerning the treatment of croup supervening on measles, that it can- 
 not be necessary to repeat the remarks which were then made ; neither 
 need I add anything to what I said on a former occasion about cancrum 
 oris — which distressing affection occasionally supervenes on the decline 
 of measles. 
 
 I will now, in conclusion, briefly sketch the more striking features of 
 scarlet fever. To describe it minutely would indeed require much time, 
 for there are few diseases whose characters vary so widely in different 
 instances. In one case it presents itself as an ailment so trifling as 
 scarcely to interrupt a child's cheerfulness even for a day ; in another 
 case it is so deadly that medicine is unable to stay its course even for 
 a moment ; and that it destroys life in a few days — sometimes even in 
 a few hours. Such a disease might seem to merit a very minute inves- 
 tigation at our hands ; and on this it would be my duty to enter, did I 
 not feel that, after all that has been written on the subject of the 
 eruptive fevers, it will be enough for me on the present occasion to 
 recal to your recollection some of those points concerning each of them, 
 which are of the greatest practical moment. 
 
 It is hardly necessary to remind you that the remarkable differences 
 in the severity of the affection, and in the symptoms which attend it, 
 
SCARLET FEVER— GREAT DIFFERENCES IN ITS SEVERITY. 469 
 
 have given rise to its subdivision into the three varieties of scarlatina 
 simplex, scarlatina anginosa, and scarlatina maligna. In the first of 
 these the patient experiences an attack of fever, often very mild, 
 always of very short duration, and accompanied by the appearance of 
 a bright scarlet rash over the whole surface, and generally by a slight 
 degree of sore throat. In the second the fever is more intense, and 
 subsides less speedily, while, as its name implies, the attendant sore- 
 throat is very severe ; and in the third the fever generally assumes a 
 typhoid character, sloughing of the inflamed tonsils not infrequently 
 occurs, and a variety of complications in many instances supervene, 
 by which the danger is still further aggravated. 
 
 In cases of scarlatina simplex the attack is usually ushered in by 
 vomiting, which is in many instances often repeated, and which is 
 accompanied by very intense heat of skin, by great rapidity of the 
 pulse, by headache or heaviness of the head, and by so considerable a 
 degree of sensorial disturbance as to give rise to delirium in many 
 children w T ho are old enough to manifest this symptom. On the fol- 
 lowing day, often within twenty-four hours from the commencement of 
 the patient's illness, the rash of scarlatina makes its appearance. It 
 usually shows itself first on the neck, breast, and face, whence it extends, 
 in the course of twenty-four hours, to the trunk and extremities. Its 
 oclour is a very bright red, due in part to a general flush of the skin, 
 in part to the presence of innumerable red dots or spots, which look 
 like minute red papillae, though often they communicate no sense of 
 roughness to the hand. To this, however, there are occasional excep- 
 tions : the r\ash on the chest and body presenting sometimes, when at 
 its height, a\slightly papular character ; and now and then minute 
 sudamina are intermingled with the eruption. In some instances the 
 redness of the surface is universal, but in other cases the rash appears 
 in patches of uncertain size and irregular form, which never affect any 
 definite shape, and never present a clearly circumscribed margin. For 
 three days the rash usually continues to become of a deeper colour, and 
 more generally diffused over the whole surface ; it then slowly declines, 
 but does not wholly disappear until the seventh, or sometimes the 
 eighth day of the disease. The appearance of the eruption is not in 
 general succeeded by any immediate diminution in the other symptoms ; 
 but on the contrary, they often increase in severity until the eruption 
 has reached its acme, when they slowly decline with the disappearance 
 of the rash. Sometimes, indeed, when the case is very mild, the fever 
 abates so soon as the rash is fully out ; and the child regaining its 
 cheerfulness on the third day, shews no further signs of illness, though 
 the rash remains visible for two or three days longer. Now and then, 
 too, especially in young infants, the affection throughout consists of 
 little more than of an eruption on the skin, the presence of which is 
 almost the only evidence of their having been attacked by a disease 
 sometimes so deadly. Such, however, are exceptional cases ; and in 
 most instances, even when the disease is mild, a slight degree of sore- 
 ness of the throat comes on on the second or third day ; the palate and 
 tonsils appear red, and the latter are generally somewhat swollen, and 
 deglutition is slightly impeded. The tongue also is preternaturally 
 red, and its papillae, which are very prominent, project through the 
 
470 SYMPTOMS OF SCARLATINA SIMPLEX. 
 
 white or yellowish fur which coats it, and thus form an appearance as 
 characteristic of scarlatina as the rash itself. The redness fades from 
 the fauces, and the fur disappears from the tongue, as the eruption 
 declines ; but the prominence of the papillae often continues for some 
 days longer. As the rash subsides, desquamation of the epidermis 
 generally commences, the cuticle peeling off from the hands and feet 
 in large flakes, though on the face and trunk the desquamation usually 
 takes place in furfuraceous scales. Both its degree and duration vary 
 much in different cases ; sometimes it is over in five or six days, while 
 in other cases the cuticle is reproduced, and then desquamates several 
 times in succession, and the process is thus protracted for three or four 
 weeks, or even longer. It is not possible to assign a cause for these 
 differences. Some epidemics of scarlatina are characterised by the 
 abundance of the desquamation, and its almost universal occurrence, 
 while at other times it is scanty, and often wanting. 
 
 The danger of this disease is by no means in proportion to the abun- 
 dance of the rash, but rather to the degree of the affection of the throat, 
 the severity of which is the distinguishing feature of scarlatina angi- 
 nosa. In this form of the affection the premonitory symptoms are 
 usually much more severe than in the scarlatina simplex ; they are 
 also often of longer duration, the rash not shewing itself until the end 
 of the second, and sometimes even not until the third day. It is, 
 moreover, less generally diffused over the surface than in the milder 
 variety of the disease, but appears in the form of large scarlet patches 
 irregularly distributed over different parts of the body, especially on 
 the back. Almost from the commencement of the patient's illness, 
 soreness of the throat is experienced, attended with difficulty of deglu- 
 tition, and often with considerable stiffness of the neck, and pain and 
 difficulty in moving the lower jaw, due in part to the swelling of the 
 submaxillary glands. On examining the throat, it is seen to be intensely 
 red, and the tonsils are both red and swollen. The swelling of the 
 tonsils increases rapidly, until they almost block up the entrance of 
 the pharynx, and thereby render the attempt to swallow so difficult 
 that fluids have often returned by the nose. An adhesive mucus col- 
 lects about the back of the throat, and often seems to cause great 
 annoyance to the patient, and specks or patches of lymph form upon 
 the tonsils, and look like sloughs covering ulcers, though, on detaching 
 them, it is seldom that any breach of surface appears beneath. In 
 some of the severest cases, a very troublesome coryza comes on, and 
 an adhesive, yellowish, matter is secreted in abundance by the mucous 
 membrane of the nares, whence it runs down upon the upper lip, exco- 
 riating the skin over which it passes, and causing still more serious 
 suffering by the obstacle which it presents to free respiration. In some 
 epidemics the inflammation extends to the parotid glands, and to the 
 cellular tissue about the neck, the parts thus affected becoming rapidly 
 swollen, and acquiring a great size and a stony hardness. In some 
 cases this affection is. confined to one side; in others, both sides are 
 attacked in succession, while sometimes two are involved simultaneously, 
 and the integuments under the chin and in front of the neck become 
 likewise inflamed, and tense and swollen ; the lower jaw is so firmly 
 fixed, that the attempt to swallow is rendered almost impracticable, 
 
SYMPTOMS OP SCARLATINA ANGINOSA. 471 
 
 i 
 
 and the patient is exposed to a new source of danger, from the diffi- 
 culty of taking nutriment in quantity sufficient to support the feeble 
 powers of life. Coupled with this severe local affection, there is, as 
 might be expected, a corresponding intensity in the constitutional dis- 
 turbance. The heat of the skin is very great, the pulse extremely 
 frequent, and, though not small, is yet from an early period very 
 compressed ; the sensorial disturbance is considerable, and the rest- 
 lessness extreme. The tongue does not present that appearance which 
 I mentioned as being characteristic of scarlatina in its milder form, but 
 is coated with a brown fur, though red at its tip and edges, and often 
 becomes dry at a very early period of the disease, — partly, no doubt, 
 in consequence of the swelling of the tonsils and of the glands com- 
 pelling the patient to breathe with his mouth open. 
 
 Between the severer forms of scarlatina anginosa and that still more 
 dangerous variety of the disease to which the name of malignant has 
 been applied, the differences are of degree rather than of kind. Symp- 
 toms such as have just been enumerated are present in many cases of 
 malignant scarlet fever ; but the fever very early assumes a typhoid 
 character, and death takes place sooner than the amount of the local 
 lesions suffices to explain ; while in the scarlatina anginosa a direct pro- 
 portion always exists between the severity of the local mischief and the 
 degree of constitutional disturbance. 
 
 A little girl, five years old, went to bed quite well on the night of the 
 20th May, but awoke vomiting at 4 A. M. on the 21st. Through the 
 whole of the 21st, the child seemed very ill, and her bowels were much 
 purged. Towards evening a red rash appeared on her body, and she 
 complained o:f sore throat. On the following day the soreness of her 
 throat continued, and the submaxillary glands began to swell. On the 
 23d I saw her : she was lying in her mother's lap, with her face of a 
 deep scarlet, verging on a crimson hue, and the rash, which was gene- 
 rally diffused over the whole body, presented the same colour ; her eyes 
 were half open, and the conjunctiva injected ; the submaxillary glands 
 somewhat swollen ; the tonsils very red, covered with shreds of mucus ; 
 deglutition difficult ; respiration hurried ; pulse too frequent and too 
 feeble to be counted. She had been delirious during the whole of the 
 preceding night. Ammonia was given in doses of gr. iij. every four 
 hours ; but at 4 p. M. on the 24th, I found her lying on her back in a 
 semi-comatose condition, though capable of being roused ; her surface 
 quite cool, of a generally livid colour; her pulse exceedingly feeble; 
 her respiration noisy and difficult, rendered so in part by an abundant 
 secretion of yellow adhesive matter in the nares. The swelling on the 
 right side of the throat was much the same as on the previous day, but 
 the left parotid was greatly swollen and of a stony hardness ; the tonsils 
 were more swollen ; deglutition was difficult, and a large quantity of 
 tenacious mucus was collected about the faeces. The diarrhoea still con- 
 tinued, and at 10 o'clock the same night the poor child died, within 
 ninety hours from the commencement of her illness. 
 
 Death sometimes takes place even more rapidly, at an interval of less 
 than forty-eight hours intervening between the commencement of the 
 illness and its fatal close. In some instances petechise and vib'ces 
 appear on the surface, or haemorrhages take place from the bowels, — 
 
472 SYMPTOMS OF SCARLATINA MALIGNA. 
 
 i 
 
 the tokens and consequences of the changes in the circulating fluid ; 
 while convulsions, succeeded by coma, destroy the patient in other 
 cases, before time has passed sufficient to allow of the appearance of 
 the eruption. 1 Some epidemics of scarlet fever are characterized by 
 the frequency of these cases of extreme malignancy, while in others they 
 are extremely rare ; but the general mildness of the disease is no gua- 
 rantee against their occasional occurrence. During the early part of 
 this autumn scarlet fever broke out in a public institution some miles 
 from London. Almost all of the cases, which occurred among lads 
 from 14 to 18 years of age, were extremely mild ; but one youth, more 
 robust than most of the others, sank from the moment he was taken, and 
 died with typhoid symptoms before the end of the third day. His case 
 stood by itself, unlike any of those which preceded or which followed it. 
 Even in the malignant form of scarlatina, however, it is seldom that 
 death takes place with this extreme rapidity; but the patient more 
 commonly survives to the end of the sixth or seventh day, and under 
 these circumstances the affection of the throat generally goes on 
 increasing in severity. These are the cases which went during the last 
 century under the name of putrid sore throat, cynanche maligna, 
 angina putrida; and the occurrence of which constituted a marked 
 feature in the epidemic scarlatina of 1839 and 1843. The inflammation 
 of the tonsils terminates in the formation of excavated, ragged, 
 unhealthy ulcerations, which I have occasionally found, indeed, in the 
 pharynx, and at the upper part of the oesophagus ; or sometimes a more 
 extensive sloughing involves the parts at the back of the throat. The 
 tongue and soft palate are found in such cases denuded of their epithe- 
 lium ; the papillae of the tongue very prominent, and those at its base, 
 as well as the lingual glands in that situation, extremely enlarged, and 
 covered by a dirty tenacious mucus. The coryza, to which reference 
 was made just now, is generally very severe, while the mischief at the 
 back of the throat sometimes extends to the air-passages; and I have 
 found the mucous membrane at the under surface of the epiglottis, and 
 about the arytenoid cartilages, much injected and thickened : a condi- 
 tion which, during life, was sufficient to occasion intense dyspnoea, and 
 to give rise, on each attempt at deglutition during the last twenty-four 
 hours of the child's life, to a struggle for breath which threatened every 
 moment to be fatal. The swelling of the parotids in some of these 
 cases increases with very great rapidity, and forms not unfrequently, 
 by the implication of the integuments of the neck, a sort of collar of 
 brawny hardness, which interferes alike with deglutition and respiration. 
 These swellings are remarkable for the slight tendency which they 
 show to suppurate ; and even after they have attained a very consider- 
 able size, and been in great measure instrumental in occasioning the 
 child's death, I have found the parotids much enlarged, of a rose red 
 colour, infiltrated with thin serum, and a dirty sero-purulent fluid also 
 pervading the cervical cellular tissue, but no true pus either in the 
 substance of the gland itself or in the surrounding cellular tissue. Now 
 and then, however, suppuration takes place, not in the substance of the 
 glands themselves, but in the surrounding cellular tissue ; and the 
 quantity of pus which is formed there is sometimes very considerable. 
 1 Of which a case is related in Lecture III. p. 35. 
 
COMPLICATIONS OP SCARLET FEVER."] 473 
 
 The destruction of tissue, too, is not always the result of mere suppura- 
 tion, but a process of sloughing sometimes destroys the cellular 
 membrane very extensively ; and, by involving the large vessels of the 
 neck, has sometimes caused the child's sudden death from haemorrhage 
 — an occurrence, indeed, which I have not met with, but which came 
 thrice under the observation of Dr. H. Kennedy, of Dublin, whose 
 excellent account of the epidemic which prevailed in that city will well 
 repay your attentive perusal. 
 
 As in other blood diseases, so in scarlatina, we meet now and then 
 with secondary inflammation of the joints, which may even go on to the 
 formation of pus. It is, however, not a common occurrence ; but I saw 
 the hand thus affected in a child who died on the sixth day of the 
 disease, and in another child, who had recovered from scarlatina in the 
 course of which inflammation attacked the right shoulder-joint, the 
 humerus remained perfectly anchylosed. Both the pericardium and 
 endocardium are also sometimes affected, but in this stage of the disease 
 that special tendency to inflammation of the serous membranes which 
 is afterwards observed does not manifest itself. Pneumonia, indeed, is 
 a more frequent affection, running its course without any marked 
 symptom, though a large portion of one or both lungs may be found 
 after death in a state of hepatization. 
 
 The other post-mortem appearances observed in scarlatina are to a 
 great degree identical with those observed in malignant fevers generally. 
 The blood is usually semi-coagulated, of the appearance and consistence 
 of gooseberry-jelly, or even altogether fluid, and the coats of the vessels 
 are often stained by it. The mucous membrane of the bronchi, stomach, 
 oesophagus, and trachea, is often of an intensely red colour, though 
 nothing can be more arbitrary than the extent, degree, and situation of 
 this redness. The texture of the kidneys and heart is also often very 
 much softer than natural, so as to tear very readily; and once I found 
 the heart exceedingly flaccid, its tissue infiltrated with reddish serum ; 
 and not merely tearing easily, but even being so soft that the finger 
 could be pushed through its walls with the slightest effort. 
 
 Such are the chief modes of death from scarlet fever, and such the 
 more important appearances discovered afterwards : at least as far as 
 my personal observation extends, — though I scarcely need remind you 
 that there are but few diseases of which the characters are liable to 
 greater variations ; so that no account how minute soever can be taken 
 as a true portraiture of more than just that one form of the fever with 
 which its describer may chance to be most familiar. 
 
 Unhappily the first few days of the disease do not by any means com- 
 prise the whole period of danger, but even though the patient should 
 survive the peril of the fever, a long catalogue of sequelae remains, some 
 of which may endanger or even destroy life. Sometimes, indeed, the 
 patient passes through the first week of the disease with few or no 
 symptoms to excite anxiety; and then, when the rash is on the decline, 
 the parotid glands swell, grow hard, and intensely painful, and on one 
 or two occasions I have seen the integuments covering them become 
 gangrenous ; or sloughing ulcers form on the tonsils, which had not 
 seemed to be very much inflamed previously ; an acrid discharge takes 
 place from the nostrils, and death follows in the course of four or five 
 
474 SEQUELS OP SCARLET FEVER. 
 
 days. In the majority of instances, however, the glandular swellings 
 which come on after the lapse of a week from the commencement of the 
 disease, though tedious and painful, yet do not endanger life. Occa- 
 sionally, indeed, death occurs in consequence of the matter formed by 
 the inflammation of the glands, or of the cellular tissue around them, 
 burrowing backwards behind the pharynx, instead of pointing exter- 
 nally. In these cases of retro-pharyngeal abscess, after more or less 
 evident indications of inflammation in the neighbourhood of the parotid 
 or submaxillary glands, accompanied, in all probability, with a swelling 
 on one or other side of the neck or jaw, the patient begins to experi- 
 ence difficulty in deglutition, which goes on increasing until the attempt 
 to swallow becomes quite impracticable. As the dysphagia increases, 
 respiration becomes also very difficult, but the dyspnoea continues to 
 increase progressively, and is not aggravated in paroxysms, as in cases 
 of cynanche trachealis, though the effort to swallow will sometimes 
 bring on threatening suffocation. Moreover, there is seldom any modi- 
 fication in the tone of the voice, such as occurs in croup, though the 
 voice becomes by degrees whispering and then extinct; while if the 
 throat be examined, the tonsils are observed to be free from swelling ; 
 and sometimes neither they nor the soft palate show the slightest in- 
 crease in redness or other token of inflammation. These general symp- 
 toms, coupled with the negative results afforded by examination of the 
 fauces, point tolerably plainly to the real nature of this affection ; but 
 positive certainty concerning it can be obtained only by a means which 
 Mr. O'Ferrall, of Dublin, was, to the best of my knowledge, the first 
 to point out, and which consists in passing the finger for some distance 
 down the throat, when the presence of a tumor pressing forward the 
 posterior wall of the pharynx or oesophagus, will at once reveal the 
 cause of the patient's sufferings. 
 
 Coupled with the swelling of the parotid glands, or even indepen- 
 dently of it, inflammation of the internal ear is often met with as a 
 consequence of scarlatina. This otitis terminates in abundant purulent 
 discharge, which sometimes continues for many weeks; and occasionally 
 it completely destroys the organ of hearing, and renders the patient 
 hopelessly deaf for the remainder of his life. 
 
 I have already spoken, in a previous lecture, 1 of that very frequent 
 and very serious occurrence, the dropsy which succeeds to scarlet fever, 
 and need not, therefore, refer to that subject now. But there are other 
 cases, in which, without any definite local complication, the convales- 
 cence from scarlet fever is fluctuating and protracted. In such cases 
 the bowels are irregular in their action, alternately relaxed and consti- 
 pated ; the evacuations unhealthy ; the tongue red and raw ; and aph- 
 thous ulcerations sometimes appear on the inside of the mouth ; while 
 an irregularly remittent fever harasses and weakens the child. These 
 symptoms, however, which closely resemble those that sometimes come 
 on during convalescence from measles, are of much less frequent occur- 
 rence as consequences of scarlatina. 
 
 The diagnosis of scarlatina is not in general attended with much 
 difficulty ;• and the points of difference between it and measles are so 
 well marked, that it is not easy to understand how the two diseases 
 I See Lecture XXXV. p. 419. 
 
DIAGNOSIS OF SCARLET FEVER. 475 
 
 should so long have been confounded together. Their period of incu- 
 bation is different ; that of scarlatina not exceeding a week, that of 
 measles often extending to two. 1 Their premonitory symptoms are 
 very dissimilar — those of measles closely resembling the signs of a 
 severe catarrh ; while the attack of scarlatina is announced by sickness, 
 succeeded by intense heat of skin, by sore throat, great sensorial dis- 
 turbance, and extreme rapidity of the pulse. There is no other disease 
 of childhood, indeed, in which the two last-named symptoms supervene 
 so speedily after the commencement of illness ; and their occurrence 
 will often enable you, even before the appearance of the rash, or any 
 complaint of sore-throat, to form a correct conclusion with reference to 
 the nature of the affection. The premonitory stage of measles usually 
 continues for three or four days — that of scarlet fever, in its regular 
 form, only for twenty-four hours; while the other symptoms which 
 appear in cases of scarlet fever, in which the rash is delayed, are such 
 as quite to forbid the supposition of the patient being affected with 
 measles. The character of the two eruptions is so dissimilar, that I 
 need not here dwell on their peculiarities, nor do more than remind you 
 that, while in measles the great danger to life arises from the super- 
 vention of bronchitis or pneumonia, the two great sources of hazard in 
 scarlet fever are the affections of the throat during its progress, and the 
 occurrence of dropsy after its decline. 
 
 With a few words on the treatment of scarlatina, I will bring this 
 subject, and the present course of lectures, to a close. The milder 
 forms of the disease require, as you know, but little interference ; and 
 you fulfil every indication by keeping the child in a cool and well-ven- 
 tilated chamber, placing him on a spare diet, giving some mild anti- 
 phlogistic medicine during the progress of the fever, and sponging the 
 surface occasionally with tepid water if the heat of the skin be consi- 
 derable. When the eruption is on the decline, the hot bath every night 
 is often very useful in favouring the process of desquamation ; while 
 the child must be kept strictly within doors, his diet must still be mild 
 and unstimulating, and due attention must be paid to the state of the 
 bowels, until the period has passed when there is much ground for 
 fearing the supervention of dropsy. For some time after, much caution 
 must be exercised in not allowing the child to go out when the air is 
 coo?, and in avoiding all errors of diet ; while it is also expedient that 
 flannel should be worn next the skin for a considerable period after 
 apparent convalescence from scarlet fever. 
 
 Even in severer cases of the disease, you must not be in too great a 
 hurry to resort to active measures, for you will remember that a some- 
 what stormy onset is characteristic of all but the very mildest forms of 
 scarlatina. That disturbance of the sensorium, for instance, which, 
 when the child is sufficiently old, shows itself by the early occurrence 
 of delirium, must not lead you to have recourse hastily to depletion, 
 either general or local, in order to quiet the disorder of the brain. The 
 results afforded by depletion in scarlet fever, even when the disease 
 
 1 I have purposely omitted to say any thing concerning the diagnosis between scar- 
 latina and the kindred exanthema, called Rotheln by German writers (the Rubeola of 
 some continental nosologists) ; for, though I believe there to be a foundation for this 
 distinction, my own opportunities have not enabled me to come to any positive conclu- 
 sion on the subject. 
 
476 TREATMENT OP SCARLET FEVER. 
 
 occurs in the adult, are by no means encouraging ; and in the child the 
 loss of blood under these circumstances is even less well borne ; so that, 
 unless the patient be robust and plethoric, the cerebral disturbance very 
 serious, and the evidences of congestion of the brain very marked, you 
 should content yourselves with the application of cold to the head, per- 
 haps employing cold affusion, and with cold sponging of the surface. 
 In the malignant forms of the disease there is often very considerable 
 disturbance of the sensorium, great restlessness alternating with a state 
 of stupor ; but the frequent and feeble pulse at once forbids depletion 
 in such cases and points out the necessity for adopting every means to 
 support the feeble powers of life. If there be much sore-throat, and the 
 child seem likely to bear the loss of a little blood, I sometimes apply a 
 few leeches to the angle of the jaw ; but have hardly ever carried deple- 
 tion beyond this point among my patients at the Children's Infirmary. 
 It is very likely that the low type which a disease such as scarlatina is 
 almost sure to assume in the crowded dwellings of the poor, has ren- 
 dered my practice, in this respect, somewhat different from that which 
 might be advantageously pursued in the case of children more favour- 
 ably situated. To the same circumstances it is also probably due that, 
 in a large proportion of cases, I have found it desirable to give ammonia 
 almost from the outset of the disease ; a practice which has been recom- 
 mended as universally applicable, and which (though the remedy does 
 not deserve the indiscriminate encomiums that have been lavished on it) 
 you will do well to follow, whenever the pulse presents the characters 
 of great frequency and softness combined. The state of the throat must 
 be carefully watched in every case of scarlet fever ; and whenever there 
 is much swelling of the tonsils, if the child be too young to gargle, a 
 slightly acidulated lotion should be injected into the throat, by means 
 of a syringe, every few hours, in order to free it from the mucus which 
 is so apt to collect there, and to be the source of much discomfort. If 
 there be much deposit of lymph upon the tonsils, it is generally desirable 
 to apply the strong hydrochloric acid, mixed with honey, in the propor- 
 tion of about one part of the former to six of the latter, by mea'ns of a 
 dossil of lint, or a camel's hair pencil, two or three times in the twenty- 
 four hours ; but the strength of the application must be increased if the 
 tonsils be ulcerated, or if any disposition to sloughing should appear. 
 The coryza which is so distressing and so ill-omened a symptom in 
 cases of severe scarlatina, is best treated by throwing a small quantity 
 of a solution of gr. j. or gr. ij. of nitrate of silver in Ij. of distilled 
 water, up the nostrils every four or every six hours. The glandular 
 swellings are very difficult to relieve. When considerable they do not 
 seem to be benefited by leeches ; the employment of which is also, in 
 many cases contraindicated by the feeble state of the patient's powers ; 
 while they show very little disposition to suppurate, and consequently 
 are not relieved by lancing : so that the constant application of a warm 
 poultice is often all that can be done to afford ease to the patient. 
 Children in whom the local affection is severe, or in whom the disease 
 assumes a malignant character, require all those stimulants, and that 
 nutritious diet, which we are accustomed to give to patients in certain 
 stages of typhus fever ; though, unfortunately, the best devised means 
 will, in many such cases, prove ineffectual. 
 
INDEX. 
 
 Abdomen, examination of, in sick children, 20. 
 
 shrunken, in acute hydrocephalus, 68. 
 Abdominal Tumours, from general enlarge- 
 ment of abdomen, 430. 
 suspected sometimes when not present, 
 
 436. 
 from enlarged liver — case, 432. 
 hydatids of the liver — case, 432. 
 fungoid disease of the liver — case, 434. 
 kidney — case, 434. 
 
 psoas abscess, caution as to diagnosis, 435. 
 ^ enlargement of the spleen, 435. 
 Acute Hydrocephalus, 56. 
 
 see Hydrocephalus. 
 Air, vitiated, cause of infantile trismus, 132. 
 Albuminuria, 419. 
 
 see Kidneys, inflammation of. 
 Alkalies, their use in infantile dyspepsia, 363. 
 Anasmia, bruits due to, very rare in child, 313. 
 Antimony, in treatment of bronchitis, 188. 
 pneumonia, 201. 
 croup, 225, 256. 
 dropsy after scarlatina, 424. 
 and Opium, in head symptoms of remit- 
 tent fever, 452. 
 Anus, prolapsus of, in course of chronic diar- 
 rhoea, treatment of, 401. 
 imperforate, 374. 
 see Rectum, imperforate. 
 Aphtha?, 335. 
 
 see Thrush. 
 Apoplexy, symptoms less dangerous in child 
 
 than in adult, 46. 
 Arachnoid, peculiar condition of, in acute 
 hydrocephalus, 59. 
 granulations of, in hydrocephalus; their 
 
 tubercular nature, 61. 
 lining of the ventricles, granular state of, 
 
 94. 
 haemorrhage into the, 47, 51. 
 ch. nges of the effused blood, 51. 
 obscurity of its symptoms, 52. 
 cases of, 53. 
 
 chronic hydrocephalus an occasional re- 
 sult of, 52, 97. 
 Asphyxia, of new-born child, often due to 
 cerebral haamorrhage, 47. 
 treatment of, 47. 
 Asthma Thymicum, 244. 
 
 see Spasm of the Glottis. 
 Astringents, use of, in treatment of diarrhoea, 
 
 399. 
 Atelektasis Pulmonum, 151. 
 
 see Lungs, imperfect expansion of. 
 Atrophy of Brain, 107. 
 
 see Brain, atrophy of. 
 Auscultation, general rules for, 20. 
 
 B. 
 
 Blisters in treatment of acute hydrocephalus, 
 81. 
 pneumonia, 203. 
 croup, 228. 
 hooping-cough, 273. 
 Brain in infancy, peculiarities of its circula- 
 tion, 27. 
 controlling power over spinal cord not 
 
 manifest, 31. 
 disease of, symptoms of, 29. 
 importance of vomiting as a sign of, 
 
 30, 38. 
 paralysis from, diagnosis of, 145. 
 disorder of, sympathetic, in pneumonia, 
 
 113. 
 in jaundice, symptoms of, 373. 
 Atrophy of, with premature ossification of 
 skull, 107. 
 in course of long illness, 107. 
 partial — case of, 109. 
 Cancer of, 122. 
 Congestion of, 34. 
 
 see Congestion of the Brain. 
 Dropsy of, 56. 
 
 see Hydrocephalus. 
 Ha3morrhage into substance of — cases of, 
 54. 
 see Cerebral Haemorrhage. 
 Hydatids of, 122. 
 Hypertrophy of, 101. , 
 illustrative case, and symptoms of, 103. 
 its connection with rickets, cretinism, 
 
 and idiocy, 103. 
 state of brain in, 104. 
 diagnosis from chronic hydrocephalus, 
 
 104. 
 occasional cure of chronic hydrocephalus 
 
 by, 97. 
 treatment of, 105. 
 partial, 107. 
 Inflammation of, deaths from, at different 
 ages, 56. 
 progress of knowledge concerning, 57. 
 two kinds of, simple and scrofulous, 58. 
 consequent on disease of bones of skull, 
 
 81. 
 see Encephalitis and Hydrocephalus, 
 sinuses of — case of, 88. 
 Malformation of, 107. 
 
 connection of chronic hydrocephalus with, 
 91, 93, 97, 98. 
 Softening of, in hydrocephalus, not due to 
 
 imbibition, 62. 
 Tubercle of, its frequency in childhood, 
 115, 117. 
 anatomical characters of, 115. 
 changes it undergoes, 116. 
 
478 
 
 INDEX. 
 
 Brain in infancy, 
 
 Tubercle of, capillary apoplexy in, 56. 
 in cases of acute hydrocephalus, 64. 
 symptoms of, very obscure, 117, 119. 
 sometimes absent, sometimes very sudden 
 
 in their occurrence, 11 S. 
 peculiar character of convulsions in, 33. 
 varieties in course of the disease, 120. 
 deposit occasionally external to brain — 
 
 case, 121. 
 diagnosis, 121. 
 
 treatment of suspected cases of, 121. 
 Ventricles of, changes of their lining in 
 
 acute hydrocephalus, 63. 
 Bronchial Phthisis, anatomical characters of, 
 
 283. 
 , process of cure of, 284. 
 perforation of bronchi, &c, 285. 
 symptoms of, 287, 292. 
 auscultatory, peculiarities of, 289, 292, 
 
 293. 
 exaggerated by intercurrent bronchitis, 
 
 292. 
 occasional recovery from, 288. 
 modes of death in, 288. 
 Bronchitis, points of difference in child and 
 
 adult, 171. 
 morbid appearances of bronchi in, 172. 
 dilatation of bronchi in, 173. 
 nature of vesicular, 174. 
 morbid appearances, affection of pulmo- 
 nary tissue in, 174. 
 symptoms of, 183. 
 
 similar to those of pneumonia, 175, 197. 
 sudden supervention of collapse of lungs 
 
 in, 183. 
 when chronic, may simulate phthisis, 
 
 190. 
 intercurrent, exaggerates symptoms of 
 
 phthisis, 295. 
 treatment of, depletion in, 187. 
 tartar emetic in, 188. 
 nervous dyspnoea in, 189. 
 convalescence from, 190. 
 complicating measles, treatment of, 470. 
 hooping-cough, 257. 
 treatment of, 275. 
 inflammatory diarrhoea, 390. 
 Capillary, its nature and symptoms, 184. 
 case illustrative of, 186. 
 results of auscultation in, 187. 
 average duration of, 187. 
 treatment of, 190. 
 Bronchio-pneumonia, import of the term, 172, 
 
 192. 
 its symptoms, 196. 
 
 C. 
 
 Calculus, frequency of, in childhood, 424. 
 
 symptoms of, 425. 
 
 treatment of, 426. 
 Cancer of brain, 121. 
 
 kidney, 434. 
 
 liver, 443. 
 
 lung, 435. 
 Cancrum oris, 349. 
 
 see Stomatitis, gangrenous. 
 Case-taking, rules for, 23. 
 Castor Oil, use of small doses of, in diarrhoea, 
 396. 
 
