/ -^ ,\ -/ / * »0o. I * v '^ ^ % ■=,'-*-. V V* ' -. A* * -/ V- 1 1 - \~ A PRACTICAL TREATISE ON TUL MANAGEMENT AND DISEASES 01 CHILDREN. ' RICHARD T. E\ ANSON. M.D., fr.UFK.JiOR OF Mt 1 HI IEELARD HENRI MAUNSELL, .M.D., 'R Of POLITICAL KSMCUI 1> lilt EOTAl \Ml i:i« IB i i.i\ I D1TI0M OT(tt) > B1 I), ra kNCIS < ONDIE, M.D.. FRLLUW OF 1 UM if PHILADELPHIA, MkMBHR 01 TUB AMERICAN PHILOSOPHICAL BOilRTr, ETC. iJhiiatjrlpiiia : ED. BARRINGTO^ & GEO. 1). HA8WELL 18 4 3. > dF y <\>* fb [Entered, according to act of Congress, in the year 1843, by Babrington and Haswkll, in the Clerk's office of the District Court for the Eastern District of Penn- sylvania.] / * -> PREFACE BY THE AMERICAN EDITOR. In presenting a Second American Edition of the Treatise of Drs. Evanson and Maunsell, it may not be improper to state that we consider the work, as revised and enlarged by the authors in their Fourth Edition, to constitute one of the best manuals we possess of the diseases of children, and one especially adapted for the use of the student and young practitioner. It embraces a very full account of the principal affections peculiar to the early period of existence — the phenomena of which are described with great accuracy, while the views advanced in relation to their pathological character, as well as the directions given for their therapeutical management, are evidently the result of extensive personal observations, and a careful study of the views and experience of the best modern authorities. In preparing the present edition for the press, it was not considered expedient to enlarge the size of the work by the addition of a large number of notes : nor was this necessary, — the authors' opinions and practical directions corresponding very generally with the re- sult of our own observations and experience. In two instances, however, we have been induced to extend our notes to some length. Thus, the brief notice presented by Dr. Evanson, in the Chapter on the Diseases of the Digestive Organs, of the Gangrene of the Mouth in Children, being extremely incomplete, and withal somewhat con- fused, we have appended an account of the symptoms, etiology, and treatment of this important malady, derived from our own observa- tions, and those of the principal European writers who treat espe- cially of the disease. A similar course has been pursued in relation to the account of Cholera Infantum, contained in the same chapter ; a I PKEFACE. disease of which Dr. Evanson has evidently seen but little, and which lie has strangely confounded with another and very different disease of the digestive organs. No changes have been made in any portion of the authors' text or notes — the whole being carefully printed from the last Dublin edition, with the exception of a long addendum to the seventeenth section of the sixth chapter, containing a reply to some criticisms upon Dr. Maunsell's account of infantile jaundice, that appeared in the British and Foreign Medical Review, which is omitted as altogether uninteresting to the American reader, and adding nothing either to the interest or value of the work. ADVERTISEMENT TO THE FOURTH EDITION The Publishers have to apologise for this Edition having been, owing to unavoidable circumstances, delayed somewhat beyond the period for which its appearance was at first announced. They have much pleasure, however, in stating that the time has been employed in a careful revision of the whole work, which is now greatly enlarged and, they trust, considerably improved. A new chapter has been added, in which those diseases of the skin, not treated of in former Editions, are practically considered ; thus completing the work, and, it is hoped, rendering it more worthy of a continuance of that public favour which has already been, so abundantly, bestowed upon it. On the part of the Publishers every exertion has been made in order to bring out the present volume in a creditable manner. The work was originally undertaken at their suggestion, and they have now gratefully to acknowledge the public proof of the correctness of their opinion, as to the demand for such a publication, which has been afforded by the rapid sale of three large Editions, by the republica- tion of the « Treatise' in America, and by its translation into the Ger- man language. 41, Grafton-st., April, 1842. PREFACE TO FIRST EDITION. A preface usually embraces two topics, viz. : — the Author's reasons for publishing ; and such an account as he chooses to give of his qualifications for the task he has undertaken. With regard to the first, we have only to state, that our Publisher informed us that a concise practical work upon the Management and f, PREFACE. Diseases of Children was a desideratum in British medical literature. Respecting the second, all that becomes us to say is, that we have been connected with the Institution for Diseases of Children ever since its establishment in this city : first, as students ; and subse- quently, as medical attendants. We had thus, at least, ample oppor- tunity of attaining experience in the subject. If it should now prove that we have profited by this so far as to enable us to render the fol- lowing Chapters (incomplete as we know them to be), in any degree useful to society, we shall be more than recompensed for the labour they have cost us. Dublin, Nov. 1S36. PREFACE TO SECOND EDITION. The First Edition of this Treatise having met with a favourable reception from the Profession, and a rapid sale, we might, perhaps, be excused for inferring that it has, in some degree, supplied the want of a " concise practical work upon the Management and Dis- eases of Children/' which our publisher informed us had been u a desideratum in British medical literature." If such an inference were admitted to be correct, little would now require to be said in the way of preface, but as we are ourselves still conscious of many imperfections and omissions, it may be well to state briefly our own view of the scope and character of the work which, as it appears to us, have been in some measure misunderstood. Our desire, from the commencement, was to produce a systematic Treatise upon the subject in hand, which, while strictly based upon the knowledge we had ourselves, personally, acquired during many years of painful and laborious observation of infantile disease should, at the same time, present a correct view of the most recent improve- ments, both pathological and practical, in this department of medical science. In attempting to accomplish this latter portion of our ob- ject we have taken advantage of the researches of our Continental brethren, whose industry has, in many instances, been beneficially directed towards the valuable opportunities afforded them in their numerous and extensive institutions, devoted exclusively to the study of the diseases of childhood. From their works we have been en- abled to enrich our pages with information not generally known among British practitioners, and have, therefore, found frequent oc- casion (in our wish to attribute honour to whom honour is due), to quote the opinions and names of Foreign writers. In doing so, how- ever, we have not forgotten to study and refer to works of British origin, which, though not very numerous or recent, yet exhibit much accurate acquaintance with infantile disease, and usually inculcate a sound practice. Whether quoting from British or Foreign sources, we have been always desirous to give to each due credit for every PREFACE. 7 original observation, but where opinions have become the staple and common property of science we have not thought it necessary to encumber our pages by special references to their originators, or re- vivers, believing that the names of the first should be known to all our readers, and that those of the second are entitled but to a para- sitic reputation. In addition, we must say, that though thus willing to make our work as complete as possible by collecting information from all quar- ters, we have not adopted the opinions of any authors merely on their own dicta, nor put forward any rules of practice upon the au- thority of others, to which we did not feel justified in giving assent by the results of our own practical experience. It was our primary object to make the Treatise on the Management and Diseases of Children a practical work, and it is upon our own experience that the information which it contains is founded, although we have shunned, as not fashioned to our taste, the egotistical style of trumpet- ing forth every particular observation as a new discovery. In *a word, we consider our book so far original that we are not aware of any other, constructed in the same manner, or treating in the same way of all the topics which we have introduced, several of them not having been even touched upon in other systematic works upon the subject : still, as we have already stated, we are well aware that much re- mains to be done, and not a little to be amended. Few authors have less reason or inclination than we to complain of the measure of criticism which has been dealt out to us ; even where fault has been found it has been often done with sound judgment, and generally in a good spirit. Our appreciation of this cannot be better shown than in the willingness with which we have, in the present edition, availed ourselves of judicious criticism in the amend- ments and additions which we have thought it advisable to make. To please all, however, and adopt every alteration suggested, would be a difficult and hopeless task ; in attempting which we should, indeed, find it necessary at the same time to enlarge and to curtail the same Chapter ; or in order to please one, altogether to omit that which another assures us constitutes one of the most valuable parts of the work ; while the ignorance of the subject betrayed by some, who have given their judgments with the utmost complacency, has proved to us absolutely amusing. Meaning, then, to eschew the example of that amiable old gentle- man who endeavoured to conduct his donkey to market, so as to please every one, we propose, with due submission to Messrs. the Reviewers — from whom we part in all good humour and with some sense of obligation — to ride our own hobby even in the way that likes us best. Dublin, March, 1838. PREFACE. PREFACE TO THIRD EDITION. In presenting the present Edition of this Treatise to the profes- sional public, we have little to say, beyond the expression of our wannest thanks for the kind and flattering reception met with by its predecessors. In preparing these sheets for the press, it has been our constant desire to acknowledge our numerous and heavy obliga- tions in, what appeared to us, the most suitable manner, viz., by an anxious endeavour to render the Work more deserving of the patronage which has been hitherto afforded it. Dublin, August, 1840. CONTENTS. CHAPTER I. PECULIARITIES OF THE INFANT STRUCTURE AND CONSTI- TUTION. Sect. 1. General Considerations 2. Digestive Organs 3. Organs of Respiration 4. of Circulation 5. Cerebro-spinal System 6. Locomotive Apparatus 7. Growth PAGE 13 15 17 18 20 22 23 R. T. Evanson. CHAPTER II. MANAGEMENT AND PHYSICAL EDUCATION OF CHILDREN. Sect. 1. Management immediately after Birth — Washing and Dressing 2. Food and medicine, do. 3. in the First Period 4. Choice of a Nurse 5. Artificial Feeding 6. Weaning 7. Food in Second Period 8. Cleanliness 9. Clothing 10. Sleep 11. Exercise 12. Medicine 13. Light 14. Air 15. Heat do. H. Maunsell. CHAPTER III. MENTAL AND MORAL EDUCATION. 31 35 36 39 40 41 41 45 47 49 52 54 56 57 57 Sect. 1. Mental Education 2. Moral do. H. Maunsell. 58 62 l0 CONTENTS. CHAPTER IV. PECULIARITIES OF DISEASE. PAGE Sect. 1. Etiology 66 2. Diagnosis ... ... ... •«• ••• ?. 3. Prognosis 81 R. T. Evanson. CHAPTER V. INFANTILE THERAPEUTICS. 1 ... ... 83 . ... ... 88 . ... 91 • •• ••• 94 • •. ••• 95 • ••• ... 97 • ... ... 98 • .. • ... 103 • ... ,., 103 • ... ... 107 1 ••• ... 110 . ... 113 . ... ... 116 , „, ... 117 , ,„ ... 119 1 ... ,,, 122 R. T. Evanson. Sect. 1. General Observations 2. Mercury • 3. Sedatives 4. Alkalies and Alkaline Earths 5. Carminatives 6. Stimulants 7. Tonics ... 8. Antiphlogistic Plan 9. Bloodletting 10. Blisters ... 11. Emetics 12. Expectorants 13. Diaphoretics 14. Refrigerants 15. Baths ... 16. Purgatives CHAPTER VI. ACCIDENTS AND DISEASES OCCURRING AT BIRTH, OR SHORTLY AFTERWARDS. Sect. 1. Still-born Children ... 2. Imperforate Anus 3. Vagina ... 4. Penis 5. Spina Bifida ... ... .., 6. Short Frenum Linguae 7. Hare-Lip ... 8. Deformed Feet 9. Naevi Materni 10. Ruptures ... 11. Injuries received during Birth 12. Blue Disease 13. Trismus Nascentium 14. Infantile Erysipelas ... 15. Abscesses ... 16. Induration of Cellular Tissue 17. Jaundice 18. Purulent. Ophthalmia 19. Red Gum ... 20. Swelling of the Breasts ... . 132 ... .. . 135 ... .. . 136 ... •• ; 136 ... . 137 ... .'1 , 139 ... .. . 139 ... .. 140 ... ••< 141 ... ••' , 143 ... ..< 146 ... 147 147 ... 149 ..• 151 ... 151 ... ,,, 153 ... 153 ... 157 ,,. 158 . Maunsell. CONTENTS. 11 CHAPTER VII. AGS DENTITION ... 158 R. T. Ev ANSON. CHAPTER VIII. DISEASES OF DIGESTIVE ORGANS. Sect. 1. General observations ... ... ... ... ... 167 2. Affections of Mouth, Pharynx, &c. ... ... ... 169 a. Inflammation ... ... ... ... ... 169 b. Ulceration ... ... ... ... ... 169 c. Aphthae ... ... ... ... ... 170 d. Muguet ... ... ... ... ... 173 e. Diphtherite ... ... ... ... ... 174 f. Gangrene ... ... ... ... ... 179 g. CancrumOris ... ... ... ... ... 181 Gangrene of the Mouth [D. F. Condie] ... ... 182 h. Mumps ... ... ... ... ... 189 3. Affections of Stomach and Bowels ... ... ... 190 a. Indigestion ... ... ... ... ... 192 b. Cholera ... ... ... 198 c. Diarrhoea ... ... ... ... ... 207 d. Inflammations ... ... ... ... ... 218 4. Mesenteric disease ... ... ... ... ... 228 5. Worms ... ... ... ... ... ... 236 6. Remittent Fever ... ... ... ... ... 242 R. T. Evanson. CHAPTER IX. DISEASES OF THE RESPIRATORY ORGANS. Sect. 1. Catarrh 2. Bronchitis 3. Pneumonia 4. Pleuritis — Pericarditis 5. Croup 6. Laryngitis 7. Foreign Bodies in Larynx 8. Spasm of the Glottis 9. Hooping Cough ... ... 250 ... ... 251 ... ... 254 ... ... 255 ... ... 255 ... ... 261 ... ... 263 ... ... 265 ... ... 268 H. Maunsell. CHAPTER X. DISEASES OF THE CEREBRAL SYSTEM. Sect. 1. Functional Diseases ... ... ... ... ... 274 2. Inflammatory Affections ... ... ... ... ... 280 R. T. Evanson. j CONTENTS. CHAPTER XL ERUPTIVE FEVERS. TAGE Sect. 1. Measles ... ... ... ... ... ... 292 2. Scarlet Fever ... ... ... ... ... ... 298 3. Small-pox ... ... ... ... ... ... 308 4. Chicken-pox ... ... ... ... ... ... 315 H. Maunsell. CHAPTER XII. VACCINATION ... 316 H. Maunsell. CHAPTER XIII. CONSTITUTIONAL DISEASES. Sect. 1. Scrofula ... ... ... ... ... ... ... 338 2. Rickets ... ... ... ... ... ... ... 348 3. Syphilis ... .. ... ... ... ... ... 350 4. Purpura ... ... ... ... ... ... ... 354 5. Pemphigus ... ... ... ... ... ... 356 H. Maunsell. CHAPTER XIV. DISEASES OF THE SKIN. Sect. 1. Erythema (Scalding) ... ... ... ... ... 359 2. Urticaria (Nettle Rash) ... ... ... ... ... 360 3. Scabies (Itch) ... ... ... ... ... ... sqo 4. Crusta Lactea ... ... ... ... ... ... 36i 5. Herpes (Ringworm) ... ... ... ... ... 362 6. Tinea Capitis (Scald Head) ... ... ... ... 363 H. Maunsell. PRACTICAL TREATISE ETC., ETC. CHAPTER I. PECULIARITIES OF THE INFANT STRUCTURE AND CONSTITUTION. I. GENERAL CONSIDERATIONS. In considering the peculiarities of the infant structure and consti- tution, as well as in the observations which we propose to make upon the diseases of children, we shall regard the period of childhood as consisting of two epochs — the first commencing at birth, and continuing until the twelfth month ; the second commencing at the termination of the first year, and continuing until the eighth. This division, which has been generally adopted, possesses the merit of being nearly in accordance with one definitely marked out by nature herself. About the tenth or twelfth month, the child, by its acqui- sition of teeth, becomes fitted for the use of other nourishment than the mother's milk; and the stomach and bowels receive, not merely with impunity, but with advantage, kinds of food, which, during the earlier months, would have been productive of serious derangements of the digestive functions ; at the same time, very obvious external changes have their commencement, and indicate marked alterations, both bodily and mental.* During the first period, also, the child is subject to some peculiar diseases and dangers, to which the attention of the physician requires to be specially directed, and the diminished liability to which, upon the commencement of the second epoch, together with an increasing power of resisting disease, adds materially to the chances of existence. Beyond the eighth year, we would not employ the term, child — though applied by some until the age of puberty : but before then, the peculiarities characteristic of childhood have been merging into the attributes of adult age ; while the influence of sex begins to be * " At this time," says Wendt, " the hitherto projecting forehead becomes flattened, the countenance receives expression, the eyes intelligence, the limbs firm- ness." — Die Kinderkrankheiten syslematisch dargestellt von Dr. J. Wendt. Wien, 1827. 2 14 PECULIARITIES OF INFANTS. discernible, and the individual may thenceforward be designated boy or girl. The infant, at birth, is endowed with the same organs as the adult ; but so different, for the most part 3 in structure, development, or even situation, as to constitute essential characters, which distin- guish childhood, and without a knowledge of which, neither the management nor diseases of children can be correctly understood. Infancy may be emphatically termed the period of growth. We find the infant, at birth, fully provided with the organs of nutritive or organic life — those which are essential for the sustenance and nutri- tion of the individual ; while the organs of animal life or relation, — those which connect man with the external world, and make him, on their completion, the superior being that he is, — are as yet but imperfect in development or structure, and herein is to be found the basis of that great difference observable between the infant and the adult. In the former, we have the organs of nutritive life alone, fully developed, and actively employed ; but in the latter, we have both classes of organs, relative as well as nutritive, brought to com- pletion and in full activity, constituting the period of maturity or per- fect growth. To speak in general terms, we may say, that the anatomical struc- tures in the infant differ from those in the adult, by their greater softness or want of consistency ; being surcharged with fluids, and many of them as yet unfitted for the full discharge of their appropriate functions ; while in advanced life, on the contrary, the quantity of fluids diminishes, and the structures become condensed, so that the organs, instead of being too soft, have become too rigid, as we find them to be in old age. In the infant, the glandular and capillary systems predominate ; absorption and deposition are active, and the processes of interstitial growth most vigorous ; secretion is abundant, and excretion frequent; the nervous sensibility being acute, and the membranes remarkable for their vascularity ; all which phenomena depend, not merely on the abundance of blood present, and the activity of its circulation, but on the preponderance of the arterial over the venous vessels. Before proceeding to a particular review of the several organs, and the properties by which they are characterized in childhood, it may be well to take a glance at the general appearance of the newly-born infant. The length of the body varies from about one foot and a half to a little less than two feet. Baudelocque states sixteen inches and twenty-two (or at most twenty-three) inches, as the extreme limits. The average weight is from about six to seven pounds and a half ; more has been assigned, but is not common ; six pounds is by far the most common weight, according to Camus's Tables. The skin is thin, tender, and of a reddish hue ; but covered at birth with a white unctuous matter, called vemix caseosa. There is some hair upon the scalp, and the nails reach to the ends of the fingers : the articulations are commonly flexed, the limbs round, and the body plump. DIGESTIVE ORGANS. 15 The relative dimensions of various parts differ materially from those observed in after life. The lower extremities are less developed than the upper ; the median point, — that lying midway between the two extremes of the body — being found at the umbilicus, or a line or two below it. The pelvis in the infant is small and contracted, being less developed in proportion than the thorax, which is flattened at the sides, but prominent in front ; while the abdomen and head present dimensions, not only very large in comparison with the other cavities, but also as compared with their own dimensions in after life. The newly-born infant possesses little power of motion ; none of independent support. Sensation and perception are dull or absent. Its cries and movements may be looked on as involuntary — its search for food is instinctive. One-third of its time is chiefly occupied in taking nourishment, the remainder is passed in sleep. Peculiarities not less striking or important, arrest our attention, on turning to the consideration of the internal organs ; and these we shall briefly notice in succession, commencing with those of organic life, as being first called into action ; and of these the digestive organs naturally claim precedence, and will be found in a high state of development. II. DIGESTIVE ORGANS. The mouth of the infant is fully formed, and in some respects par- ticularly adapted to the performance of its proper office of suction, as we see in the disposition of the palate and lips and the obliquity of the posterior nares ; yet appearing to be imperfect from the want of teeth, which, however, can hardly be said to be wanting — only absent ; as they already exist within the gum, in due time to make their appearance and mark a new era, when the child becomes fitted for a different aliment, from that hitherto provided by nature for its sustenance. The mucous membrane lining the fauces, pharynx, stomach, and the whole tract of the intestinal tube, is thick and villous ; being more sensitive and vascular than in after periods of life ; softer in tex- ture, and more bedewed with mucus, which is abundant, but thin ; becoming viscid, however, and much increased in quantity on the occurrence of any irritation. The sensibility of the mucous mem- brane is adapted to the mild unirritating fluid provided by nature as the suitable nourishment for the infant : any other substance proves irritating in a greater or less degree, and is therefore to be avoided. The stomach and duodenum are fully formed, their mucous mem- brane being thick, villous, and of a rosy tint. But the position of the stomach in the infant, differs from that in the adult, in hanging almost perpendicularly, so as to extend from the epigastric to the umbilical region : instead of being placed in the transverse position which it occupies in after life. The omentum, which is attached always to the great curvature of the stomach will, in consequence, be found in the infant, more towards the left than the right side. The small intestines in the infant are a third longer in proportion to 16 PECULIARITIES OF INFANTS. the Length of the whole intestinal tract, than in the adult; and the large intestines are longer in proportion to the small, but their calibre is relatively less. The valvulae conniventes are scarcely apparent ; the vermiform process is very long, and the coecum is largely de- veloped. The salivary glands and the pancreas are very large, and seem particularly active ; the whole glandular system being much larger, in proportion, in the child, and more active, so as to give to the infan- tile constitution a peculiar and important character. Digestion is rapid and incessant ; the child frequently requiring food^which, if permitted, will be often taken to repletion ; so as to be ejected without effort from the overloaded stomach, which is not capable of containing more than a few ounces of fluid at a time. The chyle, which is rapidly eliminated, is quickly absorbed, the tract of the small intestines being long, as we have seen ; while the lacteal vessels and mesenteric glands are largely developed, and in a high state of activity. The gall-bladder, though small at birth, soon enlarges ; and is found to contain bile, bitter in taste, and green in colour : but bile, in the infant, is less viscid and less charged with the principles pecu- liar to this fluid, than at a more advanced age, when concretions are liable to form. The liver undergoes a remarkable alteration in function and form after birth. The mode of circulation is changed ; the left lobe dimin- ishes, the umbilical vein and canalis venosus are obliterated ; while the vena portae is developed, and the secretion of bile becomes the peculiar function. The parenchyma of the liver becomes darker as life advances ; and the size of the organ diminishes relatively in volume, receding towards the ribs, within which it is situated in the adult ; but in the infant, it extends to the middle region of the abdo- men ; and instances are recorded, where the proportions of the liver remained through life as in the foetus. The spleen presents little peculiarity that we are as yet able to notice ; too little is known of its functions to enable us to appreciate any changes that may occur ; but we have observed, that it is sub- ject to disease at a very early period. The spleen may be felt in the infant below the false ribs, chiefly in the middle region; not in the left hypochondrium, as in the adult, in whom indeed the spleen can hardly be discovered by the touch unless when in a diseased state. The bowels, at birth, are found to contain a dark-coloured inodo- rous, insipid substance, which is called meconium, and appears to result from accumulation of intestinal secretion, for which passage had not before been provided. This is, however, soon expelled, and its place occupied by the residue of the food ; which, from the nature of the infant's aliment, we might conjecture, would be but little cha- racterised by the properties of fecal matter. — Accordingly, we find the contents of the bowels in infants, much less feculent than they afterwards become ; being thin, charged with mucus, and of a yel- ORGANS OF RESPIRATION. 17 lowish colour ; possessing little fetor, but abundant and frequently- expelled, the infant passing a stool three or four times each day. In a similar manner, we find the other excretions less odorous, more watery, and not so largely charged with their peculiar prin- ciples, saline or otherwise, as in the adult; but they are quickly discharged, though not very abundantly secreted. The perspiration is less saline and odorous, but more watery, though not copious. The urine differs in like manner from that of the adult (in particular, the quantity of urea is much less) ; and it is retained a much shorter time, being, like the feces, often expelled. This does not depend merely on the constant supply of food, or less relative capacity of the containing viscus ; but is connected with the peculiar sensibility of the lining membranes, and irritability of the muscular coats of these viscera ; which, like the other involuntary muscles, are more irrita- ble in the infant, than they are subsequently found to be. In their tissue, they are softer and of a paler hue ; nor has command over their actions been yet acquired. This latter character, in particular, attaches to the urinary bladder in the child, and occasionally continues to give annoyance for some time, by leading to frequent wetting of the dress or bed-clothes. The bladder, in the infant, is more elongated in shape, and situated higher up, than that of the adult ; but is less capacious in proportion, while the ureters are particularly large. But it is upon its difference of anatomical structure, as regards the position of the urethra, more than perhaps other circumstances, that this difficulty of retaining the urine depends ; for the pouch or fundus of the bladder (bas fond) does not exist in the fetus, the cervix or urethral opening being then most dependent ; and this state of parts still obtains to a cer- tain degree in the young subject; probably in some more than others. The kidneys undergo remarkable alteration ; their lobular for- mation disappearing, and the supra-renal capsules rapidly diminish- ing; but the relation which these changes bear to the functions of the organ, is not very obvious. III. ORGANS OF RESPIRATION. Having considered the digestive organs, or those which generate the materials for the blood, we shall now notice the respiratory organs, or those by which the blood is regenerated, and fitted again for the purposes of the circulation. In no organs do more important changes occur, at birth, than in the lungs ; in nothing does the infant more remarkably differ from the foetus than in being a respiratory animal. The lungs, which be- fore birth had been condensed, of a brownish-red hue, very vascular, and not as yet permeated by air, now suddenly augment in size, becoming, after respiration, of a rosy colour, soft and vesicular in structure, and crepitant to the touch. The respiratory process, (which, in the child, is in a great mea- sure performed by the action of the ribs alone,) is carried on with 2* IS PECULIARITIES OF INFANTS. rapidity and force, consonant to the general activity observable throughout the system ; and in particular, the constant demand for fresh supplies of blood. The inspirations and expirations are equal and frequent ; the more frequent, the younger the child ; being, during the first year, from 35 to 40 in the minute, or nearly double those of the healthy man ; while the sound emitted on the passage of the air, is so peculiar from its force and sonorousness, as to obtain the distinguishing appellation of puerile respiration. This charac- ter, respiration in the adult occasionally assumes, when the healthy portion of a lung is obliged to take on a compensatory action, in consequence of obstruction in the diseased portion (as in Pneumonia) — when the respiration in the sound part is said to be puerile, as significant of its force. Notwithstanding this activity in the process of respiration, it would appear that less oxygen is consumed in the infant than the adult, and that the power of generating heat (a process closely related to respiration) is also less. The thymus gland, which occupied a large and conspicuous space within the upper and anterior part of the thorax in the foetus, gradu- ally diminishes after birth, and is hardly to be recognised in the adult. It is freely supplied with veins and arteries, and contains at first a whitish fluid somewhat like chyle, which shows the gland to have a secreting power ; but it is not generally acknowledged that any ex- cretory ducts exist. Its supply of bloodvessels and softness of tex- ture, seem to allow of sudden augmentation of size ; and this, in instances where the gland is larger than ordinary after birth, may cause, by the pressure exerted on subjacent and important parts, very distressing or dangerous symptoms. To such cause has been attri- buted a spasmodic affection, to which some children are liable, and which often proves fatal ; at least, the thymus gland has been found distended or enlarged in some such instances. In common, it does not exceed a couple of inches in length, one and a half in breadth, and a quarter of an inch in thickness. IV. ORGANS OP CIRCULATION. The blood, having undergone the requisite changes in the lungs, is conveyed again to the heart, thence to be sent throughout the system From the moment the act of respiration is performed, the circulation undergoes a total change ; and the heart is altered accordingly, be- coming complete in its functions, but still retaining some remarkable peculiarities in the infant. Its volume is proportionably large ; but the relative capacity of its cavities differs from what is afterwards observed, those of the left side, — particularly the ventricle, and, in connection, the arteries — preponderating decidedly at first: the balance, however, is gradually altered, until we find, in the adult, the cavities of the right side of the heart nearly three times the size of those of the left. The thickness of the parietes of these cavities, however, changes inversely with their capacity ; for,frombeing nearly equal, the parietes ORGANS OF CIRCULATION. 19 of the left ventricle become almost four times as thick as those of the right — a change which rapidly proceeds after the obliteration of the ductus arteriosus, and the closure of the foramen ovale, when the left ventricle has the sole conduct of the circulation through the system. The parietes of the heart are softer and paler than in after life, when the relative bulk is less, but the texture firmer, and colour deeper ; this organ being then called upon to propel its contents with greater force, as they have to traverse a longer space. In the infant, the large volume but feebler power of the heart fits it for the propul- sion of a larger quantity of blood, but through a less distance ; while the peculiar irritability of this, as well as the other hollow muscles, during infantile life, ensures more active contractility, and so, more rapid action, suited to the constant demand for fresh supply. Ac- cordingly, we often find the pulse in the infant, like the respiration, nearly double in frequency that of the adult, varying from 120 to 140 oeats in a minute.* The part of the nervous system more immediately connected with the class of organs which we have just been considering, should naturally be in a high state of development, to allow of that fulness of function which we have seen these organs to possess: and accord- ingly, we find the ganglions, or system of the sympathetic nerve, very perfectly formed at birth ; while the brain, and its nervous con- nections, on the contrary, are very imperfectly formed, though largely developed — more especially the brain itself. We now come to the consideration of the second class of organs, — those of animal life, or relation to external objects ; and here we shall find remarkable changes manifested in the advance of organs from a state of essential imperfection, to one of completeness — this advance in organization, and successive development of function, constituting the most interesting eras of infantile life, looked forward to with * The pulse in the child varies so much in different individuals, and according to different circumstances, that it is very difficult, if not impossible, to assign a rate of frequency according to the age. Some general conclusions may, however, be come to, and a proximate, if not accurate, guide thence derived in disease ; but the most experienced practitioners are most cautious in drawing conclusions from the frequency of the pulse in the young child. The influence of position is very re- markable — a change from the recumbent to the sitting posture at once adding greatly to the frequency of the pulse — much more when the attitude is erect and the child in motion. We have often found the pulse, which at night (during sleep) was 80, full and steady ; up to 100 or even 120 during the day, small and hurried — and that in more grown children (six or seven years of age), and in perfect health. While, on the other hand, in very young infants (under six months old), the pulse may continue quite unaffected during dangerous illness — particularly serious ab- dominal affections. The most general conclusion which our observations have enabled us to make, is, that the pulse is not most frequent immediately after birth, but at the age, or at least the time of teething ; and that it thence gradually dimi- nishes in frequency. This view accords with the experiments of Dr. J. Gorham, who assigns 130 as the mean number of the pulse from five months to two years old; and 107.G3 from two to four years of age; whence the number continues almost the same up to the tenth year. See the Mtdical Gazette for 1837. [Note to 4th Edition.] 20 PECULIARITIES OF INFANTS. eagerness, and remembered with pleasure, as the periods of dawning intelligence, and independent muscular exertion — when the infant first begins to take notice, to walk alone, and to speak. y. CEREBRO-SPINAL SYSTEM. The brain, though large in volume, is very imperfect in structure in the infant, being so soft as to be almost fluid, the quantity of aqueous matter preponderating much over the albuminous ; it is of a reddish hue, but with the cortical portion less deeply coloured than in adult age, and the convolutions less deeply marked. The brain is altogether inadequate to perform, on first entrance into life, those exalted functions which afterwards render it so im- portant an organ, and so characteristic of the superiority of man ; and accordingly, we find the newly-born child incapable of thought, and apparently devoid of perception. As the action of the heart becomes more vigorous, the brain ac- quires more energy. The precise changes which this organ under- goes, in its progress towards perfection of structure, are not accurately determined ; but those appear to be as important which regard alterations in the quality,* as in the quantity of the cerebral sub- stance. The increase in size is not, perhaps, so remarkable as that in the density of the organ ; which, according to Wenzel, does not attain its greatest weight until the seventh year, — the size and weight of the brain at that time being said to differ little from what they are at mature age, when the power of function is so far superior. Such is the opinion generally entertained on this subject ; but which is not strictly accordant to fact. The fact is, the brain does con- tinue to increase in size until manhood ; and the relative size of its different parts constantly varies during several of the first years of life ; but it is not, perhaps, until about the seventh year that all its parts are fully formed. The brain of the newly-born infant seldom exceeds ten ounces in weight ; that of the adult averages about three pounds and a half — often something less — but in some individuals, the brain has ex- ceeded four pounds, or even four pounds and a half in weight. In advanced life, again, the brain diminishes somewhat in relative as well as general size, and it has been ascertained, according to Desmoulins and Cauzevielh, that it diminishes in specific gravity, from one-twentieth to one-fifteenth. It grows rigid in its quality, becomes again unequal to the due performance of its functions, as it had before been in infancy, though from an opposite cause, and second childishness is said to take place. The cerebellum is at birth somewhat more advanced in organiza- * The presence of phosphorus constitutes an essential ingredient in the chemical composition of the brain, (as proved by recent researches,) and the quantity of this substance present in the brain of the child, is much less than in that of the adult, and again diminishes in advanced life. The brain of the idiot is found to be re- markably deficient in this ingredient. CEREBRO-SPINAL SYSTEM. 2X tion than the brain ; but it is about the period of puberty that the relation between the cerebrum and cerebellum undergoes the most remarkable change, the latter becoming considerably augmented in relative size, being then nearly twice as large, in proportion, as it had been at birth. The spinal marrow is largely developed, like the brain, in the infant, but appears to be more matured in structure, and farther advanced in the performance of its functions. The general sensibility is acute, and the nervous susceptibility in the infant remarkable ; so that all impressions are vividly felt, although transient in effect, and sympathetic affections are presented in a very aggravated form, and are very prone to occur, constituting a peculiar feature in the infant constitution, which may be emphatically said to be nervous. The large endowment of nervous matter, and its peculiar susceptibility of impression from the softness of its texture, appear to confer this quality, which is never to be lost sight of in the treatment of infantile disease — a remark as old as the time of Boerhaave, but which is nevertheless too frequently forgotten. As the infant grows older, the brain, the centre of nervous power, becomes capable of perceiving impressions made through the senses. Signs of intelligence begin to be manifested : the infant takes notice, and becomes sensible of the qualities of bodies, recognizing them and exhibiting symptoms of gratification or annoyance. The nerves of sensation, however, though freely developed, are as yet but im- perfect in their functions, and inadequate to the conveyance of their appropriate impressions ; while we find that the apparatus by which the external sources of these sensations are supplied, is more or less imperfect, and destined to undergo much alteration. To notice particular senses, we shall commence with vision, which does not appear to exist in the newly-born babe, though the eye is fully developed : and it has been ascertained, that perfect images are formed on the retina. Vividly illuminated objects seem soon to attract notice; but the eye follows or is fixed on them, at first, in an apparently passive manner, little dependent on the will. Light is at all times agreeable to the infant, which seems naturally to dislike dark- ness ; but a very bright light is injurious, as well as annoying, to the eye. The sense of hearing is as little exercised as that of sight, in the first instance. It is doubtful if the young infant can hear at all ; at least for some time it does so but very imperfectly ; and that this must be the case is manifest, from the deficiency of structure in the exter- nal ear, which is as yet ill calculated to collect or receive vibrations of sound, the pinna being very inelastic, the tympanum small, and its membrane oblique, while a soft matter, little favourable to vibra- tion, covers all. Taste early exists, and provision is made for its exercise in the full development of the mouth ; but probably perception of flavours is enjoyed to a less extent than we might at first suppose. The appa- ratus connected with the sense of smell, is much less fully formed ; and although this sense be manifested early, there is little probability that delicacy of perception is early enjoyed by it. 2 o PECULIARITIES OF INFANTS. The absence of speech, or the capability of uttering articulate sounds, is a deficiency characteristic of infancy, (as indeed the word infant ia implies,) but not to be accounted for by mere anatomical examination of the organs of voice, though these certainly are but imperfectly developed. The larynx is small, and nearly circular : the lips of the glottis, and the superior ligaments, being, therefore, very short. This condition of parts, combined with an immature muscu- lar endowment, sufficiently accounts for the shrill, feeble tone, and wailing cry, peculiar to the infant ; but the acquisition of the power of speech, is connected with the advance of intellect, rather than alteration of mechanical structure, in this part of the apparatus of voice. The gradual alteration going on in the larynx, does not become very evident until the period of puberty, when the rima glottidis enlarges, the thyroid cartilage, and thyro-arytenoid muscle, become elongated, and a change in the tone of voice is consequently occasioned. In the male this assumes the deep and grave sound, which characterises the full-toned voice of manhood ; while in the female little change takes place in the larynx ; and the acute tones still remain characteristic of the female voice, which always more or less resembles that of childhood. The mechanism on which depends the power of articulating intelligible sounds, is more connected with the increased growth and power of the muscles of the mouth and pharynx, which, even before intellect begins to dawn, become, by a happy provision, early developed, being necessary both for sucking and deglutition. The infant begins to articulate at from half a year to a year old ; and usually speaks plainly, or so as to be under- stood by a stranger, at from two to three years of age. The general sense of tact, or perception of contact, makes us con- scious of the presence of external bodies ; and, to a certain extent, is exercised by the whole cutaneous surface, though not in like degree. In the young infant, however, the skin does not seem well disposed for the active exercise of this power, the papillae being less developed, and its structure more gelatinous than in after life. The sense of touch, strictly so called — or that perception by contact, in virtue of which we not only recognise the presence, but certain of the qualities of bodies, — exists only in some organs — almost solely in the hands — and is but little developed in the infant. Whether the skin be less sensitive or not, the muscular endow- ment necessary for the exercise of this sense is but very imperfect, — the use of the fingers for this purpose being as yet unknown, or the attempts to employ them sufficiently awkward. The assistance of muscles is necessary for the exercise of all the special senses ; and the imperfection of the muscular apparatus is a principal cause of the deficiencies of these senses in the iufant. VI. LOCOMOTIVE APPARATUS. The organs of locomotion are those that enable us voluntarily to come into contact with external objects ; and these organs are but little developed in the child, in either of their chief component parts, bone or muscle. GROWTH. 23 The osseous system, in particular, is imperfectly and unequally developed, varying according to the purposes of its different parts. The bones necessary to contain and protect important organs, as the bones of the head or chest, are much more advanced in ossification than those destined merely for muscular support, or locomotion, — which are but imperfectly ossified, or exist as yet only in the form of cartilage.* The bones in general are characterised by their small- ness of size, redness of colour, and softness of texture, being very vascular, and the earthy part not only much less in proportion than in the adult bone, but even the animal portion being less firm, in consequence of the larger proportion of gelatin. The bones in the infant, then, are little calculated, from their formation or structure, for the support of the body in the erect posture, or the endurance of strong muscular exertion; nor are the muscles themselves better pre- pared for such efforts. We have already noticed the characters of the muscular tissues of organic life, or the involuntary muscles in the infant. Similar cha- racters of structure belong to the voluntary muscles. They are pale in colour, and easily torn, being soft in consistence, and slender in shape, the bellies of the muscles not being yet formed. They con- tain less fibrin than in after life, and have their fibres but loosely united, the fasciculi not being embraced by fasciae or aponeuroses. Similarly imperfect are the tendons and ligaments, or muscular ap- pendages. In the child, the irritability of the muscles, or tendency to contract, is more easily excited, but less easily sustained, than in after life. Hence the motions of the child are quick or sudden, and frequent, but fail in capability of effecting powerful action, or sustaining continued exertion. The first efforts of the infant at voluntary movements are thus necessarily imperfect. It begins to attempt walking at about twelve months of age, and has generally acquired the power of walking alone between the second and third year. But many are the mis- chances which such efforts entail ; foreseeing which, nature has providently furnished a shield of defence in the yielding and elastic cellular tissue, in which the body of the child is so liberally encased. VII. GROWTH. We have already designated infancy as the period of growth ; and this character, which continues during childhood, is sufficiently mani- fested by the progressive and rapid advance made in the body at * " The most striking fact of this kind," to use the words of Dr. Symonds, in his able article "Age," Cyclopaedia of Anatomy and Physiology, "is presented in the spinal column. The annular portions of the vertebrae, which form the canal of the medulla spinalis, are found strongly ossified at birth : but the bodies of these bones, which are to be used hereafter in supporting the weight of the head and trunk, are very slightly expanded, and all but devoid of earthy particles; while the processes to which the muscles employed in the flexion and extension of the column, after- wards contract attachments, are either only shaped in cartilage, or may be said to have no existence." 24 PECULIARITIES OF INFANTS. large, and its several organs in detail. The progress of this advance is uniform; so that the successive developments of different parts observe stated periods and a well-known order. In this progress we are most attracted by the advance made in the organs of animal life : but the changes which take place in the organic functions are not less remarkable, though less noticed ; consisting principally of a decrease in activity, if not power, and occurring out of sight, so as to be little obnoxious to observation .* As the infant grows older, digestion ceases to be so active, and the digestive tube so sensitive. Food is less frequently required ; and the kind of food may be more varied, a more stimulating variety being borne, and necessary. The secretions begin more to resemble those of adult life, and the evacuations require less frequently to be voided, being no longer passed independently of the will. The involuntary muscles generally acquire more tone, grow firmer in structure, and deeper in colour, losing their puerile irritability. Respiration becomes slower, and the pulsations of the heart less frequent, — the respiration gradually parting with the attributes of puerility, and the pulse diminishing in rapidity. The activity of secretion becomes abated, and the membranes are not so vascular or sensitive. Less mucus is secreted naturally, or poured out on the occurrence of irritation. The capillary vessels are no longer so abundant, nor do the arterial branches preponderate so much over the venous. As the child advances in age, the activity of the ganglionic system of nerves is less manifested, while that of the cerebro-spinal system comes more into play ; and the body, gradually losing the characters of infancy, begins to assume the attributes of adult age. In these various stages of advance, we are particularly struck by the progress made in the powers of sensation, perception, and volun- tary motion, or in the organs of animal life. Sensation awakens, and the senses successively and rapidly expand. Perception is mani- fested, and reflection in due time succeeds. Thus endowed, the child is competent to voluntary efforts ; and muscular power is pro- portionably developed, and brought into action. The several senses improve as they are exercised, and mutually aid each other by cor- roborating or correcting the impressions received by each. Our perceptive faculties are thus brought first into action, and we obtain a knowledge of the existence and properties of external objects. Memory, " the storehouse of the understanding," becomes furnished, and the intellect is supplied with the materials of knowledge, and business for thought. * In both systems of nerves, sensibility precedes activity, the course or current of innervation being-, at first, from sensation to motion, although afterwards the opposite often obtains. There is also a certain correspondence between sensation and action, but this is more remarkable in the organic nervous system than in that of animal life; for in the former, action is directly proportioned to sensation, being, in fact, a necessary consequence of it: but in animal life, this relation is uncertain, the result not being invariable, but controlled by the brain, through which impressions must pass, or in which they originate. (Note to 4lh Edition.) GROWTH. 25 The progress of growth in the organs devoted to the exercise of the senses, the intellect, and voluntary motion, is remarkable and characteristic, but unequal in advance, and tardy in completion. The perfecting of these organs, finishes the process of growth ; and is not fully completed until the period of maturity, or near to the meridian of life. Perfect development of the bones and muscles, connected with the apparatus of the organs of sense, is necessary for the full exercise of the several senses, and is not finally completed until long after the period of childhood ; nor are the powers of sensation brought to perfection before then. The acuteness of the early impressions is probably great, whether in consequence of their novelty, or the sensi- bility of the nerves : and such impressions seem to be recollected as peculiarly pleasurable. But it is only by practised experience that the perfection of sensation can be attained, as is remarkably exem- plified in the sense of touch. The advance in the organs of voluntary motion, — the knitting of the frame and development of the muscular power, — constitute the most noted feature of growth ; and the completion of these organs, the most characteristic attribute of manhood. The form of the skeleton, and its several parts, alters much ; and the chemical consti- tution of the osseous system, also, undergoes change. The relative development of the pelvis and lower extremities, comes to bear a better proportion to that of the thorax and the rest of the body. The form of the spine assumes more of the alternate curvatures of full growth. The shafts of the bones become firmer, and more closely united to their heads, and the processes shoot out ; while the quantity of calcareous matter gradually increases, until the completion of bony growth, when the framework of the muscular system is brought to perfection. The muscles do not remain stationary while the bones advance. Their colour deepens, and the fibres become well defined and firm, being developed so as to form the belly, or central fulness ; more fibrin enters into their composition. The aponeurotic sheaths, and tendinous appendages, have become necessary, and are added. Mus- cular exertion now comes into busy operation, but continues to be characterised by activity rather than power. The child has a con- stant tendency to muscular movement, and loves exercise ; but the power is soon expended, and rest is required, — well-concerted, or long-sustained, muscular exertion being beyond its capability. This is an important moral as well as physical check, the corporeal power being limited, and full strength not acquired, until the controlling influence of a matured intellect has been provided. This brings us to consider the progress of growth in the cerebro- spinal portion of the nervous system ; particularly the brain, the organ of thought and feeling, and that in which remarkable changes takes place. As the body elongates, the spinal marrow of course becomes en- larged, until it bears to the brain a greater proportion in size than it did at birth ; but having been more forward in structure from the first, its advance in this respect is less remarkable. 3 2(3 PECULIARITIES OF INFANTS. The brain grows, and the head enlarges remarkably, within the first year after birth — particularly, during the first few months. The imperfect state of ossification in the bones of the skull at this period, admits readily of the rapid enlargement of the cranium and its con- tents ; this being one of the uses of the fontanelles, in addition to the facility which they can afford in delivery, by allowing the bones to overlap each other, and so diminishing the bulk of the head. Six of these deficiencies in ossification are found at birth, the spaces being covered by membrane : nor have the sutures yet begun to form. The principal of these openings is called the bregma, and is situated at the top of the head, between the frontal and parietal bones ; an- other is found behind, between the occipital and parietal bones ; and of the remaining two, (each of which is double, thus constituting six in all,) one in found in the temporal fossa, at each side, the other above each mastoid process. The presence of these fontanelles (particularly that on the top of the head,) is a source of uneasiness to the ignorant, imparting to the hand an uncomfortable sensation, as if the brain were devoid of protection ; and improper, and often injurious attempts are accordingly made to remove them, by com- pressing the head, for the purpose of bringing the bones together. But so far from being a cause for alarm, these openings are a source of advantage. The effects of blows or falls on the head, (to which the infant is so liable,) are thus mitigated, the shock being inter- cepted before it has affected the brain ; while, in cases of disease, the danger from effusion is lessened by the possibility of quick expan- sion thus permitted, and which diminishes the effects of compression. These openings gradually close by a natural process, and will be found completely united by the fifth year, when the sutures are well marked and formed. Occasionally, the fontanelles are later in closing, the process of ossification being slow or imperfect ; and this is a just cause for uneasiness, having its source usually in a general deli- cacy of constitution, often connected with a strumous taint. The brain not only increases much in size in the child, but also alters sensibly in structure, advancing towards more complete organ- ization ; and this remarkably, at the time when signs of intelligence begin to be displayed. Prom about the period when the first teeth appear, this advance in structure is striking, that in size having been before more remarkable. The brain now becomes firmer, more con- sistent, and less vascular ; the difference between the medullary and cortical portions is more pronounced ; the former is less red, the latter deeper coloured ; the convolutions are better marked, and so the peripheral surface more extended. The advance in quantity and quality continues manifest to the age of seven years, or about the period of second dentition, which appears to be on many accounts remarkable. The brain has now assumed considerable volume, and its structure apparently resembles that of adult life; but after this period, advance in structure, and increase of size, may still be ob- served, though not so remarkably.* The concretions of the pineal gland have begun to form about this period ; and they are redder in colour, but fewer in number, than in after life ; in some instances, however, they never form. GROWTH. 27 The character begins now to be defined, and some indications of the mental endowments of the future man are afforded ; the features form, and the physiognomy begins to exhibit traces of a marked dis- position. But in regarding the countenance, we must take into account the development of the bones and muscles connected with the head and face, which occurs about this age : yet the general en- largement of the head is not so much connected with the expansion of the skull and its integuments, as some insist. When the circum- ference of the head, taken above the orbits, does not exceed thirteen inches in the adult, idiotcy always attends, according to Gall : and Dr. Voisin found, on careful examination, that idiotcy was complete, when this measurement varied fromeleven to thirteen inches ; while that from the root of the nose over the head, to the occipital spine, measured only between eight and nine inches. In the full-sized head, the former measurement averages two and twenty inches ; the latter fourteen. A very small head is usually accompanied by feebleness of character ; but the head may be large, and the person dull or even idiotic, — the deficiency existing in the structure or quality, not in the size of the brain. The advance of growth in the brain does not seem to proceed equally, either as to size or structure, in all parts. Vimont notices, that the increase of size, during the first months, is most remarkable in the parts situated at the base of the skull, and occupying the anterior and inferior regions of the frontal bone ; while, of the cerebral con- volutions, those soonest acquiring firmness of structure, are placed in the lateral and middle parts of the base. All know that the cere- bellum does not acquire its full development until about the period of puberty. The head varies with the progress of growth not only in size, but shape, — the different regions of the brain being found to bear a dif- ferent relative proportion at different ages — particularly, during youth ; while at all periods there exists a certain degree of individual peculiarity, and a capability of alteration in size, whether by increase or diminution. Not less remarkably do we observe a certain order or relation in the successive development of the several moral and intellectual powers ; which is, doubtless, dependent upon this relative advance in size or structure in different parts of the brain, though not yet generally confessed to be directly connected therewith, — observa- tions for determining this point having been but partially made, and the importance of the subject not yet duly appreciated. However this may be, it is certain, that the disposition and intellect are gra- dually unfolded ; and that attempts to force the one or the other be- fore its appointed time and proper progression, are sure to be attend- ed with injurious, if not dangerous, consequences. The reason is obvious and physiological ; because, what is called the cultivation of the mind, is in truth but the exercise of the brain ; and this, like every other organ, if over-tasked, will be debilitated or destroyed. In noticing the development of the intellectual powers, we see that the child observes before he reasons — that the perceptive faculties 2S PECULIARITIES OF INFANTS. come into play before the reflective. The child early observes and recollects things, and the qualities and relations of things ; and is inquisitive about events. He constantly asks what this or that is. But the senses advance still more rapidly than the perceptive faculties, and are thus prepared to furnish these faculties with know- ledge of the various properties of matter. The differences to be ob- served, however, in the power of appreciating these qualities of bodies depend on differences in the constitution of the perceptive faculties — not of the senses. The eye may see well, and clearly perceive differences in size or form, and yet not be able to distinguish differences in colours ; the ear that hears best, is not that which best appreciates those variations in sound that constitute melody. The various degrees of talent exhibited by some children more than others, depend much on the different degrees with which they are endowed with those faculties that take cognizance of the physi- cal properties of things. In these qualities and relations of bodies we have the foundation of the physical and natural sciences ; and for these sciences (especially the latter), mental capacity exists at a much earlier age than seems commonly supposed. The gift of language as a mental power, is that which earliest attracts attention, and is first cultivated. Hence, facility in this respect, with a quick observation, are taken as indications of great intellectual capacity. But the reflective faculties must be in full operation, to constitute a really good understanding ; and these are always the latest to be developed, and often not very liberally be- stowed. It is, indeed, upon a due balance between the reasoning and perceptive faculties, that the superiority of the intellect will de- pend. Where the latter preponderate, they early show themselves, and give a quickness of apprehension which, in the child, is often taken for superior talent. But the smartest boy does not necessarily make the cleverest man ; there must be a full endowment of the re- flective faculties, to give depth of thought, or soundness of under- standing. When these faculties early preponderate, however, the child may be slow in apprehension, and will probably be esteemed dull ; but when the period for their exercise arrives, powers will be exhibited which had not been anticipated. Peculiarities of disposi- tion, moreover, affect these results as much as differences in talent, though seldom, if at all, taken into the account. A careless disposi- tion will often forfeit all advantages of superior intellect ; while per- severing industry may more than compensate for the absence of brilliant talents. The child often exhibits (from the earliest age) a marked disposition, as it occasionally does some peculiar talent. Almost from the moment of birth some infants are observed to be peevish, passionate, or obstinate ; while others are gentle and affec- tionate, or timid. A determined infant may be seen to rule a weak parent, and even exercise an influence over a whole family. A very gentle child may never acquire sufficient force of character to make his way in the world, no matter how intellectual he may be. The higher sentiments, generally speaking, are the more slowly developed ; and superior moral powers, as the sense of justice and GROWTH. 29 religion, are among the latest to come into operation, requiring some assistance from the understanding for their direction and support. Before we are generous we should be just ; but to be just we must be wise — knowledge is necessary to justice. No doubt can exist that the child is endowed with certain powers, moral and intellectual, varying in different individuals, and consti- tuting natural differences of character ; but this militates not against the necessity for education or training, and the vast influence exer- cised thereby ; on the contrary, it serves as a guide and a limitation, — pointing out what requires to be cultivated, and what to be re- pressed ; and shows us what is possible to be done. How important, then, to acquire a knowledge of the primitive faculties of man, and the laws by which they are regulated in their natural development, or influenced by artificial training. Nor is the necessity for such knowledge confined to the system more immediately connected with mental manifestation. The same holds good respectr ing all the other systems in the body, muscular, circulatory, and digestive, as well as nervous ; for without due attention to each, we shall not be able to do justice to any, nor secure for the whole its best advantages during the period of development or growth. With regard to the general growth of the body, and the advance in height, weight, and strength, differences arise from age and sex ; and these have been accurately investigated by M. Quetelet.* According to him, the average weight of the male infant at birth, is about half a pound more than that of the female, and the length about an inch more ; and the annual growth of the female infant is less than that of the male, but her development is more early com- pleted. Immediately after birth, the weight of the infant is found to diminish ; nor does it begin again sensibly to increase until after the first week. The growth of the stature is most rapid during the first year, when it amounts to nearly eight inches; it is less rapid as the child ap- proaches the fourth or fifth year, appearing to diminish in direct ratio to the age, up to that time ; the growth in the second year being only half that of the first ; in the third year,t only one-third ; but afterwards it increases with a tolerably regular progression. A remarkable difference is often to be observed in the degree of development, or proportional growth of one organ or system of organs more than another, and in the consequent predominance of the class of functions which this system of organs performs. In some children the head is very large, and great liveliness and intelligence are early displayed, the cerebrospinal system of nerves being that which pre- ponderates ; and this lays the foundation for a particular tempera- ment, which, according to the rational view of M. Thomas,^ would, in this instance, be the cranial or nervous temperament. * Sur l'Homme et le Developpement de ses Facultes, &c, &c. t It is a popular observation that the height is never more than doubled after the third year, the maximum medium, particularly in females, being attained at that age. [Note to 4th Edition.] t See Physiologie des Temperamens ou Constitutions, &c, &c, par F. Thomas, 30 PECULIARITIES OF INFANTS. Iii other children, great muscular power is early displayed, the chest is large, the body well nourished, and the complexion florid. This constitutes the thoracic, or, as it is more commonly called, the sanguineous temperament — the circulatory system predominating. The child is strong and active, but not particularly intelligent. When the abdomen is very large, and the circulation languid,— the child being pale, indolent, and dull, with a large appetite, but little activity of mind or body, — the abdominal organs preponderate, and the temperament is abdominal or lymphatic. The expression of the countenance or form of the features is also some indication of the temperament. Thus, the development of the forehead indicates the proportion of the encephalon : the part between the forehead and mouth is, in general, in harmony with the develop- ment of the thorax : while the lower part of the face is in relation to the size of the abdomen ; so that in each we have an index of the temperament, whether cranial, thoracic, or abdominal. Other varietes of temperament exist ; and in some individuals no temperament is strongly marked ; or more than one are mixed together ; — the mixed temperament existing, when the cavities bear an exact proportion to each other. In infancy and childhood the abdominal temperament has a tendency to prevail. The nervous or cranial becomes more particularly manifest at or after the age of seven ; when, as we have seen, the brain attains a full development, while the thoracic rather belongs to a later period, when the thoracic organs (at first so little developed) begin considerably to increase. Attention to this subject is important, as modifying our plan of management both in health and disease. These varieties of constitution may be born with the child, or looked on as hereditary : but they will be much influenced by the manner in which the individual is managed ; according as one system of organs, or another, is exercised or neglected. The great principle that should guide us is, to afford to all and each its proper or appro- priate share of exercise or occupation, so as to strengthen and even enlarge the weak or ill-developed organs ; while we repress those that are disproportionately developed, or over active, by consigning them to quiescence. To be enabled to do this, however, we must study the subject as physiologists. Thus have we, in a brief and summary manner, sketched those peculiarities of infancy, a knowledge of which must serve as our guide in understanding aright the management of children in health or disease. This object we have kept exclusively in view, and re- sisted the temptation of pursuing any of these subjects, however interesting, further than the end proposed would warrant. We have seen the infant presented to us, in the first instance, as a mere vegetative being, with the organs of nutritive life preponder- ating in development and activity. As growth proceeds, however, the little being asserts its claim to a higher order of existence. The organs of organic life diminish relatively in importance, while those of animal life advance, and ultimately preponderate — the infant becomes a rational being. MANAGEMENT IMMEDIATELY AFTER BIRTH. 31 To promote this preponderance, and ensure the mens sana in cor- pore sano, is the great end proposed in the rearing and management of children. The principles by which we are to be guided in our attempts to attain this object, have been already pointed out ; and the manner in which these principles are to be carried into effect, will constitute a chief part of the subjects treated of in the two ensuing chapters. CHAPTER II. MANAGEMENT AND PHYSICAL EDUCATION OF CHILDREN. In the consideration of the subject of this chapter, we shall adopt the division already made, into the two epochs of infancy and child- hood ; and shall, therefore, first proceed to consider the management of the infant directly after its birth. I. MANAGEMENT IMMEDIATELY AFTER BIRTH WASHING AND DRESSING. Let us suppose a healthy child to be placed in our hands immedi- ately after birth : the duty of the accoucheur having been duly per- formed, any mucus, or other matter likely to obstruct its breathing, has been removed from its mouth, and the cord has been tied and divided at the distance of three or four inches from its navel. The young being will be observed to cry stoutly, and to move its limbs in such a manner as forcibly to convey to us the impression that it is suffering pain, which we can readily account for, when we recollect that it has experienced a sudden transition of temperature, from the heat of the mother's body, about 9S°, to that of the atmosphere, which, at the highest, will seldom exceed 70°. The production of pain, however, is but a necessary consequence of the access of air to the surface of the body ; which in itself is highly beneficial, exercis- ing, as we learn from the ingenious researches of Dr. Edwards,* a vivifying influence, well calculated to counteract the greater or lesser degree of insensibility induced by the pressure to which the brain is subjected during birth. The pain, also, by exciting the infant to cry, contributes materially to the perfect filling of the lungs with air ; the non-effecting of which, as we shall subsequently find, is not unfre- quently attended by fatal results. Such are the good effects of ex- posure to cold ; it should however be but momentary, as its continu- ance would certainly be productive of the worst consequences to the well-being, and even existence of the child. " Instinct," says Dr. Edwards, " leads mothers to keep their infants warm, though philosophers, by more or less specious reasoning, have, * Dr. Edwards on the Influence of Physical Agents on Life. Translated by Drs. Hodgkin and Fisher. (Published in the Select Medical Library.) 3 o MANAGEMENT OF CHILDREN. at different times, and in different countries, induced them to abandon this guide, by persuading them that external cold would fortify the constitutions of their children, as it does those of adults." To this distinguished physiologist we are indebted for the observations, that the heat of mature infants at birth, is from 3° to 5° less than that of adults — varying between 93° and 95°; that the heat of premature infants is still less ; and that the power of producing heat being, in all young animals, at its minimum at birth, they have not the same capability, as adults, of resisting a diminution of their temperature, from exposure to cold. From Dr. E.'s discoveries, indeed, we are fully warranted in concluding that the philosophers of whom he speaks are in the wrong ; and that nature has, with her usual wis- dom, conferred a proper instinct upon mothers, in teaching them to keep their offspring warm. It is for us, therefore, immediately upon taking charge of the newly-born child, to have it well wrapped up in soft, warm flannel; to take care that, in cold weather, it shall be dressed in the neighbourhood of a comfortable fire ; and that, during the operation, it shall not be unnecessarily exposed to cold.* When we examine more carefully the body of the infant, we shall find that it is more or less covered with a white, greasy, or curd-like substance. This is denominated the vernix caseosa, and appears to be provided for the purpose of defending the tender skin from the in- jurious effects of the warm, aqueous fluid in which it floats while in its mother's womb. After birth this coating has no useful purpose to serve; and would be injurious, by obstructing the pores of the skin, and by intercepting the vivifying influence of the air of which we have already spoken.t It is, therefore, advisable to remove it ; and, accordingly, the first act of the nurse is, to wash the new-born child. The washing should be performed with warm water, and a fine sponge, and as the soft bones of the infant render it unfit to bear much pressure from the hands, the operation will be most safely and * The views of Dr. Edwards have been practically confirmed by some observa- tions of Dr. Milne Edwards, and Dr. Villerme. It is the custom in France, to convey infants, within a few hours of their birth, to the office of the mayor of the commune, in order that their birth may be registered ; and Drs. E. and V. discovered that the proportion of deaths, within a very limited period after birth, compared with the total births, was much greater in winter than in summer, — in the northern and colder, than in the southern and warmer departments, — and in parishes where the inhabitants were scattered over a large surface of ground, than in others, where they were more closely congregated round the mayor. f If any authority were wanting for the removal of the vernix caseosa, we have it in the practice, which obtains universally among animals, of licking their offspring immediately after birth. [Note to 1st Edition.] In a note by the German translator of this work, we find Oesterlen (CEtiol. und Pathol, der Krankheiten neugeborner Kinder. Heidelberger Klinische Jlnnalen Iter Band Istes Heft 1831), quoted in support of a different view of this subject. This author, it appears, is of opinion that the chief use of the vernix caseosa is found subsequent to birth, and that it is designed to protect the skin from the overstimulating effects of the oxygen of the atmosphere. He states that premature children have a smaller quantity of this covering than those born at the full time, and that the deficiency is in proportion to the immatureness. Such has not been the result of our observations, nor have we noticed the ill consequences which he attributes to the removal of the vernix caseosa, viz., aphthae, jaundice, and ophthalmia. [Note to 4th Edition.] MANAGEMENT IMMEDIATELY AFTER BIRTH. 33 conveniently effected by placing the body and limbs in a basin con- taining a sufficient quantity of water to cover them, while the head is suffered to rest upon the left arm of the nurse. The eyes should be washed with particular care, and clean water used for this purpose, as the allowing of impurities to remain in contact with these tender organs is the most common cause of the dangerous ophthalmia of infants. All extraneous matters should also be removed from the folds of the skin in the groins, arm-pits, &c. ; but no force likely to hurt the surface should be employed, nor need any extraordinary anxiety be felt for the perfect removal of the vernix, as it never fails to dry and scale off in a day or two : we have not found soap to be required, although it is recommended by many writers. In this country, where whiskey is in universal use, the nurses generally employ a little of it for washing the child's head, under the idea that it prevents the taking of cold. This practice is certainly not a neces- sary one in ordinary cases ; but at the same time, it does not appear to be attended with any injurious consequences : and when we can say so much for any popular custom, it is as well to let people have their way, and direct our attention the more closely to the prevention of such interference as may be really prejudicial. [Even if the practice could be viewed as one productive of neither beneficial nor injurious effects, it is better that the physician should discountenance it: but as washing the head of a new-born child with ardent spirits must produce more or less irritation of the scalp — especially where the application of the spirits is repeated daily, as we have known it to be, for weeks or even months — the custom should be denounced as one decidedly prejudicial. — C] The washing having been accomplished, with as little delay as pos- sible, and the surface carefully dried with a soft napkin, the next business of the nurse is, to dress her charge. This process is com- menced by an arrangement for the protection of the remnant of the navel string. The cut surface of this should be carefully examined, lest, as frequently happens, secondary bleeding should take place, in consequence of the loosening of the ligature, dependent on the oozing out of the gelatinous fluid, which makes the bulk of the cord. This occurrence is most likely to take place when the cord is particularly thick ; and the gelatinous fluid very abundant, as the pressure of the ligature is then less directly applied to the vessels ; when hemorrhage has taken place, a fresh ligature must be applied firmly, and its ends cut off close to the knot. The cord is then to be drawn through a small circular hole, cut in a piece of old linen, about four or five inches in diameter, which is to be gently folded around it. In the prepara- tion of this envelope, nurses are particularly anxious to have it ex- tremely dry and warm. It is always held carefully to the fire, and sometimes even scorched, before they will permit its application — a prejudice which is certainly harmless, and probably but one indica- tion of the general instinct which teaches them that a new-born infant 3 4 MANAGEMENT OF CHILDREN. requires its heat to be carefully husbanded.* The cord, thus enve- loped, is to be placed flat on the child's abdomen, and secured there by a band of thin flannel, five or six inches broad, and long enough to go twice round the body. The chief use of this band is, to support the navel-string and its covering : we cannot think that it is required, as Dr. Deweest supposes, as a support to the abdomen ; indeed, it never should be applied so as to make any pressure upon that cavity ; and on that account, it is well to have it made of the thinnest flannel, cut diagonally or bias, so as that it may be perfectly elastic. In fast- ening it, pins are usually employed ; but the fewer of these used in dressing an infant, the better ; and it would be well, if we could have strings substituted for them in every possible case. The further dressing of the body of the child, is very much a matter of fashion, with which the physician has little to do further than to see that the clothing is light, soft, and sufficiently warm, and not calculated to place any restrictions upon the movements of the chest, abdomen, or limbs. It would now be a work of supererogation, in this country, to denounce the swaddling of the limbs practised in former times ; but we cannot too forcibly impress the necessity of avoiding all constric- tion or pressure upon the chest or abdomen. The due performance of respiration is of the first importance to the young as well as to the adult animal, and this will be materially impeded by any restriction upon the free motion of the ribs or diaphragm such as would be occa- sioned by tight bandages upon the body of the child. The arrange- ment of the head-dress must be conducted upon principles similar to those which guide us with respect to the other clothing : the head is to be protected from the cold air by a moderately thick, muslin cap, but so as that it shall neither suffer compression, nor be placed in a constrained position. Over all, a thin flannel shawl is to be wrapped in such a way as will not impede the free access of air to the mouth, or hamper the extremities, so as to prevent their spontaneous move- ments. The infant is then to be placed in a cradle or bed, so situated, as that it shall not be exposed to draughts of cold air ; and that, while it is not absolutely in the dark, still its eyes may be protected from a strong light, which, as yet, they are unable to endure : thus placed, it will usually fall asleep, and remain so for several hours, until awakened by the calls of hunger. [The use of a cap for young infants is unnecessary — as the head may be effectually protected from the effects of cold without it. Caps are much more likely to produce injury than benefit, and we are happy to find that they are rapidly falling into disuse.— C] * As a curious instance of this dread of abstracting heat from the child, we often find the peasants of this country carefully warming the scissors, before using it for the division of the cord. It is easy, and, no doubt, appears scientific, to ridicule popular customs and superstitions ; but would it not be more discreet and philoso- phical, to endeavour to discover their origin from some instinct to which thev mav generally be traced 1 J J f On Physical and Medical Treatment of Children. London, 1826.. FOOD AND MEDICINE IMMEDIATELY AFTER BIRTH. 35 II. FOOD AND MEDICINE IMMEDIATELY AFTER BIRTH. During foetal existence, the various organs designed for the per- formance of digestion, produce a greater or lesser quantity of their peculiar secretions ; and, as there is no exit provided for these, they accumulate in the intestines of the child, constituting the dark green, or brownish, pitch-like substance denominated meconium. By many persons even at the present day, the retention of this meconium is supposed to exert a most baneful influence upon the health of the child ; and it is believed that no time should be lost in effecting its speedy removal. Accordingly, very few children in this country are fortunate enough to escape being dosed with castor oil, immediately upon their arrival in the world : and many are obliged to undergo the additional peril of having a quantity of calomel forced down their throats. Neither of these practices, however, is constantly neces- sary, and the last is positively injurious : the delicate mucous mem- brane of the child's intestines, only fitted for the reception of the mildest nutriment, is always injured by the operation of a medicine so active and so irritating as calomel. To the milder action of castor oil, the same objection does not apply ; and where the abdomen of the child is full, and no evacuation takes place for five or six hours after birth, it will usually be found advantageous to administer half a drachm of oil, provided we can procure it fresh, and free from rancidity.* We are, however, decidedly of opinion, that it is better and more natural to allow an infant to sleep quietly for five or six hours after birth ; and not, before that period, to disturb it, or irritate its stomach, by the administration of anything whatsoever. Those who advise the immediate employment of purgatives, assert that such practice is consistent with the plans of nature,t inasmuch as they suppose the milk first secreted by the mother (or colostrum, as it is termed), to possess a purgative property. The argument is obvi- ously a contradictory one ; for, if nature herself provides a purgative, why should we seek to supersede her efforts by artificial means ? The fact, however, of the first milk being purgative, is not proved, and is altogether denied by some.J It is probable that it possesses no specific purgative quality, but excites the intestines merely by mechanical distention, and so in effect produces expulsion of the meconium, as other food is found to do, in cases in which it is given in consequence of the secretion of milk not being established in the mother's breasts, for two or three days after labour. So much for medicine, immediately after birth ; and upon the same principle, viz., that sleep is what the infant most requires, we do not think it necessary to give it food, for some hours. Should the mother be able to supply the natural nutriment at the end of * This is a matter of considerable importance. In the interior of Germany, where, inconsequence of the long land-carriage to which it is subjected, castor-oil is almost universally rancid, this purgative is considered as peculiarly irritating. [Note to 3d Edition.] + Dewees. % Jdrg, Handbuch zum Erkennen u. Heilen der Kinderkrankheiten. 36 MANAGEMENT OF CHILDREN. eight or ten hours, or even earlier, as is often the case, we think th infant should then be applied to the breast; and that it is highl desirable to avoid giving, in the interim, any other food whatsoevei Should the secretion of milk not be perfectly established for two o three days, as sometimes happens, the child will be cross and evinc signs of hunger, and we shall then generally find it necessary to give small quantity of thin gruel, mixed with a little milk. Even in thes cases, Professor Jorg recommends, that nothing should be given bu a few teaspoonfuls of lukewarm water ; and we happen to knov that such is his practice, without any bad results, in the Lying-i: Hospital of Leipzig. Notwithstanding this, however, should it no be practicable to have the child suckled within ten or twelve hour after birth, we think it advisable to give, every five or six hours, : few teaspoonfuls of such food as has been mentioned above, but t desist immediately upon a nurse being procured, or the mothe becoming herself capable of supplying sufficient nourishment. Having premised thus much respecting the attentions required b; the infant immediately upon its entrance into the world, we sha now proceed to consider its further management with regard to fooc cleanliness, clothing, sleep, exercise, medicine, and the action upo. it of physical agents, as light, air, and heat. III. FOOD IN THE FIRST PERIOD. It is unnecessary to go at any length into the question of the pro priety of mothers nursing their own children; the weight of th» moral and physical considerations which leave no choice as to th< propriety of obeying the dictates of nature, being now universally acknowledged. Women are not, at least at the present time, and ii these countries, the unnatural deserters of their offspring that sys tematic writers would lead us to suppose ; and, we think, mos experienced physicians will join us in declaring, that our duty les frequently is, to urge maternal nursing, than to explain, and ever enforce, in individual instances, the exceptional causes whereby nature herself sometimes renders it impossible or inexpedient to com ply with her general law. We are, in fact, oftener obliged to sav< an infant from destruction, and a delicate mother from injury, b] forbidding ineffectual attempts at nursing, on the part of the latter than we are called upon to remind a robust and healthy parent o the urgency of the natural claims upon her. We shall therefore assume, as a general rule, that all mothers should nurse their owi children ; and merely indicate those cases in which it become; necessary to substitute another mode of rearing the child. Women who labour under any mortal or weakening disease, — a: phthisis, hemorrhages, epilepsy, &c, — are obviously disqualifiec for the office of nurse ; some, who are in other respects healthy have breasts incapable of secreting a sufficient supply of milk, anc this may be temporarily the case with one child (especially the first) while upon other occasions the same individuals make excellem nurses. In other instances the breast may perform its function* FOOD IN THE FIRST PERIOD. 37 well, but the nipple may be naturally so small, or may be so com- pletely obliterated by the pressure of tight stays, as not to admit of its being laid hold of by the child. These are actual, physical hindrances to nursing. Again, women may, and in the higher classes frequently do, possess such extremely sensitive and excitable temperaments as will render it imprudent for them to suckle their own children. Frightened and excited by every accidental change in the infant's countenance, and inordinately moved by the common agitations of life, such persons are kept by their own tenderness, and over-anxious desire to do their duty, in a state of continual fever, which materially interferes with the formation of milk, both as to quantity and quality. Women, also, who become mothers for the first time at a late period of life, have seldom the flexibility of disposition, or the physical aptitude for secretion of milk, required to constitute a good nurse. Another disqualification for nursing we must notice, although we hope and believe that it is rarely observ- able among our countrywomen : if women of fashion are not con- tented to give up their engagements in society in favour of their domestic duties, it is better for them not to undertake the latter — " In this matter," says Wendt, " it is better to do nothing than only half." We have already stated, that the child should be put to the breast as soon as the latter contains anything for it to extract ; this gene- rally happens when the mother's system has been relieved, by sleep and ten or twelve hours' rest, from the fever which is always more or less attendant upon labour. Unless there has been some secretion of milk, it is better not to apply the child, as it becomes disappointed by continued ineffectual attempts at obtaining nourishment, and there may subsequently be some difficulty in getting it to engage seriously in the business of sucking.* As soon, however, as it has fairly commenced, it will require no other food ; and if the mother be a good nurse, she should be able to support her infant indepen- dently of artificial nutriment, during at least two-thirds of the period of infancy, — that is to say, until the seventh or eighth month. About that time the teeth usually begin to appear, indicating that the digestive system is assuming a capability of doing more work than it was adequate to at first ; and, accordingly, we should then, taking the hint from nature, begin gradually to train and exercise its powers. The suckling of the infant, which during the first months should be performed at regular intervals of about four hours, should now be repeated not more than three or four times during the day and night ; and twice during the same period some artificial food should be given. This at first may consist of soft bread, steeped in hot water, with the addition of a little sugar and fresh cow's milk ; * We have heard the propriety of the advice given above, called into question. Practical men will, however, have no difficulty in understanding the advantage of preventing the disappointment to the child, and the injury to the nipple itself, some- times occasioned by protracted drawing at an absolutely empty breast : this is the utmost extent of delay which we wished to recommend, and to this recommendation we must still adhere. [Note to 2d Edition.] 