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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 sometimes 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 contents 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 cther considerations, 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 completion 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 supervene 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, 21 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 well as usual, and had a tolerably good night; but immediately 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 whole 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 wrist; the great toe was drawn far apart from the other toes, which were flexed, and the whole foot was stiffly bent on the ankle. The child was then breathing quietly, and seemed drowsy; but he screamed out the moment he was touched, as if the least disturbance of his limbs gave him pain.

Eight leeches were applied to his temples, and drew much blood, 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 74 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

See Formula No. 2. p. 43.

NECESSITY FOR DEPLETION-CURE.

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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, applicable alike to all cases of spasm of the glottis. Sudden excitement, and especially a fit of crying, are likely to bring on the attack, and since there is a possibility of any one of these attacks proving fatal, the greatest care must be taken in the management of the child to avoid all unnecessary occasions of annoyance or distress.

Although the benefit that accrues from fresh air, or from a change. of air, is often very great, yet it is very important that the child should not be exposed to the cold or wind, for I have seen such exposure followed by a severe attack of dyspnoea, or by the occurrence of general convulsions. The hazard of such an occurrence is greater in proportion to the severity and long continuance of the affection; and, in such cases, the excitability of the spinal cord, and the irritability of the surface, seem sometimes to become as great as they may be observed to be in frogs when narcotized, whom you may then throw into convulsions by merely shaking the table on which they are placed. It is possible that this condition in the infant may be due to a cause not unlike that which produces it in the lower animal. In the latter, it is manifestly due to the influence on the nervous system, of blood impregnated with opium; in the former, a similar influence may be exerted by blood, the proper depuration of which has been prevented by the frequent recurrence of spasm of the glottis.

There is also another reason for caution in exposing the child to cold or wind, namely, that the occurrence of catarrh is almost sure to be followed by an aggravation of the spasmodic affection. On more than one occasion I have seen the supervention of catarrh convert a 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, I 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

Dr. J. H. Kopp, Denkwürdigkeiten in der ärztlichen Praxis, 8vo. vol. i. pp. 77-107. Frankfort, 1830.

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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 together, 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. Schöpf-Merei, 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. Few persons attain to adult age without having experienced 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 affection 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

In his very interesting essay on Spasms and Convulsions of Children, in the Monthly Journal of Medical Science, for 1850.

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to be exaggerated by the most trivial cause, or rendered fatal by the slightest error in treatment; while the highest effort of our art is limited to mitigating the severity and warding off the urgent danger of symptoms which we are unable wholly to subdue, and which we must trust to time and nature thoroughly to cure.

Such great differences in the course of the disease in different cases have given rise to many ingenious theories as to its nature and seat, framed with the view of explaining that which cannot but strike all observers as so enigmatical in its character. None of these speculations, 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 peculiarities become more and more manifest; during each paroxysm the child turns red in the face, and its whole frame is shaken with the violence of the cough. Each fit of coughing is now made up of a number of short, hurried expirations, so forcible, and succeeding each other with such rapidity, that the lungs are emptied, to a great degree, of air, and the child is brought by their continuance into a condition of impending suffocation. At length, the child draws breath with a long, loud 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 retching, or actual vomiting, free inspiration takes place, and quiet breathing by degrees returns. If you listen to the chest during a fit of hooping-cough, you will hear no sound whatever in the lungs; but when the hoop occurs, you will once more perceive air entering, though not penetrating into the minuter bronchi. It is not till the fit is over, and respiration once more goes on quietly, that the air reaches the pulmonary cells again; but then you will hear vesicular murmur as clear as if nothing ailed the child or at most interrupted only by a little rhonchus, or slight mucous râle. 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