 Catarrh, influence of age and of season of year 
 in its production, 170. 
 its special importance in infancy, 181. 
 symptoms of, 170. 
 treatment of, 171. 
 Suffocative, 184. 
 
 see Bronchitis, capillary. 
 Cephalhematoma, its character and changes, 
 48. 
 case illustrating process of cure of, 49. 
 diagnosis and treatment of, 50. 
 subaponeurotic, 50. 
 Cerebral Circulation, its peculiarities in in- 
 fancy, 27. 
 Congestion, 34. 
 
 see Congestion of the Brain. 
 Croup, 248. 
 
 see Spasm of the Glottis. 
 Haemorrhage, 46. 
 
 frequent cause of asphyxia, 47. 
 into Substance of Brain, 54. 
 generally capillary, 47. 
 capillary in cases of tubercle, 56. 
 into Sac of Arachnoid, 48, 51. 
 treatment of, 56. 
 external to Skull, 48. 
 see Cephalhaamatoma. 
 Bespiration, meaning of the term, 30. 
 Chest, elasticity of walls of, 149. 
 
 examination of, in sick children, 20. 
 Chicken pox, essential differences from Small- 
 pox, and symptoms, 463, 464. 
 Children, high mortality of, 17. 
 
 peculiarities of their diseases, 18. 
 rules for conducting examination of, 19. 
 feebleness of inspiratory power in, 149. 
 imperfect expansion of lungs in new- 
 born, 150. 
 Chlorate of potash, in treatment of stomatitis, 
 
 344, 349. 
 Chorea, rare in early childhood, 138. 
 
 influence of sex and other causes in pro- 
 ducing it, 138. 
 its treatment, 139. 
 partial — case of, 139. 
 Chronic Hydrocephalus, 90. 
 
 see Hydrocephalus. 
 Cod-liver Oil, in treatment of phthisis, 302. 
 Cold, influence of exposure to, 149. 
 mode of applying to head, 41. 
 external application of, in acute hydro- 
 cephalus, 80. 
 Affusion in congestion of brain, 41. 
 Congestion of the Brain, its frequency, 34. 
 first stage of many cerebral diseases, 35, 
 
 38. 
 apparent, how distinguished after death 
 
 from real, 58. 
 fatal, may leave very slight post-mortem 
 
 appearances, 35. 
 active, causes of, 35. 
 cases of at onset of eruptive fevers, 35. 
 case of, from exposure to sun, 37. 
 symptoms of, 37. 
 its stages and modes of termination, 38, 
 
 39. 
 treatment of, 39, 40. 
 rules for depletion in, 40. 
 use of purgatives in, 40. 
 cold affusion in, 41. 
 passive, causes of, 35, 44. 
 
INDE X. 
 
 479 
 
 Congestion the of Brain, case illustrative of 
 
 symptoms of, 43. 
 treatment of, 39, 44. 
 Constipation, from congenital malformation of 
 
 intestines, 373. 
 strangulated hernia, 379. 
 intussusception, 379. 
 
 see Eectum, imperforate, and Intussus- 
 ception, 
 Convulsions in child answer to delirium in 
 
 adult, 31. 
 deaths from, at different periods of life, 
 
 (note) 32. 
 due to predominance of spinal system in 
 
 early life, 31. 
 description of a fit of, 34. 
 importance of ascertaining their cause, 32. 
 in hydrocephalus, 68, 69. 
 occur from slight causes, 28, 31, 32. 
 independent of disease of brain, 136. 
 complicating hooping-cough, 260. 
 from intestinal worms, 418. 
 malaria, 393. 
 Copper, Sulphate of, in advanced stages of 
 
 croup, 226. - 
 Coryza, symptoms of, 167. 
 
 malignant, case in illustration of, 168. 
 its treatment, 169. 
 its connection with syphilis, 169. 
 sometimes sole symptom of infantile 
 
 syphilis, 438. 
 Cough, peculiar, in disease of brain, 30. 
 at onset of hydrocephalus, 70. 
 paroxysmal, in course of capillary bron- 
 chitis, 185. 
 bronchial ^phthisis, 287. 
 spasmodic, in bronchial phthisis, intestinal 
 
 rritation, cerebral inflammation, 247. 
 peculiar, in croup, 218. 
 Cretinism, connection of, with hypertrophy of 
 
 brain, 103. 
 Croup, definition of the disease, 214. 
 
 character, influenced by various causes, 
 
 214. 
 peculiarity of the field in which the au- 
 thor's observations were made, (note), 
 
 214. 
 influence of age, sex, climate, &c, in 
 
 causing it, 215. 
 prevails epidemically, 216. 
 morbid appearances, modified by locality, 
 
 216. 
 observations of the author, 217. 
 N peculiarities in croup after measles, 217. 
 symptoms of, onset, and first stage, 218. 
 second stage, pathognomonic sound of 
 
 voice and cough, 218. 
 third stage, delusive appearances of im- 
 provement, 220. 
 results of auscultation in, 221. 
 spasmodic dyspnoea in, 225, 237, 238. 
 duration of, and prognosis in, 221, 222. 
 treatment of, premonitory symptoms of, 
 
 222. 
 depletion in, 223. 
 employment of antimony in, 224. 
 calomel in, 225. 
 inflammation of lungs in course of croup, 
 
 225. 
 danger of over-treatment in, 225. 
 convalescence from the disease, 225. 
 advanced stages of, 226. 
 
 Croup, of uso sulphate of copper in, 227. 
 
 caution with reference to emetics in, 227. 
 
 use of blisters in, 228. 
 
 bronchotomy in, 228. 
 
 difference of results in England and 
 
 France, 228. 
 reasons for not rejecting it, 229. 
 asthenic variety of, influence of local 
 
 causes in predisposing to it, 232. 
 its symptoms, probable identity with 
 
 diphtheritis, 232. 
 occurrence as a sequela of measles, 233. 
 post-mortem appearances in, 235. 
 treatment of, 235, 237. 
 cauterization of larynx in, 236. 
 with predominance of spasmodic symp- 
 toms, 237. 
 illustrative case, 238. 
 Spasmodic, 239. 
 see Spasm of the Glottis. 
 Cri Hydrencephalique, 67. 
 Cry in infancy, its two periods, 22. 
 
 characteristic, in imperfect expansion of 
 the lungs, 153. 
 Cyanosis, cases of, 313. 
 
 Cynanche Laryngea, Cynanche Tra<ehealis, 
 214. 
 see Croup. 
 Parotidea, symptoms of, 357. 
 
 treatment of, 358. 
 Tonsillaris, 354. 
 
 D. 
 
 Dentition, tardy in human subject, 325. 
 order of appearance of the teeth, 340. 
 pauses in its course, 247, 341. 
 development of digestive system during, 
 
 382. 
 disease frequent during, 18. 
 high mortality during, and reasons for it, 
 
 33'9. 
 affections of mouth during, 341. 
 connection of, with diarrhoea, 381. 
 congestion of brain,, frequent during, 37, 
 
 38. 
 occurrence of paralysis during, 141. 
 connection of, with spasm of the glottis, 
 
 243. 
 diagnosis of pneumonia supervening 
 
 during, 199. 
 dysuria during, 425. 
 treatment, use of the gum-lancet, 342. 
 constitutional, 343. 
 treatment of affections of mouth during, 
 
 343. 
 of eruptions of scalp, &c, caution con- 
 cerning, 344. 
 of diarrhoea during, 375. 
 Depletion in congestion of brain, 40. 
 in acute hydrocephalus, 78. 
 in bronchitis, 187. 
 in pneumonia, 200. 
 in pleurisy, 212. 
 in croup, 224. 
 
 from head in hooping-cough, 272, 274. 
 in spasm of the glottis, 248. 
 in inflammatory diarrhoea, 396. 
 in tubercular peritonitis, 414. 
 from head in remittent fever, 453. 
 in affections of chest in course of measles, 
 
 476. 
 
480 
 
 INDEX. 
 
 Depletion, caution concerning, in affection of 
 
 head in scarlet fever, 475. 
 in dropsy after scarlet fever, 424. 
 excessive, its peculiar dangers in infancy, 
 
 27, 114. 
 Diabetes, rarity of, in childhood, 428. 
 
 symptoms of, connection with dyspepsia, 
 
 428. 
 treatment of, 429. 
 Diarrhoea,, its frequency and importance, 380. 
 table illustrating, 381. 
 influence of age on ; of dentition, 381. 
 season on, 382. 
 
 locality on ; malaria, 383, 393. 
 two forms of, 381. 
 
 simple or catarrhal, symptoms of, 382. 
 during teething, 383. 
 danger from exhaustion, 383. 
 of supervention of dysentery, 384. 
 inflammatory, or dysentery, 384. 
 its resemblance to dysentery in the adult, 
 
 385. 
 morbid appearances, chiefly in large in- 
 testine, 385. 
 in other parts, 386. 
 symptoms of acute attack of, 387. 
 occasional rapidity of course of, 388. 
 chronic course of, 389. 
 various causes and modes of death from, 
 
 390. 
 relapses of, 390. 
 supervention of cerebral symptoms from 
 
 exhaustion in course of — cases, 263. 
 complicating hooping-cough, 263. 
 sometimes associated with congestion of 
 
 brain, 43. 
 possibility of its occurrence in hydroce- 
 phalus, 89. 
 treatment of simple form, 393. 
 during teething, 394. 
 in its decline, 395. 
 inflammatory form ; depletion, 396. 
 vomiting, and of nervous symptoms, 397. 
 use of stimulants in, 398. 
 aromatics and astringents, 399. 
 chronic stage of, 399. 
 diet in, 400. 
 intertrigo in, 401. 
 prolapsus ani in, 401. 
 Diphtheritis, 232. 
 
 see Croup. 
 Digestive System, peculiarities of, in early 
 
 childhood, 335. 
 form, 331. 
 changes in, with advancing years, 338, 
 
 382. 
 deaths from diseases of, and from other 
 
 causes, compared, (note), 147. 
 disorder of, associated with diabetes, 483. 
 Disease, peculiarities of, in childhood, 18. 
 difficulties of investigating, 18. 
 how to investigate, 19. 
 hereditary tendency to, important, 23. 
 Dropsy after Scarlatina, 419. 
 
 see Kidneys, inflammation of. 
 Dura Mater, inflammation of sinuses of, 54, 88. 
 Dyspepsia of infants, symptoms of, 360. 
 
 treatment, when dependent on debility, 
 
 361. 
 gastric disorder, 362. 
 use of alkalies in, 363. 
 strumous, as a symptom of phthisis, 286. 
 
 Dyspnoea, nervuos, in course of bronchitis, 
 189. 
 hooping-cough, 254, 261, 262, 263. 
 treatment of, 272, 274. 
 Dysuria of young children, 425. 
 treatment of, 425. 
 
 from calculus in urethra ; from long pre- 
 puce, 425. 
 
 E. 
 
 Ear, inflammation of internal, 86. 
 
 symptoms of, 86. 
 
 diagnosis from inflammation of brain, 87. 
 
 extending to brain, 85, 86. 
 
 treatment, 86. 
 Emetics, in treatment of croup, 224, 227, 238. 
 
 caution with reference to their use, 228. 
 Emphysema, its association with pneumonia, 
 178. 
 
 relation of hooping-cough to its produc- 
 tion, 268. 
 Encephalitis, or simple inflammation of the 
 brain, 58. t 
 
 its differences from hydrocephalus — cases 
 illustrative of, 82, 83. 
 
 morbid appearances in, 84. 
 
 its occurrence rare, 85. 
 
 treatment of, 85. 
 Endocarditis, idiopathic, 308. 
 
 effects of, tend to increase — cases, 309. 
 
 occasional amelioration in — cases, 310. 
 
 see Heart, Diseases of. 
 Epilepsy, 136. 
 
 rare in early childhood, 137. 
 
 its causes, 137. 
 Exanthemata, general characteristics of, 443. 
 
 F. 
 
 Facial Hemiplegia in new-born infants, 146. 
 Peeding, Artificial, of Infants, high mortality 
 from, 326. 
 its injurious effects explained, 328. 
 morbid appearances produced by, 330. 
 rules for, when necessary, 332. 
 caution as to occasional unhealthiness of 
 cows' milk, 334. 
 Fevers in childhood, chiefly Exanthemata, 
 443. 
 Simple fever, same in child and in adult, 
 444. 
 identical with Remittent Pever, 444. 
 see Remittent Pever. 
 
 Gangrene of the Lung, 179, 205. 
 see Lung, gangrene of. 
 Mouth, 349. 
 
 see Stomatitis, gangrenous. 
 Gastric Disorder, diagnosis of, from pneu- 
 monia, 198. 
 pleurisy, 210. 
 Gastric Disorder, diagnosis of, from remittent 
 
 fever, 449. 
 Gums, lancing of, rules for, during teething, 
 341. 
 caution needed in cases of spasm of the 
 glottis, 248. 
 
INDEX. 
 
 481 
 
 n. 
 
 Haeniatemesis, circumstances under which it 
 occurs, 367. 
 illustrative cases, 368. 
 spurious, 370. 
 Haemoptysis rare in phthisis of children, 286. 
 
 cases of fatal, 289. 
 Haemorrhage from Umbilicus in new-born 
 
 children, 373. 
 Heart, Diseases of, 303. 
 Table of 33 cases of, 317. 
 frequency in childhood underrated, 303. 
 acute rheumatism most frequent cause of, 
 
 304. 
 associated with scarlatina ; with pleurisy, 
 
 305. 
 idiopathic, 306. 
 
 their tendency to increase, 310. 
 occasional pauses in advance of, 311. 
 rarity of analmic bruits, 313. 
 congenital — cases of, 314. 
 Hectic, rare in phthisis of children, 286. 
 Hemiplegia, facial in new-born infants, 146. 
 Hernia, Strangulated, in infants, 379. 
 Hip-joint disease, diagnosis from partial palsy 
 
 of the leg, 145. 
 Hooping-cough, essentially a disease of child- 
 hood, 252, 266. 
 symptoms of — the hoop, 253, 255, 256. 
 catarrhal stage, 254. 
 varying at onset of, 255. 
 nervous dyspnoea in, 256, 261, 262, 263. 
 at its acme, 256. 
 nocturnal exacerbations of, 256. 
 indications of amendment and deteriora- 
 tion, 2o%. 
 cough often, diminished by intercurrent 
 
 febrile affections, 259, 268. 
 complications of, with bronchitis and 
 
 pneumonia, 259. 
 disorder of nervous system, 260. 
 congestion of brain, 42. 
 convulsions, 31, 262. 
 
 tubercular hydrocephalus — case illustra- 
 tive of, 263. 
 diarrhoea, 265. 
 
 irritable stomach and vomiting, 261, 266. 
 measles and varicella, 266. 
 duration of, 267. 
 its catarrhal stage, 254. 
 recurrence of, 268. 
 causes of ; influence of sex and age, (and 
 
 note), 268. 
 season and temperature, 269. 
 .contagion, 270. 
 
 deaths from, at different ages, (note), 269. 
 from different complications, (note), 258. 
 morbid appearances in, (and note.) 270. 
 state of the lungs, Alderson's observa- 
 tions, (note,) 271. 
 pneumo-gastric nerves, 272. 
 treatment of, of first stage, 273. 
 second stage; use of hydrocyanic acid, 
 
 274. 
 sedatives, 275. 
 depletion, counter-irritation and blisters, 
 
 279. 
 third stage, 274. 
 
 the nervous dyspnoea; danger of over- 
 treatment — case in illustration, 272, 
 274. 
 
 31 
 
 Hooping-cough, bronchitis complicating, 274. 
 
 decline of, 275. 
 Hydatids of Brain, 120. 
 
 Hydrocephaloid Disease, Dr. M. Hall's account 
 of, 110. 
 
 supervention of, in course of diarrhoea, 
 111. 
 
 pneumonia, and consequent on cerebral 
 congestion, 113. 
 
 caution against mistaking its symptoms, 
 114. 
 
 rules for its prevention and treatment, 
 115. 
 Hydrocephalus, Acute, or scrofulous inflamma- 
 tion of the brain, 58. 
 
 ages at which it occurs, 76, (note) 77. 
 
 predisposition to, in phthisical families, 
 77. 
 
 morbid appearances in, two kinds of, 58. 
 
 table of 36 dissections of, (note) 64. 
 
 at base of brain, 59. 
 
 granulations of the membranes, 60. 
 
 their tubercular nature, 61. 
 
 state of cerebral substance in, and relation 
 to fluid in ventricles, 61. 
 
 softening not due to imbibition of fluid, 63. 
 
 result of inflammation ; its relation to 
 changes in lining of ventricles, 64. 
 
 tubercular deposits in brain in, 64. 
 
 complications of, 65. 
 
 symptoms of first stage of, 67. 
 
 second, 67. 
 
 third, 68. 
 
 vary in different cases, 70. 
 
 approach sometimes very gradual, 71, 75. 
 
 three stages of, not always distinct, 77. 
 
 occasional occurrence of diarrhoea in, 80. 
 
 diagnosis of, from inflammation of inter- 
 nal ear, 89. 
 
 night terrors, 135. 
 
 remittent fever, 72. 
 
 remissions in, irregular, 73, 75. 
 
 gastric disorder, 73. 
 
 pneumonia, 198. 
 
 pleurisy, 209. 
 
 prognosis in, very unfavourable, 74. 
 
 appearances of improvement delusive, 74. 
 
 caution as to sleep in, 75. 
 
 duration of, 76. 
 
 treatment of, prophylaxis of, 77. 
 
 depletion in, 79. 
 
 purgatives in, 79. 
 
 use of mercurials, and application of cold 
 in, 80. 
 
 diet, use of narcotics, application of blis- 
 ters in, 81. 
 
 last stage of, 82. 
 Chronic, circumstances under which it 
 occurs, 89. 
 
 occasional result of cerebral congestion. 
 39. 
 
 connected with malformation of the brain, 
 98, 101, 102, 103. 
 
 external and internal, 98. 
 
 internal, symptoms of, 98. 
 
 changes of skull in, 99. 
 
 progress and termination of, 100. 
 
 age at which it comes on, 101. 
 
 post-mortem appearances in, 101. 
 
 frequent connection with inflammation- 
 cases, 101, 103. 
 
 sometimes arrested, rarely cured, 104. 
 
482 
 
 INDEX. 
 
 Hydrocephalus, chronic, external, its various 
 causes, 105. 
 symptoms and those of internal nearly 
 
 coincident, 105. 
 diagnosis from hypertrophy of brain, 113. 
 treatment of, 106. 
 
 Golis's plan and use of compression, 107. 
 by puncture, 108. 
 Spurious, 110. 
 
 see Hydrocephaloid Disease. 
 Hydrocyanic Acid in treatment of hooping- 
 cough, 271. 
 Hypertrophy of Brain, 101. 
 
 see Brain, Hypertrophy of. 
 
 I. 
 
 Icterus Neonatorum, 371. 
 
 see Jaundice. 
 Idiocy, connection of, with hypertrophy of 
 
 brain, 103. 
 Induration of the cellular tissue, symptoms of, 
 164. 
 appearances after death, 165. 
 connection of, with collapse of the lung, 
 
 166. 
 treatment of, 166. 
 Infants, Artificial Feeding, of, injurious; high 
 mortality from, 326. 
 injurious action of, explained, 328. 
 farinaceous substances unsuitable for, 329. 
 . Atrophy of, causes of, various, 335. 
 post-mortem appearances in, 330. 
 Inoculation of small-pox, comparative advan- 
 tages and evils of, 455. 
 Intellect, temporary weakening of, after long 
 
 illness, 107. 
 Intertrigo in course of chronic diarrhoea, 
 
 treatment of, 401. 
 Intestinal Worms, 416. 
 
 see Worms. 
 Intestines, Softening of, 366. 
 Intussusception of Intestines, symptoms of, 
 379. 
 diagnosis of, 380. 
 treatment of, 381. 
 Inward Fits, meaning of the term, 33. 
 
 J. 
 
 Jaundice, of New-born Infants, different 
 opinions concerning, 371. 
 
 influence of cold and bad air in causing it, 
 372. 
 
 sometimes depends on obstruction or mal- 
 formation of biliary ducts, 372. 
 
 treatment of, 372. 
 
 of Children, sometimes associated with 
 head symptoms, 373. 
 
 treatment of, 373. 
 
 Kidneys, Simple Inflammation of, 419. 
 Inflammation of, with Albuminuria, 419. 
 as sequela of scarlatina, 419. 
 composition of urine in, 420. 
 post-mortem appearances, results of the 
 microscope, 421. 
 
 Kidneys, Inflammation of, treatment of, 422. 
 Gravel and Calculus in, very frequent in 
 children, 424. 
 lithic acid very frequent in new-born 
 
 children, 425. 
 formed during teething, 425. 
 Fungoid disease of, 435. 
 
 L. 
 
 Laryngismus Stridulus, 239. 
 
 see Spasm of the Glottis. 
 Laryngitis Stridula, 237. 
 
 see Croup. 
 Laryngitis, Ulcerative, 218. 
 
 see Croup. 
 Leeches, rules for applying to the head, 97. 
 
 employment of, in congestion of brain, 40. 
 Leucorrhoea of young children, 441. 
 
 see Vulva, discharge s'from. 
 Lithates, formation of, in new-born children, 
 425. 
 during dentition, 425. 
 connection of, with dyspepsia and rheu- 
 matism, 425. 
 treatment of excess of, 425, 426. 
 Liver, hypertrophy of, 431. 
 hydatids of, 432. 
 fungoid disease of, 434. 
 Lungs, Elasticity of, 150. 
 Imperfect Expansion of, 150. 
 
 conditions under which it occurs, 151, 
 
 152. 
 anatomical characters, and effects of in- 
 flation on the lung, 152. 
 symptoms of, 153. 
 cases illustrative of, 154. 
 diagnosis of, from congenital phthisis, 
 
 155. 
 treatment of, 155. 
 see Lungs, Collapse of. 
 Carnification of, 158, 175. 
 see Lungs, Collapse of. 
 Collapse of, erroneously regarded as pneu- 
 monia, 157. 
 anatomical characters and symptoms of 
 
 this supposed lobular pneumonia, 158. 
 effects of inflation on lung, 159. 
 researches of Bailly and Legendre on it, 
 
 159. 
 cases illustrative of its occurrence, 160. 
 occurs from similar causes in adults as in 
 
 children, 162. 
 observations of its occurrence in the 
 
 aged, 163. 
 its supervention in course of bronchitis, 
 
 175, 183. 
 in hooping-cough, 271. 
 association with it of induration of the 
 cellular tissue, 165. 
 Congestion and other changes of substance 
 
 of, in course of bronchitis, 175. 
 Inflammation of substance of, 177. 
 
 see Pneumonia. 
 Abscess of, 175, 178. 
 Emphysema of, 179. 
 Acute (Edema of, 203. 
 generally succeeds to scarlatinal dropsy — 
 
 illustrative cases, 204. 
 post-mortem appearances, 205. 
 treatment of, 205. 
 
INDEX. 
 
 483 
 
 Lungs, Gangrene of, 179. 
 
 case illustrative of, 205. ' 
 to be regarded as a blood-disease, 207. 
 symptoms of, 207. 
 treatment of, 208. 
 Tubercle of, table of 81 cases of, (note), 280. 
 miliary, and grey granulations, often 
 
 exist alone, 281. 
 yellow infiltration frequent, 281. 
 cavities from, rare, 282. 
 small cavities, or vacuoles, 282. 
 frequent affection of bronchial glands, 
 
 283. 
 of bronchial glands, characters of, 283. 
 sometimes got rid of, and how, 284. 
 perforation of bronchi, <fcc, from, 285. 
 
 M. 
 
 Measles and scarlatina, mortality from, 465. 
 
 resemble but essentially different, 465. 
 
 essentially a disease of early childhood, 
 465. 
 
 symptoms of, 465. 
 
 characters of the eruption, 466. 
 
 diagnosis of, from scarlatina, 474. 
 
 complicated with bronchitis and pneu- 
 monia, 467. 
 
 croup, 233. 
 
 in early stage of, 233. 
 
 complicated with croup, desquamative 
 stage of, 234. 
 
 post-mortem appearances of, 234. 
 
 relation of,\to hooping-cough, 467, 266. 
 
 treatment of\467. 
 
 of symptoms of affection of chest in, 467. 
 
 of croup in, 235, 237. 
 
 cauterization of larynx in, 236. 
 Mehena, 367. 
 
 see Hasmatemesis. 
 Meningitis, Acute, 82. 
 
 see Encephalitis. 
 Tubercular, 56. 
 
 see Hydrocephalus. 
 
 of Spinal Cord — cases illustrative of, 128. 
 
 post-mortem appearances in, 129. 
 
 see Spinal Cord. 
 Mercury in treatment of acute hydrocephalus, 
 77. 
 
 pneumonia, 201. 
 
 croup, 225, 229, 236. 
 
 infantile syphilis, 440. 
 Microcephalus, 107. 
 Milk, human, composition of, 325, 332. 
 
 and of animals compared, 332. 
 
 peculiar adaptation of, to nourishment of 
 child, 331. 
 
 its spontaneous coagulation in the sto- 
 mach, 363. 
 
 deterioration of, in scrofulous subjects,' 
 Klencke's remarks on, 301. 
 
 unhealthy, chemical and microscopic cha- 
 racters of, 334. 
 
 best substitutes for, 332. 
 
 of cow occasionally unhealthy, 333. 
 Muguet, 336. 
 
 see Thrush. 
 Mumps, 357. 
 
 N. 
 
 Narcotics, in treatment of acute hydrocepha* 
 
 lus, 81. 
 Nervous System, diseases of, extremely fre- 
 quent in early life, 27. 
 
 frequency of, accounted for, 27. 
 
 deaths from, at different ages, (note), 31. 
 
 and from other causes, (note), 143. 
 
 symptoms of, 28. 
 
 difficulties of study of, 28. 
 
 disorders of, complicating diarrhoea, 385, 
 392. 
 
 treatment of, 397. 
 
 influence of malaria in producing, 394. 
 Nephritis, simple, 418. 
 
 albuminous, 419. 
 
 see Kidneys, inflammation of. 
 Night Terrors of children, description of an 
 attack of, 133. 
 
 not indicative of primary mischief in the 
 brain — cases, 135. 
 
 dependent on gastric disorder, 136. 
 
 treatment of, 137. 
 Noma, 347. 
 
 see Stomatitis, ulcerative. 
 Nurse, statements of, not to be undervalued, 
 24. 
 
 Odontitis Infantum, 341. 
 
 treatment of, 342. 
 
 see Dentition. 
 
 (Edema of Lungs, 203. 
 
 see Lungs, oedema of. 
 Opium in treatment of hooping-cough, 270. 
 
 and Antimony in head symptoms of re- 
 mittent fever, 452. 
 Otitis, 86. 
 
 see Ear, inflammation of. 
 Otorrhcea, importance of head symptoms in, 
 85, 87. 
 
 chronic, treatment of, 88. 
 
 P. 
 
 Paralysis, import of, less serious in child than 
 in adult, 139. 
 
 sometimes congenital, 139. 
 
 of portio dura from injury in birth, 146. 
 
 most frequent during period of dentition, 
 141. 
 
 results of twenty cases, and tabular view 
 of, 142. 
 
 recovery from, uncertain, 144. 
 
 diagnosis of, 144. 
 
 treatment of, 145. 
 
 electricity in, 146. 
 Percussion, general rules for, 20. 
 Pericarditis, usually connected with rheuma- 
 tism, 304. 
 
 sometimes associated with pleurisy — 
 cases of, 305. 
 
 idiopathic — cases of, 306, 315. 
 
 not always discovered during life, 308. 
 Peritonitis, in the foetus sometimes connected 
 with syphilis, 403. 
 
 in early infancy, 403. 
 
484 
 
 INDEX. 
 
 Peritonitis, sometimes acute and epidemic, 
 403. 
 in childhood, acute, idiopathic, rare, 401, 
 
 404. 
 symptoms, case illustrating, 404. 
 discharge of pus through abdominal walls 
 
 in, 89, 406. 
 secondary to scarlatina, 407. 
 to inflammation of caecum — case of, 407. 
 treatment of, 408. 
 chronic, usually tubercular, 409. 
 morbid appearances in, 409. 
 symptoms and general course of, 410. 
 varieties in its onset and course, 412. 
 relations of, to Tabes Mesenterica, 412. 
 See Tabes Mesenterica. 
 Phlebitis, of Sinuses of Dura Mater, 88. 
 
 Umbilical Vein not a cause of trismus, 132. 
 Phthisis, differences between disease in child 
 
 and adult, 278. 
 tables illustrative of various peculiarities, 
 
 (note) 280, 281. 
 affects different organs in child; illustra- 
 tive table, 279. 
 assumes different forms, 280. 
 owing in part to its rapid progress, 281. 
 symptoms of, their peculiarities, 285,293. 
 auscultatory, 289, 294. 
 congenital, 155. 
 in early infancy, 288. 
 of bronchial phthisis, 287, 293. 
 spasmodic cough in, 239. 
 auscultatory, 290, 293. 
 diagnosis of, from worms and remittent 
 
 fever, 286, 450. 
 tuberculous pneumonia, 295. 
 import of frequent attacks of catarrh, 171. 
 duration of, 298. 
 rapid course of — case, 294. 
 chronic course of — cases, 298. 
 prognosis of, more hopeful in child than 
 
 in adult, 302. 
 in bronchial phthisis — case of recovery 
 
 from, 288. 
 death from, various modes of, 299. 
 supervention of hydrocephalus in, 71, 77. 
 head symptoms — case, 300. 
 treatment of, prophylaxis, 301. 
 treatment of, remedies in ; cod-liver oil, 
 
 Ac, 302. 
 Pia Mater, its changes in acute hydrocephalus, 
 
 60. 
 Pleurisy, acute idiopathic, very rare in early 
 
 childhood, 208. 
 post mortem appearances of, 208. 
 complicated with pericarditis, 306. 
 symptoms and physical signs of, some 
 
 peculiarities in, 209. 
 diagnosis of, from head affection, 210. 
 affections of the abdomen, 210. 
 pneumonia; its difficulty, 197, 214. 
 treatment of, 212. 
 secondary and chronic, 212. 
 chronic, a sequela of scarlatina, 213. 
 Pneumonia, causes and frequency of; illustra- 
 tive table, 180. 
 post-mortem appearances in, 177. 
 termination in abscess, 178. 
 gangrene, 179. 
 
 association with emphysema, 179. 
 Idiopathic, symptoms of first stage of, 192. 
 second, 194. 
 
 Pneumonia, Idiopathic, third, 194. 
 
 results of, death in second stage, occa- 
 sional, 194. 
 
 imperfect recovery from third stage, occa- 
 sional, 195. 
 
 auscultatory signs of, 196. 
 
 recurrence of, 180. 
 
 diagnosis of, from pleurisy, 197, 228. 
 •hydrocephalus, 198. 
 
 head symptoms in, 113. 
 
 gastric disorder, 198. 
 
 dentition, 199. 
 
 treatment of, depletion in, 200. 
 
 tartar emetic in, 201. 
 
 mercurials in, 201. 
 
 stimulants and blisters in, 202. 
 Secondary to bronchitis; a point of differ- 
 ence from disease in adult, 171. 
 
 symptoms of, 196. 
 
 various diseases, 181. 
 
 measles, 468. 
 
 hooping-cough, 279. 
 Lobular, cases properly so called, 175. 
 
 description under the name of collapse of 
 the lung, 158. 
 
 Tuberculous, characteristics of, 295. 
 Psoas Abscess, characters of tumours formed 
 
 by, 435. 
 Puerile breathing not heard in early infancy, 
 
 and why, 149. 
 Pulse, great variations in its frequency, 19. 
 
 frequency of, in infancy and childhood, 
 150. 
 
 and of respiration, diminished during 
 sleep, 24. 
 
 and that of respiration to be compared, in 
 sick children, 19. 
 
 peculiarities in hydrocephalus, 67, 68, 72, 
 77. 
 Purgatives, remarks on different kinds of, 247. 
 
 in congestion of brain, 41. 
 
 in acute hydrocephalus, 79. 
 
 P. 
 
 Rectum, Imperforate, three varieties of, 374. 
 
 its rarity; its symptoms, 374. 
 
 circumstances modifying prognosis, 376. 
 
 various operations for its cure, 378. 
 Remittent Pever, identity with simple fever 
 in adult, 444. 
 
 post-mortem appearances of, 444. 
 
 symptoms of milder form of, 445. 
 
 appearance of eruption in, 446. 
 
 severer form of, 446. 
 
 eruption in, 447. 
 
 symptoms of severer form of, delirium in, 
 448, 450. 
 
 death rare in ; causes of, when it occurs, 
 448. 
 
 diagnosis of, from simple gastric disorder, 
 449. 
 
 acute tubercular disease, 286, 449. 
 
 hydrocephalus, 72. 
 
 occasional supervention of cerebral mis- 
 chief in, 449. 
 
 treatment of, 450. 
 
 the abdominal symptoms of, 457. 
 
 cerebral disturbance in, use of antimony 
 and opium, 452. 
 
 depletion in, 453. 
 