4 3S MANAGEMENT OF CHILDREN. subsequently some light broth, free from fat and vegetable matters, may be given once during the day. With respect to the rnode of feeding at this period, the spoon will be the best vehicle, as it is an object to give food somewhat more solid than could be drawn through the sucking bottle. The child, however, should not be placed hori- zontally on its back, and gorged until it is rilled to the throat, as is often done ; but its head should be kept elevated, and its actions be carefully attended to, so that we may know, and at once stop, the moment it appears to be satisfied. During the first five or six months, the infant must be suckled during the night as well as the day, but this should be done at the regular intervals of four hours ; and if it sleeps with the mother or nurse, the nipple should not be allowed to remain in its mouth, as it is not our object to keep the stomach constantly full, but to give it time, when filled, to digest its contents. A child nursed as we have recommended, will be found to awaken, with a good deal of regu- larity, at the proper periods for its meals. During the process of weaning, the intervals between the times of suckling at night, may be at first gradually lengthened ; but in order to ensure unbroken rest, at a subsequent period, both for the attendants and the child itself, it is very desirable not to accustom it to receive any artificial nourishment during the hours proper for sleep. In nursing, the infant should be put alternately to each breast ; as a neglect of this precaution will frequently be followed by an un- equal lateral growth of the body, limbs, and even head ; and some- times by squinting. Such deformities (all except that last named) are commonly not permanent ; disappearing as the child grows ; but it is better to avoid them in the first instance. We have been hitherto supposing the mother to be a perfect nurse, and the relative supply and demand to be well adjusted between her and her infant ; but these are not exactly the cases which we always meet with in practice. We shall frequently have a demand greater than the supply, long before the seventh or eighth month ; and in such instances, we shall be obliged to give food at an earlier period, and often find it to agree well, if its kind and administration be regulated upon the rules just laid down. The great maxim to be observed is, not to let the infant want nourishment which will agree with it. If this can be furnished by the mother alone, so much the better ; if the deficiency'can be supplied by artificial food without the infant suffering, there will be no necessity for making any further change : but if neither of these conditions obtain, we must have recourse to a strange nurse. As we have stated it to be desirable, that as much as possible of the infant's nourishment should be derived from the nurse, it of course becomes an object to render our source of supply as available as may be ; and we are, therefore, legitimately called upon to consider how this may be done most efficiently. The grand secret, in a word, is, to keep the nurse in good health ; if we succeed in this, we render the milk, both as to quantity and quality, as good as it can be pro- duced by the individual. Now, how is this to be done ? Is it by CHOICE OF A NURSE. gg overloading the stomach by a mass of indigestible food and drinks, and keeping the system under a continued fever of digestion ? or, is it not rather by allowing the person to live, as much as possible, in the manner customary with her, supposing that to be one which has hitherto preserved her in good health, — permitting her to eat her usual meals, which she will probably do with increased appetite, and not inculcating upon her the necessity of taking drinks more stimu- lating, or in larger quantities (relatively with her probably increased consumption of food), than she has been in the habit of using ? With hired nurses, it is especially necessary to act upon the principle just laid down ; for these persons, coming from the scanty table of their own homes, are apt to indulge their appetites, from mere novelty, if, as is usually the case, their employers show any disposition towards the encouragement of a stall-feeding system. Nurses should not be kept upon any one description of food exclusively, but should have, as is natural, a wholesome, mixed, animal and vegetable diet, with or without wine, according as they may have been accustomed to live ; but we may, perhaps, allow them, with advantage, somewhat of an extra, though never an unreasonable quantity of malt drink, providing always that it be found to agree with their digestive system. [Wine and malt drinks are neither proper nor necessary additions to the diet of nurses. A healthy nurse requires nothing beyond good wholesome food of easy digestion, and water as a drink. — C] The catemenia, in some instances, appears in a nursing woman, and, where it does, is likely to interfere with the thriving of the child Whenever, therefore, we find an infant becoming thin, weakly and cross, without any sufficient cause being assignable, we should inquire into this circumstance, and if a change has occurred, it will generally be found advisable to procure another nurse ; or to anticipate the time of weaning. Irritability of temper, and indulgence in passion, interfere with the secretion of milk to such an extent, that a child has been known to be attacked with convulsions immediately after being suckled by a nurse, who was at the time suffering under the effects of a fit of anger. A knowledge of this circumstance influences many persons to indulge nurses in the most extravagant whims, lest their temper should be crossed, and the child thereby injured. Irritable persons are, unquestionably, unfitted to nurse or manage children ; but we apprehend, that over-indulgence is not the way to improve temper : and as we fear that the most learned diatribe from us, would have little efficacy in supplying a good disposition where Providence has not created it, we shall not pursue this subject farther. IV. CHOICE OP A NURSE. When circumstances prevent a parent from suckling her own child, it is important that we should have some principle to guide us in our selection of a strange nurse. Medical men are constantly asked for 40 MANAGEMENT OF CHILDREN. an opinion upon this subject, aud we shall therefore lay down a few rules, which may be useful in enabling us to form one. The great thing we have to look to is, to ascertain that both woman and child are in good health ; and of this we must endeavour to judge from the following signs: — The woman's general appearance and form should be observed ; and they ought to be such as betoken a sound constitution. Her skin should be free from eruptions ; her tongue clean, and indicating a healthy digestion ; her gums and teeth sound and perfect ; the breasts should be firm, and well formed, — not too large or flabby, — and with perfect, well-developed nipples. We should see that the milk flows freely, upon slight pressure ; and we should allow a little of it to remain in a glass, in order that we may j udge of its quality.* It should be thin, and of a bluish-white colour ; sweet to the taste ; and when allowed to stand, should throw up a considerable quantity of cream. A nurse should not be old ; but it is better that she should have had one or two children before, as she will then be likely to have more milk, and may also be supposed to have acquired experience in the management of infants. The more recently the nurse's own confinement has taken place, provided she has recovered from its effects, the better, as we may count upon her services so much the longer. It is, however, not generally a serious objection should two or three months have elapsed after that event. Having examined the mother, we must next turn to the child, which should be well nourished, clean, and free from eruptions, especially on the head and buttocks. We should, also, carefully examine its mouth, to ascertain that it is free from sores or aphthae. If both woman and child bear such an examination as we have mentioned, we may, with tolerable security, pronounce the former to be likely to prove a good nurse.t V. ARTIFICIAL FEEDING. What we have already stated as to the management of an infant's food, negatives altogether the question of the propriety of ever choosing to rear a child entirely by artificial feeding. Certain cases, however, * N urses who have not a good supply of milk will, occasionally, be found to adopt a practice commonly employed with milch cows when brought to market, and called by the cattle dealers stocking ,- that is, they allow the milk to accumulate in their breasts for several hours before presenting themselves for examination, so as to cause the examiner to believe that they are very abundantly provided. Young prac- titioners should be especially on their guard against this deception. | The following is the beau ideal of a good nurse, according to Wendt. Some of its Germanisms may amuse. "Youth, fulness of health, plenty of milk, and a good build of breasts and nipples — a rather phlegmatic temperament, — a quiet disposition, and no inclination to sensuality or dissolute habits, — a white, delicate skin, traversed by blue veins, and covered with freckles, — fair or reddish hair, large blue eyes, sound teeth, a fresh breath, a clean skin, no disagreeable odour, no unnatural discharges, a bluish-white, — rather thin, than thick and tenacious milk, which, dropped upon the thumb-nail, flows off rather quickly, — it should have no smell, and a mildly-sweet taste, — along with these, large and firm nipples, a cleanly person, and a harmless temper, — form the ideal of a good nurse." — Die Kinder- krankheiten syslematisch dargestellt von Dr. Johann Wendt. Wien, 1827, 2tc ausgabe. ARTIFICIAL FEEDING. 41 occur, in which we have no alternative. Peculiar circumstances may preclude the possibility of procuring a nurse ; or an infant, whose mother is incapable of nourishing it, may be the subject of some contagious disease, to contamination by which, we cannot, in common honesty, permit a stranger to be exposed. The necessity of resorting occasionally to artificial feeding, obliges us, therefore, to consider how we can render it least injurious, for such is really the question ; although, we do not mean to deny, that in certain instances extremely healthy children have been reared in this way. These are, notwith- standing, but exceptions ; for a very extended experience, in different countries, has proved that spoon-feeding is generally unsuccessful. The kind of artificial food proper to be employed, forms the subject of our first inquiry ; and, as a general rule, we may say, that it should be as like the natural nutriment as possible. This rule, however, is easier laid down, than acted upon ; "for nature," says Dr. Prout, " will not permit the chemist to officiate as her journeyman, even in the most trifling degree.* In the present state of our knowledge, then, it is vain to attempt any preparation, upon chemical principles, of a food resembling human milk. It will be better to be satisfied with employing the food of some other young animal, and modifying it, so as to make its sensible properties, as nearly as possible, similar to the milk in question. For this purpose, good cow's milk is usually the most convenient ; and as it is thicker and whiter, and not so sweet as human milk, we may add to two parts of it, one of very thin barley water, and sufficient white sugar to make the necessary increase in sweetness. Asses' milk approaches more nearly, in sen- sible properties, to what we require ; but it is richer, and requires to be diluted with about a third part of water. So modified, it maybe used, if the cow's milk disagrees, or it can be conveniently procured. As the child becomes a little older, thin bread pap, made as we have already directed,! may be advantageously employed ; and it will also be advisable to give, occasionally, some light beef or chicken tea. In managing spoon-feeding, all our ingenuity will frequently be required for varying the kinds of food ; as one which agrees well with the infant at first, may, after a little, derange the bowels, — producing acidity, gripes, and purging, or perhaps costiveness. Thus, prepared barley, dressed with water and unboiled milk, will some- times purge, — an effect which may be obviated by having the milk boiled. In other cases, we must employ arrow-root, for a short time, for the purpose of restraining the bowels, and again recur to the barley when costiveness has been produced. A great matter is accomplished, if we can prevent the production of acid fermentation in the stomach and bowels ; and, on this account, we must be most particular in requiring every article of food to be freshly prepared before use, and in enforcing the strictest attention to cleanliness with respect to every vessel employed. All kinds of food should be used tepid or luke- warm ; that is, at about 96°, or 98°, F., the natural temperature of milk, as it would be obtained from the breast by sucking. * Gulstonian Lecture, 1831. f Page 37. 4* 42 MANAGEMENT OF CHILDREN. Our second inquiry relates to the mode of administering artificial food. This may be accomplished either with the spoon or sucking- bottle.* The former has the advantage of leaving less opportunity for uncleanliness, as a spoon is easily washed, and its condition at once perceptible ; while the bottle may appear clean, and yet contain a leaven of acidity, which will do material injury. On the other hand, the bottle has the advantage of giving out the food in a mode somewhat analogous to that employed by nature ; with it the child has some trouble in procuring what it wants, and will therefore not be likely to take too much ; the action of sucking must also be prac- tised, whereby a degree of pressure is made upon the child's salivary glands, and the necessary secretion from these organs, in all proba- bility, usefully promoted. In the earlier periods, we think, the bottle possesses, in these respects, decided advantages ; but while using it, too much precaution cannot be taken to secure cleanliness. No food should ever be allowed to remain in it after the infant has been fed ; and there should always be two bottles in the nursery, in order that one may be exposed to the air, and dried, while the other is in use.t VI. WEANING. The time of weaning, we have already intimated, should be that indicated by nature, (that is to say, between the seventh and twelfth months in ordinary cases,) when, by providing the child with teeth, she furnishes it with the means of obtaining nourishment from sub- stances of a somewhat solid form. The mode of weaning may be easily deduced from the rules which we have laid down for the feeding of the infant. If it has been gradually accustomed to a dimi- nished supply of maternal, and an increase of artificial food, weaning will be an easy process, and a great deal of suffering will be spared both to parent and offspring. No violent change should be made ; and by proceeding gradually, the child will come to prefer artificial food contemporaneously with the failure of the maternal supply. This is what the term weaning imports, and this is the mode in which U should be accomplished, VII. FOOD IN THE SECOND PERIOD. For some time after weaning, the child's food should consist of those materials which we have mentioned as proper during the latter months of suckling. Regularity in the times of feeding, is probably ot nearly as much importance as the quality of the food itself. No definite rules, however, can be laid down, as to particular hours, as much must be dependent upon the habits of the child, and of its nri*fi, TheSe b0 ! tleS . have a narrow neck ' about the size of the ni PPle, with a small sack. :ZT% W £u a teat u of u w J Mh ^ sh ammy leather, through which the infant sucks the food I hey can be had at any druggist's, ready for use. and ohp^f \ -♦ BrUck ,e*au, has written a book to prove that goats are the best ktotm 8 Toan^ n n Se ^- *•*"" would ^difficult to introduce the practice into this country,~£ te Ziege als beste u. wohlfeihte Saugamme, 1816, 2r thtil 1819 FOOD IN THE SECOND PERIOD. 43 guardians, as to sleep, &c. ; but the general principles should, under all circumstances, be observed, of permitting no variation, from day to day, in the time for the different meals, and of not breaking in upon these by giving food at irregular periods ; while, at the same time, protracted fasting must not be allowed. During the day-time, about four hours is quite sufficient interval between any two meals : this will give time enough, in children, for the stomach, and commence- ment of the small intestines, to perform their offices in the process of digestion, and allow the former an opportunity of recovering energy after the discharge of its function.* It is better not to allow a child to acquire a habit of being fed during the night, as uninterrupted sleep is what they then require most ; to ensure which, it is neces- sary that the stomach should be in a state of comparative rest. Per- haps, the best mode in which we can illustrate our ideas with respect to the plan upon which a child should be fed, will be, to describe specifically a day's feeding of a healthy child, — premising that we do not mean to enforce a literal observance of certain hours, &c, specified, but merely to give an example of the working of the prin- ciples we have laid down. A healthy child, of two or three years old, commonly awakes hungry and thirsty, at five or six o'clock in the morning ; sometimes even earlier. Immediately after awaking, a little bread and sweet milk should be given to it, or (when the child is too young to eat bread) a little bread pap. The latter should be warm ; but in the former case, the bread may be eaten from the hand, and the milk allowed to be drunk cold, as it as well, at this meal, to furnish no inducement for eating, beyond that of hunger. After eating, the child will generally sleep again for an hour or two ; and about nine o'clock, it should get its second meal, of bread softened in hot water, which latter is to be drained off, and fresh milk, and a little sugar, added to the bread. Between one and two, the child may have dinner, consisting, at the younger ages, of beef, mutton, or chicken broth (deprived of all fat), and bread. When a sufficient number of teeth are developed to admit of chewing being performed, a little animal food, as chicken, roast or boiled mutton, or beef, not too much dressed, should be allowed, with a potato or bread, and some fresh, well-dressed vegetable, as turnips or cauliflower. After dinner, some drink will be requisite ; and a healthy child requires, or indeed wishes for, nothing but water. Light, fresh table beer, would not be injurious to a child of four or five years old; but it is unnecessary, and no advantage would, in this instance, result from the creation of a new want. a Between six and seven o'clock, the child may have a [Independently of the appetite for stimulating drinks which may be created by allowing children beer, it will in most cases produce a directly injurious effect upon their stomachs, and thus disturb the regular nutrition of their bodies. — C.J * The importance of not setting the stomach to work during the latter stages of digestion, is well put by Dr. Paris, in his able article on Dietetics, in the Cyc. of Pract, Med, The maxim should be carefully attended to in feeding children. 44 MANAGEMENT OF CHILDREN. its last meal, of bread steeped in water, &c, as at nine o'clock in the morning. A healthy child, who has been in the open air, during the greate/part of the day, will be ready for bed shortly after this last mentioned supply, and will require nothing more until next morning. Similar regimen and hours may be adopted throughout the whole period of childhood ; only, as the fourth or fifth year approaches, giving, for breakfast and supper, bread and milk, without water, and either warm or cold, according to the weather or the child's inclina- tion. The supply of food, upon first awaking in the morning, may also be gradually discontinued, and breakfast given somewhat earlier. The foregoing, we conceive, may fairly be offered as a model of a suitable diet for children ; but, as Dr. Barlow* judiciously observes, " No exclusive system can be right, nor can any precise rule of diet be possibly laid down, as this requires to be adapted, in every case, to the particular constitution concerned." With the stomach of one child, for example, so much milk as we have recommended may disagree, and produce acidity, and it may be advisable to substitute for it, tea or cocoa ; with another, a meat dinner every day may produce plethora, and it may be necessary to alternate it with rice, or some other vegetable substance. The constitution of the child, its habits of exposure to the air, and its residence in a city or the coun- try, must be taken into account ; and something must also be allowed for the customs of the community in which it is brought up. A judicious parent or physician will recollect all these matters ; and while, as we hope, they will be able to derive something like a foundation of principles, from our recommendations, they will yet recognize the expediency of occasional modifications in matters of detail. It is of great importance, that no preconceived system or theory, with respect to diet, should be assumed and adhered to, with unreflecting obstinacy, as is but too often the case. Thus one class of persons, arguing that the growth of a child requires an active nutrition, adopt the theory that an excess in the quantity or quality of nutritious matter supplied, cannot be committed. Such theorists are apt, by cramming and overloading the stomach, to cause the di- gestive powers to be impaired to such an extent as will prevent the food from being converted into nutriment, and so to produce the defect in supply of new material which it is their object to avoid. Others, observing a healthy remnant of potato-fed children in an Irish cabin, and hearing that the Hindoos live and thrive upon rice, in- stantly infer that scanty vegetable food is the true panacea for health and longevity ; and accordingly, condemn their offspring or patients to the miseries and perils of an insufficient, non-animal diet. Most unfounded prejudices are also taken up from ex-parte observations as to the wholesomeness or unwholesomeness of individual articles of food. Fruits, for instance, are under a general interdict from the dietary of children j and the consequence is, that the schoolboy, * See his excellent article on Physical Education, in the Cyc. Pract. Med. CLEANLINESS. 45 impelled by his instinct* on the one hand, and restrained by his ma- nagers on the other, devours, in secret, and often to his great injury, the unripe, ill-cultivated, and pernicious trash of the fruit-stall, instead of moderately using, as he should be permitted to do, such whole- some, cooling, and antiseptic fruit as the season may afford. Much learned trifling has also escaped from writers with respect to the pro- priety and necessity of " living naturally, and on such food as is presented to us by nature :" and we are often told that children should be fed upon bread and milk alone •, because the former is pre- pared by the simplest cookery, and the latter in what they call the laboratory of nature. Dr. Fordyce, however, has met the question, and settled it at once, by declaring that " man has no natural food." Let those who may be startled by this proposition call to their recol- lection the difference between the milk afforded by a cow kept alive upon the weeds and scanty vegetation of a neglected common, and one fed upon the riches of a pasture which has experienced the transforming power of cultivation ; let them recollect that the wheat, of which their so-called natural diet is composed, is itself the result of a long course of cultivation, and a full employment of all the re- sources of the complicated art of agriculture. " The potato/' says Dr. Paris, among many other examples, — " whose introduction has added so many millions to our population, derives its origin from a small and bitter root which grows wild in Chili, and at Monte Video."t The science of Dietetics is, in truth, an uncertain one ; any facts that we know respecting it, being liable to be influenced by many varying conditions, all of which should be taken into the considera- tion of every individual case ; and after all, no theory should be permitted the slightest weight in a particular instance in which it may be contradicted by experience. If an article of food, in favour of whose wholesomeness we have universal testimony, should dis- agree with a certain individual, its use with that person must not be insisted upon.J VIII. CLEANLINESS. The importance of the excretion from the skin is universally ac- knowledged, and is sufficiently proved by the amount of the daily perspiration, which was estimated by Lavoisier and Seguin at an average of lib. 14oz. in the adult.§ This discharge being natural *'We have the authority of Dr. Paris for the fact, " that artisans and labourers, in the confined manufactories of large towns, suffer prodigiously in their health, whenever a failure occurs in the crops of common fruits. This fact was remarkably striking in the years 1804 and 1805." — Art. Dietetics, in Cyc. Prac. Med. f Op. citat. X Some very unexpected facts and opinions with regard to the nutritive properties of various kinds of food have been lately brought forward in the Report of the Com- mission on Gelatin, to the Academy of Sciences of Paris. A translation of this remarkable document, in the preparation of which MM. Thenard, Dumas, Flourens, Serres, Breschet, and Magendie, were engaged during ten years, will be found in the Medical Press, vol. vi., p. 129, and will well repay the trouble of perusal. [Note to 4th Edition.] § Lavoisier's Traite Elementaire de Chimie. 46 MANAGEMENT OF CHILDREN. and essential for the preservation of health ; the necessity of remov- ing from the body of the child, any obstructions to it which might be offered by the adhesion of extraneous matters, must be sufficiently obvious. The beneficial action of the physical agents upon the sys- tem (of which we shall again speak), as these agents must act i through the medium of the skin, leads us to infer a similar necessity. The accumulation of impurities upon the surface will also be ob- served to produce very distressing excoriations, and even permanent i cutaneous diseases, which, when once established, are often with difficulty removed. With these considerations in view, we therefore feel authorised to advance the dogma, that too much attention cannot : be paid to the subject of cleanliness, during both periods of child- I hood. The infant's body, we have already stated, requires to be carefully washed immediately after birth ; and the same operation should be performed daily, until the child becomes old enough to attend to its own comforts. Washing should at first be performed with warm water and a fine sponge, — taking care, in the early periods, that no exposure be permitted long enough to produce an impression of cold. As the infant grows stronger, and when the weather is warm, we may gradually lessen the temperature of the water, until at length it may be used nearly quite cold. It is better, however, for the rea- sons assigned in p. 32, to be in no hurry about employing a perfectly cold bath; and under any circumstauces, we would not recommend water to be used without allowing it to remain in the nursery, during the night, in order that it may so acquire a slight increase of tempera- ture. 3 It is not necessary to use soap, except with parts of the body (as the hands and arms) which are particularly exposed to the re- ception of impurities ; even with these it should only occasionally be employed. Brown soap is better than white, as being less likely to cause cracking of the skin, which is often a source of much annoy- ance to the child. In all cases, great care should be taken to dry the surface well with a soft napkin, especially where there are folds of the skin, as between the nates, on the front of the neck, arm-pits, &c. A neglect of this precaution will be sure to occasion excoriation, and often troublesome sores. To make matters more secure, we shall do well in fat children, after carefui drying, to dust the skin, in such situations, with some fine dry powder, as hair powder, or starch a [Great caution must be observed in the use of a cold bath for a young child. If the infant be feeble, or from any cause debilitated, a ' perfectly cold bath/ or even one < nearly quite cold,' will be liable to produce decided injury. In young children, even of a perfectly robust constitution, if from any cause the surface of their bodies have become chilled, or they are at the time labouring under the effects of fatigue, immersing them in cold water is rather a dangerous experiment. Of so doubtful propriety, indeed, is the cold bath in cases of children generally, and so many circumstances occur to render its use alto- gether improper, that we should in all cases, especially during in- fancy and early childhood, prefer the tepid or warm bath. — C] CLOTHING. 47 finely levigated and sifted through a muslin bag. This will absorb the secretions from the surface, and prevent friction. While washing the infant, during the first few days of its life, attention must be paid to the condition of the navel-string. The linen in which we envelope this part immediately after birth usually adheres firmly to it ; and if it remains dry, we need not disturb it, but merely raise it gently, so as to admit of the abdomen underneath being carefully washed and dried. In ordinary cases, the cord dries up and falls off between the sixth and tenth days, ulceration taking place at the navel. A small healthy sore remains for a few days longer, which will commonly heal up without requiring any inter- ference, except the daily application of a piece of dry, old linen. The frequency of the discharges from the bowels and bladder of an infant, requires us to enforce especial care in changing the napkin placed for the reception of those matters — otherwise the skin will be injured, and disagreeable excoriations produced. We are to re- collect, that, in the natural state, these evacuations are regularly periodical ; and an observant nurse will soon discover the periods when they are about to take place, and not only anticipate them, but teach the child, at a very early age, to give intelligible warning of its necessities : the complaint is often made to us of a child's being dirty, but it may be relied upon that the fault is almost always with the nurse. Indeed, we have no doubt that an orderly education of these functions, commenced in the earliest infancy, will be the means of establishing a regularity of the bowels which will continue through- out the whole of life, — and the more tenaciously, because in such training we are not altering or improving nature, but merely work- ing in unison with her tendency to periodicity. As the child ad- vances, we must continue an unabated attention to cleanliness ; the hair must be carefully combed and brushed ; and the ears, eyes, and all other openings of passages from the interior of the body, must be kept perfectly clean, as well as the skin itself. By adopting such a line of conduct, we may count upon certainly preventing most of the eruptions, upon the scalp or skin, which have not been directly communicated by contagion, and of materially diminishing any ten- dency, that may exist, to scrofula, marasmus, or rickets. Mere washing would, of course, have little effect, if scrupulous exactness was not observed in making frequent changes of the child's clothes: an infant, or young child should have a complete change of dress every day ; and the linen of elder children should be changed very frequently, — so often as to prevent the accumulation of any impurity. IX. — CLOTHING. We have already dwelt, at sufficient length, upon the principles which should guide us in the clothing of an infant immediately after birth. They are, simply, to preserve a sufficient quantity of heat ; and to do so without setting any restrictions upon the free movements of all parts of the child's body and limbs ; or irritating 4g MANAGEMENT OF CHILDREN. its tender skin. Although the discoveries of Dr. Edwards, to which we have referred at the commencement of this chapter, lead directly to the establishment of the first principle now laid down, yet the subject is one of such great importance, and so much mystified by the phantasies of systematic writers, that we shall make no apology for the following long quotation. " It (mortality from cold) is not con- fined to children whom the misery of their parents cannot guard from the rigour of the weather, but it operates to a great extent, without being either perceived or suspected, in families enjoying affluence, and in which it is believed that the necessary precautions are taken, — because, cold being relative, it is difficult from our own feelings to judge of its effects on others, and because it does not always manifest itself by determinate and uniform sensations. They do not feel the cold, but they have an uneasiness or an indisposition which arises from it ; their constitution becomes deteriorated by passing through the alternations of health and disease, and they sink under the action of an unknown cause. It is the more likely to be unknown, because the injurious effects of cold do not always manifest them- selves during or immediately after its application. The changes are at first insensible ; they increase by the repetition of the impression, or by its long duration ; and the constitution is altered, without the effect being suspected.""* We wish we could, as a commentary upon the foregoing passages, adequately depict one of those miserable victims of parental vanity, whose appearance in our streets will sometimes, upon a March or November day, strike cold into our hearts. The cap and feathers set upon, not covering, the child's head, and probably of a colour and richness contrasting mournfully with the blue ears, sharpened nose, and shrunkened cheeks, in which cold has assumed the features of starvation — the short kilt and Highland hose, exposing, between them, cracked and quivering knees — altogether require for their de- scription more graphic power than we presume to lay claim to. We hope, however, that we have said enough to call attention to the ab- surdity of the " hardening" system, as it is called, and to show that the adoption of a clothing, regulated so as to obviate the rigours of our climate, is both demanded by our sensations and sanctioned by our knowledge. The material of clothing is not, we conceive, of very great conse- quence. We are rather inclined to discourage the use of flannel, next the skin, in young children ; it is liable to injure the tender and irri- table surface, and it is more likely than linen to permit the concealed accumulation of dirt. For these reasons, and as children need not be exposed to wet, we think flannel next the skin had better be avoided. The feet should be protected in winter, by warm stockings, and suf- ficiently strong shoes ; and when the weather is particularly cold, woollen gaiters should be drawn over the legs, when the child is about to be exposed to the air. It has latterly been a good deal the fashion to allow children, when a little advanced, to sleep without night- * Edwards, op. citat. SLEEP. 49 caps ; and this, we think, may be permitted with advantage, as the tendency to morbid excitement of the brain, which is so marked a characteristic of childhood, makes it desirable that the circulation through that organ should be preserved in as tranquil a state as pos- sible ; which can be most effectually done by keeping the head cool. The non-confinement of the hair will also promote its growth, and in this instance we may very safely leave nature to herself. In every article of dress the principle should be carefully followed, of placing no constraint upon the motions of any part. For the boy, tight-waisted trowsers, or braces ; and for the girl, stays and corsets of all kinds, must be forbidden during the whole period of childhood. The injuries that may be committed upon the organs in the chest and abdomen, by the latter article, are well known to be of the most serious nature ; the chest may be completely altered in shape, and the lungs diminished in their capacity by a continued pressure so applied ; while, at the same time, the stomach and liver are driven from their natural position, and made to press upon the other organs of the ab- domen. Derangements of the functions of respiration, circulation, and digestion, follow as natural consequences, and but too often lead to an early grave, or what is perhaps worse, to a life of prolonged deli- cacy and ill-health. After all these risks, the object held in view in the use of stays is not attainable by their means. By active and con- tinued compression upon the lower part of the chest, its shape may no doubt be altered, — the ribs may be brought together, so as to form a narrower circle, and a shape be produced which, however it may be fancied to approach the ideal of beauty, yet bears no resem- blance to the human form, either as it comes from the hands of na- ture, or exists in the conception of the artist. The only way in which we can assist in the production of a really fine figure is, to remove all restrictions, and secure, as far as possible, so free an action of the muscles as will lead to their perfect development. By such a course, also, we shall best promote the acquirement of a good carriage, which is infinitely more likely to be the result of a perfect balance of the muscles, than of any mechanical support whatsoever. If the principle of avoiding constraint were to be held in view, in the management of a child's feet, much suffering would be spared in after life. Corns and tumours upon the toes are almost always the results of tight, or ill-fitting shoes ; and therefore it is highly desirable, that we should have these articles so constructed as to protect the foot equally, and not injure it by any undue pressure upon particular parts. x. — SLEEP. For several weeks after birth, the infant is disposed to sleep con- tinuously, only awakened when pressed by the demands of hunger ; and it should certainly be our object not to disturb its repose. As its senses become more capable of bearing external impressions ; and probably as its sensorium begins to elaborate these latter into ideas, the waking interval becomes gradually longer, and, after some time, the chief portion of sleep is taken during the night. Throughout the 5 I ■,: 50 MANAGEMENT OF CHILDREN. whole period of childhood, however, more sleep is required than in ; adult age ; and up to the third or fourth year, the child will be dis- c posed, and ought to be allowed, to sleep for an hour or two during the day time. In regulating the periods for sleep, as in other matters, we should i not forget the periodical plan almost universally adopted by nature ; and by a little training, or rather by permitting that plan to operate 3 without disturbance, the nurse will be saved many a sleepless night. ; Matters should be arranged in the nursery, so as that no obstacle shall be opposed to the child's sleeping, about the middle of the day, an hour or two before its time of dinner; it will thus be again suffi- \ ciently tired, in the evening, to ensure its sleeping soundly from seven I or eight o'clock, until the following morning. On the other hand, if \ we defer its mid-day rest, to a later hour of the day, its night's sleep ; . will not commence so early, and (the child being less fatigued) it will probably be interrupted before morning. A question is often put to a physician : should the child sleep with its mother or nurse ? For a month or two after birth, it is unques tionably desirable that it should ; for the infant, as we have seen possessing a low temperature, and but a small power of generating \ heat, requires to be kept warm by contact with another being. In support of this conclusion, we may allude to the care which is taken by birds and other warm-blooded animals, to preserve heat in their young offspring by the almost continual application of their own bodies. In our care for the infant, however, we must not forget the mother ; and as her health would be likely to suffer from the anxiety and disturbance occasioned by being obliged to attend to a child during the night, we need not prolong unnecessarily the period of its sleeping with her. At the expiration of a month or six weeks, espe- cially when the weather is warm, the infant, if healthy, will, with due precautions, be able to maintain its own heat, and we may then allow it to sleep in a cradle or bed by itself. A sufficiency of bed- clothes should be used, and the temperature of the room, during the first few months, should not be allowed to fall below 60° F. While we are anxious to keep the young being warm, we must be equally carefully to permit a free access of pure air, to its mouth, which should also be strictly attended to while it sleeps with the mother or nurse. In placing the child in a cradle or bed by itself, care should be taken to lay it upon its side, as that is the position in which it naturally lies upon the arm of the nurse ; and the flowing of saliva and other matters from the mouth is thus facilitated. There has been, at all times, a considerable expenditure of words, and much learned trifling, with regard to the question of the salubrity or insalubrity of cradles. It appears to us that their employment, or non-employment, is a matter that may very safely be left to the fancy or convenience of the parents. A cradle makes a clean, airy, and, from the facility of moving it about, a convenient bed, and, as such, has advantages over more ponderous pieces of furniture. As to the injury likely to be inflicted upon the cerebral system, by rocking, we have not the shadow of a proof, that such a species of motion is ever SLEEP. 51 injurious to the brain, either of infants or adults ; if it were so, how- would the sensorium of the infant escape the effects of the thousand shocks to which it is exposed, and that too in an inverted position, before birth ; or, among adults, what sort of brains would the veteran sailor possess ? Throughout all our views respecting the management of children, we wish to avoid speculating or dogmatising, in the absence of any basis of facts ; and to lean to popular opinions, (whose antiquity, we are not ashamed to confess, is, in our minds, prima facie evidence of their having originated in accurate observation,) rather than to affect a pretension to science by abusing, upon a theory, practices which possess the sanction of long and general use. We cannot, therefore, agree that * rocking must be utterly disallowed," or that the reason for its disallowance, viz., that : " Sleep here ensues, because the motion promotes a congestive state of the vessels of the brain, inducing a degree of vertigo"* — is any thing more than a very shadowy hypothesis. During the whole of the second period, a child should, decidedly, sleep alone, in a bed without any hangings which might impede the free access of air, and in a room as larget as can conveniently be pro- cured ; not cold, or admitting draughts of wind, but provided with the means of free ventilation. As few persons as possible should be allowed to sleep in the nursery, and in winter a fire is an essential requisite, both for the perservation of a sufficient temperature, which should be permitted to fall as little below 60° F. as possible ; and also for the promotion of a free circulation of air. With respect to early rising, we are ready to admit, to the fullest extent, the great advantages, physical and moral, of the habit, but still we must protest against a child being, under any circumstances, curtailed of its due proportion of sleep. The way to promote early rising, safely and usefully, is to train the child to habits of retiring early to bed, and then to encourage it to rise immediately upon its spontaneous awaking, but by no means to force it from its bed before the latter occurrence. No definite rules can or ought to be laid down as to the number of hours' sleep to be allowed : one child may require more or less than another ; and our only safe guide will be, to train it to go to bed shortly after its last meal in the evening, and then permit it to sleep, without disturbance, until it awakes, of its own accord, upon the following morning. The composition of the infant's or child's bed, is a matter of some moment — it should be firm and elastic, and of such materials as can readily be dried, or altogether changed, when wet. To answer these * Cyc. Pract. Med. art. Physical Education. f According to Dr. Edwards' view, the advantages of large rooms are not merely to be referred to the greater purity of the air : he thinks also that the slight agita- tion of the atmosphere, caused by the space being extended, produces such a feeling of well-being, that the chest dilates in consequence, and admits a larger proportion of air. The agreeable sensation which is experienced on breathing in the country is, he says, principally due to that cause. Henke refers short-sightedness to the narrow circle of vision rendered customary in confined nurseries. — ddolphe Henke Eandbuch der Kinderkrankheiten. Fkt. a M. 1813. MANAGEMENT OF CHILDREN. cads, a small tick, stuffed with straw, forms the best bed for the infant and young child ; the straw should be frequently changed, and the tick as often washed, and well exposed to the air. For a more advanced child, a hair mattrass answers all purposes. It should be exposed daily to a draught of air ; and in summer, placed for an hour or two in the sunshine, when that is practicable. XI. EXERCISE. From the very earliest periods of infancy, some degree of muscular motion is necessary for the well-being of the child ; and as Dr. Barlow judiciously observes, "it is advisable to suffer them to exercise their limbs freely, by laying them frequently on a bed, sofa, or carpet, and allowing them to roll and kick at their good pleasure." This, and being carried about in the nurse's arms, is all the exercise a mere infant requires.* In handling and carrying the very young infant, the nurse should never forget the delicate and feeble organization of its bones and muscles, which are altogether unfit to sustain any weight or pressure. During the first four or five months it should never be placed in a sitting posture, and when it is carried about, the head should always be supported upon the arm or breast of its bearer. In lifting an infant also, the arms should never be laid hold of: and care should always be taken to make no undue pressure upon the chest, the shape of which may, by a neglect of this precaution, be permanently altered. It may be" well here to advert to a similar hazard noticed by Dr. Barlow, as likely to attend the practice of hoisting, as it is termed ; by the hand of the person holding the child being placed with the thumb and fingers on each side of the sternum. Hoisting should not be practiced with an infant under six or seven months old ; but even at that age, it appears to us extremely probable that some impression may be made upon its chest in the manner referred to, and we should therefore caution the nurse against allowing it to be so grasped. The act of hoisting, itself, appears to be always attended with pleasure to a healthy child ; probably in consequence of that sense of well-being which we have already noticed as being produced by agitation of the atmosphere ; and provided it be practised with care, that no risk of a fall shall be incurred, and the child be old enough to bear it, it need not be interdicted. With respect to the period of the child's walking, we conceive that its commencement should be left entirely to nature. Spontaneous efforts will never be made to an extent likely to produce injury ; but go-carts, &c, should be banished from the nursery, as by such con- trivances, the child will be supported, and induced, prematurely, to walk, before its limbs have acquired sufficient firmness to enable them to support the weight of the body. By these attempts at anticipating * Nurses are in the habit of rubbing the infant's body gently with their hand, during the time of dressing. This friction appears to be agreeable to the child, and is probably useful by stimulating the surface, and promoting the cutaneous circula- tion. It may be considered as a species of exercise. EXERCISE. 53 the child's strength, its legs may be made crooked, or a still worse effect may be produced in female children by causing distortion of the bones of the pelvis, the evil consequences of which may be first discovered when the child herself is about to become a mother : such results, however, are scarcely to be dreaded when the commencement of walking is a voluntary act. As soon as the child is able to support itself in a sitting posture, that is from the eighth to the twelfth month, it should be occasionally placed upon a carpet, with some playthings spread about it. Towards these it will soon endeavour to creep, and after some time, when its locomotive muscles have acquired greater strength, attempts will be made to assume the erect posture, and ulti- mately to walk alone. In early childhood, the taking of exercise may in like manner be left altogether to nature; all we have to do is to provide opportunity, by allowing the free and unrestrained use of a garden or field, in fine weather ; or of a large nursery at other times. The active and rest- less spirits of the child will then prompt it to do all that is required for its health, and its own sense of fatigue will be the best monitor as to the proper duration of its exertions. When the child grows into the boy or girl, more consideration becomes due to the management of its muscular system, as the neces- sity for dedicating definite portions of time to mental education then, first, arises. It then becomes an object to economise the hours of exercise, and for this purpose the gymnasium and dancing-school are sought by parents, and recommended by physicians. The latter is generally considered rather as a place for acquiring an accomplish- ment than for exercise ; but under a judicious master, who avoids constrained positions and restrictive machinery, dancing may do ex- cellent service, by giving vent to the buoyant spirits of youth, and exercising almost all the muscles. The gymnasium has certainly been an improvement in modern education, but it, too, has its evils and hazards. In it also a skilful teacher is required, whose know- ledge of muscular anatomy will enable him to contrive means of generally exercising the frame, and whose judgment will constantly interfere to prevent the youth from being carried on by spirit and emulation to an overtaxing of his own powers. When practised to too great an extent, gymnastic exercises certainly stop the growth,* by directing all the energy of the individual towards a development of the muscular system : if improperly directed, they may also occa- sion ruptures, and injuries to the joints ; but under a skilful teacher, such abuses may be certainly and safely prevented. Neither gym- nastics nor dancing ought, however, to supersede the daily play in the green fields, and both parents and children are fortunate, when * Any person who recollects the stunted stature of a boy, servant in a gymnasium in this city, will admit the truth of the above statement. We are happy in being able to corroborate our, somewhat heterodox, notions, respecting the abuse of gym- nastic exercises, by the authority of Dr. James Johnson. He, also, very correctly, points out their tendency to call into activity diseases of the heart and great vessels, in young individuals previously predisposed to those affections. — Vide Economy of Health. Lond. 1837. 5* 5{ MANAGEMENT OF CHILDREN. not called upon by circumstances to sacrifice this, the most healthful and most invigorating of exercises. Our plan, (restricting our observations to the management of child- hood,) does not warrant us in considering at any greater length the exercises of youth, — a full view of the merits and peculiarities of the different kinds of which belonging more to the province of the physiologist, than of the child's physician. With respect to the quantity of exercise to be permitted to the child, we can give no rules more definite, than to allow the dictates of nature to be followed - when fatigue is experienced and rest called for, and to adopt the views j already put forward as to the proper periods for sleep and food ; by ;, carefully attending to these latter, regular interruptions to play or continuance in the open air, will, of course, be provided for, and that to an extent adequate to the wants of the individual.* XII. MEDICINE. There is no subject connected with the management of children, in which such fatal errors have prevailed, as the treatment of their bowels; and unfortunately, the influence of certain medical theories has, of late years, tended rather to the increase than diminution of those mistakes. The importance which has, in many respects very justly, been attached to the condition of the digestive system in disease, has attracted much attention to its state in health. Unhap- pily, however, the great majority of persons fall into the grievous fallacy of supposing that what is useful as a remedy, must also be useful as a preventive ; and as the multitude have, in the case of the system in question, but one idea, cognate with either remedy or preventive, viz., the idea of purging, the propriety of adopting a regular system of purgation with healthy children, has been admitted almost without question. There cannot, however, be a more danger- * It is much to be desired that public gardens should be established in our large towns, to which the inhabitants, of all classes, and their children, could have access. They should be planted with shrubs and trees, so as to afford moderate shelter, — - and be provided with a large shed, in which refuge might be taken from the vicissi- tudes of our variable climate. Most, large, continental towns have a provision of this kind, as well as numerous private gardens, tow T hichthe poorest can resort at no greater expense than the price of a cup of coffee. We know that it will be objected, that, in our country, such places would become scenes of drunkenness acd riot; but we are sanguine enough to hope, that the opportunity of enjoying temperate amuse- ments in the presence of their fellow-citizens, of abetter rank, would be appreciated by our artisans, and ultimately tend to restrain their ferocity, and elevate them in their own opinions. The lower classes, of these countries, are too much thrown upon the one brutal indulgence of drinking; and it is an absurdity to suppose that the strictest revenue laws will have any effect, except to aggravate the evil. Make spirits dearer, and the labourer will certainly diminish his allowance of food and clothing to procure the only means within his reach, of relieving his mind from the pressure of toil and want. Give him an opportunity of being amused, w 7 hen his day's labour is ended, with music ; and of enjoying the pleasures of a public garden, in the presence of his superiors, and we hope, (perhaps too sanguinely,) that he will be gradually led to lessen his allowance of spirits, in order to enable him to procure dress sufficiently decent to admit of his partaking in these amusements, without a sense of degradation. MEDICINE. 55 cms absurdity than such a system ; and in proof of our opinion, we shall ask a single question, and bring forward a single fact. What is the mode of action, and effect of every aperient drug in the phar- macopoeia ? — Is it not irritation, direct or indirect, of the intestinal mucous membrane, in a greater or lesser degree ; and does it not pro- duce, as a necessary effect, in every instance, a larger or smaller quantity of increased secretion ? So much for our question. We presume that, except among the disciples of St. John Long, no person will be found to maintain that irritation producing increase of secre- tion, can ever be necessary in the healthy body. With respect to our fact — let any person with regular, or moderately regular bowels, take an aperient, and he will certainly find that after its immediate effects have passed away, a state of costiveness will be the conse- quence. All the operations of nature are characterised by a tendency to periodicity, and whenever the regular periodical action, which she has ordained for the digestive canal, is interrupted by the production of evacuations, at irregular periods, she will require some time to enable her to recur to the simplicity of her original design. This is the true theory of the constipating after-effect of purgatives. We wish it to be distinctly understood, that what we are now advancing has no reference to the use of purgatives in disease, but solely to their abuse during health ; and we are the more particular in endeavouring to convey our own views upon the subject, because we know that the impropriety of a needless resort to medicines of this kind, is not sufficiently thought of by medical men. We have, indeed, too often had occasion to lament over the display of drugs upon the mantel-piece of even a medical man's nursery, not to feel special interest in this matter. The least judicious would surely grieve, did he see an ointment of cantharides rubbed upon a healthy skin with no other apparent intention than that it might be followed by a healing salve ; yet, what, less absurd, is portended by the accu- mulation, in such a situation as we have alluded to, of packets of aperient draughts, bundles of restraining powders, and bottles of car- minative mixture — all designed for the same unlucky children. This is no imaginary description ; we have, but too often, seen its original; yet, better and more merciful would it be, towards many of the victims, to destroy them in the birth, than, by such a course, to pro- vide for them the enduring, moral and physical, miseries of an irrita- ble mucous membrane. The bowels of a healthy infant, after the meconium has passed away, should be opened from two to four times in the twenty-four hours. The discharge should be fluid, of a lightish-yellow colour, free from fetid or acid smell, and destitute of lumps, or white curdy mat- ter: it should pass without pain, or any considerable quantity of wind. As long as these conditions exist, there is no occasion for medicine; should they be, materially, deviated from, a state of dis- ease must be present, and will be indicated by other symptoms, the nature and treatment of which shall be considered in the proper place. The infant may, however, labour under a degree of costive- ness which can scarcely be called disease, and may yet require 5 g MANAGEMENT OF CHILDREN. medical interference. Having less than two stools, for example, in the twenty-four hours, calls for an aperient; and so also does a lumpy, or partially solid, condition of the discharge. The medicine, in such cases, should be of the mildest nature. For an infant, from half a drachm to a drachm of fresh castor oil, will generally answer every purpose ; or a dessert-spoonful of a mixture, formed of a couple of drachms of manna dissolved in an ounce of fennel or carraway water, may be given, and repeated every hour until the bowels are opened. These are probably the only safe nursery medicines. Calomel, which is but too commonly the first article in the list, should be banished from it altogether, and never given for the mere removal of, what we may perhaps call, healthy costiveness. Its use seldom fails to produce motions of a green colour, mixed with gelatinous mucus ; thereby showing that it is likely to do much more than we want, when our object is merely to empty the bowels of their con- tents. During childhood, the bowels should be regularly freed once or twice a day (some difference existing in individuals as to the precise number of their periodical motions). The discharge should be rather of a darker yellow than in the infant, and more solid, but less so than in the adult ; it should have a feculent smell, and be free from mucus, or lumps of indigested matter. When a healthy child has been treated upon the principles which we have indicated, — under the heads of food, exercise, and cleanliness, — it will seldom require any purgative medicine ; but occasionally, from some error of diet, or other accidental circumstance, costiveness will occur, and we must then be prepared to recommend a mild aperient. A couple of drachms of castor oil will usually answer very well ; or, if that should disagree with the stomach, a table-spoonful of the mixture directed below, may be given every second or third hour, until it operates.* In childhood, as in infancy, the domestic use of calomel cannot be too strongly interdicted. XIII. EIGHT. The influence of this physical agent in the vegetable kingdom, is known to every one who has observed the bleached appearance of a plant growing in the dark, or has noticed the efforts made by flowers, placed near a window, to turn towards the light, even though they may not be exposed to the direct action of the solar rays. It can scarcely be doubted that similar effects are produced upon animals, and Dr. Edwards has made some ingenious experi- ments to show the influence of light upon their development. In the course of his researches, he found that those imperfect animals R. Infusi Sennee Compositi, ^iv. Aquse Carui, ^ii. Tartratis Potassae, Jii. Mannae Optionee, 5i M.. Fiat mistura. AIR — HEAT. 57 which naturally change their form, as tadpoles, were prevented from doing so by the withdrawal of light, In man it is not easy to obtain any information as to the specific effect of light unaided by air and heat ; but from the facts just alluded to, we are warranted in inferring analogically that light must materially influence develop- ment of form. The infant, therefore, as soon as its eyes lose their extreme sensibility, should be freely exposed to light. The nursery should never be darkened during the day ; and at night, it is better that the shutters should be left unclosed, and no window- curtains used. xrv. — AIR. We hope the stress which we have laid upon the propriety of keeping up a due degree of warmth in the nursery, will not be inter- preted as warranting any measure likely to interfere with a free access of air. Both objects are perfectly compatible. The purity of the air in which the child resides and sleeps should be secured, by providing means of ventilation, in a sufficient number of windows, and a chimney, which latter is absolutely essential to the establish- ment of a current of air ; and also by restricting the number of indi- viduals residing in the apartment, within the narrowest possible limits. It has been already stated, that a certain agitation in the atmosphere is healthful j and, therefore, the nursery should be as large as possible, in order to favour motion of the air contained within it.* But our attentions with regard to air, should not be confined to the nursery; the vivifying influence which it has been shown to produce upon the system, by contact with the surface of the body, furnishes us with an explanation of the advantageous results, which experience shows to be derivable from an exposure of the child to the open air as freely as possible, consistently with an observance of the principles already inculcated under other heads. It is this vivify- ing influence which renders the play in the open fields so much more useful than the most carefully directed exercises of the gym- nasium. XV. HEAT. We have already incidentally said so much upon this subject, that anything further would be merely repetition. We may, however, take the opportunity of controverting a very common fallacy, viz., that exposure to heat renders the body more susceptible of the ill effects of cold. Dr. Edwards found, that "in exposing animals to successive applications of cold, their temperature will fall the more slowly, the longer they shall have been subjected to the influence of warmth. Hence, that those who are liable to frequent exposure to severe cold, are rendered more capable of supporting it, by subject- * Mr. Carmichael, in his admirable lectures on Scrofula, published in the 3d Vol. of the Medical Press, deprecates the practice, common in these countries, of placing nurseries in the attic stories of houses, where they must of necessity be re- cipients of all the foul aif generated in the apartments beneath. The caution is well worthy of being attended to. [Note to 3d Edition.] 5S MENTAL AND MORAL; EDUCATION. ing themselves, in the intervals, to a high temperature." We find, in point of fact, that the Russians, and other northern nations, pre- serve, by means of stoves, and double doors and windows, a very high temperature in their dwellings during winter, and yet leave them with impunity to pursue their occupations in the open air.* This should make us hesitate in denying access to a fire, to a cold and shivering child, under the idea that we shall render him, by the prohibition, hardier, and less likely in future to suffer from cold. CHAPTER III. MENTAL AND MORAL EDUCATION. The connexion between mental and moral education, and the phy- sical management of children, is so close, and the action and reaction of the one upon the other so constant and influential, that an essay upon the latter would be incomplete, indeed, almost useless, without some notice of the former subject. In turning our attention, how- ever, to this most important of human concerns, we feel considerable embarrassment, both from the difficulties incidental to the subject, and from the narrowness of the limits within which the nature of Our present plan obliges us to confine our observations ;_ at the utmost we can deal but in generalities, and even with these only in the briefest manner. In the foregoing chapter we commenced our consideration of phy- sical education, by supposing an infant to be placed in our hands immediately upon its entrance into the world. We found it naked and helpless, in fact a mere vegetative beingjwith its organs of nu- tritive life fitted, and ready to act, but altogether dependent upon the care of others for such a supply of material for these organs to work upon as was absolutely necessary to preserve its extstence. Pursuing the subject, we endeavoured to investigate the nature of the various physical wants of the child, and to point out the princi- ples which should guide us in administering to and supplying them. We are now in a precisely similar position with regard to the moral and intellectual system of the young being — it is placed in our hands fresh from nature, and we are called upon to make a like investiga- tion into the wants of the system in question, and to consider, in like manner, the principles upon which we can most safely and prudently obviate or regulate them. The progressive development of the various intellectual powers in the child has been already alluded to in the first chapter, and to the course of this development we must Look for our only natural guide * The common winter temperature of houses in St. Petersburg, is 64° F. ; while, out of doors, it is frequently so low as 20°. — Dr. GranvilWs Travels. MENTAL EDUCATION. 59 in all attempts to educate these powers. The infant at birth, we have seen, (p. 21,) possesses little capability of perception; some of its senses are still imperfect, and all are, from want of training, unfitted to convey correct information to the mind ; the memory is as yet unfurnished with facts ; and the whole system is, as it were, a ma- chine in some degree ready for work, but from which the moving power is still withheld. Soon, however, the process of learning com- mences ; the senses first receive a knowledge of the agents which act specifically upon them ; the eye becomes acquainted with light, and afterwards notices objects which are presented to it; the ear is affected in like manner with regard to sound ; the skin, the seat of the sense of touch, becomes gradually instructed in the more obvious properties of matter. Subsequently the infants learns to compare the impressions made upon the different senses, and to derive infer- ences from the comparison. A familiar example will best illustrate this dawning of intelligence. Thus, the mother's nipple is soon re- cognised by the sense of sight, and probably the first item of know- ledge laid up in the memory is the fact that this is the source from whence nourishment is derived. A careful observation of the young infant will, however, soon teach us that although it very early per- ceives the nipple, and is not ignorant of its use, still it has at first no knowledge of its position in relation to that of its own body. Such knowledge is the result of a comparison between the impressions made upon two senses, and it is not until a later period that the information conveyed by the sight is corrected by the touch, so far as to enable the mouth or hands to be directed with certainty towards the object in question. After a short period, the power of perceiving external objects is so far educated, and the memory so well stored with facts, the result of observations, that the infant can determine the differences between persons, and becomes capable of recognizing its mother or nurse. All this is really mental education, and that too of the most im- portant kind ; for what a small proportion does the learning of the schools bear to the knowledge of external agents, and of our own .powers and relations, which we must acquire during the period of childhood, and without which we should be incapable of supporting our existence. What countless observations must be made before we ascertain our ability to speak or walk, and what a wondrous mass of facts must be learned before we understand in the most general way the difference between animate and inanimate bodies ; between the firm and resisting land, and the yielding and unstable water. We cannot, however, directly aid in the communication of such knowledge ; the demands of the senses for their proper excitements will not fail to force its acquisition upon the young being ; and we refer to it, here, only to show that the young child who is permitted to use its eyes and ears, is always busily employed in learning, and that the hours of play are not to be considered as periods of intel- lectual idleness. At what time the business of formally instructing the intellect should be commenced, becomes an interesting question, and one 60 MENTAL AND MORAL EDUCATION. upon which much difference of opinion exists ; if we begin too early, we shall certainly injure the health; and if we delay too long, we shall often experience much difficulty in restraining the habits of bodily activity, (which in such cases will generally be acquired,) within limits favourable to the necessary exertion of the mental powers. In this, as in most other matters, we shall probably find our best guide, if we carefully observe the plans of nature. She seldom fails to implant in the child a most restless and prying curiosity, which is in reality the appetite for knowledge, and should never be denied its gratification. Books and pictures never fail to attract the attention of very young children ; and allowing them to apply it, at their own pleasure, to these, and especially to the latter, is doing for the mind precisely what we do for the body when we place it in the garden or field — it is giving it an opportunity of taking wholesome exercise, which will be desisted from upon the first approach of fatigue. In the one case the child will, itself, learn to walk and run with firmness ; and as its muscles and bones become stronger, it will usually show an inclination to practise the more artificial exercises of riding and swimming. In the other case, an acquaintance will be imperceptibly established with the forms of letters, and of animals and other external objects ; and the uses of the one being gradually learned, and a curiosity respecting the others being excited, a growing desire for information will lead the child to devote more and more time to its acquirement, until at length we shall find it no difficult matter to include, among our periodical arrangements, an allotment of a short portion of each day for the purposes of instruction. The precise age for adopting this latter arrangement cannot be exactly defined — it must differ a little according to the strength of the child, but we conceive it should not be before the sixth year. The space of time to be allotted for instruction is also a matter of moment ; it should never be long enough to produce fatigue, and we think should not exceed two hours daily during any part of the period of childhood. When considering, in the last chapter, the subject of physical education, we avoided entering into a detailed examination of the various exercises suited to the development of the muscular system in youth, considering such a detail as lying rather within the province of the general physiologist, than of the child's physician. In like manner, we now conceive that a special consideration of the subjects of mental education would be encroaching upon the domain of the moral philosopher; the objects, however, of this process, and the mode of attaining them, may fairly engage a small share of our attention, from their intimate connection with the bodily health of the child. In the first place, then, we cannot but think that a grand mistake is very generally made with respect to the proper object of education, which is commonly supposed to be the storing of the memory with a quantity of verbal knowledge, with a mere crowd of words, often to the exclusion of the ideas which those words are designed to con- vey. Thus, very young children are mechanically taught lengthy rhymes, or verbose catechisms of geography and history, and their MENTAL EDUCATION. 61 repetition of these by rote is looked upon and exhibited by their parents as a pregnant proof of a precocious understanding. All the time, however, the poor child comprehends nothing of what it has been repeating, and its memory, which, it must be recollected, has abundant employment during the first years of childhood, in storing up the facts derived from impressions upon the senses, has been, not wholesomely exercised, but injuriously fatigued by the exertion. We were much struck with the monstrous absurdity of this wordy instruction, upon observing its effects in some of the parochial schools of this country. Many of those institutions are under the patronage of a society whose inspectors annually visit them, and examine the pupils. The examination chiefly consists in ascertaining how much of the Scripture can be repeated by rote, and the rule is, that unless a certain number of children be produced, each capable of reciting, at least, four chapters of the New Testament, no remuneration is to be given to the master. The result of this system, as we have re- peatedly found from personal investigation, is, that while so much as an entire epistle will, in some instances, be correctly repeated, the sense of a single paragraph will often not be comprehended by the child. In the course of. a very extended visitation of these schools, we have been repeatedly told by the masters that their own time, and that of the pupils, was so completely occupied with the committing of mere words to memory, that it became utterly impossible to pay any attention to their meaning. Now, if we reflect for a moment upon the exercise to which the memory of the young child is subjected in laying up a knowledge of its relations to the things and persons which surround it ; and if we recollect the mental exertion it undergoes in obtaining a practical acquaintance with its obligations to society, and receiving instruction as to its expectations of the future, we must surely pause before tasking it with the remembrance of words of which it is unable to comprehend the value. The acquisition of verbal knowledge, or indeed of almost any knowledge which can be conveyed by words, we do not look upon as a legitimate object of early education. The effort should rather be made to instruct the mind in the performance of its functions ; and in choosing a mode of doing this, due regard must be had to the order in which the mental powers are developed. The perceptive facul- ties, for example, coming earliest into play, the instructor's object should at first be to impress upon the child a knowledge of the pro- perties and relations of matter in its various forms ; and in doing this, he should, as far as possible, train the mind to habits of correct observation. Materials for thought will in this way be stored for future use, and at the same time an orderly and accurate habit of observing will be impressed upon the mind. As the reasoning powers begin to be developed, these, too, should be trained into their proper action. Comparisons should be instituted between things which have been already the subjects of separate observations. General laws may be explained, and the child may be encouraged to investigate the causes of various natural operations which it has previously ob- 6 MENTAL \M> MORAL EDUCATION. I - , ,1 \11 this, however, must be done gradually,and with caution, mind of the child, like its body, is incapable of great or long- r«ed exertion, and to subject it to such before its powers are developed, would be to urge it into premature decay. "We must » to borrow the words of an ingenious writer, "attempt to iorce Iheir inteilectoal growth, must not feed them with meat, until they have teeth to masticate it. There is a great deal which they ought to learn, can Learn, and must learn, before they can or ought to under- hand n."- _ ' ' . So much for intellectual education : it must not be forgotten that our consideration of it has been restricted to the first eight years oi life, and during that period it should scarcely, in our opinion, be made a matter of formal business, but the foundation of it should rather be laid by such playful exercise of the faculties as we have sketched. A^ more "important subject, however, is what we have designated as vwml education, this commences at the earliest period of infancy, and, we almost believe, is finished, for good or for evil, before the individual passes the epoch of childhood. In moral qualities the child is indeed father to the man ; and the education of these requires the most anxious attention, even during the earliest periods of infancy. one who is familiar with the habits of infants can avoid observing, that from the moment of birth they display obvious marks of being endowed with active passions and affections, and that, too, in proportions varying much in different individuals. Anger is per- haps the first of these which is displayed to our notice, but shame and jealousy soon make their appearance, and also some, of a more amiable character, as compassion and brotherly affection. Now, we must recollect that these emotions, and all the other elements of our moral constitution, are originally designed, and implanted in us, for good. " It is very true," says Dr. Chalmers,! " that the anger, and the shame, and the emulation, and the parental affection, and the com- passion, and the love of reputation, and the sense of property, and the conscience of moral sense, are so many forces of a mechanism, which, if not thus furnished, and that too within certain proportions, would run into a disorder that might have proved destructive both of the individual and of the species.' 7 We shall give an example of our meaning, and again in the words of the pious and eloquent writer just quoted. " The more patent view of anger is, that it is an instru- ment of defence against the aggressions of violence or injustice, and by which they are kept in check from desolating, as they otherwise would, the face of society."{ In this way the passion of anger, (which we take merely as an example,) is not to be considered as in itself evil, which is too often the view taken by superficial observers, but it is to be looked upon as a necessary constituent of our moral system, without which we should be unable to feel a suitable abhorrence of sin or of injustice, such as in the present state of man is absolutely necessary for the holding together of society. It is only the improper ♦j'The Doctor," generally (we believe) attributed to the pen of Southey. t Bndgewater Treatise, vol. i. , p. 196. % Op. citat. p. 208. MORAL EDUCATION. 63 direction of anger, or its indulgence unrestrained by the other elements of our moral constitution, which is productive of evil. In like manner, all the other passions and affections are designed for good : and we conceive, therefore, that our object in morally educating a child, should be, not to obliterate those forces of his moral mechanism, but to guide them into a system of harmonious operation with each other. Now, how is this most likely to be accomplished ? Is it not by cul- tivating those affections which are more obviously good, and by their influence regulating the violence of others, whose unrestrained indul- gence would certainly lead to evil ? — Thus, the anger even of a very young infant will be hest restrained, not by a display of anger upon the part of its parent, but by a steady exhibition of parental affection, and by showing it a practical example of calmness. Causes likely to excite irritability should also be carefully removed from the infant, as a habit of indulgence in anger will readily be acquired before the counteracting affections can be correspondingly excited. As the child advances in age, new passions and affections call daily for our notice ; and as its mental education simultaneously progresses, and it is constantly acquiring an increased knowledge of external objects, we are furnished by this progress and knowledge with addi- tional and powerful instruments for influencing its moral nature. He displays, indeed, but a small acquaintance with the human heart, who hopes by an apothegm to extinguish the passion of jealousy, or to repress the cravings of ambition by a dry statement of the unques- tionable truth ; that all is vanity. But, still the natural feeling of emulation, which is the commencement of jealousy, can be restrained within just and wholesome limits, by calling into play the family affection, and the compassion, which are equally original elements of the moral constitution ; and the love of reputation maybe prevented from growing into a dangerous ambition by encouraging, along with the affections just mentioned, a development of the conscience or moral sense, and of the sense of property, both of which we conceive to be inherent in our nature. The child may in this way be practically shown, that while a generous rivalry in its sports and lessons is not forbidden, still that benevolence, and natural affection for its brothers and playmates teach it to stop short, in every instance, of carrying this so far as to wound the persons or feelings of others ; and, again, that while it may be lawfully anxious to obtain credit and praise from its teachers, still that its sense of property forbids it to seek for either by making an unpermitted use of the labour of others,and its conscience peremptorily interdicts any advantage which might be attained by a departure from truth. In this way we avoid overtaxing nature ; — we do not vainly denounce, or attempt to obliterate, forces which are as much part of our moral frame, as hunger is of our physical ; — we do not tell the hungry man he shall not eat, because gluttony is a vice, but we furnish him with a guide as to the quantity and quality of food which is wholesome and necessary. Above all the restraining prin- ciples (if one may be preferred to another), we would be inclined to endeavour with most care to bring into activity the sense of property ; and conscience, or the moral sense, as Dr. Chalmers terms it. Upon 6 ^ MENTAL AND MORAL EDUCATION. these the well-being of society mainly depends ; if not encouraged in early childhood, they are of all others the most likely to remain dormant j but if once well developed in the child, a long course of vice will scarcely effect their overthrow. The progress of mental knowledge may be brought into useful operation in this part of our work, if we direct the growing faculties of the child to a contemplation of such portions of the general plan of nature as may be within its comprehension. Thus, admiration of the skill of Providence may, at a very early age, be excited by calling attention to the more obvious adaptations of means to ends, as in the forms of animals, in the benefits conferred by the mode of distribution of water over the earth, and in a thousand other examples which will constantly suggest themselves, and a perception of beauty can be called up in a very young mind, by the colours and fragrance of flowers, and the influence of music. From all these the watchful parent can derive practical lessons of humility and love, which would be sought, in vain, in the maxims of a dry morality.* * We were sorry to observe that Dr. James Johnson, in his able and justly popu- lar work upon the " Economy of Health," has, in his desire to prevent the abuse of music, been led away from a fair appreciation of its use as an agent in moral education. We would heartily join with him in discountenancing the system which leads to a periling of the health of our young ladies for the purpose of con- verting them into opera singers ; but this is altogether different from the wholesome use of music as a language proper forgiving expression to the milder, and for taming the fiercer qualities of our nature — as the gentlest, and yet most enduring of our social bonds. So far, perhaps, the advantages of music are generally appreciated, at least in the case of the upper classes of society ; but its suitableness as an agent for the moral education of the poor, is, we regret to say, totally overlooked in this country, and yet the education which the poor man chiefly requires is to have his fierceness tamed, and his gentler affections called into play — to be bound to his fellow-man by partaking in a common source of enjoyment, rather than to be divided from him by that jealousy which must exist between the poor and the rich, when- ever the intellects of the former are educated without simultaneous attention to their physical comforts, and simultaneous instruction of their moral nature. The poor man, as well as the rich, requires recreation after labour, a fact which appears to be totally forgotten by our philanthropists, who, while they enjoy the indulgences of their comfortable homes, can see no excuse for the intemperance of the hard- worked labourer, or artisan ; whiskey, however, is merely resorted to as the only attainable means of relieving the exhaustion of protracted toil, and the first effec- tual temperance institution will be the placing within reach of the poor, some tran- quillizing and social amusement. Those who have mixed in the society of the lower class of beer-houses and gardens, in the North of Germany, will not deny that music may be made to answer this end. Many will admit the justice of the foregoing views, but will ask, how are they to be acted upon ? We answer — let those who have the direction of the great ex- periments of education, at present in progress, abandon polemical controversies, and seek for guidance by examining the merits and demerits of systems which have been tried in other countries. If they inquire into the state of the Prussian and Saxon schools, and their enviable results in the happy condition of the people of those nations, they will, or we are much mistaken, change their course. They will probably be content with training the minds of the children to work without burdening those who are to live by manual labour with much intellectual know- ledge : they will especially try to regulate the moral nature of their pupils, and they . will, we hope, make musical instruction, as it is in Saxony and Prussia, a part of the system of every school. [Note to 2d Edition.] We are rejoiced to find that the views put forward in the foregoing Note are be- MORAL EDUCATION. 65 To work out in practice the principles we have attempted to lay- down, we are well aware, would require qualifications on the part of the parent or teacher, of no ordinary kind ; and will, no doubt, in too many cases be impossible of accomplishment : but the nearer we can approach to them, the more likely are we to produce the mens sana, which we feel confident is fully as certain of producing, as of inhabit- ing, the corpus sanum. Our limits forbid us to enter at greater length into this most inter- esting subject ; but one word we must add, to prevent misconception. We have not yet spoken of religious instruction as a part of moral education, because we have been considering the management of the moral faculties as they exist in the natural man : we are deeply con- vinced, however, of its necessity and importance ; and we are firmly of opinion, that in no way can we promote the interests of an indi- vidual, both as regards himself and hisrelations with society, so effec- tually, as by encouraging in him early habits of religious observ- ances ; in no way can we so surely call forth and strengthen his best affections, as by early setting before his view the living truths of revelation. As general conclusions from the views we have put forward, we would say, that during childhood {i. e., until the eighth year) educa- tion should have for its main object the cultivation of the moral qualities ; and that, during the greater portion of the same period, the intellect will be pretty fully occupied in obtaining such most necessary information, as can be acquired by the use of the senses without much formal assistance, and therefore that schooling, pro- perly so called, should not be commenced, at the very earliest, before the termination of the sixth year. Until then, the confinement of a school is injurious to the bodily health, and not required for the men- tal improvement of the child. In coming to these conclusions, we may appear to undervalue those useful inventions of late years, — infant schools. We conceive, however, that they are designed for a specific purpose, which, when well regulated, they effect usefully — viz., to take charge of the children of the poor in large cities, when their parents are engaged in daily labour, and unable to attend to their wants. In this view, the value of these institutions is inestima- ble ; but still they are but the substitution of a lesser for a greater evil : all the ties of social affection, of well-regulated obedience, and of mutual co-operation, which constitute the bonds of society, are learned by the infant in the domestic circle, andean be learned nowhere else. If we can leave it, therefore, in the care of an intelligent mother, and in the society of its brothers and sisters, we should not send it to an infant school, where it is governed by, and associated with, stran- gers, with none of whom it is likely to have natural sympathies. What the child may be expected to gain specifically in these schools, ginning to prevail ; and especially that they have been adopted by the Select Com- mittee of the House of Commons in their late report on Education in Ireland. In this masterly document, which we understand to be the work of Mr. Wyse, music is included among 1 the subjects of instruction in the proposed elementary schools. [Note to 3d Edition.] 6* 66 PECULIARITIES OF DISEASE IN CHILDHOOD. beyond mere protection, can only be regularity of habits, which cer- tainly is of great importance, but not so great as to countervail the advantages of a well-regulated domestic circle. For the reasons we have advanced, we conceive that infant schools, though most service- able in large cities for the poor, are totally unfitted for the children of more opulent parents. With the latter, the system might be cha- racterized, as Dr. Chalmers has done another artificial system, as " a taking to pieces of the actual framework of society, and reconstruct- ing it in a new way or on new principles — which is altogether fruit- less of good, and often fruitful of sorest evil, both to the happiness and virtue of the commonwealth.' 7 * CHAPTER IV. PECULIARITIES OF DISEASE IN INFANCY AND CHH.DHOOD. I. ETIOLOGY. The great activity which pervades the whole body in the child, united to the peculiar susceptibility of the nervous system, and the abundant supply of bloodvessels, more especially arterial capillaries, predispose, in a particular mariner, to the sudden occurrence of dis- ease, its rapid progress, and frequently fatal termination during in- fancy, when organic change so readily takes place. In addition to this general activity, necessarily connected with the process of general growth, we observe a peculiar state of excite- ment or increased action in particular parts of the body at certain periods of growth, when these parts are found in a special manner to undergo rapid development, and are hence peculiarly liable to become diseased. Thus, the brain is undergoing a particularly rapid process of growth about the time that dentition commences, or * Since writing the above, we have had the pleasure of reading an interesting little treatise on Infant Education, published in Chambers' Educational Course. Edin- burgh, 1836. At the same time that we are most gratified to find that the princi- ples which we have attempted to lay down for early education, are those sanctioned by the experience of Mr. Wilderspin and others, still we cannot change our opinion with respect to the class of society for which the infant school is really adapted ; and we must be excused for preferring the family circle, as a place of education for the very young, in all cases in which it can be made use of without important sacrifices. We do not agree that the element of numbers, as Messrs. Chambers assert, is indispensable for exercising the social virtues of the child, particularly of the female child ; but we acutely feel, that a tenderness, not less than parental, is required to keep unceasingly awake the sense of responsibility which ought to be felt by the infant's instructor: and we conceive that this responsibility is intended, by a wise Providence, not merely for the child's advantage, but also for a strong and wholesome check upon the morality of the parent, which it would not be be- neficial to society to weaken by division, in any case admitting of its being left whole and undivided. [Note to 2d Edition.] ETIOLOGY. 