GREAT DANGER WHEN CONVULSIONS RETURN FREQUENTLY.

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above twenty-four hours, and be not referable 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 by 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 symptoms are associated with a more or less complete suppression of the hoop; the cough losing something of its distinctly paroxysmal character, 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 causelessly; 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 spasmodic closure of the larynx, and consequent congestion of the brain: you watch for a few moments the fruitless expiratory efforts 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

G G

450 GREAT DANGER WHEN CONVULSIONS RETURN FREQUENTLY.

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 system if, indeed, they be not already present. It is especially in cases of this sort that you will observe a degree of dyspnea which you cannot 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 convulsions. If treatment fail, the carpopedal contractions will become permanent, 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 occur 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; 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 indications 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.

COMPLICATIONS OF HOOPING-COUGH-ACUTE HYDROCEPHALUS.

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I mentioned that true tubercular hydrocephalus is now and then met with as a complication of hooping-cough. Fortunately it is not of frequent occurrence, though the danger of its supervention should never be forgotten in the case of weakly children who have long suffered from severe hooping-cough. Two instances of it have come under my observation; 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 importance, as showing 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 edema 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 considerable, 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 partially 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

452 COMPLICATIONS OF HOOPING-COUGH-ACUTE HYDROCEPHALUS.

week from the commencement 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 opalescent 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.

LECTURE XXVII.

HOOPING-COUGH continued.-Complications with diarrhea and intestinal disorderwith 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 temperaturedanger of overtreating 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 supervenes during its course. We have already examined the two most frequent and most formidable sources of danger to patients labouring under hooping-cough, but others remain, against which it behoves 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 childhood. 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 subsides, but in other cases it harasses the patient at intervals during the whole course of the affection. It is,