INDEX. 
 
 485 
 
 Remittent Fever, diet in, 453. 
 
 stimulants in, 453. 
 Rheumatism, Acute, followed even when 
 
 slight hy heart disease, 304. 
 Chronic, its connection with excess of 
 
 lithates in the urine, 425. 
 Respiration, peculiarities of, in early life, 148, 
 
 160. 
 its frequency in infancy and childhood, 
 
 159. 
 feebleness of inspiratory power, 160. 
 similarity of its characters in infancy and 
 
 old age, 163. 
 frequency of, and of pulse, diminished 
 
 during sleep, 24. 
 its general characters to be noticed in 
 
 sick children, 21. 
 its frequency, and that of pulse, to be 
 
 compared in sick children, 19. 
 peculiarities of, in cerebral disease, 30. 
 organs of, death from diseases of, and from 
 
 other causes, compared, (note) 147. 
 susceptibility of their mucous membrane, 
 
 166, 170. 
 this susceptibility less at birth than 
 
 afterwards, ] 67. 
 inflammatory affections of, 167. 
 Retro-pharyngeal abscess, its symptoms, and 
 
 means of diagnosis of, 174. 
 Re- vaccination, reasons in favour of, 462. 
 Rickets, connection of, with hypertrophy of 
 
 brain, 102, 103. 
 
 Scarlatina, varieties of, 469. 
 Simplex, symptoms of, 469. 
 characters a,nd progress of the eruption, 
 
 469. \ 
 
 Anginosa, symptoms of, affection of throat 
 
 in, 470. 
 Maligna, symptoms of, case illustrative of, 
 
 471. 
 affection of throat and parotids in, 472. 
 various complications of, 472. 
 supervention of endocarditis in course of, 
 
 306. 
 post-mortem appearances in, 473. 
 diagnosis of, from measles, 476. 
 sequelae of — retro-pharyngeal abscess, 
 
 474. 
 dropsy, 419. 
 exciting causes of, 422. 
 symptoms of, 419. 
 composition of urine in, 420, 423. 
 state of kidneys in, 421. 
 sources of danger in, 422. 
 occasionally arises from mere debility, 
 
 423. 
 treatment of, 475. 
 caution as to depletion in head affections 
 
 in, 476. 
 the coryza and affection of throat in, 476. 
 dropsy in, 422. 
 depletion in, 422. 
 use of tartar emetic in, 423. 
 Sedatives in treatment of hooping-cough, 272. 
 Sleep, frequency of pulse and respiration 
 
 diminished during it, 24. 
 its characters to be observed in sick chil- 
 dren, 19. 
 caution concerning, in hydrocephalus, 75. 
 
 Small-pox, influence of inoculation and of vac- 
 cination on, 456. 
 
 mortality from, 456. 
 
 symptoms of, and diagnosis from other 
 eruptive fevers, 457. 
 
 symptoms of, progress of the eruption, 
 458. 
 
 peculiarities of the confluent form, 458. 
 
 secondary fever, its dangers, 458. 
 
 treatment of, 459. 
 
 the secondary fever of, 460. 
 
 local symptoms — prevention of pitting, 
 461. 
 
 after Vaccination, its usually mild cha- 
 racter, 462. 
 
 peculiarities of its course and symptoms, 
 463. 
 Spasm of the Glottis, 239. 
 
 symptoms of, 240, 242. 
 
 carpopedal contractions in, 241. 
 
 import of, 242. 
 
 circumstances under which it occurs, 243. 
 
 case illustrative of its connection with 
 enlarged thymus gland, 244. 
 
 treatment of, 246. 
 
 caution as to lancing the gums in, 247. 
 
 case illustrative of occasional necessity 
 for depletion, 248. 
 
 caution as to sudden exposure to air, 249. 
 
 the paroxysm, 249. 
 
 proposed, when dependent on enlarged 
 thymus, 249. 
 Speech, temporary loss of power of, after long 
 
 illness, 107. 
 Spinal cord, predominance of, in early life, 31. 
 
 special obscurity of disease of, in the 
 child, 123. 
 
 Dr. Weber's observations on vascularity 
 of, 131. 
 
 irritation and congestion of — cases, 124. 
 
 membranes of, usually involved in, sim- 
 ple encephalitis, 84. 
 
 inflammation of its membranes sometimes 
 epidemic, 125. 
 
 cases illustrative of inflammation of, 125. 
 
 acute inflammation of substance of, 128. 
 
 chronic inflammation of substance of, 129. 
 
 softening of, generally connected with 
 disease of vertebrae, 129. 
 
 remarkable case of, without disease of the 
 bones, 130. 
 Spleen, enlargement of, 435. 
 Stimulants, use of, in treatment of diarrhoea. 
 
 398. 
 Stomach, peculiarities of form of, in infancy, 
 324. 
 
 changes in form of, with advancing years, 
 326. 
 Softening of, different opinions concerning, 
 365. 
 
 characters of, 365. 
 
 alleged influence of mode of death on, 
 366. 
 
 its frequency in infancy, theories ac- 
 counting for, 367. 
 Stomatitis, three varieties of, 344. 
 Follicular, symptoms and course of, 345. 
 
 treatment of, 341, 346. 
 Ulcerative, or Noma, symptoms and course 
 of, 346. 
 
 tendency to pass into gangrene very 
 slight, 347. 
 
486 
 
 INDEX, 
 
 Stomatitis, Ulcerative, treatment of, 343, 348. 
 Gangrenous, fatality of, 348. 
 
 its connection with blood diseases, 349. 
 
 does not depend on administration of 
 mercury, 354. 
 
 point of departure of the gangrene, 349. 
 
 symptoms and cause of, 350. 
 
 morbid appearances in, 351. 
 
 treatment; importance of cauterization, 
 352. 
 Sulphate of Magnesia, use of small doses of, 
 
 in diarrhoea, 394. 
 Syphilis, Infantile, dependent on congenital 
 taint, 436. 
 
 relation of, to foetal and infantile peri- 
 tonitis, 403. 
 
 symptoms of, 437. 
 
 coryza sometimes the only one, 438. 
 
 rarity of affection of bones, 438. 
 
 syphilitic cachexia, 440. 
 
 relapses and tertiary symptoms, 440. 
 treatment of, 440. 
 
 local applications in, 441. 
 
 Tabes Mesenterica, relation of, to tubercular 
 peritonitis, 412. 
 anatomical characters of, 413. 
 symptoms not pathognomonic of, 414. 
 treatment of, and of tubercular peritonitis, 
 414. 
 Temperature, in infancy and chilhood, 149. 
 pneumonia, 193. 
 remittent fever, 20. 
 scarlatina, 470. 
 Thirst, indications of, in the infant, 24. 
 Thrush, etymology of the word uncertain, 
 (note,) 356. 
 ifcs characters described, 356. 
 disorder of health attending it, 357. 
 opinions as to intimate nature of the de- 
 posit, 357. 
 treatment of, 358. 
 Thymic Asthma, 244. 
 
 see Spasm of the Glottis. 
 Tongue, in infants, how to examine the, 22. 
 Tonsils, Inflammation of, 355. 
 Hypertrophy of, its symptoms, 355. 
 its influence on the form of the mouth, 
 
 and chest, 356. 
 
 its treatment, 357. 
 
 Tracheotomy, in croup, 228. 
 
 difference of results in England and 
 
 France, 228. 
 objections to performance of, 229. 
 remarks of M. Trousseau on, 230. 
 reasons for not rejecting, 231. 
 Trismus, infantile, symptoms of, 131. 
 post-mortem appearances in, 131. 
 opinions as to its cause, 132. 
 modes of prevention, and of treatment, 
 133. 
 
 Tubercle of Brain, 115. 
 
 see Brain, Tubercle of. 
 Mesenteric Glands, 412. 
 
 see Tabes Mesenterica. 
 Tubercular Peritonitis, 409. 
 
 see Peritonitis, chronic. 
 Tumors, Abdominal, 430. 
 
 see Abdominal Tumors. 
 
 U. 
 
 Umbilicus, discharge of pus from, in perito- 
 nitis, 89. 
 haemorrhage from, in new-born children, 
 373. 
 Urea, excess of, 426, 427. 
 Urine, incontinence of — causes, 428. 
 treatment, 429. 
 
 V. 
 
 Vaccination, drawbacks from its universal 
 success, 456. 
 great benefits of, 462. 
 adoption of, followed by increase of 
 measles and scarlatina, 465. 
 Varicella, 463. 
 
 relation of, to hooping-cough, 271. 
 see Chicken-pox. 
 Variola, 456. 
 
 see Small- pox. 
 Vertebrae, disease of the cervical, extending 
 to brain, 85. 
 affection of spinal cord in cases of, 129. 
 Vomiting, in infants, its frequency accounted 
 for, 358. 
 treatment of, 359. 
 as a sign of dyspepsia, 360. 
 in course of diarrhoea, 397. 
 treatment of, 388. 
 important as a sign of cerebral disease, 
 
 30, 38. 
 in first stage of hydrocephalus, 67. 
 persistent, of great importance as a sign 
 
 of hydrocephalus, 73. 
 in hooping-cough, 261, 266. 
 Vulva, discharges from, 441. 
 
 circumstances under which they occur, 
 
 442. 
 treatment of, 442. 
 
 W. 
 
 Waterstroke, meaning of the term, 77. 
 
 case of, 83. 
 Whytt, Dr. his observations on Acute Hydro- 
 cephalus, 57. 
 Worms, intestinal, five varieties of, 417. 
 
 symptoms of, 418. 
 
 convulsions from, 419. 
 
 treatment of, 418. 
 
 of Blood, 369. 
 
 see Hsematemesis. 
 
INDEX TO FORMULA 
 
 NO.^ PAGE. 
 
 Acid Mixture for hooping-cough xviii 277 
 
 -ffithereal stimulant for fever xxxiv 454 
 
 Alterative, saline xxvi 364 
 
 tonic xxxiii 415 
 
 Alum Mixture for hooping-cough xvii 276 
 
 Antimonial, nauseating . xiii 223 
 
 Aperient v. 77 
 
 aloetic xxiii 362 
 
 ■ febrifuge » i. 42 
 
 saline vi. 77 
 
 Astringent xxyii 395 
 
 ■ aromatic, opiate xxix 391 
 
 gallic acid, opiate xxx 399 
 
 lead and opium xxxi 400 
 
 sulphate of iron and opium xxxii 400 
 
 Cinchona and hydrocyanic acid mixture xx 277 
 
 Cough Mixtures viiii. ix. x 169,171 
 
 Decoction Blanche 45 
 
 Demulcent xxi 343 
 
 Expectorant, stimulating xii. 190 
 
 Febrifuge, aperient i. 42 
 
 calmant ii.^ 43 
 
 Hooping-cough, alum mixture for xvii. 276 
 
 acid mixture for xviii 277 
 
 Hydrocyanic acid , xiv. xv 271 
 
 with bark xx. 277 
 
 Iron, expectorant mixture for chronic bronchitis or hooping-cough xix 277 
 
 Liniment, stimulating, for the chest xi. 190 
 
 Oleaginous, opiate, for diarrhoea xxviii 396 
 
 Opiate powder xvi 272 
 
 Saline, antimonial xiii. 223 
 
 Sedative, hydrocyanic acid xiv. xv 271 
 
 opiate powder xvi. 272 
 
 Stimulant aethereal xxxiv 454 
 
 expectorant xii. 190 
 
 Tan-bath 106 
 
 Tonic, alterative xxxiii 415 
 
 aperient .-. vii. 77 
 
 astringent iii. 45 
 
 chalybeate iv. 45 
 
 ■ — alum and sulphuric acid xvii. 276 
 
 chalybeate, expectorant xix. 277 
 
 cinchona, and hydrocyanic acid xx. 277 
 
 hydrochloric acid xviii 277 
 
 vegetable, alkaline xxiv 363 
 
 with mineral acids xxii. xxv. ... 361,364 
 
 THE END. 
 
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 WEST ON ULCERATION OF THE OS UTERI, and 
 
 BROWN ON THE SURGICAL DISEASES OF FEMALES, with wood-cuts. 
 WEST ON DISEASES OF WOMEN, Part I. 
 
 While in the number for January, 1858, is commenced a new and highly important work, 
 
 HABERSHON ON DISEASES OF THE ALIMENTARY CANAL. 
 
 It will be seen that this treatise covers the whole ground of affections of the Digestive Organs, 
 which furnish so very large a portion of the daily practice of the physician. The author's position 
 in Guy's Hospital, and the fact that the work has only just appeared in London, are sufficient guar- 
 antee that it is up to the hour, and presents the most advanced condition of this department of medi- 
 cal science, while its thorough practical character is manifested by the great number of cases on 
 which it is founded, no less than one hundred and sixty-three being carefully analyzed in all their 
 details, throughout its pages. It is therefore hoped that it will be found to fully maintain the valu- 
 able practical character of the works heretofore presented to subscribers through this medium. 
 
 It will thus be seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber 
 will obtain a Quarterly and a Monthly periodical, 
 
 EMBRACING NEARLY SIXTEEN HUNDRED LARGE OCTAVO PAGES, 
 
 mailed to any part of the United States, free of postage. 
 
 These very favorable terms are now presented by the publishers with the view of removing all 
 difficulties and objections to a full and extended circulation of the Medical Journal to the office of 
 every member of the profession throughout the United States. The rapid extension of mail facili- 
 ties will now place the numbers before subscribers with a certainty and dispatch not heretofore 
 attainable ; while by the system now proposed, every subscriber throughout the Union is placed 
 upon an equal footing, at the very reasonable price of Five Dollars for two periodicals, without 
 further expense. 
 
 Those subscribers who do not pay in advance will bear in mind that their subscription of Five 
 Dollars will entitle them to the Journal only, without the News, and that they will be at the expense 
 of their own postage on the receipt of each number. The advantage of a remittance when order- 
 ing the Journal will thus be apparent. 
 
 As the Medical News and Library is in no case sent without advance payment, its subscribers 
 will always receive it free of postage. 
 
 Remittances of subscriptions can be mailed at our risk, when a certificate is taken from the Post- 
 master that the money is duly inclosed and forwarded. 
 
 Address BLANCHARD & LEA, Philadelphia. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 ALLEN (J. M.), M. D., 
 - Professor of Anatomy in the Pennsylvania Medical College, &c. 
 
 THE PRACTICAL ANATOMIST; or, The Student's Guide in the Dissecting. 
 ROOM. With 266 illustrations. In one handsome royal 12mo. volume, of over 600 pages, lea- 
 ther. $2 25. (Just Issued.) 
 
 In the arrangement of this work, the author has endeavored to present a complete and thorough 
 course of dissections in a clearer and more available form for practical use, than has as yet been 
 accomplished. The chapters follow each other in the order in which dissections are usually con- 
 ducted in this country, and as each region is taken up, every detail regarding it is fully described 
 and illustrated, so that the student is not interrupted in his labors, by the necessity of referring from 
 one portion of the volume to another. 
 
 However valuable may be the " Dissector's 
 Guides" which we, of late, have had occasion to 
 notice, we feel confident that the work of Dr. Allen 
 is superior to any of them. We believe with the 
 author, that none is so fully illustrated as this, and 
 the arrangement of the work is such as to facilitate 
 the labors of the student in acquiring a thorough 
 practical knowledge of Anatomy. We most cordi- 
 ally recommend it to their attention. — Western Lan- 
 cet, Dec. 1856. 
 
 We believe it to be one of the most useful works 
 upon the subject ever written. It is handsomely 
 illustrated, well printed, and will be found of con- 
 venient size for use in the dissecting-room. — Med. 
 Examiner, Dec. 1856. 
 
 From Prof. J. S. Davis, University of Va. 
 
 I am not acquainted with any work that attains so 
 fully the object which it proposes. 
 
 From C. P. Fanner, M. P., Demonstrator, Uni- 
 versity of Michigan. 
 
 I have examined the work briefly, but even this 
 examination has convinced me that it is an excellent 
 guide for the Dissector. Its illustrations are beau- 
 tiful, and more than I have seen in a work of this 
 kind. I shall take great pleasure in recommending 
 it to my classes as the text-book of the dissecting- 
 room. 
 
 ANALYTICAL COMPENDIUM 
 OF MEDIQAL SCIENCE, containing Anatomy, Physiology, Surgery, Midwifery, 
 Chemistry, Materia Medica, Therapeutics, and Practice of Medicine. By John Neill, M. D., 
 and F. G. Smith, M. D. New and enlarged edition, one thick volume royal l2mo. of over 
 1000 pages, with 374 illustrations. EF* See Neill, p. 24. 
 
 ABEL (F. A.), F. C.S. AND C. L. BLOXAM. 
 HANDBOOK OF CHEMISTRY, Theoretical, Practical, and Technical j with a 
 
 Recommendatory Preface by Dr. Hofmann. In one large octavo volume, extra cloth, of 662 
 pages, with illustrations. $3 25. 
 
 > 
 
 ASHWELL (SAMUEL), M.D., 
 
 bstetric Physician and Lecturer to Guy's Hospital, London. 
 
 A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. 
 
 Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third 
 and revised London edition. In one octavo volume, extra cloth, of 528 pages. $3 00. 
 The most useful practical work on the subject in I The most able, and certainly the most standard 
 the English language. — Boston Med. and Surg, and practical, work on female diseases that we have 
 Journal. | yet seen. — Medico-Chirurgical Review. 
 
 ARNOTT (NEILL), M. D. 
 ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. 
 
 Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, 
 M. D. Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra- 
 tions. $2 50. 
 
 BUDD (GEORGE), M. D., F. R. S., 
 
 Professor of Medicine in King's College, London. 
 
 ON DISEASES OF THE LIVER. Third American, from the third and 
 
 enlarged London edition. In one very handsome octavo volume, extra cloth, with four beauti- 
 fully colored plates, and numerous wood-cuts. pp. 500. $3 00. (Now Ready.} 
 
 Has fairly established for itself a place among the 
 olassical medical literature of England.— British 
 and Foreign Medico-Chir. Review, July, 1857. 
 
 Dr. Budd's Treatise on Diseases of the Liver is 
 now a standard work in Medical literature, and dur- 
 ing the intervals which have elapsed between the 
 successive editions, the author has incorporated into 
 the text the most striking novelties which have cha- 
 racterized the recent progress of hepatic physiology 
 and pathology; so that although the size of the book 
 
 $3 00. 
 
 is not perceptibly changed, the history of liver dis- 
 eases is made more complete, and is kept upon a level 
 with the progress of modern science. It is the best 
 
 work on Diseases of the Liver in any language. 
 
 London Med. Times and Gazette, June 27, 1357. 
 
 This work, now the standard book of reference on 
 the diseases of which it treats, has been carefully 
 revised, and many new illustrations of the views of 
 the learned author added in the present edition. — 
 Dublin Quarterly Journal, Aug. 1857. 
 
 BY THE SAME AUTHOR. 
 
 ON THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OF 
 
 THE STOMACH. In one neat octavo volume, extra cloth. $1 50. 
 
 From the high position occupied by Dr. Budd as 
 a teacher, a writer, and a practitioner, it is almost 
 needless to state that the present book may be con- 
 sulted with great advantage. It is written in an easy 
 
 style, the subjects are well arranged, and the practi- 
 cal precepts, both of diagnosis and treatment, denote 
 the character of a thoughtful and experienced phy- 
 sician.— London Med. Times and Gazette. 
 
BLANCHARD & LEA'S MEDICAL 
 
 BROWN (ISAAC BAKER), 
 
 Surgeon- Accoucheur to St. Mary's Hospital, &c. 4 
 
 ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT- 
 MENT. With handsome illustrations. One vol. 8vo., extra cloth, pp 276. $160. 
 Mr. Brown has earned for himself a high reputa- 
 tion in the operative treatment of sundry diseases 
 and injuries to which females are peculiarly subject 
 
 We can truly say of his work that it is an important 
 addition to obstetrical literature. The operative 
 suggestions and contrivances which Mr. Brown de- 
 scribes, exhibit much practical sagacity and skill, 
 
 and merit the careful attention of every surgeon- 
 accoucheur. — Association Journal. 
 
 We have no hesitation in recommending this book 
 to the careful attention of all surgeons who make 
 female complaints a part of their study and practice. 
 — Dublin Quarterly Journal. 
 
 BENNETT (J. HUGHES), M.P., F. R. S. E., 
 
 Professor of Clinical Medicine in the University of Edinburgh, &c. 
 
 THE PATHOLOGY AND TREATMENT OF PULMONARY TUBERCU- 
 
 LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken 
 for or associated with. Phthisis. One vol. 8vo., extra cloth, with wood-cuts. pp. 130. $1 25. 
 
 BENNETT (HENRY), M. D. 
 A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, 
 
 ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. Fourth 
 American, from the third and revised London edition. To which is added (July, 1856), a Review 
 of the Present State of Uterine Pathology. In one neat octavo volume, extra cloth, of 
 500 pages, with wood-cuts. $2 00 Also, the "Review," for sale separate. Price 50 cents. 
 The addition of the " Review" presents the recent aspects of the questions discussed in this 
 
 well-known work. $. 
 
 This edition has been carefully revised and altered, | When, a few years back, the first edition of the 
 
 and various additions have been made, which render j present work was published, the subject was oneal- 
 
 it more complete, and, if possible, more worthy of 
 the high appreciation in which it is held by the 
 medical profession throughout the world. A copy 
 should be in the possession of every physician. — 
 Charleston Med. Journal and Review. 
 
 We are firmly of opinion that in proportion as a 
 knowledge of uterine diseases becomes more appre- 
 ciated, this work will be proportionably established 
 as a text-book in the profession. — The Lancet. 
 
 most entirely unknown to the obstetrical celebrities 
 of the day ; and even now we have reason to know 
 that the bulk of the profession are not fully alive to 
 the importance and frequency of the disease of which 
 it takes cognizance. The present edition is so much 
 enlarged, altered, and improved, that it can scarcely 
 be considered the same work. — Dr. Ranking' s Ab- 
 stract. 
 
 BIRD (GOLDING), A. M., M . D., &c. 
 URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND 
 
 THERAPEUTICAL INDICATIONS. A new and enlarged American, from a late improved 
 London edition. With over sixty illustrations. In one royal 12mo. vol, extra cloth, pp.372. $130. 
 
 extension and satisfactory employment of our thera- 
 
 It can scarcely be necessary for us to say anything 
 of the merits of this well-known Treatise, which so 
 admirably brings into practical application the re- 
 sults of those microscopical and chemical researches 
 regarding the physiology and pathology of the uri- 
 nary secretion, which have contributed so much to 
 the increase of our diagnostic powers, and to the 
 
 peutic resources. In the preparation of this new 
 edition of his work, it is obvious that Dr. Golding 
 Bird has spared no pains to render it a faithful repre- 
 sentation of the present state of scientific knowledge 
 on thesubject it embraces.— The British and Foreign 
 Medico-C hirurgical Review. 
 
 BY THE SAME AUTHOR. 
 
 ELEMENTS OF NATURAL PHILOSOPHY; being an Experimental Intro- 
 
 duction to the Physical Sciences. Illustrated with nearly four hundred wood-cuts. From the 
 third London edition. In one neat volume, royal 12mo., extra cloth, pp. 402. $1 25. 
 
 BOWMAN (JOHN E.), M.D. 
 PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Second Ame- 
 rican, from the third and revised English Edition. In one neat volume, royal 12mo., extra cloth, 
 with numerous illustrations, pp. 288. $1 25. 
 
 BY THE SAME AUTHOR. 
 
 INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- 
 LYSIS. Second American, from the second and revised London edition. With numerous illus- 
 trations. In one neat vol., royal 12mo., extra cloth, pp. 350. $1 25. 
 
 BEALE ON THE LAWS OF HEALTH IN RE- 
 LATION TO MIND AND BODY. A Series of 
 Letters from an old Practitioner to a Patient. In 
 one volume, royal 12rno., extra cloth-, pp. 296. 
 80 centB. 
 
 BUSHNAN'S PHYSIOLOGY OF ANIMAL AND 
 VEGETABLE LIFE; a Popular Treatise on the 
 Functions and Phenomena of Organic Life. In 
 one handBome royal 12mo. volume, extra cloth, 
 with over 100 illustrations, pp.234. 80 cents. 
 
 BUCKLER ON THE ETIOLOGY, PATHOLOGY, 
 AND TREATMENT OF FIBRO-BRONCHI- 
 TIS AND RHEUMATIC PNEUMONIA. In 
 
 one 8vo. volume, extra cloth, pp.150. $125. 
 
 BLOOD AND URINE (MANUALS ON). BY 
 JOHN WILLIAM GRIFFITH, G. OWEN 
 REESE, AND ALFRED MARKWICK. One 
 thick volume, royal 12mo., extra cloth, with 
 plates, pp. 460. $1 25. 
 
 BRODIE'S CLINICAL LECTURES ON SUR- 
 GERY. 1 vol. 8vo., cloth. 350 pp. $1 25. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 BARCLAY (A. W.) M. D., 
 
 Assistant Physician to St. George's Hospital, &c. 
 
 A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Signs 
 
 and Symptoms of Disease. In one neat octavo volume, extra cloth, of 424 pages. (Now Ready.) 
 
 $2 00. 
 
 Of works exclusively devoted to this important 
 branch, our profession has at command, compara- 
 tively, but few, and, therefore, in the publication of 
 the present work, Messrs. Blanchard &, Lea have 
 conferred a great favor upon us. Dr. Barclay, from 
 having occupied, for a long period, the position of 
 Medical Registrar at St. George's Hospital, pos- 
 sessed advantages for correct observation and reli- 
 able conclusions, as to the significance of symptoms, 
 which have fallen to the lot of but few, either in 
 his own or any other country. He has carefully 
 systematized the results of his observation of over 
 twelve thousand patients, and by his diligence and 
 judicious classification, the profession has been 
 presented with the most convenient and reliable 
 work on the subject of Diagnosis that it has been 
 our good fortune ever to examine; we can, there- 
 fore, say of Dr. Barclay's work, that, from his sys- 
 tematic manner of arrangement, his work is one of 
 the best works " for reference" in the daily emer- 
 gencies of the practitioner, with which we are ac- 
 quainted ; but, at the same time, we would recom 
 
 has not exceeded his powers. We have thus given 
 a specimen of Barclay's geneializing spirit in one 
 direction; but the same pervades his whole work-, 
 and will, we are sure, induce teachers to recommend 
 it strongly to their pupils. ( It is impossible for us 
 here to follow the book into its particulars; and, in- 
 deed, we think it enough to indicate, as we have done, 
 the importance of the teaching which it offers to the 
 rising generation of medicine, to insure for it a hearty 
 reception at the hands of the profession. It is the 
 work of a physician and a gentleman. — British Med. 
 Journal, Dec. 5, 1857. 
 
 We hope the volume will have an extensive cir- 
 culation, not among students of medicine only, but 
 practitioners also. They will never regret a faith- 
 ful study of its pages. — Cincinnati Lancet, Mar. '58. 
 
 This Manual of Medical Diagnosis is one of the 
 most scientific, useful, and instructive works of its 
 kind that we have ever read, and Dr. Barclay has 
 done good service to medical science in collecting, 
 arranging, and analyzing the signs and symptoms 
 
 mend our readers, especially the younger ones, to I ?f s° man y diseases. It must have cost him great 
 read thoroughly and study diligently thewhole work, labor, and the profession should snow their appre 
 
 and the ' ; emergencies" will not occur so often. — 
 Southern Med. and Surg. Joum., March, 1858. 
 
 ciation of it by their desire to procure and apply its 
 valuable hints and suggestions to the thousand ob- 
 scure cases which perplex and baffle the unaided 
 efforts of any one man, be he ever so wise, and his 
 opportunities ever so good. Another most valuable 
 
 To give this information, to supply this admitted 
 deficiency, is the object of Dr. Barclay's Manual. 
 
 The task of composing such a work is neither an \ feature in the work is that it has been furnished 
 easy nor a light one ; but Dr. Barclay has performed ! with a copious index, which increases its utility 
 it in a manner which meets our most unqualified j very much as a volume of reference. — N. J. Med. 
 approbation. He is no mere theorist; he knows his and Surg. Reporter, March, 1858. 
 work thoroughly, and in attempting to perform it, I 
 
 BARLOW (GEORGE H.), M.D. 
 
 Physician to Guy's Hospital, London, &c. 
 
 A MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D- 
 
 F. Condie, M. D., author of " A Practical Treatise on Diseases of Children," &c. In one hand- 
 some octavo volume, leather, of over 600 pages. (A new work, just issued, 1856.) $2 75. 
 
 We recommend Dr. Barlow's Manual in the warm- 
 est manner as a most valuable vade-mecum. We 
 have had frequent occasion to consult it, and have 
 ■found it clear, concise, practical, and sound. It is 
 eminently a practical work, containing all that is 
 essential, and avoiding useless theoretical discus- 
 sion. The work supplies what has been for some 
 time wanting, a manual of practice based upon mo- 
 dern discoveries in pathology and rational views of 
 treatment of disease. It is especially intended for 
 the use of students and junior practitioners, but it 
 
 will be found hardly less useful to the experienced 
 physician. The American editor has added to the 
 work three chapters — on Cholera Infantum, Yellow 
 Fever, and Cerebro-spinal Meningitis. These addi- 
 tions, the two first of which are indispensable to a 
 work on practice destined for the profession in this 
 country, are executed with great judgment and fi- 
 delity, by Dr. Condie, who has also succeeded hap- 
 pily in imitating the conciseness and clearness of 
 style which are such agreeable characteristics of 
 the original book. — Boston Med. and Surg. Journal. 
 
 BARTLETT (ELISHA), M. D. 
 THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS 
 
 OF THE UNITED STATES. A new and revised edition. By Alonzo Clark, M. D., Prof, 
 of Pathology and Practical Medicine in the N. Y. College of Physicians and Surgeons, &c. In 
 one octavo volume, of six hundred pages, extra cloth. (Now Ready.) Price $3 00. 
 
 It is the best work on fevers which has emanated 
 from the American press ; and the present editor has 
 carefully availed himself of all information exist- 
 ing upon the subject in the Old and New World, so 
 that the doctrines advanced are brought down to the 
 latest date in the progress of this department of 
 Medical Science. — London Med. Times and Gazette, 
 May 2, 1857. 
 
 This excellent monograph on febrile disease, has 
 stood deservedly high since its first publication. It 
 will be seen that it has now reached its fourth edi- 
 tion under the supervision of Prof. A. Clark, a gen- 
 tleman who, from the nature of his studies and pur- 
 suits, is well calculated to appreciate and discuss 
 the many intricate and difficult questions in patho- 
 
 logy. His annotations add much to the interest of 
 the work, and have brought it well up to the condi- 
 tion of the science as it exists at the present day 
 in regard to this class of diseases. — Southern Med. 
 and Surg. Journal, Mar. 1857. 
 
 It is a work of great practical value and interest, 
 containing much that is new relative to the several 
 diseases of which it treats, and, with the additions 
 of the editor, is fully up to the times. The distinct- 
 ive features of the diflferentforms of fever are plainly 
 and forcibly portrayed, and the lines of demarcation 
 carefully and accurately drawn, and to the Ameri- 
 can practitioner is a more valuable and safe guide 
 than any work on fever extant. — Ohio Med. and 
 Surg. Journal, May, 1857. 
 
 CURLING (T. B.), F.R.S., 
 Surgeon to the London Hospital, President of the Hunterian Society, &c. 
 
 A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMA- 
 TIC CCRD, AND SCROTUM. Second American, from the second and enlarged English edi- 
 tion. In one handsome octavo volume, extra cloth, with numerous illustrations, pp. 420. (Just 
 
 | Issued, 1S56.) $2 00. 
 
BLANCHARD & LEA'S MEDICAL 
 
 CARPENTER (WILLIAM B.), M. D., F. R. S., &c, 
 
 Examiner in Physiology and Comparative Anatomy in the University of London. 
 
 PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to 
 
 Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from 
 the last and revised London edition. With nearly three hundred illustrations. Edited, with addi- 
 tions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsyl- 
 vania Medical College, &c. In one very large and beautiful octavo volume, of about nine hundred 
 large pages, handsomely printed and strongly bound in leather, with raised bands. {Just Issued, 
 1856.) $4 25. 
 
 In the preparation of this new edition, the author has spared no labor to render it, as heretofore, 
 a complete and lucid exposition of the most advanced condition of its important subject. The 
 amount of the additions required to effect this object thoroughly, joined to the former large size of 
 the volume, presenting objections arising from the unwieldy bulk of the work, he has omitted all 
 those portions not bearing directly upon Human Physiology, designing to incorporate them in 
 his forthcoming Treatise on General Physiology. As a full and accurate text-book on the Phy- 
 siology of Man, the work in its present condition therefore presents even greater claims upon 
 the student and physician than those which have heretofore won for it the very wide and distin- 
 guished favor which it has so long enjoyed. The additions of Prof. Smith will be found to supply 
 whatever may have been wanting to the American student, while the introduction of many new 
 illustrations, and the most careful mechanical execution, render the volume one of the most at- 
 tractive as yet issued. 
 