67 the teeth first begin to appear ; and at this very time we find the mucous membrane of the intestinal canal also making an important progress in development, the mucous follicles, or glands, beginning now rapidly to be evolved ; so that independently of any morbid action, set up directly in connection with dentition, we have the nervous system naturally in a high state of susceptibility, about the period of its occurrence, and the intestinal mucous membrane in a condition of peculiar irritability. All this it is important to keep in mind the better to be able to meet the contingencies of this period ; for these are mainly connected with this peculiar condition of the cerebral and abdominal systems, independently of the process of dentition, to which, however, it is the popular practice to attribute all mischances occurring at this age ; an error not less unfounded than injurious, and against which we would, in a special manner, warn the young practitioner. If one source of diseased action be a plus of vitality in any organ, as Broussais has taught, or an over-exercise of the natural function, in no subject is disease from such a source so likely to be found as in the child. This great activity of all organs and functions, how- ever, while it predisposes parts so much to take on diseased action, confers at the same time a peculiar energy or power of reparation, in virtue of which the danger in infantile disease is in a particular man- ner diminished, when once the acute stage of the disorder has been subdued, or has subsided. Thus the danger in infantile complaints is principally from the rapid occurrence of organic change, with fatal result, in the first instance, — the establishment of chronic disease being less liable to occur than in the adult, and more easily pre- vented ; while, should such take place, the child has more chance of recovery, no matter to what extremity it may have been reduced. The great nervous sensibility of the infant, and consequent irrita- bility, is a prime source of disease, and gives a particular character to all disorders occurring in the child. Irritation is easily set up in any organ, by causes acting directly or indirectly upon it ; and indirect or sympathetic irritation is very liable to occur in the child, particularly in certain organs, and is often presented in a very severe form. The most common seat of irritation arising from a cause directly applied, is in some part of the alimentary canal, and this is generally induced by the ingestion of unwholesome aliment. The presence of any irritating matter in the stomach or bowels of a child gives rise to symptoms often very formidable, particularly when it occasions sympathetic disturbance in the brain. The intestinal mu- cous membrane itself soon takes on the irritative action, and becomes the seat of disease ; the attendant symptoms generally assuming the type of remittent fever. The suffering caused by difficult dentition is a familiar example of direct irritation, which, though slight in itself, may occasionally lead to most serious results, by sympathetic disturbance of important organs. The lung may be directly irritated ; but often are sympathetically so, as when disease has existed in the abdomen or occasionally in the head. The cough in the first case will be irritative, generally pro- tracted, and may be violent 5 it is in the second usually spasmodic. cs PECULIARITIES OF DISEASE IN CHILDHOOD. The brain is less liable to irritation from any cause acting directly upon it, but often takes on this state, sympathetically, in consequence of disease in the digestive organs, or during the existence of protracted thoracic disease, especially if the cough be violent, as in pertussis. From the observations we have been enabled to make, we would conclude that the head sympathises most directly with the digestive apparatus, less so with the chest. The lungs sympathise frequently with disordered state of the bowels, less frequently with disorders of the head. The digestive organs sympathise readily with all the others, — remittent fever arising during almost all protracted diseases of childhood, as we see in most of the severe forms of pulmonary com- plaint ; and the stomach and bowels are immediately affected on the occurrence of irritation or inflammation of the brain. The mucous membrane of the bowels, in particular, sympathises with the cuta- neous surface, many diseases of which arise from disorders of the digestive tube. In the infant, irritation, whether existing primarily or only set up as a secondary occurrence, readily passes into congestion or inflam- mation. In the brain, in particular, congestion often arises suddenly during states of irritation ; or inflammation quickly follows the latter condition. The greater number of the diseases of childhood are inflammatory, and inflammation in the child is generally very severe, and often runs its course rapidly, giving rise to remarkable morbid productions. Exudations of lymph, or other matters, are quickly thrown out, and occur in situations where they are not liable to be found in the adult — on the mucous membrane, for example, as we see in croup. Effu- sions readily occur in serous membranes, as the arachnoid ; and soften- ing or ulcerations take place in the mucous membranes, as we find throughout the whole tract of the intestinal canal. Inflammation in the healthy child exhibits, in a particular manner, its tendency to end in the formative process, or the effusion of coagulable lymph, especially when situated in serous membranes ; but when occurring in the unhealthy subject, or towards the sequel of febrile disorders — as the exanthemata — the tendency is to serous or sero-albuminous effusions. Plethora is frequently present in the child, and is often the result of over-feeding ; but does not necessarily give rise to disease, as it does in the adult, the redundant material being consumed in the active processes of growth ; excretion being naturally much exceeded by supply at this period, and general corporeal increase the necessary result. The full fat child is a natural and wholesome object, and not so prone to disease as the pale, slender subject of misguided solicitude, that has been doctored into delicacy, and which, though not so vio- lently affected by inflammatory disease when attacked, is more ex- posed to illness, and more liable to protracted affections and relapse. It is in the child, reduced to a state of anaemia, by previous illness, mismanagement, or mistreatment, that we meet with the most formid- able maladies, and find all maladies presented in the most formidable forms. ETIOLOGY. 6 9 Morbid action once set up in the mucous membrane, shows a marked tendency to spread or extend itself along the course of this membrane, in a manner that not only constitutes a peculiarity of dis- ease in the child, but becomes a serious source of danger. Thus ulcerations or inflammation of the membrane of the fauces or pharynx are liable to extend into the oesophagus, or, more especially, into the larynx and trachea. The exudation thrown out in croup, tends to extend down the air-passages ; and even common inflammation of the bronchi often shows so strong a disposition to spread universally over the bronchial surfaces, that the danger of the disease in the infant is much more commensurate with the extent of surface thus occupied, than with the intensity of degree in any one place. So of the gastro-intestinal mucous membrane ; it being equally remarkable here, that the tendency to spread is downwards along the mucous membrane, but seldom in the opposite direction. Metastasis, or transference of diseased action from one part to another, is particularly liable to occur in the child — hence the popular dread of the disappearance, or going in, as it is called, of eruptions, exanthems, &c, &c, — which apprehension, however, is commonly carried too far, and leads to very erroneous practice. We must, how- ever, shun the sudden suppression of inflammatory action going on in the skin, whether attended with fever or not, — as the eruption of measles, scarlet fever, extensive itch, or other cutaneous disease, — for this is often followed by morbid action set up in the alimentary canal, chest, or head. The first is perhaps most common ; but in measles, the chest is often attacked under such circumstances, and at the close of scarlatina, the head. The suppression of an accustomed discharge, as chronic diarrhoea, may have the same effect ; and this appears but natural, when we recollect the great susceptibility of the system, and the power of counter-irritation in the child. Disorders strictly to be called nervous do not occur in childhood, though the nervous system is so susceptible and so subject to disturb- ance ; but this usually displays itself in spasm or convulsion, and arises directly from morbid action going on in the brain or spinal marrow, or sympathetically, in consequence of disorder of the diges- tive organs. Convulsions occur in the infant, and epilepsy or chorea in the child: the latter, in particular, about the fourth or fifth year; but nervous affections, such as hysteria or hypochondriasis, are not to be seen at this age, neither do we often meet with neuralgic pains. Mental impressions, so fertile a source of disorders of the nervous system in the adult, do not in the same manifest manner effect the child, who, little disposed to anticipate evil, and quickly forgetful of past suffering, is possessed of spirits equal and lively, nor disturbed by disorders of the imagination. Yet the deteriorating influence of the depressing passions upon the health may be witnessed in the pale and dejected appearance of children who, through a mistaken zeal, are subjected to an over rigid discipline ; or, we may behold painful examples of what may be termed infantile nostalgia, among children recently removed to our public schools ; — the young heart appearing to pine in vain for " home and all its charities." Fear or anger, if 70 PECULIARITIES OF DISEASE IN CHILDHOOD. sudden or violent, may produce serious consequences. We have seen dangerous cerebral irritation thus excited ; and fatal convulsions, or idiotcy for life, have been caused in the child by a sudden fright. Some disorders are congenital, or may be born with the infant, as syphilis, and occasionally hydrocephalus ; as also affections of the alimentary canal. Some are peculiarly liable to occur immediately after birth, as purulent ophthalmia; while trismus nascentium is restricted in its period of invasion to the first nine days, never appear- ing after that period. There seems to be an hereditary predisposition to the occurrence of certain disorders, as croup, and hydrocephalus, among the children of some families ; all or most of whom are in succession attacked, and that often about the same age. The common causes of disease affect the child with more severity, in general, than the adult ; but from some the infant is perhaps free. Irregularities of diet, or improper food, constitute one of the most frequent sources of illness in childhood ; and derangements of the stomach and bowels, which are so liable to be thus induced, lead to serious results at this period of life. We have noticed the liability to dangerous sympathetic affections, particularly those of the head. Fever of an obstinate character, and generally of remittent form, is thus induced ; and inflammatory affections of the abdominal viscera have their frequent origin in this cause. A single indigestible meal will cause flatulency and acidity to an inordinate degree, soon to be followed by diarrhoea and more serious consequences. Such occur- rences take place frequently at the time of weaning ; and we should always make inquiries on this point, when an infant suffering under such symptoms is brought to us. Indeed, so common a cause of infantile disease is disorder of the bowels, that many have regarded it as the sole source of children's disorders.* Impressions of cold or damp, or vicissitudes of temperature, the most fertile source of disease at all periods of life, are particularly so with the child : this we were prepared to expect, having seen that the infant has but low powers of generating heat, and so of resisting the injurious effects of cold, especially when associated with damp- ness. During sleep, in particular, (when these powers are at the lowest degree ; some depression both of circulation and innervation being then present,) there is a susceptibility of the injurious influence of sudden alternations of temperature ; and to such the infant is espe- cially exposed, much of its time being passed in sleep, even in the open air ; and, when in bed, it often throws off the clothes, while * Etmuller, in his " Valetudinarium Infantile," attributes the diseases of the first year to some peculiar alteration in the digestive system ; Harris regarded acid- ity as the chief cause of infantile disease ; and Sydenham attributed much to this cause, combined with debility. The increase of mucus consequent on intestinal irritation, we have already noticed ; and this, Dr. Armstrong assigns as a prime source of infantile disorders ; but erroneously, as it is to be regarded rather as a provision of nature, to protect the membrane from the injurious impression of im- proper ingesta, and relieve it by evacuation when irritated thereby, or from any other cause. •" J ETIOLOGY. 71 warm or, it may be, perspiring. Here we have the origin of many inflammatory affections, particularly of the throat, chest and abdomen. Some forms of disease are said to arise often, in certain situations, in consequence of the lowness and dampness of the place, as croup, or even hydrocephalus, which latter is looked upon as almost ende- mic in the Valais, where the best effects result from the removal of children from the district. Want of light and air is an abundant source of ill-health in chil- dren, and consequent delicacy of constitution in the adult. Thus is scrofula commonly generated or called forth, and all epidemic diseases aggravated or spread. To such sources of malady, however, the children of the poor, especially in large cities, are sure to be exposed ; and the detriment to the common weal arising from this cause, though now little noticed, is such as well to deserve national con- sideration.* We have paid particular attention to the influence of season, or states of the atmosphere, in generating or modifying peculiar forms of complaint in the child, and have found this influence to be most remarkable, so much so, as to cause an established uniformity in the variety of inflammatory affection prevailing at different periods of the year. This variety generally arises from a different tract of the mu- cous membrane being affected at different seasons ; and a degree of uniformity or order seems to be observed in the course of this mor- bid migration, which may be seen to commence with the nose and mouth, coryza and catarrh prevailing generally among children at the beginning of winter. Bronchitis, and the severer forms of pul- monary inflammation, appear as the winter advances, and prevail during the spring, especially in the earlier months. As summer approaches, disease lessens, and pulmonary affections nearly disap- pear ; but as the season advances, the seat of disorder changes ; and now the gastro-intestinal mucous membrane becomes engaged, and on the arrival of autumn, we have diarrhoea, dysentery, or cholera, constantly presented to us in the sick child ; the tendency of disease to spread downwards along the mucous membrane, as already noticed, being here again to be observed. From attention to these particulars we may derive some information as to the nature of a child's disease, when it is only complaining, or out of order. Autumn and winter seem to be the most unhealthy seasons, sum- mer and spring less so ; but this rule does not hold good alike in all towns, and occasionally much illness obtains during spring. At this season some epidemic usually prevails, and we most generally meet with one of the exanthematous disorders to which children are sub- ject. It is a more favourable time for the occurrence of such, how- ever, than the winter months, as the approach of summer facilitates recovery during convalescence. It has been doubted whether the very young child is susceptible of contagion; but infants have been born covered with small-pox, and are said to have come into the world afflicted with hooping-cough ; * See p. 54. n PECULIARITIES OF DISEASE IN CHILDHOOD. and we know that they mav be affected with these complaints at the very earliest age. Continued fever is a very rare occurrence m the young child, being seldom, if ever, seen before the third or fourth year. Daring the prevalence of fever in the winter of 1838, however, we saw an unusual number of cases of fever in children, which was, in several instances, obviously received by contagion, and presented characters similar to those of the fever in the adults from whom it was taken, although there is no doubt that young children are not so susceptible of the contagion of fever as adults ; nor is the disease so fatal to them as after the middle period of life. Fever usually presents itself in the child in the form of symptomatic fever, or constitutional disturbance, attendant on some inflammatory affection, seated in one of the great cavities, most frequently in the abdomen. This form of fever usually assumes the remittent cha- racter, and may be presented in a severe degree in the more grown children; but it is remarkably modified by age, and the seat of the affection of which it is symptomatic; little or no constitutional dis- turbance being, at times,' present in the very young infant, or before the sixth or seventh month; even though extensive morbid action may be going on, particularly in the abdomen. There is a particular class of febrile diseases which spread epide- mically, if not by contagion ; as measles, hooping-cough, &c, that are peculiarly liable to occur during childhood, and generally prevail among many children at the same time. These disorders run a certain course, or last for a particular period ; and during their pro- gress, are liable to become complicated with some phlegmasia or local inflammation, whether occurring coincidently with the invasion of the disease, or arising during its progress, thus inducing inflam- mation during fever, the reverse of what takes place in the class of febrile complaints just considered. Such complication is particularly liable to occur in measles, which often sets in with bronchial inflam- mation, or soon becomes complicated therewith. The same often occurs during the course of hooping-cough. In scarlatina, gastric affections are liable to arise ; or cerebral inflammation may set in suddenly, at the conclusion of the disease ; to say nothing of the ordinary attendant inflammation of the throat. In small-pox, the pleura may be suddenly attacked by inflammation, although the abdomen is most frequently the seat of disease — but in all, these complications occur most frequently in very young children. These complaints are sometimes represented as peculiar to infancy and childhood, and the individual once affected is said never to have the disorder again. The same individual, however, may have any of these complaints a second time ; but this is rare, though it occasion- ally happens, as with scarlet fever, and even small-pox. The adult is certainly less liable to take these disorders than the child ; but we have seen a person of seventy, in hooping-cough, and a mother will occasionally take measles from her own offspring. Of these com- plaints, small-pox is that which has least of an epidemic character, being the most decidedly propagated by contagion ; and is hence, perhaps, to be looked upon as less peculiarly a disease of childhood ETIOLOGY. 73 than the others. It is desirahle that such diseases should have been passed through in early life ; and we may be consulted as to the prudence of leaving a child exposed to any of these complaints, or removing it for security. If the child be healthy, and the type of the prevailing epidemic mild,* it will in general be best to allow the child to remain ; but when the infant is delicate, teething, or only recovering from a former illness, and under any circumstances, when the type of the prevailing disorder is severe or malignant, it will be advisable to take every precaution against the malady. It is well, also, to keep in mind that contagion is most liable to be communi- cated at the decline of these complaints, after maturation has taken place, and while desquamation is going on. Hence, we may not be too late in separating children after the disease has actually appeared in a family ; but cannot, with any safety, permit them to come together on its decline, or too soon, during convalescence. Cutaneous diseases, to which children are so liable, from the deli- cacy of their skin, and the great sympathy between the cutaneous surface and the lining membrane of the digestive organs, partake not a little of the nature of the eruptive fevers, many running a regu- lar course, or stated period of increase, maturation, and decline ; while some are highly contagious, differing chiefly from the exan- themata in the absence of fever ; more unsightly than dangerous in their nature, when not mismanaged in treatment. We need not participate in the great horror in which diseases of the skin are held by the fond mother, who little likes to see the beauty of her offspring thus deformed ; while as far are we from agreeing with the ignorant nurse, who rejoices in the great good which the constitution is to derive from the coming out of the eruption. Some may be occa- sionally beneficial, as points of derivation to counteract cerebral, or oftener, abdominal irritation, or that induced by the process of teething; and a few are, perhaps, criacal. But none do we hesitate to remove after proper precautions ; and many, which, to ordinary means, prove most rebellious, will be found, in due time, to disap- pear, under a well regulated discipline. The protracted continuance, however, of most, does serious damage to the health, wearing out the child by constant irritation, inducing disorders of the digestive organs, and ultimately leading to a cachectic state, in which the glandular system becomes implicated, and mesenteric disease at length esta- blished. A few forms of disease of the skin appear only in infancy; some are most liable to occur during childhood ; and all are modified by the influence of that age : but a large class is to be found in the adult alone. The subject is one of so much importance, that we devote to it a distinct chapter. — (See Cutaneous Diseases.) Diseases of the urinary organs are not very frequent or formidable in the child ; but a disordered state of the urine often exists, and is easily induced by derangement of the digestive organs, when a deposit, * The type of an epidemic is not to be judged of by the character of a particular case, but by the general character of the complaint then prevailing; as very severe forms of disease may be communicated by a mild case; the opposite occasionally occurs. [Note to the 4th Edition.] 7 7 j PECULIARITIES OF DISEASE IN CHILDHOOD. mostly whit©, (appearing as the urine cools, or remaining after it has evaporated.) makes its appearance ; or the urine is passed white, in the first instance. Gravel often forms in the child, particularly in the children of the poor, or in the offspring of gouty and dyspeptic parents ; but this usually consists of lithic acid, and is presented in the state of a red deposit, or as an amorphous sediment, and passed without irri- tation ofthe urinary organs ; or in the form of crystallized lithic acid, and accompanied in its passage by irritation more or less severe. Atten- tion to these circumstances are most important, that we may, by timely interference, prevent the formation of calculus, to which children — at least, the children of the poor* — are peculiarly liable. The calculus will, in this instance, mostly consist of the lithate of ammonia, being generally of a clay colour and small size, as occurring principally in children. (See Prout on Diseases of the Urinary Organs.) Symptoms of dysuria, however, are not confined to cases of stone in the bladder, but will attend irritation or inflammation of that organ itself, or of the abdominal viscera, as in the adult. Even ischuria, or total suppression of urine, may originate in this latter cause ; or more directly from disease of the kidney. But an opposite condition, one of irritability — increased flow of urine, or incontinence, is what par- ticularly appertains to childhood, and is oftenest met with at that age. Dentition, so fertile a source of sympathetic irritation, not unfrequently displays its disturbing power in the urinary organs. A distressing state of dysuria attends the cutting of the teeth ; or more commonly, a great irritability of the bladder, with a frequent and copious flow of limpid urine. This symptom also attends nervous irritability, from any cause, in the child as in the adult. This flow of urine in the child we have seen antecedent to attacks of hydrocephalus : occurring, pro- bably, at that period when nervous excitement precedes inflammatory action. Incontinence of urine, however, is the morbid condition most incident to childhood, and confined more exclusively to that period of life. We have already noticed some anatomical peculiarities in the formation of the bladder, which, at this early period of life, predispose to this affection ; although it may, perhaps, mostly be looked upon as sympathetic of a deranged state of health, particularly disorder of the digestive organs. It occurs generally about the same hour towards morning, and only in bed, being very irregular in its time of duration ; but by no means confined to boys, as commonly thought, although much less frequent in the other sex. Scrofula is much a disease of childhood, though not confined to that period of life ; neither does it often make its appearance before the second or third year. It is about the seventh year, or the period of second dentition, that scrofulous affections become most manifest. * Sir Benjamin Brodie remarks, in his Lectures on the Urinary Organs, that the deposit of red sand which occurs in adults among the rich, is found principally in children among the poor ; among whom, also, children are much more liable to calculi than adult persons. And this from the same cause, though originating in a tlifierent source, namely, derangement of the digestive organs, caused, in the rich, by indolence and luxurious living ; but in the children of the poor, by unwholesome diet and neglect : so do extremes meet. [Note to 4th Edition.] ETIOLOGY. 75 In the child, scrofula is particularly liable to display itself by attacking the glands of the neck ; and enlarged tonsils are frequently met with at this period of life ; but mere enlargement of the tonsils or cervical glands is not to be looked upon as necessarily originating in scrofula, or as constituting of itself evidence of its existence. Glandular disease is common at this age ; mumps, an affection of the parotid gland, occurs usually in childhood ; and even this is liable to be transferred by metastasis to other glands ; the testicle or the mammas. Enlargement of the mesenteric glands, leading to disorganization, and the establish- ment of tabes mesenterica, usually commences during childhood. The formation of tubercle in the child is not less remarkable than the liability to glandular disease, and both seem alike allied to a scrofulous taint or strumous diathesis, but the former has not attracted the atten- tion that it deserves. Infants have been born with tuberculous deposits in different parts of the body, and these in various stages of advance- ment, even to softening and ulceration. Tubercle seldom occurs in other parts of the body without being found at the same time in the lungs ; and true tubercular phthisis is a disease which we have not only seen in the young infant, but which appears to be an affection to which children are very liable, particularly about three or four years of age.* We have seen such cases regarded, to the last, as instances of remittent fever complicated with cough, and hopes thus held out which could not be realized. These tubercular formations are most liable to occur in the debilitated state of constitution following febrile attacks in children, or during protracted convalescence therefrom, and are often called into action by attacks of bronchitis, especially after remittent fever, measles, or scarlatina ; or when the system has long suffered from severe cutaneous disease. Hence, there is a particular danger in inflammatory affections occurring under such circumstances in children, or under any circumstances in those of a highly strumous habit ; such attacks being, in general, very insidious in their nature, not admitting of very active treatment, and appearing often to be connected with, or to end in, the formation of tubercle. — (See Scrofula.) This may occur even in cerebral inflammation in the child, a particular form of meningitis, hence getting the appellation of Tubercular. — (See Diseases of the Cerebral System.) The bones are often engaged in disease during childhood, and the scrofulous diathesis, which then so often obtains, doubtless contributes to this; but the greater vascularity of the osseous structure, also acts its part. If this contributes to the occurrence of disease, it also aids materially in its reparation ; for recoveries may be looked for in early life, that could not be expected at a later period. It is in early life that we meet with those alterations in the structure of bone, which tend to the production of personal deformities ; an early example of which we occasionally see in the deformed chest sometimes met with soon after birth, and known by the appellation of chicken-breasted — for a good account of which see Copeland's Dictionary of Medicine, * See Sir James Clarke's valuable " Treatise on Consumption and Scrofula," p. 171. ~q PECULIARITIES OF DISEASE IN CHILDHOOD. Article, Chest (Deformities of). But more usually, aud at a later period, we meet with distortions of the limbs, spine, or joints. These occur mostly where the strumous diathesis prevails, when the bodies of the bones are liable to be affected with rickets; or their articular extremities involved in the disease. Acute inflammation, on the con- trary, seldom attacks the articular extremities of the bones in children, though not unfreqnently seen in the femur or tibia ; being the common cause of necrosis in these bones. In consequence of the great vascu- larity of bone, fractures unite with certainty and rapidity ; and the greater softness of the osseous matter, also imparts the peculiarity, that partial fracture, or only bending of the bone, may take place ;* while, from anatomical peculiarities, some fractures can scarcely occur, as, for example, that of the neck of the femur. This power of yielding without being fractured, is remarkably exemplified in the bones of the head ; for a depression will occasionally be found in the skull of the child from injury, which is in truth a mere bulging in, not fracture, and which will ultimately disappear without the interference of art ; but which could not have taken place in the adult, without the bone giving way. The power of spontaneous rectification in cases of fracture, is also remarkable ; for, however crookedly united, the bone has a tendency in the child to become straight, and will occa- sionally do so completely, even in bad cases. A similar power of reparation exists in the soft parts ; but great losses of blood are ill borne by the child ; and the peculiar suscepti- bility of the nervous system, which gives such a tendency to the rapid supervention of depression or sinking, makes the shock from opera- tions and injuries always dangerous — it may be fatal. Hence, sur- gical operations are generally objected to till after the third month. II. DIAGNOSIS. It is particularly necessary to be versed in the diagnosis of infan- tile disease, as our chief prospect of success, in acute cases, depends on an early discrimination, so as to be able promptly to apply the necessary remedies; nor can we in the more chronic, "hope for'suc- cess, until we have accurately determined the seat and nature of the malady, and particularly whether it be a primary or secondary affec- tion ; while the little patient cannot in general give any information itself, or only such as is likely to lead astray. This loss, however, will be the less felt, if we pay sufficient atten- tion to the information conveyed by the physical signs in infan- tile disease, the appearance of a child imparting more knowledge to the experienced eye, than any account given by attendants could convey. We shall always have occasion, however, to inquire from them the history of the case. The healthy child is cool, plump, and lively, the flesh firm, and movements free. It likes to be played with, and carried about. The abdomen is full and soft, and pressure upon it seems rather to please * See paper by Dr. Hart, in the Dub.. Med. Jour. vol. i. DIAGNOSIS. 77 than annoy the child. The tongue in generally white, but not over- loaded ; and the mouth is always moist. It sleeps quietly on its side, with the limbs flexed, generally going to rest at the same hour.; and awaking cheerfully, soon demands food. It is scarcely necessary to add, that the secretions are natural and regular. Not so with the child when ill : it is more or less peevish — dislikes being stirred, or even cries when handled ; its hour of sleep is uncertain, and it rests ill, or awakes startled or crying. The skin is hot and dry, particularly the hands, feet, or head. The flesh is soft or wasted. There is thirst and a dry mouth, with unnatural appetite and de- praved secretions. When a sick child is brought to us, or we visit it, our attention should first be directed to the expression of the countenance, then to the attitude, state of the limbs, and skin. In the child in particular, the expression of the countenance or peculiar character of certain of the features, indicates a morbid condition of particular organs ; for at this age the muscles of the face are not endowed with much mobility, and the expression of the countenance is an index of phy- sical, rather than mental, operations ; sensation more than thought being expressed thereby. Three principal indications of physio- gnomy present themselves, connecting a particular set of features with one of the three great cavities — as we observed when speaking of the temperaments, and related in a similar manner. The expression of the upper part of the face, the forehead, eyes and brows, indicat- ing disease of the brain or nervous system ; the features of the middle of the face, in particular the nose, being affected by morbid conditions of the organs of circulation or respiration ; while abdominal affections are in a peculiar manner pointed out by the expression of the mouth or state of the lips.* We next proceed to examine more minutely into the several symptoms, — to determine the seat of the disorder, whether in the head, chest, or abdomen, — and its nature, or the particular lesion on which it depends. When the brows are knit, the eyes fixed and staring, or looking wild or vacant, our attention is at once directed to the head. We try whether it is unusually hot, the vessels full or in over-action, and examine the fontanelle, to see if it be depressed, or in a state of distention. We now observe the attitude, and see whether the child's head hangs heavily on the nurse's arm, or rolls from side to side, sunk upon the pillow ; and try whether the neck be stiff, or retracted, which it occasionally is. We observe or inquire whether the child puts its hands to its head, as in health infants seldom raise the hand above the mouth. We examine the limbs, to see whether they be rigid or relaxed, — lying motionless, or tossed about, and affected with spasm — in particular, we try whether the hands are clenched, and the thumb turned in, or toes bent. According as the upper or lower extremities are affected, one or both, an indication is given as to the seat and extent of the disease. The state of the * M. Jadelot has treated this subject with ingenuity and elaborateness, but we have not been able to discover all that he points out. 7* 7S PECULIARITIES OF DISEASE IN CHILDHOOD. pupil next demands investigation. It may be found contracted and the child will start, as if frightened, or scream out, on being touched ; or the pupil maybe dilated and insensible to light,— the child being motionless or unconscious. We shall hear that the child hashadstart- ing in its sleep, grinding of the teeth, or movements of the lips ; and that when awakened, it started up affrighted, or screamed out ; the bowels are obstinately costive, or the evacuations very foul and dark- coloured. The hands are usually hot, but the feet Cold ; and one cheek is often deeply flushed. No doubt can now exist that the head is the seat of disease ; but what that particular disease may be, and whether a primary or secondary affection, is to be determined by symptoms hereafter to be detailed, in their proper place. " Occasionally we see a child lying completely prostrate, the limbs being relaxed and motionless, the belly sunk, and the eyes fixed, with the lids half-closed ; we are told, however, that it is now much better than it was, as it had been affected with convulsions which have quite ceased ; and no suspicions seem to exist that it is in the last stage of cerebral disease, — the attendants actually congratulat- ing themselves on its quietness. It is not uncommon to find one or more of the extremities quite paralytic in the young infant, without any notice having been taken of the circumstance. There is another expression of countenance very different from that last described, but which denotes much suffering. The lips are retracted, or drawn, so as to show the teeth or gums ; the counte- nance is pale, or sallow and sunk ; the child seems to dread motion, lies on its back, with the knees bent or drawn up, and is pained by pressure on the abdomen. Here neither the brow is knit, nor the pupil of the eye affected. The skin is very hot, shrivelled, and harsh ; there is much wasting, great thirst, particularly for cold water, and a distinct diurnal exacerbation. The tongue is loaded, or dry, red, and pointed ; aphthse may be present ; and diarrhoea constantly attends, — the stools being generally thin, green or dark brown, and fetid. The abdomen is here obviously the seat of disease ; and such a state of things often occurs at the period of weaning, as the state before depicted does during dentition. In the autumnal season, we often see an infant lying sunk in the nurse's arms, the* face pale, the features sharp, the lips apart, and the countenance betokening distress ; it may be that the eyes are sunk, and the skin around them, as also the lips, dark-coloured. On our first query, we will be told that the child has vomiting and purg- ing ; but a look must be sufficient to tell the experienced eye that this is a case of infantile cholera. When a child coughs, the eyes are red, and the nose runs, with sneezing or snuffles, we know that it has a catarrh, but cannot say whether it may not be getting measles, or some epidemic then pre- vailing : we should, therefore, be cautious in our diagnosis, until the case has shown some more determinate symptoms. Cough is a usual attendant, on affections of the chest, and cough in-the child is often violent or spasmodic. In the young infant, how- ever, we must recollect that pertussis may be present without any DIAGNOSIS. 79 whoop. When the larynx is the seat of disease, the cough will be acute or hoarse, according as inflammation or ulceration be present, and almost always spasmodic. The peculiar crowingcough of croup is an important diagnostic, which cannot be too early recognised. The young child almost always swallows any matter expectorated, and therefore this can scarcely become an object of diagnosis. Some of the false membrane in croup, however, is occasionally coughed up. We should always recollect the influence which the expectoration swallowed may have on the stomach and bowels, and allow for the effect which it must produce on the appearance of the stools. The quantity of mucus thrown out, on even slight irritation of the mucous membranes, sufficiently accounts for the loud wheezing, or rule heard during the existence of pulmonary inflammation in the child ; but this circumstance alone need not cause the alarm it often does. The indications afforded by percussion and auscultation in the child differ, in some respects very materially, from those in the adult, even in the same disease, while they often are very difficult of attain- ment, and not always of equal certainty as signs of disease. Hence, the use of the stethoscope in the pectoral diseases of children, must be studied as a distinct subject in itself; and will require to be actually practised before it can be correctly understood. Antecedent to the information to be derived from auscultation, however, we have intimation from the expression of the countenance, and attitude of the child, as to the chest being the seat of disease. When acute or extensive inflammation is present, the respiration is hurried, the countenance discoloured, the eyes more or less staring, and the alae nasi dilated or in quick motion. Respiration is carried on more or less by the aid of the diaphragm and abdominal muscles ; while the thorax remains comparatively quiescent. On the contrary, when the abdomen is the seat of the inflammation, it is by the thoracic muscles that respiration is carried on, the abdominal remain- ing quiet, and the alee nasi unaffected, though the breathing be hur- ried. The deep depression noticed at the scrobiculus cordis and the upper part of the sternum, when respiration is very difficult, indicates a severe degree of pleuro-pneumony ; but our intention here is not to forestal the diagnostics of particular diseases of the chest, but to furnish a general sketch by which thoracic diseases may readily be recognised and distinguished from diseases of the other cavities. It is very necessary, but often difficult, to determine the existence of pain and its seat in the child ; or the cause that may make an infant cry. The character of the cry will vary according as it arises from acute suffering or not, and will also be modified by the age of the child. In the young child, especially, when fresh and robust, the cry that arises from acute suffering is clear, loud, sounding, and con- tinuous, and has been remarked as belonging more to the expiration, than inspiration ; the latter being in this case short, and lost, as it were, in the former > when the child is feeble or fatigued, however, and cries more from annoyance than suffering, the cry of inspiration seems to prevail, being longer and more marked, especially as the SO PECULIARITIES OF DISEASE IN CHILDHOOD. child grows older. There is also in this case more of sobbing, and sighing ; and the circulation is little if at all accelerated. A hoarse cry, if not caused by exhaustion, should cause attention to the state of the larynx, more particularly if the cry be dry and husky, such being caused by an erythematous or aphthous condition of the organs of voice. A peculiar ringing sound in the cry is often our earliest warning of the approach of croup or spasm of the glottis — the sound of the cry in the child supplying those indications which we derive from the voice in adults. The shrill peevish scream that characterizes the advanced stage of hydrocephalus can hardly be mistaken ; but in general the pain of acute inflammation rather checks than excites crying in the child, alow moaning or sighing being rather the sounds of distress that belong to that state. To determine the seat of the pain, we observe whether the child puts its hand to the head, throat, or other place, as if indicating distress ; and if this indication be cor- roborated by other symptoms, and it does not appear that the child is hurt by any thing in its dress, we may consider that part to be a seat of suffering. We have thus been led to detect otitis in the infant, when its cries could not otherwise be accounted for. We must be cautious not to credit a child's statement of having pain (or, as it generally expresses it, i being sick,') in the head, stomach, or else- where, without getting it to point to the part complained of, but which it often misnames. The peculiar expression of the counte- nance also assists us : the brows being contracted, when the uneasi- ness has its seat in the head ; the lips drawn and apart, when in the abdomen ; and the alae nasi in motion, when the respiration is im- peded and painful. The softness of the muscles or degree of emaciation to which a child is reduced, are important in diagnosis, but not to be judged of by merely regarding the face : this may appear full and firm, and yet the rest of the body be much reduced.* In mesenteric disease, the emaciation proceeds steadily, but may be slow in progress. Derange- ment of the intestinal mucous membrane is soon attended with softness and wasting of the muscles ; the body of the child wasting much more rapidly than that of the adult, under the influence of any cause that impedes digestion. In protracted cases the emaciation becomes extreme — the skin growing harsh, dry, wrinkled, and dis- coloured ; and the countenance often assuming an appearance of old age that looks almost unearthly. When consulted respecting cutaneous disorders in children, it is important to be able to determine which are contagious and which are not ; and in particular, we should make ourselves familiar with the forms in which psora or itch may be presented, as it appears often in a very severe form and has been taken for a syphilitic erup- tion ; while syphilis is at times overlooked, and the child perishes before the true nature of the disease is discovered. "W Th c e ° bservant nu ^e, curious in such matters, will point out the firm or flaccid state ot the scrotum as the best indication of good or bad health. [Note to the 4th Jcidition.j L PROGNOSIS. si III. PROGNOSIS. Determining the nature of a disease will often at once decide our prognosis. Thus trismus nascentium is almost necessarily fatal : and a particular form of hydrocephalus generally so; while syphilis, however severe in the infant, may almost certainly be cured : and so of other diseases. In no class of complaints is correct diagnosis of more importance than in children's, as so much of the danger arises from their not being distinguished in sufficient time to allow of a prompt employ- ment of remedies. Thus all acute inflammatory affections are highly dangerous in themselves; but if seen sufficiently early and detected, our prognosis may be favourable, so influential will always be found adequately active and judicious treatment. When the acute stage has passed by, or been subdued, we have again excuse for a hopeful prognosis, even though some organic change may have taken place ; so vigorous in general is the infant constitution, and such powers of reparation does it possess. Generally speaking, we may say that, however severely a child may be affected in the first stage of an acute disorder, or to whatever extremity it may be reduced in the progress of a protracted one, it will be wise not absolutely to give up hope, however guarded our prognosis may be. Few who had not witnessed it, could credit the immediate benefit to be derived from the employment of sufficiently energetic means in the early stages of the severer forms of infantile disease ; or the apparently moribund state from which a child may be restored by judicious management. One evil arises from early despairing of a child, which the practitioner should keep in mind and guard against. The attendants, who are always ready to give up administering medicines, which they often look on as only a source of annoyance, will from that time do nothing; and thus children are allowed to perish for want of proper perseverance in the administra- tion of the remedies prescribed. On the other hand, we should inquire carefully as to the plan of treatment that has been pursued with a child which has been long ill, and which may be brought to us in an apparently hopeless state, and, before we pronounce an opinion, see whether that state be not owing more to the remedies employed than the original disorder. Thus we often see children run down to the last extremity by inces- sant purging, which will almost of itself cease, if the little powders which it has been for so long a time taking, be but discontinued: these powders almost invariably consisting of calomel, or some other irritating medicine. Or, a child which appears to be in the last stage of hydrocephalus, may be found, on examination, to have been brought into this state by the excessive evacuations to which it has been subjected : and of course, the mistake being discovered, our prognosis may be more favourable than it otherwise would be. Again, if we find our efforts to subdue inflammatory action inef- fectual, though apparently sufficient for the object proposed — that S2 PECULIARITIES OF DISEASE IN CHILDHOOD. in fact the child, though relieved after each application, is again quickly thrown back, — we may suspect improper interference on the part of attendants, who are usually in dread of the little patient being too much weakened. By at once charging them with the delinquency, or expressing our opinion that now some stimulant would be beneficial, we shall in general obtain a confession, made either in contrition or exultation — the attendants owning their fault, or boasting of their sagacity in knowing that wine or spirits was re- quired, and having administered it accordingly. Having thus dis- covered the source of failure in our remedies, our prognosis may consequently improve. We have noticed the liability to the occurrence of sympathetic affections in the child. In such affections there is less danger than the same symptoms would indicate did they belong to a primary disease, particularly when the true nature of the case is early de- tected, and the original source of disease removable. We must keep in mind, however, that functional disorder, if continued, will change into organic disease, and that the secondary affection may thus become more formidable than the primary, which must influ- ence our prognosis accordingly. This tendency to sympathetic affection, or disease arising secondarily during the progress of any disorder, in the child, is in itself a particular source of uncertainty and danger; and must make us always guarded in promising abso- late recovery in any complaint that has to run a certain course, or shows a tendency to become protracted. Thus remittent fever, how- ever slight at the commencement, is liable to be tedious in its course ; and so time is allowed for the occurrence of sympathetic affections of the head or chest, which but too often supervene. In no disease is the necessity for this precaution better exemplified than in pertussis. We have already pointed out the greater liability of some of those sympathetic affections to occur than others. It now remains to notice the degree of danger with which these complications are liable to be attended. This will mainly depend on the facility with which the original disease may be removed, or the degree of interference with treatment which the complication involves. Thus the com- bination of pulmonary inflammation with gastro-enteritis, or the occurrence of either during the existence of the other, is particularly dangerous from both sources. When the head becomes engaged during the existence of pertussis, the danger is augmented in conse- quence of the persistence of the primary disease, which has to run its course ; and the occurrence of gastric, or intestinal irritation, during affections of the head or chest, adds much to the danger by embar- rassing the treatment; as the free use of aperients or antimonials is then precluded. The type of the prevailing epidemic will give us an early intima- tion as to the liability of danger, in many instances. There are times when measles and hooping-cough are comparatively mild complaints ; while, again, a most dangerous character, or malignant type, will, at some seasons, prevail ; so that to be attacked, is to be in danger. When an hereditary disposition to the occurrence of particular GENERAL OBSERVATIONS. 83 diseases of childhood exists, such diseases when they do occur must be looked on unfavourably, and all preventive means should be adopted to avert them. The same rule holds good with respect to disorders arising from particular situations. One peculiarity in the symptoms of disease, as it approaches a fatal termination, is often manifested in the child in so remarkable a degree, as in a special manner to call for precaution, to prevent our being signally misled in our prognosis. We allude to the remission, or at times total suspension of severe symptoms, which occasionally precedes death, but by the unwary will be taken as the harbinger of recovery. In no instance is this more striking than in affections of the head in the child. Consciousness or even intelligence may be suddenly restored just as death was expected — but they prove to be only precursors of the fatal moment. CHAPTER V. INFANTILE THERAPEUTICS. I. GENERAL OBSERVATIONS. In nothing are the peculiarities of infancy more remarkable than in the influence which they exercise over the action and uses of medi- cines ; and of no subject is a special knowledge more necessary for the successful treatment of infantile complaints. Most medicines act with great energy on the child, and some have a peculiarity of action differing from that in the adult ; while all require to be given in diminished doses, regulated by the age. If attention be not directed to these points, the practitioner can hardly fail to meet with embar- rassment in treating infantile disease. An attempt was long since made by Gaubius to express with arithmetical precision the difference of dose according to the age ; and his table is useful, though not always implicitly to be followed. According to his arrangement, if the dose for an adult be one, half the quantity will be the dose at fourteen years of age, (or puberty,) and half this again, or a fourth, at four years of age, and half this again, or an eighth, at two years. Expressed in a tabular form, with the intermediate ages from childhood, the table will stand thus : Dose for an adult, 1, say 1 drachm, For a child 7 years old, £ — 1 scruple, 4 ... ... ^ — 15 grains, 3 -£ — 10 grains, 2 ... ... £ — 8 grains, 1 and under 1-12 to 1-15 — 5 or 4 grains. We have here a useful general index, and one of practical appli- cation, but to attain facility in prescribing and accuracy in adapting our doses to the different ages of childhood, attention must be paid S4 INFANTILE THERAPEUTICS. to the several medicines themselves, and the action of each dose watched so as to suspend the use of the medicine when the desired effect is produced ; or hasten its repetition when this is too long delayed. With children in particular, we avail ourselves of the ad- vantages to be obtained from administering medicines in divided doses, so as to ensure the result proposed, neither more nor less. Thus, opiates require to be given at first in very guarded doses, and the repetition of the dose carefully watched, while purgatives will often fail of their effect even in very young children, and unless the dose be quickly repeated, or the form of the medicine varied, much valua- ble time will, in some instances, be lost before the desired effect on the bowels be produced. To specify the precise dose of every medi- cine according to each year of age, would be but to attempt the per- formance of a tedious task, more calculated to complicate than to simplify the subject. Under the head of each medicine, however, we shall assign the doses for the earlier years of childhood; and sup- ply a set of formulas exhibiting suclneombinations of medicines as we have found most serviceable in the treatment of infantile disease. For the sake of uniformity we have made our mixtures to consist of two ounces, as a quantity convenient to order for a child ; and the doses prescribed are adapted to the two first years of life; after which they may be increased one-half until four years of age and then be doubled. The number of medicines which it is necessary or advantageous to give to the child is not great ; and still more are we limited as to our mode of administering them ; the liquid form or that of powder, being almost the only shape in which medicine can be given to the young child. No less important an object is it to render medicine as much as possible palatable to the taste, as all must acknowledge who have wit- nessed the misery, and often injury, caused to children, by the forcible administration of nauseous drugs. We should endeavour, then, to select such medicines as are most free from strong taste or smell ; and moreover try to disguise their flavour by the addition of sugar or syrup, children being so little select of taste, as, in general, to'deem that good which is sweet ; while we not only choose the most con- venient form, but the least bulky dose. Hence, very light powders (as pulvis sennse) are inconvenient for administration to children, and in no case should the quantity of a powder exceed ten grains. When very heavy or insoluble, the vehicle selected for the exhibition of a powder should be sufficiently thick for its suspension, when mixed therewith, so as to ensure the whole being swallowed. The dose of a liquid medicine is from a tea-spoonful or drachm, to a dessert- spoonful or two drachms ; a larger quantity being objectionable, in one dose, for an infant. Medicine is not required in all cases of illness in the child, altera- tion of diet or in the mode of management being often sufficient ; and in many instances the mildest medicines will suffice. This is no excuse, however, for giving nothing but ptisans or syrups to infants, and so letting them perish in acute disorders through fear of using adequate means. When obliged to employ active measures, it is GENERAL OBSERVATIONS. S5 necessary to be prompt in their application, and carefully to look for the earliest moment when their use may be suspended and milder means resorted to, or the case left to the resources of nature ; which in infancy are so powerful when the strength is not too much broken by the protracted use of depletion. We must be attentive to support the child by suitable nourishment during illness ; at least it must not be left too long without some kind of sustenance, as the infant cannot exist many hours without food ; and we would solicit particular attention to this precept, neglect of which we have seen attended by fatal results. During febrile or inflammatory complaints, the diet must be restricted to barley-water, whey, or very thin gruel ; even the breast milk may be too stimulating, and will require to be mixed witli water or exchanged for lighter drink ; but this must be supplied at sufficiently short intervals. During depression or convalescence, change to a more nourishing food than usual will serve, to a certain degree, as a substitute for sti- mulant or tonic medicines ; so susceptible of excitement is the child. Change of air exercises the most beneficial influencein infantile disease, often putting an end to protracted illness in a few days. With the child we can avail ourselves of this measure at an earlier stage of acute disorders than with the adult. Being brought abroad or changed to another room in the same house (if more elevated and airy), willalmost always be useful; and we cannot be too particular in insisting on the apartments of a sick child being kept cool and airy, at least sufficiently ventilated and of an equable temperature. When labouring under affections of the head, however, or recently recovering therefrom, there is risk in too sudden exposure of the child to the excitement of light and air by bringing it abroad ; and danger in the fatigues, added to the excitement of a journey, so that we should prefer, in the first instance, seeking the advantages of fresh air, by its admission into the chamber, while light and noise were, at the same time, excluded ; and even after convalescence had been established, we should rest satisfied with merely bringing the child abroad, without venturing upon a journey for the sake of change of air, until the condition of the nervous system warranted us in hazarding the disturbance thus likely to be induced. Inattention to these considerations we have seen attended with disastrous conse- quences, relapses being thus brought on, or cerebral symptoms alto- gether induced, during recovery from merely febrile disorders. In some disorders of the chest, particularly in the chronic form, or when accompanied or induced by a spasmodic affection, the good effects of change of air are often most remarkable ; as in chronic bronchitis, the advanced stages of pertussis, and occasionally even in spasm of the glottis ; the beneficial influence of change of air being not less remark- ably manifested in lessening irritability and restoring tone to the ner- vous system, than in producing similar effects upon the mucous membranes. In all affections of the abdominal viscera this is uni- formly the case ; particularly in protracted forms of remittent fever, and in all forms of diarrhoea or dysentery. Climate. — In broken-down states of the system, and especially 8 g 6 INFANTILE THERAPEUTICS. in those cachectic conditions induced by or connected with strumous disease, not only change of air, and travelling, but change of climate, become absolutely essential to the restoration and preservation of health. A moment's reflection on the influence exercised over the structures of the body during growth, by the effects of the locality in which a child is placed ; or recollection of the direct results observ- able in the health from the same cause, must prepare us to expect most important benefits from residence in a dry, equable, and warm climate ; as we are so repeatedly obliged to deplore the miserable results of residence in situations of an opposite character. But it is not merely as conclusions from reasoning, however just, or principles however sound, that we draw these inferences ; but as the results of actual observations and long experience in the climates of which we speak — and which lead us earnestly to call the attention of the pro- fession, (as we find that of the public has already been directed,) to the great advantage of employing change of climate as a resource in the delicacies of childhood, without waiting for the more hope- less effort of employing it as a last refuge to escape from the delicacies of youth. Whatever form these degeneracies of health may assume, we know how essentially they are connected with, if not dependent on, tubercular formations ; and we have already noticed the relation of these to strumous disease. How much better, then, to take effectual — indeed, the only feasible — means of averting in childhood that tendency to degeneracy of constitution, which is so certain, in such cases, to manifest itself in youth, than to delay combating the evil until it has arrived, and we have to contend with some of those actual deposits of tubercular matter, which can so seldom be restrained — and never, perhaps, removed. In children so disposed — subject to glandular enlargements, and membranous inflammations, (whether exhibited in the form of fre- quent bronchial attacks, liability to croup, or gastric and intestinal irritation) — threatened with hydrocephalus or mesenteric disease — we would recommend immediate removal for the winter months to the more genial climates of the south of France or Italy. This re- moval will be seen to exercise its best results so early as three or four years of age — but more particularly at the ages of five or six, and especially seven, when, at the period of second dentition, strumous affections are so liable to develope themselves, or become established in the constitution. We have, in such climates, seen children pass a whole winter without one day's illness, and everyday in the open air, who had for more than one preceding winter been seldom out of the sick room, and never, perhaps, once out of doors. The places on the Continent best suited as winter residences for children are Nice or Rome ; but in the commencement of the season, Naples is equally eligible : and for those with whom a soft, but rather moist atmosphere is calculated to agree, Pau is a convenient place to select. Having passed a winter in all these places, we are, unfortunately, but too well qualified to speak of the relative merits of each. Rome is commonly considered the most eligible for the child ; and this opinion receives the high support of Sir James Clarke ; but as a place of common resort for delicate children, we would GENERAL OBSERVATIONS. 87 decidedly give the preference to Nice. The place to be selected in any particular instance, however, must depend upon the nature of the case ; but, as a general rule, the dry, invigorating, and even ex- hilarating air of Nice, (situated, as it is, on the sea-shore, and with its atmosphere often highly charged with electricity,) will best agree with the feeble frame and delicate constitution of the sick child, whose delicacies of health are so often connected with strumous disease. Where the tendency is, on the contrary, to acute inflammatory attacks, the nervous system excitable, and the mucous membranes disposed to irritability, the mild and equable temperature of Rome, little dis- turbed by high winds, and occasionally softened by the relaxing sirocco, will be found best to agree ; and if a single place is to be selected for both winter and spring, Rome is that to which preference must be given. Naples should never be persevered in, as a residence, on the approach of spring ; but the child be removed to Rome, or the still milder air of Pisa, early in February, when the keen northern and north-eastern winds begin to blow. The same change will be occasionally necessary at Nice, but not so frequently, nor then at so early a period — not before the middle of March. Pau is very free from cold spring winds, but the moistness of the atmosphere must be taken into account, as with strumous children, in general, it is damp- ness rather than cold that so much disagrees. Where passive diar- rhoeas exist, with a lax state of frame, or open ulcers are present, such a climate will disagree, and Rome, in particular, should be avoided, as ulcers heal ill there, and diarrhoea is liable to occur during the prevalence of the south wind. Nice, as a permanent residence, or Naples, at the commencement of winter, will best suit such cases. The choice of a particular house is of almost as much importance as the selection of the place in which to reside. Inattention to this point may forfeit all advantages of a change of climate. Not only must a good quarter of the town be chosen, and the aspect of the rooms be southerly, but we should be certain that the sunshine actually enters the apartments, unobstructed by opposing buildings or any other obstacle. Hence, the upper rooms of a house are often preferable to those lower down, as admitting the sun when the others do not. In sending children into the open air, great care must be taken to pro- tect them from the heat of the sun in spring ; and it must not be forgotten that the brightest sunshine is often co-existent with the keenest wind, when the child should not be permitted to go abroad, however fine looking be the day. In the management of children's diet, the principal point to be remarked is the necessity of diminishing the quantity of milk, which is not found to agree well in Italy. But the light and excellent bouillon, or broth, will, in part, make a good substitute ; and goat's milk (always easily to be had) will be found excellent ; the fact being, that it is the want of good pasture rather than any other influence of climate, which causes cow's milk so much to disagree in those climates.* * Those who have seen cows feeding on the refuse vegetables of the stalls, largely intermixed with orange and lemon-peel, as we have seen in Italy, will not be surprised if their milk is not accounted wholesome. g8 INFANTILE THERAPEUTICS. During a journey, children are liable to have their bowels out of order. Irregularities in diet may cause diarrhoea, and such not in- frequently occurs; or deposits appear in the urine, just after the journey is over ; but during travelling, a state of constipation is that which is oftenest present, and even diarrhoea, which had before existed, ceases. Hence, a lax state of bowels should not prevent a child being taken to travel ; and the constipation which may occur is easily mitigated by any mild aperient. But the great and important matter in bringing children abroad, is so to conduct the journey, as not to injure the children by over excitement and fatigue — in fact, to keep in mind, that it is for the benefit of the child, not for our own amusement, that we travel — a matter, forgetfulness of which has caused much misery in many a journey. II. MERCURY. Of medicines which act in a peculiar manner on the child, one of the most remarkable is mercury ; which proves, according as it is well or ill employed, the most useful or injurious medicine given to chil- dren. Mercury may be administered with impunity to the youngest child ; and, indeed, infants often appear to bear large doses better than adults ; but this by no means excuses the universal and empirical manner in which mercury is too commonly dealt out to children ; nor secures us against the evils which this abuse of so active an agent, is certain, sooner or later, to entail. One remarkable circum- stance connected with this mineral is, that mercury does not seem capable of salivating an infant. We have never seen it do so, nor are we aware of any such case being on record ; our experience, in this respect,coinciding with that of Dr. J. Clarke, as we have never suc- ceeded in salivating a child under three years of age — indeed, even at four and rive years old, it is not easy to do so. But we would here give warning, that in children after that age, at six or seven years and upwards, sudden and severe salivation is liable to take place, when mercury is given in any large dose, while the strength is broken down after fever, or any of the exanthems ; more especially if much mercury has been given (as it too often is) during the previous illness. This is a frightful and fatal affection, which, although it must be well known to practical men, has been but casually noticed by medical writers ; we shall, therefore, treat especially of this subject, under the head Cancrum Oris Mercuriale (which see). To the fre- quent employment of mercury hasalso been attributed thatpremature tendency to decay, which sometimes leads to the almost universal destruction of the teeth at an early age. The absence of salivation in the infant somewhat impedes us in the employment of mercury, in acute inflammations ; at least we are thus deprived of a useful crite- rion by which to judge of the effects of medicine on the constitution, and so to regulate its administration. Hence the pushing of mercury, so as to induce salivation in inflammatory diseases, and thus cut short the complaint, as we do with adults, cannot be practised with the young child. But mercury, notwithstanding, constitutes our chief MERCURY. 59 agent in subduing inflammatory action on infantile disease, and ac- cordingly we find that some consider mercury as exerting a special influence in controlling inflammation independently of salivation. This influence is explained by supposing that mercury exercises a particular action upon the bloodvessels, or upon the blood itself, so as to change the condition of the one, and the constitution of the other, in such a manner as to interrupt or alter the morbid action going on, so as to prevent the effusion of coagulable lymph, or cause the absorption of it, and other fluids when effused, and thus obviate or remove structural changes ; results, which we know attend the adminis- tration of mercury, in whatever manner we are to attempt their expla- nation. However this may be, we are not to overlook the influence which mercury is acknowledged to exercise upon the secretions, and which is particularly manifested in the child ; but this, though bene- ficial, fall far short of a specific influence in arresting inflammation, and is liable to do mischief, if not cautiously resorted to. In connec- tion with this power, mercury has the character of quickening the action of other medicines, and so ensuring their effects; and hence it is often joined with diaphoretics, expectorants, cathartics, &c. It is its action on the intestinal canal, and particularly the biliary secretion, that is most manifest in the child ; and some give a prefer- ence to calomel as a purgative for infants. No mistake can be greater : though occasionally useful, it is at all times liable to create intestinal irritation, and its continued use is certain to cause it, — producing griping, diarrhoea, and green stools ; accompanied by fretfulness, feebleness, and pallor. This irritation, however, is sometimes resorted to in the treatment of cerebral affections, as a source of derivation or counter-irritation. On the other hand, the occasional use of a mild mercurial is service- able, by restoring the natural functions, when the stools are very foul and unnatural in appearance. Calomel is the preparation of mercury most frequently employed with the child, particularly in inflammatory affections. Blue pill is an inconvenient form, but useful preparation, and may be given bruised down in some liquid. Hydrargyrum cum creta vel magnesia are mild mercurials ; and from their mildness and combination with an antacid, are peculiarly suited to the bowels of children, when acidity is present, with or without diarrhoea. Calomel may be given alone to act on the bowels, in doses of from one-fourth to one or two grains at most, and usually requires to be followed, in two or three hours, by a dose of castor oil, or other aperient. Calomel is generally given in combination with other medicines, as purgatives, to quicken their operation ; or with ipecacuan, squill, or James' powder, as an expec- torant or diaphoretic. The dose is usually one-fourth or half a grain, or, at most, a grain or two, repeated every second or third hour. It is in such combinations and in such manner, that calomel is given in inflammatory affections, according to the seat or nature of the inflammation. Combined with aperients in affections of the head, and with expectorants or antimonials in thoracic inflammations and inflammatory fevers. When the intestinal mucous membrane is 8* 90 INFANTILE THERAPEUTICS. the part affected, or we fear the mercury running off by the bowels, an opiate (most generally Dover's powder) is added, or mercury and chalk selected instead. When inflammation is very acute, seated in an important organ, as the head or throat, or very protracted, as in chronic hydrocephalus, we employ in addition mercurial inunction, to aid the influence of the medicine on the constitution. In urgent cases, this must be freely had recourse to, even in infants ; for although the gums will not be made sore, we shall find the mouth grow hot, and an indication thus afforded to regulate our use of this remedy. From one scruple to half a drachm of the strong mercurial ointment may be rubbed in, twice a day, after the first year of age. Mercurial inunction has been recommended for the cure of infan- tile syphilis; but will hardly be found necessary ; neither need we often have recourse to calomel, for the treatment of a complaint which will be found almost always to yield to a mild course of hydrargyrum cum creta. (See Syphilis.) The hydrargyrum cum creta is given particularly when diarrhoea is present, and a mercurial indicated ; but in this case the dose must be small (not exeeding one grain), or combined with an opiate. Hydrar- gyrum cum creta alone is by no means to be taken as a cure for diarrhoea, as some seem to suppose ; and even when guarded by an opiate, any mercurial is, in certain cases, injurious. Mercury, in fine, constitutes one of the most powerful but danger- ous medicines employed in infantile therapeutics. In inflammations of membranous tissues with tendency to effusions of serum or lymph, the use of mercury, after depletion, constitutes our most efficacious agent of cure: particularly in inflammatory affections of the serous membranes, as meningitis, peritonitis, pleuritis, &:c. In ordinary inflammation of the mucous membrane of the air-passages it is less frequently required ; but in those forms in which lymph is thrown out, as in croup or diphtherite, the necessity for its use becomes again equally urgent, as also in the inflammatory affections of the stomach and bowels. In passive diarrhoeas and chronic dysentery, after the cessation of inflammatory action, mercury often proves highly irrita- ting or injurious ; and even in cerebral affections tending to serous effusion, we must discriminate between the truly inflammatory form and that depending on scrofulous disease, before we have recourse to mercury as our plan of cure. In virtue of its action on the secer- nent functions, particularly of the lymphatic system and the skin, mercury is often indicated in the child, in whom glandular and cuta- neous disease so often exists ; but the action which mercury exercises in promoting the biliary and other secretions of the chylopoietic viscera, is not confined to this medicine but shared in common with it, by several of the neutral salts and some of the vegetable purgatives ; while in glandular disease having a strumous origin we must use great circumspection in our employment of mercury. The continued morbid irritation of some febrile disorders and the chronic inflamma- tory characters of others, is perhaps best broken in upon by the use of mercurials ; but the abuse of these medicines in the treatment of all febrile attacks, as measles, scarlet fever, small-pox, &c, fee., appears SEDATIVES. 91 justly to have been blamed as accelerating or inducing the develop- ment of scrofula, during convalescence therefrom. In confirmed scrofula we must be most sparing in the employment of mercury ; or altogether interdict its use — never, except under the most urgent circumstances, attempting to put the system under its influence — and the same is to be said of scorbutic states of the constitution, especially if attended by hemorrhage. In certain conditions of strumous disease, however, assuming the form of ulcerations connected with indurated glands, the alterative action of corrosive sublimate will be found of signal service, both in dispersing the glandular enlargement and disposing the ulcerations to heal, as we often witness in such ulcerations seated in the throat and fauces ; and even in the amelioration of mesenteric disease. Employed for this purpose, the bi-chloride must be given in very minute doses — not too long continued at one time, and exhibited in combination with sarsaparilla, which we have found decidedly more eligible than combination with tinctures of rhubarb or bark, as ad- vised by Sir Astley Cooper. Under the use of this medicine, the urine will be found to increase in quantity, and the stools often be- come of an olive-green colour. Underwood claims credit as being the first medical writer to re- commend the use of calomel in infantile disease ; and doubtless the medical profession is much indebted to the first introducer of so active a remedy ; nor should the blame of its abuse attach to him. III. SEDATIVES. Irritation is a usual attendant on infantile disease, which often arises directly from this source ; and in all cases, nervous suscepti- bility to a greater or less degree is present. Hence we are prepared to expect much good from the employment of sedatives, which are often indicated, but concerning the use of which a very general ap- prehension appears to prevail. This has probably arisen from the injurious, or even fatal results, which have followed the administra- tion of soothing syrups, &c, to young children by ignorant attendants. The ingredients of such compounds, or at least the quantity of nar- cotic which they contain, are seldom known ; so that their employ- ment, even by the regular practitioner, is dangerous, independently of the objection that recommending such, fosters popular prejudice respecting the ignorance or indifference of medical men about infan- tile disease. Hence the physician should a\\v&ys formally prescribe them ; and from no class of medicines does more signal service arise, when judiciously administered to the child. The evil effects of the habitual administration of narcotics are soon visible in infants who are subjected to this soothing system. The digestive organs become altogether deranged ; the appetite is lost or precarious ; the bowels are constipated and evacuations white. The body dwindles, and the face pale, shrunk, and sallow, with eyelids red and swollen, pre- sents, in its stupid aspect, an appearance not to be mistaken. When called upon to treat such children, it is necessary to keep in mind, QO INFANTILE THERAPEUTICS. that however injurious this practice, it is one that cannot with im- punity be at once discontinued, as extreme irritability of the nervous system, accompanied by spasm and convulsions, will follow, it the accustomed sedative be not gradually withdrawn. Opium acts with much energy and rapidity, particularly within the first few months after birth, and due caution must be exercised in prescribing it. But when once the proper dose with which to begin is known, and we are aware of the quickness with which it acts, and the length of time during which its influence lasts, we can avoid the danger of an over-dose, or one too frequently repeated. Conditional orders should always be given to suspend the medicine, while the child sleeps, or until the symptoms have returned. The infant fre- quently begins to slumber immediately on the administration of the first dose of the medicine, and continues to sleep for several hours, — the effect lasting from four to five hours, or more, at a time. Hence an opiate should not be renewed oftener than every third or fourth hour, — twice or thrice a day being in general sufficiently often. In some cases, however, it may be required so often as every hour or half-hour, until the desired result is attained, as in severe cholera, but its effects must in such cases be narrowly watched. The influence of opium is more immediate and remarkable when the tincture of opium, or the pulvis cretae comp. c. opio, are exhibited, than the syrup of white poppy, or Dover's powder, though the doses be equivalent. Syrup of poppy is generally preferred as the opiate for children ; but it is uncertain in its strength, being liable to spoil or be adulterated. When genuine and well-preserved, one ounce is considered equivalent to a grain of opium ; so that thirty drops, or half a tea-spoonful, would be equal to 1-16 of a grain of opium, or about a drop of laudanum ; this would be the dose for a child two or three months old. During the first month, however, we would not advise more than § or \ of a drop of laudanum to be given at once until the effect was tried, — even this minute quantity occasionally producing more of a narcotic effect than might be anticipated, or would be caused by a larger proportionate dose of syrup of poppy. The best and safest form for exhibiting opium to the young infant is by diffusing a given quantity of laudanum in a mixture with simple syrup, so that the dose will be always definite, however minute, as in the following formula, which we name the simple sedative syrup : No. 1. — Syrupus Sedativus Simplex. R. Aquae Destillatae, %\. Mucil. Gurn. ac. ^ss. Syrupi Simplicis, ^ss. Tincturae Opii, guttam. M. A tea-spoonful will be the dose, repeated every half hour till rest be produced ; but after the first month, double that quantity may be begun with. At the third month, half a drop of laudanum may be given for a dose, — one drop at six months old, and two after the first year. SEDATIVES. 93 The camphorated tincture of opium presents a preparation with more of sedative, and less of narcotic properties than the simple tincture, and also of weaker strength ; so that it may be given in triple the quantity, and is preferable to allay spasm and quiet irrita- bility, especially when connected with cough. The same may be said of the ammoniated tincture, which is best added to a carmina- tive mixture, when we want to allay pain or spasm caused by flatus ; the dose being double that of laudanum. The sedative influence of lettuce or orange-flower water would point them out as eligible vehicles ; but not being officinal in our Pharmacopoeias, they are not always to be obtained. Laurel water, however, can always be procured, and it is a seda- tive peculiarly serviceable in allaying pain, spasm, or convulsion, arising from intestinal irritation in the child. Hence we propose another sedative mixture to be called, No. 2. — Syrupus Sedativus Compositus. R. Mucil. Gum. ac. 5SS. Aquae purse, 3L Aqua? Lauro-cerasi, gtts. viii. Syrupi Aurantii, 5SS. Tincturee Opii, guttam. M. If we wish to obviate costiveness while employing this mixture, from one to two drachms of which may be given every second or third hour, syrup of violets may be used instead of simple syrup, or a drachm of rhubarb wine added. If, on the contrary, we wish to check diarrhoea, allay pain, or remove flatulency, — aromatics, alka- lies, or astringents may be combined. Dover's powder is a mild and safe opiate for the child, and less liable to disagree than perhaps any other. From i to \ a grain may be given at a dose, during the first three months ; and from one grain to two, after a year old. The compound powder of chalk with opium acts more energetically, and must be used with greater caution. The very small quantity of opium present, however, enables us to give it apparently more freely : from half a grain to a grain will be borne during the first six months, and two grains after that period, three times a day, or four grains by a child two years old. Narcotics readily produce their effect when applied to the skin of the child, and require proportionate caution when thus employed, so delicate and susceptible is the cutaneous surface. In this manner tincture of digitalis is often used in continental practice ; and opiate plasters are found most serviceable in protracted bowel complaints, while an English physician, Dr. Bow, extols the use of opiate frictions in the inflammatory affections of children. The form he employs is as follows; and he relates many cures effected in this way. No. 3. — Br. Bow's Opiate Liniment. B. Opii, 51. Saponis, £ss. Linim. Camph. comp. %\. Digere per dies aliquot et effunde linimentura. Sleep being almost as essential to the child as food, we can scarcely INFANTILE THERAPEUTICS. 94 foil to benefit it bv inducing a state of rest during illness, and this the use of opium seldom fails to do. Many alarming symptoms, as screaming, spasm, or convulsion, may be thus mitigated, or at once removed, if dependent on irritation alone. When using narcotics for J such a purpose, however, we should examine into the cause of irri- ; tation, and try to remove it, while we palliate the symptoms, — as, 1 for example, "by dividing the gums, or freeing out the bowels, if re- quired ; and in inflammatory cases, depletion should always pre- cede or accompany the use of sedatives. After bloodletting, opium j appears to possess, in some instances, a distinct influence in control- ling inflammatory action, more especially when seated in a serous membrane. In cerebral irritation, or in meningitis, after depletion, the beneficial effects of an opiate in procuring rest and tranquillity is often very remarkable ; but in this case judgment and experience are particularly required, as cerebral irritation is very liable to pass into congestion in the child, and inflammation to end in effusion ; and the narcotic effects of an opiate would tend to obscure or aggravate the symptoms, and might increase the liability to congestion. The irri- table or spasmodic character which often belongs to the cough or breathing in the pulmonary affections of children, is generally miti- gated, and at times removed, by the use of an opiate ; and some tinc- ture of opium, or Dover's powder, is a useful adjunct to expectorant medicines, which are also better borne by the stomach when thus combined. In all cases of gastric or intestinal irritation, whether sympathetic or not, opium is a chief resource, and must in severe cases be admi- nistered in a decisive manner. An injection containing one, two, or three drops of laudanum, according as the child is three, six, or twelve months old, will often at once check a diarrhoea which has lasted long, and been in vain treated otherwise. [Too much caution cannot be inculcated upon the young practi- tioner in regard to the use of opium or any of its preparations in the case of infants and young children. Important as the remedy is, in many of their diseases, it is, nevertheless, apt at times to produce the most alarming effects, even in the minutest doses. The protracted use of opiates in young children has invariably a mischievous tend- ency. — C] IV. ALKALIES AND ALKALINE EARTHS. These exert a decided sedative influence, especially upon the mucous membranes, when in a state of irritation or chronic inflam- matory action ; while they, at the same time, alter and improve their secretions. Their antacid properties, in addition, render them pecu- liarly eligible in the treatment of infantile disease ; and we have often experienced their utility, more especially in controlling gastric or intestinal irritation. The stomach may be thus often quieted, and many of the more distressing attendants on diarrhoea or dysentery removed. They mitigate pain and spasm, appearing to restore or equalize the peristaltic motion. Tenesmus is often speedily removed CARMINATIVES. 95 by the use of one of these alkalies, and the character of the stools altered, their fetor being destroyed. In pertussis, or in spasmodic cough, they tend much to mitigate the severity of the symptoms ; and in the advanced stages of bronchitis, &c, the alkalies, in addition, exercise an influence over the morbid action, causing the phlegm to be less viscid, and consequently more easily excreted. In prescribing these medicines, however, we must not employ them in the early stages of inflammation, and we must be careful to exhibit them suffi- ciently diluted or guarded by some mucilaginous menstruum. Com- bination with opium, or its alternate use, adds much to their efficacy, and is frequently adopted. According to the object in view, will we combine, or select the alkali we would employ. In general, the bi-carbonates are preferable to the carbonates, as being less caustic ; and, for this reason, carbonate of soda is preferable to carbonate of potash, as well as because it is not deliquescent, and therefore may be given in the form of powder; but these objections do not apply to the bi-carbonate of potash, which should therefore be preferred to the carbonate, and is altogether the most eligible of these alkalies for ordinary use. When the stomach is very irritable, the liquor of potash, or lime water, will often answer best, or magnesia, if the bowels be confined. When the bowels are irritable, chalk in the form of pulvis cretae com- positus, with or without opium, is usually selected ; or chalk mixture instead. Where the stomach is at the same time irritable, however, carbonate of lime will not be borne; and we choose carbonate of soda, or, better, bi-carbonate of soda or potash. If much flatulency be present, with acidity, any carbonate is objectionable : the additional extrication of gas, caused by its decomposition, adding to the distress and oppression. A few drops of liquor of ammonia, or of its aro- matic or fetid spirit, will answer best in this case — often putting an end at once to the flatulency, as well as acidity, by its stimulant and alkaline properties. Should the action of a stimulant be objectiona- ble, calcined magnesia should be preferred. Liquor of potash, in particular, exercises an influence on the glands and skin, diminishing irritation and its consequences, when seated in either of these struc- tures, especially if connected with morbid states of the primae viae, as is so often the case. Enlargement of the glands of the neck, groin, and even mesentery, we have seen diminished under its use, when iodine could not be borne, or as a medicine introductory to its em- ployment ; and in those forms of cutaneous disease more directly con- nected with derangement of the digestive organs, the useful effects of this medicine are most remarkable. In employing this class of medicines, however, we must occasionally interrupt their use ; as too protracted a course is liable to debilitate the stomach and otherwise derange the digestive organs. V. CARMINATIVES. A stimulant action is often looked to as a principal agent in restor- ing the mucous membrane to a healthy tone. For this purpose, an 9G INFANTILE THERAPEUTICS. aromatic stimulant is usually preferred, and some of the distilled waters, or a few drops of an aromatic oil, diffused through the mix- ture selected. Indeed, with some, no medicine is prescribed for a child, without the intervention of dill or fennel water; but this is objectionable, when unnecessary, as their strong odour is always offensive, and adds much to the disgust for medicine. To all these aromatic waters is attributed an antiflatulent or antispasmodic action ; but to some, peculiar properties are ascribed. Thus mint water is selected when the stomach is irritable ; but in such cases the simple compound infusion of mint, or fresh mint tea, is preferable. Cinnamon water is chosen when the bowels are the seat of irrita- tion. On such principles are constructed the carminative mixtures so commonly given to children when affected with gripings, acidity, flatulency, or convulsions ; and when these arise independently of inflammatory action, those mixtures are often of great utility. But we must be careful to avoid stimulants when such symptoms are connected with inflammation of the stomach, bowels, or any other organ. The most celebrated compound of this description is Dalby's car- minative, the prescription for which we give in a note ;* but some of the following formulas, which are more simple, will be found con- venient : No. 4. — Mistura Jlnti-emetica. R. Infusi Menthae, %i. Mucil. Gum. ac. gss. Syrupi Aurantii, ^ss. Spir. Lavandulae, c. ^ss. Tinct. Opii, gtts. ij. M. 3i. — 5'J* sumat hora quaque 2da. In irritability of stomach with flatulency and acidity, or diarrhcea, when much griping or spasm is present without inflammatory action, the following mixture is to be employed ; to which a drachm of tincture of rhubarb can be added to ensure a purgative effect, if desired : No. 5. — Mistura Carminativa. R. Aquae Carui, gi. Mucil. Gum. ac. gss. Magnesias Carbonatis, Jss. Olei Cajeputi, gtts. iv. Syrupi Croci, ^ss. Spir. Ammoniae Foetid. Jss. M. 3ss. — 3'j- sumat ter indies. Daily's Carminative. R. Aqua? Menthae Piperita?, ^ii. Carbonatis Magnesiae, ^ij. Olei Menthae, guttam Anisi, guttas iii. Tincturae Castorei, ^ss. Cardam. Comp. Jss. ■ ■'■ ■ — Assafoetidae, gtts. xv. Spiritus Pulegii, gtts. xv. Tincturae Opii, guttas v. M. STIMULANTS. 