paroxysm. Monday morning.-Passed an easy night, having had three hours sleep, which has refreshed him much, having had none since early on Saturday morning; drinks water easily, with calves-foot jelly dissolved in it; sputa in great quantity, the spitting up of which gives him no pain, yet coughing does. Countenance cheerful; the appearance of the fauces natural; epiglottis not so red; and there are a great many more spots of lymph on it, which in the course of the day increased, so as to coat it; blister discharged freely, and he seems to have been more alive to the pain of it than formerly; breathing easy at times. A rough inspiration is emitted when he inspires, as was noticed at the commencement of the disease. Tuesday morning--Had a good night. The external fauces, when pressed upon, give him more uncasiness than yesterday. The lymph on the epiglottis has disappeared, yet it is still large, though of a darker red. Makes a full inspiration, without emitting any sound; swallows liquids casily, yet cannot perfectly command the muscles of deglutition. Wednesday.-Swallowed a teacupful of panado. Breathes naturally. No change in the aspect of the epiglottis, which induced me to request a repetition of the blister. Thursday.-Blister answered; epiglottis not so red; pulse 74. Friday. Has been out of bed some hours. Swallows panado freely; epiglottis rather less; pulse 76. In looking at the throat eight days after, the epiglottis was still large, and he was sensible of its being so. - CASE III. Greenock Infirmary, Saturday, 13th January 1816.-FLORA SMITH, æt. 24, very plethoric, and short in stature, has been complaining of sore throat and hoarseness. On Monday last, these symptoms were aggravated, so that she has been induced to apply at the hospital for relief. No tumour perceptible in the external fauces. When asked where she is pained, she applies her finger to the cricoid cartilage. On depressing the tongue, and looking at the internal fauces, they appear red and inflamed, and slightly swollen. The epiglottis red, erect, and swollen deglutition difficult; pulse 120, small and sharp; tongue dry; heat of skin moderate; feet cold. Bowels under the operation of salts. Ft. v. s. ad 3xvi. Applicet. emp. vesicator. gutturi. Inhale the steam of warm water. ; 11 o'clock P. M.-Feels better since losing the blood. Pulse 112; thirst considerable. 14th.-Passed a sleepless night. Hoarseness no better; in spirations wheezing. There is a slight stridulous noise when she expires. On looking at the posterior fauces, they are, together with the epiglottis, inflamed, and covered with lymph. Complains of some difficulty of deglutition, which pains the thyroid cartilage, to which she applies her finger when asked where it is most painful. The blister answered well. Blood sizy, soft, and very slightly cupped; pulse 128; skin hot; tongue dry. Salts operated. Fiat v. s. ad 3xii. Applicent. parti dolent. hirudin. viij. Habeat omni horâ submur. hydrarg. gr. v. 15th.-Had some sleep during the night; seems better to-day; wheezing much the same; has some stifling cough, which pais her throat; deglutition rather difficult; pulse 120; bowels rather costive; tongue dry. Continuent. pulver. Habeat q. p. ol. ricini i. ži. 16th.-Had some sleep since morning. The throat does not appear to be so much inflamed. Pulse 112, small and feeble; tongue clean; bowels loose. Habeat juscul. bovin. Omittant. pulveres. 17th.-Slept little during the night; the difficulty of breathing still continues; deglutition little impaired; fauces very dry, but there is seemingly little inflammation; pulse 120; tongue dry; thirst great; bowels loose. Repet. pulv. ex submur. hydr. 18th.-Was much troubled during the night with vomiting, cough, and difficulty of breathing; the hoarseness still continues; pain of throat not so great; deglutition easy; pulse 120; tongue dry; bowels loose. Continuent. pulveres. - 19th. Symptoms much the same as yesterday. Continuent. pulveres. 22d.-Symptoms very much relieved. Omittant. pulveres. 2d February 1816.-Dismissed cured. Inflammation of the larynx, or cynanche laryngea, has been so well described by Drs Baillie and Farre, and subsequently commented on by them, and other practitioners of great eminence, that it is with the greatest deference I shall add any thing by way of remark. In reviewing these cases, I cannot help thinking, that they have a strong resemblance to croup, particularly Cases I. and III.; and, were I to hazard a conjecture, it would be, that croup is the primary affection, cynanche laryngea being a supervening disease, in consequence of the increased extent of the inflammation, of which we have an example in some cases of pneumonia, where it extends to the pericardium and the heart, and in several other instances of the phlegmasiæ, In no case I have met were the leading symptoms of croup more strongly depicted than in Case I.; and it may be worth mentioning, that all the friends and bystanders gave it at once the name of the stopping,' the popular name by which croup is well known here. Case II. having proceeded from a mechanical injury, is not so applicable; but the paroxysms of threatening suffocation, and the loud sonorous inspirations were pretty characteristic. Case III. is not so strongly marked, but sufficiently so to favour my conjecture. I am aware, that inflammation of the fauces, and difficulty of deglutition, are no part of the character of croup; but I have met them in several instances, and have always found them indicative of a more severe attack of the disease. It is true, that the membrane in the trachea peculiar to croup has not been found in the adult; but, as has been suggested by the ingenious editor of the London Medical Journal, in the Number for May last, this may be owing to the difference of age; the effusion of lymph or adhesive inflammation being more common in the earlier periods of life. And here I may mention, that, in two