 For upwards of thirteen years Dr. Carpenter's 
 work has been considered by the profession gene- 
 rally, both in this country and England, as the most 
 valuable compendium on the subject of physiology 
 in our language. This distinction it owes to the high 
 attainments and unwearied industry of its accom- 
 plished author. The present edition (which, like the 
 last American one, was prepared by the author him- 
 self), is the result of such extensive revision, that it 
 may almost be considered a new work. We need 
 hardly say, in concluding this brief notice, that while 
 the work is indispensable to every student of medi- 
 cine in this country, it will amply repay the practi- 
 tioner for its perusal by the interest and value of its 
 contents. — Boston Med. and Surg. Journal. 
 
 This is a standard work — the text-book used by all 
 medical students who read the English language. 
 It has passed through several editions in order to 
 keep pace with the rapidly growing science of Phy- 
 siology. Nothing need be said in its praise, for its 
 merits are universally known ; we have nothing to 
 say of its defects, for they only appear where the 
 science of which it treats is incomplete. — Western 
 Lancet. 
 
 The most complete exposition of physiology which 
 any language can at present give. — Brit, and For. 
 Med.-Chirurg. Review. 
 
 The greatest, the most reliable, and the best book 
 on the subject which we know of in the English 
 language. — Stethoscope. 
 
 To eulogize this great work would be superfluous 
 We should observe, however, that in this edition 
 the author has remodelled a large portion of the 
 former, and the editor has added much matter of in- 
 terest, especially in the form of illustrations. We 
 may confidently recommend it as the most complete 
 work on Human Physiology in our language. — 
 Southern Med. and Surg. Journal, December, 1855. 
 
 The most complete work on the science in our 
 language. — Am. Med. Journal. 
 
 The most complete work now extant in our lan- 
 guage. — N. O. Med. Register. 
 
 The best text-book in the language on this ex- 
 tensive subject. — London Med. Times. 
 
 A complete cyclopaedia of this branch of science. 
 — N. Y. Med. Times. 
 
 The profession of this country, and perhaps also 
 of Europe, have anxiously and for some time awaited 
 the announcement of this new edition of Carpenter's 
 Human Physiology. His former editions have for 
 many years been almost the only text-book on Phy- 
 siology in all our medical schools, and its circula- 
 tion among the profession has been unsurpassed by 
 any work in any department of medical science. 
 
 It is quite unnecessary for us to speak of this 
 work as its merits would justify. The mere an- 
 nouncement of its appearance will afford the highest 
 pleasure to every student of Physiology, while its 
 perusal will be of infinite service in advancing 
 physiological science. — Ohio Med. and Surg. Journ. 
 
 BY the same author. (Lately Issued.) 
 
 PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from 
 
 the Fourth and Revised London edition. In one large and handsome octavo volume, with over 
 three hundred beautiful illustrations, pp. 752. Extra cloth, $4 80 ; leather, raised bands, $5 25. 
 
 The delay which has existed in the appearance of this work has been caused by the very thorough 
 revision ana remodelling which it has undergone at the hands of the author, and the large number 
 of new illustrations which have been prepared for it. It will, therefore, be found almost a new 
 work, and fully up to the day in every department of the subject, rendering it a reliable text-book 
 for all students engaged in this branch of science. Every effort has been made to render its typo- 
 graphical finish and mechanical execution worthy of its exalted reputation, and creditable to the 
 mechanical arts of this country. 
 
 This book should not only be read but thoroughly 
 studied by every member of the profession. None 
 are too wise or old, to be benefited thereby. But 
 especially to the younger class would we cordially 
 commend it as best fitted of any work in the English 
 language to qualify them for the reception and com- 
 prehension of those truths which are daily being de- 
 veloped in physiology. — Medical Counsellor. 
 
 Without pretending to it, it is an encyclopedia of 
 the subject, accurate and complete in all respects— 
 a truthful reflection of the advanced state at which 
 the science has now arrived. — Dublin Quarterly 
 Journal of Medical Science. 
 
 A truly magnificent work — in itself a perfect phy- 
 siological study. — Ranking's Abstract. 
 
 This work stands without its fellow. It is one 
 few men in Europe could have undertaken ; it is one 
 
 no man, we believe, could have brought to so suc- 
 cessful an issue as Dr. Carpenter. It required for 
 its production a physiologist at once deeply read in 
 the labors of others, capable of taking a general, 
 critical, and unprejudiced view of those labors, and 
 of combining the varied, heterogeneous materials at 
 his disposal, so as to form an harmonious whole. 
 We feel that this abstract can give the reader a very 
 imperfect idea of the fulness of this work, and no 
 idea of its unity, of the admirable manner in which 
 material has been brought, from the most various 
 sources, to conduce to its completeness, of the lucid- 
 ity of the reasoning it contains, or of the clearness 
 of language in which the whole is clothed. Not the 
 profession only, but the scientific world at large, 
 must feel deeply indebted to Dr. Carpenter for this 
 great work. It must, indeed, add largely even to 
 his high reputation. — Medical Times. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 , CARPENTER (WILLIAM B.), M. D., F. R. S., 
 
 Examiner in Physiology and Comparative Anatomy in the University of London. 
 {Just Issued, 1856.) 
 
 THE MICROSCOPE AND ITS REVELATIONS. With an Appendix con- 
 
 taining the Applications of the Microscope to Clinical Medicine, &c. By F. G. Smith, M, D. 
 
 Illustrated by lour hundred and thirty-four beautiful engravings on wood. In one large and verv 
 
 handsome octavo volume, of 724 pages, extra cloth, $4 00 ; leather, $4 50. 
 
 Dr. Carpenter's position as a microscopist and physiologist, and his great experience as a teacher 
 eminently qualify him to produce what has long been wanted — a good text-book on the practical 
 use of the microscope. In the present volume his object has been, as stated in his Preface, " to 
 combine, within a moderate compass, that information with regard to the use of his ' tools,' which 
 is most essential to the working microscopist, with such an account of the objects best fitted for 
 his study, as might qualify him to comprehend what he observes, and might thus prepare him to 
 benefit science, whilst expanding and refreshing his own mind " That he has succeeded in accom- 
 plishing this, no one acquainted with his previous labors can doubt. 
 
 The great importance of the microscope as a means of diagnosis, and the number of microsco- 
 pists who are also physicians, have induced the American publishers, with the author's approval, to 
 add an Appendix, carefully prepared by Pressor Smith, on the applications of the instrument to 
 clinical medicine, together with an accormt of American Microscopes, their modifications and 
 accessories. This portion of the work is illustrated with nearly one hundred wood-cuts, and, it is 
 hoped, will adapt the volume more particularly to the use of the American student. 
 
 Every care has been taken in the mechanical execution of the work, which is confidently pre- 
 sented as in no respect inferior to the choicest productions of the London press. 
 
 The mode in which the author has executed his intentions may be gathered from the following 
 condensed synopsis of the 
 
 CONTENTS. 
 
 Introduction — History of the Microscope. Chap. I. Optical Principles of the Microscope. 
 Chap. II. Construction of the Microscope. Chap. III. Accessory Apparatus. Chap. IV. 
 Management of the Microscope Chap. V. Preparation, Mounting, and Collection of Objects. 
 Chap. VI. Microscopic Forms of Vegetable Life — Protophytes. Chap. VII. Higher Cryptoga- 
 mia. Chap. VIII. Phanerogamic Plants. Chap. IX. Microscopic Forms of Animal Life — Pro- 
 tozoa — Animalcules. Chap. X. Foraminifera, Polycystina, and Sponges. Chap. XI. Zoophytes. 
 Chap. XII. Echinodermata. Chap. XIII. Polyzoa and Compound Tunicata. Chap. XIV. 
 Molluscous Animals Generally. Chap. XV. Annulosa. Chap. XVI. Crustacea. Chap. XVII. 
 Insects and Arachnida. Chap. XVIII. Vertebrated Animals. Chap. XIX. Applications of the 
 Microscope to Geology. Chap. XX. Inorgauic or Mineral Kingdom — Polarization. Appendix. 
 Microscope as a means of Diagnosis — Injections — Microscopes of American Manufacture. 
 
 Those who are acquainted with Dr. Carpenter's 
 previous writings on\Animal and Vegetable Physio- 
 logy, will fully understand how vast a store of know- 
 ledge he is able to bring to bear upon so comprehen- 
 sive a subject as the revelations of the microscope ; 
 and even those who have no previous acquaintance 
 with the construction or uses of this instrument, 
 will find abundance of information conveyed in clear 
 and simple language. — Med. Times and Gazette. 
 
 Although originally not intended as a strictly 
 
 medical work, the additions by Prof. Smith give it 
 a positive claim upon the profession, for which we 
 doubt not he will receive their sincere thanks. In- 
 deed, we know not where the student of medicine 
 will find such a complete and satisfactory collection 
 of microscopic facts bearing upon physiology and 
 practical medicine as is contained in Prof. Smith's 
 appendix; and this of itself, it seems to us, is fully 
 worth the cost of the volume. — Louisville Medical 
 Review. Nov. 1856. 
 
 BY THE SAME AUTHOR. 
 
 ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- 
 LOGICAL ANATOMY. Second American, from a new and revised London edition. With 
 one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566. 
 $3 00. 
 
 In publishing the first edition of this work, its title was altered from that of the London volume, 
 by the substitution of the word " Elements" for that of " Manual," and with the author's sanction 
 the title of "Elements" is still retained as being more expressive of the scope of the treatise. 
 
 To say that it is the best manual of Physiology 
 now before the public , would not do sufficient justice 
 to the author. — Buffalo Medical Journal. 
 
 In his former works it would seem that he had 
 exhausted the subjectof Physiology. In the present, 
 he gives the essence, as it were, of the whole. — N. Y. 
 Journal of Medicine. 
 
 Those who have occasion for an elementary trea- 
 tise on Physiology, cannot do better than to possess 
 themselves of the manual of Dr. Carpenter. — Medical 
 Examiner. 
 
 The best and most complete expose" of modern 
 Physiology, in one volume, extant in the English 
 language. — St. Louis Medical Journal. 
 
 BY the same author. (Preparing.) 
 
 PRINCIPLES OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC 
 
 CHEMISTRY AND HISTOLOGY. With a General Sketch of the Vegetable and Animal 
 Kingdom. In one large and very handsome octavo volume, with several hundred illustrations. 
 The subject of general physiology having been omitted in the last editions of the author's " Com- 
 parative Physiology" and '"'Human Physiology," he has undertaken to prepare a volume which 
 shall present it more thoroughly and fully than has yet been attempted, and which may be regarded 
 as an introduction to his other works. 
 
 BY THE SAME AUTHOR. 
 
 A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH 
 
 AND DISEASE. New edition", with a Preface by D. F. Condie, M. D., and explanations of 
 scientifio words. In one neat 12mo. volume, extra cloth, pp. 178. 50 cents. 
 
8 
 
 BLANCHARD & LEA'S MEDICAL 
 
 CONDIE (D. FJ, M. D., &c. 
 A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fourth 
 
 edition, revised and augmented. In one large volume, 8vo., leather, of nearly 750 pages. $3 00. 
 From the Author's Preface. 
 
 The demand for another edition has afforded the author an opportunity of again subjecting the 
 entire treatise to a careful revision, and of incorporating in it every important observation recorded 
 since the appearance of the last edition, in reference to the pathology and therapeutics of the several 
 diseases of which it treats. 
 
 In the preparation of the present edition, as in those which have preceded, while the author has 
 appropriated to his use every important fact that he has found recorded in the works of others, 
 having a direct bearing upon either of the subjects of which he treats, and the numerous valuable 
 observations — pathological as well as practical — dispersed throughout the pages of the medical 
 journals of Europe and America, he has, nevertheless, relied chiefly upon his own observations and 
 experience, acquired during a long and somewhat extensive practice, and under circumstances pe- 
 culiarly well adapted for the clinical study of the diseases of early life. 
 
 Every species of hypothetical reasoning has, as much as possible, been avoided. The author has 
 endeavored throughout the work to confine himself to a simple statement of well-ascertained patho- 
 logical facts, and plain therapeutical directions— his ^lief desire being to render it what its title 
 imports it to be, a practical treatise on the diseases of children. 
 
 Dr. Condie's scholarship, acumen ? industry, and 
 practical sense are manifested in this, as in all his 
 numerous contributions to science. — Dr. Holmes's 
 Report to the American Medical Association. 
 
 Taken as a whole, in our judgment, Dr. Condie's 
 Treatise is the one from the perusal of which the 
 practitioner in this country will rise with the great- 
 est satisfaction.— Western Journal of Medicine and 
 Surgery. 
 
 One of the best works upon the Diseases of Chil- 
 dren in the English language. — Western Lancet. 
 
 Perhaps the most full and complete work now be- 
 fore the profession of the United States ; indeed, we 
 may say in the English language. It is vastly supe- 
 rior to most of its predecessors. — Transylvania Med. 
 Journal, 
 
 We feel assured from actual experience that no 
 physician's library can be complete without a copy 
 of this work.— N. Y. Journal of Medicine. 
 
 A veritable pediatric encyclopsedia, and an honor 
 to American medical literature. — Ohio Medical and 
 Surgical Journal. 
 
 We feel persuaded that the American medical pro- 
 fession will soon regard it not only as a very good, 
 but as the very best "Practical Treatise *n the 
 Diseases of Children." — American Medical Journal . 
 
 We pronounced the first edition to he. the best 
 work on the diseases of children in the English 
 language, and, notwithstanding all that has been 
 published, we still regard it in that light. — Medical 
 Examiner. 
 
 CHRISTISON (ROBERT), M. D./ V. P. R. S. E., &c. 
 A DISPENSATORY; or, Commentary on the Pharmacopoeias of Great Britain 
 
 and the United States ; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- 
 tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- 
 proved, with a Supplement containing the most important New Remedies. With copious Addi- 
 tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. 
 In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50. 
 
 It is not needful that wfl should compare it with I this branch of knowledge which the student has a 
 the other pharmacopoeias extant, which enjoy and I right to expect in such a work, we confess the omis- 
 merit the confidence of the profession : it is enough sion has escaped our scrutiny. We cordially recom- 
 to say that it appears to us as perfect as a Dispensa- mend this work to such of our readers as are in need 
 tory, in the present state of pharmaceutical science, of a Dispensatory. They cannot makcchoice of a 
 could be made. If it omits any details pertaining to better. — Western Journ. of Medicine and Surgery. 
 
 COOPER (BRANSBY B.), F. R. S. 
 LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. 
 
 In one very large octavo volume, extra cloth, of 750 pages. $3 00. 
 
 COOPER ON DISLOCATIONS AND FRAC- 
 TURES OF THE JOINTS.— Edited by Bransby 
 B. Cooper, F. R. S., &c. With additional Ob- 
 servations by Prof. J. C. Warren. A new Ame- 
 rican edition. In one handsome octavo volume, 
 extra cloth, of about 500 pages, with numerous 
 illustrations on wood. $3 25. 
 
 COOPER ON THE ANATOMY AND DISEASES 
 OF THE BREAST, with twenty-five Miscellane- 
 ous and Surgical Papers. One large volume, im- 
 perial 8vo., extra cloth, with 252 figures, on 36 
 plates. $2 50. 
 
 COOPER ON THE STRUCTURE AND DIS- 
 EASES OF THE TESTIS, AND ON THE 
 THYMUS GLAND. One vol. imperial 8vo., ex- 
 tra cloth, with 177 figures on 29 plates. $2 00. 
 
 COPLAND ON THE CAUSES, NATURE, AND 
 TREATMENT OF PALSY AND APOPLEXY . 
 
 In one volume, royal 12mo., extra cloth, pp. 326. 
 80 cents. 
 
 CLYMER ON FEVERS; THEIR DIAGNOSIS, 
 PATHOLOGY, AND TREATMENT In one 
 octavo volume, leather, of 600 pages. $1 50. 
 
 COLOMBAT DE L'ISERE ON THE DISEASES 
 OF FEMALES, and on the special Hygiene of 
 their Sex. Translated, with many Notes and Ad- 
 ditions, by C. D. Meigs, M. D. Second edition, 
 revised and improved. In one large volume, oc- 
 tavo, leather, with numerous wood-cuts. pp. 720. 
 $3 50. 
 
 CARSON (JOSEPH), M. D., 
 
 Professor of Materia Medica and Pharmacy in the University of Pennsylvania. 
 
 SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA 
 
 AND PHARMACY, delivered in the University of Pennsylvania. Second and revised edi- 
 tion. In one very neat octavo volume, extra cloth, of 208 pages. $1 50. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 CHURCHiki. (FU^ETWOOD), M. D., M. R. I. A. 
 ON THE THEORY AND PRAC'm^ OF Mll> ir xi^.ry. Edited with 
 
 Notes and Additions, by D. Francis Condie, M. d., author of a "Practice T reat j se , on tne 
 Diseases of Children," dec. With 139 illustrations. In one very handsome oct'avC -o„ me 
 leather, pp.510. $3 00. 
 
 To bestow praise on a book that has received such 
 marked approbation would be superfluous. We need 
 only say, therefore, that if the first edition was 
 thought worthy of a favorable reception by the 
 medical public, we can confidently affirm that this 
 will be found much more so. The lecturer, the 
 practitioner, and the student, may all have recourse 
 to its pages, and derive from their perusal much in- 
 terest and instruction in everything relating to theo- 
 retical and practical midwifery.— Dublin Quarterly 
 Journal of Medical Science. 
 
 A work of very great merit, and such as we can 
 confidently recommend to the study of every obste- 
 tric practitioner. — London Medical Gazette. 
 
 This is certainly the most perfect system extant. 
 It is the best adapted for the purposes of a text- 
 book, and that which he whose necessities confine 
 him to one book, should select in preference to all 
 others. — Southern Medical and Surgical Journal. 
 
 The most popular work on midwifery ever issued 
 from the American press. — Charleston Med. Journal. 
 
 Were we reduced to the necessity of having but 
 one work on midwifery, and permitted to choose, 
 we would unhesitatingly take Churchill. — Western 
 Med. and Surg. Journal. 
 
 It is impossible to conceive a more useful and 
 elegant manual than Dr. Churchill's Practice of 
 Midwifery. — Provincial Medical Journal. 
 
 Certainly, in our opinion, the very best work on 
 the subject which exists. — N. Y. Annalist. 
 
 No work holds a higher position, or is more de- 
 serving of being placed in the hands of the tyro, 
 the advanced student, or the practitioner. — Medical 
 Examiner. 
 
 Previous editions, under the editorial supervision 
 of Prof R. M. Huston, have been received with 
 marked favor, and they deserved it; but this, re- 
 printed from a very late Dublin edition, carefully 
 revised and brought up by the author to the present 
 time, does present an unusually accurate and able 
 exposition of every important particular embraced 
 in the department of midwifery. * * The clearness, 
 directness, and precision of its teachings, together 
 with the great amount of statistical research which 
 its text exhibits, have served to place it already in. 
 the foremost rank of works in this department of re- 
 medial science. — N. O. Med. and Surg. Journal. 
 
 In our opinion, it forms one of the best if not the 
 very best text-book and epitome of obstetric science 
 which we at present possess in the English lan- 
 guage. — Monthly Journal of Medical Science. 
 
 The clearness and precision of style in which it is 
 written, and the great amount of statistical research 
 which it contains, have served to place it in the first 
 rank of works in this departmentof medical science. 
 — JV". Y. Journal of Medicine. 
 
 Few treatises will be found better adapted as a 
 text-book for the student, or as a manual for the 
 frequent consultation of the young practitioner. — 
 American Medical Journal. 
 
 BY THE SAME AUTHOR. (J list Issued.) 
 
 ON THE DISEASES OF INFANTS AND CHILDREN. Second American 
 
 Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D. In 
 
 one large and handsome volume, extra cloth, of over 700 pages. $3 00, or in leather, $3 25. 
 
 In preparing this work a second time for the American profession, the author has spared no 
 labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, 
 while every portion of the volume has been subjected to a severe scrutiny. The efforts of the 
 American editor have been directed to supplying such information relative to matters peculiar 
 to this country as might have escaped the attention of the author, and the whole may, there- 
 fore, be safely pronounced one of the most complete works on the subject accessible to the Ame- 
 rican Profession. By an alteration in the size of the page, these very extensive additions have 
 been accqmmodated without unduly increasing the size of the work. 
 
 A few notices of the former edition are subjoined : — 
 
 We regard this volume as possessing more claims 
 to completeness than any other of the kind with 
 which we are acquainted. Most cordially and ear- 
 nestly , therefore, do we commend it to our profession- 
 al brethren, and we feel assured that the stamp of 
 their approbation will in due time be impressed upon 
 it. After an attentive perusal of its contents, we 
 hesitate not to say, that it is one of the most com- 
 prehensive ever written upon the diseases of chil- 
 dren, and that, for copiousness of reference, extent of 
 research, and perspicuity of detail, it is scarcely to 
 be equalled, and not to be excelled, in any lan- 
 guage. — Dublin Quarterly Journal. 
 
 After this meagre, and we know, very imperfect 
 notice of Dr. Churchill's work, we shall conclude 
 by saying, that it is one that cannot fail from its co- 
 piousness, extensive research, and general accuracy, 
 to exalt still higher the reputation of the author in 
 this country. The American reader willbenarticu- 
 larly pleased to find that Dr. Churchill has done full 
 justice throughout his work to the various A merican 
 authors on this subject. The names of Dewees, 
 Eberle, Condie, and Stewart, occur on nearly every 
 page, and these authors are constantly referred toby 
 the author in terms of the highest praise, and with 
 the most liberal courtesy. — The Medical Examiner. 
 
 The present volume will sustain the reputation 
 acquired by the author from his previous works. 
 The reader will find in it full and judicious direc- 
 tions for the management of infants at birth, and a 
 compendious, but clear account of the diseases to 
 which children are liable, and the most successful 
 mode of treating them. We must not close this no- 
 tice without calling attention to the author's style, 
 which is perspicuous and polished to a degree, we 
 regret to say, not generally characteristic of medical 
 works. We recommend the work of Dr. Churchill 
 most cordially, both to students and practitioners, 
 as a valuable and reliable guide in the treatment of 
 the diseases of children. — Am. Journ. of the Med. 
 Sciences. 
 
 We know of no work on this department of Prac- 
 tical Medicine which presents so candid and unpre- 
 judiced a statement or posting up of our actual 
 knowledge as this. — JV". Y. Journal of Medicine. 
 
 Its claims to merit both as a scientific and practi- 
 cal work, are of the highest order. Whilst we 
 would not elevate it above every other treatise on 
 the same subject, we certainly believe that very few 
 are equal to it, and none superior. — Southern Med. 
 and Surgical Journal. 
 
 BY THE SAME AUTHOR. 
 
 ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- 
 CULIAR TO WOMEN. Selected from the writings of British Authors previous to the close of 
 the Eighteenth Century. In one neat octavo volume, extra cloth, of about 450 pages. $2 50. 
 
10 
 
 BLANCHARD & LEA'S MEDICAL 
 
 CHURCHILL (FLEETWOOD), *♦- D.. *f. R. I. A., &c. 
 ON THE DISE A e^^ ^ WOMEN/ including those of Pregnancy and Child- 
 bed A i*"-* Alner i can edition, revised by the Author. With Notes and Additions, by D. Fran- 
 _.^ Condie, M. D., author ot " A Practical Treatise on the Diseases of Children." With nume- 
 rous illustrations. In one large and handsome octavo volume, leather, of 768 pages. (Now Ready, 
 May, 1857.) $3 00. 
 
 This edition of Dr. Churchill's very popular treatise may almost be termed a new work, so 
 thoroughly has he revised it in every portion. It will be found greatly enlarged, and thoroughly 
 brought up to the most recent condition of the subject, while the very handsome series of illustra- 
 tions introduced, representing such pathological conditions as can be accurately portrayed, present 
 a novel feature, and afford valuable assistance to the young practitioner. Such additions as ap- 
 peared desirable for the American student have been made by the editor, Dr. Condie, while a 
 marked improvement in the mechanical execution keeps pace with the advance in all other respects 
 which the volume has undergone, while the price has been kept at the former very moderate rate. 
 A few notices of the former edition are subjoined : — 
 
 It comprises, unquestionably, one of the most ex- 
 act and comprehensive expositions of the present 
 state of medical knowledge in respect to the diseases 
 of women that has yet been published. — Am. Journ. 
 Med. Sciences, July, 1857. 
 
 We hail with much pleasure the volume before 
 us, thoroughly revised, corrected, and brought up 
 to the latest date, by Dr. Churchill himself, and 
 rendered still more valuable by notes, from the ex- 
 perienced and able pen of Dr. D. F. Condie, of Phil- 
 adelphia.— Southern Med. and Surg. Journal, Oct. 
 1857. 
 
 This work is the most reliable -which Ave possess 
 on this subject; and is deservedly popular with the 
 profession. — Charleston Med. Journal, July, 1857. 
 
 Dr. Churchill's treatise on the Diseases of Women 
 is, perhaps, the most popular of his works with the 
 profession in this country. It has been very gene- 
 rally received both as a text-book and manual of 
 practice. The present edition has undergone the 
 most elaborate revision, and additions of an import- 
 ant character have been made, to render it a com- 
 plete exponent of the present state of our knowledge 
 of these diseases. — N. Y. Journ. of Med., Sept. 1857. 
 
 We now regretfully take leave of Dr. Churchill's 
 book. Had our typographical limits permitted, we 
 should gladly have borrowed more from its richly 
 stored pages. In conclusion, we heartily recom- 
 mend it to the profession, and would at the same 
 time express our firm conviction that it will not only 
 add to the reputation of its author, but will prove a 
 work of great and extensive utility to obstetric 
 practitioners. — Dublin Medical Press. 
 
 We know of no author who deserves that appro- 
 bation, on "the diseases of females," to the same 
 
 extent that Dr. Churchill does. His, indeed, is the 
 only thorough treatise we know of on the subject ; 
 and.it may be commended to practitioners and stu- 
 dents as a masterpiece in its particular department. 
 The former editions of this work have been com- 
 mended strongly in this journal, and they have won 
 their way to an extended, and a well-deserved popu- 
 larity. This fifth edition, before us, is well calcu- 
 lated to maintain Dr. Churchill's high reputation. 
 It was revised and enlarged by the author, for his 
 American publishers, and it seems to us that there is 
 scarcely any species of desirable information on its 
 subjects that may not be found in this work. — Tkt 
 Western Journal of Medicine and Surgery. 
 
 We are gratified to announce a new and revised 
 edition of Dr. Churchill's valuable work on the dis- 
 eases of females We have ever regarded it as one 
 of the very best works on the subjects embraced 
 within its scope, in the English language; and the 
 present edition, enlarged and revised by the author, 
 renders it still more entitled to the confidence of the 
 profession. The valuable notes of Prof. Huston 
 have been retained, and contribute, in no small de- 
 gree, to enhance the value of the work. It is a 
 source of congratulation that the publishers have 
 permitted the author to be, in this instance, his 
 own editor, thus securing all the revision which 
 an author alone is capable of making. — The Western 
 Lancet. 
 
 As a comprehensive manual for students, or a 
 work of reference for practitioners, we only speak 
 with common justice when we say that it surpasses 
 any other that has ever issued on the same sub- 
 ject from the British press. — The Dublin Quarterly 
 Journal. 
 
 DICKSON (S. H.), M. D., 
 
 Professor of Institutes and Practice of Medicine in the Medical College of South Carolina. 
 
 ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thera- 
 peutics, or the History and Treatment of Diseases. In one large and handsome octavo volume, 
 of 750 pages, leather {Lately Issued.) $3 75. 
 As an American text- book on the Practice of Medicine for the student, and as a condensed work 
 
 of reference for the practitioner, this volume will have strong claims on the attention of the profession. 
 
 Few physicians have had wider opportunities than the author for observation and experience, and 
 
 few perhaps have used them better. As the result of a life of study and practice, therefore, the 
 
 present volume will doubtless be received with the welcome it deserves. 
 This book is eminently what it professes to be; a 
 
 distinguished merit in these days. Designed for 
 
 " Teachers and Students of Medicine," and admira- 
 bly suited to their wants, we think it will be received, 
 
 on its own merits, with a hearty welcome. — Boston 
 
 Med. and Surg. Journal. 
 
 Indited by one of the most accomplished writers 
 of our country, as well as by one who has long held 
 a high position among teachers and practitioners of 
 medicine, this work is entitled to patronage and 
 careful study. The learned author has endeavored 
 to condense in this volume most of the practical 
 matter contained in his former productions, so as to 
 adapt it to the use of those who have not time to 
 devote to more extensive works. — Southern Med. and 
 Surg. Journal. 
 
 Prof. Dickson's work supplies, to a great extent, 
 a desideratum long felt in American medicine. — N. 
 O. Med. and Surg. Journal. 
 
 Estimating this work according to the purpose for 
 which it is designed, we must think highly of its 
 
 merits, and we have no hesitation in predicting for 
 it a favorable reception by both students and teachers. 
 
 Not professing to be a complete and comprehensive 
 treatise, it will not be found full in detail, nor filled 
 with discussions of theories and opinions, but em- 
 bracing all that is essential in theory and practice, 
 it is admirably adapted to the wants of the American 
 student. Avoiding all that is uncertain, it presents 
 more clearly to the mind of the reader that which is 
 established and verified by experience. The varied 
 and extensive reading of the author is conspicuously 
 apparent, and all the recent improvements and dis- 
 coveries in therapeutics and pathology are chroni- 
 cled in its pages. — Charleston Med. Journal. 
 
 In the first part of the work the subject of gene- 
 ral pathology is presented in outline, giving a beau- 
 tiful picture of its distinguishing features, and 
 throughout the succeeding chapters we find that he 
 has kept scrupulously within the bounds of sound 
 reasoning and legitimate deduction. Upon the 
 whole, we do not hesitate to pronounce it a superior 
 work in its class, and that Dr. Dickson merits a 
 place in the first rank of American writers. — Western 
 Lancet. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 11 
 
 DRUITT (ROBERT), M.R. C.S., &.C. 
 THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. Edited 
 
 by F. W. Sargent, M. D., author of " Minor Surgery," &c. Illustrated with one hundred and 
 ninety-three wood-engravings. In one very handsomely printed octavo volume, leather, of 576 
 large pages. $3 00. 
 
 Dr. Druitt's researches into the literature of his 
 subject have been not only extensive, but well di- 
 rected ; the most discordant authors are fairly and 
 impartially quoted, and, while due credit is given 
 to each, their respective merits are weighed with 
 an unprejudiced hand. The grain of wheat is pre- 
 served, and the chaff is unmercifully stripped off. 
 The arrangement is simple and philosophical, and 
 the style, though clear and interesting, is so precise, 
 that the book contains more information condensed 
 into a few words than any other surgical work with 
 which we are acquainted. — London Medical Times 
 and Gazette. 
 
 No work, in our opinion, equals it in presenting 
 so much valuable surgical matter in so small a 
 compass. — St. Louis Med. and Surgical Journal. 
 
 Druitt's Surgery is too well known to the Ameri- 
 can medical profession to require its announcement 
 anywhere. Probably no work of the kind has ever 
 been more cordially received and extensively circu- 
 lated than this. The fact that it comprehends in a 
 comparatively small compass, all the essential ele- 
 ments of theoretical and practical Surgery — that it 
 is found to contain reliable and authentic informa- 
 tion on the nature and treatment of nearly all surgi- 
 cal affections — is a sufficient reason for the liberal 
 patronage it has obtained. The editor, Dr. F. W. 
 Sargent, has contributed much to enhance the value 
 of the work, by such American improvements as are 
 calculated more perfectly to adapt it to our own 
 views and practice in this country. It abounds 
 everywhere with spirited and life-like illustrations, 
 which to the young surgeon, especially, are of no 
 minor consideration. Every medical man frequently 
 nteds just such a work as this, for immediate refer- 
 ence in moments of sudden emergency, when he has 
 not time to consult more elaborate treatises. — The 
 Ohio Medical and Surgical Journal. 
 
 The author has evidently ransacked every stand- 
 ard treatise of ancient and modern times, and all that 
 
 is really practically useful at the bedside will be 
 found in a form at once clear, distinct, and interest- 
 ing. — Edinburgh Monthly Medical Journal. 
 
 Druitt's work, condensed, systematic, lucid, and 
 practical as it is, beyond most works on Surgery 
 accessible to the American student, has had much 
 currency in this country, and under its present au- 
 spices promises to rise to yet higher favor. — The 
 Western Journal of Medicine and Surgery. 
 
 The most accurate and ample resumfe of the pre- 
 sent state of Surgery that we are acquainted with. — 
 Dublin Medical Journal. 
 
 A better book on the principles and practice of 
 Surgery as now understood in England and America, 
 has not been given to the profession.— Boston Medi- 
 cal and Surgical Journal. 
 