97 The stimulant effect of this mixture can be increased, when depres- sion attends, by the addition of half a drachm of compound spirit of lavender, or one scruple of nitrous spirit of ether, or Hoffman's ano- dyne liquor. In flatulent colic, half a drachm of the ammoniated tincture of valerian will make a preferable addition ; or four drops of laudanum may be added when an anodyne effect is desired. VI. STIMULANTS. Much caution is required in administering stimulants to the child, as excitement is easily induced, and consequently the depression often attendant on local disease increased, instead of being dimi- nished. Great mischief is thus done by the improper administration of stimulants to infants, to whom they are commonly given to expel flatus, allay pain or spasm, and throw out eruptions, or stimulate the child when thought to be debilitated during the progress of inflam- matory affections, particularly of the alimentary canal. When ex- hibited in such cases, all the symptoms become aggravated ; and yet their use is often persevered in to the last. We must not fall into the popular notion that the diseases of children arise from debility — an error of which even Sydenham seems to have partaken, often prescribing ammonia in infantile dis- ease ; but when we do find infants habituated to the use of stimu- lants, it will be necessary to exercise due discretion in subjecting them suddenly to the depressing influence of a lowering plan of treatment. When a stimulant is required, as in cases of sudden sinking or much depression, such as attends severe vomiting and purging, the volatile alkali is one of our best for children, being qujck and tran- sient in its action — not likely to disturb the head, or give rise to continued excitement, as alcoholic preparations do. Hence aromatic tinctures, wines, &c, should seldom be given to the infant; but the aromatic waters, volatile oils, or some of the milder aromatic spirits, may be commonly employed as vehicles or adjuncts. During the course of the eruptive fevers, when the eruption has receded, or come but scantily out, some stimulant may be required ; and when these fevers assume the typhoid type, stimulants must be employed ; but their universal use in measles, small-pox, &c, &c, as practised by some, cannot be too strongly reprobated. In dyspnoea dependent on debility and spasms, or occurring in the advanced stages of pulmonary catarrh, from accumulation of phlegm in the bronchi and inability through weakness to expel the same, stimulants must be employed, and the aromatic spirit, or car- bonate of ammonia, combined according to the circumstances of the case, is perhaps the best we can prescribe. When restlessness, spasm, or convulsions, arise from exhaustion, as in cases where depletion has been carried too far, or illness has been long protracted, a stimulant is most beneficial ; but if used as an antispasmodic where such symptoms arise from an opposite cause, as they more frequently do, an aggravation of every symptom will be induced. 9 i ' 98 INFANTILE THERAPEUTICS. The following will be found a good general stimulant for the child: No. 6. — Mistura Excitans. R. Aquae Menthae, ^iss. Spir. Ammoniae arom. £ss. Spir. iEtheris nitrosi, gtts. xij. Spir. Lavandulae Comp. Ji. Syrupi Simplicis, ^ss. u M. 3i. hora quaque secunda. Turpentine as a stimulant and antispasmodic, is peculiarly adapted for children — one or two drops often at once removing flatulency or spasm. In protracted diarrhoea, its action is most serviceable : and it has also anthelmintic powers, which recommend it in particular cases. The following formula will be found convenient : No. 7. — Mislura Terebinthinata. ]£. Aquae Anisi, ^i. Mucil. Gum. ac. ^ss. Olei Terebinth. Rec. £ss. Oiei Limon. volat. gtts. iv. Syrupi Simplicis, ^vr. M. 31. — 3U' h° r 3< quaque 3tia. VII. TONICS. Children often require tonics during convalescence, or in the ad- vanced stages of inflammatory and febrile disorders ; but they must be tried with caution, and used very moderately, as they are much more liable to induce excitement than in the adult. A principal object in giving tonics to the child is to restore appetite, as when once that is established, strength will soon be renewed by the use of nutritious food. For this purpose any of the simple bitters or sulphate of quinine, may be used. The infusions of cascarilla. columba, gen- tian, hop, or chamomile, diluted with equal parts of an aromatic water, and given in doses of two drachms or half an ounce, twice or thrice daily, appear to be the bitters best adapted for the child ; but sulphate of quinine may be looked on as a substitute for all — and in sufficiently small doses can be given to the youngest infant, as in the following formula : No. 8. — Mistura Corroborans* R. Aquae Destillatae, ^iss. Quinae Di-Sulphatis, gr. ij. Acidi Sulphur, arom. 9i. Tinct. Aurantii, ^ii. Syrupi Aurantii, Jiii. M. Capiat 3i« — 3'J* ter quaterve indies. Bark and steel are the best tonics we possess, and those most calculated for general use — bark is to be preferred for making a sudden impression in cases of urgent debility or attacks assuming a distinctly intermittent or periodic form ; steel for its more gradual TONICS. 99 influence in protracted cases, or those merely remittent in their type. A combination of both will be found more serviceable than either singly, when debility is dependent on a cachectic state of the system, and spasmodic or other attacks assume a periodic form. In such cases, a grain of sulphate of quinine and a grain of sulphate of iron, dissolved (by the aid of six drops of dilute sulphuric acid) in two ounces of infusion of columba, (as recommended by Dr. Cheyne,) will be found an excellent combination, and may be given in doses of two drachms to half an ounce, twice or thrice a day ; or we may at once prescribe, in similar doses, the mistura ferri aromatica of the Dublin Pharmacopoeia. Iron and iodine are tonics of peculiar power, especially in the treatment of serofula, and hence, often employed in infantile medicine. Their efficacy in restoring appetite, when properly administered, is remarkable, particularly so with iron, which also possesses the pro- perty of improving the quality, if not of increasing the quantity of the blood, so as to add colour to the cheeks, while it gives strength to the frame ; and is altogether the best tonic we can employ in convalescence, after much blood has been lost during illness, or in cases of relaxed fibre and general debility ; in consequence of its astringent as well as tonic powers. Iodine is not so uniform in its beneficial effects upon the appetite, which it appears occasionally to derange rather than augment ; and this result has been estimated to occur in about one case out of six. When its use is too long con- tinued, an irritable state of the intestinal mucous membrane is liable to be induced, and then colicky pains, griping, or purging, with febrile excitement will follow ; as also if the medicine is given during the existence of gastric irritation ; but in such cases, its use must be abandoned or suspended, as must that of all tonics, when excitement or fever attend their administration. The tartrate of iron is altogether the best preparation for children, and that generally employed, both on account of the absence of taste, and the mildness of its action. In addition to its tonic properties, it joins a tendency to open the bowels : and this effect may be height- ened, and its taste quite hidden, by combination with treacle. When it is an object to increase the aperient aetion,this may be done to any extent by joining it with Rochelle Salt, or tartrate of potash. And if in addition, or instead, a diuretic action be desired, as in cases of oedema attendant on debility, we may add to the foregoing, or sub- stitute therefor, the bitartrate of potash. Tartrate of iron may be given in the form of powder, combined with an aromatic, and sugar, as in the following formula :* No. 9. — Pubis Chalybeatus. R. Ferri Potassio Tartratis, gr. ij gr. v. Pulveris Aromatici, Sacchari Albi, aa. gr. ij. M. Sumat pulverem talem ter quatcrve indies. * When thus prescribed, we must point out the Pharmacopceia according to which the preparation is made, as that of the Dublin College is so deliquescent as not to admit of being exhibited in this form. 100 INFANTILE THERAPEUTICS. Or a similar combination may be given in the form of bolus, and the dose of the tartrate carried so far as ten or twenty grains, three times a day, in children three or four years old, when much debili- tated by protracted strumous disease. In the vinum ferri of the Pharma'copceia, we have a similar preparation in the liquid form, which may be given to the youngest infant in doses of from five to twenty drops, twice or thrice a day ; or be carried to drachm doses, when given to more grown children. In a similar manner we may give a tincture made of acetate of iron, which is more active than the last preparation, but not so energetic as the muriated tincture. Asses milk or whey make good vehicles, and assist in disguising the taste ; but in cases of much relaxation, conjoined with debility, the muriated tincture, in doses of five or ten drops, given several times a day, and largely diluted, makes a most powerful chalybeate prepa- ration, uniting a strong astringent with a tonic power. Conjunction with muriate of tin or baryta adds to its efficacy in cases of scrofula, for which it is occasionally necessary largely to prescribe it. Combination with muriate of ammonia (ferrum ammoniatum) pre- sents the advantage of uniting the deobstruent properties of this salt of ammonia, with the tonic power of the muriate of iron, so as to temper the action of the latter, and render this compound one of the mildest and most useful chalybeates we can administer to the child. It is admissible during a state of vascular excitability, in which other preparations of iron would not be borne ; and is given with the best advantage in cases of glandular enlargements connected with ab- dominal obstruction, and an atonic state of the mucous membranes. It is well, before administering this or any other chalybeate, to get the secretions into a favourable state by the exhibition of suitable aperients ; or the ferri ammonio-chloridum may be joined with such, as rhubarb or taraxacum. When our object is to abate the activity of iron to the utmost, so as to render it least liable to heat the skin or confine the bowels, and thus enable us to take advantage of its tonic power at the earliest period after febrile or inflammatory com- plaints, the best combination of this kind will be made by joining tartrate of antimony with tartrate of iron; two parts of antimonial wine being added to one of iron wine, and given in scruple or half drachm doses, in white wine and water, three or four times a day, as advised by Tortual. From one to two grains of the ferrum ammo- niatum may be given to infants, twice or thrice a day, and double the quantity to children three years old. The dose of the tinctura ferri ammoniati is from five to thirty drops. This preparation is, in particular, recommended in rachitis, but there are, perhaps, good reasons why the phosphate of iron should, in such cases, have the preference. The carbonate of iron is a mild and efficacious preparation, re- sembling iron filings in action, though not possessed of equal anthel- mintic virtues, but more convenient for administration to the child, as not being attended with fetid eructations, and appearing to pos- sess particular efficacy in some spasmodic affections, or those accom- panied with periodic pains. To be useful, however, it must be recently precipitated, or still moist, as in the mistura ferri composita TOKICS. 101 — a useful, but disagreeable form for its exhibition. The ferri car- bonas saccharatum of the Edinburgh Pharmacopoeia, is an eligible form for exhibiting this medicine to children, but must be given in large doses, from ten grains to half a drachm. When prescribing iron in the form of carbonate, it is well to add some grains of a bicarbonate, which will, in general, aid the objects of the medicine, and always help to preserve it from chemical alteration. Sulphate of iron, the most irritating but powerful of the chalybeate salts, ranks high for its anthelmintic virtues and astringent powers, checking secretion and excretion ; but is so liable to disorder the stomach, as to be unsuited for very young children ; and even for those more grown it should be ordered only in cases of extreme relaxation and debility, accompanied by profuse discharge, when its free exhibition will often be attended with the happiest results. The disturbance which iron occasionally causes to the head, is said to be best removed or obviated by the use of camphor, which may be given to the child suspended in milk : but we must keep in mind that camphor is liable to disagree with children, causing dyspnoea and nervous agitation. The best time for administering either iron or iodine is about two hours after a meal, when the stomach is not too full nor yet empty. Iodine, in the form of tincture or hydriodated solution, can be safely administered to the youngest child. From one to five drops of either preparation may be given at a dose in some sweetened water ; but sugar should not be added until the dose is about being taken, as decomposition would otherwise occur ; and distilled water alone should be ordered for the solution of iodine. The tincture, when recent, is precipitated on being added to water ; but this does not occur when it has been some time kept ; and it is altogether one of our best preparations of iodine. For external use, at all events, it is a milder application than the compound tincture, or hydriodated solu- tion in alcohol, which is now substituted for it in the London Phar- macopoeia. The following aqueous hydriodated solution nearly resembles that proposed by Lugol, and may be administered in a similar manner ; but the dose can be carried much farther than Lugol ventures, if we are only careful sufficiently to dilute the medicine^ and occasionally to intermit its use. Baudelocque found that irrita- tion of the stomach was induced when the proportion exceeded one- eighth of a grain of iodine, and one-fourth of a grain of hydriodate of potash, to an ounce of water, but with proper precautions, a grain of iodine, and two of the hydriodate may be given in the day to a child from four to seven years old, and double, or even treble these quantities after that age ; so that the dose of the hydriodated solution may be carried to half a drachm, or a drachm, twice or thrice a day — beginning, however, cautiously, with only a few drops at a time. Union with starch deprives iodine of its acrimony, (as has been observed by Dr. A. Buchanan,) and barley water presents us with a vehicle for extemporaneously effecting this compound — its amylaceous properties causing the immediate formation of an iodide of starch, indicated by change to a blue colour on the addition of iodine. It will be well to give warning to the attendants of this 9* 102 INFANTILE THERAPEUTICS. change of colour. To obviate, in particular, the sense of oppression or uneasiness of the stomach, sometimes caused by iodine, wine of bark is the best adjunct we can employ. No. 10. Solutio Iodinii Hydriodata. R. Aquse Destillatae, ^ij. Iodinii, gr. v. Hydriodatis Potassse, gr. x. M. § The combination of iodine and iron, presents particular advantages, and, in some of the more protracted forms of strumous cachexy, the administration of iodide of iron affords advantages which perhaps no other medicine does. Such combination may be extemporaneously made by adding from three to ten drops of muriated tincture of iron to the same quantity of the hydriodated iodine solution (as given above), or the compound tincture, and administering this dose in sweetened water, or barley water, twice or thrice a day. The external application of iodine is of not less importance than its internal administration in the dispersion of glandular enlarge- ments, healing of scrofulous ulcerations, and even the removal of unsightly scars. Ioduretted ointments are generally employed for this purpose, but the simple tincture is a most convenient preparation for general use, and may be applied to ulcerated surfaces as well as to the unbroken skin. It is in particular useful in those ulcerations within the mouth or nostrils, which often prove so intractable in young persons. The sense of burning heat, or pricking, which occa- sionally attends these applications, soon wears off ; and as the ulcer heals, the surface becomes altogether insensible to the irritative action of the medicine. The union of iodine with mercury presents a powerful combination, but we should hardly venture to order such extemporaneously when prescribing for a child ; for although mercurial ointment, or blue pill, may be joined to iodine with impunity, the presence of even a small portion of hydriodate of potash will create an irritating compound, highly dangerous either for external or internal use. It is better to prescribe mercurials antecedent to iodine, or to alternate their employ- ment ; which may often be done with advantage, as by improving the secretions and unloading the bowels, we prepare the system for the influence of the iodine. In cachectic states of the system, such as we often see in children who have been neglected or mismanaged, iodine is most useful as a stimulating tonic, especially if unhealthy inflammation, or ulceration, tending to sloughing, be present, as in pemphigus, &c. In glandular enlargements, which occur so generally at a young age, it is unneces- sary to point out the utility of iodine ; but we should keep in mind that children are in particular obnoxious to the evil effects of this medicine. For a good account of iodine, as applicable to infantile disease, see Dr. Ure's Practical Materia Medica, which we here refer to, once for all, as a valuable compendium of infantile therapeutics ; our own limits not allowing us to enter more minutely into the uses of individual medicines. ANTIPHLOGISTIC PLAN OF TREATMENT — BLOODLETTING. 1Q3 VIII. ANTIPHLOGISTIC PLAN OF TREATMENT. The class of remedies which we shall have most occasion to use in the treatment of infantile disease, is that which is employed to combat acute inflammation : and hence called antiphlogistic. These remedies act principally by depletion, or as evacuants ; but we must not forget that a certain part of their action is stimulant, — especially exciting some organ or tissue, as the kidneys or skin, and so pro- ducing a diuretic or diaphoretic effect. This is most manifest in the case of cathartics, which often irritate the bowels, as well as purge, thus acting more or less as counter-irritants, some of their remedial power arising from this source. This action may, however, be carried too far, so as to do injury by the special irritation thus pro- duced, which may also prevent the expected evacuation, and aggra- vate, or even create, local inflammation. Much mischief arises from overlooking these circumstances in the treatment of children's dis- eases ; for in consequence of the susceptibility of their organs, this irritative action is peculiarly liable to be carried to an injurious degree. Thus it is that we see intestinal irritation induced by pur- gatives continued to be given to children, until nothing but a little bloody mucus is evacuated ; or stimulating expectorants employed, until expectoration has been suppressed, and a slight catarrh changed into a severe bronchitis. These errors we shall avoid by recollecting that the use of evacu- ant medicines is not necessarily followed by evacuation, as their names (purgatives, diaphoretics, &c, &c.) would imply, unless the necessary precautions be taken to ensure such results. These are, to employ only the least stimulating in the early stages of inflamma- tory diseases, and to premise direct depletion when required. IX. BLOODLETTING Is the first step in the antiphlogistic plan of treatment, and the most powerful, not only in subduing inflammation, but in ensuring the beneficial results of the other remedies ; most evacuants acting with more speed and certainty when bloodletting has been premised. In the child, more particularly, bleeding is required in the first stage of all acute inflammations. It may be practised with safety in the youngest infant, provided we hold in view the relation between the necessities of the case and the strength of the patient — the only true rule applicable to depletion in old or young. Repetitions of blood- letting are not well borne by the child. Dr. Clarke justly states that very young children, although they bear so well one or two full bleedings, but ill endure a further repetition of bloodletting, and hence an additional reason for its prompt employment when neces- sary. In all cases of inflammatory or febrile affections in the child, our first consideration should be — is it necessary to bleed ? And this will be necessary in all severe cases, not only for the purpose of 104 INFANTILE THERAPEUTICS. mitigating the malady and rendering it more amenable to medical treatment, but as our chief means of, at once, arresting the disease. When inflammation is seated in the substance of any organ, or in a serous membrane, bleeding is the more necessary — less so, if only a mucous membrane be affected. But the necessity again becomes urgent, when membranous and parenchymatous inflammations are united, as we see in the broncho-pneumonia of infants — a frequent and fatal disease of childhood, for which full bloodletting is indispen- sable. In croup, again, although only a mucous membrane be affected, the importance of the organ implicated and the peculiar character of the inflammation, demand prompt and free blood- letting ; but before deciding on this measure, we must be careful to distinguish between truly inflammatory croup, and those affections of the trachea, which originate in the extension of ulceration or exudation from the fauces or pharynx ; or the purely nervous affec- tion, denominated spasmodic croup. So in affections of the head, while we employ bloodletting largely in decided cerebral inflamma- tion, or when determination of blood to the head is clearly mani- fested in convulsive affections, we will be reserved in its use in the more ordinary cases of inflammatory action, which is of a low or asthenic form, such as usually occurs in scrofulous children, and constitutes the greater number of cases commonly denominated hydrocephalus ; while in cerebral irritation arising from exhaustion, and often seen antecedent to coma or convulsions, as well as in those affections when originating in the same causes, bloodletting, how- ever much it may seem called for to the uninitiated, must be altogether forbidden. In inflammatory affections of the intestinal mucous membrane, abstraction of blood, although necessary, is but moder- ately required ; but before employing this remedy we should make sure that inflammatory action is present, and not take every instance of vomiting or purging, even though accompanied with abdominal sensibility, for a case of gastritis or enteritis. In the febrile affec- tions of children when symptoms run high, a timely bleeding will often prove a preventive measure, by curtailing the duration of the fever and sparing the necessity for protracted use of other evacuants : thus best preserving the strength, as we have often witnessed even in cases of remittent fever. In the eruptive fevers, however, although the urgency of febrile symptoms in the first instance, or the occur- rence of local inflammation subsequently, may render necessary the abstraction of blood, this must always be done with reference to the necessary continuance of a disease, which, having a course to run, cannot be cut short ; and is liable, in its progress, to assume a typhoid or asthenic type. In symptomatic affections, as when the head becomes engaged during the existence of abdominal disease, blood- letting, although required, should not be carried to the same extent, as in a primary affection. During dentition, when so much increased vascular action as well as nervous sensibility is present, bleeding may be practised more freely than under ordinary circumstances ; while in scrofulous diseases, on the contrary, or in children of a highly strumous constitution, bloodletting should be employed with BLOODLETTING. 105 the utmost reservation that the nature of the case will admit, so unwilling should we be to detract from the red blood circulating in the system. In the infant, or young child, we can seldom draw blood from the brachial veins, which are usually small and obscured by fat. We can generally, however, procure as much as we require from a vein on the dorsum of the foot, or back of the hand, or, when these fail, from the jugular vein. The latter might be often opened in inflam- mations of the head or chest, with peculiar advantage, on account of its vicinity to the disease; but it is sometimes difficult to stop the bleeding — and the employment of a bandage is here badly borne, especially when the respiration is affected. The brachial veins, after the period of first dentition, become in general sufficiently well marked to allow of their being readily opened, unless the child be very fat. Leeches, however, can always be applied, and will take a sufficiency of blood to answer all the purposes of general bleeding. The quan- tity of blood obtained by one good leech, allowed to bleed for half an hour, may be estimated at one ounce ; while this method has the advantage, from the gradual manner in which the blood flows, of not being liable to induce sudden collapse in young children. The safest place for their application is the hand or foot, as we can then ensure stoppage of the hemorrhage at any moment, by the use of a compress and bandage. When applied in other situations, as the cIk'M. tin . leeches have led to fatal results by a continuance of hemorrhage. They may. however, in affections of the head, be safely placed over the mastoid process, and, occasionally, in those of the throat or chest, over the clavicles, as we then have a firm point of resistance upon which to make pressure, should they continue to bleed. Great difficulty is at times experienced in commanding the hemor- rhage from leech-bites ; whether from the greater redundancy of blood in the capillary circulation of the child, the less liability of this fluid to coagulate, or the want of tone in the vessels consequent on loss of blood and preventing their contraction. However this be, fatal results have frequently arisen from this cause, and the physician should never omit giving the necessary cautions on the subject, nor neglect himself to see that the bleeding is arrested before quitting the child for the night. Indeed it is as well to avoid, if possible, ordering leeches to be applied to children late at night. When simple expo- sure to the air or compression by means of the finger and a dossil of lint fail in restraining the hemorrhage from the bites of leeches, which have been placed in a situation forbidding the use of a bandage, we must dust the part with some dry powder, as starch or gum arabic, or, if this fails, press a fine pencil of lunar caustic into the wound. The actual cautery may be required, as touching the bite with a red hot wire or knitting needle ; or we may pass a needle and silk thread through the sides of the wound and close it by knotting the ends together, as recommended by Dr. M. Hall ; or in the way employed in securing the vein of a horse, in which manner also the jugular vein can be secured when ordinary methods fail. 106 INFANTILE THERAPEUTICS. Cupping is a more definite and manageable mode of abstracting blood than leeching, and may be practised even in young children, if skilfully performed. The nape of the neck, or interscapular space, present the best situations, being sufficiently large in surface and out of sight, so as to cause least alarm to the child. The quantity of blood to be taken must, of course, be determined by the urgency of the symptoms. It should be always drawn from the child in the erect posture, and be sufficient to make an impression upon the system — of which we judge best in the child by observing the colour of its lips and eheeks ; the former especially quickly indicate the approach of faintness, by the paleness which they assume, and are a much better guide than the state of the pulse, which is very variable. In cerebral affections in particular we must be guided rather by the condition of the vessels about the head, than the state of the pulse at the wrist, which may be small or appear feeble, while the carotid or temporal arteries are full and throbbing. As a general estimate of the absolute quantity to be removed at one time, we may say, that during the first year, from an ounce to three ounces of blood, (or the application of two or three leeches,) will be sufficient ; and, after the first year, we may usually take an additional ounce for each year of the child^s age, seldom having occasion within the period of childhood to exceed eight ounces of blood, or to apply more than twelve or at most six- teen leeches. We have noticed the caution necessary to be observed in employing repetitions of general bloodletting. The necessity for this will be much lessened, and the efficacy of the general bloodletting greatly enhanced by quickly applying leeches over the part inflamed, or in its near neighbourhood, so as to keep up the impression made on the system, and while the general circulation is yet enfeebled, thus directly to deplete the affected organ. A second employment of bloodletting, if required, should seldom be had recourse to before the lapse of twelve or sixteen hours ; but by this method it may often be avoided. Dr. Mills lays much stress on this mode of using leeches in affections of the head in children ; but it is a practice of general application, and we suppose always adopted by the judicious physi- cian. It must also not be forgotten that the ill-fed and enfeebled children of the poor will not bear bleeding to the same extent, nor require it so often as those of the more wealthy classes. When a child has been blooded too largely or too frequently, an alarming state of collapse may be suddenly induced, the system not possessing in early infancy much power of rallying from depression. In this state of deficient power of reaction, the child will be observed to become extremely pale, even the colour of the iris may change, and present a paler tint ; the extremities are cold, pulse feeble and fre- quent, breathing hurried or rattling, the respiration appearing to be performed almost solely by the diaphragm, and accompanied by much- evolution of flatus. The child becomes irritable, agitated and wakeful, and should depletion be persevered in, or suitable remedies (stimulants or sedatives) not be employed, coma or convulsions ensue ; the powers of life sink, and the child dies from exhaustion, passive exudation taking place into the- ventricles of the brain. We have seen such BLISTERS. 107 cases, and Dr. Ure notices the unexpected occurrence of such symp- toms in children apparently strong, and to be accounted for only on the supposition of a peculiar idiosyncrasy, derived from a delicate and highly sensitive mother. At all events we should be on the alert immediately to arrest the bleeding when any such symptoms appear ; and, as a general rule, it is well to stop the flow of blood when decided pallor takes place without waiting for actual fainting, which does not readily occur in young children, and from which they do not quickly recover. The more ordinary and less urgent evils attendant on over active sanguineous depletion, are the reduc- tion of a child to a state of anemia, in which the strength fails, although the appetite may continue or increase ; the child becomes very fretful, wakefulness alternating with stupor ; passive diarrhoea is established, or more generally dropsical effusions take place. The buffing of the blood is not a safe guide in the child, as we have diseases absolutely requiring bleeding (e. g., croup, bronchitis, &c.) which seldom produce in the blood the appearance in question ; and it is even said to be more generally absent when inflammation is present, while it may be seen where none exists or only in a very slight degree. X. BLISTERS Are much employed in the treatment of inflammatory affections in children, and, when judiciously used, are signally efficacious ; but, as they induce much local and constitutional excitement, very inju- rious consequences follow their improper application. Hence, blisters should never be used in the early stages of severe inflammations, as a substitute for bleeding ; nor should they even follow soon after the employment of this remedy, unless a decided impression is made on the local disease and fever — otherwise, both will be aggravated by the effects of a blister ; and we have had occasion to order repe- titions of bleeding, which would not have been requisite, had not acute symptoms been renewed in this way. We, therefore, altogether reprobate the popular practice of at once applying a blister to the throat or chest on the first appearance of croup or cough in the child, and equally interdict the very early or direct application of blisters, in which some practitioners are fond of indulging. In croup, in par- ticular, when of a highly inflammatory character, blistering should not be attempted until the acute symptoms are subdued or have passed away ; and then the blister should be applied rather to the nape of the neck or upper part of the sternum than directly to the throat itself. In bronchitis or pneumonia, blisters may be used at an earlier period, and more directly to the seat of the malady, with the best effect. But it is in affections of the head that we have the clearest evidence of the manner in which blisters should be employed, for every observant practitioner must have noticed the different effects of a blister in the different stages of these disorders — at once aggra- vating all the symptoms, if applied to the scalp in the first or acute stage ; but mitigating them if only placed in the neighbourhood, as the nape of the neck — while in the advanced or last stage of the 103 INFANTILE THERAPEUTICS. disorder, when coma is present, and effusion has, perhaps, taken place, covering the whole scalp with a blister is at times attended with the most marked improvement. Some attempt to obviate all evils, by applying blisters at some distant part (as one of the ex- tremities), in the first instance ; and such practice is common on the Continent, in the abdominal and cerebral inflammations of infants ; but the plan is not very efficacious, while it is accompanied by all the risks attendant on excess in the local irritation. We therefore prefer waiting until the proper time, and then applying the blister near the affected organ ; from which method, when judiciously employed, the happiest effects will often result. The application of a blister may often be made a substitute for bleeding in feeble children, or in cases of mere irritation or doubtful inflammatory character, as occurs in some forms of diarrhoea or cholera, convulsions or coma. In all cases, even of an inflammatory character, which appear clearly to have arisen from the suppression of an accustomed discharge, or long standing eruption, the use of blisters, in particular, is indicated. Thus obstinate convulsive attacks may, at times, be quickly removed by restoring the discharge from behind the ears, to which some chil- dren are so prone, by means of a blister, or simply by a thread smeared with blistering ointment ; and even diarrhoea or cholera, occurring during dentition, may be prevented or much benefited by a similar ap- plication, according to the statement of Dr. Paris, in cases where this eruption has not made its appearance, or has been repressed. The application of irritating ointments, liniments, or sinapisms, is in such cases particularly available, and may, in many instances, save the necessity for blistering. The application of a blister is sometimes followed by the appear- ance of a troublesome pustular eruption, which not only surrounds the blistered surface, but occasionally spreads extensively over the body. It is the supervention of violent local irritation in the blistered surface itself, however, leading to sloughing, gangrene, and death, that makes so serious an objection to the use of blisters with children, and demands so much precaution, in order to lessen the liability to such disaster. To effect this, we guard against the two irritating action of the blistering plaster, by using it of only half the ordinary strength; or we protect the surface by the interposition of some thin substance, as fine muslin, or tissue paper. In no instance is the blister to be left on more than a few hours (from two to four) — not longer, in fact, than until the skin is reddened, when vesication will follow ; but this result should not be waited for, as attendants always will do, unless the most express directions to the contrary be given. When the blister is removed, the part should be dressed with simple cerate, fresh, and spread on lint, in preference to linen, which does not lie so smoothly on the part. a When it is wished to continue counter-irritation, we prefer the employment of a succession of blis- - a [A much better practice is to cover the part to which the blister has been applied with a soft, emollient poultice. — C] BLISTERS. 109 ters to keeping open the part by means of irritating ointments, as being less distressing and hazardous to the child, although these are the very reasons for which others recommend the opposite practice. Should the blistered surface become irritable, looking very red, and showing a disposition to inflame, the dressing should be changed for the use of some fine powder, as flour, starch, or prepared chalk. This should be industriously applied, so as to keep the parts con- stantly dry, when frequently all symptoms of irritation will disap- pear. Should this not occur, however, but inflammation of the sur- face set in, with surrounding redness, a soft poultice will be the best application ; or raw cotton, which is occasionally employed from the first, as with scalds, and from the use of which we have seen excel- lent results. According to the character of the irritated surface, however, and the attendant constitutional symptoms, our treatment must be guided, as to whether we are to employ soothing or stimulating applications, — or attempt the total alteration of the action on the surface, as by nitrate of silver. When the constitutional symptoms run high, and the ulcer is very irritable, we use emollient applications ; and of these, the following ointment, thickly spread upon lint, is that which we have found answer best. Its consistence prevents the necessity for frequent renewals, as it does not dry so quickly as the Carron oil, of which it may be looked on as a modification. We have seen it produce ease, in irritable ulcerations, when no other application could be borne. No. 11. — Unguentum Sedativum. R. Aquae Calcis, Olei Amygdal. aa. ^ss. Bene admisce et adde Adipis Preparatae, ^i. M. Ft. Unguentum. When the ulcerated surface is pale, with ash-coloured spots, and surrounded by a dull or livid redness, some stimulant application must be used, particularly if the accompanying fever assume the ty- phoid type (as in such case it usually does). A favourite one with Mr. Colles is a lotion of camphorated spirits of wine and infusion of chamomile flowers (3i. to the ^i.) : his mode of employing this lotion is to place upon the part lint wetted with it, over which another piece of lint is then laid, the piece next the surface not being subsequently removed, but kept wet from time to time with the lotion, by means of a sponge. We have found advantage from the fermenting poultice, or lotions of chloride of soda, more particularly if gangrene have set in, accompanied by fetid odour. An excellent mode of treating the surface in such instances, when it begins to slough, is to alter the action going on, by brushing it over with a solution of nitrate of silver (gr. x. — 9j. to the 3i.) and then applying a soft warm poultice, as much pain often attends the application. In these cases, the full employment of tonics and stimulants is essential to support the constitution, so as to pre- 10 110 INFANTILE THERAPEUTICS. serve life. The child will rapidly sink, unless supplied with nutritious diet — broth, jelly, or arrow-root, with a little wine ; and the qui- nine or ammonia mixture should be freely given, according to the circumstances of the case. No matter how acute the original inflam- mation may have been, it usually all disappears when sloughing takes place. Such result is liable to occur, when blisters are applied (no matter how cautiously) to children much debilitated, or living in very- unwholesome situations ; and we should be slow to employ them, if any disposition to unhealthy ulceration has been manifested, as when spreading aphthse, pemphigus, &c, are present. In applying sinapisms to children, the powdered mustard seed should be mixed with an equal quantity of flour, or crumbs of bread, and wetted with water only. The interposition of a piece of gauze or fine muslin will further protect the skin if irritable ; and the sinapism should not be left on longer than to redden the skin, when it causes much heat and pain, generally in ten or twenty minutes. These precautions are the more necessary, when the child, from insensibility, cannot complain, as troublesome ulceration, or even sphacelus, has followed the protracted application of sinapisms. Judiciously employed, they are a good substitute for blisters, in those slighter affections arising from irritation, and in particular, when connected with retrocession of an exanthematous eruption. The other antiphlogistic remedies, like bloodletting, act principally as evacuants — yet not exclusively so, some special influence apper- taining to most of them, while several act in more ways than one, being Emetic, Diaphoretic, or Expectorant, according to the circum- stances under which they are administered. We shall briefly consider each class in reference to infantile medi- cine, the variety of drugs employed in which is not great. XI. EMETICS Are often given to the child, and are particularly serviceable in the first invasion of inflammatory and febrile complaints, which they occasionally cut short, and very generally mitigate. During the pro- gress of remittent or other fever, an emetic may induce crisis, or give a favourable turn to the complaint ; and in the exanthematous, in particular, when the eruption does not come kindly out, the greatest aid may often be derived from the administration of an emetic ; and the supervention of bronchitis or pneumonia, as so often occurs in measles, is an additional occasion for the use of emetics in this class of complaints. It is in bronchial inflammations, indeed, that emetics are so necessary with the child, for clearing out the overloaded bronchial tubes, as well as emptying the stomach of what may have been accumulated there ; children, as has been already remarked, being constantly in the habit of swallowing expectorated matter. At times they afford the only chance of relief, when suffocation ^threatens, in consequence of the quantity of mucus secreted, as we often see in catarrhal fevers. The power of an emetic in thus mechanically freeing the air passages, is remarkably exhibited in EMETICS. 1 1 1 cases of croup, where portions of false membrane have been thus ejected. Emetics are not to be employed when the head is much engaged, or any gastric affection present. We should ascertain the type of a prevailing epidemic, so as to avoid the use of emetics at the commencement of the attack, when gastritis is liable to occur. In some epidemics we have seen the vomiting, caused by an emetic, persist until death took place. When the stomach is overloaded with indigestible matter, as after an over-full or unwholesome meal, an emetic is the immediate and certain remedy; often, at once, putting an end to the whole train of morbid symptoms, whether exhibited in the form of spasm and convulsion, or the more ordinary occur- rences of pain, flatulency, and distension, attended by vomiting and constipation, or followed by diarrhoea. But it is only in the early stages of diarrhoea, and occasionally in colic, that emetics are admis- sible; as their injudicious use would only serve to complicate the case, by the addition of gastric irritation. In scrofulous or delicate children, with voracious appetite, but feeble powers of digestion, the tone and sensibility of the stomach may be often renewed, by the occasional use of a mild emetic, which not only frees the stomach from the accumulation of morbid secretions, but benefits the system at large by the stimulus thus given to exhalation and absorption, so aiding in the resolution of strumous deposits. The milder emetics, only, should be given to children, and of these, ipecacuanha is the chief. Tartar emetic may be administered, but is not to be chosen without good reason. Squill, though commonly given to infants, in the form of syrup, is objectionable, its operation being violent, though certain. Sulphate of copper has been recommended, in particular, to expel the false membrane in croup ; and continued in small doses, to prevent its formation. But no one acquainted with the disease would imitate the Germans in this practice ; nor does the emetic action of the remedy seem to possess any peculiar advantages for the purpose proposed. Sulphate of zinc has, with better reason, been selected as an emetic, in the advanced stages of hooping cough, when the strength is unequal to expel the viscid phlegm without the aid of an emetic ; and the benefit derived from sulphate of zinc is often so remarkable, as to make it a popular remedy of some repute. Ipecacuanha may be given as an emetic to the youngest infant, in doses of half a grain or a grain, blended with sugar, and repeated every quarter of an hour until it vomits ; or ipecacuan wine may be similarly given, in doses of twenty drops, half a tea-spoonful, or a tea-spoonful. After a year old, these doses may be doubled and re- peated at shorter intervals. On the Continent, a syrup of ipecacuan (containing 16 grs. to the 3i.) is used as we use ipecacuan wine; or an infusion made by digesting 3ij- of the root in 3iv. of boiling water, which may be sweetened, and given in tea-spoonfuls. Ipecacuan is a very certain, as well as mild emetic, and will occasionally vomit a child when tartar emetic has failed. In addition to its effects as an evacuant, ipecacuanha has the power of counteracting inordinate action of the bowels, while it, at the same time, acts upon the skin, so as to restore the equilibrium of disturbed functions. In giving j 12 INFANTILE THERAPEUTICS. tepid drinks to assist its emetic action, we should wait until vomiting has begun, or is threatened, otherwise we may cause the ejection of the emetic before the stomach has fully expelled its contents. The following is a good general formula for its administration: — No. 12. — Mistura Emelica. R. Aquae, %i. Vini Ipecac, ^ss. Syrupi Simplicis, ^ss. M. 5i. — Jij. s8B P e a ^ emesem. Tartarised Antimony is a powerful, though not always certain emetic. Its action is accompanied by much depression, and evacua- tion by the skin or bowels constantly follows its use. Hence, it is preferred in severe inflammatory affections of the chest, and its use is afterwards continued as a contra-stimulant. Tartar emetic may be given in minute doses — from one-eighth to one-sixteenth of a grain — to young infants ; but when much depression is present, or the acute stage of the disorder passed, ipecacuan or squill is prefer- able. When gastric or intestinal irritation is present, tartar emetic is generally inadmissible ; and, under all circumstances, it is advisable to have some fluid present in the stomach, before administering this medicine in doses sufficient to vomit, as poisonous effects have been observed to follow its use, when given on an empty stomach. Hence the judiciousness of Professor Hamilton's advice, that the child should be allowed previously to suck, or be given some drink. No. 13. — Mistura Emetica Antimoniata. R. Aquae Destillatae, ^iss. Antimon. Tart. gr. i. Syrupi Simplicis, £ss. M. 51. contains 1-16 of a grain; and from one to two or three tea- spoonfuls can be given every quarter of an hour till vomiting occurs. ^ss. of ipecacuan wine, added to the foregoing, will make the action more certain, but less violent. The addition of squill still farther adds to the efficacy of the compound, as follows: — No. 14. — Mistura Emetica Composita. R. Aquae Destillatae, %'\. Vini Ipecacuanhas, J;ss. Liquor. Antimon. Tart. 3 ij. Syrupi Scillae, 3ij. M. 3i« — ij. saepe ad emesem. Squill, though so generally given to infants as an emetic, is too stimulating for common use, and should never be given at first, but in the advanced stages of pulmonary inflammation, or when other emetics have failed. The syrup or oxymel of squill, in half drachm doses, will be certain to evacuate the stomach, when repeated suffi- ciently often, particularly if combined as above. We have met a few children that resisted the action of all emetics, and had never been known to vomit. EXPECTORANTS. 113 XII. EXPECTORANTS. All the foregoing medicines act as expectorants, when given in small and repeated doses, or so combined as not to vomit. Ipecacuan is that most commonly employed with children, and alone often suffices to remove slight catarrh, given in doses of a quarter or half a grain, three or four times in the day. In severe attacks of bronchitis, ipecacuan alone cannot be relied on ; but after the use of bloodletting, or tartar emetic, when the more acute symp- toms have subsided, and much mucus is secreted, it is particularly indicated. It may be added to the tartar emetic, and given in mix- ture ; or in powder, united with calomel. A minute quantity of opium in the form of laudanum, or Dover's powder, is usually added, to allay the irritability of the cough, and enable the stomach to bear the expectorant. If the proportion of opium be too great, its effect is injurious, by suppressing expectoration, and checking the cough, so as to add to the embarrassment of the breathing. No. 15. — Mistura Expectorant. R. Aqu« Destillatae, 5L Mucil. Gum. ac. g Vim [pecacuanhe, Jij. Syrupi Limonuiii, JL r u pi Papav. Boffioif. 5i- M. 3i. hora quique secunda. This may be continued at longer intervals, or given between the doses of the following powder : No. 16. — Pulvis Ipecacuanhx tt Culomelanos. R. Pulv. Ipecacuanha?, Suiunur. H vdrargyri, UL gr. x. Saochari albi, gr. xx. M. gr. i. — gr. ij. hora quaque tenia. One grain of this compound contains \ of a grain, each, of ipecacuan and calomel, and constitutes the dose until twelve months old, when two grains are to be given : halt' a grain or a grain of Dover's powder may occasionally be added. Calomel is thus frequently combined with ipecacuanha, and in severe cases its junction is essential for subduing the inflammatory action ; but in ordinary cases, it is unnecessary or objectionable, as being liable to irritate the bowels, and when this occurs to any ex- tent, the mercury must be suspended. Nothing embarrasses the treatment, or adds more to the danger of inflammatory affections of the lungs, than complication with gastric or intestinal irritation. Tartar emetic cannot then be employed ; and if mercury be given, it must be in very minute doses, and well guarded by opium. Our chief reliance in such cases must be on ipecacuanha, which will check the irritability in the bowels, if we can get it borne by the stomach. This we will be assisted in doing 10* 114 INFANTILE THERAPEUTICS. by combination with carbonate of potash or soda, and the addition of an opiate The following formula? will be found serviceable in such cases, and also during pertussis, or spasmodic cough : No. 17. — Mistura Ipecacuanhas Sedativa. R. Aquae purse, ^iss. Vini Ipecacuanhas, ^iss. Bi-carbonatis Soda?, gr. xij. Syrupi Simplicis, 3U« Tinct. Opii, gtts. iv. M. Ji. — 5U- h° r a quaque 2da. No. 18. — Pulvis Ipecacuanhas Sedativus. R. Pulveris Ipecacuanha?, gr. \. Carbonatis Sodae siccat. gr. i. Pulveris Doveri, gr. ^ vel Pulv. Cretae Comp. c. Opio, gr. ij. M. Sumat pulverem talem hora quaque 3tia vel 2da. Tartar Emetic is a more active agent in the treatment of acute inflammations, and in such cases is, therefore, to be preferred, particu- larly in pneumonia. Our object is to get a sufficient quantity of the medicine borne ; and the tolerance of tartar emetic can be attained with the child, as well as with the adult, though not, perhaps, quickly. When much depression attends its use, the addition of a few drops of spirit of lavender, or tincture of cinnamon, will tend to obviate this. The following is the common form of expectorant mixture con- taining tartar emetic : — No. 19. — Mistura Expectorans JLntimoniaia. R. Aquae Mentha?, ^i. Mucil. Gum. ac. ^ss. Liquor. Antimon. Tart. >>i. — 3'J" Syrupi Limonum, 3ij. Tinct. Opii, gtts. ij. M. 3>' — 3U« h° r a quaque 2da. In severe cases, bloodletting should precede the use of the tartar emetic ; in the milder forms, the latter alone will suffice ; and in feeble children, from whom we may fear to abstract blood, tartarized anti- mony will serve as a substitute ; or still better, the combination of this medicine, or James' powder, with calomel : by which means, also repetitions of bloodletting may, in many cases, be saved. Squill is employed as an expectorant in chronic bronchitis, &c, &c, particularly when the phlegm is viscid and difficult to get up, the febrile heat having subsided. Squill is seldom employed alone — when it is, twenty drops of the syrup, or ten of the vinegar of squill, may be given every third hour. It may be added to either of the expectorating mixtures already given, in the proportion of 5i. of the syrup, or 3ss. of the vinegar or tincture, to each ounce of the mixture ; or from § to i of a grain of the powder of squill added to each dose of the powder of calomel and ipecacuan. By combining squill in this manner, we can sooner have recourse to its use, and EXPECTORANTS. 115 longer continue that of the other expectorants. Combination with an alkali lessons the acrid qualities of squill, without depriving it of its expectorant power. The following mixture will be found very- serviceable in pertussis ; or spasmodic cough, with chronic bronchitis and secretion of viscid phlegm. No. 20. — Mutura Scillas Sedativa. R. Aquae Fueniculi, ^iss. Tincturae Scillae, 5' ss » Carbonatis Soda?, gr. xij. Syrupi Tolutani, Jij. Croci, 5'j* Tinct. Opii Camphor, ^ss. M. 3i. — 3'j' hora quaque 3tia. Polygala Senega. — This is a very stimulating expectorant, and used only in advanced stages of pulmonary inflammation, or after inflammatory action has been subdued. In such cases when a dry, hoarse cough remains, attended by some difficulty of breathing, polygala will be found very serviceable ; and Eberle prefers it to every other expectorant in the sequelae of chronic catarrhal affec- tions, particularly if of a croupy character. It is very liable to cause purging and vomiting ; but the latter result is at times desira- ble, when the air tubes are much loaded, and the strength inade- quate to coughing up their contents. Ammonia is often added to the polygala in such cases, — the acetate, citrate, or carbonate being prescribed, as follows : — No. 21. — Misturx Polygalx. R. Decocti Polygalse Seneg. %\. Aquae Ammonia? Acet. ^ss. Syrupi Scillae, Xn, Syrupi Papav. Alb. 3»j« M. 5i. — 3'J- ^ora quaque 2da. ^ No. 22. R. Decocti Polygala?, ^iss. Carbonatis Ammoniae, gr. iv. Tinct. Cinnam. C. Syrupi Tolutani, aa. ^ij. Syrupi Papav. Alb. 3*j- M. 3i. — 3'J* h° r ^ quaque 3iia. It is at that critical and dangerous period of catarrhal fevers (often so difficult to detect) when inflammation passes into debility, that the peculiar stimulant action of polygala, when exhibited in such combinations, is particularly manifested. In feeble children, the quantity of ammonia may be increased to double the amount above prescribed, and freely exhibited, until the obstructing phlegm be re- moved ; when the happiest results may be witnessed, children being thus restored to safety, when apparently at the point of suffocation. In less urgent cases the muriate of ammonia may be used instead of the carbonate in the foregoing formula, in the proportion of five or 11(5 INFANTILE THERAPEUTICS. .six mains to the ounce. This salt of ammonia is a favourite remedy- in Germany, though so seldom employed internally by British prac- titioner* : we have ourselves witnessed its good effects in several instances. Polygala, in union with the other expectorants, makes a very powerful and celebrated compound. In free doses, it vomits strongly, and, as an expectorant, exercises a decided control over the more advanced stages of inflammation in bronchitis, croup, pertussis, &c, when other means have failed. Coxe's hive syrup, so famous in America, in such cases, is a compound of this kind ; but we prefer the following formula (which resembles the anti-croup mixture of the Parisian Hospitals), as being more easily prepared. No. 23. — Mistura Pulygalae Comp. R. Decocti Polygalae Seneg. 3iU ss ' Oxymel. Scillae, 3 °i u aq u e tertia. Aloes is not often given to the young child, from the bitterness of its taste, and its liability to gripe : however, there is no purgative that, if judiciously employed, is more useful. It combines a tonic, as well as purgative power, in virtue of its bitterness : it has a par- ticular relation to the liver, either as a substitute for bile, when defi- 130 INFANTILE THERAPEUTICS. cient, or as passing through the liver, and so causing its flow ; and it is well known, from its action on the rectum, to be peculiarly hostile to ascarides. The taste of aloes is well hidden by combination with extract of liquorice, and perhaps there are few medicines to the taste of which children sooner become reconciled : of its various prepara- tions, the compound decoction, and the vinum aloes, are those best fitted for administration to the child. No. 35. — Mistura Mdetica^ R. Decocti Aloes Compositi, giss. Extracti Glycirrhizse, ^ij. M. gi £ii. bis terve indies. In cases where the head threatens to be engaged, without inflam- matory action being present, particularly in children of a leucophleg- matic habit or lethargic tendency, this mixture, as a derivative purgative, is the best we can employ — as also- when we wish to expel ascarides. Its anthelmintic powers will be much enhanced by the addition of half a drachm or a drachm of the muriated tincture of iron, which also corrects the tendency to regeneration of worms. Aloes, when used as an anthelmintic, may be employed in the form of suppository or ointment. The following suppository is recom- mended by Swediaur ; and the ointment is used in the German hos- pitals by rubbing a small portion round the navel,, in cases of colic,, connected with worms* No. 36. — Suppositorium Anthelminticum. K. Pulveris Aloes, gss. Muriatis Sodse, ^U]. Farinse, ^'ij. Mellis,.q*. s. ut ft. massa. M. Instar nucis, in forma suppositorii, utendum. No. 37. — Unguentum Jnthelminticum. R. Pulveris Aloes, 2i. Extracti Fellis Bovini, SJij. Unguenti Simplicis, §i. Mv Ft. unguentum. When the bowels are obstinately costive, purgative enemata must be had recourse to : care is required, however, in administering them to the child, as mechanical injury has been caused by their use. The tube is to be introduced cautiously, inclining its direction slightly towards the left side, while we soothe the child whose cries or struggles would so much impede the operation ; the fluid is to be injected slowly, or at intervals, so as gradually to distend the bowels, and thus penetrate far up the intestines, without causing too great or sudden distention thereof. In children the intestinal tube readily dilates, and if over-distended soon loses its contractility ; the more so the younger the child, so that great inconvenience or even danger may arise from over-distention caused by injection of too large or ACCIDENTS AND DISEASES AT BIRTH. 131 too frequently repeated enemata; as Guersent has justly pointed out, and as we have seen. Four ounces of fluid are the most that should be administered to an infant, and not more than six ounces, until after five years of age, nor is it necessary that an enema should exceed eight ounces during the period of infancy. The following is a good general formula : No. 38. — Enema Purgans. R. Decocti Hordei, ^v. Muriatis Sodae, Qu. Olei Olivarum, 3 v. M. A drachm or two of spirits of turpentine may be added, if much flatulency be present. The cautious introduction of the tube far up the bowel so as to allow the flatus to escape is an important measure of relief in such cases ; the distress thus caused at times amounting to such a degree as to threaten suffocation. We have occasionally been able to confer great benefit in preventing the accumulation of flatus, by allowing the ivory pipe (detached from the tube) to remain in the anus. CHAPTER VI. ACCIDENTS AND DISEASES OCCURRING AT THE PERIOD OF BIRTH, OR SHORTLY AFTERWARDS. The infant at birth may labour under certain morbid conditions, or it may suffer from accidents or diseases either peculiar to the first moments of existence, or materially modified by the circumstances belonging to that period. These are usually first noticed by the ac- coucheur,and require to be considered se/?«ra^e/y, in a system of child's medicine, both on account of the great danger attending many of them, and also of the peculiarities which remove them from under the rules applicable to diseases of the same name in the general prac- tice of medicine and surgery. Of the importance of these affections of early infancy, we may judge from the great improvement that takes place in the probability of life after the season for their occurrence has gone by. Thus, according to the Northampton Tables, we find that out of 1000 per- sons born at the same time, the probability is, that 257, or more than one-fourth, will be dead at the close of the first year ; while of the remaining 743, but 118, or less than one-sixth, will be dead at the close of the second year.* The Annual Reports of the Registrar General of births, deaths, and marriages also show that of the deaths, at various ages, registered in England and Wales, during the two * Macculloch's Dictionary of Commerce. ACCIDENTS AND DISEASES AT BIRTH. I o -■ rears ending June 30, 1839, 216-29 per 1000 (more than a fifth) IcZZlmderUvel^ months of age; while only 126-6 per 1000 (about an eighth) occurred between the first and second years In the present chapter we shall include notices of a number of those ailments which are not susceptible of nosological arrangement, havino- no connexion with each other except their occurrence at the same early period of life ; and we propose, in doing so, to limit our observations to peculiarities belonging to that period, and, as far as possible, to avoid occupying our pages with discussions upon general principles of medicine, when these require no variation to suit them to the case in hand. I. STILL-BORN CHILDREN (ASPHYXIA NEONATORUM). Children are occasionally born in a state of asphyxia, and without active interference upon the part of their attendants, would be cer- tainly lost. The causes of this state are natural feebleness of consti- tution, existing to such an extent as to render the infant incapable of spontaneously making the muscular exertion necessary for the com- mencement of respiration,— or similar incapacity produced by long continued pressure upon the brain, — or interruption of the foetal cir- culation by compression of the funis, before respiration has been esta- blished. 'To these causes, Dr. Edward Jorg, in his ingenious essay on the foetal lungs, has added the circumstance of a too rapid and -easy delivery, which fails to produce such a degree of compression of the placenta, and obstruction to the foetal circulation, as he sup- poses to be requisite for making the system feel the necessity of respi- ration.* The state of asphyxia may exist in a greater or lesser degree ; the child may be completely still-born, with no indication of life except, perhaps, the pulsation of the funis, or a feeble action of the heart : or it may make ineffectual efforts at breathing, or even cry faintly, and yet subsequently perish, from want of strength to establish per- fectly the process of respiration. Under all these circumstances a good deal can often be effected by art : and we are encouraged to persevere in efforts at restoring animation, both by experience, and by reasoning upon the fact that the less heat an animal produces, the longer it can exist under a condition of asphyxia. We have already seen,! that the heat of the new-born child is about 3° less than that of the adult ; and hence we have an explanation of what experience proves, — viz., that it can exist longer without respiration. In every instance, therefore, in which we have not positive evidence of the child's being dead, in the existence of putrefaction, or such malfor- mation as is incompatible with life, we should give a fair trial to the means of restoring suspended animation, presently to be spoken of. What length of time is sufficient for a fair trial cannot be exactly * Die Fcetuslunge im Gebornen Kinde, &c, von Ed. Jorg. Grimma, 1S35. f See p. 32. STILL-BORN CHILDREN. 133 specified, as it must depend upon the degree of asphyxia, and upon the progressive success attending our efforts. As long as the slightest attempt at motion of the respiratory organs is evinced, or the least pulsation of the heart continues, we have good grounds for persever- ing, in the hope of ultimate success, and we shall, probably, be stimu- lated to a longer continuance of our exertions, if we recollect that cases are upon record, in which infants have been resuscitated even after having been buried in the earth for several hours.* A remarka- ble instance of this tenacity of life once fell under our own observa- tion in the case of an immature child, which, having come into the world by the process of spontaneous evolution, underwent so much compression as produced complete asphyxia. As the child retained no signs of vitality, it was placed in a corner of the apartment, with- out being separated from the placenta, (which was expelled along with it,) and allowed to remain exposed to the cold air for nearly an hour, when, upon an accidental examination, the heart was found to beat feebly, and proper means being employed, resuscitation was effected, and life prolonged for twenty-four hours. The treatment of still-born infants must be, in some degree, regu- lated by the cause of the asphyxia which, as we have already stated, varies in different cases, and is accordingly attended with different symptoms. Thus we may have the naturally feeble infant, with pallid face and lips ; open and flaccid mouth ; relaxed limbs ; and cord pulseless, or beating feebly ; or we may have the full, large, and, as it were, plethoric child, in which the face is swollen, and purple, and the cord tense and pulsating strongly ; indicating the presence of a condition somewhat approaching to that of apoplexy. These two conditions are, by some, denominated, respectively, asthenic and sthenic, and will, of course, require some variation of treatment; but, in either variety, our first object should be to remove every obstruction to the passage of air into the lungs. For this purpose, we place the child with the mouth uncovered, and pass our finger into the fauces, for the purpose of removing any mucus or other matter which may obstruct the access of air, and also to tickle those parts, and thereby excite respiratory movements. With the latter object in view, we should also rub and gently slap the chest, and expose it, for a short time, to the stimulating operation of the cold air. If these means do not succeed, we must further stimulate the thorax, and soles of the feet, by friction with spirits, and irritate the nostrils and fauces with a feather dipped in the latter ; or by holding hartshorn, or carbonate of ammonia to the nose. The foregoing steps are proper in both forms of asphyxia, and may be taken before dividing the funis, which should not generally be done, as long as it continues to pulsate, unless respiration be fully established. If the child's face be livid and swollen, indicating con- gestion within the head, and marking the case as belonging to the sthenic species, it will be well to endeavour to relieve the circulation by dividing the cord, and allowing some blood to escape from the * Johannes Bohn de renunciatione vulnerum, &c. Lipsiae, 1755. 12 134 ACCIDENTS AND DISEASES AT BIRTH. umbilical vessels, before applying a ligature. If the blood flows freely, it shows that circulation is still active, and is an additional reason for perseverance. Should the funicular circulation have been obstructed before birth, or cease shortly afterwards, it will be most convenient to divide the cord at once, as we shall then have the management of the child more within our power, for th<3 application of other means of resuscitation of which we are about to speak. Two practices are invariably adopted with still-born children, after the separation of the funis — viz., inflation of the lungs, and the warm bath. These, when used with judgment, are unquestion- ably means of great power in exciting respiratory action — but when injudiciously employed or persevered in, we have no doubt, they frequently become agents of destruction. It is now well ascertained that there is no more certain and speedy means of destroying ani- mals, than a brisk insufflation of air into the trachea ; and therefore it is positively wrong to use any powerful mechanical means for this purpose, in the new-born child. The gentle filling of the lungs with air does, however, frequently excite respiratory movements, and also facilitates pulmonary circulation, and should therefore be cautiously practised. In doing it, no trachea pipe or bellows should, we think, be employed ; but air simply blown into the mouth — the operator applying his own lips (with a bit of silk or muslin intervening for the sake of cleanliness) to those of the child. While doing this the head of the child is to be slightly drawn backwards ; its nostrils must be held between the finger and thumb of one hand, and the fingers of the other should be placed upon the pit of the stomach, so as to prevent the air from passing into that organ. When the chest has been distended, it may be compressed gently with the hand, so as again to empty it, and the inflation may be repeated three or four times, or until the commencement of natural respiration is announced by a sneeze or deep sigh. In addition to the evil consequences likely to attend upon the force that would be exerted by bellows or other apparatus for inflation, we may mention that insufflation of cold air, in the event of resuscitation, seldom fails to produce dangerous bronchitis ;* a fact, the -knowledge of which furnishes an additional reason for employing the air that has been previously warmed in our own lungs. The disadvantage of using air already deteriorated by having been respired is more than counterbalanced" by the other advantages of this plan. With respect to the warm bath, those who have frequently wit- nessed its employment with still-born children will recollect that when it does good it is at the first moment of its application : imme- diately upon plunging the child into it, respiration may be set agoing, and a cry uttered — but if this does not occur at once, keeping the child longer immersed in the water will seldom prove successful. This is explained by the discoveries of Dr. Edwards,! who found that the lower the natural or artificial temperature of an animal may * See Dublin Practice of Midwifery, p. 239. f Op. cit. p. 283. DEFORMITIES— IMPERFORATE ANUS. I35 be, the longer it can exist in a state of asphyxia ; but that, at the same time, the momentary application of heat, as well as of cold, acts as a stimulus, and produces more forcible motions. Conse- quently, he says, " the immersion of a great part of the body in warm water, is frequently an efficacious means of reanimating a child just born without signs of life. As soon as motion is produced, or if it be slow in manifesting itself, it will be right to abandon a method the prolonged use of which would be fatal." The object, then, is to plunge the infant quickly into a bath hot enough to stimulate it (probably about 100°) ; and if respiratory motions be produced, to withdraw it, and continue the excitement of the surface by friction with dry, warm flannel ; and when respiration is well established, to lay it in a warm bed. A prolonged immersion in warm water would have the effect of raising the temperature of the child, so as to render it less capable of enduring the state of asphyxia, and would also prevent access of air to the surface of its body, which is known to possess a powerfully vivifying influence. We may, sometimes, especially in the sthenic form of asphyxia (when the child's face is red and swollen), advantageously combine the stimulating action of cold with that of heat; by dashing the head with cold water while the lower part of the body is immersed in the warm bath. The same rule applies to this plan as to the simple use of the warm bath; it must not be persisted in if not immediately successful. The researches of Dr. Edward Jorg, published in his work already quoted, show that our care for the establishment of perfect respiration is not to cease when we get the child to breathe so well as to enable it to live for days, or even weeks. It may survive so long and yet die from the effects of an imperfect filling of its lungs with air. Many cases of cyanosis, infantile bronchitis, atrophy, and even convulsions owe their origin to a partial continuance of the lungs in their foetal condition — a state to which Dr. Jorg has given the name of atelec- tasis pulmonum. Should the child, therefore, continue to breathe feebly, and show an inability to suck, after animation has been restored, we must endeavour to promote more perfect respiration by friction on the surface, and stimulate the intestines by an aperient of castor oil ; or, if there be much mucus obstructing the bronchi, it may be advisable to excite vomiting by administering half a drachm of ipecacuan wine. It is useless to speak of the employment of tobacco fumes, electri- city, or enemata, as recommended by some writers in the treatment of still-born children : for the two latter there is no time, and the former is now deservedly expunged from the list of means of restoring suspended animation. * II. DEFORMITIES IMPERFORATE ANUS. Several varieties of this morbid condition are to be met with. The anus may be simply closed by skin, or a membranous septum, at the termination of the rectum ; or the rectum may terminate in a cul-de- sac, at a greater or lesser distance from the natural situation of the j n 6 ACCIDENTS AND DISEASES AT BIRTH. anus • or the amis may appear perfect, but an obstruction exist in the gut, at some distance within it. In other cases we have known the "rectum to terminate by opening into the vagina ; or bladder in the male subject. When there is no anus, the case is usually disco- vered early, and time given for deciding upon the steps necessary to be taken ; but when the opening appears perfect, and the obstruc- tion exists at some distance within it, we do not become aware of the circumstance until it is observed that no discharges can be procured from the bowels ; or, perhaps, until a vomiting of meconium takes place. As soon as our attention is called to the matter, in such a case, we must institute a careful examination of the anus by means of a probe or flexible bougie, and be guided in further steps by the result of the investigation. The only relief that can be given will, of course, be by an operation ; and the exact nature of this must depend upon the particular circumstances. If the anus be merely closed by skin, or a membrane, all we have to do is to make a sufficient incision with a bistoury, and prevent closure of the opening by the use of tents. If there be no vestige of the rectum, an attempt must be made to reach it by incisions with the scalpel ; and if there be an obstruction in the gut at some distance from its external opening, its removal must be aimed at with the bistoury or trocar. By some it has been recommended to make an artificial anus in the groin in cases in which the gut cannot be found. The operation would be a very hopeless one ; but a consideration of its merits, and of the exact modes of performing the other operations, belongs rather to the province of the surgeon, than of the child's physician — who, in that capacity, has merely to ascertain the nature of the deformity, and must draw upon his own general knowledge of surgery, or apply to another practitioner for the means of its removal.* III. IMPERFORATE VAGINA. The labia occasionally cohere at birth, and sometimes the vagina opens into the rectum, or terminates in a cul-de sac. Unless the closure of the labia interferes with the opening of the urethra, nothing is required, or proper to be done, during infancy, and the case belongs to the general practice of surgery. If the urethra be obstructed, which seldom happens, we must have the obstruction removed in whatever way may suit the individual case. IV. IMPERFORATE PENIS. Deformities of various kinds occur in the urinary organs of the male. The urethra may be altogether deficient, in which case there * In a paper lately read before the French Academy of Sciences by M. Amussat, a successful case of operation for imperforate rectum is detailed in which the safe establishment of the artificial anus is attributed by M. A. to the drawing down of the intesline, and securing of its mucous membrane by sutures, to the skin, so as to prevent the infiltration of fecal matter between the extremity of the rectum and the wound in the integuments. In these almost hopeless cases, every hint is of value. — Gazette Medicate, torn. 3. [Note to 2d Edition.] SPINA BIFIDA. 137 is usually concurrent deformity in the bladder: the anterior wall and corresponding portion of abdominal integuments being deficient, and the mucous membrane, with the mouths of the ureters, protruded through the opening. Examples of this deformity are to be seen in every museum, but are, of course, beyond the reach of remedial art. In other cases, the urethra is not carried through the glans, but ter- minates by an opening behind that body, on the under surface of the penis. This variety, which receives the name of hypospadias, is also irremediable, and is seldom of any importance during childhood, as the urine will usually find its way through the irregular passage. Sometimes, but rarely, the orifice of the urethra, or of the prepuce, will be found imperforate, and will require treatment. In the latter case, the operation of circumcision may as well be performed at once, and will remove all difficulty. In the former, the natural opening must be rendered pervious, if necessary, by a cutting instrument, and kept so by the regular introduction of a small bougie. Retention, or rather sujjpression of urine, may, and often does, occur in infants, without the existence of any malformation or disease whatsoever. We are often told, for example, twenty-four hours after birth, that no urine has been voided. In such cases, we should care- fully examine the parts concerned to ascertain if any physical obstruc- tion exists, and also feel the lower part of the abdomen to learn if the bladder be distended. If it be, and that the external openings are free, we may introduce a probe or small bougie into the urethra for the purpose of removing any mucus, which might block up its canal. We do not recollect having ever found it necessary to intro- duce a catheter. Most usually the stoppage of urine is owing to its non-secretion ; and this may obtain for many hours after birth, with- out any evil consequences. All we need to do is to place the infant, for a few minutes, in a warm hip-bath, and leave the rest of the treatment to nature.* Many deformities of the urinary and genital organs occur in both males and females, and are now and then dragged into a disgusting notoriety as instances of hermaphroditism. As these, however, have no practical bearings upon our subject, we shall not at present delay to notice them. V. SPINA BIFIDA. By this term is designated a malformation of some part of the vertebral column, in which the spinous processes are deficient, and the contents of the spinal canal protruded in the form of a round, compressible tumour, containing fluid. In some instances this tumour is covered with integument; in others, it is divested of this, and pre- sents a reddish fungous appearance. The place of its occurrence is most commonly in the lumbar vertebrae ; but it may exist in any * A curious case of retention of urine and diseased bladder, in a new-born infant, dependent upon an encysted tumour in the pelvis, will be found in the 2d volume of the Medical Press, p. 386, related by Dr. Peebles of Dublin. [Note to 3d Edi- tion.] 12* 13 § ACCIDENTS AND DISEASES AT BIRTH. other part of the column, or in the sacrum. The size of the tumour varies from the bulk of a nut to that of the closed fist \ or it may be even larger: at birth it is usually flat, owing to the compression which it undergoes while passing through the vagina, but shortly afterwards it is protruded by the passage of fluid from the spinal canal into its cavity, and is then in some instances semitransparent. A paralytic or deformed state of the lower extremities frequently, but not constantly, coexists with spina bifida. In some cases the fluid can be forced out of the tumour, back into the canal, and the margin of the bony opening felt through the integuments ; but pressure of this kind will usually produce convulsions. In a case which we lately saw, the integuments appeared as if cut by a sharp instrument round the base of the tumour, which was itself quite destitute of skin, and pre- sented a reddish appearance, resembling the fungus which we occa- sionally see occupying the situation of the brain in, what is termed, an acephalous fostus. The prognosis in spina bifida is very unfavour- able — the tumour commonly sloughing and bursting soon after birth, and occasioning immediate death : or the child perishing early in convulsions. Instances, however, are upon record in which the patients have lived for months, and even years ; and Sir A. Cooper has published two cases, in which he effected what may be termed cures.* The plan which he adopted was, in one case, the continued employment of pressure by means of a concave mould of plaster of Paris, lined with lint, and held on by a roller, until at length the tumour could be altogether reduced within the spinal canal, when the opening was permanently protected by a suitable truss. In the other instance, repeated punctures with a needle were made at inter- vals in the tumour, and the fluid drawn off, pressure being in the meanwhile applied by means of a piece of pasteboard and a roller. By these means adhesive inflammation was excited in the coverings, and the opening thereby permanently closed. More recently M. Dubourg has related two cases in which he effected perfect cures by amputation of the tumour and subsequent application of the twisted suture, so as to bring the edges of the divided skin into apposition. In the performance of the operation, M. D. attaches much importance to the preventing, so far as is possible, the escape of the spinal fluid, or the entry of air into the spinal canal.t In managing these cases shortly after birth, our chief object should be to protect the tumour from any pressure or irritation, which might occasion inflammation and gangrene, as instant death is to be dreaded from bursting of the sac. At a subsequent period we may cautiously try pressure ; or if that cannot be borne without producing convul- sions, repeated punctures with a needle, as practised by Sir A. Cooper, may be attempted, — and the bulk, perhaps, by that means reduced so much as to admit of a truss being applied. Spina bifida is occasionally complicated with hydrocephalus, and sometimes tumours of a nature precisely similar to it are met with * Med. Chir. Trans, vol. ii. | See Gazette Medicate, also Medical Press, vol. vi., p. 117. TONGUE-TIED — HARE-LIP. 1 3 9 upon the head — the fluid passing out, in a sac of dura- mater, through an opening in one of the cranial bones. The same principles of treatment apply to these affections as to actual spina bifida. VI. SHORT FRENUM LINGU2E (TONGUE-TIED). The frenum linguae is sometimes so short, or its attachment to the tongue extended so near to the tip, as to interfere with the motions of the organ in sucking or speaking. Nothing is more common than to have infants brought to us, alleged to be tongue-tied, and yet the existence of the malformation, to an extent requiring artificial aid, is extremely rare. If the tip can be protruded beyond the lips, nothing need be done, as sufficient motion will then be permitted to allow of sucking, and the frenum will gradually lengthen as the tongue comes to be more employed. The division of the frenum should, therefore, not be wantonly performed, especially as it is not altogether unat- tended with danger — instances having occurred of serious hemor- rhage ; and even of suffocation from a turning back of the loosened tongue to such an extent as to impede the access of air into the glottis.* When interference is absolutely necessary, a very slight nick with a sharp scissors is all that will be required. The mode of operating is, to place the two fore-fingers of the left hand under the tongue, on each side of the frenum, and to raise it as much as possi- ble from the floor of the mouth ; then with the scissors in the right hand to divide the edge of the frenum, taking care to direct the points downwards, so as to avoid injuring the ranine arteries. The child must be watched for a little, lest hemorrhage should occur ; and it is to be recollected that the blood may pass down into the stomach, arid a considerable quantity be lost without the issue of any from the mouth. VII. HARE-LIP. The consideration and treatment of this deformity belongs to the surgeon — all that the child's physician, as such, has to do with it, is to consider when the operation should be performed. If the child can suck, it is better not to submit it to the hazards of an operation in early infancy. But cases occasionally occur in which such a degree of deformity exists as to demand immediate assistance, in order to give the infant a chance of life. The nature of the operation, and modes of performing it, belong altogether to the province of surgery. We occasionally meet with a child born with one or more teeth, which may require to be extracted in order to prevent injury to the nurse's nipple : but if they be not productive of the latter effect, it is wiser not to meddle with them, as by extraction, we may do perma- nent injury to the rudiments of the second tooth, which is buried in the gum beneath that which we remove. * Petit, Mem. de l'Academie des Sciences. 14 ACCIDENTS AND DISEASES AT BIRTH. VIII. DEFORMED FEET. Three varieties of deformity of the feet are to be met with. These are termed — valgi, when the foot is turned outwards; vari, when it is turned inwards ; and pes equinus, when the toes are pointed downwards, the foot being extended so as to cause it to approach a right line, with the leg. The immediate cause of these deformities appears generally to exist not so much in the bones, as in the muscles which influence the motions of the foot — •. any alterations observable in the former, in old cases, being probably often consecutive. Delpecji found that, upon dividing the tendo-Achillis in young persons who had died subject to one of these deformities, it became easy to restore the foot to its natural position, no trace of deformity remaining. Ac- cordingly, he inferred that the primary alteration is a shortening of the gastrocnemii and other extensor muscles, and that the distortion primarily produced is the pes equinus, or extended foot : that subse- quently the varus, or turning of the foot inwards, is easily induced, because the posterior extremity of the os calcis is naturally inclined a little in that direction, and the distortion is favoured by the ordinary action of the gastrocnemii upon that bone, tending to bring the foot somewhat inwards. As the turning inwards increases, the plantar muscles, ligaments, and aponeurosis, are gradually contracting ; and the deformity becomes greater, until first the external margin, and subsequently the dorsum of the foot, comes to be the part resting upon the ground. The valgus, or turning of the foot outwards, so as to make a resting place of the inner margin, is not so common as the other deformities. It is produced by a shortening or inordinate contraction of the mus- cles situated on the anterior and external surface of the leg, whose office is to rotate the foot outwards. The remote cause of these deformities, M. Delpech refers to an original defect in the nerves supplying the limb, in consequence of which there is a want of balance in the development and action of the antagonist muscles. His view is borne out by a fact which we have already stated, viz., that spina bifida, which, of course, must often involve a lesion of those nerves while in the spinal canal, is fre- quently complicated with deformed feet. The treatment of deformed feet must be based, in principle, upon the view we have taken of the immediate cause. Our object must be gradually to extend the muscles, whose shortness or inordinate contraction produces the distortion ; and as far as possible to encou- rage the action of their antagonists. The first object is to be attained by mechanical contrivances, in the nature of shoes, adapted to the foot in such a way as to tend gradually to bring it into its natural position. The form of shoe required will vary according to the kind and degree of distortion, and its construction must depend upon the ingenuity of the surgeon and the instrument-maker.* The principle * For a description of an excellent form of shoe for vari, see Professor Colles's valuable paper in the first volume of the Dublin Hospital Reports. NiEVI MATERNI. 14l of its application should be to make the extending force very gradual, and to apply it so as to act upon the shortened muscles : particular care should be paid to the prevention of any injurious pressure upon the part which is made the point d'appui. The action of the anta- gonist muscles should be encouraged by friction, and by daily moving the foot in the directions in which these muscles would naturally act. The period most favourable for the removal of all these deformities is early infancy, the parts being then most flexible and susceptible of alteration in position, and the patient most easily managed. In more advanced life, the rigidity of the muscles is so great, as usually to frustrate any attempts at elongating them ; and under these circum- stances; M. Delpech has recommended, and successfully practised a division of the tendo-Achillis. Our business, however, as child's physician, is to recommend the early employment of curative means ; and if these be properly adopted upon the principles just suggested, there will, probably, be no occasion for any more violent expedients.* Supernumerary toes and fingers will sometimes be met with in an infant, and perhaps so situated and attached as to make their removal desirable. We should not, however, recommend an opera- tion for that purpose in early infancy. The child is then little able to endure the shock of any operation, however slight ; and as this is not a necessary one, it will be better to defer it for a few months. IX. NiEVI MATERNI. The new-born child may labour under a variety of organic mal- formations in the texture of the skin, all of which are classed under the name of nssvi, although they differ very materially from each other, both in degree and nature. The most common forms of naevus are the brownish mole, and the claret stain. These are frequently met with upon all parts of the body, and vary very much in size. They appear to be simple discolorations of the skin, occasioned by an alteration in the structure of the rete mucosum. They are not much elevated above the rest of the surface : and as they commonly remain stationary during life, without causing any injury except from their unsightliness, it is better not to meddle with them. We know of no means whereby they can be removed without the danger of leaving a greater deformity in their stead, and therefore think it wiser not to interfere. t All these marks are attributed, but without any good * For full information respecting these deformities, we may refer to L'Ortho- morphie, par J. Delpech, Paris, 1828 ; to Professor Jbrg's Ueber Klumpfiisse und eine leichte u. zweckmassige Heilart derselben, Leipzig, 1806; and also to Pro- fessor Scarpa's Memoire sur la torsion congenitale des pieds des enfans, &c, tra- duit per J. B. F. Leveille, Paris, 1804. [We may also direct our readers to the 1st, 2d, and 3d vols, of the Medical Press, passim, for several interesting disquisitions upon Delpech's operation, to which, attention has been recently re-directed by M. Strohmeyer. [Note to 3d Edition.] f Dr. Frankel, in his German translation of this work, mentions a proposal for the treatment of this form of naevus, which was communicated by Dr. Paulli of 142 ACCIDENTS AND DISEASES AT BIRTH. foundation, to effects produced upon the mother's imagination during pregnancy, and accordingly they are usually likened, by the aid of an active 'fancy, to objects for which she has longed, or by which she has been frightened, as fruits of various kinds, mice, spiders, or other disgusting animals. Other nsevi exhibit a more important alteration of structure, being raised in granulated tumours above the skin, and consisting of a con- geries of vessels, sometimes venous and sometimes arterial, imbedded in a sort of parenchymatous tissue, and often identical in their nature with the disease termed ( aneurism by anastomosis.' The colour and external characters of these tumours vary considerably, — being sometimes dark-blue, or livid ; in other instances of a vermilion hue — occasionally raised on a neck or pedicle, and again growing from a broad base. Their size and situation are also very various — not being always confined to the skin, but appearing at times in the tongue, lips, labia pudendi, &c. A particular disposition to their formation appears to exist in some individuals, and we have seen so many as sixteen upon the body of a young child. Some nasvi, like simple moles, remain stationary during life, and do no injury ; others show a constant tendency to enlarge, which is much stimulated by any trifling irritation, as a bruise, scratch, or slight pressure. Any circumstance which quickens the circulation, as anger, warm weather, or active exercise, may increase their bulk and heighten their colour, by producing a greater determination of blood to the surface ; and the skin covering them being usually very thin, they frequently burst, and may occasion alarming, or even fatal, hemor- rhages. When nsevi are small in size ; in situations unlikely to suffer from pressure ; and show no tendency to enlarge, they call for no treat- ment ; but .when opposite conditions exist, surgical aid is required, and must often be had recourse to even in very young infants.