dissections I lately had of children, from three to four years old, who died of croup, I found the membrane lying loose on the back part of, and extending a little way down, the trachea. It was extremely soft, and could hardly be decerned to have been tubular, and occupied so small a space as by no means to be considered as the cause of suffocation; but when the bronchi were examined, they were completely filled with a viscid purulent fluid. But whatever difference of opinion may prevail as to the nature or diagnostic of the disease, notwithstanding the few cases we have on record, the majority is in favour of the practice that has been adopted in these cases I have submitted. Early depletion, both gene ral and local, proportioned to the urgency of the symptoms, the age, and strength of the patient, must be our principal dependence. This is fully evinced from the particulars in Case I., though the time was most unfortunately lost, owing to the particular circumstances under which the patient was placed; cir cumstances that would have perhaps misled a more experienced practitioner. In Case II. an opiate was given with happy effect, but not until evacuations had been pushed to the most justifiable ex tent. In Case III. large doses of calomel were prescribed; but little advantage, I apprehend, accrued from them; the patient was peevish and disobedient; she submitted to almost every thing that was done for her, with reluctance; several of the doses were afterwards found concealed about her bed, and there were no apparent effects from the mercury, so that, like J. H., she owes her recovery entirely to depletion. IX. Notes on the Swelling of the Tops of the Hands and Feet, (describ ed by Dr UNDERWOOD as a Symptom of painful Dentition), and on a Spasmodic Affection of the Thumbs and Toes, which very commonly attends it. By GEORGE KELLIE, M. D. Leith. D R UNDERWOOD, in his treatise on the Diseases of Children, after having enumerated the more common symptoms of disease which occur in children during the period of dentition, and which are believed to have their origin in the excitement and sympathics arising in the constitution of some individuals from that process, makes mention of a swelling of the tops of the feet and hands, as one of less ordinary occurrence. A symptom,' he observes, less common than any of the foregoing, and appearing only in certain habits, is a swelling of the tops of the feet and hands:-it seems, however, to be of no importance, and goes away upon the appearance of the teeth. I have met with it but in infants who cut them painfully, and, being seldom accompanied with a purging, it is likely may in its stead prevent that fever which is otherwise so apt to attend. In some instances, however, this symptom has been accompa nied with considerable fever; but in such, children have either been costive, or the stools been fetid and clayey, and the swelling of the extremities very considerable.' This swelling I also have frequently met with in the course of an extensive practice amongst children; and in some cases I have observed it thus slight, and transitory, as described by Dr Underwood, the only writer, in so far as I can, discover, who has at all noticed its occurrence as a morbid symptom of difficult dentition. But in many cases this remarkable tumour of the hands and feet has appeared to me to constitute but a part of a disease, of a somewhat more serious and striking nature. Even the swelling itself deserves a more particular description than has been bestowed upon it by Dr Underwood. It has a considerable degree of roundness and elevation, and looks like that sort of tumour which might arise on the same parts from a blow or contusion. It seems to arise suddenly, as it has generally this roundness and elevation from the time of its first attracting observation. When first observed, it has somewhat of a mottled, livid, and purplish colour; I would say it looks cold like, or that it resembles the chilled hand of a full and healthy child after exposure to a cold and frosty atmosphere. It feels cold also, at least it has no inflammatory heat, and does not appear to be morbidly sensible, or to give any pain to the child when handled. It does not pit on pressure, but rather gives the sensation of firmness and resistance; and when pinched, and attempted to be moved sideways, it has always conveyed to me the notion of a disease of infants, which is known by the name of Skin-bound. This swelling, which is confined to the anconal aspect of the metacarpus of the hand, and to the rotular aspect of the metatarsus of the foot, terminates abruptly at the carpus and tarsus, insomuch, indeed, that, in lusty children, it seems in these places as if confined by a cord or bandage. I have known this tumour to continue for weeks together. Sometimes it disappears in a few days, not again to return. In other instances, it has from time to time disappeared, and reappeared at short intervals. When it continues without abatement for any length of time, for a week or two, it sometimes softens, becomes looser and more compressible; its colour changes to paler, and acquires more of a leucophlegmatic hue; in a few cases it has become truly leucophlegmatic, and the oedema has spread upwards on the legs and thighs. But this is a very rare, occurrence, of which I have seen but one or two examples. Its more sudden disappearance, without undergoing these changes, or without passing to the state of leucophlegmasia, is by far more common. But this swelling of the tops of the hands and feet is, according to my observation, connected, in a great pro-. portion of cases, with another appearance of a more formidable nature, a spastic contraction of the flexor muscles of the thumbs in the upper, and of the toes in the lower extremities. The thumb is rigidly contracted, and permanently bent downwards, and laid flat upon the palm of the hand; and, in like manner, Ff VOL. XII. No. 48. |