 An unsurpassable compendium, not only of Sur- 
 gical, but of Medical Practice. — London Medical 
 Gazette. 
 
 This work merits our warmest commendations, 
 and we strongly recommend it to young surgeons as 
 an admirable digest of the principles and practice of 
 modern Surgery. — Medical Gazette. 
 
 It may be said with truth that the work of Mr. 
 Druitt affords a complete, though brief and con- 
 densed view, of the entire field of modern surgery. 
 We know of no work on the same subject having the 
 appearance of a manual, which includes so many 
 topics of interest to the surgeon ; and the terse man- 
 ner in which each has been treated evinces a most 
 enviable quality of mind on the part of the author, 
 who seems to have an innate power of searching 
 out and grasping the leading facts and features of 
 the most elaborate productions of the pen. It is a 
 useful handbook for the practitioner, and we should 
 deem a teacher of surgery unpardonable who did not 
 recommend it to his pupils. In our own opinion, it 
 is admirably adapted to the wants of the student. — 
 Provincial Medical and Surgical Journal. 
 
 DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. 
 THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on 
 
 the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women 
 and Children, Medical Jurisprudence, &c. &c. In four large super-royal octavo volumes, of 
 3254 double-columned pages, strongly and handsomely bound, with raised bands. $12 00. 
 *■%* This work contains no less than four hundred and eighteen distinct treatises, contributed by 
 sixty-eight distinguished physicians, rendering it a complete library of reference for the country 
 practitioner. 
 
 The most complete work on Practical Medicine ! titioner. This estimate of it has not been formed 
 extant; or, at least, in our language.— Buffalo j from a hasty examination, but after an intimate ac- 
 
 ' quaintance derived from frequent consultation of it 
 during the past nine or ten years. The editors are 
 practitioners of established reputation, and the list 
 of contributors embraces many of the most eminent 
 professors and teachers of London, Edinburgh, Dub- 
 lin, and Glasgow. It is, indeed, the great merit of 
 this work that the principal articles have been fur- 
 nished by practitioners who have not only devoted 
 especial attention to the diseases about which they 
 have written, but have also enjoyed opportunities 
 for an extensive practical acquaintance with them, 
 and whose reputation carries the assurance of their 
 competency justly to appreciate the opinions of 
 others, while it stamps their own doctrines with 
 high and just authority. — American Medical Journ. 
 
 Medical and Surgical Journal. 
 
 For reference, it is above all price to every prac- 
 titioner. — Western Lancet. 
 
 One of the most valuable medical nublications of 
 the day — as a work of reference it *„ invaluable. — 
 Western Journal of Medicine and Surgery. 
 
 It has been to us, both as learner and teacher, a 
 work for ready and frequent reference, one in which 
 modern English medicine is exhibited in the most 
 advantageous light. — Medical Examiner. 
 
 We rejoice that this work is to be placed within 
 the reach of the profession in this country, it being 
 unquestionably one of very great value to the prac- 
 
 DEWEES'S COMPREHENSIVE SYSTEM OF 
 MIDWIFERY. Illustrated by occasional cases 
 and many engravings. Twelfth edition, with the 
 author's last improvements and corrections In 
 one octavo volume, extra cloth , of 600 pages. $3 20. 
 
 DEWEES'S TREATISE ON THE PHYSICAL 
 AND MEDICAL TREATMENT OF CHILD- 
 REN. Tenth edition. In one volume, octavo, 
 extra cloth, 548 pages. $2 80. 
 
 DEWEES'S TREATISE ON THE DISEASES 
 OF FEMALES. Tenth edition. In one volume, 
 octavo, extra cloth, 532 pages, with plates. $3 00. 
 
 DANA ON ZOOPHYTES AND CORALS. In one 
 volume, imperial quarto, extra cloth, with wood- 
 cuts. $15 00. Also, AN ATLAS, in one volume, 
 imperial folio, with sixty-one magnificent colored 
 plates. Bound in half morocco. $30 00. 
 
 DE LA BECHE'S GEOLOGICAL OBSERVER. 
 In one very large and handsome octavo volume, ex- 
 tra cloth, of 700 pages, with 300 wood-cuts. $4 00. 
 
 FRICK ON RENAL AFFECTIONS; their Diag- 
 nosis and Pathology. With illustrations. One 
 volume, royal 12mo., extra cloth. 75 cents. 
 
12 
 
 BLANCHARD & LEA'S MEDICAL 
 
 DUNGLISON (ROBLEY), M. D., 
 
 Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. 
 
 NEW AND ENLARGED EDITION, Now Ready. 
 MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise 
 
 Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, 
 Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry, 
 &c. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic 
 Preparations, &c. With French and other Synonymes. Fifteenth edition, revised and very 
 greatly enlarged. In one very large and handsome octavo volume, of 992 double-columned pages, 
 in small type ; strongly bound in leather, with raised bands. Price $4 00. 
 
 JNo care, labor, or expense has been spared in the preparation of this edition to render it in every 
 respect worthy a continuance of the very remarkable favor which it has hitherto enjoyed. The 
 rapid sale of Fifteen large editions, and the constantly increasing demand, show that it is regarded 
 by the profession as the standard authority. Stimulated by this fact, the author has endeavored in 
 the present revision to introduce whatever might be necessary to make it a satisfactory and desira- 
 ble — if not indispensable — lexicon, in which the student may search without disappointment for 
 every term that has been legitimated in the nomenclature of the science. To accomplish this, 
 large additions have been found requisite, and the extent of the author's labors may be estimated 
 from the fact that about Six Thousand subjects and terms have been introduced throughout, ren- 
 dering the whole number of definitions about Sixty Thousand, to accommodate which, the num- 
 ber of pages has been increased by nearly a hundred, notwithstanding an enlargement in the size 
 of the page. The medical press, both in this country and in England, has pronounced the work in- 
 dispensable to all medical students and practitioners, and the present improved edition will not lose 
 that enviable reputation. 
 
 The publishers have endeavored to render the mechanical execution worthy of a volume of such 
 universal use in daily reference. The greatest care has been exercised to obtain the typographical 
 accuracy so necessary in a work of the kind. By the small but exceedingly clear type employed, 
 an immense amount ol matter is condensed in its thousand ample pages, while the binding will be 
 found strong and durable. With all these improvements and enlargements, the price has been kept 
 at the former very moderate rate, placing it within the reach of all. 
 
 This work, the appearance of the fifteenth edition 
 of which, it has become our duty and pleasure to 
 announce, is perhaps the most stupendous monument 
 of labor and erudition in medical literature. One 
 would hardly suppose after constant use of the pre- 
 ceding editions, where we have never failed to find 
 a sufficiently full explanation of every medical term, 
 that in this edition " about six thousand subjects 
 and terms have been added," with a careful revision 
 and correction of the entire work. It is only neces- 
 sary to announce the advent of this edition to make 
 it occupy the place of the preceding one on the table 
 of every medical man, as it is withoutdoubt the best 
 and most comprehensive work of the kind which has 
 ever appeared. — Buffalo Med. Journ., Jan. 1858. 
 
 The work is a monument of patient research, 
 skilful judgment, and vast physical labor, that will 
 perpetuate the name of the author more effectually 
 than any possible device of stone or metal. Dr. 
 Dunglison deserves the thanks not only of the Ame- 
 rican profession, but of the whole medical world.— 
 North Am. Medico-Chir. Review, Jan. 1858. 
 
 A Medical Dictionary better adapted for the wants 
 of the profession than any other with which we are 
 acquainted, and of a character which places it far 
 above comparison and competition. — Am. Journ. 
 Med. Sciences, Jan. 1858. 
 
 We need only say, that the addition of 6,000 new 
 terms, with their accompanying definitions, may be 
 said to constitute a new work, by itself. We have 
 examined the Dictionary attentively, and are most 
 happy to pronounce it unrivalled of its kind. The 
 erudition displayed, and the extraordinary industry 
 which must have been demanded, in its preparation 
 and perfection, redound to the lasting credit of its 
 author, and have furnished us with a volume indis- 
 pensable at the present day, to all who would find 
 themselves au niveau with the highest standards of 
 medical information. — Boston Medical and Surgical 
 Journal, Dec. 31, 1857. 
 
 Good lexicons and encyclopedic works generally, 
 are the most labor-savin? contrivances which lite- 
 rary men enjoy; and the labor which is required to 
 produce them in the perfect manner of this example 
 is something appalling to contemplate. The author 
 
 tells us in his preface that he has added about six 
 thousand terms and subjects to this edition, which, 
 before, was considered universally as the best work 
 of the kind in any language. — Silliman's Journal, 
 March, 1858. 
 
 He has razed his gigantic structure to the founda- 
 tions, and remodelled and reconstructed the entire 
 pile. No less than six thousand additional subjects 
 and terms are illustrated and analyzed in this new 
 edition, swelling the grand aggregate to beyond 
 sixty thousand ! Thus is placed before the profes- 
 sion a complete and thorough exponent of medical 
 terminology, without rival or possibility of rivalry. 
 — Nashville Journ. of Med. and Surg., Jan. 1858. 
 
 It is universally acknowledged, we believe, that 
 this work is incomparably the best and most com- 
 plete Medical Lexicon in the English language. 
 The amount of labor which the distinguished author 
 has bestowed upon it is truly wonderful, and the 
 learning and research displayed in its preparation 
 are equally remarkable. Comment and commenda- 
 tion are unnecessary, as no one at the present day 
 thinks of purchasing any other Medical Dictionary 
 than this.— St. Louis Med. and Surg. Journ., Jan. 
 1858. 
 
 It is the foundation stone of a good medical libra- 
 ry, and should always be included in the first list of 
 books purchased by the medical student.— Am. Med. 
 Monthly, Jan. 1858. 
 
 A very perfect work of the kind, undoubtedly the 
 most perfect in the English language. — Med. and 
 Surg. Reporter, Jan. 1868. 
 
 It is now emphatically the Medical Dictionary of 
 the English language, and for it there is no substi- 
 tute.— N. H. Med. Journ., Jan. 1858. 
 
 It is scarcely necessary to remark that any medi- 
 cal library wanting a copy of Dunglison's Lexicon 
 must be imperfect. — Gin. Lancet, Jan. 1858. 
 
 We have ever considered it the best authority pub- 
 lished, and the present edition we may safely say has 
 no equal in the world. — Peninsular Med. Journal, 
 Jan. 1858. 
 
 The most complete authority on the subject to he 
 found in any language. — Va. Med. Journal, Feb. '58. 
 
 BY THE SAME AUTHOR. 
 
 THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and The- 
 
 rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. $6 25. 
 
AND SCIENTIFIC PUBLICATIONS. 13 
 
 DUNGLISON (ROBLEY), M.D., 
 
 Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. 
 
 HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- 
 sively modified and enlarged, with five hundred and thirty-two illustrations. In two large and 
 handsomely printed octavo volumes, leather, of about 1500 pages. {Just Issued, 1856.) $7 00. 
 In revising this work for its eighth appearance, the author has spared no labor to render it worthy 
 a continuance of the very great favor which has been extended to it by the profession. The whole 
 contents have been rearranged, and to a great extent remodelled ; the investigations which of late 
 years have been so numerous and so important, have been carefully examined and incorparated, 
 and the work in every respect has been brought up to a level with the present state of the subject. 
 The object of the author has been to render it a concise but comprehensive treatise, containing the 
 whole body of physiological science, to which the student and man of science can at all times refer 
 with the certainly of finding whatever they are in search of, fully presented in all its aspects; and 
 on no former edition has the author bestowed more labor to secure this result. 
 
 We believe that it can truly be said, no more com- > The best work of the kind in the English lan- 
 plete repertory of facts upon the subject treated, j guage. — Silliman's Journal. 
 
 can any where "be found. The author has, moreover, j The prese nt edition the author has made a perfect 
 that enviable tact atjJescription^andUiat facility j m j rror „f t he science as it is at the present hour. 
 
 As a work upon physiology proper, the science of 
 the functions performed by the body, the student will 
 find it all he wishes.— Nashville Journ. of Med. 
 Sept. 1856. 
 
 That he has succeeded, most admirably succeeded 
 in his purpose, is apparent from the appearance of 
 an eighth edition. It is now the great encyclopaedia 
 on the subject, and worthy of a place in every phy- 
 sician's library. — Western Lancet, Sept. 1856. 
 
 and ease of expression which render him peculiarly 
 acceptable to the casual, or the studious reader. 
 This faculty, so requisite in setting forth many 
 craver and less attractive subjects, lends additional 
 charms to one always fascinating. — Boston Med. 
 and Surg. Journal, Sept. 1856. 
 
 The most complete and satisfactory system of 
 Physiology in the English language. — Amer. Med. 
 Journal . 
 
 BY the same atjthob. (Now Ready.) 
 
 GENERAL THERAPEUTICS AND MATERIA MEDIC A; adapted for a 
 
 Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth 
 Edition, revised and improved. With one hundred and ninety-three illustrations. In two large 
 and handsomely printed octavo vols., leather, of about 1100 pages. $6 00. 
 
 Prom the Author 's Preface. 
 
 " Another edition of this work being called for, the author has subjected it to a thorough and careful 
 revision. It has been gratifying to him that it has been found so extensively useful by those for whom 
 it was especially intended, as to require that a sixth edition should be issued in so short a time after 
 the publication of a fifth. Grateful for the favorable reception of the work by the profession, he has 
 bestowed on the preparation of the present edition all those cares which were demanded by the 
 former editions, and. has spared no pains to render it a faithful epitome of General Therapeutics 
 and Materia Medica\ The copious Indexes of Remedies and of Diseases and their Remedies can- 
 not fail, the author conceives, to add materially to the value of the work." 
 
 This work is too widely and too favorably known to require more than the assurance that the 
 author has revised it with his customary industry, introducing whatever has been found necessary 
 to bring it on a level with the most advanced condition of the subject. The number of illustrations 
 has been somewhat enlarged, and the mechanical execution of the volumes will be found to have 
 undergone a decided improvement. 
 
 BY the same author. (A new Edition.) 
 
 NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND 
 
 ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo 
 
 volume, leather, of 770 pages. (Just Issued.) $3 75. ' 
 
 Another edition of the " New Remedies" having been called for, the author has endeavored to 
 add everything of moment that has appeared since the publication of the last edition. 
 
 The chief remedial means which have obtained a place, for the first time, in this volume, either 
 owing to their having been recently introduced into pharmacology, or to their having received novel 
 applications— and which, consequently, belong to the category of " New Remedies"— are the fol- 
 lowing : — 
 
 Apiol, Caffein, Carbazotic acid, Cauterization and catheterism of the larynx and trachea, Cedron, 
 Cerium, Chloride of bromine, Chloride of iron, Chloride of sodium, Cinchonicine, Cod-liver olein, 
 Congelation, Eau de Pagliari, Galvanic cautery, Hydriodic ether, Hyposulphite of soda and silver, 
 Inunction, Iodide of sodium, Nickel, Permanganate of potassa, Phosphate of lime, Pumpkin, Quinidia, 
 Rennet, Saccharine carbonate of iron and manganese, Santonin, Tellurium, and Traumaticine. 
 
 The articles treated of in the former editions will be found to have undergone considerable ex- 
 pansion in this, in order that the author might be enabled to introduce, as far as practicable, the 
 results of the subsequent experience of others, as well as of his own observation and reflection; 
 and to make the work still more deserving of the extended circulation with which the preceding 
 editions have been favored by the profession. By an enlargement of the page, the numerous addi- 
 tions have been incorporated without greatly increasing the bulk of the volume. — Preface. 
 
 One of the most useful of the author's works.— 
 Southern Medical and Surgical Journal. 
 
 This elaborate and useful volume should be 
 found in every medical library, for as a book of re- 
 ference, for physicians, it is unsurpassed by any 
 other work in existence, and the double index for 
 diseases and for remedies, will be found greatly to 
 enhance its value. — New York Med. Gazette. 
 
 The great learning of the author, and his remark- 
 able industry in pushing his researches into every 
 source whence information is derivable, have enabled 
 him to throw together an extensive mass of facts 
 and statements, accompanied by full reference to 
 authorities; which last feature renders the work 
 practically valuable to investigators who desire to 
 examine the original papers.— The American Journal 
 of Pharmacy. 
 
14 
 
 BLANCHARD & LEA'S MEDICAL 
 
 ERICHSEN (JOHN), 
 
 Professor of Surgery in University College, London, &c. 
 
 THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical 
 
 Injuries, Diseases, and Operations. Edited by John H. Brinton, M. D. Illustrated with 
 three hundred and eleven engravings on wood. In one large and handsome octavo volume, of 
 over nine hundred closely printed pages, leather, raised bands. $4 25. 
 
 rarely encounter cases requiring surgical manage- 
 ment. — Stethoscope. 
 
 Embracing, as will be perceived, the whole surgi- 
 cal domain, and each division of itself almost corn- 
 
 It is, in our humble judgment, decidedly the best 
 book of the kind in the English language. Strange 
 that just such books are notofiener produced by pub- 
 lic teachers of surgery in this country and Great 
 Britain Indeed, it is a matter of great astonishment, 
 but no less true than astonishing, that of the many 
 works on surgery republished in this country within 
 the last fifteen or twenty years as text-books for 
 medical students, this is the only one that even ap- 
 proximates to the fulfilment of the peculiar wants of 
 youngmen just entering upon the study of this branch 
 of the profession. — Western Jour .of Med. and Surgery. 
 
 Its value is greatly enhanced by a very copious 
 well-arranged index. We regard this as one of the 
 most valuable contributions to modern surgery. To 
 one entering his novitiate of practice, we regard it 
 the most serviceable guide which he can consult. He 
 will find a fulness of detail leadinghim through every 
 step of the operation, and not deserting him until the 
 final issue of the case, is decided. For the same rea- 
 son we recommend it to those whose routine of prac- 
 tice lies in such parts of the country that they must 
 
 plete and perfect, each chapter full and explicit, each 
 subject faithfully exhibited, we can only express our 
 estimate of it in the aggregate. We consider it an 
 excellent contribution to surgery, as probably the 
 best single volume now extant on the subject, and 
 with great pleasure we add it to our text-books. — 
 Nashville Journal of Medicine and Surgery. 
 
 Prof. Erichsen's work, for its size, has not been 
 surpassed; his nine hundred and eight pages, pro- 
 | fusely illustrated, are rich in physiological, patholo- 
 gical, and operative suggestions, doctrines, details, 
 and processes ; and will prove a reliable resource 
 for information, both to physician and surgeon, in the 
 hour of peril. — N. 0. Med. and Surg. Journal. 
 
 We are acquainted with no other work wherein 
 so much good sense, sound principle, and practical 
 inferences, stamp every page. — American Lancet. 
 
 ELLIS (BENJAMIN), M.D. 
 THE MEDICAL FORMULARY : being a Collection of Prescriptions, derived 
 
 from the writings and practice of many of the most eminent physicians of America and Europe. 
 Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added 
 an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The 
 whole accompanied with a few brief Pharmaceutic and Medical Observations. Tenth edition, 
 revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the 
 Philadelphia College of Pharmacy. In one neat octavo volume, extra cloth, of 296 pages. {Lately 
 Issued.) $1 75. 
 
 After an examination of the new matter and the 
 alterations, we believe the reputation of the work 
 built up by the author, and the late distinguished 
 editor, will continue to flourish under the auspices 
 of the present editor, who has the industry and accu- 
 racy, and, we would say, conscientiousness requi- 
 site for the responsible task. — Am. Jour, of P harm. 
 
 It will prove particularly useful to students and 
 young practitioners, as the most important prescrip- 
 tions employed in modern practice, which lie scat- 
 tered through our medical literature, are here col- 
 lected and conveniently arranged for reference.— 
 Charleston Med. Journal and Review. 
 
 FOWNES (GEORGE), PH. D., &c. 
 ELEMENTARY CHEMISTRY; Theoretical and Practical. With numerous 
 
 illustrations. Edited, with Additions, by Robert Bridges, M. D. In one large royal 12mo 
 volume, of over 550 pages, with 181 wood-cuts 
 We know of no better text-book, especially in the 
 difficult department of organic chemistry, upon 
 
 which it is particularly full and satisfactory. We 
 would recommend it to preceptors as a capital 
 " office book" for their students who are beginners 
 in Chemistry. It is copiously illustrated with ex- 
 cellent wood-cuts, and altogether admirably "got 
 up." — N. J. Medical Reporter. 
 
 A standard manual, which has long enjoyed the 
 reputation of embodying much knowledge in a small 
 space. The author has achieved the difficult task of 
 condensation with masterly tact. His book is con- 
 cise without being dry, and brief without being too 
 dogmatical or general. — Virginia Med. and Surgical 
 Journal. 
 
 In leather, $1 50; extra cloth, $1 35. 
 
 The work of Dr. Fownes has long been before 
 
 the public, and its merits have been fully appreci- 
 ated as the best text-book on chemistry now in 
 existence. We do not, of course, place it in a rank 
 superior to the works of Brande, Graham, Turner, 
 Gregory, or Gmelin, but we say that, as a work 
 for students, it is preferable to any of them. — Lon- 
 don Journal of Medicine. 
 
 A work well adapted to the wants of the student. 
 It is an excellent exposition of the chief doctrines 
 and facts of modern chemistry. The size of the work, 
 and still more the condensed yet perspicuous style 
 in which it is written, absolve it from the charges 
 very properly urged against most manuals termed 
 popular. — Edinburgh Journal of Medical Science. 
 
 FISKE FUND PRIZE ESSAYS. 
 THE EFFECTS OF CLIMATE ON TUBERCULOUS DISEASE. By Edwin 
 
 Lee, M. R. C. S., London, and THE INFLUENCE OF PREGNANCY" ON THE DEVELOP- 
 MENT OF TUBERCLES. By Edward Warren, M. D., of Edenton, N. C. Together in 
 one neat octavo volume, extra cloth. $1 00. (Just Ready.) 
 
 FERGUSSON (WILLIAM), F. R. S., 
 
 Professor of Surgery in King's College, London, &c. 
 
 A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third 
 
 and enlarged London edition. In one large and beautifully printed octavo volume, of about 700 
 pages, with 393 handsome illustrations, leather. $3 00. 
 
 No work was ever written which more nearly I The addition of many new pages makes this work 
 comprehended the necessities of the student and | more thnnever indispensable to thestudentand prac- 
 practitioner, and was more carefully arranged to titioner. — Ranking's Abstract. 
 that single purpose than this. — N. Y. Med. Journal. | 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 15 
 
 FLINT (AUSTIN), M. D., 
 
 Professor of the Theory and Practice of Medicine in the University of Louisville, &c. 
 (An Important New Work.') 
 
 PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- 
 
 ING THE RESPIRATORY ORGANS. In one large and handsome octavo volume, extra 
 
 cloth, 636 pages. $3 00. 
 
 We can only state our general impression of the 
 high value of this work, and cordially recommend 
 it to all . We regard it, in point both of arrangement 
 and of the marked ability of its treatment of the sub- 
 jects, as destined to take the first rank in works of 
 this class. So far as our information extends, it has 
 at present no equal. To the practitioner, as well as 
 the student, it will be invaluable in clearing up the 
 diagnosis of doubtful cases, and in shedding light 
 upon difficult phenomena. — Buffalo Med. Journal. 
 
 This is the most elaborate work devoted exclu- 
 sively to the physical exploration of diseases of the 
 lungs, with which we are acquainted in the English 
 language. From the high standing of the author as 
 a clinical teacher, and his knowndevotion, during 
 many years, to the study of thoracic diseases, much 
 was to be expected from the announcement of his 
 determination to embody in the form of a treatise, 
 
 the results of his study and experience. These.ex- 
 pectations we are confident will not be disappointed . 
 For our own part, we have been favorably impressed 
 by a perusal of the book, and heartily recommend it 
 to all who are desirous of acquiring a thorough ac- 
 quaintance with the means of* exploring the condi- 
 tions of the respiratory organs by means of auscul- 
 tation and percussion. — Boston Med. and Surg. 
 Journal. 
 
 A work of original observation of the highest merit. 
 We recommend the treatise to every one who wishes 
 to become a correct auscultator. Based to a very 
 large extent upon cases numerically examined, it 
 carries the evidence of careful study and discrimina- 
 tion upon every paare. It does credit to the author, 
 and, through him, to the profession in this country. 
 It is, what we cannot call every book upon auscul- 
 tation, a readable book.— Am. Jour. Med. Sciences. 
 
 NOW COMPLETE, 
 GRAHAM (THOMAS), F. R. S., 
 THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applica- 
 tions of the Science in the Arts. New and much enlarged edition, by Henry Watts and Robert 
 Bridges, M. D. Complete in one large and handsome octavo volume, of over 800 very large 
 pages, with two hundred and thirty-two wood-cuts, extra cloth. - $4 00. 
 
 #*% Part II., completing the work from p. 431 to end, with Index, Title Matter, &c, may be 
 had separate, cloth backs and paper sides. Price $2 50. 
 
 The long delay which has intervened since the appearance of the first portion of this work, has 
 rendered necessary an Appendix, embodying the numerous and important investigations and dis- 
 coveries of the last few years in the subjects contained in Part I. This occupies a large portion 
 of Part II., and will be found to present a complete abstract of the most recent researches in the 
 general principles of the science, as well as all details necessary to bring the whole work thoroughly 
 up to the present time in all departments of Inorganic Chemistry. 
 
 The great reputation which this work has enjoyed since its first appearance, and its recognized 
 position in the front rank of scientific treatises, render eulogy unnecessary to secure for it imme- 
 diate attention on the part of those desiring to procure a complete exposition of chemical facts and 
 principles, either as\n introduction to the subject for the student, or as a work for daily reference 
 by the practical chemist. 
 
 Gentlemen desirous of completing their copies of the work are requested to apply for Part 11. 
 without delay. It will be sent by mail, prepaid, on receipt of the amount, $2 50. 
 
 It is a very acceptable addition to the library of 
 standard books of every chemical student. Mr. 
 Watts, well known as the translator of the Cavendish 
 Society edition of Gm.elin's Chemistry, has made in 
 the supplement an able resume of the progress of 
 the science since the publication of the first volume. 
 It is plain from the number and importance of the 
 
 topics there discussed, that great progress has been 
 made in the interval, both in chemical physics and 
 in general inorganic chemistry. No reader of Eng- 
 lish works on this science can afford to be without 
 this edition of Prof. Graham's Elements. — Silliman's 
 Journal, March, 1858. 
 
 GRIFFITH (ROBERT E.), M. D., &c. 
 A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- 
 ministering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu- 
 tists. 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, extra cloth., of 650 pages, double columns. (Just Isszted.) $3 00; or 
 bound in sheep, $3 25. 
 
 nistering medicines that can be desired by the physi- 
 cian and pharmaceutist.— Western Lancet. 
 
 The amountof useful, every-day matter. for a prac- 
 ticing physician, is really immense. — Boston Med. 
 and Surg. Journal. 
 
 We predict a great sale for this work, and we espe- 
 cially recommend it to all medical teachers. — Rich' 
 
 It was a work requiring much perseverance, and 
 when published was looked upon as by far the best 
 work of its kind that had issued from the American 
 press. Prof Thomas has certainly "improved," as 
 well as added lothis Formulary, and has rendered it 
 additionally deserving of the confidence of pharma- 
 ceutists and physicians.— Am. Journal of Pharmacy. 
 
 We are happy to announce a new and improved 
 edition of this, one of. the most valuable and useful 
 works that have emanated from an American pen. 
 It would do credit to any country, and will be found 
 of daily usefulness to practitioners of medicine; it is 
 better adapted to their purposes than the dispensato- 
 ries.— Southern Med. and Surg. Journal. 
 
 It is one of the most useful books a country practi- 
 tioner can possibly have in his possession.— Medical 
 Chronicle. 
 
 This is a work of six hundred and fifty-one pages, 
 embracing all on the subject of preparing and admi- 
 
 BY THE SAME AUTHOR. 
 
 MEDICAL BOTANY ; or, a Description of all the more important Plants used 
 in Medicine, and of their Properties, Uses, and Modes of Administration. In one large octavo 
 volume, extra cloth, of 704 pages, handsomely printed, with nearly 350 illustrations on wood. $3 00. 
 
 mond Stethoscope. 
 
 This edition of Dr. Griffith's work has been greatly 
 improved by the revision and ample additions of Dr. 
 Thomas, and is now, we believe, one of the most 
 complete works of its kind in any language. The 
 addition! amount to about seventy pages, and no 
 effort has been spared to include in them all the re- 
 cent improvements which have been published in 
 medical journals, and systematic treatises. A work 
 of this kind appears to us indispensable lo the physi- 
 cian, and there is none we can more cordially recom- 
 mend. — N. Y. Journal of Medicine. 
 
16 
 
 BLANCHARD & LEA'S MEDICAL 
 
 GROSS (SAMUEL D.), M. D., 
 
 Professor of Surgery in the Jefferson Medical College of Philadelphia, &c. 
 
 New Edition (Now Ready.) 
 ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly 
 
 revised and greatly improved. In one large and very handsome octavo volume, with about three 
 
 hundred and fifty beautiful illustrations, of which a large number are from original drawings. 
 
 Price in extra cloth, $4 75; leather, raised bands, $5 25. 
 
 The very rapid advances in the Science of Pathological Anatomy during the last few years have 
 rendered essential a thorough modification of this work, with a view of making it a correct expo- 
 nent of the present state of the subject. The very careful manner in which this task has been 
 executed, and the amount of alteration which it has undergone, have enabled the author to say that 
 " with the many changes and improvements now introduced, the work may be regarded almost as 
 a new treatise," while the efforts of the author have been seconded as regards the mechanical 
 execution of the volume, rendering it one of the handsomest productions of the American press. 
 A very large number of new and beautiful original illustrations have been introduced, and the work, 
 it is hoped, will fully maintain the reputation hitherto enjoyed by it of a complete and practical ex- 
 position of its difficult and important subject. 
 
 We most sincerely congratulate the author on the . We have been favorably impressed with the gene 
 
 successful manner in which he has accomplished his 
 proposed object. His book is most admirably cal- 
 culated to fill up a blank which has long been felt to 
 exist in this department of medical literature, and 
 as such must become very widely circulated amongst 
 all classes of the profession. — Dublin Quarterly 
 Journ. of Med. Science, Nov. 1857. 
 
 ral manner in which Dr. Gross has executed his task 
 of affording 1 a comprehensive digest of the present 
 state of the literature of Pathological Anatomy, and 
 have much pleasure in recommending his work to 
 our readers, as we believe one well deserving of 
 dilisrent perusal and careful study. — Montreal Med. 
 Chron., Sept. 1857. 
 
 BY THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND 
 
 MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, AND 
 THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eighty- 
 four illustrations. In one large and very handsome octavo volume, of over nine hundred pages. 
 In leather, raised bands, $5 25 ; extra cloth, $4 75. 
 
 A volume replete with truths and principles of the 
 utmost value in the investigation of these diseases. — 
 American Medical Journal . 
 
 On the appearance of the first edition of this work, 
 the leading English medical review predicted that it 
 would have a " permanent place in the literature of 
 surgery worthy to rank with the best works of the 
 present age." This prediction has been amply ful- 
 filled. Dr. Gross's treatise has been found to sup- 
 ply completely the want which has been felt ever 
 since the elevation of surgery to the rank of a science, 
 of a good practical treatise on the diseases of the 
 bladder and its accessory organs. Philosophical in 
 its design, methodical in its arrangement, ample and 
 
 sound in its practical details, it may in truth be said 
 to leave scarcely anything to be desired on so im- 
 portant a subject, and with the additions and modi- 
 fications resulting from future discoveries and im- 
 provements, it will probably remain one of the most 
 valuable works on this subject so long as the science 
 of medicine shall exist. — Boston Med. and Surg. 
 Journal. 
 
 Whoever will peruse the vast amount of valuable 
 practical information it contains, and which we 
 have been unable even to notice, will, we think, 
 agree with us, that there is no work in the English 
 language which can make any just pretensions to 
 be its equal. — N. Y. Journal of Medicine. 
 
 BY THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS- 
 
 SAGES. In one handsome octavo volume, extra cloth, with illustrations, pp. 468. $2 75. 
 
 A very elaborate work. It is a complete summary i conclude by recommending it to our readers, fully 
 of the whole subject, and will be a useful book of j persuaded that its perusal will afford them much 
 reference. — British and Foreign Medico-Chirurg. practical information well conveyed, evidently de- 
 Review . j rived from considerable experience and deduced from 
 
 A highly valuable book of reference on a most im- an ample collection of facts. — Dublin Quarterly 
 portant subject in the practice of medicine. We I Journal, May, 1855. 
 
 by the same author. (Preparing-.) 
 
 A SYSTEM OF SURGERY ; Diagnostic, Pathological, Therapeutic, and Opera- 
 tive. With very numerous engravings on wood. 
 
 GLUGE (GOTTLIEB), M. D., 
 
 Professor of Physiology and Pathological Anatomy in the University of Brussels, &c. 
 
 AN ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes 
 
 and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylva- 
 nia. In one volume, very large imperial quarto, extra cloth, with 320 figures, plain and colored, 
 on twelve copperplates. $5 00. 
 