* The principles upon which this aid is to be afforded are threefold. Their growth may be restrained by the continued application of cold washes, and the gentle pressure of a bandage ; or inflammation may be excited in them by various means ; or lastly, they may be extirpated by the knife or ligature. The first-named plan has the sanction of Mr. Abernethy's recommendation ; but still can scarcely be looked upon as more than palliative, and, so far as the bandage is concerned, is inapplicable to many cases of the disease, both on account of local situation, and of the likelihood of severe irritation being occasioned by pressure. Landau to the Meeting of German Naturalists and Physicians, held at Stuttgart in 1834. Dr. P.'s plan consists in tattooing the naevus with needles and a while pig- ment, in a manner similar to that adopted by the South Sea Islanders, and often by sailors of our own country. Dr. Frankel states that Dr. Paulli succeeded in this operation in several instances. The tattooing must be proceeded with gradually, and caution observed not to make the punctures too deep. We are not aware of the nature of the pigment used. [Note to 4th Edition.] * For a case of extirpation of a nsevus six hours after birth, by Mr. Balby, see Med. Chir. Review, vol. viii., p. 204. RUPTURES. 143 For the production of inflammation, various means have been devised : caustics of different kinds were applied by the old surgeons, and by producing ulceration, occasionally destroyed the disease. But this practice was often followed by considerable irritation, and some- times by dangerous hemorrhages, and is now in a great degree laid aside. It was, however, in some measure consonant with the plans of nature, as we have seen many cases of large naevi in which ulcer- ation set in spontaneously, and the whole disease was removed, leaving a healthy cicatrix. Latterly it has been recommended by Mr. Hodgson, of Birmingham, to vaccinate naevi; and in some in- stances, this plan has been productive of good effects. It has also been proposed by Dr. M. Hall to pass a couching needle into the centre of the tumour, and by moving it from side to side, to break down the vascular network of which it is composed; by repeating this process at intervals of a month or six weeks, he has found a gradual diminution to be occasioned. In other instances a seton has been drawn through the nsevus for the purpose of exciting inflamma- tion ; a modification of which plan, viz., to pass twelve or fourteen threads through it at different points has been recommended by Mr. Adams of this city, and has been found to answer very well. Where every part of the disease can be removed by the knife, it is, perhaps, the least severe plan, and likely to be attended by the slightest mark ; but if it cannot all be taken away, there is consider- able danger of hemorrhage, and of a further growth of the tumour. Ligatures have been employed in several ways, viz., by applying a single ligature round the tumour, where that was practicable ; or, by passing a double thread through its substance, and tying the tumour m two portions ; or, what we believe to be a very useful plan, by passing five or six common sewing needles through the skin surround- ing the naevus,and bringing out the points (also through the skin) on the opposite side, so as to make the needles cross each other in the form of a star, and then winding a ligature tightly under them in the same manner as is done in the operation for hare-lip, or in securing the vein of a horse after bleeding. By these means an artificial pedicle is formed for the naevus, and sufficient pressure may be ap- plied to cause it to slough away. X. RUPTURES (HERNIA). The new-born infant is liable to several forms of hernia, and in some individuals there appears to be a remarkable predisposition to the disease. We know a family of three children in each of whom there existed at birth an umbilical hernia — in one, combined with a single, and in the third, with a double scrotal rupture. The form of protrusion which we most commonly meet with is the omphalocele, or umbilical hernia. In the early foetus we are to re- collect that there is naturally a pouch at the commencement of the umbilical cord, which contains convolutions of intestine, and that these are not retracted within the abdomen until some months of foetal life have elapsed. In the perfect state the opening at the navel 144 ACCIDENTS AND DISEASES AT BIRTH. should gradually close, until at birth it should only be capable of admitting the passage of the vein and arteries ; but in many instances such perfect closure does not take place — a round, well-defined opening, is left in the linea alba, and through this a sac of peri- toneum, containing a hernia, may protrude. The protrusion may vary very much in size and contents, but commonly it ranges from the bulk of a hazel-nut to that of a walnut, and contains intestine or omentum. The diagnosis is simple ; we find a tumour at the navel, which increases when the infant cries or coughs, and can be replaced when we relax the abdominal muscles, and use gentle pressure ; an empty pouch remaining ; and an aperture, into which we can insert the point of the finger, being perceptible in the wall of the abdomen. Instances are upon record, in which the liver and other viscera formed the contents of an omphalocele, but most commonly there is merely a fold of intestine. When the aperture in the linea alba is not very large, the pro- gnosis is usually favourable ; but much care and attention are required, both from the medical attendant and nurse. Until the funis has fallen off, and the navel healed, nothing more should be done than to apply a fold or two of old linen over the part in the ordi- nary manner of dressing the child ; but as soon as cicatrization is perfected, a more effectual course of treatment must be commenced, and the earlier this can be done, the better will be the chances of success. Our object is to keep the protrusion permanently within the abdomen, so as to permit a free scope to the natural efforts at closure of the opening. The means of effecting this are various. Spring trusses have been invented for the purpose, but are inappli- cable, from their strength, to the tender bodies of very young chil- dren. Sir A. Cooper recommends a section of an ivory ball to be applied over the umbilicus, and retained there by adhesive plaster and a belt. The plan which we ourselves usually adopt, and find successful, is to apply a graduated compress, made of white leather, spread with adhesive plaster, over the opening, and above this the common flannel roller or belly band. The apex of the compress, which is to be placed next the navel, should be as nearly as possible of the size of the opening ; the compress should consist of three or four pieces, — the largest being about three inches in diameter, — and a double stitch should be passed through them, and knotted externally, so as to keep each piece in situ. We should always apply the compress with our own hands, as great care is necessary to ensure a complete return of the hernia. Unless the child exhibits marks of uneasiness, it should not be removed until the plaster loses its adhesive quality, and then a new one should immediately be applied. In conducting the case, patience will be greatly exercised, as many months will be required for the completion of a cure, and this should be explained to the friends at the beginning. We have tried a plan, originally adopted, we believe, by Mr. VVoodroofe, of Cork, and which answers well when there is a small opening with a considerably elongated sac, but cannot be employed in broad, flat hernise ; it is, after reducing the contents, to hold the pouch firmly RUPTURES. 145 between the fingers, and then wind round it a narrow strip of adhe- sive plaster, commencing as close as possible to the abdomen, and continuing to the apex. This plan may succeed, by causing adhe- sion of the walls of the sac, which will thus form a natural truss, and prevent protrusion through the opening in the iinea alba. A rougher variety of this plan was sometimes practised by Baron Dupuytren, by tying a ligature firmly round the pouch, as close as possible to the navel. We would not, however, recommend its adoption as the cicatrix formed after the falling off of the strangu- lated portion of the pouch could scarcely be firm enough to resist future protrusion, and the operation would have no direct tendency to diminish the opening in the abdominal wall. Inguinal hernia may also exist, at one or both sides, at the period of birth, and then constitutes what has been denominated hernia congenita. The distinctive character of this form of rupture is, that the protrusion descends into the sac of the tunica vaginalis, before the latter is closed, and thus comes to be in direct contact with the testicle. In many cases of congenital inguinal hernia, the testi- cle will not have descended from the abdomen ; and into this circum- stance we must particularly examine, by feeling for the testicle in the scrotum, as no truss should in any case be applied, as long as it remains within the belly. The diagnosis of inguinal rupture is less easy than that of ompha- locele, as it may be confounded with hydrocele, which is not uncom- mon in infants: or the testicle, while in the act of descending through the inguinal channel, may be mistaken for a hernia : after breech presentations, also, considerable tumefaction of the scrotum may exist, which should not be confounded with rupture. Hydrocele is to be distinguished from hernia by its transparency, and by our not being able to feel the cylinder of the intestine rolling under our fingers within the integument. The fluid may, however, be return- able into the abdomen as hernia is, and in like manner may be in- creased when the infant cries or coughs, so that caution is required in making our discrimination — the more so, as congenital hydrocele requires little or no treatment, usually disappearing spontaneously. The testicle is to be known by its solidity, and by not being usually returnable into the abdomen. The enlargement of the scrotum from pressure will be recognised from the history of the case, and will also, in general, rapidly subside. The principle of treatment in inguinal hernia is, of course, to keep the protrusion within the belly, and favour the closure of the ring. The accomplishment of this, however, is attended with immense dif- ficulty in the young child : the smallness of the pelvis renders it next to impossible to get any truss to fit ; and in early infancy, the con- stant wetting of the straps will cause chafing of the skin, notwith- standing the most careful attention. On these accounts we have, after repeated and patient trials, almost given up the idea of using a truss before the child is a year old ; and even at that age, we have been repeatedly foiled. A child subject to hernia should be kept in as tranquil a state as possible, and every means adopted to prevent 13 14 6 ACCIDENTS AND DISEASES AT BIRTH. it from crying, or using any exertion likely to increase the protru- sion. When this has been carefully attended to, and the parts bathed daily with cold water, we have often observed a spontaneous cure to be effected, without the employment of any artificial support what- soever. All the forms of hernia in the child may be the subject of strangu- lation, and require the operation, the performance of which is strictly within the province of the surgeon, and requires no remarks from us. XI. INJURIES RECEIVED DURING BIRTH. When, in the course of tedious labour, an extraordinary degree of pressure is exerted upon any part of the child, all the consequences of a contusion may result. Bloody tumours may be formed upon the head, or face, or in the scrotum ; or inflammations may be ex- cited, which will terminate in abscess, or even gangrene.* To all these injuries, the ordinary rules of surgery apply : the bloody tumour should be left to itself, and never on any account opened, as un- healthy suppuration would be thereby induced ; inflammation must be treated by the moderate use of cold lotions, as spirits or vinegar and water, and by preventing any continuance of irritation from pres- sure of clothes, &c. ; when suppuration or sloughing ensues, we must employ poultices. Considerable alteration is sometimes effected in the shape of the child's head ; and in face presentations, the features are often fright- fully disfigured ; but neither of these cases require or warrant any interference; and it will be often a matter of surprise to ourselves, how very rapidly the parts will return to their natural state. Fractures of the bones of the extremities^ are sometimes produced during birth, especially in cases of preternatural presentation, when turning or other manual interference is required. They unite readily, and are to be treated upon common principles, only adapting our means to the delicate organization of the child — making our splints, for example, of Bristol board, instead of wood, and carefully preserv- ing the skin from irritation. One thing we would recommend to the young practitioner in midwifery — viz., when such accidents un- fortunately occur, never to think of concealing them, but at once to inform the friends, and explain the steps necessary for the occasion. This is the honestest plan, and we sincerely hope it will also be found to be the best. When pressure by means of a blunt hook or fillet, or in any other way, has been applied to the groin or axilla, such injury may be * The foetus while yet in the womb is subject to many diseases, and among others to inflammation and its consequences. We lately had an opportunity of ob- serving a remarkable instance of this in the child of a prisoner in one of the jails of this city, which was born with two large sloughing ulcers upon the forearm. TNote to 2d Edition.] " t It is asserted by Schmidt, Jorg, Klein, and others, that in severe labours, with disproportioned pelvis, fractures of the cranial bones may be produced by the force of the pains alone. BLUE DISEASES — NINE-DAY FITS. I47 done to the nerves in those situations, as will be followed by paralysis of the limbs. Such an affection is probably altogether beyond the reach of remedial art, and it is unnecessary for us to consider it at any greater length. XII. BLUE DISEASE (CYANOSIS). This term is applied to a morbid appearance of the skin, in which it assumes a blue, purple, or leaden colour, and which is occasionally observed in new-born iufants. The change of colour is particularly remarkable in the lips, cheeks, and nails, and is generally accom- panied with reduction of temperature, and paroxysms of difficult respiration, during which the blueness becomes deeper, and isextended over the surface of the body — the pulse stops, the extremities become cold, and syncope resembling death often occurs. From these fits the child may recover, but usually to be again attacked, and ulti- mately to perish in one of them. Anything which hurries the cir- culation — as crying, or quick motion, — is likely to bring on a paroxysm. The cause of these symptoms was attributed by Senac, Morgagni, and others, solely to a continuance of the foetal condition of the heart — or iu other words, to a permanent patency of the foramen ovale. Corvisart, however, observed the symptom of cyanosis in cases in which there was no communication between the ventricles ; and Dr. J. Crampton has met with others, in which there was no blue colour, and yet the openings between both auricles and ventricles must have been unclosed for many years.* Other causes, therefore, must exist ; and in new-born children, we conceive, it may often be accounted for by the imperfect filling of the lungs which we have already spoken of as having been noticed by Dr. Ed. Jorg. When the disease arises from organic imperfection, the prognosis is highly unfavour- able, and nothing can be done by art ; yet the unfortunate subjects sometimes drag on a wretched existence for years, as in Morgagni's well-known case of the girl who survived to her sixteenth year with a foramen ovale so large as to admit of the passage of the little finger through it. When the symptom belongs to an imperfect filling of the lungs with air, we must have recourse to those means of exciting respiration indicated under the head of ' still-born children,' and may sometimes be successful in our efforts. During a paroxysm, all we can do is to sprinkle the child's face with cold water, and expose it freely to cold air. XIII. NINE-DAY FITS (TRISMUS NASCENTIUM). This fatal affection is stated to commit great ravages among infants of all classes in warm climates,! but in this country, although occa- * See Med. Trans. Coll. of Physicians in Dublin, vol. i., new series. f It is also very fatal in the Westmann Islands, on the southern coast of Iceland. See M'KenzWs Iceland, 14 8 ACCIDENTS AND DISEASES AT BIRTH. sionally to be met with in private practice, it may justly be considered as an hospital disease. Its ordinary period of occurrence is within nine days from birth, — about the time of the falling off of the funis, — and it appears in two forms, distinguished by nurses as " black" and " white fits." The first of these is violent and rapid in its progress, terminating fatally in from eight to thirty hours ; the second may be protracted to three, five, or even nine days. Sometimes the disease sets in without any warning; in other cases there are certain premonitory symptoms, as whining and starting during sleep, twisting of the upper extremities, the appearance of a livid circle about the lips, sudden changes in the countenance, and compression and puckering of the mouth, accompanied with a pecu- liar screeching. The child's appearing to smile during sleep is also commonly considered as an indication of the approach of fits. An extraordinary greediness for food or suck, as if occasioned by inward pain, is sometimes observed. The stools may be regular and natural, or they may exhibit considerable derangement, being greenish, slimy, and knotted. When the paroxysm actually comes on, the infant is seized with violent, irregular spasms of the muscles, particularly of those of the limbs and face, recurring at uncertain intervals. In the " black fits," the muscular contractions are very violent ; there is foaming at the mouth ; the thumbs are turned firmly into the palm of the hand; the jaws are closed, and any attempt to separate them considerably aggravates the paroxysm; the face, and often other parts of the body, are swoln, and of a dark copper colour ; during the interval, the muscles retain a greater or lesser degree of rigidity. In the " white fits," there is not so much violence ; the face is pale, and the body becomes quickly emaciated. Both are equally fatal. With respect to the pathology of trismus, nothing is certainly known ; but the researches of Dr. Joseph Clarke* make it highly probable, that a powerfully predisposing cause exists in a vitiated state of the atmosphere of large hospitals ; and Professor Collest has ingeniously put forward the suggestion, that this operates by inducing "an unhealthy or unkindly form of inflammation or ulceration" at the navel, and that the disease is in fact a species of traumatic tetanus, having its immediate cause in the wound occasioned by the separa- tion of the cord. This view has, however, been impugned by Dr. Labatt, who has published particulars of some post-mortem exami- nations in which no appearance, satisfactorily accounting for the dis- ease, showed itself in the cord.± The views of Dr. Clarke led him to pay much attention to the prevention of trismus in the Dublin Lying-in-Hospital, by establishing a free ventilation, and perfect cleanliness in the wards; and his numerical statements, certainly, appear strongly to corroborate his opinions. They are also further borne out by the facts contained in * Tran. R. I. Acad. vol. iii. | Dub. Hosp. Reports, vol, i. % Ed. Med. and Surg. Journal, yoI. xv. INFANTILE ERYSIPELAS. 149 Dr. Collins' book,* to which we may refer the student and statistician for much valuable numerical information, upon this and other sub- jects connected with midwifery. Whether we can fully assent to the exact number of lives (16,371) said to have been saved by Dr. Clarke's suggestions, is a matter of very trifling importance ; but we would strongly recommend that his principles with respect to venti- lation and cleanliness, shouM be carried into effect, as perfectly as possible, in every lying-in institution. Professor Colles suggests as a preventive measure, in every case, the propriety of dressing the umbilicus with spirits of turpentine, from the birth of the infant ; but the small average occurrence of the disease, especially in private practice, scarcely appears to demand such a step. With respect to the treatment of trismus nascentium ; when it has once set in, we believe that every thing is empiricism, and that little is to be expected from any plan. We have tried, or seen tried, almost every variety of treatment — mercury, leeching, blistering, opium, tobacco, &c, &c, — without any impression being made upon the affection ; and we must candidly confess, it is not in our power to propose any means with confidence. Dr. Breen,t of this city, speaks encouragingly of the administration of an eighth of a drop of laudanum every second hour until narcotic effects are produced, together with " a grain and a half of calomel every fifth or sixth hour up to the third time ; afterwards not more unfrequently than twice or three times in twenty-four hours, with intermediate doses of castor oil, in the quantity of a large-sized tea-spoonful, sometimes joined with a third part of spirits of turpentine." Dr. B. has not found the warm bath productive of advantage. XIV. INFANTILE ERYSIPELAS. Inflammation of an erysipelatous nature sometimes attacks infants, especially those born in lying-in hospitals. The disease in its worst form appears about the navel, or lower part of the belly (from which latter situation, it has sometimes been denominated erysipelas pubis) ; but it also frequently attacks the limbs, and particularly in the vici- nity of joints, as the ankle and wrist. It is a very dangerous affection, running quickly into suppuration or gangrene, and usually occurs at periods when the existence of other malignant diseases, as diffused infl animation, puerperal fever, scarlatina, &c, prove the constitutio anni to be of a typhoid charac- ter. Its affinity with such affections is also further shown by the morbid appearances observable in fatal cases of the disease — the different cavities being usually found to contain effusions of curdy gelatinous lymph and serum, and the organs often exhibiting soften- ing, and infiltrations of sero-purulent matter. Infantile erysipelas first appears in the form of a dark red, shining * Pract. Treatise on Midwifery, by Robt. Collins, M.D. London, 1835. (Pub- lished in the Select Medical Library.} t See Dub. Med. Journal, vol. viii. 13* 15 ACCIDENTS AND DISEASES AT BIRTH. spot, which quickly extends in size, and becomes of a purplish colour ; there is not a great deal of swelling, but the skin is tense and very- hard. When it commences on the belly, vesications, destruction of the cellular tissue, and gangrene of the skin, quickly follow. The genital parts are not unfrequently destroyed altogether ; and we have sometimes seen the scrotum become black and slough away, leaving the testicles bare and hanging loosely by the cords. In such cases, the fever is of a typhoid kind and very severe, usually carrying off the child in a very few days. The erysipelas which attacks the limbs, in the first instance, is milder in its nature ; although suppura- tion often follows, prognosis is not so unfavourable as in that which commences upon the abdomen, as it less frequently runs into gan- grene. Before the setting in of erysipelas, the bowels are generally deranged, the stools being offensive, slimy, and knotted. It often, however, makes its attack so speedily after birth, that we have not time to recognise any premonitory signs. The general symptoms during the existence of the disease are great restlessness and peevishness, diarrhoea, with ill-conditioned motions, very rapid, feeble pulse, and, towards the termination, a state of coma. The prognosis is very unfavourable, and yet (so little are we war- ranted in despairing of children under the most doubtful circum- stances) we have seen a case recover in which the whole scrotum and skin about the pubes had sloughed away, the bare testicles being again covered up by an extension and cicatrization of the neighbour- ing integuments. In treating infantile erysipelas, we must hold in view the circum- stances under which it occurs, and its usual course. It is commonly a disease of hospitals, and must therefore be presumed to have its predisposing cause in some impurity of the atmosphere ; accordingly we should lose no time in transferring the child, if it be practicable, to a different and well-ventilated apartment : this we conceive to be an essential step in the treatment. From the usual course of the disease, its quickly running into gangrene, and the fever being typhoid, we learn the necessity of supporting the child's strength, at the same time that the gastric derangement demands from us a care- ful attention to its bowels. Should the mother not have sufficient milk, or not be free from disease, we must at once procure a wet nurse ; and if the child be unable, or disinclined to suck, a tea-spoon- ful of white wine-whey must be administered every hour or half hour. An alterative aperient should at once be given ; and when it has operated, small doses of quinine (one-third to one-fourth of a grain), every three or four hours, in conjunction with one-fourth of a grain of aromatic powder. Ammonia has been recommended by some ; but we think the wine- whey a better stimulant, as combining also nutritive matter. With respect to local treatment ; in the first instance, we probably cannot do better than to dust the part with starch-powder or common flour ; and subsequently, when suppura- tion or gangrene is approaching, most relief will be given by warm fomentations and light poultices, as of bran or chamomile flowers ; or the fermenting poultice. When matter is formed, incisions will ABSCESSES — INDURATION OF THE CELLULAR TISSUE. 151 be required in order to give exit to the sloughing cellular membrane, and prevent, as far as possible, further destruction. Underwood and Burns recommend, as local treatment, compresses of linen wrung out of camphorated spirit ; but we rather think we have seen more benefit result from the use of warm applications. Perhaps, when the disease attacks the limbs, it would be advisable to try a modifica- tion of Mr. Higginbottom's plan in erysipelas, by drawing, with a pencil of lunar caustic, a sort of cordon round the diseased part. We cannot speak from experience of this suggestion ; but it appears worth trying, especially as erysipelas, when it attacks the limbs, is frequently of an erratic nature. XV. ABSCESSES. We have frequently had occasion to treat large collections of matter in very young children, which, if the short course of life already per- mitted to the little patient did not forbid, we should be almost tempted to call chronic abscesses. These formations of matter we do not recollect to have seen noticed by any author ; yet they are of very frequent occurrence. Their usual situation is in the axilla, neck, or lower part of the leg; but we have observed them in almost every part of the body. They set in and increase with little appearance of inflammation, and often attain a very considerable size, without having excited any general fever. We have sometimes given exit to a wine-glassful of matter from one existing in a child of a few weeks old. The disease consists at first of a tumour, apparently not very painful to the touch, until it approaches the surface, when the skin becomes inflamed, and a process of pointing commences. We can then satisfy ourselves, by the touch, of the presence of a fluid — and the sooner we give vent to it, by a small opening with a lancet, the better. The pus is sometimes fetid ; at others healthy. After being opened, the abscess commonly gets well without any treat- ment, beyond the use of a poultice, being required. XVI. INDURATION ON THE CELLULAR TISSUE (OEDEME DU TISSU CELLULAIRE DES NOUVEAUX-NES ', SKIN-BOUND DISEASE). This appears to be a very common disease in the French hospitals, and extremely fatal ; so much so, that in the years between 1808 and 1811 there died, in the Hospice des Enfans trouvh, 576 out of 643 who were attacked. In Great Britain, however, it is not by any means so common. It occurs during the first few days after birth, and in some instances the infants has been born with it. It usually attacks premature or feeble children, in whom respiration has not been fully established, andcommences in the extremities — most commonly in the feet. These parts become somewhat swollen, dry, hard, and cold. The skin is sometimes of the natural colour ; at others, livid or purple. It appears as if stretched tightly over the subjacent parts, and is cold and hard, pitting slightly upon pressure. From the ex- tremities the disease commonly proceeds, with rapidity, to the trunk 152 ACCIDENTS AND DISEASES AT BIRTH. of the body, the whole or parts of which it affects in like manner. The diminution in temperature is remarkable, and the body often appears to be acted upon by external heat merely as so much dead matter. No febrile condition accompanies this affection, wherein it differs from infantile erysipelas, which in other respects it much resembles. The child will not suck, is restless, and continually whines in a manner compared by Dorfmiiller to the crying of young mice. Respiration becomes gradually more and more difficult, until death ensues, usually before the fourth day, but sometimes so late as the second or third week. The prognosis is very unfavourable ; but in mild cases, the respiration sometimes improves, heat begins to be evolved, and recovery slowly takes place. Post-mortem examinations show the results of this disease to con- sist of an effusion of yellowish or greenish sero-albuminous fluid into the cells of the cellular membrane, both the subcutaneous tissue, and that which lies between the muscles. The peculiar hardness has been attributed by some to the coagulable quality of the effused fluid, which was analysed by Chevreul ; but we have the authority of Dr. Carswell* for stating that this quality does not exist in a greater degree in the serum in question that in that which constitutes the oedema of adults; and that further, it is not found in a coagulated state in the cellular tissue of children subject to this disease. It is probable that the peculiar hardness and tightness of the skin depends upon the condensation of the fat produced by the mechanical pressure of the effused fluid. All observers are agreed upon the constant existence of congestion in the large veins, and accumulation of black blood in all the viscera, as concomitants of this disease ; which state, however it may be produced, sufficiently explains the diminution of temperature, serous effusion, and other phenomena. Other lesions, which are only occasionally observed, as open foramen ovale, inflamed conditions of organs, &c, must be merely considered as accidental coincidences. With respect to the remote cause, much difference of opinion exists. By Dr. Andry, who first accurately^ described the disease, and sub- sequently by M. Duges, it was attributed to cold ; M. Breschet con- ceived it to depend upon an open state of the foramen ovale ; M. Denis considered it to be an inflammatory affection of the cellular membrane ; M. Billard assigns several predisposing causes, the most prominent being a natural debility of the child, which of course is merely an asylum ignorantise. It appears to us highly probable, that a frequent cause may be the imperfect filling of the lungs with air, at the time of birth, of which we have already spoken. Treatment in so fatal a disease is, of course, the subject of much difference of opinion. The earlier plans had for their object the application of heat by means of the warm and vapour bath, and wrapping the child in wool or cotton. The lowness of temperature, * Cyc. of Pract. Med. article Induration. t It was previously noticed by Drs. Denman and Underwood. JAUNDICE — PURULENT OPHTHALMIA OF INFANTS. 153 however, is merely a symptom of the state of commencing asphyxia ; and we have already observed that that state is not likely to be removed by the application of external heat alone. We must endeavour to lessen the venous congestion, and if we succeed in doing so, the production of heat will proceed naturally. For this purpose we would recommend friction with warm flannel ; the administration of an emetic of ipecacuan, for the purpose of remov- ing mucus, and exciting respiration ; and the internal use of stimu- lants, as warm wine-whey. We cannot put forward this plan as the result of experience ; but we conceive it to be based upon a rational view of the pathology of the disease. Palletta recommends leeches to be applied to the oedematous parts, as a means of promoting cir- culation ; but his plan has not succeeded in other hands. XVII. JAUNDICE (ICTERUS NEONATORUM, OR YELLOW GUM). A more or less marked yellowness of the skin and tunica conjunc- tiva of the eye is a very common occurrence with infants of two or three days old. This, in ordinary cases, appears to depend merely upon the active commencement of the secretion of bile ; more than is required for the uses of the digestive function being formed, and then disposed of by means of the skin and other excreting organs. Viewed in this light, it can scarcely be called a disease, commonly disappearing spontaneously, and requiring no medical treatment. When it does not go off in two or three days, we may set matters to rights by the administration of a drachm of castor oil, or two or three grains of rhubarb with one of hydrargyrum cum creta. Jaundice may occur in a young child as the result of malformation or obstruction of the biliary ducts ; but under such circumstances it is permanent, and if there be an organic defect, cannot be removed, and will probably prove fatal. XVIII. PURULENT OPHTHALMIA OF INFANTS. An inflammation not unfrequently attacks the eyes of new-born children, which is speedily followed by a copious secretion of pus from the conjunctiva, and when neglected, often terminates in sloughing of the cornea, or permanent opacity of that tissue. This disease commonly sets in the second or third day after birth, and commences with increased vascularity of the conjunctiva lining the eyelids, which latter become swollen and permanently closed. The inflammation soon extends to the conjunctiva of the eyeball — the swelling of the lids increases very much, and a copious discharge of thick, white, purulent matter ensues. If we attempt to open the eye at this period, a gush of matter takes place, and, frequently, the lower lid is everted, exhibiting its internal surface highly inflamed and of a bright red colour. In some severe instances, the tumefac- tion of the lids is so great as to cause eversion without its being the result of an attempt at opening the eye. We can seldom get a view of the cornea, as the intolerance of light is so great as to cause a 154 ACCIDENTS AND DISEASES AT BIRTH. turning upwards of the eyeball upon every attempt at separating the lids. Some difference of opinion prevails as to the cause of purulent ophthalmia. It is attributed by many solely to a specific infection communicated during the birth of the child ; while by others it is supposed to be a species of epidemic ; and others, again, attribute it to cold, or the stimulus of too much light. It is probable that any one of these causes may occasionally produce it ; but our own expe- rience certainly goes in support of its usually being the result of infection, as we have, in a large majority of instances, traced it to a gonorrheal or leucorrhceal discharge existing in the mother before parturition. The prognosis is usually favourable, if the case be seen in time, and carefully attended to ; but it has too often happened to us to be first called upon when sloughing or opacity had already taken place. The treatment of purulent ophthalmia has been conducted upon very different principles by different practitioners. The violence of the inflammation has induced some to apply a leech to the lid or temple, in almost every instance, and to repeat the application as often as three or four times. We have, however, but seldom found it necessary to draw blood at all ; and the most protracted examples of the disease, we have seen, have been those in which leeching was repeatedly employed. It has frequently appeared to us that the loss of blood by two or three leeches — (it is to be remembered that we are treating an infant two or three days old) — produces such general and local debility as favours very much a protracted continuance of the discharge, merely by causing relaxation of the inflamed vessels. It is only then, in an extreme case, when the inflammation is very rapid and violent, and the child strong, that we would venture upon the application of a leech. Our common plan is to employ astringent or stimulant collyria from the commencement ; and by the use of these, and the most scrupulous attention to cleanliness, we have generally been successful in saving the eyes. The kind of collyrium to be used is not of great consequence. A very good formula is six grains of alum to an ounce of rose water ; or three grains of sulphate of zinc to the same quantity of rose water. We generally prefer collyria of this description to those composed of nitrate of silver. Much benefit has, however, been derived, in chronic cases, from the use of a strong solution (say ten grains to the ounce) of the latter substance in distilled water. A drop or two of the collyrium should be introduced into the eye three or four times a day ; and the dis- charge should be frequently removed by dropping from a sponge, or injecting between the lids, lukewarm water, or chamomile tea. Without attention to cleanliness, and removal of the discharge in this way, any treatment we can adopt, whether energetic or mild, will be quite inadequate to the safe management of the disease. When the inflammation is severe, and the lids adhere strongly together, a poultice of bread and cold water enclosed in a muslin bag, and applied between the periods of washing, will be found of great service. The application of the solid nitrate of silver to the inflamed PURULENT OPHTHALMIA OF INFANTS. 155 eye has been tried by some, and no doubt often with benefit ; but we are never desirous in our practice of trying what can be done with impunity, but rather of safely removing a disease with the least possible artificial interference. In conjunction with the local treat- ment, we must attend to the condition of the child's bowels — and will generally perceive a necessity for aperients, and if the intestinal discharges be unnatural, for small doses of hydrargyrum cum creta as an alterative. Should the discharge begin to decrease, we must continue our attentions to cleanliness, and persevere in the use of the astringent collyria, as the disease is likely to relapse. Even when considerable opacities of the cornea remain, in severe or improperly treated cases, so active are the absorbents of the child, that we shall frequently find the speck gradually to disappear. Many cases of the purulent ophthalmia of infants depend upon the state of the con- stitution, and are consequently only removable by an improvement of the general health. We have known change of air or change of nurse, especially the former, to act like a charm in the cure of this disease. The following remarks on this important subject will be read with the interest which attaches to every contribution to ophthalmic surgery, from the able pen of Professor Jacob : — My dear Maunsell, You ask me to give my opinion as to the treatment of the purulent ophthalmia of infants, for insertion in the edition of your's and Dr. Evanson's book on Diseases of Children, now going through the press. This I can do without adding much to the bulk of your volume, or imposing much labour on myself. In fact the matter appears to me to be in a nut-shell. If we can prevent or stop the slough, abscess, or ulceration of the cornea, whichever it is, or what- ever we call it, we do almost all that is required, nature sooner or later does the rest. This, however, is the great difficulty, and I am skeptical as to our power to overcome it. As in other diseases medi- cal men, with great confidence and composure, attribute the success- ful issue to their treatment, when the recovery is a natural result, and, perhaps, even a result obtained by the operation of natural causes in defiance of the counteracting influence of art. I wish those who boast of their " cures " would have the goodness to let us know how many per cent, of this disease recover if not meddled with at all. If we knew why the cornea suffers this destruction in this complaint we might, perhaps, suggest a remedy with more confidence ; but of this we are entirely ignorant notwithstanding plausible theories and hardy assertions. We are told that this structure gangrenes or sloughs, because its vitality being lower than surrounding parts, it cannot resist the consequences of that inflammatory action which other textures bear with impunity, which is, after all, a mere begging of the question. What grounds have we for assuming that the vital functions are less energetically or effectually exercised in this piece of organization ? On the contrary, we have good grounds for believing 156 ACCIDENTS AND DISEASES AT BIRTH. that its powers of life and growth are of the most active kind. In general inflammation of the eyeball commonly called iritis, the cor- nea is more implicated than in this inflammation of the conjunctiva, yet we do not find it gangrene or slough. All we know, I believe, is that in this disease the cornea often suffers from gangrene, abscess, or ulceration, one, or both, or all three, and that the consequence is cicatrix or opacity, more or less destructive to vision. As you have argued in a preceding paragraph, neither the results of the treatment, nor the reasoning upon which it is founded, are conclusive as to the value of bloodletting in this disease. We are prejudiced in favour of this resource in all inflammations, because we see its value in many ; but I am sorry to say in inflammations of this mucous membrane, and, perhaps, of mucous membranes in general, we have no reason for being very sanguine as to its decisive beneficial influence. If an infant be vigorous and full of blood I would apply a leech or two, and allow the bites to bleed until vas- cular action is enfeebled, but more with the view of reducing the inflammation of the lids, and thereby diminishing the tumefaction and consequent pain, than the hope of preventing the formation of the slough, abscess, or ulceration. On the contrary, if we are to look on the mischief, as gangrene or slough in the first stage, we have good reason for fearing that the debility produced by depletion may contribute to that consequence. It has been proposed, and many, I believe, practise it, to drop a strong solution of nitrate of silver into the eye even in the first or active stage of inflammation, with the view of preventing the sloughing of the cornea. How such an effect can be expected to follow such a cause, I cannot understand, but the advocates of the remedy will tell me they do not pretend to explain why it is so, but to state that it is so. Now this is not quite so cer- tain as they suppose. That many babes escape blindness who are thus treated I admit, but whether they escape in spite of it, or in con- sequence of it, is another affair. If I had a child of my own suffer- ing from purulent ophthalmia, 1 am sure I would not put strong solution of nitrate of silver into its eyes in the first or inflammatory stage. I find it inculcated that the purulent discharge should be constantly carefully removed, and directions are given for syringing and wiping the lids to free them from it. If this advice be given from a belief that the purulent matter is injurious to the inflamed surface, or unfit to form a covering for it, the notion is surely a mistaken one. The purulent matter is nature's dressing, and the art of man has never invented a better or as good a one. It may, perhaps, give trouble from its accumulation, should the lids be glued up by its drying on their edges, but that it scalds or irritates the eye cannot in my opinion be admitted. It may be well, whenever the baby awakes, just to draw the lids gently up and down, and delicately to squeeze out the matter which has gathered during sleep, and then to wipe it off the skin with a soft sponge, but to wash it all out with a syringe, or brush it off with a hair pencil, is what I would forbid. After the period of active inflammation has passed, and that the profuse puru- RED GUM. 157 lent discharge constitutes the principal, if not the only cause of an- noyance, it must then be stopped, and this, I believe, may, in the great majority of cases, be effected by the solution of nitrate of silver, ten grains to the ounce of water, or if this be ineffectual, fifteen or twenty may be employed without danger. Before dropping the solution into the eye the purulent matter must, however, be removed. This I effect by gently pulling open the lids, and then squeezing them together, after which I drop some lukewarm water between them, out of a hair pencil, and squeeze them gently again, then I let the baby become quiet, and suddenly raising the lid drop in the solu- tion. Next to the nitrate of silver solution I prefer that of alum ; it has more astringent with less stimulating qualities than, perhaps, any other. Five grains to the ounce of water may be employed for common use, and the saturated solution once in the twenty-four hours. I believe strong solutions of nitrate of silver are sometimes resorted to, and other active remedies adopted, with the view of preventing the enlargement of the palpebral glands, commonly called granular conjunctiva. I have even heard of the solid nitrate of silver being rubbed to the inside of the lids for this purpose, which I hope is not the case. As far as my experience has gone, the mucous glands of the conjunctiva lining the eyelids, do nor become enlarged from in- flammation at this time of life, and therefore the so-called granular conjunctiva is not to be feared from this disease. In fact, as I have said before, if the cornea escapes from the destruction which some call slough, and some call abscess, but which may, perhaps, be either or both, and the consequent ulceration, nature sooner or later effects the cure. I do not here enter on the treatment of the slough, abscess, or ulcer of the cornea, the prolapsed iris, the opacities or the staphy- loma which take place in this disease, because I am sure that the safest course to be pursued by the accoucheur when any of these occur is to hand over the case to the management of a good surgeon, who understands the treatment of it. He will gain little credit should the case recover perfectly, and must bear all the blame should it be otherwise. Believe me, Yours, very truly, A. JACOB. Dublin, Oct. 1, 1841. XIX. RED GUM (STROPHULUS INTERTINCTUS). Almost every infant is affected three or four days after birth, with an eruption of papula?, which has received the foregoing appellations. In its ordinary form this consists of a few red pimples, appearing in greatest number upon the face, neck, and hands, and interspersed with diffused red patches. When there is a slight degree of redness a distinction has been made, and the eruption termed strophulus 14 158 DENTITION. albidus ; and a rash of the same nature which occurs during denti- tion in larger quantity and with more irritation has been termed strophulus confer tus. The ordinary red gum of infancy can scarcely be called a disease. It arises probably from the slight irritation at- tendant upon the new circumstances under which the skin and mucous membranes are placed, and requires no treatment. The nurse constantly looks for its appearance as a favourable occurrence ; and we believe it merely indicates a healthy state of sensibility of the integuments and mucous membrane. XX. SWELLING OF THE BREASTS. The breasts of infants, both male and female, contain at birth a secretion somewhat resembling milk, and which is generally sup- posed by the attendants to require speedy removal. Accordingly, they frequently set about pressing the part until inflammation, and occa- sionally an abscess is produced. This notion, however, is altogether erroneous. No measure for getting rid of the secretion is necessary ; and we should forbid any attempt at adopting one. We have re- peatedly had to open an abscess produced by pressure, in the way alluded to, but which, nevertheless, was always attributed by the nurse to the want of sufficient removal of the fluid in question. CHAPTER VII. DENTITION. Absence of teeth has already been remarked as a character be- longing to the mouth at birth. Infants, however, have been born with teeth ;* while in a few instances none have ever grown. The first appearance of teeth usually begins about the sixth or seventh month. It may be much earlier, as the third or fourth month ; but oftener is delayed to a later period ; the age at which the teeth first begin to appear varying much, and often without any apparent relation to the constitutional powers of the child. The process is commonly completed during the first year, or year and a half; but may be pro- tracted beyond the second year. * When teeth are in the gums at birth (usually the central incisors of the under jaw), they occasionally cause distress by irritating the tongue during the act of sucking. In such cases, their edges, when sharp, may be filed down ; or the teeth themselves extracted. But unless inconvenience arise, it is well to leave them undisturbed ; for they are not always, as stated by Mr. Fox, merely the upper parts or crowns of teeth, without fangs. DENTITION. 159 The number of the first set, or milk teeth, is 20 ;* and they make their appearance usually in pairs, — those of the lower jaw coming out before the corresponding pairs of the upper; and a degree of uniformity is to be observed in the order and times of their appear- ing. The middle incisors are those that first come out; then come the lateral incisors, and after these the anterior molars ; but not uni- formly (as some assert), for the canine teeth occasionally precede. The posterior molars are the last to appear, at a period varying from the 20th to the 30th month. Mr. Bell (in his Treatise upon the Teeth) expresses these facts, as to the appearance of the teeth, in the following tabular form: — From 5 to 8 months the four central incisores. From 7 to 10 do. the four lateral incisores. From 12 to 16 do. the four anterior molares. From 1-1 to 20 do. the four cuspidati. From 18 to 36 do. the four posterior molares. In the foetus the rudiments of the teeth are observable about the second or third month ; and are found (as they advance in size) to consist of a double membranous sac. From the bottom of this arises a pulp, which is composed of nervous and vascular matter, and around which is found a colourless consistent fluid, which is gradu- ally absorbed as the pulp increases in size. On the summit of this pulp (upon which the future tooth is moulded) ossification becomes visible about the end of the third month. The enamel is not formed until afterwards, which it most probably is by secretion from the vascular membrane lining the sac.t The groove or channel which had run uninterruptedly along the edge of the jaw-bone, now becomes divided by osseous septa, which grow across ; and thus the alveoli are formed. At birth ossification is already advanced in most of the first set of teeth ; much of the crowns of the molars are formed, and those of the incisors are in general completed. Subsequent to the ossification of the crowns of the teeth, that of their roots takes place ; and as ossi- fication advances, the roots of the teeth continue to elongate, until first those of the incisors, and subsequently others, can no longer be contained within the alveoli, and the tooth is thus pushed upwards, * 4 Incisors in each jaw, 8 2 Canines, 4 4 Molars, 8 —20 In the second set there are — 4 Grinders additional in each jaw, 8 2 Dentes Sapientiae do. 4 —32 Just previous to the temporary shedding of any of the teeth there are no less than 48 teeth, at one time, in the two jaws: namely — Deciduous teeth (all perfected), 20 Permanent do. (more or less perfect), 28 —48 f According to recent researches, (by Mr. Nasmyth and others,) the tooth is formed by conversion of the vesicles or cells of the pulp, into the cells or fibres of the ivory, by the deposition of osseous matter. 160 DENTITION. the development of the alveoli themselves aiding in the process. The consequent absorption of the surface of the gum, and the apex of the enveloping sac, at length makes its way for the appearance of the tooth, which is then said to be cut. This process is a natural one, and does not necessarily lead to dis- eased action ; but such is liable to occur in consequence of the irrita- bility of the infant constitution, which is at this time particularly re- markable, as well as the proneness to sympathetic disturbance. Some irritation must attend the passage of the tooth through the gum ; and this is caused both by the pressure of the crown of the tooth on the parts above, and of the root on the dental nerves below. Hence arises pain; and to this we are to attribute, as a chief cause, the morbid sympathies that accompany dentition. The degree to which these may amount, however, depends more upon the state of the infant at the time, than the extent of local irritation caused by the tooth ; for we see what little suffering attends upon cutting the large double-teeth compared with the small ones, which preceded them at a time when the susceptibility of the infant constitution was at its height. Certain symptoms must naturally accompany dentition, however favourably it may proceed ; and the attendant determination of blood to the parts contributes to these. Saliva flows in increased quantity from the mouth when a child is teething, and the gums are more or less swollen, hard, and hot. Thirst appears to be felt ; for the child takes the breast more frequently, though for shorter periods than usual, dropping it, as if from the tender state of the gums — but the fingers, or whatever it can grasp, are often thrust into the mouth. The child is frequently fretful or peevish, and gets sudden fits of crying, or starts in its sleep, which is liable to be disturbed. The cheeks are occasionally flushed ; and increased heat, or pulsation, may be felt about the head. A tendency often exists to disturbance of the stomach or bowels, the food being rejected ; or slight diarrhoea attends. These symptoms, however, are not to be looked upon as constituting disease, but in general work their own cure, the local excitement being relieved by the inordinate flow of saliva, and the constitutional disturbance by the attendant diarrhoea ; while some of them are obviously but indications of an increased activity in the process of ossification, as they often precede the appearance of the tooth by many weeks but subside again in some days, from eight or ten to fourteen. This may be looked upon as the first stage of den- tition ; and is called, in popular phraseology, "breeding the teeth." The symptoms again occur, but in a somewhat modified form, when the tooth begins to approach the surface of the gum. The relation which subsists between dentition and disease, as arising directly therefrom, or merely complicated therewith, is most important; and upon a right understanding of this, will depend our success in the management of children while teething. On no sub- ject does more misapprehension, in common, prevail. All complaints occurring about this time are attributed to dentition as their cause, and hence are frequently mismanaged, being altogether neglected as salutary efforts of nature, or attention paid only to the state of the DEXTITIOX. 161 gums ; yet the just medium seems sufficiently obvious. Whenever a child is ill about the time at which the teeth may appear, we should carefully examine the gums, to ascertain how far the symptoms may be connected with their' state ; and act accordingly. But attention is not to be confined exclusively to the gums, nor are we to rest satisfied with remedial means directed thereto. The illness may be merely an accidental complication, or, even if connected with teething, may require active treatment on its own account. In a word, neglect of the state of the gums may render our other treatment unavailing, or attention to this alone, prove inadequate. The morbid phenomena so often witnessed during dentition are influenced, first, by the degree of irritation caused directly by the teeth : secondly, by the degree of susceptibility of constitution existing at the time: — the age and condition of the child affecting both. The more suddenly the teeth are developed, and the greater the number coming out together, the more will be the local irritation, particularly should any obstacle be presented, as a disproportion between the rate of development of the teeth and the jaws, &c, &c. The earlier the age at which dentition commences, the severer is likely to be the constitutional disturbance, from the greater suscepti- bility of the system ; for the natural susceptibility is heightened by the rapid evolution which the brain is undergoing at this early period, in addition to which, there is local determination of the blood, caused by the process going on : so that the nervous system is in the highest state of irritability: hence is symptomatic disturbance of all parts, but more particularly of the brain, so liable to be induced at the time of teething. The proneness to this will be increased by any thing that tends to deteriorate the general health, as the injurious effects of improper food, bad air, &c, &c. Delicate children suffer more con- stantly than the robust, their dentition being tedious ; and in them, bowel complaints, with wasting, frequently attend. Any complaint, in short, to which a predisposition may have existed, is likely now to be developed : and any disease contracted at this time (as measles, pertussis, &c), is attended with additional danger. Dentition is, however, no longer regarded by the well-informed practitioner, as a universal source of infantile disease ; and we shall treat only of such complaints as are to be traced distinctly to this source, resting satisfied with a general notice of its incidental relation to other maladies. Many of the symptoms caused by dentition are truly nervous ; but inflammatory aflections do often arise from, or are complicated with it. The local symptoms of irritation in the gums are at times severe : and here, in truth, lies the origin of all the others. There may be much swelling, heat, redness, and pain in the gums, which will be so tender as not to tolerate the slightest pressure. This most usually occurs on the first irritation, during the "breeding of the teeth ;" and the redness of the whole gum is then often very intense. At a later period, when the tooth is coming forward, the sensibility undergoes a modification, and pressure gives ease rather than uneasi- ness, the redness being now confined to the base of the gum, the sur- 14* 16 o DENTITION. face being white, or looking like a vesicle stretched over the tooth. Aphtha? or ulceration may be present, and the cervical, or more usually the salivary glands, enlarged and tender, accompanied by a very profuse flow of saliva. The determination of blood may extend further, and engage the head, which will be hot and heavy ; the cheeks red and swollen ; and the eyes suffused and watery. Great thirst, heat of skin, restlessness and alternate heaviness, with disturbed sleep, or sudden startings therefrom, now attend. This symptomatic fever is remarkable for its suddenness and variableness, often recur- ring and remitting within a few hours. Distant organs soon become implicated in a marked manner, and suffer sympathetically, either from inflammatory disease, or mere nervous disturbance. Acute inflammatory affections, wholly independent of dentition, may occur during this process, which predisposes to them ; but no doubt can exist that many such affections are directly connected therewith, as they rapidly subside when the irritation in the gums is mitigated, but are little relieved by any means, so long as this subsists undiminished. The treatment of such cases requires no modification beyond the necessity for paying primary attention to the state of the gums. Nervous disturbance of various organs still more frequently arises in connection with dentition ; and upon a correct diagnosis between these and the inflammatory affections, will depend much of our suc- cess in practice. Some of these secondary affections appear to be rather of a salu- tary character, as if efforts of nature to afford relief by counter-irrita- tion or derivation, as we see in the abundant flow of saliva, and lax state of bowels, so constantly attendant upon teething. Suddenly suppressing these is certainly dangerous ; and so long as they retain their merely sympathetic character, little should be done to interfere ; but we are by no means to fall into the popular error, that treatment for such is never to be adopted, and so allow children to die of purg- ing or vomiting, because they are getting their teeth. The mucous membrane is the tract most liable to suffer from these secondary affections, and the gastro-intestinal mucous membrane is that most frequently affected. The brain and nerves, however ; the lungs, the skin, and the lymphatic glands, are all subject to this irritative dis- turbance; and we remark that occasionally the urine becomes pale and copious, as it is observed to do in the nervous affections of adults. It is at times, however, scanty and turbid, and passed with difficulty when fever is high and the bowels, in particular, much disordered; or a purulent discharge may take place from the urethra, and great pain attend the passage of the urine. Symptomatic disturbance of the brain or nerves often induces sleeplessness, or very uneasy slumbers, with startings and sudden awakenings out of sleep, the child screaming and looking frightened. If there be grinding of the teeth, with tremor or rapid motions of the lips, convulsions are likely to follow, particularly if the fever be high, and bowels costive. These symptoms may depend on mere nervous excitement, or arise from congestion, or be connected with derange- DENTITION. !63 ment of the digestive organs. Indeed in all severe affections of the bowels, the brain is certain, sooner or later, to participate : but the brain itself may be the seat of disorder without the condition of the bowels, becoming necessarily disturbed. The convulsive movements are often confined to mere twitchings of spasmodic motions of the face, eyes, and arms, and in such cases are not so dangerous as is commonly thought. In no case, however, are they to be neglected ; for great danger attends when they become general, violent, and frequent. Death may take place suddenly, as if by apoplexy ; or an incurable paralysis be the result, as we have more than once witnessed. In these as well as other instances of cerebral affections in the child, we should bear in mind that a state of exhaustion, as well as plethora, may give rise to the symptoms ; and search out the cause accordingly. An affection of the hands and feet has been described by Dr. Kellie, of Leith as connected with dentition, in which a spastic contraction of the flexors of the thumbs and toes is a principal character ; but a peculiar swelling of these parts also mentioned by him, shows it to be an affection before described by Underwood. This swelling arises suddenly, is of a mottled or purplish hue, very round and elevated, and cooler than the surrounding skin. It may last some weeks, but usually terminates favourably in a few days, ceasing spontaneously when the tooth appears. Of the spasmodic affections connected with dentition, those of the respiratory organs are especially formidable, as spasm of the glottis, &c, &c. The most frequent of these, however, is the dry, nervous, irritative cough, that so often attends dentition, and which is sure to be aggravated by any derangement of the bowels. This, like all the other symptoms dependant on irritation in the gums, will be mitigated, or at once removed, by the liberation of the tooth. Diseases of the skin often occur during dentition, being popularly denominated " tooth rashes," but we should not look upon such as arising directly therefrom, unless they appear or disappear in relation to the condition of the tooth, which they do occasionally in a remarka- ble manner. Affections of the lymphatic glands appear to arise rather in conse- quence of the debility induced by teething, than directly from the irritation caused thereby. Guersent, however, appears to look upon the early and rapid development of the teeth as occasionally the cause of tubercle and such affections ; a view nearly the reverse of that of Gardien, who considered very early dentition as caused by a scrofulous diathesis. To this view we ourselves subscribe ; having observed that not only is the appearance of the teeth likely to be precocious in scrofulous infants, but that this process is mostly unfavourable in such ; especially when the strumous diathesis is marked by external signs, as deficiency of ossification in the bones of the head, chronic hydrocephalus, &c, &c, — so much is dentition influ- enced by the congenital condition of the constitution. By far the most frequent of the symptomatic affections attendant upon teething are those of the stomach and bowels, which therefore 164 DENTITION. we have reserved for last. Purging or vomiting often attends denti- tion. The purging is characterized by being unaccompanied by pain on pressure ; the tongue is moist and white, not red or dry ; the appetite remains unimpaired, nor does the child lose flesh. Acidity, however, and flatulency, with griping, frequently attend, when the stools are green, and smell sour, as does also the breath. Vomiting is often conjoined with purging, during dentition, and may be, like it, merely symptomatic ; but when they are carried to a great degree, this combination is a most formidable one, and often proves fatal. M. Cruveilhier has described a disease of this kind, as also M. Guersent (though with some difference) ; but we cannot agree with them in regarding it as necessarily connected with dentition, though often appearing at this period, as we have seen it prevail at times quite as an epidemic, and must regard it, with Dr. Joy,* as a species of cholera morbus. This disease, which German writers denominate gastro- malacia infantum, requires very decisive treatment, and will be noticed in the proper place (see Cholera Infantum) ; but we should be cautious in interfering with the slight purging and vomiting that so often attend dentition, so long as the child's strength remains unimpaired, and no signs of inflammation make their appearance. Treatment. — The management of the morbid conditions connected with dentition is in nothing peculiar, beyond what concerns the local treatment of the teeth and gums, which we now proceed to consider, — leaving the diseases in question to be treated of each under its proper head. When dentition proceeds favourably, as a natural process, little interference is required. Generally speaking, the child should be kept calm and cool (more especially the head), and much in the open air ; the bowels rather free ; and great care taken to avoid overload- ing the stomach, or giving stimulating food. And this precaution is as important to attend to with respect to the nurse as the infant. Exposure to cold air should be avoided, inflammatory affections being very liable to occur at this period. As dentition advances, or on its completion, the child usually suffers somewhat in its general strength, and will require improvement of diet, as the occasional use of a little weak chicken broth, &c, &c. ; the object being to keep the system at a just medium. Dr. John Clarke especially recommends sponging the head daily with cold water. So long as no particular irritation or suffering exists in the gums, the less they are interfered with the better. Something, however, will always be done, and it is well to understand what that should be. One of the first symp- toms of teething is tenderness of the gums, which are often so sensi- tive as not to tolerate any pressure ; the child attempts to put things into its mouth, but appears to be hurt ; and, at this time, such should not be supplied. Gentle friction with the nurse's finger soothes the gums most : and if they are very hot, the finger may be previously dipped in cold water, or other fluid, that has been sweetened. * f ee " ^ entition >" Cyclopedia of Practical Medicine — one of many excellent articles by Dr. Joy, to which we shall have occasion to refer. DENTITION. 16 5 At a more advanced stage, as the tooth is coming forward, the mode of sensibility seems altered, and pressure on the gums gives satisfaction, so that the presence of hard substances is enjoyed. This is the period for corals, ivory rings, &c, &c. The latter, from their shape, are less liable to hurt than the former, and should therefore be preferred. Some particular virtues have long been ascribed to a ring of gold ; but, even if not too expensive for common use (it should be large, to be safe), the reasons assigned for its utility are unfounded ; as we cannot agree with Mason Good, that because ptyalism followed friction of the gums with powder of gold, in the experiments of Dr. Chrestien, of Montpelier, such effects are to ensue from the use of the metal in form of a ring. The production of an increased flow of saliva is attempted, in some parts of Germany, by the use of little bags of spice and sugar ; while in France they dip any substance used in honey, or sweet decoction of barley, as being relaxant to the gums. Such practices succeed in occupying or soothing the child ; but mis- chief arises from stimulating or overloading the stomach and bowels with sweets or spices. A good and simple plan is, to allow a child the use of a small wax candle, or occasionally a stick of liquorice root ; but, in truth, a crust of bread answers all useful purposes. When much local irritation prevails, and the gums become very hot, tender, and swollen, the tooth may be obviously on its way, to pro- trude. The local treatment is now the most important point, often removing the necessity for any other ; and without it, all other means may prove ineffectual. To relieve the tension, and remove the irri- tation, is our object, and the gums should be scarified ; but there are two purposes for which this may be done, and according to which the operation will vary. We may wish merely to draw blood, which will be done by scarifying the gum freely, but not deeply ; this may be advisable in the first stage of irritation, and before the tooth appears to be coming forwards. Such practice, however, is not often required ; and we should never omit to explain our object, as a tooth is always expected to appear soon after the gums are scarified, and in this instance disappointment only would ensue. When our object is to open the gum so as to free the tooth, our incision must be made freely and firmly through the gum and capsule, until we feel the instrument grate upon the tooth. If it be a molar tooth, the incision should be crucial, or double, so as to enclose a small flap, which some advise to be cut out, but this is seldom required. The child's head should be held firmly by an assistant, while the operator stands before or behind, according as the tooth is in the under or upper jaw, and with the fore-fingers of his left hand keeps the tongue and cheeks out of the way, while he makes his incision longitudinally with a gum- fleam.* The instrument should be sharp and clean, and no fear need * It is often difficult to make a child open its mouth, and it may be well to men- tion the plan we have found most convenient: by pressing firmly with the finger and thumb upon each cheek, we never fail to separate the jaws ; and, in children who have already cut the front teeth, we can keep the mouth open, and prevent our - 66 DENTITION. be entertained of ulceration. The bleeding that follows always does good, nor need apprehension be entertained about hemorrhage. The operation is scarcely attended with pain, and is followed by quick relief; but the tooth will not always immediately appear, even though the capsule be opened. A repetition of the operation is not unfre- quently required ; but when the local distress is relieved, the mere absence of the tooth is not a sufficient reason for its renewal. No one need suppose, that if a cicatrix be formed, it tends to retard the progress of the tooth, by its callosity, — the fact being, that newly cicatrised parts are those most easily absorbed. This operation should never be omitted when the local irritation runs high ; and its prompt employment will always mitigate, and often remove, any attendant symptoms, particularly if merely sympathetic, or of the nervous class ; even when inflammatory, relief is afforded, and the usual treatment will seldom require to be pushed so far afterwards as in ordinary cases of like inflammation. II. SECOND SET, OR PERMANENT TEETH. The first set of teeth begin to fall or be shed at about seven years of age, and are replaced by the second or permanent set, the whole of which are, by this time, more or less ossified, with the exception of the dentes sapientise, whose ossification does not, in general, com- mence until about the ninth year. This process of changing the teeth occupies from five to six years in its completion ; but is very variable both as to the time of its commencement and period of dura- tion, much irregularity altogether prevailing as to the age at which the different permanent teeth are cut. They may begin to appear" so early as five years old or not until eight, or eight and a half, and the termination of the process, or appearance of the third molares (dentes sapientiae), may be delayed to the seventeenth or nineteenth year. With the second as first set the teeth in the lower jaw generally pre- cede those of the upper ; and the first permanent molares frequently pierce the gum before the loss of the temporary central incisores — their appearance being in fact an indication of the approaching change. The immediate cause of this change in the milk teeth seems to be (according to M. Serres), the obliteration of the artery of these teeth, and its canal, which takes place about the seventh year, more or less completely, when the fangs and sockets become absorbed. The ascent of the second set contributes somewhat to the general process, by destroying the nerves and vessels, but does not do so directly, as might be supposed ; for the absorption of the root seldom if "ever commences at its extremity, but generally at some distance from it, fingers from being bitten, by turning a portion of the under lip into the mouth, be- tween their teeth and our own thumb. Dr. Blake recommends the incision to be made towards the external plate of the alveolar processes, so as to avoid injuring the connecting membranes and sacs of the permanent teeth. See Blake's Essay on the Teeth, p. 177. * DISEASES OF THE DIGESTIVE ORGANS. 167 often near the neck; while the permanent teeth have separate sockets of their own, and in consequence of the prolongation of the jaw-bones, which takes place at this age, do not lie immediately under the shedding teeth that correspond. Yet the presence, though not the pressure, of the new tooth is necessary, for in cases in which the temporary teeth remain, the corresponding permanent ones are found not to have been formed. In the foetus, we see the germs of the greater number of the second set lying behind or below the first. The increase in length and perfection in the articulation of the jaws makes a great difference between the adult and the infant in the powers of motion as well as in the form of the jaw. In the child the shape of the jaw-bones, anterior to the tubercle in the upper, and ascending plate in the lower jaw, is semicircular; and the articula- tion very imperfect (before the teeth are produced), the glenoid cavity little exceeding the condyle in size, and the articular eminence not yet being formed ; the centre of motion being in fact in the con- dyle, and the movements restricted to simple depression and elevation with hardly any approach to rotation — all id truth, that is necessary to the infant for the mastication of its simple food. In the growth of the jaw, the elongation takes place principally between the second bicuspides and the tubercle in the upper jaw, and the same teeth and the ascending plate in the lower ; in the situation of the permanent molares or additional teeth, and posterior to the temporary ones. The cutting of the second set of teeth is seldom attended with dis- tress ; and when local irritation does occur, it is little felt by the constitution, which has lost by this time its acute sensibility ; but occasionally much local suffering and consequent constitutional dis- tress, does attend, and the free use of the gum lancet is required. When the teeth come up very irregularly, and press against those before them, or protrude by their side, so that some of the same teeth of both sets are apparent together, extraction of one or more of the first set will become necessary ; but this matter belongs to the pro- vince of dental surgery, — as also the use of dentifrices, &c, which, however, children should be early taught to employ — at least, they should be instructed to brush their teeth once or twice each day, with a soft tooth-brush and water. CHAPTER VIII. DISEASES OF THE DIGESTIVE ORGANS. I. GENERAL OBSERVATIONS. The gastro-intestinal mucous membrane is, in particular, subject to disease even in the youngest infant, being easily irritated and often inflamed ; but an opposite state, or one of relaxation or mere debility, .•I DISEASES OF THE DIGESTIVE ORGANS. will be found not un frequently to be present, whether as a sequel to morbid conditions, or existing independently thereof. The mucous membrane may be affected through its whole tract ; or what is more usual, in one part only, as the mouth or stomach ; but fre- quently two or more portions are at the same time the seat of disease, gastto-enteritis being much more frequently seen than simple gas- tritis ; and of these parts some, as the small intestines, are much more liable to be attacked than others. Again, different structures may be separately engaged, as the serous or mucous membrane, or merely the mucous glands ; and hence will vary the name of the disease according to its seat, or the nature of the affection. Inflammatory affections are very common ; and the inflammation may be simply erythematous, or may lead to ulceration, exudation, softening, or gangrene. The ulceration may be of a common kind, or what is more usual, of an aphthous character; and exudation may take place as a con- sequence of this ulceration, or independently of it ; inflammation of mucous membranes having a peculiar tendency to the formation of such deposits in the child. Exudations upon the mucous membrane are of two distinct characters, either white and soft, being made up of the crusts of aphthous ulceration, or consisting of a peculiar secretion resembling milk or curd, and said to result from a particular form of in- flammation; or the exudation maybe firm and tenacious, truly consist- ing of an effusion of lymph. Any of these forms of disease may end in gangrene, or from the commencement show a disposition thereto ; but this is more likely to occur in ulcerative than inflammatory affections, particularly of the mouth and throat. In the mouths of children, in particular, we may witness every one of these affections of the mucous membrane ; and most of them may be seen in any tract of the intestinal canal. But some are much more liable to occur in certain regions than others, as aphthous ulcer- ation in the mouth, follicular ulceration in the ileum, and exudations in the pharynx or fauces, while a few are very rare in any. The mucous membrane of the mouth in children shows a disposi- tion to disease from the earliest age, and may be seen in a state of congestion at birth, or of inflammation almost immediately after. Ulceration, or exudation, are common consequences ; and are always attended with a degree of danger, even in the mildest cases, from their liability to spread, and so pass into the digestive tube, or en- croach on the air-passages. So long as the disease is confined to the mouth, even in severe cases, little constitutional disturbance is per- ceived if the infant be young. But these affections are seldom merely local, being usually complicated with gastric or intestinal disease, or symptomatic thereof. Hence constitutional treatment, particularly as regards the state of the bowels, is never to be neglected ; but atten- tion must not be confined to this alone. Not less important is the local treatment ; a prime source of danger, in such affections being (as already noticed) their tendency to spread. Hence no time is to be lost before trying to arrest their progress by topical applications. AFFECTIONS OF THE MOUTH, PHARYNX, ETC. 159 II. AFFECTIONS OF THE MOUTH, PHARYNX, ETC. Inflammation of the mucous membrane of the mouth — Stoma- titis — is not an uncommon disease among children; and maybe brought on by cold, stimulating or improper food, the too frequent use of the sucking -bottle, &c, &c, or may be symptomatic of a simi- lar condition of the stomach, or other part of the intestinal canal. The symptoms are heat, and redness of the lining membrane of the mouth, to a greater or less extent. The tongue and mouth are often dry ; the lips may be swelled and excoriated, or surrounded by an eruption ; and when the disease is protracted, and the infant but a few months old, a profuse flow of saliva occasionally attends. But there is seldom any appreciable fever, unless the infant has reached the fifth or sixth month, when such is usually present. Inflammation of the mouth, when slight and uncomplicated, is attended with little danger, and usually yields to mild emollient applications, such as mucilage of gum, decoction of barley, or, better, the linctus recommended by Boerhaave, and consisting of equal parts of mucilage of gum, white of egg, and simple syrup ; attention being at the same time paid to the state of the bowels, and care taken to remove any source of irritation, as in the nature of the food, the mode of feeding, &c, &c. When complicated with intestinal disease, or symptomatic thereof, the case becomes serious, and the principal attention must be paid to the more dangerous disorder. When a tendency to run into ulcera- tion, or sloughing, and to spread, is manifested, local applications, calculated to alter the morbid action, or arrest its progress, must be adopted ; as recommended in the following section. Inflammation of the mouth with ulceration — Ul§erous Stoma- titis. — Inflammation, if intense or protracted, soon leads to ulcera- tion, especially in children who are mismanaged, or placed in unfa- vourable situations, and whose general health is in consequence deteriorated. These ulcerations may be of a common character, or, what is more usual, of that peculiar form denominated aphthous, and long known under the general appellation of thrush. Symptoms. — The common ulcer is usually large and irregular in shape ; it is covered with a white or yellowish slough, and sur- rounded by much redness. These ulcers are seldom numerous — often single, and are situated on the inside of the cheek, the roof of the mouth, or may be found on the tongue. We have occasionally seen in infants at the breast, an ulceration of the gums of a very acute character; but which seldom occurs after the first year. The gum appears spongy, vascular, or of a purplish hue ; and the ulcera- tion often runs deep, being disposed to bleed, and assuming a green- ish or ash colour; but it is not liable to slough. It occurs usually about the period of first dentition. Much local irritation attends these ulcerations of the mouth, with fever, which occasionally runs high, and is accompanied by great restlessness ; the digestive organs being in particular deranged. 15 170 DISEASES OF THE DIGESTIVE ORGANS. Treatment. — In mild cases, it will be sufficient to touch the ulcerated surface occasionally with a linctus composed of borax or alum, from gr. v. to gr. x., dissolved in an ounce of honey of roses ; care being at the same time taken to regulate the state of the bowels, supply light but nutritious food, and expose the child freely to the fresh air. In severer cases, it may be necessary to have recourse to one or two applications of the nitrate of silver, lightly touching the ulcerated surface therewith ; but the local remedy from which we have uniformly derived most benefit in this and other forms of ulcera- tion of the mouth, even when the surrounding inflammation runs high, is the sulphate of copper. A linctus, consisting of ten grains of this salt recently dissolved in an ounce of honey should be applied two or three times a day by means of a camel-hair pencil. When the child is very irritable or restless, an anodyne will become necessary, and tonics, particularly quinine, must be had recourse to in protracted cases, or stimulants, as ammonia, when the strength begins to fail. The state of the bowels will of course be attended to, and the occa- sional exhibition of an emetic when the breath is foul and efforts made to vomit will be found useful. Aphthous ulceration — Vesicular Stomatitis. — The form of ulceration most commonly seen in the mouths of children is the small circular white ulcer, called aphtha, and which occurs with them in a truly idiopathic form (especially at the period of teething, being seldom seen before that time), and is not necessarily connected with any constitutional or other cause, as is always the case when they appear in adults. Most generally, however, aphthae arise in connexion with derange- ment of the digestive organs ; and are hence oftenest seen in children artificially fed, and whose food not being properly digested, becomes a source of irritation to the stomach and bowels. We also see aphthae appearing in the mouths of children sympathetically with disorder of some part of the intestinal canal, which is itself similarly affected. Thus, in the advanced stages of gastro-intestinal disease, aphthae may spread from the stomach to the mouth, or co-exist at the same time, in two distant parts, being visible at the verge of the anus as well as inside the lips — but this does not necessarily imply that the whole intestinal tract is occupied by the disease. When situated far back in the mouth or on the pharynx, aphthae are liable to spread downwards, either into the oesophagus or air- passages ; the former is most likely to occur ; but it is only in chil- dren much broken in health, or placed in crowded and unwholesome situations, that such in general takes place. Under these circumstances many children may be found affected with the disease at the same time ; aphthae appearing to spread epi- demically ; they are also capable of being communicated by direct contact to a similar structure, as true aphthae have been taken by kissing the lips of an infant affected with the disease ; but the nipple of the nurse does not seem to be affected with this form of ulceration, though often made sore or excoriated, from suckling an infant affected xvith the disease. AFFECTIONS OF THE MOUTH, PHARYNX, ETC. 171 Symptoms. — An inflammatory condition of the mucous membrane of the mouth does not appear to be a necessary antecedent to the appearance of aphthae, neither is the aphthous ulcer always sur- rounded by a red or inflammatory border. The mouth, however, is usually hot, and the child fretful and uneasy. The appearance of the ulcer is that of a small white spot or speck, occurring singly or in clusters, on some part of the mucous membrane of the mouth or throat. When single or few, aphthae are usually found on the inside of the lower lip, on the gums or on the tongue. When numerous or confluent, the inside of the cheek is often quite covered with them, or they extend backwards to the fauces. In these cases the aphthae become covered with a continuous crust or coating of a whitish hue ; but on this being removed, or becoming detached, the ulcerated points are visible beneath: and the secretion by which they had been covered, is quickly renewed. The whole process takes three or four days for its completion, from the bursting of the vesicle to the forma- tion of the crust and the cicatrization ; but a succession of single aphthae may continue for several days or even weeks. When two or more run together, or become confluent, they are much more slow to cicatrize ; and altogether an attack of aphthae usually runs a course of eight or ten days. The crusts, on being swallowed, become a source of irritation to the stomach and bowels, and it is thought that the disease itself may be thus propagated to these parts. The bowels are usually deranged when aphthae are present, being costive, and the secretions vitiated ; or frequently diarrhoea attends, and acidity of the stomach is present : but there is not in general much accompanying fever, especially if the child be very young. Difficulty of mastication or deglutition may attend, the child being unable to suck, and so becoming restless and peevish from hunger ; but we should specially note any alteration in the tone of the- voice, peculiarity of breathing, or the occurrence of cough. When aphthae present a yellowish or dark coloured appearance, we should be care- ful to examine whether this be caused merely by their being tinged with bile or blood, or is an indication of their assuming an unhealthy or gangrenous character. Such may be apprehended when we see, in very delicate children or protracted cases, crusts of this description succeeding to the white appearance at first presented. When aphthae do become gangrenous, the surface grows brown, being covered with a hard eschar, or one soft and pultaceous ; but when detached, the part beneath appears very red or granulated. The edges of the ulcer assume a torn, soft, or burned appearance, and the surrounding parts are soft and easily depressed, being swollen, and of a violet hue. As the disease advances, the mouth hangs open, allowing the saliva to escape, and a fetid odour usually attends. This condition is most liable to occur where aphthae are situated at the back of the fauces ; and seems to constitute that form of the com- plaint, known of old by the name of the black thrush, but which is not often witnessed except among the most wretched of the children of the poor. Diagnosis and Prognosis. — Aphthae are particularly character- 172 DISEASES OF THE DIGESTIVE ORGANS. ised by their small size, circular shape and white colour, appearing like small white round dots or specks on the inside of the mouth, and leaving a slightly depressed or ulcerated spot on the removal of this white covering or crust. So long as they retain this appearance, not showing any disposition rapidly to spread, nor the child's strength in any remarkable manner giving way, no apprehension need be entertained respecting the presence of aphthae, which are not attended with danger in themselves, even though numerous or of long stand- ing, though they may prove troublesome from liability to repeated attacks ; but when they show a disposition to alter their appearance, assuming any of the characters already pointed out as indicative of their taking on an unhealthy action, or when they proceed to spread along the pharynx, much danger is to be apprehended. In the first case we have not merely to dread the occurrence of gangrene, but must look upon the alteration in the appearance of the ulcers, espe- cially when occurring in the advanced stage of intestinal disease and accompanied by prostration of strength, as indicating a state of constitution in which recovery can hardly be looked for. When aphthae occur symptomatically, or during intestinal disease, they appear more on the fauces than in the idiopathic variety, and are in general an unfavourable symptom, but not necessarily a dangerous one, so long as they retain their healthy aspect, and the child's strength holds up. The extension of aphthae down the oesophagus, though a serious symptom, is of little moment, compared with the danger that attends the extension of the disease to the air-passages. When the child's voice becomes hoarse or indistinct, the breathing stridulous or spasmodic, with fits of suffocation and cough, immediate danger threatens, if indeed the case be not hopeless ; for those who have not witnessed it, could scarcely credit the small amount of ulceration that seems capable of destroying life, if once aphthae pass, or even reach, the rima glottidis. Pathology. — Aphthae in general are seen to originate in an erup- tion of small, white vesicles, filled with a gelatinous or puriform fluid, but unless watched from the first, the vesicles may be over- looked. Ulceration succeeds, or a crust is formed of a white, pultaee- ous matter, consisting in the first instance of the collapsed cuticle left after the bursting of the vesicle, and then of a thin layer of lymph or concrete pus, or even of a slight slough, which leaves, on being removed, an ulcerated spot beneath. M. Billard, however, represents aphthae as truly an ulceration of the muciparous glands, or follicles, which, becoming inflamed, soften in the centre, and ulcerate. But, as Dr. Benson justly observes in his valuable lectures (see Medical Press, vol. v.), " the superficial character of an aphthous ulcer is very different from the deep set ulcer of a mucous gland." Treatment. — When aphthae are merely a local affection, they may be often quickly removed by local means alone ; but in most instances attention must be paid to the general state of health, particularly the condition of the bowels; and a mild laxative will in some cases at once remove the disease. When the bowels are merely costive, a dose of castor oil will be sufficient for this purpose, but if acidity of AFFECTIONS OF THE MOUTH, PHARYNX, ETC. 173 the stomach, or derangement of the secretions, be in addition present, we must have recourse to the pulv. rhei et magnesise, or the pulv. rhei comp., as advised at pp. 126, 127. We should be careful, how- ever, to avoid irritating the bowels or stomach by the use of purga- tives or emetics, although an emetic may occasionally be serviceable at the commencement of the disease ; but when of long standing there is risk of adding to the irritation already going on in the mucous membrane. When diarrhoea occurs, or the aphthae appear during its presence, the chief attention must be paid to allay the irritable state of the bowels, and to support the strength when this begins to fail ; particularly when the aphthae assume an unhealthy aspect. Small doses of the hydrargyrum cum creta, with Dover's powder, may in the first instance be employed, and then the compound powder of chalk, with or without opium, according to the urgency of the symptoms. Regulation of diet or changing the nurse, attention to cleanliness, the occasional use of the warm bath, change of air, or at least free exposure to the fresh air, are essential in protracted cases ; or when aphthae are prone to recur. When the ulcers present an unhealthy aspect, we must early have recourse to the quinine mix- ture, and in the more advanced stages, the free use of ammonia will be found specially serviceable. The local applications to be used in the treatment of aphthae differ little from those recommended for the treatment of simple ulcerations of the mouth. The solution of borax in the first instance, and that of alum subsequently, will be found most serviceable — when the aphthae are few or very irritable, touching them lightly with nitrate of silver, will best dispose them to heal, and lessen their sensibility. In the more protracted cases we have derived signal benefit from the linctus of sulphate of copper. A solution of chloride of soda answers welL to correct the fetor when the ulcers show an unhealthy aspect ; but should sloughing actually occur, we must have recourse to the more decided measures required for gangrenous ulceration. Inflammation ivith exudation — soft — white — muguet or millet. — We occasionally see in young infants an inflammation of the mouth more or less extensive, but not appearing to be of an intense kind, which is attended by an exudation of a soft, white, cream-like or curdy substance, being disposed in specks or patches, or even covering the whole surface, (particularly on the palate or base of the tongue,) so as to give the appearance of the child's mouth being lined with cream or curd; on removing this substance, the membrane beneath is found red and shining, but unbroken, the secretion being external to the epithelium, and not the result of ulceration as in aphthae. M. Billard considers that in this instance the papillae of the mucous membrane in particular are the seat of this peculiar form of inflam- mation, which chiefly occurs in young infants antecedent to the time of teething, and may be even seen in those but a few days old. Our experience is, decidedly, opposed to his, however, when he says that aphthous ulceration is never seen in infants until the period of dentition. Aphthae may appear at the same time with muguet ; but we cannot agree with VVillan in regarding the latter as a vesicular 15* 174 DISEASES OF THE DIGESTIVE ORGANS, disease. Neither do we coincide with Billard in considering the exudation in muguet as merely concrete mucus, but rather as some peculiar deposition, intermediate in consistence between the soft crusts of aphtha? and the true tenacious lymph in diphtherite. This morbid secretion, to which the French have applied the term muguet, and to which perhaps belongs the English appellation white thrush, is seldom seen in this country, but appears, at all times, to prevail in the French hospitals where infants are crowded together and fed principally by hand. It is not, however, looked upon there as being contagious, even by direct contact, children being said to drink, with impunity, from the same cup with those affected by the disease. We have occasionally seen it in infants who were very delicate or ill fed ; and in one or two instances to such an extent that the white fluid exuded from the nostrils. The mucous membrane near the anus also may present a similar deposit ; or it may appear in the stools, for muguet, like aphthae, occasionally occurs in the tract of the intestinal canal, but much more rarely. Like aphthae, it may extend down the oesophagus or into the air- passages ; but it is not a disease attended with much danger ; neither have we any directions to give as to its treatment differing from those already advised for the management of aphthae ; except, per- haps, that the alum solution, in particular, seemed to us to exercise an effectual control in checking the tendency to the renewal of the secretion.* Inflammation ivith exudation — firm — tenacious — lymph — Angina membranacea — Diphtherite. — An inflammatory affection, intense in degree, and peculiar in kind, being attended by a pellicular exudation, may be seen affecting the pharynx, soft palate, or tonsils in children. This disease is not confined to children, but is seen more frequently in them than in adults, particularly in very young children that are unwholesomely fed and placed in low, damp situations. Under such circumstances, the disease occasionally occurs in the form of an epidemic, and appears to be highly contagious ; but is not a disorder commonly met with. It is very necessary to distinguish true diphtherite from other affections of the same parts with which it is confounded, as our chief chance of success depends on an early dis- crimination of the nature of the case, so as at once to apply remedies to arrest its progress. True diphtherite (as its etymology implies) is " a pellicular inflammation,"! or one attended with a membranous exudation; but unaccompanied by any breach of surface or ulcera- tion. It is, however, liable to be attended with gangrene or slough- * We may here remark, that whatever applications be used in those affections of the mouth, orders should be given to have them laid on gently with a feather or camel-hair pencil, not rubbed in with a piece of linen, as attendants will be sure to do, if not warned against their rude propensity for scrubbing the child's mouth, by way of making it clean — a certain method for aggravating the disease or even causing ulcers to slough. [Note to 4th Edition.] t For a full account of this disease see Bretonneau's work : — Des inflammations speciales du tissu muqueux, et en particulier de la diphtherite, ou inflammation pelliculaire, connu sous le nom de croup, &c, &c. AFFECTIONS OF THE MOUTH, PHARYNX, ETC. 175 ing, and this constitutes a variety of the complaint differing from the more acute or highly inflammatory kind, in which this termina- tion need not be apprehended, and hence this source of danger is removed ; but in both forms, the tendency of the false membrane to spread and enter the air-passages, constitutes a special source of danger in this complaint. Symptoms. — These will vary according to the form of the com- plaint, and this seems to depend much on the class of persons attacked ; the affection of the throat assuming more or less of the acute inflam- matory character in children that are well fed and robust, while it quickly presents the gangrenous aspect in the feeble, ill-conditioned children of the poor. In the acute form, we find the mucous membrane of the fauces presenting at first a bright red colour ; then quickly becoming stud- ded with specks or patches of false membrane, seen on the posterior pharynx, the tonsils, or the velum. This will assume the appearance of a continuous layer of a thin, white and smooth, concrete substance, when the inflammation is of a severe form, or in still severer cases, the lymph is deposited in masses of a grey or yellowish colour, pre- senting an irregular surface and of a soft consistency, so as easily to be detached but being again soon renewed ; the palate and tonsils in addition to being highly inflamed, being considerably swelled, yet deglutition gives little uneasiness, and the throat is but slightly pain- ful. In very mild cases, the disease nearly resembles muguet, the lymph being so soft or pulpy that it can be marked by the finger like concrete mucus, and this variety is hence caWedpultacea or caseiform. The constitutional disturbance is not in general great ; the skin is warm, but the pulse though full is not quick. Far otherwise are the symptoms, both local and general, in the other form of the disease, when it assumes the malignant type and is presented to us as an epi- demic of a fearful and fatal nature. The invasion of this form of the disease is often slight or hardly perceptible, the throat giving no uneasiness at first, nor presenting, when examined, any very marked redness — soon, however, diffi- culty is experienced in deglutition, and often liquids are returned through the nostrils, before there is swelling of the throat to any de- gree sufficient to account for this occurrence. The submaxillary glands, however, often become swollen and painful. The lymph thrown out on the inflamed surface in this form of the complaint is soon presented in the shape of a dense and extensive membrane, of a yellowish grey, or a dirty ash colour, and, when tinged with blood, appears from its dark colour, and the dreadful fetor that often ac- companies the disease, to constitute an extensive gangrenous slough. On accurate examination, however, this appearance is found to be altogether deceptive, no sloughing or even softening of the mucous membrane taking place, as is plain on detaching the false membrane, which leaves the surface beneath without any of the peculiar odour of gangrene : the fetor, however intolerable, arising solely from the detached membrane, which seems to undergo a putrefactive process. This distinction is so absolutely insisted upon by French writers, that we might presume such must be always the case ; but undoubtedly |7Q DISEASES OF THE DIGESTIVE ORGANS. the mucous membrane itself does occasionally slough, being found of ft deep ash, or even black, colour, beneath the detached lymph, and coming away therewith, until the throat presents a hideous chasm. Blood frequently exudes from the lips and gums, or an acrimonious discharge from the nostrils ; and the membrane may be so exten- sively deposited as to reach to the nasal fossae themselves ; portions being occasionally discharged with the acrimonious secretion there- from. It is the extension of the membrane into the air-passages, however, that in a particular manner constitutes the danger of this form of diphtherite, and this is certain to occur, if the progress of the disease be not arrested, or the patient does not first fall a victim to the malignant fever that attends the complaint. From the very commencement of the attack, a great prostration of strength and disorder of the nervous system usually attend. The skin is cool or only moderately warm ; and the pulse, though not rapid, is feeble. The general powers soon begin to give way in many of the severer cases, and in some the powers of life rapidly sink ; the breathing becomes hurried, delirium is succeeded by stupor ; the pulse grows very soft and feeble ; the patient dying, often unexpect- edly, in a day or two ; or at times even within twenty-four hours after the first invasion of the disease. So rapid a catastrophe, how- ever, is not the ordinary course of the disease even in fatal cases. The strength may hold up, and death be protracted to the tenth or sixteenth day ; with deceitful intermissions, especially in children who may be playing about shortly before death; which, in such instances, will be found to be hastened by some sudden extension of disease to the trachea. It may not be until the fifth or sixth day that the disease begins to assume a serious aspect, the breath becoming foul and the lymph thick and dark coloured, while the pulse grows soft and compressible. The bowels now also begin to be in a par- ticular manner affected, there being griping, with thin, watery, brown- ish stools, though without bile ; and occasionally nausea, vomiting, and tenderness of the epigastrium ; which certainly take place when there is any extension of the disease to the stomach. The symptoms increase in severity, and about the tenth day signs of sloughing mani- fest themselves, and our worst fears are too generally realised. When the fatal result is more directly connected with the exten- sion of the false membrane into the air-passages, we find symptoms of suffocation present. There is indistinctness or hoarseness of the voice, and a cough, frequent, harsh, and of a croupy sound ; the breathing becomes laborious and often convulsive, while the nostrils dilate, and the veins of the neck swell. As the case proceeds, the efforts to carry on respiration grow more feeble and languid ; the face assumes a pallid hue, the eyes are sunk, the chest heaves, and as the powers of life subsides, the child dies comatose or convulsed. When the membrane extends down the bronchial tubes (as it occa- sionally does), the expectoration is limpid and mucous ; the respira- tion gives a mucous sound ; the dyspnoea increases ; and occasionally shreds of the false membrane are spat up ; or even portions moulded, as it were, in the air-tubes, and bearing their shape. The form in which the disease presents itself appears to depend AFFECTIONS OF THE MOUTH, PHARYNX, ETC. 177 much on the class of persons attacked, or the situation in which it arises; the malignant form being that usually seen when the disease occurs in low, damp situations, and in the crowded habitations of the poor, among whose children it often spreads with frightful rapidity, attacking in particular those that are very young and weakly. The most robust children and best situated, however, are not safe from even this form of the disease, when spreading, as it does at such times, (generally during the spring months,) with the rapidity of an epide- mic, rather than merely as a contagious disease ; but in general, strong and healthy children suffer only from the acute form of the disease, which, if not severe in degree, is unattended with any par- ticular danger, as- the false membrane remains confined to the pharynx, without a disposition to spread farther down. Diagnosis and Prognosis. — The affections with which diphtherite is most likely to be confounded, are aphthous ulceration existing in the pharynx, the gangrenous sore throat, or muguet. It is not un- common to find aphthous ulceration in the situation described, denomi- nated diphtherite ; for with some every spreading ulceration at the back of the throat goes by this name ; yet, the distinction is at once obvious and easy, the ulcerated state of the mucous membrane, on removing the aphthous incrustation, distinguishing it from the merely inflamed condition of the same surface in diphtherite. Equally decisive is the distinction between gangrene of the throat, in which the mucous membrane is found in a state of slough or sphacelus, and that malignant form of diphtherite, in which this membrane, although it may be dark red or even livid in colour, is still found in a state of integrity on the removal of the putrid membrane. Even should the mucous membrane slough in diphtherite, the presence of the peculiar lymphy coating distinguishes it from simple gangrenous sore throat, in which, although spots of lymph may be deposited, no concretion takes place. The distinction between muguet and diphtherite is some- times not so easily to be made ; but the deposit in muguet com- mences in the mouth, and is not so continuous nor tenacious ; while the age of the child, and history and progress of the case, soon help us to a diagnosis. Our prognosis in this disease must be always guarded, and in particular we must take care not to be misled by the absence of any uneasiness in the throat in the first instance, but when diphtherite prevails, be particular in examining the fauces, the moment a child sickens or appears ill ; for in some instances the disease will be found to be decidedly established before any complaint has been made of the throat, and the worst form of the disease may commence in this insidious manner ; the malady being mGre dangerous when spreading as an epidemic than when occurring in isolated cases ; and also more fatal in very young children than in those more advanced. When the child is healthy, however, and the disease of the acute kind, but not severe in degree, there is no particular cause for alarm, for the thin white and smooth exudation does not in general show a dispo- sition to spread beyond the pharynx, and may be seen not uncom- monly as an accompaniment of scarlatina or measles. Even in the 17S DISEASES OF THE DIGESTIVE ORGANS. still severer form, where the lymph is thrown out in masses, as already described, there is not a tendency to spread to the larynx, though the deposition at times appears on the oesophagus. In very acute cases of the most healthy form, however, the false membrane will spread into the larynx, if not early arrested ; and in some in- stances its formation seems to occur almost simultaneously in the air- passages and on the pharynx, the croupy symptoms appearing to co-exist with the appearance of the lymph on the fauces : such a case we need hardly say must be almost necessarily fatal. In favour- able cases, on the contrary, the lymph is occasionally absorbed even without being shed, growing gradually thinner, so that the red papillae begin to appear through it like a veil ; or the lymph, when detached in patches, (as it usually is after a few days,) is renewed in a much slighter form ; and in a few favoured cases, does not again reappear. In the malignant form of diphtherite we have a double source of danger, a fever of the typhoid type being added to the almost certain affection of the trachea, for unless arrested in its pro- gress, the false membrane uniformly descends into the air-passages in this form of the complaint, which constitutes one of the most fatal and fearful diseases to which the child is subject. We are happily, however, not left without resources even in this formidable disorder, and although our prognosis must always be unfavourable, the prompt application of remedial means exercises a decided control over the disease. Even after the air-passages have become engaged, re- covery seems in some cases to have been effected. Pathology. — Having noticed so fully the nature of the deposition in this disease, and the condition of the mucous membrane connected therewith, it only remains to observe, that on the post-mortem ex- amination, the false membrane has been found extensively deposited, covering not only the parts visible to the eye during life, but ex- tending in some instances along the oesophagus, even to the cardiac orifice of the stomach ; and almost uniformly occupying the trachea, to a greater or less extent ; the bronchial tubes even not being free from its presence. The membrane is a deposit of true lymph, though varying in appearance and consistency, according to "the nature of the case. Hence, this disease has been looked upon as identical with croup by Bretonneau ; and Guersent seconds him in this opinion, which is, however, obviously to confound two distinct diseases, and fall into a grave error in practice. Treatment. — Passing over, in the first instance, any notice of remedies commonly employed in inflammatory affections of the acute or malignant kind, we at once inquire are there any topical applica- tions that, locally applied, are capable of altering the morbid action going on, and so arresting the progress of the disease, or destroying the false membrane when formed ; or do we know of any constitu- tional remedy that would give hope of success even after the disease had extended beyond the pharynx. To both queries we are able to answer in the affirmative ; but more reliance is to be placed on the topical than general remedy ; and early recourse to either is essen- tial to success. On the very first appearance of the affection of the AFFECTIONS OF THE MOUTH, PHARYNX, ETC. I79 throat, a strong solution of nitrate of silver (at least, gr. xx. to 3 i.) should be extensively applied by means of a camel-hair pencil, to the sound parts as well as those already affected, and repeated, to prevent renewal of the membrane, which, though it may be removed in the first instance, is still liable to recur. By this means the spread of the inflammation has been arrested, and the deposition of lymph checked, when the case was not of the worst form, and has been taken at the outset. We have seen a similar result attend the use of a saturated solution of sulphate of copper. In the more formidable form of the disease, or at a more advanced stage, however, a much more energetic application must be employed : and all agree in giving a preference to the application of the muriatic acid, undiluted, or mixed with one or two parts of honey. It is to be applied by means of a piece of sponge attached to the end of a probang, and pressed firmly against the inflamed part. By this means the membrane, even after it has become putrid, has been destroyed and detached, the acid occasionally requiring, however, to be applied a second or even third time ; this application exercising its influence specially in destroying the membrane, as the other does in preventing its formation. The administration of mercury so as to affect the system, is the constitutional mode of treatment which has been looked to for arrest- ing the disease, even after the membrane has spread. In very young children this result, however, can hardly be expected, but in the more grown the testimony in favour of this plan of treatment is so strong, that it should certainly not be left untried. When mercury has affected the system, we may look with confidence to an arrest of the progress of the disease towards the trachea, if not even to the staying of its course there, but the tendency to sloughing is not likely to be mitigated thereby, if not, indeed, the reverse ; and we must be careful to watch the influence of the mercury on the gums, as the fetor of the disease is likely to disguise the odour of the mineral, and so, excessive, if not dangerous, salivation be induced. As to common antiphlogistic measures, local or general, little reli- ance is to be placed upon them, even in the acute or inflammatory form, though a few leeches to the throat may be occasionally of ser- vice : bloodletting is not to be relied on, and often proves injurious ; and such measures are quite inadmissible in the other form of the complaint. An emetic, in the commencement, may be of use : and purgatives, according to circumstances; but we must early look to supporting the strength by nourishing diet ; and the administration of tonics and stimulants, as quinine and ammonia. Particular atten- tion should be paid to ventilation. Changing the child to an airy and healthful situation is always serviceable, if not. essential to recovery ; and we must insist on the necessity for at once removing healthy children from any place in which the disease has appeared. Gangrene — Gangrena Oris. — A particular form of gangrene of the mouth, without preceding inflammation or ulceration, occasion- ally attacks infants, especially such as are very feeble at birth, or ISO DISEASES OF THE DIGESTIVE ORGANS. broken down by disease ; but this disorder may occur in older children, from two to six years of age, when debilitated by ill health, or of a feeble, strumous habit of body ; particularly such as have suffered from worms, or live in low, damp situations in towns — the disease often appearing, indeed, to appertain exclusively to one locality. An oedematous circumscribed swelling appears on the cheek, with a central point more or less hard, over which occurs a dark red spot. This spot may appear on the inside or outside of the cheek ; and the skin over the oedematous part is characterized by an oily appear- ance ; while the whole cheek presents a deadly pale hue, and the oedema generally extends to the eyelids of that side, so as to close them. An eschar forms from within outwards on the central point ; and the soft parts mortify, often extensively, down to the bone, so that the parietes of the cheeks and gums are destroyed, — falling off in shreds, mixed with a dark sanguineous fluid, and accompanied by a very fetid odour. The pallid hue of the affected cheek is, in this disease, very characteristic ; but such an appearance is more or less to be observed in most cases of inflammation or ulceration of the mouth of children, as a natural consequence of the increased action going on within, and is the more remarkable when contrasted with a heightened colour in the opposite side — a circumstance judiciously pointed out, by Mr. W. C. Byrne, (see Medical Press, vol. iv., p. 182,) as an indication of morbid action, which should lead us to examine the mouth, although no complaint may have been made of that part, nor other indication of the disease given. No disease can be more frightful or formidable than sloughing of the mouth in children. Recovery seems impossible, when once the disease has set severely in, the child sinking beneath the constitutional disturbance, independently of the local ravages of the disorder, which, however, are often such as to render recovery not to be desired, so frightful is the deformity necessarily entailed : yet occasionally recovery will take place, after the disease has committed much local ravage ; and even the appetite and rest may continue unimpaired up to an advanced period of the complaint. The fever, which may have been at first high, then sinks into low t}rphus; the bowels become great- ly deranged, and diarrhoea often attends at the close.* The early application of the muriatic acid, as already advised (p. 179), is the only efficient application in these forms of gangrene, unless we would try the butter (chloride) of antimony, as a powerful caustic, capable of destroying the unsound surface, without causing any inflammation in the surrounding parts. This, however, is by no means a merely local disorder ; and attention to the state of the bowels, the administration of bark, wine, and the mineral acids, with a nutritious diet, the occasional use of an opiate, and above all, change * Mr. Dease the elder describes a disease of this description, under the name of "gangrenous erosion of the cheek;" and by Mr. Burns, a similar disorder is de- scribed as Noma. The subject has been largely treated of by Continental writers. See Isnard's Dissertation sur une Affection Gangreneuse particuliere aux Enfans; and Baron's Memoire sur une Affection dela Bouche. — Bullet, de la Faculte, 1816. AFFECTIONS OF THE MOUTH, ETC. igl to a new and healthy locality, afford us our principal chance of success in attempting to arrest the progress of the complaint, which is one, happily, of rare occurrence. td malignant pustule, commencing on the inside of the cheek, and extending outwards to the skin, may succeed to small-pox, measles, or scarlatina ; and take a course as severe or destructive as that of the disease just described, from which, in truth, it does not essentially differ. Huxham notices, in his Reports for July, 1745, mortification of the mouth and fauces as occurring after measles, the disease during which we have oftenest seen this affection, although by no means confined thereto ; neither does it take place only in female children, as some have asserted. Dr. M. Hall (see Edinb. Med. and Surg. Journal, vol. xv.) states, that all the cases he observed occurred after antecedent disorders of the digestive organs, typhus fever, or some inflammatory disease. The malignant pustule of the cheek is obviously analogous to the pemphigus infantilis, or gangrenosus, if not identical therewith, as we have been accustomed to regard it ; differing only as to the part of the body in which it occurs ; for the two diseases (or rather two forms of the same disease), have been seen occurring at the same time and place among sick children. A striking example of this fact is given by Mr. Ryland, in his interesting Report on the diseases of children, in the seventh vol. of the Transact, of the Prov. Med. and Surg. Association ; for at the time that these affections of the mouth prevailed among several children at the Birmingham Asylum, labouring under measles, other children were attacked, while suffer- ing from the same complaint, with the affection of the pudenda, described by Mr. Kinder Wood, and recognised as a pemphigus in this work (see Constitutional Diseases). The affections of the mouth occurring, however, during these febrile complaints, or when recover- ing therefrom, are not necessarily of so severe a character, but oftener present the milder and more ordinary form of ulceration of the gums, known by the name of canker, and in which, although sloughing may occur, the ulcerative process predominates. Cancrum Oris. — It is not uncommon to see ulceration of the mouth occurring in children, and at times ending in mortification, which has been described by authors under this appellation, and is noticed by Dr. Cuming, (formerly assistant physician to the Dublin Institution for the Diseases of Children,) in an excellent paper on this subject, printed in the fourth volume of the Dublin Hospital Reports. He confines this appellation to a form of ulceration, generally com- mencing in the gums, and thence extending to the lips and cheeks. It may be acute or chronic ; and is more liable to be attended by sloughing, the more acute it is ; but the ulcerative process still pre- dominates, and by it, principally, is the destruction effected. This variety of the disease, according to Dr. Cuming, does not attack in- fants at the breast, nor under a year and a half old ; but is met with in children between twenty months and seven years of age ; and 16 1S o DISEASES OF THE DIGESTIVE ORGANS. occasionally assumes a very destructive character, running into a deep, foul, dark, and sloughing ulcer. We, not unfrequently, see ulcerations of the gums and mouth in children, particularly about the periods of first and second dentitiou, which present some of these characters, but are, generally speaking, neither severe in form, nor dangerous in degree. The gums are more or less spongy, and the ulcers deep and foul, but small in size. At the period of second dentition, in particular, such may be seen ; the worst cases appearing to arise from the irritation caused by several teeth being shed at the same time; or rotten stumps being allowed to remain in the gums, without being extracted. When such is the cause, the removal of this source of irritation must be our first step towards effecting a cure. The several remedies already recommended in ulcerations of the mouth are applicable in this disease ; the nitric acid lotion or the muriatic acid being, in bad cases, our chief resource. Black wash has, in milder cases, proved very beneficial ; or the tincture of iodine as recommended by Mr. John Davies. The danger of ulceration of the mouth in children is enhanced, or a new danger created, when mercury is intemperately given during the progress of these febrile complaints, or indiscreetly exhibited during recovery therefrom ; or, indeed, while the system in children labours under any disease of low vital manifestation. Sudden, severe, and destructive salivation is thus not unfrequently set up, by which the gums are quickly destroyed, so that the alveoli have been laid completely bare, and the ulceration extending to the cheek and taking on a phagedenic character, has produced all the most frightful ravages already described; with the additional suffering and danger of a state of mercurial erythism. This affection has been noticed by Dr. Stokes in his lectures ; and some cases will be found recorded in the 1st vol. of the Lancet for the years 1838-39. We have seen the disease brought on oftener by the incautious administration of a dose of calomel given as a purgative to a feeble child, just recovering from scarlatina or measles, than as the result of mercurials administered during these diseases — but thus also may the attack be induced. It is a frightful and fatal affection, to be treated on principles similar to those already laid down, with the addition of such measures as are usually adopted to mitigate or counteract excessive salivation. It is more than this, however, being a form of destructive ulceration that seems to be peculiar to the child, and deserving of a distinct notice, un- der the name of cancrum oris mercuriale. [gangrene op the mouth. The frequent occurrence of gangrene of the mouth in children, and the great importance of detecting the true character of the disease in its earliest stages, from its being then very generally within the control of appropriate and well directed remedial measures, but, if it be neglected or mismanaged until the greater portion of the soft parts about the mouth have been destroyed, its fatal termination AFFECTIONS OF THE MOUTH, ETC. 183 can seldom be prevented, or if haply life, under such circumstances, is preserved, a serious and permanent deformity being entailed upon the patient, are reasons which seem to demand a more full and ex- tended notice of the etiology and treatment of this affection than is given in the text. The invasion of gangrene of the mouth is often slow, it being pre- ceded, for days or even weeks, by a state of indisposition more or less decided in different cases. The child is commonly observed to labour under symptoms of general debility, listlessness, and indisposition to engage in play, or even to move about — it cries frequently, is discon- tented, and desires to sleep, without the ability. The countenance is pale and dejected, and a puckering of the cheeks about the corners of the mouth is, not unfrequently, remarked. The bowels are either cos- tive, the discharges when procured being dark and fetid ; or frequent, small, and unhealthy stools occur, often attended with severe griping pains. The child becomes emaciated, and is subject to nocturnal sweats. The appetite for food is lost, or irregular and capricious — the thirst is in general increased. This state of things having con- tinued from eight days to two weeks, the patient begins to complain of sharp pains in his mouth and gums ; fetor of the breath soon manifests itself, accompanied with an increased secretion of saliva, — a sense of itching or pricking, and heat, is experienced in the gums, which assume a dark red hue, become tumid, and bleed upon the slightest touch. The salivation augments rapidly, accompanied, in general, with a slight discharge of blood ; the salivary glands at the same time become enlarged and painful. The appearance of the disease at this stage has a very marked similarity with the affection of the mouth resulting from a mercurial impression, and we have known even experienced physicians to mistake it for the latter. When the disease of the gums is allowed to progress, the perios- teum separates from the roots of the teeth ; these become loose, and are covered with a coating of mucus of a dirty-white colour. Fre- quently they fall out of their sockets. It is at this period that fever generally occurs, at first, in the latter part of the day, and accom- panied with an increase of the night sweats ; diarrhoea, also, is not unfrequent. The disease may continue in this state for many weeks, or even months, as Drs. Wepfer* and Coatest have observed. More commonly, however, in a few days the gums become covered with vesicles of an ash colour, which rapidly enlarge, unite together, and rupturing, show the gums beneath to be black and gangrenous ; or gangrenous ulcerations occur, with slightly inflamed, elevated, uneven and irregularly circumscribed edges, their surface being of a gray, or rather greenish colour, and rough. When the black or gangre- nous portions of the gums separate, an ulcer, similar in form to the slough, is left, which assumes immediately a gangrenous appearance. The gangrene extends itself very rapidly, laying bare the alveola and a large portion of the inferior maxillary bone. The teeth fall * Observations Med. Prac. 1727, p. 947. f N. A. Med. and Surg. Journ., vol. 2. 184 DISEASES OF THE DIGESTIVE ORGANS. out, and portions of dead bone are thrown off, should the little sufferer not sink under the disease at an earlier period. From the gums, the gangrene is propagated to the lips, cheeks, and other soft parts of the face, which become more and more swollen as the dis- ease progresses. Upon the mucous membrane of the mouth one or more grayish spots make their appearance, and in a few hours change into ulcers that present the same characters as those already described, and occasion invariably a great loss of substance. In from three to seven days the mortification will frequently extend itself to the whole of the soft parts surrounding the mouth, which exhale a cadaverous odour, and discharge a putrid sanies. The fever, which now augments in intensity, assumes a hectic character, and the child dies, generally about the eighth, or at the latest on the fourteenth day after the commencement of gangrene. In another form of gangrene of the mouth, the general system is not affected to so great an extent as in that just described, and the disease attracts but little attention, until the gangrene has commenced. Until then, the patients preserve much of their accustomed gaiety — play about, and, in fact, present no symptoms from which the occur- rence of so serious a malady could be anticipated. The patient becomes, in general, all at once fretful and peevish, and affected with slight accessions of fever, especially towards evening. These symp- toms are, in general, accompanied with restlessness, nausea, vomit- ing, diarrhoea or constipation. The mortification, in these cases, generally makes its appearance on the centre of one of the cheeks, or at the commissure of the lips, from whence it extends, in many instances, when the disease has arrived at its height, to the gums and maxillary bones. Usually, the cheek becomes swollen, hard, red, or perfectly white, and shining ; an increased secretion of saliva takes place, and there is exhaled from the mouth a peculiar and highly offensive odour. On examining the inner surface of the affected cheek, one or more small, ill-looking vesicles are perceived, which, after a few days, rupture and form a malignant ulcer of a dirty-gray colour, which augments rapidly in size, having a rounded form, with red, distinctly circumscribed, edges. This ulceration is not always immediately detected, and occasionally it is entirely overlooked, in consequence of the attention of those about the child being fixed entirely upon the external swelling of the cheek, as well as from the little patient being unable, in consequence of the swell- ing, to open his mouth to any extent. When the ulceration upon the internal surface of the cheek has continued some time, and become deeper and more extended, there occurs on the external surface, where the tumefaction is the greatest, a livid spot, surrounded by a red areola, — this soon becomes of a darker colour, and increasing in size, extends finally, in the course of from four to eight days, to the lips, nose, and surrounding parts. Portions of it are soft, and of a gray or greenish hue, and present all the characters of humid gan- grene, while other parts are completely mumified, hard, and of a deep black. On examining the mouth, the gums are found to be destroyed only in that part opposite to where the gangrene in the AFFECTIONS OF THE MOUTH, ETC. X85 cheek had commenced — while the rest of the gums are to all appearance entirely unaffected. In the progress of the disease, the general functions of the system become more and more impaired, — the appetite is destroyed, — the thirst augments, — the symptoms of gastric disorder augment in intensity, — the diarrhoea becomes more copious, and the abdomen is distended with gas, — the debility of the patient rapidly increases, while the intellectual functions remain unimpaired. The fever finally assumes a low nervous cha- racter — the little sufferer falls into a soporose condition; symptoms of universal colliquation now manifest themselves, and death occurs. The examination of the bodies of those who have fallen victims to gangrene of the mouth are too few in number, and have been performed with too little accuracy, to furnish any facts calculated to throw light upon the nature of the disease. So far as our own observations extend, which, however, have been very limited, the stomach, intestines, and liver have presented indications of preceding inflammation of a more or less chronic character. It is stated by Dr. Anderson, formerly physician to the Childrens ? Asylum of this city, that in the examination of the bodies of those who had died of the disease in that institution, under his care, he detected a very considerable enlargement and induration of the mesenteric glands, a scrofulous condition of the glands of the neck, and in every instance a diseased condition of the lungs, — these organs being, in general, thickly studded with tubercles in various stages of inflammation and softening. Gangrene of the mouth usually occurs in children of a delicate constitution, of a scrofulous diathesis, with soft and flaccid muscles, pale skin, and in whom, very generally, the functions of assimila- tion and nutrition have become deranged, from a series of morbific causes to which the little patients have been for a long time exposed. The disease seldom occurs excepting among the children of the poor. The causes which are enumerated as those favouring its pro- duction are, insufficient or unwholesome food — the influence of a damp or impure atmosphere, or that rendered impure by a number of persons being crowded together in small, low, and ill-ventilated apartments; personal and domestic filth; want of sufficient exer- cise, and various chronic affections of the stomach and bowels. As the children of those who live on the borders of the sea are exposed, at one and the same time, to many of these causes, gangrene of the mouth is, in consequence, an affection extremely prevalent in Holland, Sweden, and many parts of England. According to Thomassen* and Thysen,t two Dutch writers, who have published interesting accounts of the disease, it occurs frequently as an epidemic in the Netherlands, after various eruptive and gastric diseases. It likewise often pre- vails epidemically in hospitals destined for the reception of children; in the Childrens' Asylum of Philadelphia, Dr. Coates states, that at * Geneeskondig Magazyn, vol. 3. j- Amsterdam, 1824. Rust and Caspar's Reperlorium, 1825. 16* lg6 DISEASES OF THE DIGESTIVE ORGANS. one period, among the two hundred and forty inmates, seventy were affected with the disease. In the cases which have fallen under our notice, the gangrene of the mouth occurred invariably in individuals who had laboured for some time under symptoms referable to gastro-intestinal irritation. Richter* enumerates, as a fruitful cause of the disease, the previous existence of febrile affections, especially the exanthematic : an imper- fect crisis, or the sudden suppression (metastasis) of acute affections of the skin would appear, he remarks, to favour, in an especial manner, the development of gangrene of the mouth. The disease is almost exclusively confined to the period of child- hood. It occurs most commonly at some period between the first and tenth year, but especially between the second and fourth. Seldom, if ever, has it been observed in infants during the period of suckling. As to the real nature of the gangrene of the mouth of children, there still exists much obscurity. Klaatsch,t G. C. Hesse,J and Weigand§ maintain, that what has been so generally viewed as a gangrenous affection of the gums, and soft parts surrounding the mouth, is to be attributed to a decomposition of their tissues, perfectly analogous to what takes place in the softening of the stomach, uterus, and other organs, entirely independent of gangrene. This hypothesis is strongly opposed by Richter, who maintains, that the disease is a simple mortification, resulting from preceding inflammation of the parts in which it occurs, of an asthenic character. Dr. Seibert,|| who has traced the diagnosis of the disease with much skill, believes that a scorbutic tendency in the system is essen- tial to its production, but that the scorbutic character is only fully developed in consequence of the reaction which takes place in the system when the disease of the mouth has reached its acme, and hence it is very frequently taken for the effect of the former rather than its cause. We believe the disease to be, in every instance, the result of inflam- mation, occurring in subjects in whom assimilation and nutrition have been impaired by preceding long-continued gastro-intestinal irritation. But why the inflammation should attack particularly the mouth, and so generally terminate in gangrene or gangrenous ulcer- ation, are questions to which we are able to offer no satisfactory answer. Dr. HeuterIF conceives it to be probable, that the affection of the mouth is caused by the predisposition to disease in the gums of children, owing to the irritation of teething. This irritation, he remarks, which occurs with the first dentition, and is again induced by the appearance of the second set of teeth, may predispose to gan- * Der Wasserkrebs, Berlin, 1828. f Hufeland's Journal, 1823. J Pierer's Medizinischen Annalen, 1826. § De Canoro, quem aqnaticum vocant, 1827. || Hufeland's Journal, 1811. f Der Wasserkrebs, Berlin, 1829. AFFECTIONS OF THE MOUTH, ETC. 187 grene of the mouth in patients exposed to the influence of particular morbific causes. That the irritation of teething may be the exciting cause of the disease in many cases is very probable, but that it is not so in all is shown by the observations of Dr. Coates, who found few if any cases to occur during either the first or second dentition. In regard to the prognosis of gangrene of the mouth, we may remark, that it is in all cases to be viewed as a disease of a very formidable character. According to Richter, it produces, in at least the majority of instances, the death of the patient : — by the fifth, or at furthest, the fourteenth day from its invasion, the patient ordinarily sinking under the state of exhaustion which then suddenly occurs. Saviard* states, that he lost every patient affected with the disease under seven years of age. Muys,t Lund,J Seibert, Klaatsch, and Reimann§ assert, that they very generally succeeded in curing the gangrene of the mouth when it commenced by a tumour in the cheek, or by a livid spot. Richter considers, that when gangrene of the mouth occurs subsequently to affections of the stomach, it is less malignant than when it succeeds to fever or affections of the skin, in individuals of a scorbutic habit. Judging from our own experience, we should say that whenever the physician is enabled to attack the disease by appropriate reme- dies at the period of its development, in the greater number of cases he will be enabled to arrest its further progress, and save the life of the patient. It is important, therefore, that he should be aware of the circumstances under which gangrene of the mouth ordinarily occurs — and of the phenomena of the disease in its earliest stages. In very few instances have we failed to effect a perfect cure when we have been called in sufficiently early. This is also the experi-* ence of Dr. Coates, and other practitioners of this city, who have seen much of the disease. The disease is, however, peculiarly unmanageable and destructive to life when it occurs as an epidemic, especially in hospitals destined to the reception of children, and the asylums of orphans. In children, likewise, who are constantly exposed to the influence of causes injurious to health, gangrene of the mouth is seldom recovered from. Whenever, also, the gangrene is of any extent, the recovery of the patient is rarely to be anticipated, — the restoration of the parts destroyed always demanding a degree of vital energy which seldom exists in the delicate and enfeebled system of the little sufferer. In the majority of cases, the treatment of gangrene of the mouth consists simply in the application of remedies adapted to arrest the further progress of the local disease. When, however, we are called in previous to the appearance of the gangrene, in many cases, much may be done to prevent its occurrence — by adapting our remedial measures to remove the existing predisposition. Whenever * Observations Chirurgicales, 1702. f Praxis Chirurgica, 1685. X Transactions of the Royal Swedish Academy, 1765. § De Nomate, 1824. 1SS DISEASES OF THE DIGESTIVE ORGANS. it can be accomplished, the patient should be subjected to the influ- ence of a dry and pure atmosphere ; the strictest cleanliness of both person and clothing should be enjoined, together with a diet suffi- ciently nourishing, unirritating, and easy of digestion, and adapted, in respect to the substances of which it is composed, to the actual condition, in each case, of the digestive organs. Whatever disease the patient may be labouring under, which, judging from our own experience, will, in the majority of instances, be found to be some form of gastro-intestinal irritation — should be treated by its appro- priate remedies, recollecting, however, that alterative doses of calo- mel, even when indicated by the symptoms present, are to be em- ployed with the utmost caution, in every instance in which we have reason to apprehend the occurrence of gangrene of the mouth — when cautiously prescribed, and their effects carefully watched, they will, nevertheless, often be productive of beneficial results. In a few in- stances, we have found the administration of the sulphate of quinia, and a lotion to the gums of a strong decoction of black oak bark, re- peated frequently in the course of the day, to be beneficial in pre- venting gangrene of the mouth, where we had every reason to anti- cipate its speedy occurrence. The remedies that have been employed externally, with the view of arresting the local disease, are very numerous. All of them are reported to have succeeded in the hands of some physicians, while in those of others they have entirely failed. The lotion which we have found by far the most successful, is a solution of sulphate of copper, as employed by Dr. Coates in the Childrens' Asylum. His formula is as follows : — R. Sulph. Cupri, 3ij. Pulv. Cinchonse, ^ss. Aquae, ^iv. M. This is to be applied twice a day very carefully, to the full extent of the ulcerations and excoriations. The addition of the cinchona is only useful by retaining the sulphate of copper longer in contact with the edges of the gums. A solution of the sulphate of zinc, 5j- to an ounce of water, by itself, or combined with tincture of myrrh, Dr. Coates found to be also useful in some cases. Lunar caustic, which is spoken of in the highest terms by Guer- sent* in that form of the disease in which the gangrenous destruction commences on the internal surface of the cheek, was the only local re- medy employed in the cases of gangrene of the mouth which occurred in the Childrens' Asylum in this city, from June 1st, 1S27, to January 1st, 1830 — the greater proportion of which cases terminated favour- ably. As soon as the disease of the mouth was detected, the caustic, either in pencil or in solution, was applied freely to the parts affected, t The lunar caustic was tried, also, by Dr. Coates, but without any decided advantage ; we have, ourselves, never employed this remedy, * Journal Hebdomadaire, No. 91. t See North Amer. Med. and Surg. Journ., vol. 2, p. 3S. AFFECTIONS OF THE MOUTH, ETC. 189 having always been perfectly satisfied with the effects of the sulphate of copper : — the success, however, which has attended its use in the institution referred to, recommends it strongly to the attention of the physician. Richter considers that, as a local application, a decided preference should be given to the sulphuric, muriatic, and acetic acids, and the muriate of soda in solution. Heuter likewise states, that these are the local remedies most to be depended on, especially the acetic and muriatic acids used in conjunction, — while Guersent considers one of the very best local applications in the gangrenous affection of the cheek to be a mixture of muriatic acid and honey. When the acids are employed, Richter remarks, that to obtain from them beneficial effects, their application should be repeated every half hour, or at furthest, every hour. They should be applied either by a pencil, or by covering the affected parts with lint moistened with them, and continued until the gangrene ceases to spread, and granulations are formed. The administration of internal remedies would appear to interfere but little with the progress of the disease, or aid in arresting its fatal termination. In general, a light and nutritious diet — and the administration of the sulphate of quinia in solution, will, however, be found beneficial as adjuvants to the local treatment. The early extraction of the loosened teeth is an important measure, which should never be neglected. — C] Cynanche Parotidoea — Mumps. — Children are liable to an inflam- matory affection of the parotid gland, which often extends to the sub- maxillary, and is of a specific character,not tending to suppuration, but running a regular course of about four days' duration, when it usually ends by resolution. This disease, which is known by the familiar appellation of the mumps, is not exclusively confined to childhood, though most frequently seen at that period ; at times it spreads as an epidemic, particularly among the children of the poor ; and it is decidedly contagious. Symptoms. — A small external tumour, occupying the site of the parotid gland, appears generally at both sides of the neck together ; but is occasionally to be seen at one side only. The tumour which was at first remarkable and circumscribed, soon becomes extensive and diffused, often involving the maxillary glands in the inflammation, and continuing to increase until the fourth day. The tumour is hard and somewhat painful ; but little fever or constitutional disturbance in general attends, unless when the swelling becomes of considerable magnitude, as it occasionally does, so as to impede deglutition or respi- ration, and cause congestion of the brain. At times, but very rarely, the tumour will thus proceed to suppuration, and may cause imme- diate death, by discharging its contents into the larynx, if it bursts internally ; or lead to great deformity, when it opens outside. Most usually, however, the tumour begins to decline on the fourth day, altogether disappearing in a few days more, and with it any 190 DISEASES OF THE DIGESTIVE ORGANS. febrile symptoms that may have attended. The swelling, when going off, is liable to be transferred to other glands, the testicle in the male or mammary gland in the female, where it runs a course similar to that which it does in its first situation, or occasionally alternating between these glands, and those of the neck ; and is at times so severe as to cause suppuration in the testis or mamma. In general, how- ever, this transference of the disease is to be regarded rather as a favourable occurrence, the chief danger in mumps arising from the sudden suppression of the disease in the neck. When the swelling rapidly and prematurely disappears, the febrile symptoms all become aggravated ; and in particular, the head appears to be engaged, or the respiration becomes laborious, and death may follow. The sud- den disappearance of the morbid action from the testicle, after it has been established there, may also be followed by similar results. Mumps are not otherwise attended by danger, running their course in general safely, though occasionally proving troublesome from a chronic enlargement of the gland, remaining behind. Like other epidemics, a bad form of the complaint may at times prevail, espe- cially among the children of the poor. Treatment, -—Little is required in general to be done in the treat- ment of such a mild complaint running a specific course. When the febrile symptoms seem to demand interference, an emetic in the first instance, and some mild aperients after will be all that is required. In the severer cases a few leeches may be necessary to relieve the head, or reduce the swelling of the neck, and when the swelling is suddenly suppressed, stimulating liniments or a blister should be applied to the part where it had been. III. AFFECTIONS OF THE STOMACH AND BOWELS. The stomach and bowels are peculiarly liable to be disordered in the child; and these disorders may arise from mere functional derange- ment, as in some forms of diarrhoea, cholera, &c, or from inflamma- tory action, leading to organic change of structure. The functional derangements are most commonly induced in consequence of the administration of improper food ; or they may be purely sympto- matic, arising from sympathy with some other organ, which is in a state of disease. However originating, these derangements of the digestive organs soon tend to the production of diseased action in the parts affected — irritation frequently giving rise to inflammation and its consequences. This, however, is not necessarily the case ; and mere functional derangement may be so severe, or protracted, as to destroy life, and yet no trace of organic change be found after death; at least no signs of inflammatory action. To distinguish such cases from those which are truly inflammatory, is often a difficult, but always an important task. We shall endeavour to draw the line of distinction, being careful to set down the symptoms which indicate inflammatory action, and those which may exist independently of it; while we candidly point out those cases respecting which doubts must unavoidably exist. It is only by attention to the whole group INFLAMMATION OF THE STOMACH AND BOWELS. i 91 of symptoms, not to any particular one, that the true distinction is to be attained ; and we must keep in mind that symptoms of inflamma- tion are liable to arise during the progress of a complaint not neces- sarily or originally inflammatory, as occurs in infantile cholera, pro- tracted diarrhoea, or remittent fever; while, on the contrary, a state of irritability dependent upon debility will, at times, follow true in- flammation as enteritis ; but which would be only aggravated by a perseverance in antiphlogistic measures. Inflammatory affections of the stomach and bowels are of frequent occurrence in the child ; and may arise directly from impressions of cold, or the effects of damp, particularly when associated with a pecu- liar influence exercised by the season, as we see in the frequent bowel complaints of children observed during autumn ; or inflamma- tion may be the result of a severe or continued irritation of the mu- cous membrane, induced by improper food ; or symptomatic of some existing disorder. The stomach alone may be inflamed ; but much more frequently the inflammation extends farther, involving the mucous membrane of the small intestines to a greater or less extent, and constituting a case of gastro-enteritis. The lower portion of the ileum, in particular, is a frequent seat of inflammation ; or the large intestines may be affected, and give rise to dysentery. The inflammatory action, going on in the mucous membrane, soon tends to its disorganisation ; ramollissement is induced, or ulceration set up ; but death may ensue before either of these states occur, the mucous membrane being found merely reddened, or injected. In ramollissement, the membrane becomes friable, easily peeling off" in soft reddish masses, when the disorganisation is caused by inflam- mation; but there is another form of this affection in which the softened membrane is white, and does not owe its origin to inflam- matory action. When ulceration ensues, it is found to have its seat in the muciparous glands or follicles, being analogous to the aphthous ulceration of the mouth, with which it is often combined. Excite- ment of the muciparous glands, however, may give rise to severe or serious symptoms, without their being actually inflamed or ulcerated. An alteration of secretion, identical with that observed in the mouth, and called muguet, may occur in the intestinal canal, but is seldom seen. Gangrene has, in some instances, resulted from intense inflammation of the mucous membrane of the stomach ; but more particularly of the ileum. The intestines have been thus perforated, and peritonitis induced on the escape of their contents ; but this is more frequently caused by follicular ulceration. The peritonitis thus induced is the most dangerous with which we can have to contend. Such cases are, however, happily rare in the child, but peritonitis, independently of this cause, occurs in the infant as well as the adult. When the mucous membrane of the lower portion of the canal is much irritated or inflamed, pain or straining attends the passage of the stools, or prolapsus ani is induced ; and hemorrhage of rather a severe character may attend, or be induced in consequence of con- gestion, or inflammation of the mucous membrane. ig2 DISEASES OF THE DIGESTIVE ORGANS. The fever attending inflammatory affections of the bowels is often severe, and the local symptoms well marked, particularly if the child be grown, and the attack recent ; so that in many instances no doubt need be entertained as to the nature of the case. In others, however, where the infant is very young, the invasion of the disorder and its progress may be so insidious, as to tend to extensive organic altera- tion, before the true nature of the case is suspected. The fever attendant on disorders of the digestive organs in the child, usually assumes the remittent form ; infantile remittent fever being now well understood to be connected with intestinal irritation, whether caused by extraneous matters, as worms, or undigested food; or by a morbid condition of the mucous membrane itself. We must recollect both these sources of disorder, and learn to distinguish them, if we wish to understand or treat this disease aright. The sympathetic disturbances of the head, chest, or skin, caused by disease of the digestive organs, whether acute or chronic, in a particular manner demand attention, and shall be specially noticed. We now proceed to consider separately the several disorders of the stomach and bowels, to which the child in particular is so sub- ject — beginning with those which are merely functional. Functional Disorders of the Digestive Organs — Infantile Indi- gestion. — The infant, as well as the adult, is subject to a train of symptoms arising in consequence of disagreement of the food, which, being unfit for the process of digestion, deranges the functions of the stomach, and is inadequate to supply nourishment. This may result from the quality of the food being such as to be unsuited to furnish the necessary supply of nutriment, or being unfit to undergo the digestive process — the infant perishing for want of sustenance, or in consequence of the disorder of the stomach and bowels, induced by improper food. The first form occurs with infants at the breast, who are not pro- vided with wholesome milk ; the other, with children who are im- properly or too soon fed ; and this usually takes place at the time of weaning. Hence we would divide infantile indigestion into two varieties: the indigestion of suckling, and the indigestion of weaning. Indigestion during Suckling. — Infants at the breast are often observed to look pale, lose the firmness of their flesh, and become emaciated. They are peevish and fretful, and constantly cry until they receive the breast, for which they show great avidity, seizing the nipple with force, and sucking eagerly; but this seems to avail them little, either in appeasing their hunger, or affording them nou- rishment. The more they suck, the more does their food disagree with them, being soon rejected from the stomach, or passed by the bowels in a curdled state. Griping, flatulency, and acidity soon attend ; and a protracted diarrhoea sets in, which carries off the infant in a period varying from two to four weeks. Such a state of things is often witnessed in infants suckled by nurses who are out of health, whose milk is too old for the infant, or who do not observe the rules already laid down for the manage- ment of infants at the breast. It is at foundling hospitals, or among AFFECTIONS OF THE STOMACH AND BOWELS. I93 the nursed children of the poor, that we have extensive opportunities for observing such cases, many dying annually from this cause during the first months of infantile life. In fact, these children die of starva- tion. The milk they get is unable to sustain them — and tormented by hunger, they suck in vain to supply the deficiency by the quantity taken, until the overloaded stomach and bowels become irritated, or at length inflamed. Many, however, die merely of inanition, no trace of inflammatory action being visible after death ; but the intes- tines being found, like the rest of the integument, blanched and atten- uated ; the mucous membrane being soft and friable, in the state of white ramollissement already alluded to. Diagnosis and Prognosis. — This disorder is distinguished by the absence of inflammatory symptoms during life, or the traces of them after death ; and by originating in the want of nutritious properties in the food, not in its irritating qualities. Our prognosis may be favourable, if the true nature of the case be early detected, and the cause removed by procuring a good and healthy nurse ; or substituting the best mode of artificial feeding, as already specified. On the contrary, little hope of success can attend the method too often adopted, in which the symptoms are attempted to be met by alternate laxatives and astringents, while the cause remains undetected, or unremoved. Treatment. — If much purging be present when we first see the infant, this must be checked ; and a mixture of soda with opium will answer best. Derangement of the biliary secretion may be met by small doses of mercury with chalk, sparingly employed ; but if the child be much reduced, some tonic, as small doses of the quinine mixture, or a little weak chicken broth, will be required ; great cau- tion, however, is necessary in administering any stimulating food, however nutritious, as irritation thus caused would interfere with the process of digestion, and give rise to the train of symptoms so com- monly seen at the period of weaning, and which constitutes our second variety of infantile indigestion. Indigestion during Weaning. — Any sudden change of diet, even in the adult, is liable to be attended with derangement of the diges- tive organs, especially if the food given be indigestible or irritating. Much more is it likely to occur in the infant, whose intestinal mucous membrane is so sensitive and vascular. This risk all children have to pass through at the period of weaning, or when artificial food I comes to be substituted for the breast milk. The irritability often attendant upon teething may predispose to ! such disagreement, if the change of food be made at this time ; but I there is no necessary connection between dentition and the derange- ' ment of bowels so often attendant upon weaning, as this occurs ( equally when artificial food is injudiciously given before as after the I teeth have appeared ; and is the more likely to be induced, the earlier j and more suddenly the infant is weaned. There seems more reason in the connection established between the rapid development of the i glandular system going on at this period, and the susceptibility of the j bowels, as the muciparous glands of the intestines partake of this 17 1 94 DISEASES OF THE DIGESTIVE ORGANS. general activity, and are found about this time undergoing rapid en- largement, and in a highly sensitive state. Hence these glands are peculiarly liable to become irritated; and from their irritation arise some important peculiarities observed in the bowel complaints of chil- dren. This derangement, attendant upon weaning, has been long the subject of popular observation, and known under the name of Wean- ing Brash : — the Atrophia Mlactatorum of Cheyne, who thus trans- lates the popular name, in his essay on this disease, published in 1802.* But the history of the symptoms and appearances detailed after death in the majority of the cases observed by Dr. Cheyne, shows the disease described by him to have been of an inflammatory character, or to have arrived at an inflammatory stage, thus differing from the form of complaint, we have at present under consideration, and hence requiring a different line of treatment. The relation between the supervention of weaning brash and the autumnal season is so remarkable, that Dr. Cheyne doubts the exist- ence of the disease at any other period of the year ; and suggests that the weaning of delicate children should, if possible, be put off until this season has passed. The advice is good, in consequence of the greater liability to bowel complaints during the autumnal months ; but such will occur, as the result of improper food, at all seasons, as we have witnessed. When food, in too great quantity, or of improper quality, is given to a child, the stomach becomes oppressed ; and more or less of sick- ness or fever ensues, until the offending substance is rejected from the stomach, or, being carried into the bowels, is passed from thence. Thus vomiting or purging commonly result, in the first instance ; and it is well they should, being the efforts made by nature to get rid of the source of injury. Flatulency with pain or spasm, often attend in addition. Thus, much sympathetic irritation is induced ; and this may amount to such a degree as to cause convulsions, which not unfrequently result from an indigestible meal given to a child. Did the distress thus induced disappear with its cause, all would be well after the child had been vomited, or purged ; but the irrita- tion of the stomach and bowels, once set up, may continue ; and often involves other organs, particularly the liver, whose functions are usually more or less deranged. Thus the matters ejected from the stomach are frequently yellow or green, being tinged with bile ; and the stools are very yellow, or oftener of a deep grass-green co- lour ; so much so, that this form of purging has got the common appellation of " the green scour." On the other hand, the biliary secretion is at times suppressed ; the stools being light or clay- coloured, thin and watery, or thick, like half-boiled flummery. When the true source of the malady is overlooked, and the improper diet persevered in, under the idea that the derangement of the stomach and bowels arises from teething or some peculiarity in the constitu- tion of the child (as is commonly thought), a confirmed state of indi- * See Cheyne's Second Essay on the Diseases of Children. AFFECTIONS OF THE STOMACH AND BOWELS. 195 gestion is established ; and the child rapidly emaciates, the skin grows harsh and dry, the belly becomes tumid, and constant diarrhoea or vomiting is established. The commencement of the disease is often deferred for some time after weaning, not appearing until a month or six weeks have elapsed, when the continuance of the unwholesome diet at length produces the derangement of bowels, which, in other instances, immediately follows its use. Symptoms. — A purging of green matter is generally the first symptom ; but after some time, a retching or vomiting is added ; the matter rejected being often tinged with bile. The diarrhoea some- times ceases when the latter becomes established ; or it only occa- ally occurs. Short periods of troublesome constipation are not unfrequently interposed. The child is peevish, and restless, often cries, and has a settled discontent of countenance, indicative of pain. There is much disinclination for food ; but it shows a desire for cold drinks. Little fever, however, in general attends. There is some evening exacerbation ; but the pulse is scarcely affected ; nor is there much heat of skin ; and the extremities are disposed to be cold. The belly, though full, is not tender, and the tongue may continue long clean and moist, or only a little whitened ; but aphthae, after a time, Usually appear. Diagnosis. — The great emaciation and feebleness of the infant, with the constant whine, and countenance expressive of pain, are the most prominent characters of the case. Such a disorder cannot long exist without organic disease being induced. Irritation leads to inflammation, and intestinal ulcerations ultimately ensue ; but many children die from the foregoing symptoms, from mere functional dis- order, without signs of inflammation being present during life or to be traced after death. In these cases the intestines are found empty, pale, and transparent : in some parts inflated by gas, in others much contracted, as if by spasm : one portion being involved in another, so as to form intus-susceptions, but without any inflammation or ad- hesion of the parts involved. The disease is often protracted to a month or six weeks, the finest infants being in that time reduced to the most wretched state of marasmus ; but when vomiting is added to the purging, the case may assume the character of cholera, and will often terminate fatally in a week or fortnight. When a child dies under these circumstances, the head almost always becomes engaged, coma or convulsions being present ; but this is only a se- condary affection, and not dependent on any inflammatory action, — a state of venous congestion, with slight effusion into the ventricles, being the appearances found on dissection. Prognosis. — When we are consulted in such cases sufficiently early, and are able ourselves to determine on the absence of organic disease, our prognosis may be favourable, as by removing the source of the symptoms, in the improper food administered, a great advance is made towards effecting a cure ; and it is surprising from what a state of exhaustion an ill-fed infant may be recovered. We must not, however, be deceived by a cessation of purging which occasion- 19 6 DISEASES OF THE DIGESTIVE ORGANS. ally occurs a few days before death, but without materially amend- ing the child's condition, or retarding the fatal result. Treatment. — The substitution of a healthy nurse's milk (when the child is not too old), or asses' milk, with weak, broth, free from fat, thin arrow-root, and barley-water, (with gum or isinglass dis- solved in it,) for drink, instead of the food with which the child has been fed, are the principal changes requisite in the diet. Milk, in general, disagrees, and when given, should be previously boiled, and diluted with one or two parts of water. Boiled bread and milk, or even rice milk, though often recommended, we have frequently found to disagree. When the stomach is irritable, and much thirst present, a little cold water is the best and most grateful drink. In protracted cases, a good drink may be made by scraping some flour, which has been boiled in a napkin, and allowed to become dry, into equal parts of milk and water, and then boiling and sweetening the mixture. In general, little sugar should be used, and that of the best quality. Medicines. — Our object, in the first instance, should be to check the vomiting and purging as speedily as possible, and allay the irri- tability of the mucous membrane. For this purpose, opium is a chief resource ; and when used with the cautions already specified, we need never hesitate as to the utility of its employment. Hufe- land, in particular, commends opium in diarrhoea, consequent on weaning, or induced by unwholesome and ill-regulated diet — the kind of case now under consideration. The safest and most imme- diate way of checking the purging, when severe, will be by admi- nistering an anodyne injection, consisting of one or two ounces of mucilage of starch, with from two to four drops of laudanum, and then employing the following astringent mixture : — No. 39. R. Aquae Cinnamomi, ^k Misturae Cretse, gss. Tinctnrse Kino, 5u» Opii, gtts. viij. Syrupi Aurantii, ^U* Sumat 5i- — 5iJ- nor ^ quaque 2da. This medicine should be persevered in until sleep is induced, or the purging decidedly checked ; it will then be sufficient to give it after each liquid stool. If the stomach be very irritable, six grains of bi-carbonate of soda may be substituted for the chalk mixture in the foregoing formula, or the mistura anti-emetica (p. 96) employed. The warm bath should be ordered every night, or night and morn- ing, if the child's strength permit. Under all circumstances, fomen- tations to the abdomen, or the application of hot flannel, and friction with the warm hand, are of great service. Opiate liniments may, in protracted cases, be used with the best effect. Having thus allayed the more urgent symptoms, and allowed the child opportunity for recovering some strength, we have time to look AFFECTIONS OF THE STOMACH AND BOWELS. 197 about, and regulate our line of proceeding according to the circum- stances of the case. The course just specified is that which we commonly pursue, and by which we have seen numbers of children speedily restored from great extremity, and after other means had failed. The purgative plan of treatment for such cases we never adopt, and are only sur- prised how any one who has witnessed its destructive effects can for a moment support it. Emetics we are equally cautious in employ- ing. When a case has recently occurred, and can be distinctly traced to a meal of indigestible food, an emetic of ipecacuanha is doubtless a good measure to free the stomach, and lessen the risk of farther mischief. In the same way, a mild dose of rhubarb and magnesia,. or a little castor oil, guarded by a drop or two of laudanum, is equally serviceable in freeing the bowels of indigestible contents which may still lodge there, though diarrhoea has set in; but these are particular and obvious cases, about which no mistake can well be made. When the diarrhoea is established, we seldom use laxatives ; and even in the occasional constipation, or rather cessation of purging, which at times occurs, we equally avoid their employment, — having often seen a diarrhoea brought back by a misplaced anxiety on this score, which could not again be allayed. The addition of a scruple of magnesia, or a drachm of tincture of rhubarb, to the astringent mixture, will, in such cases, obviate or remove the tendency to cos- tiveness. The use of mercurials, whether given as purgatives, alter- atives, or specifics, (as some seem to employ them in the bowel complaints of infants,) we consider a plan of treatment requiring equal caution, though we would by no means altogether forbid it. When the biliary secretion is much deranged, and the stools very foul, an occasional small dose of the hydrargyrum cum creta, or of calomel, is undoubtedly of service, by improving the biliary secretion, and thus tending to allay the irritation of the bowels ; but we always guard the mercurial with a grain or two of Dover's powder, or from two to five of the compound powder of chalk with opium. If given alone we never employ the mercurial more frequently than every second night, and that only occasionally.. Guarded by the opiates, as we have advised, it may, however, be used night and morning, or even three times a day, for some days in continuance ; and under this plan of treatment, the stools soon lose their unnatural character, becoming consistent and less frequent, the irritability of the bowels quickly subsiding. The Dover's powder, or powder of chalk with opium, will, by themselves, however, often produce the same results. When we do employ mercury, our usual practice is to prescribe a grain of hydrargyrum cum creta, with one or two of Dover's powder, every night, or night and morning, and to employ the astringent or sedative mixture at the same time. The practice of persevering in doses of calomel, or hydrargyrum cum creta, so often pursued, as if this were a cure for irritable bowels in the child, we cannot but look upon as a most pernicious error, having repeatedly witnessed its in- jurious effects. The recommendation of the efficacy of this plan by 17* 19S DISEASES OF THE DIGESTIVE ORGANS. Dr. Cheyne, in his Essay, already alluded to, (which has doubtless led so much to the indiscriminate employment of mercurials in the bowel complaints of children,) arose from the circumstance of the cases described by him being really of an inflammatory character, or having passed into that state, and so requiring the administration of mercury for their cure ; as will be specified when treating of the in- flammatory affections of the abdomen. When much debility is present, some stimulant is required, and this will be best effected by adding two or three drops of the aro- matic, spirit of ammonia to each dose of the astringent mixture already advised ; or double that quantity of the nitrous spirit of ssther, or Hoffman's anodyne liquor, when spasms or hiccup attend. Before having recourse to stimulants, however, we must examine whether the symptoms present may not have originated in an in- flammatory affection of the mucous membrane, and truly indicate a case of gastro-enteritis. Upon this distinction will turn our line of practice, as stimulants must be interdicted if inflammation be present ; and this may exist in conjunction with much apparent debility. As injurious, however, is the error of those who, taking every case of vomiting and purging in the child for one of gastro-enteritis, indis- criminately apply leeches, and have recourse to debilitating measures — - an error that is irremediable in the young child under such cir- cumstances. The employment of opiates, sedatives, and even astringents, is common to the two classes of complaint, the inflam- matory or functional ; and the external use of warm fomentations, stimulating liniments, or blisters, may also be looked on as applicable to both : but before we decide on applying leeches, or administering stimulants, we must see and determine whether the disease be in- flammatory or not. Cholera Infantum. — A disease of a very formidable character, and well-deserving this appellation, is often to be met with in the autumnal months. It begins to appear at the latter end of summer, and seems to be nearly allied to the disorder of which we have last spoken. The greater number of cases occur in infants at the breast, more particularly those winch are teething, or have been recently weaned : but that this disease does not necessarily arise from teeth- ing or weaning, though either may predispose to it, is sufficiently proved by its constant occurrence at the autumnal season (and that season only), when its attacks are not confined to infants that are teething, or have been weaned. Many cases are presented at the same time, the disease appearing as an epidemic, like other bowel complaints prevailing at this season. Symptoms. — Its invasion is sudden and violent, and its course often rapid, soon terminating fatally, if not promptly arrested ; but its progress may be protracted, and last with intermissions for six or seven weeks. At the time when the disease prevails, an infant is often presented to us, lying in the nurse's arms, completely prostrate, and as if about to die. The countenance is pale and shrunk, and the features sharpened : with a dark circle often about the lips or eyes, which are sunk, turned up, and half closed. The infant seems coma- AFFECTIONS OF THE STOMACH AXD BOWELS. 199 tose, but is easily roused to consciousness, looking eagerly around, and appearing quite collected, but uneasy at being disturbed, and crying incessantly, until it again relapses into its former state. The pulse is slow, feeble, and may be irregular ; but the respiration, though oppressed, is not unequal, and any suspicion which may have at first existed, as to these symptoms originating in a cerebral affec- tion, is removed when we find, upon inquiry, that the attack began with purging and vomiting ; the bowels being frequently moved, and nothing remaining on the stomach. The stools are at times described as running from the child like water ; they may be yellow or white, but are much more frequently green, as if loaded with some chopped vegetable. The surface is cool, especially the limbs, which are at times quite cold ; urgent thirst often attends ; the belly is full, but not tender, though much sensibility of skin is present ; the tongue is moist, and a little white, or of a bluish tint, and feels cold : the cry is feeble, or almost extinct. This is an extreme case ; and under such circumstances, it is not wonderful that death should speedily occur, — the infant perishing in twenty-four or forty-eight hours, unless prompt relief be afforded. In many cases, however, the disease is much milder, being gradual in its development, and slow in its progress. It commences usually by purging in these instances, the vomiting being subsequently added. Remissions of the disease occur ; but the child continues restless and feverish, with evening exacerbations, and is subject to fits of drowsi- ness or oppression. The purging is occasionally absent, but again recurs, while emaciation goes rapidly on ; and the child is at last cut off by an acute attack, or gradually sinks under the disease, after a lapse of three or four weeks. Pathology. — This is obviously a species of cholera, and does not necessarily arise from inflammatory action, though symptoms some- what similar may have their origin in an insidious form of intestinal inflammation, often ending in ulceration, as will be presently noticed. That cases of inflammatory affections of the bowels often occur in common with the cholera infantum, resembling it in symptoms, and appearing at the same time, is undoubtedly, the case ; and we must bear in mind, that the simple cholera itself, when protracted, is liable to become complicated with inflammatory action ; but that the dis- ease is not necessarily inflammatory, or even commonly so, is equally certain, and not less important to recollect, as it involves a line of treatment not usually employed, and in recommending which as well as in taking this view of the subject we differ from others. Cruveil- hier has described this complaint under the title, Maladie gastro-in- testinale des Enfans,avec desorganization gelatiniforme, having on dissection found the mucous membrane of the stomach and bowels in a state of ramollissement, or reduced to a disorganised pulp, but with- out decided traces of inflammation. In a few cases, some redness has been found on portions of the intestinal mucous membrane ; but this appearance has been only casual, and therefore not necessarily connected with the disease. In general the mucous membrane is found pale and colourless, as if macerated in water, the intestines OQO DISEASES OF THE DIGESTIVE ORGANS. appearing almost transparent. The mucous follicles are natural, and even the softening of the mucous membrane is not always pre- sent, as has been pointed out by Guersent, who here differs from Cruveilhier.* Diagnosis. — The cholera infantum is liable to be confounded with congestion of the brain, or effusion, and the child generally dies with symptoms nearly resembling those states ; but consciousness will be found to exist to the last in this complaint, when the child is roused, and the history of the case will soon remove any doubts that may have been felt. Our prognosis must be guarded in all instances, but need not be hopeless even in bad cases, if seen sufficiently soon ; as recovery will often occur, no matter how much the child may be reduced, if suffi- ciently prompt measures be taken to support the strength and stop the evacuations ; but if the disease has been protracted so as to allow time for organic change, and the strength be much exhausted, the case assumes a new and very unfavourable character. Treatment. — The plan of treatment to be adopted in this com- plaint does not differ, in principle^ from that required for the disease last described ; but we must be more prompt in our proceedings, and our remedies must be carried much farther. In severe cases a mo- ment is not to be lost in attempting to stop the purging and vomit- ing, while we at the same time support the strength, and supply stimu- lants if required. The internal administration of stimulants requires some caution. Guersent altogether condemns stimulants and tonics ; but our expe- rience is quite opposed to this, unless where distinct signs of inflam- mation are present. On the contrary, our practice now is, at once to use stimulants, in conjunction with opiates and astringents, and in a much bolder manner than we at first thought of employing them. The mixture prescribed belowt is that which we commonly admi- nister, the repetition of the dose being regulated by the effect. A tea- spoonful is ordered to be given every hour, or half hour, until the * We find that Dr. Droste of Osnaburg, eonfirms the opinion which we were led to adopt from our observations on the Cholera Infantum, that neither the symptoms during life, not the morbid appearances presented after death, indicate an inflamma- tory affection in this disease. He looks upon the state of ramollissement of the intestinal mucous membrane often presented after death, as caused by an affection of the nerves, which supply the coats of the intestines ; but this suppositious origin of the softening of the membrane is less satisfactory than the opinion thrown out by Dr. Cars well, that the action of the gastric juice after death has something at least to do with producing this result. — See " Zeitschrift fur die Gesammte Medicin," ifc. Hamburg. 1 Band. Heft A. 1836. t No. 40. &. Infusi Mentha?, Aqua? Cinnamomi, aa. §i. Tincturae Catechu, %[]. Spirit. Ammon. ar. gi. Tinct. Opii, gtts. xij. Syrupi Auranti, 3ij. M. AFFECTIONS OF THE STOMACH AND BOWELS. o l purging and vomiting be checked, or sleep induced. The renewal of the medicine is then deferred until the symptoms recur, or the child awakes, uneasy or in pain. A protracted sleep frequently fol- lows the second or third dose of the mixture, with remission of the symptoms for several hours. The child awakes tranquil and refreshed, the vomiting often not recurring, and the next evacuation from the bowels beginning to assume a natural appearance. In extreme prostration, double the quantity of ammonia may be prescribed, or an equal quantity of the compound spirit of sulphuric aether be added. Port wine may be given in the arrow-root; and brandy and water, or a little burnt brandy (where much irritability of stomach attends), will be found highly serviceable. The muriated tincture of iron, given in mucilage of gum, or with the decoction and syrup of marsh-mallows, has been administered in this gastro-malacia of infants, by some German practitioners, and its efficacy highly spoken of by Pommer, Herzt, &c, &c. We cannot speak from experience of the effects of this medicine, but after the view we have taken of the disease, are ready to expect beneficial results from such a remedy; especially when we call to mind the astringent powers of iron in its local action on the parts to which it is applied. External stimulation by warm applications, friction, liniments or blisters, may be needed and will always be found useful. When reaction is restored, or symptoms of excitement occur, stimu- lants must be diminished or withdrawn ; but their continued use, in lessened quantity, is often required, and the still longer employment of opium and astringents is in most cases necessary. These cases must be often visited, and the effects of remedies nar- rowly watched. We distinguish between the narcotic effect of the opium and the drowsiness or oppression which attends the disease, by observing the readiness with which the child is aroused, and its consciousness on being disturbed ; neither of which will be mani- fested while the child is under the effect of opium, the stupor being then continued, and the pupils usually remaining contracted, on the eyes being opened. Again we are not to be misled by the suspension of the evacua- tions, or suppose that the child must be better, because the purging and vomiting have ceased. On the contrary this is an unfavourable occurrence, unless there be a corresponding general improvement, and in particular the drowsiness and oppression disappear, without being succeeded by restlessness or screaming. The purging and vomiting not unfrequently cease spontaneously, some time before death ; but the state of sinking goes on, accompanied by great rest- lessness, or sudden accession of the symptoms affecting the head. The child may appear to die comatose, yet is capable of being roused to the last. In such cases we must rely much on counter-irritation, or heat and stimulants applied to the extremities and trunk. In particular, hot fomentations should be applied to the head ; or it may be enveloped in flannels, wrung out of hot water, and then sprinkled with turpentine, or spirits of wine. 202 DISEASES OF THE DIGESTIVE ORGANS. We must be especially careful to avoid the exhibition of any pur- gative after recovery from infantile cholera has taken place, even though the bowels remain long confined : attention to this point cannot be too strongly urged. Respecting the use of mercurials we have said nothing, because we never employ them in the severe cases of this complaint ; and in its milder forms, only under particular circumstances (such as have been already specified at p. 197), and never unless guarded by an opiate. We have found it impossible to check the purging so long as any form of mercury was given, in cases which readily yielded to the treatment recommended, after the mercury had been discontinued. [In the description given by Drs. Evanson and Maunsell, the American physician would find no little difficulty in recognizing the peculiar phenomena by which the disease known as cholera infan- tum in this country, is characterized. Neither will the plan of treat- ment laid down by them be found to be the one best adapted for its cure. Our authors have been led into error by confounding cholera infantum, which, from its being an extremely rare disease in Great Britain, they could have had but little opportunity of studying, with the maladie gastro-intestinale des enfans, avec disorganization gelatiniforme of the French, afnd the gastro-malacia of the German pathologists, from which affection it differs, however, in many im- portant particulars. Cholera infantum is a disease indigenous to this country. It pre- vails every year, as an endemic, in all the large cities throughout the Middle and Southern, and most of the Western States, during the season of the greatest heat : making its appearance, and ceasing, earlier or later, according as the summer varies in the period of its commencement and close. Thus in Pennsylvania, Maryland, Vir- ginia, Kentucky, and Ohio, it commences, sometimes in the month of June, and continues until October, being most rife in July and August ; whilst in the more Southern States it appears as early as April and May, and often does not cease to occur until late in November. Its only subjects are infants, chiefly between four, and twenty months of age — very seldom attacking those younger or older — being most commonly confined to the period of the first dentition. The disease occasionally commences with a profuse diarrhoea, the stools being sometimes greenish, but more commonly light-coloured, and very thin ; the stomach, however, soon becomes extremely irri- table, everything taken into it being immediately discharged, often with great violence. In other cases almost constant vomiting and purging occur simultaneously ; the discharges from the bowels being, ordinarily, a colourless, inodorous fluid, containing minute mucous flocculi. In whatever manner the disease commences, the patient soon becomes affected with great langour and prostration, and is rapidly emaciated — being reduced in a few days to an extent, that to those AFFECTIONS OF THE STOMACH AND BOWELS. 