 GARDNER'S MEDICAL CHEMISTRY, for the 
 use of Students and the Profession. In one royal 
 l2mo. vol., ex. cloth, pp. 396, with illustrations. 
 81 00. 
 
 HARRISON'S ESSAY TOWARDS A CORRECT 
 THEORY OF THE NERVOUS SYSTEM. In 
 one octavo volume, leather, 292 pages. 81 50. 
 
 HUGHES' CLINICAL INTRODUCTION TO 
 THE PRACTICE OF AUSCULTATION AND 
 OTHER MODES OF PHYSICAL DIAGNOSIS, 
 IN DISEASES OF THE LUNGS AND HEART. 
 
 Second American, from the second London edition. 
 1 vol. royal 12mo., ex. cloth, pp. 304. 81 00. 
 
 HUNTER'S COMPLETE WORKS, in 4 vols. 
 8vo., leather, with plates. 810. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 17 
 
 HOBLYN (RICHARD D.), M. D. 
 A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE 
 
 COLLATERAL SCIENCES. By Richard D. Hoblyn, A. M., &c A new American edi- 
 tion. Revised, with numerous Additions, by Isaac Hays, M. L\, editor of the "American 
 Journal of the Medical Sciences." In one large royal 12mo. volume, leather, of over 500 double 
 columned pages. (Just Issued^ 1856.) $1 50. 
 
 If the frequency with which we have referred to 
 this volume since its reception from the publisher, 
 two or three weeks ago, be any criterion for the 
 future, the binding will soon have to be renewed, even 
 with careful handling. We find that Dr. Hays has 
 done the profession great service by his careful and 
 industrious labors. The Dictionary has thus become 
 eminently suited to our medical brethren in this 
 country. The additions by Dr. Hays are in brackets, 
 and we believe there is not a single page but bears 
 these insignia ; in every instance which we have thus 
 far noticed, the additions are really needed and ex- 
 ceedingly valuable. We heartily commend the work 
 to all who wish to be au courant in medical termi- 
 nology. — Boston Med. and Surg. Journal. 
 
 To both practitioner and student, we recommend 
 this dictionary as being convenient in size, accurate 
 in definition, and sufficiently full and complete for 
 ordinary consultation. — Charleston Med. Journ. and 
 Review. 
 
 Admirably calculated to meet the wants of the 
 practitioner or student, who has neither the means 
 
 nor desire to procure a larger work. — American 
 Lancet. 
 
 Hoblyn has always been a favorite dictionary, and 
 in its present enlarged and improved form will give 
 greater satisfaction than ever. The American editor, 
 Dr. Hays, has made many very valuable additions. 
 — N. J. Med. Reporter. 
 
 To supply the want of the medical reader arising 
 from this cause, we know of no dictionary better 
 arranged and adapted than the one bearing the above 
 title. It is not encumbered with the obsolete terms 
 of a bygone age, but it contains all that are now in 
 use ; embracing every department of medical science 
 down to the very latest date. The volume is of a 
 convenient size to be used by the medical student, 
 and yet large enough to make a respectable appear- 
 ance in the library of a physician. — Western Lancet. 
 
 Hoblyn's Dictionary has long been a favorite with 
 us. It is the best book of definitions we have, and 
 ought always to be upon the student's table. — 
 Southern Med. and Surg. Journal. 
 
 HOLLAND (SJR HENRY), BART., M. D., F. R. S., 
 
 Physician in Ordinary to the Queen of England, &c. 
 
 MEDICAL NOTES AND REFLECTIONS. From the third London edition. 
 
 In one handsome octavo volume, extra cloth, (Now Ready.) $3 00. 
 
 As the work of a thoughtful and observant physician, embodying the results of forty years' ac- 
 tive professional experience, on topics of the highest interest, this volume is commended to the 
 American practitioner as well worthy his attention. Few will rise from its perusal without feel- 
 ing their convictions strengthened, and armed with new weapons for the daily struggle with 
 disease. 
 
 \ HABERSHON (S. O.), M. D., 
 
 Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guy's Hospital, &c. 
 
 PATHOLOGICAL AND PRACTICAL OBSERVATIONS ON DISEASES 
 
 OF THE ALIMENTARY CANAL, OESOPHAGUS, STOMACH, CAECUM, AND INTES- 
 TINES. With illustrations on wood. In one handsome octavo volume. (Republishing in the 
 Medical News and Library for 1858.) 
 
 HORNER (WILLIAM E.), M. D. ? 
 
 Professor of Anatomy in the University of Pennsylvania. 
 
 SPECIAL ANATOMY AND HISTOLOGY. Eighth edition. Extensively 
 
 revised and modified. In two large octavo volumes, extra cloth, of more than one thousand 
 pages, handsomely printed, with over three hundred illustrations. $6 00. 
 
 HAMILTON (FRANK H.), M. D., 
 
 Professor of Surgery, in Buffalo Medical College, &c. 
 
 A TREATISE ON FRACTURES AND DISLOCATIONS. 
 
 o«tavo volume, with numerous illustrations. (Preparing.) 
 
 In one handsome 
 
 JONES (T. WHARTON), F. R. S., 
 
 Professor of Ophthalmic Medicine and Surgery in University College, London, &c. 
 
 THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE 
 
 AND SURGERY. With one hundred and ten illustrations. Second American from the second 
 and revised London edition, with additions by Edward Hartshorne, M. D., Surgeon to Wills' 
 Hospital, &c. In one large, handsome royal 12mo. volume, extra cloth, of 500 pages. $1 50. 
 
 We are confident that the reader will find, on 
 perusal, that the execution of the work amply fulfils 
 the promise of the preface, and sustains, in every 
 point, the already high reputation of the author as 
 an ophthalmic surgeon as well as a physiologist 
 and pathologist. The book is evidently the result 
 of much labor and research, and has been written 
 With the greatest care and attention; it possesses 
 that best quality which a general work, like a sys- 
 tem or manual can show, viz : the quali ty of having 
 all the materials whencesoever derived, so thorough- 
 
 ly wrought up, and digested in the author's mind, 
 as to come forth with the freshness and impressive- 
 ness of an original production. We entertain little 
 doubt that this book will become what its author 
 hoped it might become, a manual for daily reference 
 and consultation by the student and the general prac- 
 titioner. The work is marked by that correctness, 
 clearness, and precision of style which distinguish 
 all the productions of the learned author. — British 
 and For. Med. Review. 
 
IS 
 
 LANCHARD & LEA'S MEDICAL 
 
 JONES (C. 
 
 HANDFIELD), F. R. S., & EDWARD H. SIEVEKING, M 
 
 Assistant Physicians and Lecturers in St. Mary's Hospital, London. 
 
 A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, 
 
 Revised. "With three hundred and ninety-seven handsome wood engravings. In one large and 
 beautiful octavo volume of nearly 750 pages, leather. $3 75. 
 
 present condition of pathological anatomy. In this 
 
 As a concise text-book, containing, in a condensed 
 form, a complete outline of what is known in the 
 domain of Pathological Anatomy, it is perhaps the 
 best work in the English language. Its great merit 
 consists in its completeness and brevity, and in this 
 respect it supplies a great desideratum in our lite- 
 rature. Heretofore the student of pathology was 
 obliged to glean from a great number of monographs, 
 and the field was so extensive that but few cultivated 
 it with any degree of success. As a simple work 
 of reference, therefore, it is of great value to the 
 student of pathological anatomy, and should be in 
 every physician's library.— Western Lancet. 
 
 In offering the above titled work to the public, the 
 authors have not attempted to intrude new views on 
 their professional brethren, but simply to lay before 
 them, what has long been wanted, an outline of the 
 
 they have been completely successful. The work is 
 one of the best compilations which we have ever 
 perused. — Charleston Medical Journal and Review. 
 
 We urge upon our readers and the profession gene- 
 rally the importance of informing themselves in re- 
 gard to modern views of pathology, and recommend 
 to them to procure the work before us as the best 
 means of obtaining this information. — Stethoscope. 
 
 From the casual examination we have given we 
 are inclined to regard it as a text-book, plain, ra- 
 tional, and intelligible, such a book as the practical 
 man needs for daily reference. For this reason it 
 will be likely to be largely useful, as it suits itself 
 to those busy men who have little time for minute 
 investigation, and prefer a summary to an elaborate 
 treatise. — Buffalo Medical Journal. 
 
 KIRKES (WILLIAM SENHOUSE), M.D., 
 
 Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c. 
 
 A MANUAL OF PHYSIOLOGY. A new American, from the third and 
 
 improved London edition. With two hundred illustrations. In one large and handsome royal 
 
 12mo. volume, leather, pp. 586. $2 00. (Now Ready, 1857.) 
 
 In again passing this work through his hands, the author has endeavored to render it a correct 
 exposition of the present condition of the science, making such alterations and additions as have 
 been dictated by further experience, or as the progress of investigation has rendered desirable. In 
 every point of mechanical execution the publishers have sought to make it superior to former edi- 
 tions, and at the very low price at which it is offered,, it will be found one of the handsomest and 
 cheapest volumes before the profession. 
 
 In making these improvements, care has been exercised not unduly to increase its size, thus 
 maintaining its distinctive characteristic of presenting within a moderate compass a clear and con- 
 nected view of its subjects, sufficient for the wants of the student. 
 
 This is a new and very much improved edition of 
 Dr. Kirkes' well-known Handbook of Physiology. 
 Originally constructed on the basis of the admirable 
 treatise of Miller, it has in successive editions de- 
 veloped itself into an almost original work, though 
 no change has been made in the plan or arrangement. 
 It combines conciseness with completeness, and is, 
 therefore, admirably adapted for consultation by the 
 busy practitioner. — Dublin Quarterly Journal, Feb. 
 1857. 
 
 Its excellence is in its compactness, its clearness, 
 and its carefully cited authorities. It is the most 
 convenient of text-books. These gentlemen, Messrs. 
 Kirkes and Paget, have really an immense talent for 
 silence, which is not so common or so cheap as prat- 
 ing people fancy. They have the gift of telling us 
 what we want to know, without thinking it neces- 
 sary to tell us all they know. — Boston Med. and 
 Surg. Journal, May 14, 1857. 
 
 One of the very best handbooks of Physiology we 
 possess — presenting just such an outlina of the sci- 
 ence, comprising an account of its leading facts and 
 generally admitted principles, as the student requires 
 during his attendance upon a course of lectures, or 
 for reference whilst preparing for examination. — 
 Am. Medical Journal. 
 
 We need only say, that, without entering into dis- 
 cussions of unsettled questions, it contains all the 
 recent improvements in this department of medical 
 science. For the student beginning this study, and 
 the practitioner who has but leisure to refresh his 
 memory, this book is invaluable, as it contains all 
 that it is important to know, without special details, 
 which are read with interest only by those who 
 would make a specialty, or desire to possess a criti«- 
 cal knowledge of the subject.— Charleston Medical 
 Journal. 
 
 KNAPP'S TECHNOLOGY ; or, Chemistry applied 
 to the Arts and to Manufactures. Edited, with 
 numerous Notes and Additions, by Dr. Edmund 
 Ronalds and Dr. Thomas Richardson. First 
 American edition, with Notes and Additions, by 
 Prof. Waltek R. Johnson. In two handsome 
 
 octavo volumes, extra cloth, with about 500 wood- 
 engravings. $6 00. 
 LALLEMAND ON SPERMATORRHOEA. Trans- 
 lated and edited byHENKY J. McDottgal. In one 
 volume, octavo, extra cloth, 320 pages. Second 
 American edition. $1 75. 
 
 LUDLOW (J. LJ, 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. Designed for Students of Medicine throughout the United 
 States. Third edition, thoroughly revised and greatly extended and enlarged. With three 
 hundred and seventy illustrations. In one large and handsome royal 12mo. volume, leather, of 
 over 800 closely printed pages. (Now Ready.) $2 50. 
 
 The great popularity of this volume, arid the numerous demands for it during the two years in which 
 it has been out of print, have induced the author in its revision to spare no pains to render it a 
 correct and accurate digest of the most recent condition of all the branches of medical science. In 
 many respects it may, therefore, be regarded rather as a new book than a new edition, an entire 
 section on Physiology having been added, as also one on Organic Chemistry, and many portions 
 having been rewritten. A very complete series of illustrations has been introduced, and every 
 care has been taken in the mechanical execution to render it a convenient and satisfactory book for 
 study or reference. 
 
 The arrangement of the volume in the form of question and answer renders it especially suited 
 for the office examination of students and for those preparing for graduation. 
 
 inn 
 
 during the hours spent in the lecture room, or to re- 
 fresh, at a glance, his memory of the various topics 
 
 whom he is compelled to listen. 
 May, 1857. 
 
 -Western Lancet. 
 
AND SCIENTIFIC PUBLICATIONS. 19 
 
 LEHMANN (C. G.) 
 
 PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by 
 George E. Day, M. D., F. R. S., &c, edited by R. E. Rogers, M. D., Professor of Chemistry 
 in the Medical Department of the University of Pennsylvania, with illustrations selected from 
 Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Complete in two large 
 and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus- 
 trations. {Just Issued.) $6 00. 
 
 This great work, universally acknowledged as the most complete and authoritative exposition of 
 the principles and details of Zoochemistry, in its passage through the press, has received from 
 Professor Rogers such care as was necessary to present it in a correct and reliable form. To such 
 a work additions were deemed superfluous, but several years having elapsed between the appear- 
 ance in Germany of the first and last volume, the latter contained a supplement, embodying nume- 
 rous corrections and additions resulting from the advance of the science. These have all been incor- 
 porated in the text in their appropriate places, while the subjects have been still further elucidated by 
 the insertion of illustrations from the Atlas of Dr. OttoFunke. With the view of supplying the student 
 with the means of convenient comparison, a large number of wood-cuts, from works on kindred 
 subjects, have also been added in the form of an Appendix of Plates. The work is, therefore, pre- 
 sented as in every way worthy the attention of all who desire to be familiar with the modern facts 
 and doctrines of Physiological Science. 
 
 it treats. — Edinburgh Monthly Journal of Medical 
 Science. 
 
 Already well known and appreciated by the scien- 
 tific world, Professor Lehmann's great work re- 
 quires no laudatory sentences, as, under a new garb, 
 it is now presented to us. The little space at our 
 command would ill suffice to set forth even a small 
 portion of its excellences. — Boston Med. and Surg. 
 Journal, Dec. 1855. 
 
 The most important contribution as yet made to 
 Physiological Chemistry. — Am. Journal Med. Sci- 
 ences, Jan. 1856. 
 
 The present volumes belong to the small class of 
 medical literature which comprises elaborate works 
 of the highest order of merit. — Montreal Med. Chron- 
 icle, Jan. 1856. 
 
 The work of Lehmann stands unrivalled as the 
 most comprehensive book of reference and informa- 
 tion extant on every branch of the subject on which 
 
 BY THE SAME AUTHOR. {Just Issued, 1856.) 
 
 MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, 
 
 with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital 
 Force, by Samuel Jackson, M. D., Professor of the Institutes of Medicine in the University of 
 Pennsylvania. With illustrations on wood. In one very handsome octavo volume, extra cloth, 
 of 336 pages. $2 25. 
 
 From. Prof. Jackson's Introductory Essay. 
 
 In adopting the handbook of Dr. Lehmann as a manual of Organic Chemistry for the use of the 
 students of the University, and in recommending his original work of Physiological Chemistry 
 for their more^mature studies, the high value of his researches, and the great weight of his autho- 
 rity in that important department of medical science are fully recognized. 
 
 densed form, the positive facts of Physiological 
 
 The present volume will be a very convenient one 
 for students, as offering a brief epitome of the more 
 elaborate work, and as containing, in a very con- 
 
 Chemistry. — Am. Journal Med. Sciences, April, 1856. 
 
 LAWRENCE (W.), F. R. S., &.C. 
 A TREATISE ON DISEASES OF THE EYE. A new edition, edited, 
 
 with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi- 
 tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather 
 with raised bands. $5 00. 
 This admirable treatise— the safest guide and most 1 octavo pages— has enabled both author and editor to 
 
 comprehensive work of reference, which is within 
 the reach of the profession. — Stethoscope. 
 
 This standard text-book on the department of 
 which it treats, has not been superseded, by any or 
 all of the numerous publications on the subject 
 heretofore issued. Nor with the multiplied improve- 
 ments of Dr. Hays, the American editor, is it at all 
 likely that this great work will cease to merit the 
 confidence and preference of students or practition 
 
 do justice to all the details of this subject, and con- 
 dense in this single volume the present state of our 
 knowledge of the whole science in this department, 
 whereby its practical value cannot be excelled. We 
 heartily commend it, especially as a book of refer- 
 ence, indispensable in every medical library. The 
 additions of the American editor very greatly en- 
 hance the value of the work, exhibiting the learning 
 and experience of Dr. Hays, in the light in which he 
 ought to be held, as a standard authority on all sub- 
 ers. Its ample extent — nearly one thousand large j jects appertaining to this specialty .—N.Y. Med. Gaz. 
 
 HANDBOOKS OF NATURAL PHILOSOPHY AND ASTRONOMY. 
 
 Revised, with numerous Additions, by the American editor. First Course, containing Mecha- 
 nics, Hydrostatics, Hydraulics, Pneumatics, Sound, and Optics. In one large royal 12mo. 
 volume, of 750 pages, with 424 wood-cuts. $1 75. Second Course, containing Heat, Electricity, 
 Magnetism, and Galvanism, one volume, large royal 12mo., of 450 pages, with 250 illustrations. 
 $1 25. Third Course {now ready), containing Meteorology and Astronomy, in one large volume, 
 royal 12mo. of nearly 800 pages, with 37 plates and 200 wood-cuts. $2 00. 
 
 *_ 
 
 LAYCOCK (THOMAS), M . D., F. R. S. E., 
 
 Professor of Practical and Clinical Medicine in the University of Edinburgh, &c. 
 
 LECTURES ON THE PRINCIPLES AND METHODS OF MEDICAL 
 
 OBSERVATION AND RESEARCH. For the Use of Advanced Students and Junior Prac- 
 titioners. In one very neat royal 12mo. volume, extra cloth. Price $1 00. {Just Published, 1857.) 
 
2Q 
 
 BLANCHARD & LEA'S MEDICAL 
 
 LA ROCHE (R.), M. D., &c. 
 YELLOW FEVER, considered in its Historical, Pathological, Etiological, and 
 Therapeutical "Relations. Including a Sketch of the Disease as it has occurred in Philadelphia 
 from 1699 to 1854, with an examination of the connections between it and the fevers known under 
 the same name in other parts of temperate as well as in tropical regions. In two large and 
 handsome octavo volumes of nearly 1500 pages, extra cloth. $7 00. 
 From Professor S. H. Dickson, Charleston, S. C, 
 
 September 18, 1855. 
 A monument of intelligent and well applied re- 
 search, almost without example. It is, indeed, in 
 itself, a large library, and is destined to constitute 
 the special resort as a book of reference, in the 
 subject of which it treats, to all future time. 
 
 arduous research and careful study, and the result 
 is such as will reflect the highest honor upon thfe 
 author and our country.— Southern Med. and Surg. 
 Journal. 
 
 The genius and scholarship of this great physicitm 
 could not have been better employed than in the 
 erection of this towering monument to his own fame, 
 and to the glory of the medical literature of his own 
 country. It is destined to remain the great autho- 
 rity upon the subject of Yellow Fever. The student 
 and physician will find in these volumes a risum.6 
 of the sum total of the knowledge of the world upon 
 the awful scourge which they so elaborately discuss. 
 The style is so soft and so pure as to refresh and in- 
 vigorate the mind while absorbing the thoughts of 
 the gifted author, while the publishers have suc- 
 ceeded in bringing the externals into a most felicitous 
 harmony with the inspiration that dwells within. 
 Take it all in all, it is a book we have often dreamed 
 of, but dreamed not that it would ever meet our 
 waking eye as a tangible reality. — Nashville Journal 
 of Medicine. 
 
 We deem it fortunate that the splendid work of 
 Dr. La Roche should have been issued from the press 
 at this particular time. The want of a reliable di- 
 gest of all that is known in relation to this frightful 
 malady has long been felt — a want very satisfactorily 
 met in the work before us. We deem it but faint 
 praise to say that Dr. La Roche has succeeded in 
 presenting the profession with an able and complete 
 monograph, one which will find its way into every 
 well ordered library. — Va. Stethoscope. 
 
 BY THE SAME AUTHOR. 
 
 PNEUMONIA ; its Supposed Connection, Pathological and Etiological, with Au- 
 tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one 
 handsome octavo volume, extra cloth, of 500 pages. $3 00. 
 
 We have not time at present, engaged as we are, 
 by faff and by night, in the work of combating this 
 very disease, now prevailing in our city, to do more 
 than give this cursory notice of what we consider 
 as undoubtedly the most able and erudite medical 
 publication our country has yet produced. But in 
 view of the startling fact, that this, the most malig- 
 nant and unmanageable disease of modern times, 
 has for several years been prevailing in our country 
 to a greater extent than ever before; that it is no 
 longer confined to either large or small cities, but 
 penetrates country villages, plantations, and farm- 
 houses; that it is treated with scarcely better suc- 
 cess now than thirty or forty years ago ; that there 
 is vast mischief done by ignorant pretenders to know- 
 ledge in regard to the disease, and in view of the pro- 
 bability that a majority of southern physicians will 
 be called upon to treat the disease, we trust that this 
 able and comprehensive treatise will be very gene- 
 rally read in the south. — Memphis Med. Recorder. 
 
 This is decidedly *Ae great American medical work 
 of the day — a full, complete, and systematic treatise, 
 unequalled by any other upon the all-important sub- 
 ject of Yellow Fever. The laborious, indefatigable, 
 and learned author has devoted to it many years of 
 
 MILLER (HENRY), M. D., 
 
 Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. 
 
 PRINCIPLES AND PRACTICE OF OBSTETRICS, &c. ; includiog the Treat- 
 
 ment of Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequeat 
 cause of Abortion. With about one hundred illustrations on wood. In one very handsome oc- 
 tavo volume, of over 600 pages. (Now Ready.) $3 75. 
 
 The reputation of Dr. Miller as an obstetrician is too widely spread to require the attention of 
 the profession to be specially called to a volume containing the experience of his long and extensive 
 practice. The very favorable reception accorded to his " Treatise on Human Parturition," issued 
 some years since, is an earnest that the present work will fulfil the author's intention of providing 
 within a moderate compass a complete and trustworthy text-book for the student, and book of re- 
 ference for the practitioner. Based to a certain extent upon the former work, but enlarged to more 
 than double its size, and almost wholly rewritten, it presents, besides the matured experience of 
 the author, the most recent views and investigations of modern obstetric writers, such as Dubois, 
 Cazeatjx, Simpson, Tyler Smith, &c, thus embodying the results not only of the American, 
 but also of the Paris, the London, and the Edinburgh obstetric schools. The author's position for so 
 many years as a teacher of his favorite branch, has given him a familiarity with the wants of stu- 
 dents and a facility of conveying instruction, which cannot fail to render the volume eminently 
 adapted to its purposes. 
 
 We congratulate the author that the task is done. 
 We congratulate him that he has given to the medi- 
 cal public a work which will secure for him a high 
 and permanent position among the standard autho- 
 rities on the principles and practice of obstetrics. 
 Congratulations are not less due to the medical pro- 
 fession of this country, on the acquisition of a trea- 
 tise embodying the results of the studies, reflections, 
 and experience of Prof. Miller. Few men, if any, 
 in this country, are more competent than he to write 
 on this department of medicine. Engaged for thirty- 
 five years in an extended practice of obstetrics, for 
 many years a teacher of this branch of instruction 
 in one of the largest of our institutions, a diligent 
 student as well as a careful observer, an original and 
 independent thinker, wedded to no hobbies, ever 
 ready to consider without prejudice new views, and 
 to adopt innovations if they are really improvements, 
 und withal a clear, agreeable writer, a practical 
 treatise from his pen could not fail to possess great 
 value. Returning to Prof. Miller's work we have 
 only to add that we hope most sincerely it will be in 
 the hands of every reading and thinking practitioner 
 of this country. — Buffalo Med Journal, Mar. 1858. 
 
 In fact, this volume must take its place among the 
 standard systematic treatises on obstetrics ; a posi- 
 tion to which its merits justly entitle it. The style 
 is such that the descriptions are clear, and each sub- 
 ject is discussed and elucidated with due regard to 
 its practical bearings, which cannot fail to make it 
 acceptable and valuable to both students and prac- 
 titioners. We cannot, however, close this brief 
 notice without congratulating the author and the 
 profession on the production of such an excellent 
 treatise. The author is a western man of whom we 
 feel proud, and we cannot but think that his book 
 will find many readers and warm admirers wherever 
 obstetrics is taught and studied as a science and an 
 art.— The Cincinnati Lancet and Observer, Feb. 1868. 
 % A most respectable and valuable addition to our 
 home medical literature, and one reflecting credit 
 alike on the author and the institution to which he 
 is attached. The student will find in this work a 
 most useful guide to his studies; the country prac- 
 titioner, rusty in his reading, can obtain from its 
 pages a fair resume of the modern literature of the 
 science; and we hope to see this American produc- 
 tion generally consulted by the profession.— Va. 
 Med. Journal, Feb. 1858. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 21 
 
 MEIGS (CHARLES D.), M. D., 
 
 Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia. 
 
 OBSTETRICS : THE SCIENCE AND THE ART. Third edition, revised 
 
 and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octavo 
 
 volume, leather, of seven hundred and fifty-two large pages. $3 75. 
 
 The rapid demand for another edition of this work is a sufficient expression of the favorable 
 verdict of the profession. In thus preparing it a third time for the press, the author has endeavored 
 to render it in every respect worthy of the favor which it has received. To accomplish this he 
 has thoroughly revised it in every part. Some portions have been rewritten, others added, new 
 illustrations have been in many instances substituted for such as were not deemed satisfactory, 
 while, by an alteration in the typographical arrangement, the size of the work has not been increased, 
 and the price remains unaltered. In its present improved form, it is, therefore, hoped that the work 
 will continue to meet the wants of the American profession as a sound, practical, and extended 
 System of Midwifery. 
 
 Though the work has received only five pages of 
 enlargement, its chapters throughout wear the im- 
 press of careful revision. Expunging and rewriting, 
 remodelling its sentences, with occasional new ma- 
 terial, all evince a lively desire that it shall deserve 
 to be regarded as improved in manner as well as 
 matter. In the matter, every stroke of the pen has 
 increased the value of the book, both in expungings 
 and additions — Western Lancet. Jan. 1857. 
 
 The best American work on Midwifery that is 
 accessible to the student and practitioner — N. W. 
 Med. and Surg. Journal, Jan. 1857. 
 
 This is a standard work by a great American Ob- 
 stetrician. It is the third and last edition, and, in 
 the language of the preface, the author has "brought 
 the subject up to the latest dates of real improve- 
 ment in our art and Science." — Nashville Journ. of 
 Med. and Surg., May, 1857. 
 
 BY the same author. (Lately Issued.) 
 
 WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Lee- 
 
 tures to his Class. Third and Improved edition. In one large and beautifully printed octavo 
 
 volume, leather. pp. 672. $3 60. 
 
 The gratifying appreciation of his labors, as evinced by the exhaustion of two large impressions 
 of this work within a few years, has not been lost upon the author, who has endeavored in every 
 way to render it worthy of the favor with which it has been received. The opportunity thus 
 afforded for a second revision has been improved, and the work is now presented as in every way 
 superior to its predecessors, additions and alterations having been made whenever the advance of 
 science has rendered them desirable. The typographical execution of the work will also be found 
 to have undergone a similar improvement, and the work is now confidently presented as in every 
 way worthy the position it has acquired as the standard American text-book on the Diseases of 
 Females. 
 
 It contains a vast amount of practical knowledge, 
 by one who has accurately observed and retained 
 the experience of many years, and who tells the re- 
 sult in a free, familiar, and pleasant manner. — Dub- 
 lin Quarterly Journal. 
 
 There is an off-band fervor, a glow, and a warm- 
 heartedness infecting the effort of Dr. Meigs, which 
 is entirely captivating, and which absolutely hur- 
 ries the reader through from beginning to end. Be- 
 sides, the book teems with solid instruction, and 
 it shows the very highest evidence of ability, viz., 
 the clearness with which the information is pre- 
 sented. We know of no better test of one's under- 
 standing a subject than the evidence of the power 
 of lucidly explaining it. The most elementary, as 
 well as the obscurest subjects, under the pencil of 
 Prof. Meigs, are isolated and made to stand out in 
 
 by the same author. {Lately Published.) 
 
 QN THE NATURE, SIGNS, AND TREATMENT OF CHILDBED 
 
 FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome 
 octavo volume, extra cloth, of 365 pages. $2 50. 
 
 such bold relief, as to produce distinct impressions 
 upon the mind and memory of the reader. — The 
 Charleston Med. Journal. 
 
 Professor Meigs has enlarged and amended this 
 great work, for such it unquestionably is, having 
 passed the ordeal of criticism at home and abroad, 
 but been improved thereby ; for in this new edition 
 the author has introduced real improvements, and 
 increased the value and utility of the book im- 
 measurably. It presents so many novel, bright, 
 and sparkling thoughts ; such an exuberance of new 
 ideas on almost every page, that we confess our- 
 selves to have become enamored with the book 
 and its author ; and cannot withhold our congratu- 
 lations from our Philadelphia confreres, that such a 
 teacher is in their service. — N. Y. Med. Gazette. 
 
 The instructive and interesting author of this 
 work, whose previous labors in the department of 
 medicine which he so sedulously cultivates, have 
 placed his countrymen under deep and abiding obli- 
 gations, again challenges their admiration in the 
 fresh and vigorous, attractive and racy pages before 
 us. It is a delectable book. * * * This treatise 
 upon child-bed fevers will have an extensive sale, 
 being destined, as it deserves, to find a place in the 
 library of every practitioner who scorns to lag in the 
 rear. — Nashville Journal of Medicine and Surgery. 
 
 BY THE SAME AUTHOR J WITH COLORED PLATES. 
 
 A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK 
 
 OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest 
 style of art. In one handsome octavo volume, extra cloth. $4 50. 
 
 This book will add more to his fame than either 
 of those which bear his name. Indeed we doubt 
 whether any material improvement will be made on 
 the teachings of this volume for a century to come, 
 since it is so eminently practical, and based on pro- 
 found knowledge of the science and consummate 
 skill in the art of healing, and ratified* by an ample 
 and extensive experience, such as few men have the 
 industry or good fortune to acquire. — JV. Y. Med. 
 Gazette. 
 
 MAYNE'S DISPENSATORY AND THERA- 
 PEUTICAL REMEMBRANCER. Comprising 
 the entire lists of Materia Medica, with every 
 Practical Formula contained in the three British 
 Pharmacopoeias. Edited, with the addition of the 
 Formulas of the U. S. Pharmacopoeia, by R. E. 
 Griffith, M.D. 1 12mo. vol. ex. cl., 300 pp. 75 c. 
 
 MALGAIGNE'S OPERATIVE SURGERY, based 
 on Normal and Pathological Anatomy. Trans- 
 lated from the French by Frederick Brittan, 
 A.B.,M.D. With numerous illustrations on wood. 
 In one handsome octavo volume, extra cloth, of 
 nearly six hundred pages. $2 25. 
 
•22 
 
 BLANCHARD & LEA'S MEDICAL 
 
 MACLISE (JOSEPH), SURGEON. 
 
 SURGICAL ANATOMY. Forming one volume, very large imperial quarto. 
 With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con- 
 taining one hundred and ninety Figures, many of them the size of life. Together with copious 
 and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the 
 cheapest and best executed Surgical works as yet issued in this country. $11 00. 
 %* The size of this work prevents its transmission through the post-office as a whole, but those 
 
 who desire to have copies forwarded by mail, can receive them in five parts, done up in stout 
 
 wrappers. Price $9 00. 
 
 of keeping up his anatomical knowledge. — Medical 
 Times. 
 
 The mechanical execution cannot be excelled. — 
 Transylvania Medical Journal. 
 
 A work which has no parallel in point of accu- 
 racy and cheapness in the English language. — iV. Y. 
 Journal of Medicine. 
 
 To all engaged in the study or practice of their 
 profession, such a work is almost indispensable. — 
 Dublin Quarterly Medical Journal. 
 
 No practitioner whose means will admit should 
 fail to possess it. — Ranking^s Abstract. 
 
 Country practitioners will find these plates of im- 
 mense value. — N. Y. Medical Gazette. 
 
 We are extremely gratified to announce to the 
 profession the completion of this truly magnificent 
 work, which, as a whole, certainly stands unri- 
 valled, both for accuracy of drawing, beauty of 
 coloring, and all the requisite explanations of the 
 subject in hand. — The New Orleans Medical and 
 Surgical Journal. 
 
 This is by far the ablest work on Surgical Ana- 
 tomy that has come under our observation. We 
 know of no other work that would justify a stu- 
 dent, in any degree, for neglect of actual dissec- 
 tion. In those sudden emergencies that so often 
 arise, and which require the instantaneous command 
 of minute anatomical knowledge, a work of this kind 
 keeps the details of the dissecting-room perpetually 
 fresh in the memory. — The Western Journal of Medi- 
 cine and Surgery. 
 
 The very low price at which this work is furnished, and the beauty of its execution, 
 require an extended sale to compensate the publishers for the heavy expenses incurred. 
 
 MULLER'S PRINCIPLES OF PHYSICS AND METEOROLOGY. Edited, 
 
 with Additions, by R. Eglesfeld Griffith, M. D. In one large and handsome octavo volume, 
 extra cloth, with 550 wood-cuts, and two colored plates, pp. 636. $3 50. 
 
 One of the greatest artistic triumphs of the age 
 in Surgical Anatomy. — British American Medical 
 Journal. 
 
 Too much cannot be said in its praise ; indeed, 
 we have not language to do it justice. — Ohio Medi- 
 cal and Surgical Journal. 
 
 The most admirable surgical atlas we have seen. 
 To the practitioner deprived of demonstrative dis- 
 sections upon the human subject, it is an invaluable 
 companion. — N. J. Medical Reporter. 
 
 The most accurately engraved and beautifully 
 colored plates we have ever seen in an American 
 book — one of the best and cheapest surgical works 
 ever published. — Buffalo Medical Journal. 
 
 It is very rare that so elegantly printed, so well 
 illustrated, and so useful a work, is offered at so 
 moderate a price. — Charleston Medical Journal. 
 
 Its plates can boast a superiority which places 
 them almost beyond the reach of competition. — Medi- 
 cal Examiner. 
 
 Every practitioner, we think, should have a work 
 of this kind within reach. — Southern Medical and 
 Surgical Journal. 
 
 No such lithographic illustrations of surgical re- 
 gions have hitherto, we think, been given. — Boston 
 Medical and Surgical Journal. 
 
 As a surgical anatomist, Mr. Maclise has proba- 
 bly no superior.— British and Foreign Medico-Chi- 
 rurgical Review. 
 
 Of great value to the student engaged in dissect- 
 ing, and to the surgeon at a distance from the means 
 
 PRACTICAL PHARMACY. Comprising the Arrangements, Apparatus, and 
 
 Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, 
 by Prof. William Procter, of the Philadelphia College of Pharmacy. In one handsomely 
 printed octavo volume, extra cloth, of 570 pages, with over 500 engravings on wood. $2 75. 
 
 MACKENZIE (W.), M.D., 
 
 Surgeon Oculist in Scotland in ordinary to Her Majesty, &c. &c. 
 
 A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE 
 
 EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section of 
 the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and En- 
 larged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to 
 Wills Hospital, &c. &c. In one very large and handsome octavo volume, leather, raised bands, with 
 plates and numerous wood-cuts. $5 25. 
 
 The treatise of Dr. Mackenzie indisputably holds 
 the first place, and forms, in respect of learning and 
 research, an Encyclopaedia unequalled in extent by 
 any other work of the kind, either English or foreign. 
 — Dixon on Diseases of the Eye. 
 
 Few modern books on any department of medicine 
 or surgery have met with such extended circulation, 
 or have procured for their authors a like amount of 
 European celebrity. The immense research which 
 it displayed, the thorough acquaintance with the 
 subject, practically as well as theoretically, and the 
 able manner in which the author's stores of learning 
 and experience were rendered available for general 
 use, at once procured for the first edition, as well on 
 the continent as in this country, that high position 
 as a standard work which each successive edition 
 has more firmly established, in spite of the attrac- 
 tions of several rivals of no mean ability. We con- 
 
 sider it the duty of every one who has the love of his 
 profession and the welfare of his patient at heart, to 
 make himself familiar with this the most complete 
 work in the English language upon the diseases of 
 the eye. — Med. Times and Gazette. 
 
 The fourth edition of this standard work will no 
 doubt be as fully appreciated as the three former edi- 
 tions. It is unnecessary to say a word in its praise, 
 for the verdict has already been passed upon it by 
 the most competent judges, and " Mackenzie on the 
 Eye" has justly obtained a reputation which it is 
 no figure of speech to call world-wide. — British and 
 Foreign Medico- Chirurgical Review. 
 
 This new edition of Dr. Mackenzie's celebrated 
 treatise on diseases of the eye, is truly a miracle of 
 industry and learning. We need scarcely say that 
 he has entirely exhausted the subject of his specialty. 
 — Dublin Quarterly Journal. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 23 
 
 MILLER (JAMES), F. R. S. E. f 
 
 Professor of Surgery in the University of Edinburgh, &c. 
 
 PRINCIPLES OF SURGERY. Fourth American, from the third and revised 
 
 Edinburgh edition. In one large and very beautiful volume, leather, of 700 pages, with two 
 
 hundred and forty exquisite illustrations on wood. {Just Issued, 1856.) $3 75. 
 
 The extended reputation enjoyed by this work will be fully maintained by the present edition. 
 Thoroughly revised by the author, it will be found a clear and compendious exposition of surgical 
 science in its most advanced condition. 
 
 In connection with the recently issued third edition of the author's "Practice of Surgery," it 
 forms a very complete system of Surgery in all its branches. 
 
 The work of Mr. Miller is too well and too favor- 
 ably known among us, as one of our best text-books, 
 to render any further notice of it necessary than the 
 announcement of a new edition, the fourth in our 
 country, a proof of its extensive circulation among 
 ns. As a concise and reliable exposition of the sci- 
 ence of modern surgery, it stands deservedly high — 
 we know not its superior. — Boston Med. and Surg. 
 Journal. 
 
 It presents the most satisfactory exposition of the 
 modern doctrines of the principles of surgery to be 
 found in any volume in any language. — N. Y. Journal 
 of Medicine. 
 
 The work takes rank with Watson's Practice of 
 Physic ; it certainly does not fall behind that great 
 work in soundness of principle or depth of reason- 
 ing and research. No physician who values his re- 
 
 BY THE SAME AUTHOR. (Now Ready.) 
 
 THE PRACTICE OF SURGERY. Fourth American from the last Edin- 
 
 burgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four 
 engravings on wood. In one large octavo volume, leather, of nearly 700 pages. $3 75. 
 
 putation, or seeks the interests of his clients, can 
 acquit himself before his God and the world without 
 making himself familiar with the sound and philo- 
 sophical views developed in the foregoing book. — 
 New Orleans Med. and Surg. Journal. 
 
 Without doubt the ablest exposition of the prin- 
 ciples of that branch of the healing art in any lan- 
 guage. This opinion, deliberately formed after a 
 careful study of the first edition, we have had no 
 cause to change on examining the second. This 
 edition has undergone thorough revision by the au- 
 thor; many expressions have been modified, and a 
 mass of new matter introduced. The book is got up 
 in the finest style, and is an evidence of the progress 
 of typography in our country. — Charleston Medical 
 Journal and Review. 
 
 No encomium of ours could add to the popularity 
 of Miller's Surgery. Its reputation in this country 
 is unsurpassed by that of any other work, and, when 
 taken in connection with the author's Principles of 
 Surgery, constitutes a whole, without reference to 
 which no conscientious surgeon would be willing 
 to practice his art. The additions, by Dr. Sargent, 
 have materially enhanced the value of the work.— 
 Southern Medical and Surgical Journal. 
 
 It is seldom\that two volumes have ever made so 
 profound an impression in so short a time as the 
 " Principles" arid the " Practice" of Surgery by 
 Mr. Miller — or so richly merited the reputation they 
 have acquired. The author is an eminently sensi- 
 ble, practical, and well-informed man, who knows 
 exactly what he is talking about and exactly how to 
 talk it.— Kentucky Medical Recorder. 
 
 By the almost unanimous voice of the profession, 
 
 his works, both on the principles and practice of 
 surgery have been assigned the highest rank. If we 
 were limited to but one work on surgery, that one 
 should be Miller's, as we regard it as superior to all 
 others. — St. Louis Med. and Surg. Journal. 
 
 The author, distinguished alike as a practitioner 
 and writer, has in this and his " Principles," pre- 
 sented to the profession one of the most complete and 
 reliable systems of Surgery extant. His style of 
 writing is original, impressive, and engaging, ener- 
 getic, concise, and lucid. Few have the faculty of 
 condensing so much in small space, and at the same 
 time so persistently holding the attention ; indeed, 
 he appears to make the very process of condensation 
 a means of eliminating attractions. Whether as a 
 text-book for students or a book of reference for 
 practitioners, it cannot be too strongly recommend- 
 ed.— Southern Journal of Med. and Phys. Sciences. 
 
 MONTGOMERY (W. F.), M. D., M. R. I. A., &c, 
 
 Professor of Midwifery in the King and Queen's College of Physicians in Ireland, &c. 
 
 AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 With some other Papers on Subjects connected with Midwifery. From the second and enlarged 
 English edition. With two exquisite colored plates, and numerous wood-cuts. In one very 
 handsome octavo volume, extra cloth, of nearly 600 pages. {Just Issued, 1857.) $3 75. 
 The present edition of this classical volume is fairly entitled to be regarded as anew work, every 
 sentence having been carefully rewritten, and the whole increased to more than double the original 
 size. The title of the work scarcely does justice to the extent and importance of the topics 
 brought under consideration, embracing, with the exception of the operative procedures of mid- 
 wifery, almost everything connected with obstetries, either directly or incidentally ; and there are 
 few physicians who will not find in its pages much that will prove of great interest and value in 
 their daily practice. The special Essays on the Period of Human Gestation, the Signs of Delivery, 
 and the Spontaneous Amputation and other Lesions of the Foetus in Utero present topics of the 
 highest interest fully treated and beautifully illustrated. 
 
 In every point of mechanical execution the work will be found one of the handsomest yet issued 
 from the American press. 
 
 A book unusually rich in practical suggestions. — 
 Am. Journal Med. Sciences, Jan. 1857. 
 
 These several subjects so interesting in them- 
 selves, and so important, every one of them, to the 
 most delicate and precious of social relations, con- 
 trolling often the honor and domestic peace of a 
 family, the legitimacy of offspring, or the life of its 
 parent, are all treated with an elegance of diction, 
 fulness of illustrations, acutenessand justice of rea- 
 soning, unparalleled in obstetrics, and unsurpassed in 
 medicine. The reader's interest can never flag, so 
 fresh, and vigorous, and classical is our author's 
 style; and one forgets, in the renewed charm of 
 every page, that it, and every line, and every word 
 
 has been weighed and reweighed through years of 
 preparation ; that this is of all others the book of 
 Obstetric Law, on each of its several topics ; on all 
 points connected with pregnancy, to be everywhere 
 received as a manual of special jurisprudence ? at 
 once announcing fact, affording argument, establish- 
 ing precedent, and governing alike the juryman, ad- 
 vocate, and judge. It is not merely in its legal re- 
 lations that we find this work so interesting. Hardly 
 a page but that has its hints or facts important to 
 the general practitioner ; and not a chapter without 
 especial matter for the anatomist, physiologist, or 
 pathologist. — N. A. Med.-Chir. Review, March, 
 1857. 
 
24 
 
 BLANCHARD & LEA'S MEDICAL 
 
 NEILL (JOHN), M. D., 
 
 Surgeon to the Pennsylvania Hospital, &c; and 
 
 RANiniS ftlJRNIPY SMITH. MP 
 
 FRANCIS GORNEY SMITH, M.D.. 
 
 Professor of Institutes of Medicine in the Pennsylvania Medical College. 
 
 AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES 
 
 OF MEDICAL SCIENCE ; for the Use and Examination of Students. A new edition, revised 
 and improved. In one very large and handsomely printed royal 12mo. volume, of about one 
 thousand pages, with 374 wood-cuts. Strongly bound in leather, with raised bands. $3 00. 
 The very flattering reception which has been accorded to this work, and the high estimate placed 
 upon it by the profession, as evinced by the constant and increasing demand which has rapidly ex- 
 hausted two large editions, have stimulated the authors to render the volume in its present revision 
 more worthy of the success which has attended it. It has accordingly been thoroughly examined, 
 and such errors as had on former occasions escaped observation have been corrected, and whatever 
 additions were necessary to maintain it on a level with the advance of science have been introduced. 
 The extended series of illustrations has been still further increased and much improved, while, by 
 a slight enlargement of the page, these various additions have been' incorporated without increasing 
 the bulk of the volume. 
 
 The work is, therefore, again presented as eminently worthy of the favor with which it has hitherto 
 been received. As a book for daily reference by the student requiring a guide to his more elaborate 
 text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate 
 examination, or as a source from which the practitioners of older date may easily and cheaply acquire 
 a knowledge of the changes and improvement in professional science, its reputation is permanently 
 established. 
 
 The best work of the kind with which we are 
 acquainted. — Med. Examiner. 
 
 Having made free use of this volume in our ex- 
 aminations of pupils, we can speak from experi- 
 ence in recommending it as 'an admirable compend 
 for students, and as especially useful to preceptors 
 who examine their pupils. It will save the teacher 
 much labor by enabling him readily to recall all of 
 the points upon which his pupils should be ex- 
 amined. A work of this Bort should be in the hands 
 of every one who takes pupils into his office with a 
 view of examining them; and this is unquestionably 
 thebestof its class. — Transylvania Med. Journal. 
 
 In the rapid course of lectures, where work for 
 
 the students is heavy, and review necessary for an 
 examination, a compend is not only valuable, but 
 it is almost a sine qua non. The one before us is, 
 in most of th.e divisions, the most unexceptionable 
 of all books of the kind that we know of. Th* 
 newest and soundest doctrines and the latest im- 
 provements and discoveries are explicitly, though 
 concisely, laid before the student. There is a class 
 to whom we very sincerely commend this cheap book 
 as worth its weight in silver — that class is the gradu- 
 ates 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. — The Stetho- 
 scope 
 
 NEILL (JOHN), M. D., 
 
 Professor of Surgery in the Pennsylvania Medical College, &c. 
 
 OUTLINES OF THE VEINS AND LYMPHATICS. With handsome colored 
 
 plates. 1 vol., cloth. $1 25. 
 
 OUTLINES OF THE NERVES. With handsome plates. 1 vol., cloth. $1 25. 
 
 NELIGAN (J. MOORE), M. D., M. R. I. A., &.C. 
 
 (A splendid work. Just Issued.) 
 
 ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra 
 
 cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of 
 
 disease. $4 50. 
 
 This beautiful volume is intended as a complete and accurate representation of all the varieties 
 of Diseases of the Skin. While it can be consulted in conjunction with any work on Practice, it has 
 especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the 
 profession some years since. The publishers feel justified in saying that few more beautifully exe- 
 cuted plates have ever been presented to the profession of this country. 
 
 A compend which will very much aid the practi- 
 tioner in this difficult branch of diagnosis. Taken 
 with the beautiful plates of the Atlas, which are 
 remarkable for their accuracy and beauty of. color- 
 ing, it constitutes a very valuable addition to the 
 library of a practical man.— Buffalo Med. Journal, 
 Sept. 1856. 
 
 Nothing is often more difficult than the diagnosis 
 of disease of the skin ; and hitherto, the only works 
 containing illustrations have been at rather incon- 
 venient prices — prices, indeed, that prevented gene- 
 ral use. The work before us will supply a want 
 Ion? felt, and minister to a more perfect acquaintance 
 with the nature and treatment of a very frequent 
 and troublesome form of disease. — Ohio Med. and 
 Surg. Journal, July, 1856. 
 
 Neligan's AtlaB of Cutaneous Diseases supplies a 
 
 long existent desideratum much felt by the largest 
 class of our profession. It presents, in quarto size, 
 16 plates, each containing from 3 to 6 figures, and 
 forming in all a total of 90 distinct representations 
 of the different species of skin affections, grouped 
 together in genera or families. The illustrations 
 have been taken from nature, and have been copied 
 with such fidelity that they present a striking picture 
 of life; in which the reduced scale aptly serves to 
 give, at a coup d'czil, the remarkable peculiarities 
 of each individual variety. And while thus the dis 
 ease is rendered more definable, there is yet no loss 
 of proportion incurred by the necessary concentra- 
 tion. Each figure is highly colored, and so truthful 
 has the artist been that the most fastid ous observer 
 could not justly take exception to the correctness of 
 the execution of the pictures under his scrutiny. — 
 Montreal Med. Chronicle. 
 
 BY THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Second 
 
 American edition. In one neat royal 12mo. volume, extra cloth, of 334 pages. $1 00. 
 The two volumes will be sent by mail on receipt of Five Dollars. 
 
 OWEN ON THE DIFFERENT FORMS OF 
 THE SKELETON, AND OF THE TEETH. 
 
 One vol. royal 12mo., extra cloth, with numerous 
 illustrations. (Just Issued.) $1 25. 
 
AN 
 
 ENTIFIO PUBLICATIONS, 
 
 25 
 
 (Now Complete.) 
 
 PEREIRA (JONATHAN), M. D. f F. R. S., AND L. S. 
 
 THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. 
 
 Third American edition, enlarged and improved by the author; including Notices of most of the 
 Medicinal Substances in use in the civilized world, and forming an Encyclopaedia of Materia 
 Medica. Edited, with Additions, bv Joseph Carson, M. D., Professor of Materia Medica and 
 Pharmacy in the University of Pennsylvania. In two very large octavo volumes of 2100 pages, 
 on small type, with about 500 illustrations on stone and wood, strongly bound in leather, with 
 raised bands. $9 00. 
 
 Gentlemen who have the first volume are recommended to complete their copies without delay. 
 The first volume will no longer be sold separate. Price of Vol. II. $5 00. 
 
 The third edition of his " Elements of Materia 
 Medica, although completed under the supervision of 
 others, is by far the most elaborate treatise in the 
 English language, and will, while medical literature 
 is cherished, continue a monument alike honorable 
 to his genius, as to his learning and industry.— 
 American Journal of Pharmacy. 
 
 Our own opinion of its merits is that of its editors, 
 and also that of the whole profession, both of this 
 and foreign countries— namely, " that in copious- 
 ness of details, in extent, variety, and accuracy of 
 information, and in lucid explanation of difficult 
 and recondite subjects, it surpasses all other works 
 on Materia Medica hitherto published." We can- 
 not close this notice without alluding to the special 
 additions of the American editor, which pertain to 
 the prominent vegetable productions of this country, 
 
 and to the directions of the United States Pharma- 
 copoeia, in connection with all fhe articles contained 
 in the volume which are referred to by it. The il- 
 lustrations have been increased, and this edition by 
 Dr. Carson cannot well be regarded in any other 
 light than that of a treasure which should be found 
 in the library of every physician. — New York Journ- 
 al of Medical and Collateral Science. 
 
 The work, in its present shape, forms the most 
 comprehensive and complete treatise on materia 
 medica extant in the English language. The ac- 
 counts of the physiological and therapeutic effects 
 of remedies are given with great clearness and ac- 
 curacy, and in a manner calculated to interest as 
 well as instruct the reader. — Edinburgh Medical 
 and Surgical Journal. 
 
 PEASLEE (E. R.), M. D., 
 
 Professor of Physiology and General Pathology in the New York Medical College. 
 
 HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology; 
 for the use of Medical Students. With four hundred and thirty- four illustrations. In one hand- 
 some octavo volume, of over 600 pages. (Now Ready.) $3 75. 
 
 The rapid advances made of late years in our knowledge of the structure and functions of the 
 elements which constitute the human body, have rendered the subject of Histology of the highest 
 importance to all who regard medicine as a science. At the same time, the vast body of facts 
 covered by Physiology has caused our text-books on that subject to be necessarily restricted in 
 their treatment of the portions devoted to Histology. A want has, therefore, arisen of a work de- 
 voted especially to the minute anatomy of the body, giving a complete and detailed account of the 
 structure of the various tissues, as well as the solids and fluids, in all the different organs— their 
 functions in health, and their changes in disease. In undertaking this task, the author has endea- 
 vored to present his extensive subject in the manner most likely to interest and benefit the physician, 
 confident that in these details will be found the basis of true medical science. The very large 
 number of illustrations introduced throughout, serves amply to elucidate the text, while the typo- 
 graphy of the Volume will in every respect be found of the handsomest description. 
 It embraces a library upon the topics discussed 
 
 within itself, and is just what the teacher and learner 
 need. Another advantage, by no means to be over- 
 looked, everything of real value in the wide rarge 
 which it embraces, is with great skill compressed 
 into an octavo volume of but little more than six 
 hundred pages. We have not only the whole sub- 
 ject of Histology, interesting in itself, ably and fully 
 discussed, but what is of infinitely greater interest 
 to the student, because of greater practical value, 
 are its relations to Anatomy, Physiology, and Pa- 
 thology, which are here fully and satisfactorily set 
 forth. These great supporting branches of practical 
 medicine are thus linked together, and while estab- 
 lishing and illustrating each other, are interwoven 
 
 into a harmonious whole. We commend the work 
 to students and physicians generally. — Nashville 
 Journ. of Med. and Surgery, Dec. 1857. 
 
 It far surpasses our expectation. We never con- 
 ceived the possibility of compressing so much valu- 
 able information into so compact a form. We will 
 not consume space with commendations. We re- 
 ceive this contribution to physiological science, 
 " JNot with vain thanks, but with acceptance boun- 
 teous." We have already paid it the practical 
 compliment of making abundant use of it in the 
 preparation of our lectures, and also of recommend- 
 ing its further perusal most cordially to our alumni ; 
 a recommendation which we now extend to our 
 readers. — Memphis Med. Recorder, Jan. 1$53. 
 
 PIRRIE (WILLIAM), F. R. S. E., 
 
 Professor of Surgery in the University of Aberdeen. 
 
 THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John 
 
 Neill M D Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania 
 
 Hospital, &c. In one very handsome octavo volume, leather, of 780 pages, with 316 illustrations. 
 
 $3 75. 
 
 We know of no other surgical work of a reason- 
 able size, wherein there is so much theory and prac- 
 tice, or where subjects are more soundly or clearly 
 taught. — The Stethoscope. 
 
 There is scarcely a disease of the bones or soft 
 j>arts, fracture, or dislocation, that is not illustrated 
 by accurate wood-engravings. Then, again, every 
 instrument employed by the surgeon is thus repre- 
 sented. These engravings are not only correct, but 
 really beautiful, showing the astonishing degree of 
 perfection to which the art of wood-engraving has 
 
 arrived. Prof. Pirrie, in the work before us, has 
 elaborately discussed the principles of surgery, and 
 a safe and effectual practice predicated upon them. 
 Perhaps no work upon this subject heretofore issued 
 is so full upon the science of the art of surgery. — 
 Nashville Journal of Medicine and Surgery. 
 
 One of the best treatises on surgery in the English 
 language. — Canada Med. Journal. 
 
 Our impression is, that, as a manual for students, 
 Pirrie's is the best work extant. — Western Med. and 
 Surg. Journal. 
 
 PARKER (LANGSTON), 
 
 Surgeon to the Queen's Hospital, Birmingham. 
 
 THE MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI- 
 
 MARY AND SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphi- 
 lis bv a safe and successful method. With numerous Cases, Formulae, and Clinical Observa- 
 tions. From the Third and entirely rewritten London edition. In one neat octavo volume, 
 extra cloth, of 316 pages. $1 75. 
 
20 
 
 BLANCHARD & LEA'S MEDICAL 
 
 PARRISH (EDWARD), 
 
 Lecturer on Practical Pharmacy and Materia Medica in the Pennsylvania Academy of Medicine, &c. 
 
 AN INTRODUCTION TO PRACTICAL PHARMACY. Designed as a Text- 
 
 Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many For- 
 mulae and Prescriptions. In one handsome octavo volume, extra cloth, of 550 pages, with 243 
 Illustrations. $2 75. 
 
 A careful examination of this work enables us to 
 speak of it in the highest terms, as being the best 
 treatise on practical pharmacy ■with which we are 
 acquainted, and an invaluable vade-mecum, not only 
 to the apothecary and to those practitioners who are 
 accustomed to prepare their own medicines, but to 
 every medical man and medical student. Through- 
 out the work are interspersed valuable tables, useful 
 formula?, and practical hints, and the whole is illus- 
 trated by a large number of excellent wood-engrav- 
 ings. — Boston Med. and Surg. Journal. 
 
 This is altogether one of the most useful books we 
 have seen. It is just what we have long felt to be 
 needed by apothecaries, students, and practitioners 
 of medicine, most of whom in this country have to 
 put up their own prescriptions. It bears, upon every 
 page, the impress of practical knowledge, conveyed 
 in a plain common sense manner, and adapted to the 
 comprehension of all who may read it. No detail 
 has been omitted, however trivial it may seem, al- 
 though really important to the dispenser of medicine. 
 — Southern Med. and Surg. Journal. 
 
 To both the country practitioner and the city apo- 
 thecary this work of Mr. Parrish is a godsend. A 
 careful study of its contents will give the young 
 graduate a familiarity with the value and mode of 
 administering his prescriptions, which will be of as 
 much use to his patient as to himself. — Va. Med. 
 Journal. 
 
 Mr. Parrish has rendered a very acceptable service 
 to the practitioner and student, by furnishing this 
 book, which contains the leading facts and principles 
 of the science of Pharmacy, conveniently arranged 
 for study, and with special reference to those features 
 of the subject which possess an especial practical in- 
 terest to the physician. It furnishes the student, at 
 the commencement of his studies, with that infor- 
 mation which is of the greatest importance in ini- 
 tiating him into the domain of Chemistry and Materia 
 
 Medica; it familiarizes him with the compounding 
 of drugs, and supplies those minutiae which but few 
 practitioners can impart. The junior practitioner 
 will, also, find this volume replete with instruction. 
 — Charleston Med. Journal and Review, Mar. 1856. 
 
 There is no useful information in the details of the 
 apothecary's or country physician's office conducted 
 according to science that is omitted. The young 
 physician will find it an encyclopedia of indispensa- 
 ble medical knowledge, from the purchase of a spa- 
 tula to the compounding of the most learned pre- 
 scriptions. The work is by theablest pharmaceutist 
 in the United States, and must meet with an im- 
 mense sale. — Nashville Journal of Medicine, April, 
 1856. 
 
 We are glad to receive this excellent work. It 
 will supply a want long felt by the profession, and 
 especially by the student of Pharmacy. A large 
 majority of physicians are obliged to compound 
 their own rrtedicines, and to them a work of this 
 kind is indispensable. — N. 0. Medical and Surgical 
 Journal . 
 
 We cannot say but that this volume is one of the 
 most welcome and appropriate which has for a long 
 time been issued from the press. It is a work which 
 we doubt not will at once secure an extensive cir- 
 culation, as it is designed not only for the druggist 
 and pharmaceutist, but also for the great body of 
 practitioners throughout the country, who not only 
 have to prescribe medicines, but in the majority of 
 instances have to rely upon their own resources — 
 whatever these may be — not only to compound, but 
 also to manufacture the remedies they are called 
 upon to administer. The author has not mistaken 
 the idea in writing this volume, as it is alike useful 
 and invaluable to those engaged in the active pur- 
 suits of the profession, and to those preparing to en- 
 ter upon the field of professional labors. — American 
 Lancet, March 24, 1856. 
 
 R1CORD (P.), M. D., 
 A TREATISE ON THE VENEREAL DISEASE. By John Hunter, F. R. S 
 
 With copious Additions, by Ph. Ricord, M. D. Edited, with Notes, by Freeman J. Bumstead 
 M. D. In one handsome octavo volume, extra cloth, of 520 pages, with plates. $3 25. 
 Every one will recognize the attractiveness and 
 
 value which this work derives from thus presenting 
 
 the opinions of these two masters side by side. But, 
 
 it must be admitted, what has made the fortune of 
 
 the book, is the fact that it contains the " most com- 
 plete embodiment of the veritable doctrines of the 
 
 Hopital du Midi," which has ever been made public. 
 
 The doctrinal ideas of M. Ricord, ideas which, if not 
 
 universally adopted, are incontestably dominant, have 
 
 heretofore only been interpreted by more or less skilful 
 
 ILLUSTRATIONS OF SYPHILITIC DISEASE. 
 Translated by Thomas F. Betton, M.D. With 
 fifty large quarto colored plates. In one large 
 quarto volume, extra cloth. $15 00. 
 
 secretaries, sometimes accredited and sometimes not. 
 In the notes to Hunter, the master substitutes him- 
 self for his interpreters, and gives his original thoughts 
 to the world in a lucid and perfectly intelligible man- 
 ner. In conclusion we can say that this is incon- 
 testably the best treatise on syphilis with which we 
 are acquainted, and, as we do not often employ the 
 phrase, we may be excused for expressing the hope 
 that it may find a place in the library of every phy- 
 sician. — Virginia Med. and Surg. Journal. 
 
 BY THE SAME AUTHOR. 
 
 LETTERS ON SYPHILIS, addressed to the Chiel 
 Editor of the Union Medicale. Translated by W. 
 P. Lattimore, M.D. In one neat octavo vol- 
 ume, of 270 pages, extra cloth. $2 00. 
 
 RIGBY (EDWARD), M. D., 
 
 Senior Physician to the General Lying-in Hospital, &c. 
 
 A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. 
 Second American Edition. One volume octavo, extra cloth, 422 pages. $2 50. 
 
 by the same author. (Note Ready, 1857.) 
 
 ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. 
 
 In one neat royal 12mo. volume, extra cloth, of about 250 pages. $1 00. 
 
 The aim of the author has been throughout to present sound practical views of the important 
 subjects under consideration ; and without entering into theoretical disputations and disquisitions to 
 embody the results of his long and extended experience in such a condensed form as would be 
 easily accessible to the practitioner. 
 
 ROYLE'S MATERIA MEDICA AND THERAPEUTICS; including the 
 
 Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. 
 With many new medicines. Edited by Joseph Carson, M. D. With ninety-eight illustrations. 
 In one large octavo volume, extra cloth, of about 700 pages. $3 00. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 27 
 
 RAMSBOTHAM (FRANCIS H.), M.D. 
 THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND 
 
 SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly 
 revised by the Author. With Additions by W. V. Keating, M. D. In one large and handsome 
 imperial octavo volume, of 650 pages, strongly bound in leather, with raised bands; with sixty- 
 four beautiful Plates, and numerous Wood-cuts in the text, containing in all nearly two hundred 
 large and beautiful figures. (Lately Issued, 1856.) $5 00. 
 
 In calling the attention of the profession to the new edition of this standard work, the publishers 
 would remark that no efforts have been spared to secure for it a continuance and extension of the 
 remarkable favor with which it has been received. The last London issue, which was considera- 
 bly enlarged, has received a further revision from the author, especially for this country. Its pas- . 
 sage through the press here has been supervised by Dr. Keating, who has made numerous addi- / 
 tions with a view of presenting more fully whatever was necessary to adapt it thoroughly to 
 American modes of practice. In its mechanical execution, a like superiority over former editions 
 will be found. 
 
 From Prof. Hodge, of the University of Pa. 
 To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being 
 the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout 
 our country. 
 
 The publishers have shown their appreciation of 
 the merits of this work and secured its success by 
 the truly elegant style in which they have brought 
 it out, excelling themselves in its production, espe- 
 cially in its plates. It is dedicated to Prof. Meigs, 
 and has the emphatic endorsement of Prof. Hodge, 
 as the best exponent of British Midwifery. We 
 know of no text-book which deserves in all respects 
 to be more highly recommended to students, and we 
 could wish to see'it in the hands of every practitioner, 
 for they will find it invaluable for reference. — Med . 
 Gazette. * 
 
 But once in a long time some brilliant genius rears 
 his head above the horizon of science, and illumi- 
 nates and purifies every department that he investi- 
 gates ; and his works become types, by which innu- 
 merable imitators model their feeble productions. 
 Such a genius we find in the younger Ramsbotham, 
 and such a type we find in the work now before us. 
 The binding, paper, type, the engravings and wood- 
 cuts are all so excellent as to make this book one of 
 the finest specimens of the art of printing that have 
 given such a world-wide reputation to its enter- 
 prising and liberal publishers. We welcome Rams- 
 botham' s Principles and Practice of Obstetric Medi- 
 
 cine and Surgery to our library, and confidently 
 recommend it to our readers, with the assurance 
 that it will not disappoint their most sanguine ex- 
 pectations. — Western Lancet. 
 
 It is unnecessary to say anything in regard to the 
 utility of this work. It is already appreciated in our 
 country for the value of the matter, the clearness of 
 its style, and the fulness of its illustrations. To the 
 physician's library it is indispensable, while to the 
 student as a text-book, from which to extract the 
 material for laying the foundation of an education on 
 obstetrical science, it has no superior. — Ohio Med. 
 and Surg. Journal. 
 
 We will only add that the student will learn from 
 it all he need to know, and the practitioner will find 
 it, as a book of reference, surpassed by none other. — 
 Stethoscope. 
 
 The character and merits of Dr. Rarnsbotham's 
 work are so well known and thoroughly established, 
 that comment is unnecessary and praise superfluous. 
 The illustrations, which are numerous and accurate, 
 are executed in the highest style of art. We cannot 
 too highly recommend the work to our readers. — St. 
 Louis Med. and Surg. Journal. 
 