2 03 who have not witnessed the disease, would appear almost incre- dible. The pulse is usually quick, frequent, small, and often tense. The tongue is covered with a thin white fur. The skin is, in general, dry and harsh — the head and abdomen are hot, while the extremities retain their natural temperature, or when the attack is violent, are decidedly cold. There is always great thirst ; whatever fluid is taken, being, however, almost immediately rejected from the stomach. Towards evening there occurs, in most instances, a decided febrile exacerbation. The patient frequently suffers considerable pain, as indicated by fretfulness, frequent change of posture, drawing up of its legs, and occasional acute cries. The abdomen is often somewhat tumid, and painful when pressed upon. While, in most instances, the irritability of stomach continues, to a greater or less extent, throughout the attack ; it occasionally happens that, after a few hours, the vomiting becomes suspended, while the diarrhoea continues unabated ; the irritability of the intes- tinal canal being such often as to cause whatever food or drink is taken to pass off rapidly without the slightest change. In some cases, at a very early period, the patient becomes affected with delirium — tosses its head backwards and forwards, and attempts to bite or scratch its attendants. In very violent attacks, the prostration which ensues is so great as to destroy the patient within twenty-four hours. In general, however, the disease runs a much more protracted course. The emaciation becomes extreme — the eyes languid, hollow, and glassy — the countenance pale and contracted — the nose sharp, and the lips thin, dry, and shrivelled ; while the skin upon the forehead is smooth and shining as if stretched tightly over the bone. The child lies con- stantly in an imperfect doze, with half open eyelids, and so insen- sible to external impressions, that flies have been known to light upon the half exposed eyeballs, without the patient exhibiting the least consciousness of their presence. The skin is now cool and clammy, of a dark brownish hue, and often covered with petechias — the tongue of a dark colour, smooth and shining, or covered, as well as the whole of the inner surface of the mouth, with aphthae. At this stage of the disease the fauces become dry, causing a difficulty in deglutition, and inducing the patient to thrust his hand deep into the mouth, as if to remove some substance from the throat. The abdomen becomes tympanitic, and the hands and feet pallid and cedematous. The discharges from the bowels are now, generally, frequent and profuse — dark-coloured and very offensive ; in some cases, however, they are small in quan- tity and composed entirely of dark-coloured mucus, mixed with the food or drinks that have been taken. The little sufferer becomes weaker and weaker — rolls its head about when awake — and utters constant, short, plaintive, hardly audible cries. He falls, at length, into a state of complete coma — death being often preceded by con- vulsions. Not unfrequently, at a much earlier period of the attack, effusion takes place in the brain, and the patient dies with all the symptoms of acute hydrocephalus. 204 DISEASES OF THE DIGESTIVE ORGANS. Ill most of the protracted cases an eruption occurs upon the breast of very minute watery vesicles. This Dr. Dewees considers to be in every instance a fatal symptom. We have in many instances, how- everj seen the patient recover, even where this eruption has been most extensive and distinct. The examination of the bodies of those who have fallen victims to cholera infantum, exhibits various lesions, chiefly of the alimen- tary canal. When death takes place early in the attack, the only morbid appearance discovered is often an unusual paleness of the mucous membrane of the stomach and bowels, with more or less congestion of the liver. Where the disease has existed for a longer period, increased redness at different points of the stomach and bowels is often present — follicular inflammation to a greater or less extent, occasionally advanced to ulceration, is not unfrequentiy met with. Occasionally, portions of the mucous membrane, either of the stomach or intestines, is more or less softened ; in other instances, increased redness of some portion of the alimentary canal exists, with contraction of its calibre to such an extent as scarcely to permit the insertion of a small-sized quill. The bowels are, in general, empty, or contain merely a small amount of a thick, tenacious mucus. The liver is more or less congested in the generality of cases, and sometimes very much enlarged. The gall-bladder is usually filled with dark-green bile ; it sometimes, however, contains only a pale, nearly colourless fluid. In a large number of the more protracted cases, serous effusion upon the surface or in the ventricles of the brain is present. Cholera infantum is evidently dependent for its production on the action of a heated, confined, and impure atmosphere upon the infan- tile system, at a period when it is already strongly predisposed to disease of the alimentary canal from the effects of teething. The influence of a high atmospheric temperature in the produc- tion of the disease is shown by the fact, that its prevalence is always in proportion to the heat of the summer — increasing, and becoming more fatal with the rise of the thermometer, and declining with the first appearance of cool weather in autumn. During its continuance, it is observed to vary with every permanent change of temperature — a few hot days in succession in the month of June are sufficient to produce it ; while, during the height of its prevalence, a spell of cool weather will diminish, if not entirely suppress it. A heated and confined atmosphere is alone sufficient for the pro- duction of the disease in those infants who have been prematurely deprived of their natural aliment, or whose diet is composed of irri- tating, indigestible, or otherwise improper articles. The extensive prevalence of the disease in this country is not de- pendent however, merely upon the heat of our summers, but upon the combined influence of a high atmospheric temperature, and confined and impure air. Hence it is almost exclusively confined to the larger and more crowded cities of the Middle and Southern States, and is es- pecially prevalent, and destructive to life, among the children of the poorer classes, inhabiting small, ill-ventilated houses, situated in nar- row confined lanes, courts, and alleys, or in situations abounding with AFFECTIONS OF THE STOMACH AND BOWELS. £05 accumulations of filth. When met with in the country, which is rarely the case, it is almost invariably in low, damp, and otherwise unhealthy situations. Notwithstanding cholera infantum is a disease readily cured, whenever we are able to carry into effect the proper remedial mea- sures, it is still one by which a large number of children are annually destroyed. The chief cause of the great mortality produced by it is, the impossibility, in the majority of instances, of removing the patients from the continued influence of those causes by which the disease is produced and kept up. Without this removal there is but little hope, in any case, of effectually controlling it by medicine — while, kl most cases, in their commencement at least, little else is required to accomplish a cure. In very violent attacks, it occasionally happens that the patient sinks at once — death ensuing in a few hours. Such cases, how- ever, are of unfrequent occurrence ; sufficient time being in general afforded for the employment of means calculated to arrest the pro- gress of the disease. Even after it has continued for many days, and reduced the patient to a state in which a fatal termination seems to be inevitable, by appropriate remedies, a very rapid cure may often be effected. In the treatment of cholera infantum, it is all important that the patient be removed at once from the heated and impure atmosphere by which the disease has been generated. Whenever this can be done in the early period of the attack — the child being, at the same time, confined exclusively to the breast, and immersed daily in a bath — warm or tepid, according as the temperature of the skin is deficient or increased — the disease will, generally, be arrested with- out the administration of anything internally, excepting perhaps some cool, perfectly bland, and slightly mucilaginous drink. Even in cases in which a removal to a healthy and airy situation in the country is impracticable, much benefit may be derived from carrying the patient frequently into the open air, in a carriage or in the arms, or when its residence is near a large river, sailing it daily in an open boat. In every instance the child should, if possible, be confined to the breast of its mother or of a healthy nurse, or if entirely weaned, to a diet of pure milk, with the addition of biscuit, rice, arrow-root, or tapioca. The apartment occupied by the patient should be kept strictly clean and dry, and freely ventilated — its clothing, besides being perfectly clean, should neither be too warm, so as to overheat the body, nor so thin and flimsy as to expose it to the influence of every slight change in the temperature of the air. In every instance, a careful examination of the gums should be made, and if they are found to be hot, swollen, and inflamed, they should be freely lanced. When the disease commences with diarrhoea, the warm bath, repeated daily, and followed by gentle friction over the entire surface of the body with the hand or a soft cloth — cold mucilaginous 18 205 DISEASES OF THE DIGESTIVE ORGANS. drinks, and one of the following powders, mixed with a little water and loaf sugar, repeated every two or three hours, will, ordinarily, very quickly arrest it. R. Calomel, grs. ij. Cretse ppt. 5 SS « Acetat. Plumbi, grs. vj. M. f. ch. No. xij. When vomiting is present, and the stomach rejects immediately everything taken into it, it will generally be found, that minute doses of calomel, from one-sixth to a quarter of a grain, rubbed up with a little dry loaf sugar, and sprinkled upon the tongue, will be retained and allay speedily the irritability of the stomach. When, however, the vomiting persists, we have found a few drops of tur- pentine, or of a solution of 5i- of camphor in 3L of sulphuric ether, repeated at short intervals, seldom to fail in removing it. In cases of violent vomiting, a few leeches over the stomach will often be found decidedly advantageous. When everything else fails, we believe that we shall seldom be disappointed in allaying the gastric irritability by the prescription of a teaspoonful, every hour or two, of the following solution : R. Aquae Purae, !§j. Acetat. Plumbi, gr. r. Acid. Acetic, gtt. v. Sacch. Alb. 3hj» M. A blister may at the same time be applied over the stomach for three or four hours, and then taken off and replaced by a bread and milk or flaxseed poultice. When the patient appears to suffer much from pain — the skin being hot and dry — the abdomen tumid and tender to the touch — leeches should be applied to the epigastrium in numbers proportioned to the age and strength of the infant and the extent of the symptoms, and followed by light emollient cataplasms or warm fomentations over the whole abdomen. The tepid bath should be repeated night and morning. A teaspoonful of cold water may be allowed every fifteen or twenty minutes, but the ordinary drink of the patient should be toast, rice, or gum water. In those cases in which there exists much heat about the head, with delirium or other symptoms of cerebral irritation, leeches should be applied to the temples or behind the ears, with cold lotions to the scalp, and some stimulating embrocation to the lower extremities. In all instances in which there appears to exist a tendency to disease of the brain, blisters behind the ears, kept open by the use of some stimulating ointment, will be found decidedly beneficial. When the irritability of the stomach is removed, the remedy which we have found the most certainly and effectually to restrain the dis- ordered condition of the bowels and complete the cure, is a combi- nation of calomel, prepared chalk, acetate of lead, and ipecacuanha. AFFECTIONS OF THE STOMACH AND BOWELS. 2Q7 R. Calomel, gr. iij. Cretae ppt. gr. xxxvj. Acetat. Plumbi, gr. xij. Ipecacuanhae, gr. iij. M. f. ch. No. xij. One of these may be given every three hours. Under the use of this prescription, with the daily use of the warm bath, exposure to a dry and cool atmosphere, and an appropriate diet, we have generally found the inordinate discharges from the bowels to be quickly suspended, and replaced by natural evacuations. As soon as the frequent watery discharges from the bowels are arrested, we are accustomed to suspend the use of the acetate of lead, and continue the calomel, prepared chalk, and ipecacuanha, in the same proportions as above, until regular and healthy stools are procured. When the cholera infantum has been allowed to run into a chronic form, its treatment then will differ but little from that of chronic diarrhoea. The most efficient remedies are, — the warm bath, fre- quently repeated ; a blister over the abdomen ; anodyne injec- tions, composed of thin starch and a few drops of laudanum; light astringents, as kino, decoction of dewberry root or geranium macu- latum, with a change of air, and a diet of boiled milk, thickened with rice-flour, or plain beef tea or chicken water. In many cases the sulphate of quinia in solution, besides exerting a beneficial influence upon the disordered condition of the bowels, will be found useful in restoring strength to the patient. When the discharges from the bowels are thin, small in quantity, dark-coloured, and highly offensive, with flatulency and a tendency to a tympanitic condition of the abdomen, we have derived the best effects from the use of turpentine, in the following formula : R. Mucilag. G. Arab. %lv. Spir. Terebinth. 3ij. Magnes. Calc. gr. xiij. Lavend. Spir. Compos. 3*j- M- The dose is a teaspoonful every three hours. When great irrita- bility of the bowels is present, we generally direct the addition to the above formula of 3hj- tine, kino, and the same quantity of the cam- phorated tincture of opium. When the disease has, by a judicious course of treatment, been entirely removed, the restoration of the patient's strength and the prevention of a relapse, are only to be ensured by the influence of a cool and pure atmosphere, a mild, unirritating diet, and the most scrupulous cleanliness of his person and clothing. — C.] Diarrhoea. — The forms of bowel complaints which we have hitherto been considering, appertain more particularly to the age of infancy, and arise chiefly from disorder of the stomach, or indigestion. We now come to consider diarrhoea as more properly connected with OQ8 DISEASES OF THE DIGESTIVE ORGANS. intestinal derangement, and occurring at any period of childhood — the disease indeed to which the child is most subject. Some object to treating of diarrhoea at all as a distinct affection, looking upon it merely as a symptom of disease. This, to a certain degree, is just ; but it would be carrying our regard for pathology to a very inconve- nient extent, did we omit to give a distinct notice of an affection of such common occurrence, and originating in such various sources, as diarrhoea — particularly when no traces of organic lesion are, in many instances, to be found after death ; for diarrhoea may exist long as a mere functional disorder, and thus destroy life. It is such forms of the complaint that we now propose to notice, — diarrhoea, as a symptom of organic disease, being to be treated of elsewhere. Symptoms, — The susceptibility and activity of the digestive organs, already noticed, predispose to render the effects of any cause of irritation quickly manifested in the child, by an increase in the abundance and frequency of evacuations from the bowels. The mucous and serous excretions are copiously thrown out, the biliary secretion soon deranged •, and, the irritation being conveyed to the muscular fibre, the peristaltic action is increased, and the stools are ejected with greater force as well as frequency. Some sickness of stomach usually attends, at least on a recent attack ; but the stomach may altogether escape being disturbed, and the appetite remain good. More generally, however, the appetite is precarious, or lost ; there is thirst usually for cold drinks ; the tongue is loaded, being white or yellow, with occasionally the sides or tip red, or aphthae may be present. Flatulency, acidity, and griping, almost always accompany diarrhoea in the child. Heat of skin, particularly over the abdomen, is present, and an evening exacerbation usually attends. Such is the state of things which is certain, sooner or later, to be observed in the child who has been overfed, or with whom the use of unwholesome food is continued. Impressions of cold, the retro- cession of eruptive complaints, or the prevalence of catarrhal fevers, often lead to attacks of diarrhoea in children ; but some difference is to be observed in the form of the bowel complaint, according as it arises from one or other of these causes. Diarrhoea is also more likely to be connected with inflammatory action, or to lead thereto, when originating in such sources, than when induced merely by errors of diet. Pathology. — When diarrhoea is severe, or has long continued, the child emaciates rapidly, the febrile symptoms become much aggravated, and their remittent form strikingly marked. The skin grows harsh, dry, and shrivelled ; the features greatly altered, so as to acquire a premature resemblance to old age : the belly swells, generally becoming hard and tender ; while symptoms, more or less decisive, of organic lesion, make their appearance. In many cases, however, diarrhoea will destroy life, without any marks of morbid action being to be traced, the intestines being simply found thin, transparent, and in many parts much contracted, while in others they are inflated with gas. The bowels are usually empty of feces ; and the mucous membrane is pale, or it may be softened. AFFECTIONS OF THE STOMACH AND BOWELS. 209 The form in which diarrhoea is presented will depend on the part of the intestinal apparatus that most predominates in the morbid ac- tion. The mucous, serous, or bilious secretions may be deranged, and give to the attack a particular character and name ; but these divisions, although found in nature and useful in practice, are not to be too literally regarded, as the character of the complaint is very liable to alter, when the attack is protracted ; and, in particular, de- rangement of the liver seldom fails sooner or later to appear. Hence the necessity for a constant regard to the symptoms, and exami- nation of the evacuations, the appearance of which should be a principal guide in directing the treatment. When the powers of digestion are very feeble, and the mucous membrane relaxed and irritable, the food may be passed unchanged, almost as soon as swal- lowed ; but, in ordinary cases, diarrhoea consists simply of an increased frequency in the motions, which are feculent but loose. Simple Diarrhoea. — When diarrhoea arises directly from the irri- tation or indigestible nature of the food, the stools are in the first instance feculent, — sudden and copious purging coming on, attended with some sickness of stomach and griping, the pain usually follow- ing the contents of the bowels as they pass along, and this form of the disease may be called simple or feculent diarrhoea. The abdo- men in this case is usually found full, and it may be hard or irregu- lar in shape, but not tense nor tender. The fulness depends on the overloaded condition of the abdomen, which in fact gives rise to the diarrhoea, and will disappear therewith. Hardness or irregularity, when felt in the course of the colon, and communicating the impres- sion of lumps being present in the abdomen, may be taken as an indication that hardened faeces, or scybala, are retained in the bowels ; and the stools should be searched for such, which will soon come away after the administration of a suitable aperient, should they not spontaneously appear. If the cause of the attack be not continued, it may of itself cease, after a few loose and feculent motions ; or it may be speedily put an end to by one or two doses of some mild aperient. When the use of improper food is persevered in, however, (as too generally hap- pens,) or the irritation in the first instance has been severe, the loose- ness of the bowels is continued, and the discharges, though still feculent, begin to present other characters ; but diarrhoea arising from this source is, for the most part, feculent at its commencement. The stools soon begin, however, to be charged with mucus ; and this is one of the most frequent characters which purging assumes in the child — Mucous Diarrhaza, as it has been called, being com- mon in childhood ; in particular, at the time of teething, but not con- fined to that period, as Underwood asserts. In this form of the complaint, the stools may consist solely of mucus, appearing like jelly, quite transparent, or lying at the bottom of the vessel, like semitransparent mucilage. At first, some fecal matter will be present, and the stools be variously coloured ; but their tena- city and consistency is what gives to them their peculiar character. This form of diarrhoea is usually very acute ; it may succeed the 18* 210 DISEASES OF THE DIGESTIVE ORGANS. former variety, or be joined with it ; but often sets in as an epidemic, prevailing at the same time with other affections of the mucous membranes. It may be accompanied with marked febrile symptoms, and connected with an inflammatory state of the mucous membrane, or a highly irritable state of the mucous follicles. Frequently, how- ever, mucous diarrhoea appears independently of any inflammatory state, but connected with a super-abundance of vitiated mucus, with which the stomach as well as bowels may be loaded, as is evidenced by what is vomited, as well as by the stringy evacuations passed by stool. The presence of worms may give rise to this form of irri- tation of the intestinal canal ; and we should examine the stools, to see if any be present in such cases ; which, however, they need not necessarily be. So much irritation can hardly prevail as in either of these forms of diarrhoea, without deranging the functions of the liver, and caus- ing a suspension of the secretion of healthy bile, or, what is more frequent, an inordinate flow, or a vitiated secretion. The stools are often of a bright yellow, or a grass-green colour ; but it is hardly necessary to denominate the diarrhoea bilious on that account, — this being an accidental, though common occurrence, during the continu- ance of either of the forms of diarrhoea just described. The stools often cause much pain, heat, or scalding, as they are passed ; and hence the popular notion that acrid bile is the source of the malady ; but the derangement of the liver and the flow of bile are, in them- selves, but secondary occurrences, and, what is important to attend to, appear often to be connected with a state of high irritation, or even inflammation, of the mucous membrane, particularly of the duodenum or stomach. The green colour of the motions is commonly caused by acidity, and they smell sour when evacuated ; or the acid may be generated after they are passed, and the stools become green when kept. But yellow and frothy, or very green stools, are often found in connection with enteritis ; hence we should examine, in such cases, whether other evidences of inflammation be present ; but not attempt to judge by the appearance of the stools alone, or, indeed, by any single symptom. Derangement of the liver causes much variety in the appearance of the stools, which may be dark brown, or even black, like pitch, and very offensive ; nor is absence or deficiency of bile less remarkable in its effects. To this cause, principally, are to be attributed those pale-coloured clayey evacuations, at times seen in children, and generally accompanied with constitutional disturbance. The fault, however, does not rest solely with the liver, which is often only secondarily affected, the primary source of the malady being disorder of the duodenum. A diarrhoea of this description, the stools being occasionally lumpy or pasty, though generally thin, is not an infrequent attendant on the cutting of the double teeth, as Under- wood has noticed. Fever attends, appetite is lost, and the child rapidly emaciates ; this being always an obstinate, and often a dan- gerous form of diarrhoea. A copious discharge of thin, watery motions, often limpid or almost AFFECTIONS OF THE STOMACH AND BOWELS. 2 11 colourless, and occasionally intermixed with flakes or shreds, is often observed in infants, and, being accompanied by pain, has been termed in vernacular language the Watery Gripes. This form is truly a serous diarrhoea, arrising from inordinate excitement of the exhalants of the intestines, and is nearly allied to the mucous diarrhoea, with which it may be mixed. It may, like it, occur in an acute form, or be the result of a state of atony, or debility of the exhalant vessels. This form of diarrhoea, in particular, is liable to be induced by sudden impressions of cold on the surface, if perspiration be suppressed thereby ; or it may be brought on by cold or acid drinks, taken while the body is heated. The quantity of fluid passed by stool in this way is at times inordinately great, so that rapid emaciation and sinking ensue, the effects of the disease being like those of cholera as already described, and to which it at first bears no small resem- blance. Occasionally we meet with diarrhoea attended by the discharge of very white, as well as very copious and thin stools. This variety seems to resemble the last ; but the peculiarity of colour appears to depend on more than the mere absence of bile — probably on some peculiar alteration in the glandular secretion from the intestines, more particularly, perhaps, that of the pancreatic glands, as some have con- jectured. This kind of purging is always to be looked on in a serious light. During the highly irritable state of the intestinal canal which gives rise to these frequent and copious evacuations, it is not wonderful to find the powers of digestion impaired, and the mucous membrane little able to bear the presence of matters which, at other times, could be endured with impunity or advantage. Accordingly, we often find, in these cases of diarrhoea, that the food is passed unchanged, almost as soon as swallowed ; or, if at all digested, it is but very imperfectly changed into chyle, and even part of what is formed appears to pass before it can be absorbed. When this state of things existed, the term Lientery was applied of old, as marking a particular form of diarrhoea ; but this circumstance does not belong peculiarly to any one form, but may occur in all. M. Capuron seems to think that it belongs especially to the variety attended with white discharges ; but it occurs equally when the stools are serous. In fact, lientery exists whenever much excitability of the mucous membrane is present, and at the same time food is injudiciously given, which the stomach, being enfeebled, is unable to digest. It is while labouring under these forms of diarrhoea, the stools being slimy or watery, but almost without colour or smell, that chil- dren are presented to us in such a state of languor and distress, show- ing that tendency to coldness of the surface and sinking, to which infants are so prone when ill, especially with bowel complaints ; and when we must without delay arrest the disorder, or the child will perish from inanition, dying convulsed, before organic change has had time to take place. Severe pains and spasm often attend on diarrhoea in the child. These may arise from the acidity and flatulency present, and amount 212 DISEASES OF THE DIGESTIVE ORGANS. to such a degree as to endanger life in the young infant. Violent screaming and convulsions are induced, or the child sinks as if suffo- cated from the oppression caused by inordinate accumulations of flatus ; and which is sufficient of itself to cause death by asphyxia, in the young child. In cases of infantile colic, the abdomen becomes excessively, or often suddenly enlarged, and is tympanitic to the touch : but in general the gas is felt to be unequally distributed through the bowels, and may be heard rumbling in the large intestines, or be perceived to escape from the mouth or anus. Pressure or friction with the warm hand gives relief. It is important to distinguish between these cases of flatulency, and the tympanitic state of the abdomen to be observed in the advanced stages of intestinal inflammation ; for the general state of the child is not unlike in both, — as the infant may be found cold, languid, or fainting, with impeded respiration, (the face being swollen or livid, from obstruction to the circulation in the head,) in a severe case of colic with flatus, without any form of in- flammation having been present. Acidity occasionally amounts to such a degree as to excoriate the lips, or redden the blue colour of the dress worn by the infant. We have at times seen an attack of infantile colic become periodical, occurring at the same hour for several days in succession, generally at two or three o'clock in the morning, at which time the child would awake, screaming, the abdo- men being distended with flatus : in a few cases, this occurred at four o'clock in the afternoon. We have not met with this kind of case, however, sufficiently often to look upon it in any light but that of a casual occurrence ; but Dr. Dewees speaks of a distinctly periodical colic which attacks infants, coming on, in general, from four to six o'clock in the afternoon, and lasting three months ; so that it has got, in America, the name of " the three months' belly-ache. " When much irritation attends any form of purging, the peristaltic action of the intestines is increased, so that the stools which in the natural state are rather squeezed out from the anus, than actually passed, are now ejected with force, or even with violence, asifsquirted from the bowels. Blood not unfrequently follows in these severe cases, and passes alone, or more commonly mixed with the stools. Needing, or tenesmus, frequently attends, — the stools being small, scanty, and with difficulty expelled. Prolapsus ani, or coming down of the intestine will occasionally result from irritation of the bowels ; and this is not an uncommon affection with children who have suffered much from bowel com- plaints. Indeed children are commonly the subjects of this complaint, being more disposed thereto than adults, both from the nature and structure of the parts concerned : for, not only are the viscera of the abdomen more voluminous, and the mobility of the intestine greater, in the child, but the resistent powers are less, the intestine not being so much curved, the sacrum more perpendicular, and the coccyx still moveable thereon ; while the connections of the rectum are less ex- tensive than in the adult, in consequence of the imperfect develop- ment of the neighbouring parts. Occasionally, a large portion of AFFECTIONS OF THE STOMACH AND BOWELS. 2 13 the intestinal mucous membrane is protruded, and this appears to be highly vascular ; being presented in the form of a small pyramidal tumour, red and coiled, rather than in the shape of a circular fold, or two lateral flaps, as is most usual in the adult. If not judiciously- treated, and soon returned, it may inflame, ulcerate, and even slough. Most of these symptoms of high irritation, however, and especially hemorrhage, are connected with an inflammatory state of the bowels, and, when present, should induce a strict examination into all the symptoms. Diarrhoea is liable not merely to be protracted, but to become chronic, and is often presented in an exceedingly obstinate form, — a state of constipation alternating with that of purging, which, how- ever, is soon brought back by any error in diet, or induced by the exhibition of a purgative. In chronic diarrhoea, the great point to determine is, how far the relaxed state of the bowels depends merely on an habitual derangement of function, or want of tone in the parts, or continues to be kept up by the presence of irritating matters in the intestines, or a state of chronic disease in the intestinal mucous membrane. Our prognosis, in diarrhoea, will depend mainly on the determina- tion of the question, how far the disease, whether acute or chronic, has had its origin in inflammation. Even in severe cases of recent diarrhoea, if merely sympathetic, or induced only by the use of im- proper food, we may hope favourably, though the child be greatly reduced : in chronic diarrhoea, much will depend on the history of the case, and the probable cause which seems to keep up the com- plaint. When the purging appears to depend on want of tone simply, or on the irritability and consequently increased action dependent thereon, and especially if kept up by inattention to proper regulation of diet, or by the injudicious employment of medicines, we may look to a different mode of management as promising a favourable result. Children who have been long subject to attacks of diarrhoea, how- ever, or who have suffered much from the disease in early infancy, rarely escape with merely functional derangement of the bowels ; and though we may from time to time remove such attacks, we cannot promise, too confidently, a perfect cure ; as it will at times happen that, when least expected, an attack, apparently of no un- usual severity, will carry off the child. Treatment. — Diet. — Attention to diet is a chief point in the treatment of diarrhoea, no matter what be its form or duration. In regulating the diet, we will often remove the cause of the disease, which is commonly induced by improper food, and which may fre- quently be remedied by attention to this point alone ; while no medicines will avail, if this be neglected. The principles on which to ground our regulation of diet should be to give food only in small quantity, of the least stimulating quality, such as is easy of digestion, and likely to leave but little residue behind. We have already stated some of the points to be attended to, with respect to diet (see page 196), at the commencement of diarrhoea, but attention to this subject should never relax during the existence of the disease. In the more 214 DISEASES OF THE DIGESTIVE ORGANS. acute or recent stage, gum water and barley water, slightly sweetened, or a mixture of both, constitute at once the best food and drink. Arrow-root, when made thin, and with water, may next be given, and is the best general diet, being a mild and nutritious food, and little liable to become acescent ; but, unfortunately,children in general dislike arrow-root, and it requires to be very carefully prepared, or they will not taste it. Milk, in any form, is likely to disagree in the first instance ; even the breast milk may require to be diluted with water. Bread and milk, or rice-milk, are equally objectionable ; but rice soon becomes a chief article of diet in diarrhoea, as it leaves scarcely any excrementitious matter ; but it should be thoroughly boiled, and only moistened with a little water or broth. Light broths may be then tried, of which chicken broth is to be preferred ; as also chicken itself, for animal food, when the child is old enough, and such can be borne. Chicken may be given with the rice, or some of the gravy of roast mutton. Vegetables are to be avoided, particularly potatoes, and acid or unripe fruits; for which, however, there is often a great desire, the appetite being frequently perverted in this complaint. Young meats, as veal or lamb, are indigestible, and therefore liable to disagree ; and fish almost always does so, in con- sequence of the quantity of excrementitious matter left behind : but rules for the dietetics of children have been already laid down, and these are in particular to be observed with children who are subject to a loose state of bowels. Keeping the surface warm, and the skin, if possible, in a lax state, is a great object in the treatment of diarrhoea, particularly when chronic ; hence the utility of warm clothing, warm baths, fomenta- tions to the abdomen, and friction. Liniments containing opium, or more particularly an opiate plaster, applied over the abdomen, will be found signally serviceable in some cases, and may save the necessity for the internal administration of opium ; but we must keep in mind that the injurious influence of this drug may be thus equally induced, and hence desist from its employment in liniment, or remove its presence as a plaster, should any symptoms of narco- tism ensue. A flannel swathe round the abdomen is often of signal service, both from the warmth it imparts, and the support it gives to the contained viscera. The feet, in particular, should be kept warmly clad. The influence of change of air, and of a warm and equable state of atmosphere in removing obstinate diarrhoea, or preventing returns of the complaint, is most remarkable ; and such change, when prac- ticable, should never be omitted. Medicines. — The primary question respecting the medical treat- ment of a case of diarrhoea is, whether we should attempt its re- moval by the use of an aperient, or at once try to arrest the purging. We have already given an opinion on this subject. When the infant is very young, and the evacuations profuse, we must in all cases try to moderate the discharge from the bowels ; and we know of no case in which the judicious use of opium for this purpose can be ob- jected to, — opium being our safest, if not principal agent in such AFFECTIONS OF THE STOMACH AND BOWELS. 215 cases, whether given alone, or as an adjunct to other medicines. We may use aperients, as already recommended (page 209), when diar- rhoea is recent, occurs directly in connexion with an overloaded state of the bowels, and is accompanied by feculent discharges. In full children that are overfed, and in whom much fever accompanies the attack of diarrhoea, the aperient may require to be repeated two or three times, or occasionally renewed. So, in any case when lumps of feces appear in the stools, or they are loaded with depraved mucus, vitiated biliary secretions, or undigested matters, an aperient maybe required ; but it is not to be persevered in unnecessarily, nor administered as if it were a cure for the disease, — being, in truth, valuable only as removing one of the causes of the complaint, or sources of irritation. In the employment of mercurials, we must be regulated by similar principles, employing them occasionally to cor- rect the vitiated condition of the secretions, and so tending to re- move a source of irritation, but by no means to be persevered in longer than such effects arise from their use. When much mucus loads the stools, the addition of half a grain or a grain of ipecacuanha to each dose of the aperient, will be found a useful adjunct. This subject is treated of with much judgment in the article Diarrhoea, Cyclopedia of Practical Medicine. We attempt to check diarrhoea by delaying the irritation that gives rise to it, or employing astringents for the purpose of stopping the discharges. In all cases, the first indication is to be fulfilled, if possible ; and this will be best effected, as far as medicine is con- cerned, by the use of opium and the fixed alkalies or their carbonates. Potash or soda are preferable in the first instance ; the carbonate of lime, either as compound powder of chalk, or chalk mixture, then becomes most available, and opium always adds to the sedative effect of these medicines ; but even without opium, they exercise a de- cidedly sedative influence. This is particularly manifested when there is much tenesmus or irritation of the rectum, which is often quickly allayed by a few grains of carbonate of soda or potash, given in the starch injection, with or without opium ; for we have observed that the irritation is much more effectually removed when the alkali is added, that when the opium is used alone. A small suppository, containing from the eighth to the fourth of a grain of opium, is often a convenient and effectual substitute for the anodyne injection with the child. The following is the form in which we prescribe soda in solution : — No. 42. R. Aquse Cinnam. ^i. Mentha?, ^ss. Carbonatis Sodae, gr. x. Syrupi Aurantii, 3>j« Tinct. Opii, gtts. vj. M. gi. — £ij. hor& quaque 2da. Dried carbonate of soda may be given in powder, combined with compound powder of ipecacuanha j or ipecacuanha itself, when 216 DISEASES OF THE DIGESTIVE ORGANS. mucus is in the stools, or the skin is dry and harsh. If, in addition, much heat of skin and thirst be present, particularly when the palms of the hands or soles of the feet are hot, the use of nitre is of great advantage ; but it should be guarded by opium, or well diluted in some mucilaginous mixture. Eight or ten grains of nitrate of potash may be added to the foregoing mixture, and the dose directed to be taken in some barley water or thin gruel : and in the same way may be administered the following powders, which we have found very serviceable in diarrhoea, under the circumstances just specified. No; 43. R. Carbonatis Sodae, sic. gr. i. Pulv. Ipecacuanhae, gr. \. Ipecac. Comp. gr. i. Cinnam. Comp. gr. i. Nitratis Potassae, gr. ij. M. Ft. Pulveres tales sex. Sumat hora quaque 2da vel 3tia unum. In the more advanced stages of diarrhoea, chalk mixture is the preparation of this class on which most reliance is to be placed. When much mucus loads the bowels, lime water possesses some peculiar properties in effecting its removal. The alkalies have the advantage, in addition, of being antacids, and as such are often required in the treatment of the bowel com- plaints of infants ; but to prevent the generation of acidity, as well as to remove its presence, we must endeavour to restore the tone of the stomach, and allay its morbid irritability, by the use of narcotics and bitters. The bitter infusions make excellent vehicles for the alkalies in such cases, and are not employed in the bowel complaints of children as frequently as they deserve, — having the power of restoring the functions of the stomach, while they correct the irritable state of the bowels. Of these bitters, the infusion of hop is particularly eligible for its sedative properties — that of gentian, or chamomile flowers, as a tonic ; and the alkaline carbonates may be exhibited in either of these ; but the bitter which most decidedly possesses an astringent power is the infusion of simarouba. This is not compatible with the alkaline carbonates ; but one of the most useful compounds that can be employed, in protracted cases of diarrhoea, is a combination of simarouba, nitric acid, and opium, — a prescription which common repute attributes to the late Dr. Baillie, of London. It may be ordered as follows for children : No. 44. R. Infusi Samaroubae, ?iss. Acidi Nitrici dil. gtts. iv. — gtts. ij. Syrupi Caryophyl. $iv. Tinct. Opii, gtts. vj. One or two tea-spoonfuls of this mixture to be given in some bar- ley water, three or four times a day. Other mineral acids have been AFFECTIONS OF THE STOMACH AND BOWELS. 217 recommended as astringents, in cases of diarrhoea ; but the nitrous acid decidedly deserves the preference, appearing to possess some power of allaying the irritability of the mucous membrane. Heat of skin and thirst, are abated, and the appetite soon restored, by the use of this medicine. When diarrhoea has long existed, the use of turpentine is occa- sionally of great service, after other means have failed. In such cases, especially when much flatus attends, we would particularly recom- mend the use of the terebinthinate mixture (page 98), to which might be added a few drops of laudanum. The medicines most commonly employed to act directly as astrin- gents, however, and check diarrhoea, are the preparations of kino or catechu ; and here it may be proper to state the circumstances that contraindicate an attempt to stop the purging. These are, when diarrhoea is of long standing ; when the discharge appears beneficial or critical, as the looseness of bowels that often attends dentition ; or the copious liquid evacuations which occasionally accompany the resolution of intestinal inflammation. Respecting long standing diarrhoea, we may observe, it is not easily arrested in general ; and we need not fear attempting to do so, if we only watch the effects of remedies, and desist, should febrile symptoms, or disturbance of any important organ ensue — a rule to be regarded in all cases. The diarrhoea attendant on dentition need not be interfered with, unless profuse, and the infant much debilitated ; but we should recol- lect, that severe purging is liable to occur at this period, independently of any irritation in the gums, and which requires prompt treatment, as already pointed out. It is in the case where the head becomes engaged during the ex- istence of diarrhoea, that the greatest caution is required; and we must carefully examine into the symptoms, to determine whether they arise from sympathetic irritation, or from exhaustion in conse- quence of inordinate evacuation —in fact, whether the symptoms be hydrocephalic or hydrencep haloid. In the latter case, the purging is to be arrested, and stimulants given, without delay ; in the former case, we should hesitate about suddenly checking the discharges from the bowels; but we should try to allay the irritation, and moderate their flow, by the use of the alkaline solutions, or small doses of mer- cury, opium being added with much caution. In the same cautious manner we must proceed, where the evacuations are connected with an inflammatory affection of the bowels; but the particulars respect- ing this case belong to the next division of our subject. Allowing for these exceptions, we have no hesitation in recom- mending the use of astringents, particularly kino or catechu, in the bowel complaints of children. 21 From half a drachm to a drachm of a [We have found the acetate of lead to be one of the best and safest astringents in profuse diarrhoea, occurring in children ; it may be given in the dose of from half a grain to a grain, either alone or combined with minute doses of opium and ipecacuanha. In pre- scribing the acetate of lead, in the diseases of children especially, it 19 21 s DISEASES OF THE DIGESTIVE ORGANS. the tincture of ether, may be added to each ounce of the alkaline mixture recommended at page 215, and given in all cases where the purging is severe, even though much general excitement at the same time be present. This excitement depends much on the state of irri- tation of the mucous membrane, which also leads to those alterations in the secretions so usually manifested by the appearance of the stools, and to which the irritation has been attributed as a consequence, whereas it is commonly the cause. Accordingly, we constantly find the stools quickly becoming consistent, and assuming a natural character, as well as diminishing in frequency, under the use of this astringent compound, without the employment of a grain of mer- cury, though these effects are commonly considered as peculiarly belonging to the influence which this medicine exercises over the functions of the liver. In fact, we would support our view by the line of argument adopted by those who advocate mercury exclusively — they give mercury to alter the secretions, and so lessen the irrita- tion : we give the medicines just recommended, to lessen the irrita- bility of the bowels, and so alter the secretions, commencing, as we conceive, at the right end. It is a different case where the source of the symptoms has its origin in an inflammatory affection of the mucous membrane — there, other measures become necessary ; but it remains to be seen, even in such cases, whether astringents be necessarily excluded. We have the authority of M. Bally in favour of the utility of kino in relieving diarrhoeas, accompanied by inflammatory and febrile symptoms, — the class of abdominal affections which we now proceed to consider. Inflammatory Affections of the Digestive Organs. When diarrhoea has existed for some days in an infant, and febrile symptoms suddenly set in, we have good reason for suspecting inflam- mation, and should look for the symptoms that characterise enteritis. To determine the existence of an inflammatory affection of the sto- mach or bowels, however, we must take all the symptoms and the history of the case into account. We have seen how severe the suf- ferings may be in mere functional disorder of these organs in the infant ; and on the other hand we shall find, that intense inflamma- tion may exist, so as to destroy life, or lead to irremediable organic change, and yet be accompanied with few symptoms calculated to arrest attention or point out the serious nature of the malady. A child will perish, in such cases, with little apparent cause for the fatal result ; which is commonly attributed, in a vague manner, to an affec- tion of the head. Symptoms. — Inflammatory affections of the abdomen occur in very young infants, and are perhaps most common in those under six months old. In such young children, the symptoms are chiefly local, and often obscure ; there is little constitutional fever, and the is important that no substance be given at the same time that may- have a tendency to decompose it. — C] AFFECTIONS OF THE STOMACH AND BOWELS. 219 pulse, in particular, is seldom disturbed. When, however, we find a child with a full tense belly, and tender to the touch, — uneasy, and not liking to be moved, — lying on its back or side, with the legs drawn up, and affected with purging and vomiting, we have little reason to doubt that the case is one of intestinal inflammation. This we can have no doubt of, if we find, in addition, the skin, particu- larly over the abdomen, very hot, the tongue dry and red with thirst, and an erythematous redness around the anus. The fever will be more distinctly marked the older the child is ; and the symptoms will vary in their character, according as the inflammation is situated in the stomach, or some particular tract of the intestinal canal ; and, again, according as the inflammation be simply one affecting the mu- cous membrane, or involving an affection of the mucous glands. The acute febrile symptoms, even when present, often soon cease, and give way to those of sinking, with much prostration of strength, the skin becoming cool or livid, and the belly losing its tenderness, but remaining tympanitic ; the evacuations from the bowels may cease, and symptoms of convulsions or cerebral congestion set in. When children are presented to us in this state, the previous history must be a chief guide in determining the true nature of the case. Gastritis. — Inflammation of the mucous membrane of the stomach may occur alone, but is usually accompanied by inflammation of the bowels. Gastritis may be met with in the youngest infant, and seems, in such instances, generally to arise in consequence of a state of congestion of the mucous membrane with which the child has been born. The symptoms which in particular characterise gastritis are, pain upon pressure over the stomach, which makes the child wince or cry, the more so, the more we press ; and vomiting imme- diately on taking food, or soon after, accompanied by distressing hiccup. This symptom, however, is not common ; and there may be no vomiting, nor even dryness or redness of the tongue, — nor any febrile symptom, if the infant be very young. In those more grown the nature of the case is made clearer by heat of skin, dryness and redness of the tongue, and perhaps quick pulse, with intense thirst, particularly for cold drinks ; but in severe cases, the smallest quan- tity of fluid may not be borne by the stomach. There is great restlessness, with occasional stupor. The bowels may be costive, or the stools natural. Enteritis occurs much more frequently than gastritis, and may exist without it ; but more commonly both are combined, constituting a case of gastro-enteritis. According to M. Billard, this combination occurs in children nearly twice as frequently as enteritis alone, and ten times as frequently as gastritis. In enteritis, the tenderness over the abdomen is situated lower down, is more diffuse, and often less acute than in gastritis. The skin uniformly is dry and hot, particu- larly over the abdomen, which soon becomes tense or tympanitic. In this affection the legs are drawn up, and the countenance peculiarly expressive of distress. Much thirst is felt, and hot drinks are occa- sionally preferred. The pulse is never quickened in very young infants, seldom so in those even after six months. Vomiting is often 220 DISEASES OF THE DIGESTIVE ORGANS. present in enteritis ; but not so frequently as in gastritis, nor does it occur so immediately after taking food. The matter vomited is often yellow, and may occasionally be fecal. The state of the bowels is very variable. The stools may be natural, but generally are much depraved in appearance. Costiveness may attend, but most com- monly diarrhoea is present, — the evacuations being thin and frothy, and of a yellow, or more frequently green colour. There may be neither redness nor dryness of the tongue, nor disturbance of the stomach ; but when gastritis is conjoined, or has been superadded, the symptoms which characterise that affection are combined with those belonging to enteritis. Some varieties in the symptoms of enteritis are to be observed, according to the tract of the intestinal canal in which the inflammation is seated ; and this is found very frequently to be in the ileum, particularly in its lower portion. It is not, however, easy to deter- mine this point, especially in a child ; but it is important to have some clue to guide us in our investigations ; for these affections of the ileum are of common occurrence, and very insidious in their nature, frequently leading to a fatal result without their existence being suspected during life. Ileitis. — This affection is seldom met with before dentition has commenced. It is to be distinguished as much by negative as posi- tive signs, — the general symptoms of an abdominal affection being present, without those denoting inflammation of the stomach or of the large intestines. The child is hot, particularly over the abdomen, and some tenderness may be found, on pressure, between the um- bilicus and crest of the ileum ; but neither the heat of skin nor the tenderness are remarkable, and there is a tendency in the surface to become cool, and the extremities to grow cold. Tympanitis is uniformly present, and soon sets in. There is thirst, but not for cold drinks ; hot ones are preferred, and this is accounted a distinctive character of this affection. The tongue is usually white on its upper surface, but red at the edges and tip, and pointed. In the child, little febrile action is present. The pulse may be small and quick, with in general great prostration of strength, the features being sunk and contracted. Neither vomiting nor purging necessarily attend ; but when a child that has been feverish is affected by diarrhoea, accom- panied by greater debility than the diarrhoea could account for, we may suspect ileitis. The state of the urine serves as a diagnostic, being scanty, high-coloured, and often so distressing in this case, as to lead to the supposition that the kidneys may be affected. This symptom is particularly dwelt upon by Dr. Stokes, in his Lectures, as belonging to ileitis ; and though observations respecting the urine are not so easily made in the child, we have seen the value of this symp- tom verified. When vomiting attends, the matter rejected may be feculent, in consequence of the obstruction offered to the passage of the feces by the tumefaction of the ileo-ccecal valve, which the inflammation causes when seated therein. If the inflammation extend farther, and engage the mucous mem- brane of the large intestines, the case assumes a new character and AFFECTIONS OF THE STOMACH AND BOWELS. 221 a new name. It now becomes one of dysentery, or of colitis, ac- cording to more modern nomenclature. Inflammation of the large intestines, however, rarely occurs alone, being in general combined with that of the small intestines, and entero-colitis is, according to M. Billard, nearly as common a disease in the child as enteritis. In this complaint we universally have tumefaction of the abdomen, and pain on pressure, with that redness around the anus which attends on irritation of the lower portion of the intestines, and seems caused by the alvine evacuations. The pulse is seldom raised, and is often feeble. The skin is generally hot and dry, but has a tendency to be- come cool or livid. This is particularly remarkable when the in- flammation is confined to the large intestines ; and in this case the tympanitic swelling of the abdomen is at first less constantly observed : neither does vomiting often occur, though occasionally present. Vomiting, however, often attends when the small intestines are in- volved in the inflammation; and the tongue will be red and dry, though no gastritis is present : but the vomiting does not occur on taking food, and the matter rejected is usually yellow. This is also the general colour of the stools, which are, however, often green, — diarrhoea being a frequent, though not constant, attendant on these cases. Much irritation is present ; the stools are passed with pain, or ejected with force, accompanied by straining or tenesmus ; or only a little mucus, tinged with blood, is evacuated. Hemorrhage often accompanies intestinal inflammation in the child, and may amount to an alarming degree ; but generally, only a little blood is mixed with the stools. When blood is passed, it in- dicates a high degree of irritation or inflammation of the mucous membrane, particularly of the large intestines ; but in very young children copious hemorrhage may occur inconsequence of congestion merely, independently of inflammation. The sympathetic relations of gastro-intestinal disease are particu- larly important in the child, being very liable to occur, and very severe when they do take place ; so as often to obscure the original disorder, the local symptoms of which become so much lessened on the occurrence of the sympathetic irritation, as to be frequently quite overlooked, the case being treated altogether as a cerebral or thoracic affection. Diagnosis. — The head is especially liable to become engaged in cases of intestinal inflammation occurring in the child, the symptoms of cerebral disturbance apparently possessing the severity and assum- ing the character of acute meningeal inflammation, into which sym- pathetic irritation would soon merge, if the state of the head were neglected, or the true nature of the case overlooked. When inflam- mation of the stomach or bowels in the child runs high, or is accom- panied by decided febrile symptoms, we soon perceive the child to become restless and uneasy ; it cries out, or starts in its sleep ; the head is hot, the eye wild, or it looks fixed and rather sunk ; there is intolerance of light or sound ; with tossing of the head, spasms of the limbs, or convulsive movements. An inexperienced or inattentive observer would have no doubt that the head was the seat of disease ; 19* 222 DISEASES OF THE DIGESTIVE ORGANS. but attention to this alone will not remove the symptoms, so long as their origin in gastric or intestinal disease is overlooked. We have already noticed the cerebral symptoms resembling those of effusion, which may accompany the state of exhaustion induced by the pre- sence of abdominal disease, and shall have again to recur to them, when speaking of the hydrencephaloid disease. The respiration is always more or less hurried in acute affections of the abdominal vis- cera in children. The breathing is rapid or oppressed ; there is pal- pitation, and often cough of an irritative and harassing kind ; but we observe that the respiration, though apparently impeded, is car- ried on by the thoracic, not abdominal muscles; and we find, on examining the chest, an absence of those signs which indicate pul- monary inflammation. Examination by the stethoscope should be duly made, and our treatment directed accordingly. Whatever tract of the mucous membrane be the seat of the inflam- mation, its form may vary ; and according to the form of the inflam- mation, a difference will be observed in the progress of the case, and the appearances found after death, when the result has been fatal. The simple or erythematous inflammation may end in resolution, when the case proceeds favourably, — the symptoms becoming milder, perhaps accompanied by copious discharges from the bowels ; or, the inflammation may become chronic, — the symptoms growing milder, but still persisting in a greater or less degree. When the case has terminated fatally, we observe on the mucous membrane traces of inflammatory action more or less distinct. Morbid Appearances. — There may be a ramiform redness of some portions of the membrane ; or the redness may appear to be caused by injection of the capillary vessels, and this is considered as indi- cating a severer form of inflammation ; or the redness may be seated in the tissue of the mucous membrane, and be disposed in patches, points, or red lines. These red patches are distinct, often ending abruptly, and when seated in the small intestines, may be perceived through their attenuated coats j but when situated in the stomach, no external mark is visible. The stomach is often found distended with gas, but may be con- tracted ; and when it is so, the creases of the mucous coat will be of a deeper colour than the other parts. In slight cases of inflamma- tion of the small intestines, the valvulae conniventes alone are dis- coloured. In severe forms of intestinal inflammation, disorganisation of the mucous tissue, or gelatiniform ramollissement may occur, — the membrane being reduced to a soft, discoloured mass, easily coming off like a red pulp, and leaving the coats of the stomach so fragile and thin, as readily to give way on the slightest pressure. Perforation of the stomach may thus occur during life ; and young infants sometimes perish suddenly from this cause. Gangrene is a rare consequence of intestinal inflammation in children at the breast ; but in those more grown, it is not of unfre- quent occurrence, if the inflammation has been severe, or stimulanis have been administered, in consequence of the nature of the case not having been understood. Gangrene may occur as the result of gas- AFFECTIONS OF THE STOMACH AND BOWELS. 223 tritis : but is most frequently observed in the small intestines, near the termination of the ileum : complete perforation of the intestine, with escape of its contents, thus ensues. The papillae or villosities of the mucous membrane may be en- larged or tumefied ; and that form of inflammation which leads to altered secretion, and constitutes the disease which is denominated muguet, occasionally occurs in the mucous membrane of the intes- tinal canal, but very rarely, compared with the frequency of its oc- currence in the mouth. It may be found in the stomach ; but, in these cases, it generally passes down the oesophagus, which will be often found affected with the disease, without its having extended to the stomach. It may be met with in parts of the intestines, but is of very rare occurrence. We judge of its presence by seeing this pecu- liar white secretion passed by stool during the existence of enteritic inflammation. The alteration of the glandular apparatus of the bowels, analogous to what constitutes aphthous ulceration in the mouth, is often met with both in the large and small intestines, particularly the latter ; but is less liable to occur in the stomach. When aphthae appear in the mouth during the existence of enteritis, they often indicate a similar state of some part of the intestinal mucous membrane, gene- rally in the small intestines. When aphtha? appear at the verge of the anus, the large intestines are more likely to be their seat; but they may appear in the mouth, or anus, without occupying the in- termediate tract. The lining membrane of the stomach and bowels, when inflamed, is generally found covered by an adhesive mucus. The extension of the inflammation to the mucous follicles is of frequent occurrence, and constitutes that important variety of intestinal inflammation, which has got the distinguishing epithet of follicular. This affection of the mucous glands frequently takes place in children, and is often an unsuspected source of danger in infantile disease. These mucous glands are scattered over the membrane singly, or in patches. In the stomach and large intestines they are isolated ; but occur in clusters in the small intestines, and, when inflamed, appear slightly elevated, like small reddish pimples, with a spot or orifice in the centre. When about to ulcerate, they soften, become white, and sink in the middle, or suppurate, — appearing often like a brown slough or eschar, but without surrounding swelling. This form of disease is not common in the stomachs of children. Some cases, recorded by M. Billard, occurred in very young infants, and seem to have been attended with great debility, but without purging or vomiting. In the intestinal mucous membrane of children, however, this form of ulceration is often met with, and is a common termination of en- teritis, particularly when seated in the lower third of the ileum ; but it may occur in other parts of the small intestines, and also in the large, — ulceration of this form being the lesion on which is found to depend chronic diarrhoea, or dysentery, In most instances where they end fatally, particularly the latter disease.. These mucous follicles are hardly to be perceived just after birth, but increase in size as th$ 224 DISEASES OF THE DIGESTIVE OltGANS. infant grows older, and seem to undergo rapid development about the time of dentition, as already remarked. These glands may be excited or irritated, particularly about this period, without being actually inflamed, or passing into ulceration ; and to this excitement of the intestinal glandular apparatus, and consequent increase of their secretions, is in great measure to be attributed the copious watery diarrhoea of infants. Under these circumstances, the highly irritated glands are very liable to become inflamed, and much judgment is required in the management of the case. Suddenly arresting the discharge might tend to this effect ; but the debility often induced by the inordinate evacuation from the bowels, imperatively demands attention to this point. During the progress of febrile attacks, and often in the course of remittent fever, the follicular glands, particu- larly in the ileum, are liable to become inflamed, and to pass into ulceration. Such morbid conditions are not unfrequently the cause of those protracted illnesses, in children, which go by the names of worm- or bilious fevers. Dr. Crampton gives an account in the second volume of the Dublin Hospital Reports, of an affection of the glands of the intestines occur- ring in children during the prevalence of fever, in the year ISIS. The ages of the children varied from three to eight years. The mucous membrane was found in many places highly vascular, and covered with granulations of a yellow colour, as if a coating of yellow wax adhered to them : in others, the granulations were of a dirty white hue ; and in several, ulcerations had taken place, and was disposed in patches of small ulcers, with well-defined edges. In cases which terminated favourably, a quantity of " yellowish, branny scales" was observed in the stools, floating on the liquid discharges, " like minute portions of wax from honey-comb." This appearance in the stools of children affected with dysenteric fever, Dr. Crampton had before observed, and often witnessed during the catarrhal fever which prevailed in Dublin in the year 18 IS. It does not appear that this morbid condition was the cause of the fever, as it existed independently of any febrile disorder, in some instances. When attended by fever, there was unusual abdominal tenderness, loaded tongue, intense thirst, occasionally vomiting, but more frequently diarrhoea, tenesmus, slimy and green stools, mixed with blood. " When remedies proved ineffectual, a true dysenteric state became established, the tubercles on the mucous membrane were converted into ulcers, and the patient died in a hectic, emaciated condition." Acute attacks of mucous or serous diarrhoea, attended with much ex- citement, and soon assuming an inflammatory character, are often met with among children during the prevalence of catarrhal fevers, or after attacks of measles, scarlatina, &c, &c. The disease may assume a dysenteric form, and appears to be contagious. When, during convalescence from such disorders, we find a child losing his appetite and flesh, while symptoms of remittent fever begin to show themselves, and then diarrhoea sets iu, we may suspect a morbid condition of the mucous membrane of the small intestines, involving the muciparous glands, and should be on our guard accordingly. AFFECTIONS OF THE STOMACH AND BOWELS. 225 These various forms of intestinal inflammation are liable to become chronic. The child then emaciates rapidly ; the skin grows harsh, dry, or dirty looking, and the limbs are wasted ; but the abdomen is full, and may become hard or tense. There is thirst, with loss of appetite, or it is very precarious. The tongue is loaded, or dry and red ; the lips are parched and chapped, and often excoriated from being picked. The bowels are much deranged, diarrhoea being generally present, with foul and unnatural stools, often mixed with blood. The fever is decidedly remittent ; aphthae often appear in the mouth, or may be seen on the verge of the anus ; and if the case be mistaken or mismanaged, every symptom becomes aggravated, and the child perishes in consequence of an acute attack, or dies, worn out by the fever, — the head or chest becoming, in general, engaged towards the termination of the case. Prognosis. — The difference between inflammatory and functional disorders of the digestive organs, in the child, is not less important as regards practice, than as regards prognosis. No matter how severe are the vomiting and purging, they may often speedily be stopped, if the belly be not tense and tender, nor other symptoms of inflamma- tion present ; but when such attend, we gain little by merely check- ing the evacuations, which it may be even dangerous to attempt, so long as the inflammation is allowed to persist. In inflammatory affections, the danger is in the first instance from the acuteness of the attack, which often leads to a fatal result if not speedily arrested. When met by adequate means, however, the inflammation tends to resolution much more than to become chronic, in the child ; but we need not despair, should it take this turn, and even organic disease be set up : for ulceration of the mucous apparatus of the intestines, though a dangerous, is not necessarily a fatal disease, especially if its true nature be clearly ascertained. This is of more importance, as regards treatment at least, than attempting to determine the particular portion of the intestinal canal that maybe the seat of the inflammation or ulceration ; which it is especially difficult to do in the child. It makes little difference in our treatment, however, what particular part is affected, if we can only determine what the nature of the affection be, and thus decide whether we are to employ directly antiphlogistic remedies, or not. Treatment. — The first question is, whether leeches are to be employed in the treatment of the case, and how they are to be ap- plied. When the symptoms are decided, the case acute, and the child a little grown, or very robust, we should never omit the use of leeches in the first instance. A repetition of the leeching is preferable to allowing any lengthened flow of blood, which may run down the child, without arresting the disease : hence care is required when leeches are applied to the epigastrium ; and we should ourselves superintend the operation, so as to be able to stop the bleeding as soon as necessary. When the infant is very young, the use of leeches is a measure requiring great caution. If much tenesmus be present, with blood mixed in the stools, as occurs when the large intestines are engaged, more immediate relief will ensue from the application of leeches to the anus, than any other situation. 226 DISEASES OF THE DIGESTIVE ORGANS. The employment of fomentations and baths constitute a principal part of the treatment ; and they are never to be omitted. When the child is feeble we may rest satisfied with the former ; but they should be assiduously employed. When able to bear a tepid bath, nothing gives more effectual relief than immersing the child in one up to the ribs, and keeping it in the bath for half an hour or longer. Some have advised cold applications to the abdomen, when the heat is very intense and the fever runs high ; and the effect of evaporating lotions,, in such cases, is spoken highly of. Stimulating liniments and blisters are most available after leeching and fomenting have been employed : when the acute symptoms have subsided, or any disposition is shown to relapse. Martinet extols the effects of sinapisms applied to one of the extremities for a quarter of an hour, or twenty minutes, several times in the day. We would not venture to continue the application of mustard or turpentine so long at a time ; but when used for a few minutes, until smarting is produced, much good is often done. Opium, added to the fomentations or liniments employed, is often of signal service in mitigating the severity of the symptoms. The internal administration of medicines requires judgment and caution. When the stomach is inflamed, nothing will, at times, be borne ; and the best plan is, to abstain from attempting to give any thing. This, however, cannot long be practised with the child, which will not survive without sustenance. Some try to meet the difficulty by administering nutritive enemata, — containing thin arrow-root, milk, weak broth, &c. ; but these are liable to irritate the bowels, and thus defeat their own object. The plan which we have found to answer best is, to withhold every thing for a couple of hours, and then commence with a tea-spoonful of very cold or iced water, lemon- ade, or gum-water slightly sweetened. The breast milk of a good nurse, mixed with water, will then be borne ; and we rely on the continued use of thin mucilage of gum, as the mildest sustenance we can employ. If the local applications already advised be at the same time adopted, the irritability of stomach soon becomes allayed ; and the breast milk may then be given occasionally, but in small quantity. When the bowels are confined, the mode of managing them is a matter of some difficulty. If gastritis be present, no purgative should be given by the mouth ; mild laxative enemata alone should be used ; but these must be repeated until purgation is effected, as emptying the bowels is important in such cases. Constipation is, at times, a troublesome symptom ; but when present in enteritis, we must recol- lect the inflammatory state in which it originates, and try to remove this symptom by overcoming its cause, not by the use of active pur- gatives. Some aperient, however, may be required ; and the com- pound powder of rhubarb (p. 127,) or the powder of rhubarb and magnesia, with a little calomel, in general answers best. A laxative enema may follow ; but castor oil, though commonly given in such cases, often causes much irritation. The best and safest general rule is, to depend on enemata for opening the bowels; and the injection of warm water simply, or very thin gruel, should be preferred when the frequent use of enemata is required. In some cases, where there was much irritation of the lower tract of the intestinal canal, with AFFECTIONS OF THE STOMACH AND BOWELS. 227 needing, bloody stools, or diarrhoea, we have seen a mitigation of all the symptoms speedily follow the use of the warm water injection. The employment of mercury, in inflammation of the bowels, is as important in any other form of inflammation ; and next to bloodlet- ting holds an important rank. Calomel or hydrargyrum cum cret& may be given alone, or associated with opium, according as the bowels are confined or loose. In more grown children, the addition of mercurial ointment to the stimulating or narcotic liniments employed is of much service, and adds to the chance of affecting the month, which in severe cases may be desirable ; but even in the youngest children, mercury will exhibit its power of controlling inflammatory action, independently of salivation, though not in so striking a manner as where that can be effected. When diarrhoea is present, or the bowels irritable, the best form for giving mercury is the hydrargyrum cum creta with Dover's powder. Mercury is here used to subdue inflammatory action, not to cure diarrhoea — the mode of employing it in bowel complaints, which we have elsewhere condemned. Opium is a very important item in the treatment of inflammatory affections of the bowels in children, but caution is required in using it. Leeching, when necessary, should always precede its use ; and then the effect of opium is often remarkable in mitigating the severity of the symptoms. Opium given by the mouth helps to allay the irri- tability of the stomach, and administered in enema affords the speediest relief by lessening the irritation of the bowels; but mitigating these symptoms is doing little, unless at the same time the inflammatory action be subdued. Opium appears, in some instances, to exercise even this power, when used after bloodletting, or in cases where the child is too much reduced to admit of this measure. Peritoneal inflammation, arising from escape of the contents of the bowels through a perforation in the intestines, caused by ulceration, is liable to occur in the child; but even in such cases recovery has been effected by the administration of opium, and abstinence from purgatives, as suggested by Dr. Hart,* and practised, with success, by Drs. Graves and Stokes. If, when employing opium, sleep or stupor be induced, without the symptoms being mitigated ; or if the belly become full and tense, with increase of tenderness, when purging has been checked, we must lessen the dose of the opiate, or suspend its use. So in attempting to employ astringents where diarrhoea is severe, or dysenteric symp- toms are present, we must be careful not to have too early recourse to their use, and to lay them aside when any accession to the in- flammatory symptoms threatens. However, we have found benefit from their use where the irritation or exhaustion from excessive purging was severe, even before the febrile symptoms had dis- appeared. To support the strength during the progress of these cases, is a matter of importance, and should not be overlooked. When the * Dub. Hosp. Reports, vol. 5. 228 DISEASES OF THE DIGESTIVE ORGANS. more acute symptoms have been subdued, we must administer nutri- trious food in small quantities, as advised in the treatment of diarrhoea — beginning with a little chicken broth, which may be at first given cold. When the case has become chronic, our chief reliance must be placed on a careful regulation of diet, with the repeated use of coun- ter-irritants applied over the abdomen, and the occasional employment of opiates, when indicated. In protracted cases where the mucous membrane continues in an irritable state, accompanied by diarrhoea or dysenteric symptoms, the employment of the alkalies, astringents, or bitters, as recommended in the treatment of diarrhoea (p. 215), must be adopted ; or acetate of lead, nitrate of silver, per-sesqui- nitrate, or muriated tincture of iron, &c, be had recourse to as with adults in such cases. A powder consisting of equal parts of starch, powdered nut-galls, and Dover's powder, will be found occasionally to check chronic diarrhoea when every other remedy has failed of effect. Perseverance in the use of those remedies, when judgment is exercised in their selection, may effect recovery, even though there be evidence of intestinal ulceration. Change of air, and warmth applied to the surface, are essential aids in effecting recovery in all protracted cases. [We can speak from experience of the good effects, in the chronic diarrhoea of infants, of a combination of powdered galls, ipecacuanha and camphor, in proportions adapted to the age of the patient. — C] IV. MESENTERIC DISEASE (TABES MESENTERICA). Inflammation of the intestinal mucous membrane, or ulceration, such as we have noticed in the last section, may give rise to irritation in the mesenteric glands, leading to their enlargement, softening or suppuration, as we observe to occur in other glands from similar causes. Dr. Cheyne, in his Essay on the Bowel Complaints of Chil- dren, long since pointed out the occurrence of diseased mesenteric glands in consequence of intestinal irritation : and this view of the subject is that most popular among modern pathologists. We cannot deny, however, that disease of these glands may arise independently of disease of the mucous membrane : though such is not commonly the case. During the progress of tabes mesenterica, however, disease of the mucous membrane seldom fails to arise, especially towards the termination of the case, death generally ensuing in consequence : hence it is of great importance, both as regards the symptoms and treatment of the disease, to try and discriminate between the morbid action going on in the intestinal mucous membrane, — whether as a cause, complication, or consequence, — and that which strictly belongs to the mesenteric glands. Causes. — Most authors concur in regarding tabes mesenterica as a scrofulous disease ; and Dr. Joy (in his article, Tabes Mesenterica — Cyclopaedia of Practical Medicine), gives preference to the appel- MESENTERIC DISEASE. 229 lation adopted by Sauvages, scrofula mesenterica. Bichat notices the slow progress of the complaint as characteristic of its strumous nature, and doubtless we shall be correct in viewing it in general as such ; but we must not forget its frequently and inflammatory origin and complications, nor allow our practice to be biassed by this view of the subject to the extent that the older practitioners did. The mesenteric glands, which are scarcely perceptible at birth, undergo gradual development, until about the period of dentition, when, in common with other parts of the glandular system, they begin actively to enlarge ; and accordingly we find that disease of the mesenteric glands makes its appearance about this period. Infants are seldom affected before the eighth month ; but from that time to the eighth or tenth year, the disease is liable to occur, — most frequently, perhaps, from the third to the sixth year, or about the seventh, as stated by Gardien. The glands of the mesentery are, according to Meckel and Portal, more subject than any others to tubercular disease ; but true tabes mesenterica is not so common a disorder as may be generally thought. The disease is met with most frequently among the children of the poor, especially such as are of a strumous habit — in fact, all circumstances tending to the production of scrofula, tend also to the production of mesenteric disease. Unwholesome food, in particular, as leading to derangement and disease of the digestive organs, has a direct tendency to cause irritation in the glands of the mesentery. Predisposition to tabes mesenterica is manifested in the general characters that indicate the strumous diathesis, in particular when the digestive organs are prone to become deranged, and the abdomen is unusually prominent. The latter sign is one much regarded, in general ; but its value is overrated, if indeed it possesses any, as a sign of predisposition to the disease : for until the mesenteric glands are much enlarged, they cannot add to the size of the abdomen, and this part is naturally more protuberant in the child than in the adult. Guersent expressly declares his dissent from the popular opinion, as he did not find children with a large abdomen more prone than others to this disorder, and on the contrary found the mesenteric glands diseased in those who presented no particular protuberance of the belly during life. This fact, all who examined into the disease must have observed ; and, what is more remarkable, enlarged, or even suppurated glands, are found occasionally in the mesentery of children who have died in good condition of body, and had appeared in good health up to the time of their death. Tubercular disease of the mesentery may exist alone, as well as tubercles be found in other situations without any being present in the abdomen ; but, most generally, diseased glands are at the same time found in other parts, or well-marked scrofulous disease of some description coexists with the mesenteric disorder. The most common combination seems to be, with tubercles in the lungs ; for even in children, Guersent found only a sixth of those who died in hospital, of mesenteric dis- ease, free from this complication. Morbid Appearances. — The glands of the mesentery, as we 20 230 DISEASES OF THE DIGESTIVE ORGANS. have seen, are capable of taking on increased action, and becoming congested, enlarged, or inflamed, in consequence of the irritation caused by disease of the intestinal mucous membrane. In such cases, the progress of the morbid changes may be traced, by dissection, from an increase in the vascularity of the gland simply, to the deposi- tion of tubercular matter, or the formation of pus. The gland may be found almost natural in appearance, or only a little reddened, enlarged, or perhaps softer to the touch. More commonly, how- ever, it is partly changed into a soft, white, curd-like matter, or this is mixed with pus. These changes may occur without any dis- tinct evidence of the irritation having commenced in the mucous membrane ; and, what is not less important to recollect, tubercular matter may be deposited in the gland, or, as often happens, around it, without any appearance of previous inflammatory action, or even increased vascularity of the parts, — the glands being found pale, and not increased in density, even though examined in the first stage of their alteration. Andral is most explicit and decisive on this point. While they remain indolent, the tubercles are firm in consistence, and of a yellowish, or oftener dull white colour, and may not be larger than a pea; but as they increase in quantity, they arrive occasionally at considerable size, resembling " a heap of peeled chestnuts," to which they have not inaptly been compared. Tumours of even much larger size may be developed ; and in such cases, the tubercular matter not only occupies the place of the entire gland (which becomes absorbed), but accumulates around it ; and may even be found effused into the laminae of the mesentery, as stated by Portal. Symptoms. — The emaciation attendant upon this disease is a striking characteristic, and that from which its denomination, tabes, is derived. Tubercles in the mesentery, however, are not neces- sarily attended by emaciation from the first ; for they have been found in cases where the body was not wasted, and therefore their presence not suspected. Even in cases where emaciation has been established, and the glands in the mesentery can be felt enlarged, the wasting is not to be accounted for on the old supposition of actual obstruction to the passage of the chyle, and so wasting of the body from failure of nutrition ; for the glands, however enlarged, have not been found impervious to anatomical injections after death nor (as Cruikshank remarks) has "stagnation of the chyle in the first set of lacteals" been met with. The length of time during which mesenteric disease endures, makes also against this supposition ; when the patient dies, he perishes from the effects of some acute attack, or of the hectic fever which attends upon this, as well as other forms of tubercular disease. Indeed, emaciation does not become very remarkable, so long as the mesenteric tumours remain indolent ; but when once irritated, so as to become soft, and suppu- rate, hectic fever is set up, and emaciation rapidly ensues. The morbid condition of the digestive organs, so frequently a cause or consequence of mesenteric disease, doubtless contributes to interfere with the process of nutrition ; and probably (as suggested by Dr. Joy), the morbid condition of the glands themselves must interfere with their share in the process of perfect elaboration of the chyle. MESENTERIC DISEASE. 231 The wasting in tabes mesenterica is marked by its regularity and slowness — that attendant on bowel complaints, is rapid and vari- able, — the child recovering flesh when the disease is mitigated or subdued. It is no easy task to assign the symptoms that belong properly to tabes mesenterica, and separate them from those which belong to disorders of the mucous membrane unconnected with mesenteric disease, or which this complaint shares in common with other scrofu- lous disorders. After a careful review of the symptoms, as set down by systematic writers, and an attempt to verify them by observation, we are disposed to adopt the opinion of Guersent, and confess that the only unequivocal sign of tabes mesenterica is the perception of the enlarged mesenteric glands through the parietes of the abdomen. These we cannot expect to be able to feel, until they are decidedly developed, and the disease has made some progress, so that a degree of doubt must attend all such cases in their incipient stage ; yet there is a combination of symptoms which indicates with much probability the existence of the disease. These symptoms we shall enumerate, dwelling on those most to be relied on, and pointing out their rela- tion to treatment, which is not the least important consideration. For convenience of description, the disease has been divided into three periods or stages — First, the incipient stage, or that in which the enlargement of the glands is present, but has not yet made itself manifest by disturbing the general health, or deranging the digestive organs in any marked manner. Second, a stage of farther advance- ment, when the glands of the mesentery have become perceptibly enlarged, and the derangement of the digestive organs decidedly marked. This is the period at which the stools are observed to as- sume the white colour which they so frequently exhibit in this dis- ease ; and where glands in other parts (particularly the neck) are found enlarged. In the third stage, the mesenteric glands become irritated and suppurate ; inflammatory affections of the intestinal mucous membrane are set up ; constitutional fever is established ; emaciation becomes excessive ; and colliquative sweats and diarrhoea close the scene. Such arbitrary divisions cannot be found exactly accordant with nature ; but they have been adopted by authors, and are convenient for investigating the disease. Respecting the premonitory stage, we would observe, that though not necessarily giving rise to disorder of the digestive organs, it often arises in connection with such ; and whenever mismanaged or scro- fulous children have been subject to gastro-intestinal disease, we should be on the alert, and keep attention alive to the state of the mesenteric glands. When we find that such children recover very slowly ; are often subject to relapses ; that the belly remains full, and grows hard, while the wasting of the flesh continues (though the appetite be good, or even voracious during the period of convales- cence) ; we may suspect enlargement of the mesenteric glands, and should look for such. Occasionally the glands may be felt through the parietes of the abdomen, and this is the only satisfactory sign of their enlargement at this early stage. 232 DISEASES OF THE DIGESTIVE ORGANS. When tabes mesenterica is established, however, and approaches the second stage, its characters become better marked. At this period, we should find the glands enlarged ; and when such are detected, being found hard and knotty in a distended abdomen, no doubt can be entertained as to the nature of the case. The examination will be best made when the patient is fasting. The enlarged mesenteric glands will be felt about the centre of the abdomen, and some slight pain usually attends the examination. This serves to distinguish them from indurated feces, which cause no pain on pressure, and are found lying in the course of the colon, more particularly to the left side. The abdominal pain that attends on mesenteric disease is not increased by pressure ; nor does it occur immediately after taking food, being neither accompanied by an inclination to evacuate the bowels, nor relieved when such evacuation takes place. Dr. Joy suggests, in addition, that it is by the concussion imparted by running, leaping, or by hiccup, that most distress will in this case be caused ; and Schmalz notices, that the pain is increased by the upright posi- tion, by bending of the back, or quick movement, or shaking of the body. The pain is protracted, lasting long, and often recurring about the same hour in the day; or, if absent for a few days, it is renewed with increased severity, as Underwood remarks. In relation to scrofula, it has been noticed that, in protracted cases, the pain is most severe in spring and autumn. Authors differ as to the character of the pain. Pemberton says it is lancinating and deep-seated, resem- bling the pain of gripes, and recurring three or four times a day. Guersent says it is a dull pain, and referred chiefly to the centre of the abdomen. Dr. Young notices its tendency to come out at the back or loins, in which others agree. The appetite is very variable, often voracious, and a desire ex- hibited for acid and indigestible food. Fresh meat is not relished ; and however nutritiously fed, the child continues to emaciate ; while the abdomen enlarges and becomes hard, until it presents a strange contrast with the shrunk limbs, and shrivelled, age-looking face, which are presented in the more advanced stages of the disorder. The derangements of the digestive organs which belong particularly to mesenteric tubercle, independently of inflammatory action of the mucous membrane, are not easily determined, if indeed such exist ; but when we find no aggravation of the symptoms induced by the use of stimulating or indigestible food, such as the child often craves for, we may consider that the symptoms depend more on enlargement of the mesenteric glands, than on disease of the digestive organs. The white, chalky stools, which are often observed during this disorder, have been looked upon as particularly attending tabes mesenterica, and assigned as a symptom belonging to its second stage. This white colour has been supposed to arise from the presence of the chyle, which was obstructed in its passage through the lacteal vessels ; while others attributed it to the admixture of calcareous matter in the evacuations. The error of the first supposition has been already exposed ; and no proof, beyond mere appearance, has been brought forward in favour of the other. White stools, as we have MESENTERIC DISEASE. 