 ROKITANSKY (CARL), M.D., 
 Curator of the Imperial Pathological Museum, and Professor at the University of Vienna, &c. 
 
 A MANUAL OF PATHOLOGICAL ANATOMY. Four volumes, octavo, 
 
 bound in two, extra cloth, of about 1200 pages. Translated by W. E. Swaine, Edward Sieve- 
 king; C. H. Moore, and G. E. Day. (Just Issued.) $5 50 
 To render this large and important work more easy of reference, and at the same time less cum- 
 brous and costly, the four volumes have been arranged in two, retaining, however, the separate 
 paging, &c. 
 
 The publishers feel much pleasure in presenting to the profession of the United States the great 
 work of Prof. Rokitansky, which is universally referred to as the standard of authority by the pa- 
 thologists of all nations. Under the auspices of the Sydenham Society of London, the combined 
 labor of four translators has at length overcome the almost insuperable difficulties which have so 
 long prevented the appearance of the work in an English dress. To a work so widely known, 
 eulogy is unnecessary, and the publishers would merely state that it is said to contain the results 
 of not less than thirty thousand post-mortem examinations made by the author, diligently com- 
 pared, generalized, and wrought into one complete and harmonious system. 
 
 The profession is too well acquainted with the re- 
 putation of Rokitansky's work to need our assur- 
 ance that this is one of the most profound, thorough, 
 and valuable books ever issued from the medical 
 press. It is sui generis, and has no standard of com- 
 parison. It is only necessary to announce that it is 
 issued in a form as cheap as is compatible with its 
 size and preservation, and its sale follows as a 
 matter of course. No library can be called com- 
 plete without it.— Buffalo Med. Journal. 
 
 An attempt to give our readers any adequate idea 
 of the vast amount of instruction accumulated in 
 these volumes, would be feeble and hopeless. The 
 effort of the distinguished author to concentrate 
 in a small space his great fund of knowledge, has 
 
 so charged his text with valuable truths, that any 
 attempt of a reviewer to epitomize is at once para- 
 lyzed, and must end in a failure. — Western Lancet. 
 
 As this is the highest source of knowledge upon 
 the important subject of which it treats, no real 
 student can afford to be without it. The American 
 publishers have entitled themselves to the thanks of 
 the profession of their country, for this timeous and 
 beautiful edition. — Nashville Journal of Medicine. 
 
 As a book of reference, therefore, this work must 
 prove of inestimable value, and we cannot too highly 
 recommend it to the profession.-— Charleston Med. 
 Journal and Review, Jan. 1856. 
 
 This book is a necessity to every practitioner. — 
 Am. Med. Monthly. 
 
 SCHOEDLER (FRIEDRICH), PH.D., 
 
 Professor of the Natural Sciences at Worms, &c. 
 
 THE BOOK OF NATURE; an Elementary Introduction to the Sciences of 
 
 Physics, Astronomy, Chemistry, Mineralogy, Geology, Botany, Zoology, and Physiology. First 
 American edition, with a Glossary and other Additions and Improvements; from the second 
 English edition. Translated from the sixth German edition, by Henry Mkdlock, F. C. S., &c. 
 In one volume, small octavo, extra cloth, pp. 692, with 679 illustrations. $1 80. 
 
28 
 
 BLANCHARD & LEA'S MEDICAL 
 
 SMITH (HENRY H.), M. D., 
 
 Professor of Surgery in the University of Pennsylvania, &c. 
 
 MINOR SURGERY; or, Hints on the E very-day Duties of the Surgeon. Illus- 
 trated by two hundred and forty-seven illustrations. Third and enlarged edition. In oneghand- 
 some royal 12mo. volume, pp. 456. In leather, $2 25; extra cloth, $2 00. 
 
 A work such as the present is therefore highly 
 
 And a capital little book it is. . . Minor Surgery, 
 we repeat, is really Major Surgery, and anything 
 which teaches it is worth having. So we cordially 
 recommend this little book of Dr. Smith's.— Med. - 
 Chir. Review. 
 
 This beautiful little work has been compiled with 
 a view to the wants of the profession in the matter 
 of bandaging, &c.,and well and ably has the author 
 performed his labors. Well adapted to give the 
 requisite information on the subjects of which it 
 treats. — Medical Examiner. 
 
 The directions are plain, and illustrated through- 
 out with clear engravings. — London Lancet. 
 
 One of the best works they can consult on the 
 subject of which it treats. — Southern Journal of 
 Medicine and Pharmacy. 
 
 BY THE SAME AUTHOR, AND 
 
 HORNER (WILLIAM E.), M.D., 
 Late Professor of Anatomy in the University of Pennsylvania. 
 
 AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. 
 
 In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful 
 figures. $3 00. 
 
 useful to the student, and we commend this one 
 to their attention. — American Journal of Medical 
 Sciences. 
 
 No operator, however eminent, need hesitate to 
 consult this unpretending yet excellentbook. Those 
 who are young in the business would find Dr. Smith's 
 treatise a necessary companion, after once under- 
 standing its true character. — Boston Med. and Surg. 
 Journal. 
 
 No young practitioner should be without this little 
 volume ; and we venture to assert, that it may be 
 consulted by the senior members of the profession 
 with more real benefit, than the more voluminous 
 works. — Western Lancet. 
 
 These figures are well selected, and present a 
 complete and accurate representation of that won- 
 derful fabric, the human body. The plan of this 
 Atlas, which renders it so peculiarly convenient 
 for the student, and its superb artistical execution, 
 have been already pointed out. We must congratu- 
 
 late the student upon the completion of this Atlas, 
 as it is the most convenient work of the kind that 
 has yet appeared ; and we must add, the very beau- 
 tiful manner in which it is " got up" is so creditable 
 to the country as to be flattering to our national 
 pride. — American Medical Journal. 
 
 SARGENT (F. W.), M. D. 
 ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. 
 
 Second edition, enlarged. One handsome royal 12mo. vol., of nearly 400 pages, with 182 wood- 
 cuts. Extra cloth, $1 40; leather, $1 
 
 50. 
 
 This very useful little work has long been a favor- 
 ite with practitioners and students. The recent call 
 for a new edition has induced its author to make 
 numerous important additions. A slight alteration 
 in the size of the page has enabled him to introduce 
 the new matter, to the extent of some fifty pages of 
 the former edition, at the same time that his volume 
 is rendered still more compact than its less compre- 
 hensive predecessor. A double gain in thus effected, 
 which, in a vade-mecum of this kind, is a material 
 improvement. — Am. Medical Journal . 
 
 Sargent's Minor Surgery has always been popular, 
 and deservedly so. It furnishes that knowledge of the 
 most frequently requisite performances of surgical 
 art which cannot be entirely understood by attend- 
 ing clinical lectures. The art of bandaging, which 
 is regularly taught in Europe, is very frequently 
 overlooked by teachers in this country ; the student 
 and junior practitioner, therefore, may often require 
 that knowledge which this little volume so tersely 
 and happily supplies. It is neatly printed and copi- 
 
 ously illustrated by the enterprising publishers, and 
 should be possessed by all who desire to be thorough- 
 ly conversant with the details of this branch of our 
 art. — Charleston Med. Journ. and Review, March, 
 1856. 
 
 A work that has been so long and favorably known 
 to the profession as Dr. Sargent's Minor Surgery, 
 needs no commendation from us. We would remark, 
 however, in this connection, that minor surgery sel- 
 dom gets that attention in our schools that its im- 
 portance deserves. Our larger works are also very 
 defective in their teaching on these small practical 
 points. This little book will supply the void which 
 all must feel who have not studied its pages. — West- 
 ern Lancet, March, 1856. 
 
 We confess our indebtedness to this little volume 
 on many occasions, and can warmly recommend it 
 to our readers, as it is not above the consideration 
 of the oldest and most experienced. — American Lan- 
 cet, March, 1856. 
 
 SKEY'S OPERATIVE SURGERY. In one very 
 handsome octavo volume, extra cloth, of over 650 
 pages, with about one hundred wood-cuts. $3 25. 
 
 STANLEY'S TREATISE ON DISEASES OF 
 THE BONES. In one volume, octavo, extra cloth, 
 286 pages. SI 50. 
 
 SOLLY ON THE HUMAN BRAIN; its Structure, 
 Physiology, and Diseases. From the Second and 
 
 much enlarged London edition. In one octavo 
 volume, extra cloth, of 500 pages, with 120 wood- 
 cuts. $2 00. 
 
 SIMON'S GENERAL PATHOLOGY, as conduc- 
 ive to the Establishment of Rational Principles 
 for the prevention and Cure of Disease. In one 
 neat octavo volume, extra cloth, of 212 pages. 
 $1 25. 
 
 STILLE (ALFRED), M. D. 
 
 PRINCIPLES OF GENERAL AND SPECIAL THERAPEUTICS j In 
 
 handsome octavo. (Preparing.) 
 
 SIBSON (FRANCIS), M.D., 
 
 Physician to St. Mary's Hospital. 
 
 MEDICAL ANATOMY 
 
 Internal Organs in H< 
 To match "Maclise's 
 
 Illustrating the Form, Structure, and Position of the 
 
 Internal Organs in Health and Disease. In large imperial quarto, with splendid colored plates. 
 Surgical Anatomy." Part I. {Preparing.) 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 2!) 
 
 SHARPEY (WILLIAM), M. D., JONES QUAIN, M.D., AND 
 
 RICHARD QUAIN, F. R. S., &c. 
 
 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, leather, of about thirteen hundred pages. Beautifully illustrated with over five hundred 
 engravings on wood. $6 00. 
 
 It is indeed a work calculated to make an era in 
 anatomical study, by placing before the student 
 every department of his science, with a view to 
 the relative importance of each ; and so skilfully 
 have the different parts been interwoven, that no 
 one who makes this work the basis of his studies, 
 will hereafter have any excuse for neglecting or 
 undervaluing any important particulars connected 
 with the structure of the human frame; and 
 whether the bias of his mind lead him in a more 
 especial manner to surgery, physic, or physiology, 
 
 he will find here a work at once so comprehensive 
 and practical as to defend him from exclusiveness 
 on the one hand, and pedantry on the other. — 
 Journal and Retrospect of the Medical Sciences. 
 We have no hesitation in recommending this trea- 
 tise on anatomy as the most complete on that sub- 
 ject in the English language; and the only one, 
 perhaps, in any language, which brings the state 
 of knowledge forward to the most recent disco- 
 veries. — The Edinburgh Med. and Surg. Journal. 
 
 SMITH (W. TYLER), M. D., 
 
 Physician Accoucheur to St. Mary's Hospital, &c. 
 
 ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OF 
 
 OBSTETRICS. In one royal 12mo. volume, extra cloth, of 400 pages. $1 25. 
 
 BY THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON THE PATHOLOGY AND TREATMENT 
 
 OF LEUCORRHCEA. With numerous illustrations. In one very handsome octavo volume, 
 extra cloth, of about 250 pages. $1 50. 
 
 We hail the appearance of this practical and invaluable work, therefore, as a real acquisition to our 
 medical literature. — Medical Gazette. 
 
 TAYLOR (ALFRED S.), M. D., F. R. S., 
 
 Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. 
 
 MEDICAL JURISPRUDENCE. Fourth American, from the fifth improved and 
 enlarged English Edition. With Notes and References to American Decisions, by Edward 
 Hartshorne, M. D. In one large octavo volume, leather, of over seven hundred pages. (Just 
 Issued, 1856.) $3 00. 
 
 This standard work has lately received a very thorough revision at the hands of the author, who 
 has introduced whatever was necessary to render it complete and satisfactory in carrying out the 
 objects in view. The editor has likewise used every exertion to make it equally thorough with 
 regard to all matters relating to the practice of this country. In doing this, he has carefully ex- 
 amined all tha\has appeared on the subject since the publication of the last edition, and has incorpo- 
 rated all the ne\ information thus presented. The work has thus been considerably increased in 
 size, notwithstanding which, it has been kept at its former very moderate price, and in every respect 
 it will be found worthy of a continuance of the remarkable favor which has carried it through so 
 many editions on both sides of the Atlantic. A few notices of the former editions are appended. 
 
 We know of no work on Medical Jurisprudence 
 Which contains in the same space anything like the 
 same amount of valuable matter. — N. Y. Journal of 
 
 Medicine 
 
 No work upon the subject can be put into the 
 hands of students either of law or medicine which 
 will engage them more closely or profitably ; and 
 none eoufd be offered to the busy practitioner of 
 either calling, for the purpose of casual or hasty 
 reference, that would be more likely to afford the aid 
 desired. We therefore recommend it as the best and 
 safest manual for daily use. — American Journal of 
 Medical Sciences. 
 
 This work of Dr. Taylor's is generally acknow- 
 ledged to be one of the ablest extant on the subject 
 of medical jurisprudence. It is certainly one of the 
 most attractive books that we have met with ; sup- 
 plying so much both to interest and instruct, that 
 
 we do not hesitate to affirm that after having once 
 commenced its perusal, few could be prevailed upon 
 to desist before completing it. In the last London 
 edition, all the newly observed and accurately re- 
 corded facts have been inserted, including much that 
 is recent of Chemical, Microscopical, and Patholo- 
 gical research, besides papers on numerous subjects 
 never before published.-C harleston Medical Journal 
 and Review. 
 
 It is not excess of praise to say that the volume 
 before us is the very best treatise extant on Medical 
 Jurisprudence. In saying this, we do not wish to 
 be understood as detracting from the merits of the 
 excellent works of Beck, Ryan, Traill, Guy, and 
 others; but in interest and value we think it must 
 be conceded that Taylor is superior to anything that 
 has preceded it. — N. W. Medical and Surg. Journal. 
 
 BY THE SAME AUTHOR. 
 
 ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND 
 
 MEDICINE. Edited, with Notes and Additions, by R. E. Griffith, M. D. In one large octavo 
 volume, leather, of 688 pages. |3 00 
 
 TANNER (T. H.), M. D., 
 
 Physician to the Hospital for Women, &c. 
 
 A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. 
 
 To which is added The Code of Ethics of the American Medical Association. Second 
 American Edition. In one neat volume, small 12mo. Price in extra cloth, 87$ cents ; flexible 
 style, for the pocket, 80 cents. 
 
 The work is an honor to its writer, and must ob- 
 tain a wide circulation by its intrinsic merit alone. 
 Suited alike to the wants of students and practi- 
 tioners, it has only to be seen, to win for itself a 
 place upon the shelves of every medical library. 
 Nor will it be " shelved" long at a time ; if we mis- 
 take not, it will be found, in the best sense of the 
 
 homely but expressive word, " handy." The style 
 is admirably clear, while it is so sententious as not 
 to burden the memory. The arrangement is, to our 
 mind, unexceptionable. The work, in short, de- 
 serves the heartiest commendation.— B oston Med. 
 and Surg. Journal'. 
 
30 
 
 BLANCHARD & LEA'S MEDICAL 
 
 Now Complete (April, 1857.) 
 TODD (ROBERT BENTLEY), M. D., F. R. S., 
 
 Professor of Physiology in King's College, London; and 
 WILLIAM BOWMAN, F. R. S., 
 
 Demonstrator of Anatomy in King's College, London. 
 
 THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With 
 
 about three hundred large and beautiful illustrations on wood. Complete in one large octavo 
 
 volume, of 950 pages, leather. Price $4 50. 
 
 The very great delay which has occurred in the completion of this work has arisen from the de- 
 sire of the authors to verify by their own examination the various questions and statements pre- 
 sented, thus rendering the work one of peculiar value and authority. By the wideness of its scope 
 and the accuracy of its facts it thus occupies a position of its own, and becomes necessary to all 
 physiological students. 
 
 t^ 3 Gentlemen who have received portions of this work, as published in the " Medical News 
 and Library," can now complete their copies, if immediate application be made. It will be fur- 
 nished as follows, free by mail, in paper covers, with cloth backs. 
 
 Parts I., II., III. (pp. 25 to 552), $2 50. 
 
 Part IV. (pp. 553 to end, with Title, Preface, Contents, &c), $2 00. 
 
 Or, Part IV., Section II. (pp. 725 to end, with Title, Preface, Contents, &c), $1 25. 
 
 A magnificent contribution to British medicine, 
 and the American physician who shall fail to peruse 
 it, will have failed to read one of the most instruc- 
 
 tive books of the nineteenth century. — N. O. Med 
 and Surg. Journal, Sept. 1857. 
 
 It is more concise than Carpenter's Principles, and 
 more modern than the accessible edition of Mailer's 
 Elements; its details are brief, but sufficient; its 
 descriptions vivid ; its illustrations exact and copi- 
 ous ; and its language terse and perspicuous. — 
 Charleston Med. Journal, July, 1857. 
 
 We recommend this work not only for its many 
 original investigations especially into the minute 
 anatomy and physiology of man, but we admire the 
 constant association of anatomy with physiology. 
 The motive power is studied in its connections and 
 adaptations to the machine it is destined to guide, 
 and the student feels constantly impressed with the 
 necessity for an accurate knowledge of the structure 
 of the human body before he can make himself mas- 
 ter of its functions. — Va. Med. Journal, June, 1857. 
 
 We know of no work on the subject of physiology 
 so well adapted to the wants of the medical student. 
 Its completion has been thus long delayed, that the 
 authors might secure accuracy by personal observa- 
 tion. — St. Louis Med. and Surg. Journal, Sept. '57. 
 
 One of the very best books ever issued from any 
 medical press. We think it indispensable to every 
 reading medical man, and it may, with all propriety, 
 and with the utmost advantage be made a text-book 
 by any student who would thoroughly comprehend 
 the groundwork of medicine. — N. O. Med. News, 
 June, 1857. 
 
 Our notice, though it conveys but a very feeble 
 and imperfect idea of the magnitude and importance 
 of the work now under consideration, already tran- 
 scends our limits ; and, with the indulgtnce of our 
 readers, and the hope that they will peruse the book 
 for themselves, as we feel we can with confidence 
 recommend it, we leave it in their hands for them 
 to judge of its merits. — The Northwestern Med. and 
 Surg. Journal, Oct. 1857. 
 
 It has been a far more pleasant task to us to point 
 out its features of remarkable excellence, and to 
 show in how many particulars the results which it 
 embodies of skilful and zealous research do the 
 highest credit to its able and accomplished authors. 
 It would be a serious omission were we not to take 
 special notice of the admirable and copious illustra- 
 tions, the execution of which (by Mr. Vasey) is in 
 the very finest style of wood-engraving. — Brit, and 
 For. Medico-Chir. Revieyo, Jan. 1858. 
 
 TODD (R. B.), M. D., F. R. S., &c. 
 CLINICAL LECTURES ON CERTAIN DISEASES OF THE URINARY 
 
 ORGANS AND ON DROPSIES. In one octavo volume. {Now Ready, 1857.) $1 50. 
 
 The valuable practical nature of Dr. Todd's writings have deservedly rendered them favorites 
 with the profession, and the present volume, embodying the medical aspects of a class of diseases 
 not elsewhere to be found similarly treated, can hardly fail to supply a want long felt by the prac- 
 titioner 
 
 &c, 
 
 WATSON (THOMAS), M 
 LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. 
 
 Third American edition, revised, with Additions, by D. Francis Condie, M. D., author of a 
 
 Treatise on the Diseases of Children," &e 
 large pages, strongly bound with raised bands. 
 To say that it is the very best work on the sub- 
 ject now extant, is but to echo the sentiment of the 
 medical press throughout the country. — N. O. 
 Medical Journal. 
 
 Of the text-books recently republished Watson is 
 very justly the principal favorite. — Holmes's Rep. 
 to Nat. Med. Assoc. 
 
 By universal consent the work ranks among the 
 very best text-books in our language. — Illinois and 
 Indiana Med. Journal. 
 
 Regarded on all hands as one of the very best, if 
 not the very best, systematic treatise on practical 
 medicine extant. — St. Louis Med. Journal. 
 
 In one octavo volume, of nearly eleven hundred 
 
 $3 25. 
 
 Confessedly one of the very best works on the 
 principles and practice of physic in the English or 
 any other language. — Med. Examiner. 
 
 Asa text-book it has no equal ; as a compendium 
 of pathology and practice no superior. — New York 
 Annalist. 
 
 We know of no work better calculated for being 
 placed in the hands of the student, and for a text- 
 book; on every important point the author seems 
 to have posted up his knowledge to the day. — 
 Amer. Med. Journal. 
 
 One of the most practically useful books that 
 ever was presented to the student. — N. Y. Med. 
 Journal. 
 
 WHAT TO OBSERVE 
 AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. 
 
 Published under the authority of the London Society for Medical Observation. A new American, 
 
 from the second and revised London edition. In one very handsome volume, royal 12mo., extra 
 
 cloth. $1 00. 
 
 To the observer who prefers accuracy to blunders I One of the finest aids to a young practitioner we 
 and precision to carelessness, this little book is in- have ever seen. — Peninsular Journal of Medicine. 
 valuable. — N. II. Journal of Medicine. \ 
 
AND SCIENTIFIC PUBLICATIONS 
 
 31 
 
 WILSON (ERASMUS), M.D., F. R. S., 
 
 Lecturer on Anatomy, London. 
 
 A SYSTEM OF HUMAN ANATOMY, General and Special. Fourth Ameri- 
 can, from the last English edition. Edited by Paul B. Goddard, A. M., M. D. With two hun- 
 dred and fifty illustrations. Beautifully printed, in one large octavo volume, leather, of nearly 
 six hundred pages. $3 00. 
 
 In many, if not all the Colleges of the Union, it 
 has become a standard text-book. This, of itself, 
 is sufficiently expressive of its value. A work very 
 desirable to the student; one, the possession of 
 which will greatly facilitate his progress in the 
 study of Practical A natomy .— New York Journal of 
 Medicine. 
 
 Its author ranks with the highest on Anatomy. — 
 Southern Medical and Surgical Journal. 
 
 It offers to the student all the assistance that can 
 be expected from such a work. — Medical Examiner. 
 
 The most complete and convenient manual for the 
 student we possess.— American Journal of Medical 
 Science. 
 
 In every respect, this work as an anatomical 
 guide for the student and practitioner, merits our 
 warmest and most decided praise. — London Medical 
 Gazette. 
 
 BY THE SAME AUTHOR. (Just Issued.) 
 
 THE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third 
 
 American, from the last revised and enlarged English edition. Modified and rearranged, by 
 William Hunt, M. D., Demonstrator of Anatomy in the University of Pennsylvania. In one 
 large and handsome royal 12mo. volume, leather, of 582 pages, with 154 illustrations. $2 00. 
 The modifications and additions which this work has received in passing recently through the 
 author's hands, is sufficiently indicated by the fact that it is enlarged by more than one hundred 
 pages, notwithstanding that it is printed in smaller type, and with a greatly enlarged page. 
 
 It remains only to add, that after a careful exami- 
 nation, we have no hesitation in recommending this 
 work to the notice of those for whom it has been 
 
 ing very superior claims, well calculated to facilitate 
 their studies, and render their labor less irksome, by 
 constantly keeping before them definite objects of 
 interest. — The Lancet. 
 
 expressly written— the students— as a guide possess 
 
 BY the same author. {Now Ready, May, 1857.) 
 
 ON DISEASES OF THE SKIN. Fourth and enlarged American, from the last 
 and improved London edition. In one large octavo volume, of 650 pages, extra cloth, $2 75. 
 This volume in passing for the fourth time through the hands of the author, has received a care- 
 ful revision, and has been greatly enlarged and improved. About one hundred and fifty pages have 
 been added, including new chapters on Classification, on General Pathology, on General Thera- 
 peutics, on Furuncular Eruptions, and on Diseases of the Nails, besides extensive additions through- 
 out the text, wherever they have seemed desirable, either from former omissions or from the pro- 
 gress of science and the increased experience of the author. Appended to the volume will also 
 now be found a collection of Selected Formulae, consisting for the most part of prescriptions of 
 which the author has tested the value. 
 
 The writings of Wilson, upon diseases of the skin, 
 are by far the most scientific and practical that 
 have ever been presented to the medical world on 
 this subject. The present edition is a great improve- 
 ment on all its predecessors. To dwell upon all the 
 great merits and high claims of the work before us, 
 seriatim, would indeed be an agreeable service; it 
 would be a mental homage which we could freely 
 offer, but we should thus occupy an undue amount 
 of space in this Journal. We will, however, look 
 at some of the more salient points with which it 
 abounds, and which make it incomparably superior in 
 excellence to all other treatises on the subject of der- 
 matology. No mere speculative views are allowed 
 
 a place in this volume, which, without a doubt, will , 
 for a very long period, be acknowledged as the chief 
 standard work on dermatology. The principles of 
 an enlightened and rational therapeia are introduced 
 on every appropriate occasion. The general prac- 
 titioner and surgeon who, peradventure, may have 
 for years regarded cutaneous maladies as scarcely 
 worthy their attention, because, forsooth, they are 
 not fatal in their tendency; or who, if they have 
 attempted their cure, have followed the blind guid- 
 ance of empiricism, will almost assuredly be roused 
 to a new and becoming interest in this department 
 of practice, through the inspiring agency of this 
 book. — Am. Jour. Med. Science, Oct. 1857. 
 
 ALSO, JUST READY, 
 
 A SERIES OF PLATES ILLUSTRATING WILSON ON DISEASES OF 
 
 THE SKIN ; consisting of nineteen beautifully executed plates, of which twelve are exquisitely 
 colored, presenting the Normal Anatomy and Pathology of the Skin, and containing accurate re- 
 presentations of about one hundred varieties of disease, most of them the size of nature. Price 
 in cloth $4 25. 
 
 In beauty of drawing and accuracy and finish of coloring these plates will be found superior to 
 anything of the kind as yet issued in this country. 
 
 The plates by which this edition is accompanied I The representations of the various forms of cutane-" 
 
 leave nothing to be desired, so far as excellence of j ous disease are singularly accurate, and the coloring 
 
 delineation and perfect accuracy of illustration are | exceeds almost anything we have met with in point 
 
 concerned. — Medico-Chirurgical Review. of delicacy and finish. — British and Foreign Medical 
 
 Of these plates it is impossible to speak too highly. | Reviev} - 
 
 BY THE SAME AUTHOR. 
 
 ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON 
 
 SYPHILITIC ERUPTIONS. In one small octavo volume, extra cloth, beautifully printed, with 
 four exquisite colored plates, presenting more than thirty varieties of syphilitic eruptions. $2 25. 
 
 BY THE SAME AUTHOR. {Just Issued.) 
 
 HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- 
 tion and Management. Second American, from the fourth London edition. One neat volume, 
 royal 12mo., extra cloth, of about 300 pages, with numerous illustrations. $1 00 ; paper cover, 
 75 cents. 
 
 WILDE (W. R.), 
 
 Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin. 
 
 AURAL SURGERY, AND THE NATURE AND TREATMENT OF DIS- 
 EASES OF THE EAR. In one handsome octavo volume, extra cloth, of 476 pages, with 
 illustrations. $2 80. 
 
32 BLANCHARD & LEA'S MEDICAL PUBLICATIONS. 
 
 WEST (CHARLES), M. D., 
 
 Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for 
 
 Sick Children, &c. 
 
 LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. 
 
 Second American, from the Second and Enlarged London edition. In one volume, octavo, 
 extra cloth, of nearly five hundred pages. $2 00. 
 
 ligation by this able, thorough, and finished work 
 upon a subject which almost daily taxes to the ut- 
 most the skill of the general practitioner. He has 
 with singular felicity threaded his way through all 
 the tortuous labyrinths of the difficult subject he has 
 undertaken to elucidate, and has in many of the 
 darkest corners left a light, which will never be 
 extinguished. — Nashville Medical Journal. 
 
 We take leave of Dr. West with great respect for 
 his attainments, a due appreciation of his acute 
 powers of observation, and a deep sense of obliga- 
 tion for this valuable contribution to our profes- 
 sional literature. His book is undoubtedly in many 
 respects the best we possess on diseases of children. 
 Dublin Quarterly Journal of Medical Science. 
 
 Dr. West has placed the profession under deep ob- 
 
 • BY THE SAME AUTHOR. (Just Isstted.) 
 
 LECTURES ON THE DISEASES OF WOMEN. In two parts. 
 
 Part I. 8vo. cloth, of about 300 pages, comprising the Diseases of the Uterus. SI 60. 
 Part II. (Preparing), will contain Diseases of the Ovaries, and of all the parts, connected 
 
 with the Uterus ; of the Bladder, Vagina, and External Organs. 
 The objoct of the author in this work is to present a complete but succinct treatise on Female 
 Diseases, embodying the results of his experience during the last ten years at St. Bartholomew's 
 and the Midwifery Hospitals, as well as in private practice. The characteristics which have se- 
 cured to his former works so favorable a reception, cannot fail to render the present volume a 
 standard authority on its important subject. To show the general scope of the work, an outline of 
 the Contents of Part I. is subjoined. 
 
 Lectures I, II— Introductory— Symptoms— Examination of Symptoms— Modes of Examina- 
 tions. Lectures III, IV., V — Disorders of Menstruation, Amenorrhoea, Menorrhagia, Dys- 
 menorrhoea. Lectures VI., VII, VIII— Inflammation of the Uterus, Hypertrophy, Acute 
 Inflammation, Chronic Inflammation, Ulceration of the Os Uteri, Cervical Leucorrhoea. Lectures 
 IX., X., XI, XII, XIII— Misplacement of the Uterus, Prolapsus, Anteversion, Retrover- 
 sion, Inversion. Lectures XIV., XV., XVI, XVII— Uterine Tumors and Outgrowths, 
 Mucous, Fibro-cellular, and Glandular Polypi, Mucous Cysts, Fibrinous Polypi, Fibrous Tumors, 
 Fibrous Polypi, Fatty Tumors, Tubercular Diseases. Lectures XVIII, XIX., XX. — Cancer 
 of the Uterus. 
 Part II. will receive an equally extended treatment, rendering the whole an admirable text-book 
 for the student, and a reliable work for reference by the practitioner. 
 
 BY THE SAME AUTHOR. (Just Issued) 
 
 AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER- 
 ATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 00. 
 
 WILLIAMS (C. J. B.), M. D., F. R. S., 
 
 . Professor of Clinical Medicine in University College, London, fee. 
 
 PRINCIPLES OF MEDICINE. An Elementaiy View of the Causes, Nature, 
 
 Treatment, Diagnosis, and Prognosis of Disease ; with brief remarks on Hygienics, or the pre- 
 servation of health. A new American, from the third and revised London edition, la one octavo 
 volume, leather, of about 500 pages. $2 50. (Now Ready, May, 1857.) 
 
 The very recent and thorough revision which this work has enjoyed at the hands of the author 
 has brought it so completely up to the present state of the subject that in reproducing it no additions 
 have been found necessary. ' The success which the work has heretofore met shows that its im- 
 portance has been appreciated, and in its present form it will be found eminently worthy a continu- 
 ance of the same favor, possessing as it does the strongest claims to the attention of the medical 
 student and practitioner, from the admirable manner in which the various inquiries in the different 
 branches of pathology are investigated, combined and generalized by an experienced practical phy- 
 sician, and directly applied to the investigation and treatment of disease. 
 
 recommend it for a text-book, guide, and constant 
 companion to every practitioner and every student 
 who wishes to extricate himself from the well-worn 
 
 We find that the deeply-interesting matter and 
 style of this book have so far fascinated us, that we 
 have unconsciously hung upon its pages, not too 
 long, indeed, for our own profit, but longer than re- 
 viewers can be permitted to indulge. We leave the 
 further analysis to the student and practitioner. Our 
 judgment of the work has already been sufficiently 
 expressed. It is a judgment of almost unqualified 
 praise. The work is not of a controversial, but of 
 a didactic character : and as such we hail it, and 
 
 ruts of empiricism, and to base his practice of medi- 
 cine upon principles. — London Lancet, Dec. 27, 1856. 
 
 A text-book to which no other in our language is 
 comparable. — Charleston Medical Journal. 
 
 No work has ever achieved or maintained a more 
 deserved reputation. — Va. Med. and Surg. Journal. 
 
 WHITEHEAD ON THE CAUSES AND TREAT- I Second American Edition. In one volume, octa- 
 MBNT OF ABORTION AND STERILITY. | vo, extra cloth, pp. 308. $1 75. 
 
 YOUATT (WILLIAM), V. S. 
 THE HORSE. A new edition, with numerous illustrations; together with a 
 
 general history of the Horse ; a Dissertation on the American Trotting Horse ; how Trained and 
 Jockeyed ; an Account of his Remarkable Performances ; and an Essay on the Ass and the Mule. 
 By J. S. Skinner, formerly Assistant Postmaster-General, and Editor of the Turf Register. 
 One large octavo volume, extra cloth. $1 50. 
 
 BY THE SAME AUTHOR. 
 
 THE DOG. Edited by E. J*. Lewis, M. D. With numerous and beautiful 
 
 illustrations- In one very handsome volume, crown Svo., crimson cloth, gilt. $1 25. 
 
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