333 before noticed, attend certain forms of irritation, or inflammation of the intestinal mucous membrane. According to the condition of this membrane, will vary the symptoms as regards the state of the stomach and bowels during the progress of tabes mesenterica ; the mucous vomitings, foul discharges, diarrhoea or constipation, acidity and flatulency, which have been assigned as symptoms of the disease, being necessarily connected only with the digestive organs. These are certainly very liable to be deranged, irritated, and even inflamed or ulcerated, during the existence of mesenteric disease ; though it has not been shown how tubercles in the mesentery particularly predis- pose to such conditions more than the presence of scrofula in general, such affections being most common in scrofulous children. Worms are not unfrequently present ; and when voided, are com- monly looked upon as the source of all the symptoms : they are, however, only an accidental combination ; though, perhaps, particu- larly liable to occur from the debilitated state of the digestive organs. According as the irritation caused by the disease of these organs, or by the enlargement of the mesenteric glands preponderates, will be ob- served a difference in the local and constitutional symptoms. In the for- mer case, we shall have more or less of the signs of gastro-enteritis, and the fever will be decidedly of the remittent type ; in the latter, the signs of inflammation will be absent, and the fever will assume the hectic character. Sufficient attention has not, perhaps, been paid to this point — the fever being described by some as hectic, by others as remittent ; or these terms indiscriminately applied : it is in fact a mixture of both, varying according to the circumstances just pointed out. When the disease is rapid, or the patient quickly cut off, there are well marked symptoms of remittent fever, and the child dies gener- ally of acute abdominal inflammation ; but when tabes mesenterica is slow and protracted, according to its usual course, the fever is a decided hectic, — ending in colliquative sweats and diarrhoea. During the existence of infantile remittent fever, we may apprehend irritation of the mesenteric glands, if the case be protracted, or often renewed, or if it occurs in children recovering from measles, &c. ; and the symptoms of the fever then tend to assume the characters of the hectic that accompanies tabes mesenterica. The tendency to chilli- ness in this complaint is extreme ; the least degree of cold is sensibly felt, and the patient hangs constantly over the fire. The skin is harsh, dry, and shrivelled — particularly on the extremities, which are often cold ; but heat of skin begins towards evening ; and as the fever becomes established, morning sweats set in, — which sometimes break out profusely on the head and chest, but may often be averted by keeping awake. The sensorial powers are not much disturbed ; but, d ulness of the faculties, fretfulness, and dislike to all exertion, are manifested. The child generally sleeps well, and delirium seldom or never occurs. The pulse is at first little disturbed, but soon grows permanently quick and hard. Should the enlarged glands become numerous, they may interfere, by their compression, with the func- tions of surrounding parts, as the liver, stomach, or kidneys ; or 20* 234 DISEASES OF THE DIGESTIVE ORGANS. anasarca may be induced, by obstruction to the flow of blood through the veins. In the third or last stage of the disorder, when the diseased glands have suppurated, much irritation or inflammation of the neighbouring parts usually ensues. The peritoneum may become inflamed, and effusion take place into the abdomen ; or, what is more common, inflammation and ulceration of the mucous membrane is established. Pus is occasionally present in the stools ; but is not necessarily a sign that the suppurating glands have evacuated their contents into the intestinal canal, as Schmalz seems to assume. Con- stant diarrhoea now attends, and the child perishes, after having been reduced to the last stage of marasmus. Diagnosis and Prognosis. — We have already pointed out, with so much exactness, the several symptoms belonging to mesenteric disease, in its different stages and complications, that little remains to be said in addition, under the head diagnosis. From the liability to complication with tubercle in other parts, par- ticularly in the lungs, we should always examine the chest in tabes mesenterica, to determine whether the hectic symptoms are connect- ed with pulmonary disease or not. Enlargement of the bronchial glands, is the complication next in frequency ; but is much more difficult to determine, and may altogether escape detection. The cervical or inguinal glands are often enlarged ; and when these show a tendency to inflame and suppurate, at the same time that the me- senteric disease becomes aggravated, and irritation or inflammation of the digestive organs is set up, we have reason to apprehend that softening or suppuration has begun in the enlarged glands of the mesentery, and our prognosis cannot but be unfavourable. This has been assigned as the second stage of the disease, and recovery from it is very rare. When arrived at its full development, or third period, mesenteric disease must be looked upon as hopeless. In the first or incipient stage, especially if the premonitory symptoms be attended to, we may look to treatment with hopes of success ; but to be successful, our remedies must be applied with much discrimination. Treatment. — After the view which has been taken of tabes me- senterica, much need not be said on the subject of treatment, — as this will resolve itself into the means necessary to subdue irritation or inflammatory action, and those calculated to support the constitu- tion, and cause resolution of the enlarged glands. Irritation or inflam- mation may exist in the mucous membrane of the stomach or bowels, or in the mesenteric glands themselves ; and either may give rise to the other. Under these circumstances, we must try and remove the inflammatory action by local depletion, abstinence, or careful regulation of diet ; and the use of sedative medicines, as already ad- vised in the treatment of inflammatory affections of the bowels. In all cases, fomentations, or the warm bath, and frictions over the abdomen, are to be had recourse to. When the irritation hascommenced in the mucous membrane, it is important to persevere in the treat- ment, until this affection is, if possible, completely removed ; for even a low degree of intestinal inflammation, if long continued, will cause MESENTERIC DISEASE. 335 or keep up irritation in the mesenteric glands, in a subject predisposed to the disease. We must recollect, however, that mere depletion will not remove this condition of the glands, and if leeching be carried too far, the constitution may be enfeebled without the enlargement of the glands being resolved, — particularly if the irritation has com- menced in the glands themselves. Neither are we to employ this system too exclusively, as if there were no other sources of the malady, save gastro-intestinal irritation. The whole plan of treatment pro- posed for the cure or prevention of scrofula, often comes into play ; and must be acted upon, when a strumous child is the subject of the disease. We are not, however, at once to fly to tonics or specifics, as the older practitioners did, without regard to the inflammatory origin or complications of the disorder. Of the remedies that have got repute in this way, the fixed alkalies, or their carbonates, would soonest admit of being employed ; as when judiciously administered, advantage might be taken of their sedative influence on mucous membranes, as before explained, in addition to their known efficacy in aiding the absorption of enlarged glands. Iodine is the medicine to which we would principally look for effecting the resolution of the enlarged glands, when regarded as a tubercular deposition. Iodine appears to have effected a cure in some well-marked cases ; but we must keep in mind the liability of this medicine to irritate the stomach and bowels, and always defer or suspend its internal administration when such irritation is present, or has been induced. The compound solution of iodine (see page 102) may be employed; but the hydriodate of potash is better, if the bowels are irritable. We generally prescribe it in decoction of sarsaparilla, — beginning with half a grain, or a grain, given in a dessert-spoonful of the decoction, two or three times a day. The addition of a little laudanum, or syrup of white poppy, to each dose, will lessen the liability of the medicine to disagree. Under all cir- cumstances the external use of iodine is admissible, and will always be found beneficial. W^e may prescribe the ioduretted bath ; or the ointment of iodine, or of hydriodate of potash, may be rubbed over the abdomen night and morning ; but these ointments are liable to irritate the skin in the child, and this irritation, though not objection- able in itself, will interfere with the continued use of the ointment. Iodine may, however, be employed in this way without any fear of inducing local irritation, by using an ointment of hydriodate of lead — ten or fifteen grains of which are to be mixed with half an ounce of lard. Mercurial ointment was formerly much used, and may still occa- sionally be employed with advantage ; but the use of mercury should never be pushed so far as to produce salivation when a decidedly strumous taint is manifested. The occasional use of a mercurial, combined with an aperient when the bowels are costive, or with an opiate when intestinal irritation and derangement of the secretions is present, may always be had recourse to with benefit. Small doses of calomel and antimonial powder, or nitre, when the febrile symp- toms run high, and there is furred tongue, thirst, and hot skin, are ^36 DISEASES OF THE DIGESTIVE ORGANS. often of great service at the commencement of the disorder ; and in particular tend to improve the state of the appetite, and lessen its voraciousness. If disposed to give mercury to produce any consti- tutional influence, it should be to act as an alterative ; and we would prefer minute doses of corrosive sublimate, as recommended by Sir A. Cooper, and which we have often seen produce a beneficial effect in scrofulous disorders. Aperients were much relied on of old ; and in the commencement of the disease, when the bowels are slow, and no intestinal irritation present, they may be employed with advantage. A preference has been given to rhubarb with sal polychrest, as recommended by For- dyce ; or with sulphate of potash as more commonly employed. To keep the bowels open, and act mildly on the intestinal mucous mem- brane, so as to cause some evacuation therefrom, will doubtless be occasionally useful ; but to choose this membrane as the surface on which to produce a species of counter-irritation by the agency of purgative medicines, would be, we think, to make a very hazardous selection. Irritation excited on the surface of the abdomen, by means of stimulating liniments, is a more efficient, as well as safer plan, and should never be omitted. Even continued friction by the hand has been found serviceable in exciting the absorbents. The regulation of the diet is a matter of importance. Some advo- cate an exclusive use of vegetable and farinaceous food. When inflammatory or febrile symptoms are present, the diet should, undoubtedly, be so restricted ; but the continued use of food of this description, in more grown children, is objectionable, as being calcu- lated to debilitate the digestive organs, and generate flatulency, acidity, &c. Portal goes so far as to suppose that such food is even capable of promoting mesenteric disease, by causing a congested state of the glands, in consequence of the circulation in the abdomen being obstructed by the distension of the viscera, thus produced. Some animal food, as broths, &c, will be required to promote digestion, and support the strength ; but wine, or fermented liquors, must be given with great caution. In protracted cases, change of air, with sea-bathing during convalescence, and all means by which the strength can be supported, without the digestive organs being over stimulated, must be had recourse to. As to direct tonics, the moderate use of bitters and chalybeates are among the best ; but the preparations of iodine, or its combination with iron, are for obvious reasons to be preferred, when such medi- cines are admissible. In extreme cases, we can only palliate symptoms, trying to check diarrhoea, moderate colliquative sweats, and allay pain, principally by the use of opiates. v. WORMS. Children appear to be more subject to intestinal worms than grown people, but are by no means so subject to them as is popularly supposed ; nor do worms, of themselves, produce the many distress- ing symptoms commonly attributed to them. It has been said that WORMS. 23J worms never appear in children while at the breast ; but this obser- vation, although generally true,- is not absolutely so, as some few exceptions have been observed. Causes. — Weakly, ill-fed children, living in low situations, of a strumous habit, and such as are subject to disorders of the bowels are oftenest afflicted with worms. In general, all coexisting dis- orders are attributed to the worms, if any are present ; but they may exist in healthy children, and produce no distress, — their presence not being suspected until they are passed by stool, or discovered after death. Some attribute the origin of worms to inflammatory affections of the bowels ; but they are connected with such, only so far as these disorders, by inducing debility of the digestive organs, may predispose to the presence of the worms. Others, again, think that worms may cause inflammation or ulceration of the intes- tines, and thus, by penetrating their coats, give rise to peritoneal inflammation and death ; but no such consequences necessarily attend the presence of worms. They may exist at the same time with intestinal inflammation or ulceration, as these affections are common in strumous, unhealthy children, such as are most subject to worms ; and should the bowels be perforated by ulceration, the long round worm, if present, will often creep through, and be found in the peri- toneal cavity: but this is a consequence, not cause, of the perforation. Worms are generally found imbedded in mucus, and a super- abundance of viscid mucus in the bowels constantly accompanies their presence, and is even looked upon as promoting their forma- tion. Worms, however, have been found abundantly where the mucous membrane was dry, for want of mucus ; and, according to the statement of Andral, we cannot look upon them as necessarily causing any morbid change in this membrane, as it was as often pale as red, in situations where worms were in contact with it. The protracted use of innutritious or farinaceous diet, with little or no animal food, and an insufficiency of table salt, or other condi- ments, has been assigned as a cause of worms, and apparently with good reason. It is remarkable, that while children are so subject to worms, infants at the breast are seldom affected with them. Summer and autumn appear to be the seasons during which worms most prevail. Symptoms. — Much as is talked about the symptoms of worms, and often as we hear of worm fevers, &c, there are in fact no symptoms that truly belong to worms ; nor is there any such disease as worm fever. The existence of worms can be unequivocally demonstrated only by their having been seen. This subject should now be well understood — at least, it is correctly explained in modern works on medicine : yet popular prejudice seems to be as inveterate as ever ; and even medical men are not always exempt from error on the subject. The symptoms which are popularly regarded as indicating the presence of worms, are in truth only evidence of irritation of the mucous membrane of the intestinal canal ; and this irritation may arise from other causes, as the presence of indigestible matter, unhealthy secretions, or the existence of a morbid condition of the 2 3 8 DISEASES OF THE DIGESTIVE ORGANS. membrane itself. Indeed, the latter would seem necessary in many- instances for the production of any symptoms, although worms were present; as they have been passed by children in perfect health, who experienced no inconvenience on their account. Even the evacuation of worms does not prove that the symptoms present were caused by them, though doubtless they are likely to have been a°-°ravated thereby : but we must not overlook the fact, that the worms may have been but an accidental accompaniment, — a morbid condition of the mucous membrane being the true source of the symptoms. Hence, the passage of a worm is no reason for blindly persevering in the use of anthelmintic medicines ; or pronouncing the case cured, because worms were evacuated. It appears, then, that all the symptoms commonly attributed to worms may exist independently of their presence, and that we cannot be absolutely certain of their existence until they have been seen : yet there are a group of symptoms which pretty certainly indicate their presence, and which, when met with together, should awaken our suspicions, and direct attention to the subject. These symptoms may be divided into those depending directly on the presence of the worms in the alimentary canal, and those connected with the sympathetic relations of the digestive organs, and arising symptomatically therefrom. Some difference in the symptoms will also be observed, according to the species of worm present, or its position in the intestinal tube. Worms which are situated in the stomach, or upper tract of the alimentary canal, generally cause more severe symptoms, particu- larly of the sympathetic kind, than those which are situated lower down. We do not mean here to give any general account of the various species of worms, nor of the numerous symptoms which have been attributed to them ; but shall rest content with a notice of the varieties most commonly met with in children, and a statement of the symp- toms which more particularly characterise their presence. Worms may be suspected to be present, when a child looks pale, and grows emaciated, while his belly swells and becomes hard, — a gnawing, pungent, or twisting pain, being felt in the stomach, or about the umbilicus. The appetite is usually precarious, at times voracious ; the breath is fetid ; and the bowels often deranged, being alternately purged or costive, and much mucus passed in the stools. There is commonly picking of the nose : or irritation is felt in the rectum : and when a child is old enough, he may at times complain of a sense of sinking or faintness, which appears to attend particu- larly on the irritation caused by worms. When such symptoms are present, and cannot be accounted for by the existence of disease of the mucous membrane, or of the mesenteric glands, we have good reason for conjecturing that worms are their cause. The sympathetic disturbances are not less remarkable than these more direct symptoms. Symptomatic affections of the head, are among the most serious of those, and the most frequently met with in children. Their sleep becomes unquiet ; they are subject to start, or suddenly to awaken from slumber ; grinding of the teeth is a WORMS. 23g symptom often observed ; the eye may look fixed or wild ; the pupils are often dilated; there is listlessness, restlessness, or great depression of spirits ; pain may be complained of in the head, or convulsions attend ; but all these symptoms will often at once disappear on the evacuation of some worms ; and such we may consider to have caused them, when we observe that the symptoms are not continuous as in hydrocephalus, nor yet so intense as in that disease. Worms may, however, co-exist with it ; or the sympathetic irritation caused by them, pass into inflammatory action. When the child experiences a heavy or dull sensation in the occiput, while, at the same time, pains in the lower or middle regions of the abdomen are complained of, we have a combination of symptoms which in a particular manner indicates the presence of worms. The respiratory organs are often symptomatically deranged. The breathing may be hurried, oppressed, or difficult. The pulse is quickened, or palpitations induced ; and the cough, which so often attends, is in general dry, and of a convul- sive or suffocating kind. We discover no marks of lesion in the lungs, on exploring the chest ; and this gives additional confidence in regarding the symptoms as dependent on worms. Vomiting, hiccup, diarrhoea, tenesmus, and bloody stools, often accompany their presence. As to the varieties of worms, we notice first the Ascaris Lumbri- coides, or long round worm, which is often met with in children, and resides in the small intestines, particularly in the ileum ; but it is liable to make its way into the stomach or bowels, and may be ejected by vomiting, as well as passed by stool. The lumbricoides* may be present without producing any distress, and many of them usually exist together ; or they may be found in the same child with the small thread or maw worm. The round worm, when it gives rise to symp- toms, is in particular liable to cause sharp, colicky pains about the navel, and a distressing sense of faintness ; also, great emaciation and voracious appetite. There are two varieties of thread worm, the long and short ; and to these, children in particular are subject. The long thread worm, or Tricocephalus, is about two inches in length, of a white colour, and like a thread, whence its name. This is very commonly met with in sickly children, and inhabits the large intestines, particularly the coecum. This worm occurs in great numbers, but does not often seem to cause distress ; nor is it attended with peculiarities of symptoms. The small thread worm — Jlscaris Vermicularis — is very common in young children : and also resides in the large intestines, but prin- cipally in the rectum. They are called commonly ascarides, and may often be seen in great numbers in the stools, looking like bits of cut thread ; and, if recently voided, are usually found in rapid motion. Hence their name Ascarides ; and hence also, in all probability, the great distress which they produce, compared with the variety last * This worm is commonly called lumbricus,but erroneously, — this term having been applied by Linnaeus to the earth worm. 240 DISEASES OF THE DIGESTIVE ORGANS. mentioned. They often creep from the rectum in children affected with them, and may be found in the bed-clothes ; or seen clustering around the anus, on separating the nates. The itching and irritation felt in the rectum, is a characteristic sign of their presence — this sometimes amounts to actual pain ; or they may cause tumours about the anus. Great sympathetic irritation often attends the presence of these worms ; and this is remarkably manifested at the opposite extremity of the digestive tube,— -picking of the nose or mouth being a constant symptom of their presence. The stomach is also liable to be affected sympathetically ; for when ascarides cause irritation in the rectum, a sickening or gnawing pain is often complained of in the stomach ; and hence, most probably, the term maw worm, by which ascarides are sometimes called. The sense of sinking, or faintness, before pointed out as often caused by the lumbricoides, also accompanies the presence of ascarides in the rectum, when attended by much irri- tation ; but the existence of this irritation serves to determine which kind of worm is present. Other species of worms, as the taenia or tape worm, may occur, but those which we have enumerated are the varieties commonly met with in children, and to these, therefore, we have confined our attention. Diagnosis and Progjiosis. — To distinguish between the symptoms of intestinal irritation arising from the presence of worms, and from other causes, is important ; and when other causes cannot be detected, we may presume that they originate in worms, and try to remove these. Worms when present, need not give rise to the apprehensions that were entertained concerning them of old ; for though fatal con- sequences have arisen from them in very young children, such a re- sult is rare. Much of the danger formerly connected with worms, arose from errors in practice, the sources of which we have pointed out, and which need not now be fallen into. Treatment. — Little need be said respecting the treatment of worms in the child, as this does not differ in principle from the treat- ment adopted with adults. Our first object should be, to determine how far the symptoms present are connected with worms, or may be caused by any inflammatory affection of the intestinal canal. When inflammatory symptoms exist, these must be subdued, before we have recourse to the exhibition of any irritating substance to expel worms, even though we have proof of their presence. We must be guided, therefore, in our treatment, by the condition of the digestive organs, and avoid injuring them by the injudicious use of anthelmintics; which are generally medicines of a very irritating class. Many medicines have been proposed as anthelmintics; but those only deserve the name, which exercise a deleterious action directly upon the worms themselves. Of these substances, some appear to possess special influence over one species of worms more than another. Purgatives. — Any medicine which acts energetically upon the bowels, particularly if it tends to remove accumulations of mucus, is calculated to expel worms ; and hence, most drastic purgatives have WORMS. 241 been in repute as anthelmintics. When we suspect the presence of worms, and that the state of the digestive organs admits of the ad- ministration of such medicines, the best we can employ is a combi- nation of scammony, jalap, and calomel,* to which some strong- smelling oil, as oil of juniper, may be added as an aromatic. This compound has an extensive range of action through the alimentary canal, and is calculated to remove mucus, and act as a brisk cathartic. Hence, when worms are present, it seldom fails to cause the expul- sion of some, if judiciously persevered in ; and we are thus enabled to judge of the species present, and to adopt our measures accord- ingly. When the small ascarides are present, aloes in particular is pre- ferred, from its reputed action on the rectum. In this case, whatever medicines we employ may be given with advantage in the form of injection. Half a drachm, or a drachm of tincture of aloes, may be added to a purgative enema ; and the effect will be enhanced by the addition of double that quantity of spirits of turpentine, or some muri- ate of soda. As ascarides are not always confined to the rectum, aloes may be given by the mouth, as well as by injection. In employing purgatives, a principal use is to remove the mucous accumulations which form the nidus of the worms, and thus to expose those which have not been expelled, more effectually to the action of anthelmintic medicines. If purgatives be employed too often, or too long continued, they will cause the evil which we wish them to counteract ; and, by irritating the bowels, increase the secretion of mucus, and debilitate the digestive organs. A purgative, however, is generally necessary, after the employment of anthelmintic medi- cines, to carry off the worms which they may have destroyed. Anthelmintics. — Of the numerous anthelmintics in use, turpentine and cowhage are those which we would in particular recommend for administration to children. Turpentine acts against all the varieties of worms, and may be safely given, even to very young children, in doses of half a drachm, or a drachm, and is most easily taken when administered in milk. Castor oil may follow as a pur- gative ; and this is a better way of giving it, than combining both together. The dolichos pruriens, or cowhage, is particularly service- able in expelling the lumbricoides and long thread worm. The worms generally begin to appear after the second or third dose of the medi- cine ; and may then be removed by the aid of a purgative, often in great numbers. The medicine is prepared by dipping the ripe pods in syrup, into which the pubes or hairs are scraped, until it becomes as thick as honey ; and from one to two tea-spoonfuls are given, while the child is fasting. If care be taken to have the hairs well blended in the syrup, and not to allow the lips to be spattered by the medicine, no apprehension need be entertained in giving cowhage * Calomel seems to possess some special power as an anthelmintic; and either alone, or in combination, may be occasionally given with advantage in the treat- ment of worms. We should bear in mind, that calomel enters largely into most of the popular worm-powders, and can thus easily understand the destructive effects caused by these nostrums when ignorantly administered to children. 21 g 42 DISEASES OF THE DIGESTIVE ORGANS. to the youngest child ; for though so irritating to the skin, and offen- sive to the worms, it produces no effect on the mucous membrane. This advantage it shares in common with turpentine ; and the latter is even highly advantageous in the mucous diarrhoea which often accom- panies worms in children. Various bitters have been given as anthelmintics, and such medi- cines prove beneficial by restoring the tone of the stomach and bowels ; for by invigorating these, worms are often expelled, and their genera- tion prevented. The latter object we should never forget. It will not be enough to remove worms, unless we take means to restore the general health and improve the digestive powers, in children pre- disposed to their formation. For this purpose, change of place, or residence in a dry, airy situation, is essential. The food should be nutritious, or even occasionally stimulant, salt being very freely taken at meals. Even as a medicine, muriate of soda, whether given by the mouth or by injection, is an excellent anthelmintic. Diluted muriatic acid has in particular been recommended, for restoring the tone of the stomach, and preventing the return of worms. For this purpose, however, we rely more on the use of chalybeates ; and we have a combination of both in the muriated tincture of iron — a preparation which we have found very serviceable. Injections of sulphate of iron (from two to five grains in four or six ounces of cold water, for a child), we have found particularly successful in removing ascarides from the rectum ; and this remedy, though long since recommended, is now seldom used. The following elec- tuary, which contains iron, is given with great success at the Insti- tution for the Diseases of Children, in most varieties of intestinal worms. It in general purges briskly, and seldom fails to carry away worms, if any be present. No. 45. — Eleduar. JLnlhelmint. R. Pulveris Jalapae, Cry st. Tartar i, Carbonatis Ferri, aa. 31. l Pulv. Zingiberis, Jss. Theriacae, q. s. Utft. Electuarium. 3ss. — 3i* bi s tcrve indies. VI. REMITTENT FEVER. In classing the infantile remittent fever among affections of the digestive organs, we declare sufficiently our opinion of its origin and nature : but the disease is in itself very variable ; and according to the circumstances which have given rise to it, and the condition of the child in whom it occurs, great differences will be observed in its course and symptoms. Whatever these differences may be, however, we fully concur with those who regard this disease as symptomatic of derangement of the digestive organs ; for, as Sir Henry Marsh has long since observed,*" its characteristic symptoms, if closely analysed, * Dub. Hospital Reports, Vol. III. p. 316. REMITTENT FEVER. 243 will be found all of them to point to the mucous surface as the origi- nal seat of morbid action." The nature of this morbid action, how- ever, has not been precisely determined, nor can we suppose it to be the same in all cases : the most general manner in which we can give it expression is by saying, that the intestinal mucous membrane is in a state of irritation. It may also be inflamed or ulcerated ; but this is by no means a constant condition, as some would represent ; and in many instances, these morbid alterations arise during the progress of the complaint, or even after convalescence has commenced (as happens in continued fever), and must therefore be looked upon as a complication, not a cause. We have already noticed the tendency which febrile symptoms have to assume the remittent type in the child, no matter what be the lesion of which they are symptomatic ; but this is particularly remarkable in gastro-intestinal disease. Some authors, indeed, speak of remittent fevers as being always gastric; and all agree that fevers occurring in nervous and feeble subjects (such as infants are acknow- ledged to be), show a particular tendency to nightly exacerbations, or to assume the remittent type. We have already spoken so fully of disorders of the digestive organs in the child, that we feel called upon here to curtail much that might otherwise require to have been said, both as to the symptoms and treatment of remittent fever, although no disease of childhood is of such frequent occurrence, more precarious in its progress, or often less amenable to treatment. The symptoms of remittent fever may be seen distinctly marked, after an infant is one year old, but seldom earlier ; and they continue to present themselves in children, until the tenth or twelfth year. The duration of the disease is variable, and at all times liable to be protracted ; most commonly it lasts from one to three weeks, but it may continue for two or three months, and a low form of the com- plaint, not unfrequently met with, seldom disappears before the fourth week. Causes. — The direct relation subsisting between the symptoms of remittent fever and irritation of the gastro-intestinal surface, is suffi- ciently manifested by the rapidity with which the symptoms are at times set up, after the ingestion of over-abundant or unwholesome food. Generally, a period of indisposition of a few days' duration precedes the full establishment of the fever, which then often sets in with much severity — but we have seen it otherwise ; and in one remarkable case, where a foreign body (a marble) had been swallowed by a child in full health, violent symptoms of fever set in almost immediately, assumed the remittent form, and lasted for a few days, until the source of irritation was removed, when they as suddenly disappeared on the expulsion of the marble. It is thus that purga- tives prove beneficial, or hurtful, in this disease. When the symp- toms are caused by an overloaded state of the bowels, or the presence of vitiated and inordinate secretions, the exhibition of purgatives, by unloading the bowels and altering the secretions, is at once necessary and useful. Their protracted employment, however, or exhibition in cases where the irritation, existing in the mucous membrane itself, 244 DISEASES OF THE DIGESTIVE ORGANS. amounts to a high degree or approaches to inflammatory action, must obviously be injurious — as the experience of every day proves, when we see remittent fever brought on or kept up by the abuse of purgatives. The morbid condition of the bowels which gives rise to remittent fever may be induced by other causes, besides the use of improper food (though this is its most common source); and accordingly we find impressions of cold, variations of temperature, or the effects of season, and other causes inducing this complaint ; which indeed ap- pears at times to spread epidemically, and has by some been looked upon as being occasionally contagious. We must keep in mind the likelihood there is of meeting with remittent fever during the progress of any protracted disorder in the child (as hooping cough), and particularly during convalescence from the exanthemata. This obviously arises from the proneness of the intestinal mucous membrane to take on morbid action under the cir- cumstances ; which may be, not a little, promoted by the abuse of purgatives so common in the treatment of children's complaints. The sudden suppression of a recent eruptive disease, or the quick re- moval of a chronic one, is often followed by the symptoms of remit- tent fever. The more delicate a child is, particularly if of a strumous habit, the more liable is remittent fever to occur, and of course, the greater risk is there in the disease when established. Symptoms. — Premonitory symptoms are usually present in this disease, and may last for several days. The child looks ill, and loses his colour ; he is languid or fretful ; complains of pain in the head or belly ; is drowsy, but rests badly, starting in his sleep, or grinding his teeth. Derangement of the digestive organs early presents itself, and is remarkable. The appetite fails, the tongue becomes loaded, and the breath offensive. There is thirst, and frequent picking of the nose or lips. The bowels are always irregular, often confined ; but occasionally diarrhoea attends in the first instance. The stools are unnatural, and very offensive ; there is much flatulency ; and all the secretions are deranged, especially those of the liver. The urine looks milky soon after it-is passed, and deposits a sediment. Fever now sets in : or the attack may commence with high febrile symptoms, and be ushered in by a cold fit ; nausea and vomiting not unfrequently occurring. When once established, the fever is remark- able for the distinctness of the exacerbations ; the number of which, during the twenty-four hours, varies, however, in different cases. There may be, and in general is, but one well-marked exacerbation, occurring in the evening, and which lasts till morning, being followed by a profuse sweat. The perspiration succeeding to these exacerba- tions, however, is not always profuse, and often only partial, being Confined to the head or chest; in no instance is it critical. In some instances, several exacerbations are to be noticed in the twenty-four hours. There are often three, distinctly marked — one in the morn- ing, one in the afternoon, and another at night: the latter is gener- ally the severest, and that which lasts longest. When the febrile symptoms run high, the remissions become scarcely perceptible. " It I REMITTENT FEVER. 245 is a singular fact," as stated by Dr. Mason Good, and what we have ourselves observed, " that if the exacerbation or increase of fever take place in the night, there is wakefulness and perpetual jactitation ; if in the day time, drowsiness and stupor." However cool or lively the child may be at other periods of the day, it always becomes fretful, hot, and heavy, as the exacerbation approaches, which usually commences in the afternoon, the child being comparatively free from fever in the morning. Occasionally, how- ever, the access of fever occurs in the morning, when the child is hot, heavy, or stupid, but grows livelier as the day advances. During the access of fever, all the symptoms become aggravated; and any inflammatory affections which may be present, as inflam- mation of the eyes, skin, &c, also undergo exacerbation ; the con- junctiva becoming increased in vascularity, or the eruptions greatly heightened in colour at this time. The skin, which is, all through, dry, now grows very hot, particularly in the palms of the hands, and over the abdomen ; parts that are always hotter than the rest of the body, especially the latter, which is described as being at times burn- ing hot. The pulse rises considerably during the exacerbation, often to the amount of thirty or forty beats in the minute above what it had ranged before. The respiration is also accelerated, and the breathing hurried ; the cough which usually attends the disease becomes more troublesome ; and there are occasional palpitations. The child is drowsy, and dozes, but does not sleep soundly ; for he often moans or talks incoherently, starting in his sleep, or screaming out. There is an intense thirst, often incessant, the child calling for cold water or sour milk ; but if a large draught be taken at once, pain in the bowels is liable to be induced. There is no desire for solid food ; and, if forced upon the child, it is frequently rejected by vomiting. As the period of remission approaches, a perspiration, for the most part partial, usually breaks out. During the remission, all the symp- toms subside, but none actually disappear. The child becomes more lively, and wishes to leave the bed ; or, if sleep should occur at this time, it is more natural and refreshing : but the skin still continues dry, though perhaps cool ; and the pulse, though lessened in fre- quency, is still very quick. As the fever declines, the intermissions become lengthened ; while the exacerbations diminish in duration, as well as intensity. Remittent fever is often less distinctly formed, being milder in its symptoms ; but it may be very protracted and variable in its course. The child continues ill, appearing alternately better and worse ; it looks pale ; its flesh becomes soft, its limbs wasted, and there is a great disinclination to move or walk — even pain in the limbs may be complained of on the slightest exertion. The skin is hot and dry, particularly the hands and belly ; but the feet are often inclined to become cold. The abdomen is full and tympanitic, or may be hard, and even tender to the touch. The tongue is at first furred and white, becoming red at the edges, and soon grows dry towards the tip, where a parched spot of a triangular shape may often be ob- 21* 24 G DISEASES OF THE DIGESTIVE ORGANS. served, as Dr. Mackintosh has noticed. The bowels are always much out of order; generally at first confined, but with occasional attacks of diarrhoea. The stools are very unnatural and offensive, being of a dark brown or red colour, or even bluish, particularly when the bowels are costive. When diarrhoea attends, the stools are often very white, or green, and are always slimy or charged with mucus. At times there is much tenesmus, or only a little mucus mixed with blood is passed. The urine maybe of an orange colour ; and it has been remarked, that what is passed in the morn- ing deposits a sediment, while that passed during the day exhibits only a cloudy appearance. As the fever declines, and the skin grows moist, the urine deposits a copious sediment, over which it appears, itself, of a straw colour. The most remarkable character of the urine, however, and that which is oftenest noticed in sick children, is the white colour which it so frequently presents. The urine may appear white, or turbid, as it is passed ; but more generally becomes so on standing, when a copious white precipitate is let fall. This is particularly conspicuous, if the child happens to wet the floor, or a table, when, on the place drying, a white crust or coating is seen left behind. This white deposit is ascribed to a preponderance of the phosphates ; and this white or phosphatic uruie is to be looked on as a serious symptom, indicating a broken-down state of consti- tution, such as we find in ill-fed, sickly children, especially those of a strumous habit, and who are suffering under disorder of the diges- tive organs. The white appearance of the urine is usually assigned as a symptom belonging to worms or to tabes mesenterica : but we did not account it such, as it occurs alike in many infantile complaints, particularly in remittent fever; and belongs to worms, or mesenteric disease, only in so far as they are connected with intestinal irritation, or the existence of scrofula. Occasionally there is absence of thirst, as well as loss of appetite ; so that the child cannot be got to take either food or drink, but lies listless, fretful, or drowsy, and appears annoyed at being disturbed. Dr. Butter speaks of a variety of the disease, of this description, which he calls the low infantile remittent ; but which obviously pre- sents that form of the complaint in which there is serious abdominal disease, with the head symptomatically engaged. We not unfre- quently see a child in whom symptoms of remittent fever set in with much severity, but with no peculiarity, except that the cerebral func- tions become very early disturbed. The fever, however, soon sub- sides, and the child appears to sink, — tying immoveable in bed, indifferent to surrounding objects, hardly replying when spoken to, and asking for nothing. The disturbance of the nervous system is exhibited by frequent tossing of the upper extremities during the remissions, though the lower extremities and trunk generally remain fixed ; but in the exacerbation, the child slumbers much, yet on being roused is sensible. The condition of the digestive organs is exhibited by the state of the tongue, mouth, and lips, which are covered with sordes ; while there is frequent picking of all parts of the face. The urine or stools may pass involuntarily : the latter are very unnatural REMITTENT FEVER. 247 in appearance ; and much pain seems to precede their escape, or that of flatus, much of which is usually present. The countenance indi- cates distress. — Such is a picture of this variety of the complaint ; and in it we recognise the symptoms of a severe enteritic affection, in which the head is engaged. Diagnosis. — No organ is more liable to become engaged in the progress of infantile remittent fever, than the head; and the diagnosis between hydrocephalus and remittent fever is often so difficult, that some consider it cannot in many instances be made out, until the symptoms of hydrocephalus are so unequivocal as to leave little benefit to be derived from the discovery. This subject will more properly be discussed under affections of the head : but if we keep in mind the nature of remittent fever, and recollect how likely we are to meet with those sympathetic disturbances of the brain already pointed out, as frequently attendant on gastro-intestinal disease, we shall be early on our guard ; and by meeting the symptoms of cere- bral disturbance as they arise, while we still continue to treat the intestinal disease as their origin, we shall be in many instances suc- cessful, and in most cases escape forming an erroneous opinion. It is in the protracted remittent fever of scrofulous children, in particular, that we are to apprehend the supervention of hydrocephalus. Golis goes so far as to say that such a termination occurs in those cases, six times out of seven. The sympathetic affections of the chest may, in like manner, ter- minate in inflammatory disease, if not early met by adequate treat- ment ; but attention must still be paid to the primary disorder, which often appears to be much mitigated on the supervention of the sympathetic disease. Various eruptive complaints may appear on the skin ; and in some instances, pustular eruptions seem to occur in connection with in- flammation and ulceration of the intestinal glands. The mouth, nose, or face, are frequently made sore from being picked. In these cases, the affection of the skin claims little attention, in comparison with that of the stomach and bowels. Worms may be present in remittent fever, and give rise to many of the symptoms ; but if these persist after worms have ceased to be expelled, we must treat the case independently of this complication. Enlargement of the mesenteric glands is liable to arise, if the case be severe or protracted, and this must be borne in mind ; for it is more the complications than the disease itself, that give rise to danger in remittent fever. In addition to the affections of the intestinal mucous membrane, peritoneal inflammation and effusion occur occasionally towards the termination of the case, the child becoming affected with ascites, or dying anasarcous. Prognosis. — When the exacerbations in remittent fever become almost incessant, as well as violent, and the abdomen swells, while the sympathetic affections increase in severity, great danger is to be apprehended. On the contrary, when the remissions become length- ened, the appetite restored, and the evacuations improved, returning health is to be expected ; and this may be looked upon as near at 24S. DISEASES OF THE DIGESTIVE ORGANS. hand, when the sleep becomes natural and refreshing, the pulse falls, the sediment in the urine diminishes, and a general moisture is established on the surface. The pulse, however, will often continue quick, long after the other symptoms have subsided ; and we must never lose sight of the dangers of relapse. Treatment. — The principles upon which we conduct the treatment of infantile remittent fever must be sufficiently obvious from the view which we have taken of the complaint ; the particulars must vary according to the condition of the patient, and the period at which we see the disease. In a very recent case, obviously induced by an indigestible meal, an emetic is often of great service. In a similar manner are purgatives necessary, when an overloaded state of the bowels is present. We have already alluded to their value, and the cautions requisite when administering them (see p. 243). From the deranged state of the secretions, the occasional use of a mercurial is often very beneficial; and it maybe given combined with an aperient, or a diaphoretic, according to the circumstances. The powder of jalap, simple or compound, is that which we usually prefer ; and the addition of some ipecacuanha (as recommended at p. 128) increases the effect. When much permanent heat of skin, thirst, and restless- ness, are present, one or two grains of James's powder, joined with calomel, or given alone, will best answer to lessen the febrile action. Dr. Cheyne recommends this practice, particularly when the sensorial functions are engaged ; and we are thence led to apprehend the occurrence of hydrocephalus. This termination of infantile fevers, Dr. Cheyne thinks, would be less frequent, if bleeding were more practised at the commencement of such attacks. Without limiting the value of the practice to this point, we certainly would advise the use of leeches when the febrile symptoms run high, and the attack is recent, as deserving of more general adoption than is now the habit in treating infantile remittent fever. Leeches should never be omitted, when symptoms of intestinal inflammation are present. These may require to be repeated, and should be so when we find that such symptoms recur during the progress of the case, but we must keep in mind, that increased sensibility of the whole surface sometimes exists in this disease, so that the child cannot bear to be touched in any part ; and if the epigastrium alone were pressed, this sensibility might be taken for abdominal tenderness, and inflammation supposed to be present, when such was not the case. After the abstraction of blood, a mitigation of the febrile symptoms generally ensues : and any medicines then given will more easily produce their effects. In particular, mild purgatives will act freely, which had previously failed to have any effect. The power of the digestive organs upon the food appears often to be quite lost during remittent fever, — that swallowed being either soon thrown up, quite unchanged ; or passed through the bowels, after some time, in a putrid mass, as if it had been subjected to heat and moisture, but without having undergone any of the process of digestion, as Pemberton has distinctly noticed. Such masses may lie in the intestines, and keep up an irritation which we shall in vain REMITTENT FEVER. 249 attempt to remove, until this matter is expelled, though the symp- toms may be mitigated by the use of leeches, &c. Dr. Mackintosh, in his Practice of Physic, gives a very instructive case of this descrip- tion, in which leeches, &c, produced only temporary relief until a mass of indigested food was expelled by the agency of some castor oil. Of leeches, then, we may speak as we have of purgatives: though each may be occasionally necessary, neither is to be perse- vered in as if constituting a cure for this disease. Aperients will, however, be oftener required than leeches. Refrigerants should never be forgotten in the treatment of remit- tent fever. To give cold drinks, and keep the body cool by light clothing, and the use of an airy apartment, (while we enjoin quiet- ness, and occasionally exclude the light,) is essential to recovery. We have used nitre freely in this complaint, and have derived signal service from its employment. When the bowels are not irritable, a solution of crystals of tartar, given cold in the form of imperial, pos- sesses many advantages, as it acts on the kidneys, while it allays thirst, and tends to keep the bowels open. In the more advanced stages, when debility sets in, we have found the mineral acids use- ful ; they can be employed much sooner than quinine ; but the latter may occasionally be prescribed at the close of the complaint. When much irritability prevails, or diarrhoea is present, the judi- cious use of Dover's powder will prove very serviceable ; and recourse should be had to the soothing influence of fomentations, or the occasional use of the warm bath. Attention to diet is an important point in the treatment of this dis- ease ; and all we have said respecting regulation of diet, under the head of diarrhoea, or inflammatory affections of the bowels, applies here : in particular, we must avoid giving such food as is likely to leave much residue behind ; and we must be very cautious in allow- in 0, any sudden return to the habitual diet, during convalescence. At this period, change of air is of essential service, and, indeed, throughout the whole management of remittent fever, nothing is more remarkable than the benefit derivable from the latter source. We have frequently seen a patient who had been several weeks labouring under the disease, restored to the enjoyment of tranquil and refreshing sleep, the night after his removal to a distance of three or four miles from his ordinary abode. When diarrhoea is present, it must be treated on the principles already laid down ; but in protracted cases, we have found the use of turpentine, in particular, of service ; and when this affection be- comes chronic, after the febrile symptoms have subsided, we have derived much benefit from using the persesquinitrate of iron. 250 DISEASES OF THE RESPIRATORY ORGANS. CHAPTER IX. DISEASES OF THE RESPIRATORY ORGANS. The infant, like the adult, is subject to inflammations in the dif- ferent portions and tissues of the respiratory apparatus, as well as to some affections of these parts which are rare, or altogether absent in after life. In considering the latter, we shall attempt a complete view of their nature ; but with respect to the former, we can only* advert to their peculiarities in the young subject, as to character and treatment, — our limits forbidding anything like an extended view of those diseases which are common to both child and adult. I. CATARRH. We have seen that the mucous tissues of children are possessed of considerable irritability, and are subject to sudden alterations in the quantity or quality of their peculiar secretions ; and accordingly, as might be expected, simple Catarrh or Coryza is a frequent ailment throughout the whole period of infancy and childhood. This affec- tion begins with sneezing, watering at the eyes, and discharge of mucus from the nostrils. The latter is at first clear, but subsequently becomes thick, greenish-yellow, and at length puriform. The child's face is flushed ; its skin hot. It sleeps with its mouth open, and snuffles in breathing. The latter symptom is often very distressing ; and the tumefaction of the Schneiderian membrane may be so great, as altogether to prevent the passage of air through the nostrils, and so to interfere with sucking, in the young infant. All the symptoms just now narrated, may be but the precursors of some exanthematous disease, as measles or scarlatina, and, holding that in view, we must always be on the watch for the proper eruption. The snuffles may exist as a symptom of syphilis ; but we shall, then, have other indi- cations of that disease, which shall be noticed under the proper head. Simple catarrh is not dangerous, and requires little treatment. Any cause which may have excited it should be obviated, as draughts of cold air, or too much direct light ; the child may be placed in a tepid bath, and subsequently kept warm ; and it will generally be advisa- ble to administer a gentle aperient, as a little castor oil. The affection of the membrane of the nostrils may, however, assume a chronic form, and by interrupting the child's sucking may materi- ally interfere with its thriving, or even ultimately wear it out. The principle of treatment in these cases is, to restore tone to the mu- cous membrane, by improving the general health ; and the most likely means of effecting this will be, change of air and food, — pro- curing for the infant a healthy nurse ; or, if it have a difficulty in sucking, supplying it abundantly with asses' milk. We should also attend to the surface of its body, and endeavour to promote a healthy BRONCHITIS. 251 condition of it, by sponging once or twice daily with tepid vinegar and water. Gentle alterative aperients, as rhubarb combined with hydrargyrum cum creta, and a minute quantity of ipecacuan, will be found serviceable. Billard recommends from two to four grains of calomel to be given, for the purpose of establishing a point of deri- vation in the intestinal tube ; and the application of a small blister to the nape of the neck, or arm. These means we should only resort to when others have failed ; and we would recommend a previous trial of iodine, which appears to us to exercise a special tonic power upon mucous surfaces.* As a local application, we have found ad- vantage from the introduction into the nostrils of a bit of lint wet with a decoction of guaiacum wood ; but any means of this nature will be badly borne by the young child. Billard describes coryza as sometimes resulting in the exudation of a false membrane upon the nasal passages, which, in the cases related by him, produced death, by obstructing the access of air to the lungs. Such a case might require the performance of bronchotomy. II. BRONCHITIS — (BRONCHIAL CATARRH). Children are very subject to this affection at every age ; and in every degree of its intensity. The symptoms are — general fever, and restlessness ; with quick pulse ; hot skin, andcostiveness ; or fre- quently diarrhoea, with deranged secretions, cough, more or less vio- lent ; a mucous rale or wheezing, which may be heard by applying the ear immediately to the chest, or may often befell by placing our hands flat, upon opposite walls of the thorax ; respiration frequent (amounting sometimes to 100 in a minute) ; dilatation of the nares during inspiration, and occasionally difficulty in the act of sucking : upon percussion, we shall find the chest sonorous throughout, at the commencement ; but towards the close it may be dull in some parts ; the face may be livid and swollen, or pale and cedematous. In the latter stages, each fit of coughing is accompanied by a paroxysm of suffocation, ending often in vomiting ; and towards the termination, coma or convulsions may supervene. When the disease terminates unfavourably, it usually runs its course within eight or ten days : when the child is to recover, convalescence generally commences in five or six days ; the respiration becomes less frequent, the fever abates, and a free secretion being established from the mucous mem- brane, the cough becomes looser and less suffocative. In young children, the expectorated matters are always swallowed : but when we have an opportunity of observing them in older ones, we find that they consist at first of transparent mucus, and subse- quently of viscid, opake, yellow or greenish, muco-purulent masses. The anatomical characters are, increased vascularity of the mucous membrane, presence of viscid or purulent mucus in the air cells, and engorgement of the lungs with dark-coloured blood. Bronchitis, in children, is frequently complicated with pneumonia ; * See formula No. 10, p. 102. 252 DISEASES OF THE RESPIRATORY ORGANS. and then we have, as a morbid appearance, hepatisation of the lungs, to a greater or lesser extent, and which we have observed to be most complete in the lower and posterior portion. This combina- tion, or broncho-pneumonia (as it may be termed), frequently occurs as a complication of measles and hooping cough, and appears to be identical with the disease described by Dr. Cheyne as " the Epidemic Peripneumony of Children,"* As in the adult, bronchitis may become chronic, and will then closely resemble phthisis. The prognosis depends altogether upon the quantity of inflamma- tion, and of the accompanying fever: in a previously healthy child, the disease is generally under the control of art. The treatment may, in common, be more decidedly antiphlogistic than would be warranted in the adult (some explanation of which may be found in the fact of bronchitis being so frequently compli- cated with pneumonia in the child) ; and we shall often be obliged to employ general bloodletting by the lancet, or by leeches to the hand or foot. When we see the disease early, an emetic of ipeca- cuan wine will often quickly cut it short, and will always afford relief by causing a discharge of mucus. The administration, then, of one or two tea-spoonfuls of the medicine just mentioned, every ten or fifteen minutes, until vomiting is produced, is very often our first step ; but should the fever and difficulty of breathing be considerable, with hot skin, and the pulse not very feeble, we must at once bleed. From two to four ounces, during the first two years, will commonly be a sufficient bleeding ; but it must be carried far enough to make an impression on the system, which in young children we can always judge of by their lips becoming pale. It may be necessary to repeat the bleeding, if the symptoms which called for it at first, should re- turn ; but if a suitable quantity of blood be taken in the beginning, this will not often be the case. When the bowels are confined, or the secretions depraved, we must administer an aperient or altera- tive, as the powder of jalap and ipecacuan, No. 31, p. 12S ; but it is decidedly injurious to carry purging to any considerable extent in the treatment of bronchitis. Indeed, so intimate in children is the sym- pathy between the gastric and bronchial mucous membranes, that we have frequently seen all the symptoms of bronchial catarrh kept up, long after the inflammation had ceased, by irritation produced in the intestinal tube by over-purging. Next to bloodletting, the most powerful means of checking bron- chitis is, undoubtedly, tartar emetic ; and we shall often find great advantage to result from their combined employment. After the immediate effects of bloodletting have subsided, should the fever and dyspnoea not be materially relieved, we may administer a solution containing from the eighth to the fourth of a grain of tartar emetic (according to the age of the child) every hour, until vomiting or faintness be produced ; and by this means we shall often save the * Pathology of the Membrane of the Larynx and Bronchia. By J. Cheyne, M.D. Ed. 1809. See also, Observations on the Peripneumonia of Children, by Thomas Cuming, M.D., in Trans. Association K. and Q. Coll. of Physicians, vol. v. BRONCHITIS. 253 system the expense of a second bleeding. In the advanced stages, tartar emetic will frequently fail of producing any effect, and we think had better not be given except in cases indicating, or almost indicating, bloodletting. After the employment of tartar emetic, or in conjunction with it, the warm bath will frequently be of decided benefit ; but it must be confined to the lower extremities of the child. The pelvis and legs alone must be immersed, by which plan a derivative effect appears to be produced ; while the general warm bath excites the circulation, and always does harm. The heat of the water should be from 98° to 100°, and the child should not be left in it longer than ten or fif- teen minutes. When the disease has been neglected at the commencement, or has not been cut short by such active treatment as we have recom- mended, we often find that considerable debility sets in, at the same time that a profuse secretion is taking place from the mucous mem- brane. Under such circumstances we must not bleed, as the stage for arresting the inflammation has then passed, and strength is re- quired to throw off the secreted matters, and to enable the system to hold out until resolution be accomplished. In this stage, we have found advantage from the use of calomel and ipecacuan, in doses of from a sixth to half a grain of each, every second, third, or fourth hour ; these medicines often acting without producing any sensible evacuation, although they occasionally cause vomiting and purging. When the bowels are in an irritable slate, it will be well to combine a grain of compound-chalk powder with each dose. It is at this period also that we meet an opportunity for the appli- cation of blisters, when the skin is becoming cool, and the system obviously in need of a stimulant ; but for reasons explained in a former chapter, we must never allow one to remain on longer than three or four hours. The best situations for blisters are the front of the chest, or between the shoulders. We have often seen great benefit produced by them when employed at the proper time, and have, in many instances, observed the bronchial symptoms to sub- side altogether, simultaneously with the setting in of gangrene in the blistered part. In these cases, however, the cure is most com- monly purchased by the death of the patient from the new affection. We have not yet spoken of the use of expectorants. During the early stages, nothing of the kind is admissible, beyond the emetic medicines we have recommended. In the latter part of the stage of debility, however, stimulants will be required, and we may then join them with expectorants, e. g. — the decoction of polygala may be given every three or four hours ; and ammonia or squill may be re- sorted to, according to one of the formulas at p. 115. When the child is much weakened, white wine whey may be given in quan- tities of a tea-spoonful every hour, or half hour. But when these measures are called for, the time for curing the disease has, in all probability, passed away ; and we cannot too explicitly caution the practitioner to meet it promptly and judiciously upon its first approach. 22 254 DISEASES OF THE RESPIRATORY ORGANS. The regimen in the early stages should be antiphlogistic. Infants often snck greedily at the commencement ; and Dr. Cheyne recom- mends the breast to be withheld, and water, or thin gruel, sweetened or mixed with a small quantity of the breast milk, to be given in- stead. Older children should certainly get nothing but mild fluids, as barley-water or whey, during the early stages. During the pro- gress of convalescence a nutritious diet will be required, but it must be of the lightest and least stimulating kind. Infants will need nothing beyond a plentiful supply of breast milk. The temperature of the child's apartment should be equable, and moderately warm ; but free ventilation should at the same time be secured. In the latter stages change of air, even from one room to another, when it can be accomplished without much exposure, will often do signal service. ' III. PNEUMONIA. We have stated that pneumonia frequently exists as a complica- tion of bronchitis, and our observations lead us to doubt much if it ever occurs in young children as a primary idiopathic affection. This view may be attributed to the difficulty of recognising the dis- ease in infancy and childhood, and the insufficiency of the physical signs, at these periods of life, to the establishment of an accurate diagnosis between bronchitis and pneumonia. In cases in which post-mortem examinations disclosed to us unquestionable results of pneumonia, the disease had commenced with the symptoms of bron- chitis detailed in the last section. There was mucous, but not crepi- tant rale, and no distinct bronchial respiration. Any information to be derived from the sputa, was, of course, wanting, as children seldom or never expectorate ; and percussion commonly gave a dull sound on both sides, the induration seldom being limited to one lung. According to the observations of Dr. Gerhard,* children above six years of age are subject to pneumonia, with characters precisely similar to those which the disease presents in adults ; but, previously to that age, it is very different in symptoms and progress, occurring" mostly as a secondary lesion. Of forty cases which he noted in the Children's Hospital at Paris, of patients between the ages of six and sixteen, exhibiting the true signs and symptoms of pneumonia, but one terminated fatally ; while of sixteen patients between two and six, " who seemed attacked with pneumonia," twelve died, and pre- sented a greater or lesser degree of hepatisation of both lungs. Dr. G.'s experience, therefore, may be considered as not opposed to our own.t M. Billard, also, conceives that the pneumonia of infants always * American Journal of Med. Sciences, vol. xiv.-xv. Philadelphia, 1834. f M. Berton expresses similar opinions, considering- pneumonia in children to be frequently complicated or secondary ; he also particularly mentions the difficulty of its diagnosis by means of the physical signs. Traite des Maladies des Enfans. Paris, 1837. PLEURITIS — CROUP. 255 arises from a stasis of the blood in the lungs, acting in some sort as a foreign body, and that it possesses characters really different from those of the disease similarly named in adults; but he subsequently states, as an argument against the use of expectorants, that the bron- chi frequently take no part in the inflammation. From the views we have just put forward, it must be obvious that we can have little to add, either with respect to the symptoms or treatment of pneumonia in children, to what we have advanced when treating of bronchitis. If the disease be met with and recog- nised in young children, as a primary affection, it must be treated upon the principles laid down for the first stage of bronchial inflam- mation ; and a suitable management of that morbid condition will be the best means of preventing the appearance of pneumonia as a lesion secondary to it.* IV. PLEURITIS Is occasionally discovered upon the post-mortem examination of children, but there are no diagnostic marks which distinguish it from other inflammations of the chest during life — " the integrity of the cry" mentioned by M. Billard, being altogether insufficient for dia- gnosis. This is of the less consequence, however, as the treatment must be similar to that of any other inflammatory affection of the chest. There does not appear to be much tendency to pleuritis in the young subject, as we do not meet with traces of it in their bodies nearly so often as in those of adults. We may mention here that Pericarditis may be shown by morbid appearances to have existed in young children ; but as the discovery of it during life, in such patients, can in the present state of our know- ledge be only a guess ;t and as its treatment must be identical with that of the inflammations we have been just considering, it would be out of place to notice it at greater length. v. CROUP. Cynanche Trachealis, Angina Membranacea. — This disease may be said to be peculiar to childhood, being most common between the * MM. Rilliet and Barthez observe, that in almost all the cases of pneumonia in children, treated by them, and which terminated favourably, the improvement commenced between the seventh and ninth days, whatever might have been the treatment, or even when no treatment was adopted. Maladies des Enfans .• Affections de Poitrine. Paris, 1838. [Note to 4th Edition.] f A case remarkably corroborative of this statement was related, by Professor Benson, to the Surgical Society of Ireland, during its present session. A child, five months old, died after an illness of eight days, during which period it was treated by three medical men of experience. The illness was chiefly indicated by screaming. On examination, after death, a large quantity of fluid was found within the pericardium ; the surface of which and of the heart were coated with a thick layer of lymph ; the walls of the left ventricle, when divided, presented an unusual thickness ; where the lung lay in contact with the diaphragm there was some lymphy exudation, but there was no pneumonia. See Medical Press, vol. iii. p. 38, [Note to 3d Edition,] 256 DISEASES OF THE RESPIRATORY ORGANS. first and eighth years, and scarcely ever occurring after puberty. It consists of an inflammation of the mucous membrane of the larynx, trachea, and bronchial tubes, usually ending in the formation of a membranous concretion upon the internal surface of those parts. The predisposing cause of croup is considered by Dr. Cheyne to be the imperfect state of development of the organs of voice, there being scarcely any perceptible difference between the aperture of the glottis of a child of three and one of twelve years of age ; while, after puberty, that opening is suddenly enlarged, in the male, in the pro- portion of ten to five, and in the female, of seven to five : thus, at least, marking the limit of the period of occurrence of the affection. There appears to be a remarkable predisposition to the disease in certain families, many children of the same parents being affected with it at different times. It is also observed to be endemic in certain situations, especially in the neighbourhood of seaport towns, and about the mouths of large rivers, where the inhabitants are exposed to the effects of a damp, alluvial soil, and moist atmosphere, and at the same time usually suffer the privations incident to a dense state of population. When a child has been once affected with croup, it must be con- sidered as liable to a recurrence of the disease, at any period until the arrival of puberty. Infants at the breast are less liable to be attacked than those who have been weaned; but Dr. Home has observed that an early weaning renders children more liable to the disease. It may occur at any season of the year, but its most common period is in the end of winter and spring, and during the prevalence of north and north-easterly winds. Symptoms. — Croup is sometimes preceded, for two or three days, by symptoms of a common catarrh, attended usually with hoarseness and a rough cough. We can never be too early in our recognition of the more dangerous affection, — and, accordingly, we should look with suspicion upon the two last-named symptoms, especially when we have reason to dread any predisposition, local or hereditary, to croup. Occasionally there are no premonitory symptoms whatever, the attack taking place during the night, after the child has, perhaps, passed an evening of unusual gaiety, and exercise in the open air. The approach of the disease may then first be indicated, and alarm excited, by the child giving, during sleep, the unusual cough which is so well known as one of its most characteristic symptoms. It is a single cough, sharp and ringing, as if it passed ' through a brazen trumpet/ — and when once heard and recognised, will not easily be forgotten. When the child awakes, which soon happens, his voice will be observed to be sharp and striduious; his breathing audible, difficult, and laboured, and often accompanied, during inspiration, with a crowing sound. He is obviously suffering great distress ; the face is swelled and red ; the eyes suffused ; the skin hot ; pulse quick and hard ; if old enough, he complains that he is choking, and eagerly asks for drink ; if younger, he tosses about restlessly, and frequently grasps at his throat, as if anxious to remove some obstruc- tion to respiration. The ringing, solitary cough continues at inter- CROUP. 257 vals. In a few hours the disease, though unchecked by treatment, may appear to subside, and an interval of comparative ease may ensue. This is, however, commonly but a remission; and if the affection be not cut short in its first stage, the respiration becomes more and more laboured and wheezing; the cough hoarser and suffocative ; the voice stifled ; the countenance pale, or livid. The debility of suffocation then sets in — the extremities become cold; the skin clammy ; there are dark and fetid stools ; coma or convul- sions supervene ; and the patient dies between the third and fifth days. In the latter stages, the child, if old enough to expectorate, may cough up purifcrm matter, and portions of a whitish membranous substance. In some cases croup may assume a more chronic form, and be protracted for two or three weeks. In others, the fatal event may take place early, in consequence of a spasmodic paroxysm of dyspnoea occurring, and continuing long enough to destroy life by suffocation. During a paroxysm of this description, it has been observed that the head will be occasionally thrown back, so as to stretch the trachea, and that such a posture will afford temporary relief. The auscultatory signs in croup (independent of the peculiar cough, and crowing respiration), indicate inflammation of the air cells, and sometimes of the substance of the lungs. We have at first a mucous, and subsequently a sibilant rale. Upon percussion also, we may have a dull sound throughout a greater or less extent of the chest. When the false membrane is partially detached, we may have a clapper or valve-like sound, upon inspiration, when the upper; and upon expiration, when the lower extremity of the membrane is detached, and moved by the passage of the air through the larynx. The anatomical characters of croup are redness and swelling of the mucous membrane of the larynx, trachea, and bronchi — all of which, especially the two former, may be lined with a yellowish membranous substance, which sometimes assumes a tubular shape, and at others exists in detached portions. This is the membrane of croup. Bat the disease may terminate fatally before its formation, and we shall then find the mucous membrane of the larynx red and swollen, and perhaps covered with a yellowish, viscid fluid. The trachea commonly contains a reddish serum, which is also found in abundance in the air cells and parenchyma of the lungs. Sometimes there is even hepatisation to a considerable extent, and the pleura may share in the inflammation. These characters explain the course of the disease, in which there is — inflammation and effusion, accompanied by difficult and imper- fect respiration, and causing a circulation of blood not revivified ; loss of sensorial power ; and death. The occasional occurrence of a suddenly fatal exacerbation, after a remission of the symptoms, Dr. Cheyne refers to a valve-like closure of the tracheal tube by a portion of the membrane which has been partially detached, and the pro- duction thus, of instant suffocation. Diagnosis. — Other species of cynanche may simulate croup — e.g., cynanche maligna, or (to use a different nomenclature) diphtherite 22* #58 DISEASES OF THE RESPIRATORY ORGANS. may extend into the upper opening of the larynx, and produce croupy breathing, &c. This disease is to be distinguished from genuine croup by the existence of aphthae, or sloughs, or of a membranous concretion upon the fauces : these never exist in the latter affection. Cynanche pharyngea, or inflammation of the pharynx, may also be distinguished by the inflammation of the fauces, and difficulty of swallowing proper to it. Measles sometimes assume the features of croup upon their first attack ; the catarrhal symptoms of that dis- ease occasionally assuming a croupy character. The diagnosis can only be established by the appearance of the characteristic eruption, when it is probable that the doubtful symptoms will subside. Hys- teria may occasionally present, as one of its features, the characteristic cough and breathing of croup ; but the former disease is not of fre- quent occurrence before puberty, and the latter seldom appears after that period ; so that they are not likely to be confounded. Every affection of the larynx is subject to exacerbations, which partake much of a spasmodic character ; and, as we have already stated, a paroxysm of this nature may occur at an early period of true croup, and destroy the patient before there has been time for any very important results of inflammation to be produced. Similar paroxysms have also been observed without previous or sub- sequent symptoms of inflammation, and have subsided without active treatment ; so giving rise to the notion that there existed a distinct form of Spasmodic Croup. There are, however, no means of distinguishing between the two affections, (if two distinct affections exist,) beyond the degree of violence of the symptoms. Whenever, therefore, we meet with the symptoms already enumerated, as indi- cating the onset of croup, we should be upon the alert ; and as soon as any permanent difficulty of breathing sets in, we should forget all hypotheses of the spasmodic nature of the disease, and treat it as an active inflammation, persuading ourselves, like Dr. Kellie, " that there is truly no essential difference between them (spasmodic and inflammatory croup), other than what arises from degrees of violence, and the obvious circumstance of intermission and continuance."* Prognosis. — Croup is always a dangerous disease, even under the most favourable circumstances ; but it is also one which admits of the use of decisive means, and is thereby remarkably within the control of art. When we see a patient, then, at an early period of the disease, we may hope to be able to relieve him; but still our prognosis should always assume a doubtful tone. Treatment. — From the view we have taken of the nature of croup, it must be obvious that we are prepared to recommend a strictly antiphlogistic treatment and regimen ; and, in truth, no other plan can be relied upon throughout the disease. When we find a child affected with the ' ringing cough,' especially if it belong to a family subject to croup, we should at once place it upon a dimi- nished allowance of non-stimulating food, confine it to the house, and administer a drachm of ipecacuan wine, or of the antimonial * Letter in Cheyne's Pathology of the Larynx and Bronchia. CROUP. 25 g mixture, recommended at p. 112, every hour or two, until nausea be produced ; and this we should keep up for ten or twelve hours. We may, at the same time, apply to the throat a flannel bag filled with hot salt, as recommended by Mr. Kirby,* a measure which we have found to act most beneficially as a rubefacient, and by bringing out general perspiration. By adopting these means, we may often anticipate and prevent a seizure of croup. Let us now suppose that fever and difficulty of breathing exist, together with the other symptoms denoting that the disease has ac- tually commenced — under these circumstances the first principle to be held in view in our treatment, is obviously to subdue the inflam- mation, and obviate the tendency, which the mucous membrane of the child possesses, to the production of a membranous concretion. Our most powerful means of working out this principle is bloodlet- ting ; and this should be immediately performed by opening a vein in the arm or hand, or (if we cannot get sufficient blood from these), the jugular vein. Enough of blood must be taken to produce an effect on the system : under two years of age, from two to five ounces ; under the eighth year, from three to eight ounces — will pro- bably do what we require, at least for the time. Mr. Porterf judiciously observes, that " it is not sufficient to dimi- nish an increased action, unless the constitution be kept, until the period of danger is over, in a condition that will render a renewal of that action unlikely to occur." Now, the best means of effecting this object is, simultaneously with the bleeding, to place the system under the influence of nauseating medicines ; and, accordingly, if Ave have an emetic at hand, it will be well to give it shortly before bleeding, so as to cause the abstraction of blood to be made while the state of nausea is commencing. Thus we shall often produce, at a small expense to the constitution, a degree of depression suffi- ciently complete to overcome the disease ; and this must be kept up until the fever, hurried respiration, and other symptoms of danger disappear. To keep up the state of debility, a drachm of the tartar emetic mixture, prescribed at p. 112, must be given sufficiently often (/. e., every half hour, hour, or second hour), to maintain a continued nausea. While this is being done, the lower extremities of the child may be placed for ten or fifteen minutes, in a warm bath at the tem- perature of 98° to 100° F. and two or three grains of calomel given every third hour. The calomel we would expect to move the bowels after the second or third dose ; and if it then fails to do so, a drachm, or two drachms, of castor oil should be given. Mercury has been recommended as a substitute for bloodletting in the treatment of croup ; but it should never be solely trusted to, in the first stage of an acute attack. If the disease be violent, one bleeding will often be sufficient ; but whenever reaction takes place, we must have re- course to a second. In severe cases, it may even be necessary, in a * Dub. Med. Jour. vol. viii. f Observations on the Surgical Pathology of the Larynx and Trachea. Dublin, 1826. 260 DISEASES OF THE RESPIRATORY ORGANS. strong child, afterwards to apply leeches to the sternum (never to the throat, for the reasons specified at p. 105), always proportioning the depletion to the strength of the child, and to the continued vio- lence of the acute inflammatory symptoms. [In violent and apparently desperate cases of croup, a tobacco cataplasm, composed of the moistened leaves of tobacco mixed with the crumb of stale bread or ground flaxseed, and applied around the throat, has occasionally been found beneficial. The effects of the cataplasm should be carefully watched, lest its depressing effects be carried too far. — C] When the active measures recommended have been judiciously employed in the commencement, we shall often have the satisfaction of finding that the respiration becomes less laboured, the cough loose, and that the fever abates ; and we then know that our treatment has been, so far, successful. We must still, however, most carefully watch against the dangers of a relapse, strictly enjoining an anti- phlogistic regimen, and directing the utmost vigilance towards any return of the symptoms. When we have been unable to control the disease, or it has run into its second stage before assistance has been obtained, our principle of treatment is somewhat different. We have still an increased vas- cular action to reduce and modify, but we have also to combat the effects of that action in the production of a false membrane in the larynx and trachea, and of congestion in the lungs and, in the more advanced periods, in the brain. The time for bleeding, therefore, which should be considered rather as a preventive than a cure of in- flammation, has passed away ; and we must not, by its use, perma- nently reduce the strength of the patient, when all his resources will be wanting to carry him through a protracted, but natural effort at recovery. At this period, Dr. Cheyne recommended the continued use of anti- monial emetics ; and it is from their employment, certainly, that we would hope for most benefit. The emetic may be expected to relieve the respiration, by aiding in the removal of the effused fluid from the bronchial tubes ; and the continued, nauseating effect of the antimony will offer the best chance of reducing and altering the morbid condi- tion of the diseased parts. Half an ounce of the antimonial mixture should be given every half hour, until vomiting be produced ; and in two or three hours after the last act of vomiting, the same process is to be recommenced, and so repeated while the strength will admit. A remarkable tolerance of the medicine will often be produced, so that several grains of tartar emetic will be taken without causing any effect. The only cases which Dr. Cheyne saw recover from the second stage of croup were those in which the patient was kept under the influence of the medicine for two or three days. It is in the second stage of croup that calomel may be looked to as likely to produce a useful effect, beyond what depends upon its pur- gative quality. This medicine appears to possess, in many cases, the INFLAMMATION OF THE LARYNX. 2 61 effect of equalising and quieting increased local vascular action ; and we may, therefore, rationally employ it in the second stage of croup, in conjunction, ho we ver, with antimonials. If we look for any advantage from its use, we must give it in doses of two or three grains every second or third hour. Blisters also may be applied to the sternum in the second stage of croup ; and we would recommend their use in this disease to be always directed towards the relief of the lungs, rather than of the larynx. We shall thus be prevented from ever thinking of applying them to the throat, where they create intolera- ble annoyance, on account of the restlessness of the child, and are, moreover, too near the actual seat of inflammation to have any effect except that of keeping it active, In the latter periods of the second stage, when the child is cold and sinking, we must have recourse to wine, or even burnt brandy, or ammonia ; but these are only to be used when all other remedies have been employed to the utmost verge that prudence will permit. Children, however, have recovered, under their use, from the most hopeless condition — and we should never despair of a sick child. It has been proposed to perform the operation of bronchotomy in croup, with the objects — first, of admitting air to the lungs without the intervention of the larynx ; and, secondly, of removing, mechani- cally, the false membrane from that passage. We have already stated that the inflammation of croup is not confined to the larynx, but extends over the whole bronchial mucous membrane ; and Dr. Cheyue has shown that, in fatal cases, a space of more than two- eighths of an inch usually exists in the larynx, for the transmission of air. The patient, therefore, except in cases of sudden spasm, dies, not because air cannot have access to his lungs, but because these organs are unfitted, by their inflamed condition, from performing their own function. Consequently, bronchotomy is unnecessary for the effecting of the first object, and can do no good. As to remov- ing the false membrane, if it could be accomplished, which those who are familiar with the morbid appearances in croup will doubt, the same ultimate objection applies, viz. — that we still have the diseased condition of the lungs remaining, and to the removal of that, we con- tribute nothing by opening the windpipe^; but, on the contrary,add a new cause of irritation. Prophylaxis. — We have stated that croup appears to be endemic in low, damp situations, near the sea or large lakes ; and from such places a child who has once suffered the disease, or belongs to a family predisposed to it, should be removed. He should, also, be carefully and sufficiently clothed, and as little as possible exposed to the influ- ence of cold and damp, or easterly or north-easterly winds. VI. OTHER INFLAMMATIONS OF THE LARYNX, INCIDENT TO CHILDREN. The disease commonly known under the name of Laryngitis or Angina OSdematosa, is one rather of advanced life than of child- hood ; but there are some other inflammatory affections of the larynx, which belong more especially to the latter period, and therefore call for notice here. 2Q2 DISEASES OF THE RESPIRATORY ORGANS. One of the most common of these is the inflammation arising from the attempt, occasionally made by children, to drink from the spout of a kettle containing boiling water. In these cases, the common effects of a scald are produced upon the mouth, fauces, epiglottis, pharynx, and oesophagus, varying in degree according to the quan- tity of heat applied, either in the shape of steam, or by the boiling water itself. The symptoms are dyspnoea, resembling that in croup ; audible inspiration ; stifled voice ; usually accompanied with the sinking and debility which commonly attend severe burns and scalds, and are strikingly manifested in a sunken countenance, cold extremi- ties, and tendency to coma. The local appearances vary somewhat : there may be extensive inflammation and vesication of the tongue, cheeks, and fauces, with partial removal of the cuticle ; or the parts may appear, as in Dr. Burgess's case,* as if a piece of raw meat was thrust into the fauces ; the epiglottis is generally swollen and blis- tered, or as it were, corrugated. Upon examination after death, there has been lymph observed in the trachea, in some cases ; in others, the inflammation has not appeared to descend below the larynx. The former will more usually be observed in patients who have sur- vived the accident for some days, and then marked traces of violent inflammation of the lungs will frequently coexist. The oesophagus and stomach usually escape uninjured. These are cases in which we should, d priori, suppose that bron- chotomy would be required, and be likely to succeed, as the obstruc- tion is usually confined to the larynx ; the trachea and bronchi being, in the first instance, sound. Much success has not, however, attended the operation, probably in consequence of the severity of the accident producing a shock which the system is unable to bear. Dr. Burgess, of Clonmel, operated twice, and with success in one in- stance.t Dr. M. HallJ recommends scarifying the epiglottis, for the purpose of reducing the swelling, and the suggestion certainly deserves to be remembered. With respect to general treatment, that suggested by Dr. Cheyne — viz., the administration of small doses of opium every two or three hours — appears to be the most rational, as being likely to allay irri- tation, and support the system under the shock which it has sustained. Dr. C. places no great confidence in bleeding ; and in thinking of this remedy, we must recollect that in accidents of this kind a sudden im- pression upon the nervous system is produced, which makes them different from ordinary inflammations, and appears generally to con- traindicate bloodletting. Small quantities of soothing fluids, as almond emulsion, or cream, should be constantly placed in the mouth ; and perhaps cream-ice, used in the same manner, might be of service. When the difficulty of respiration is so great as to threaten death, bronchotomy should certainly be performed without loss of time. * Dublin Hospital Reports, vol. iii. t For the particulars of a case of this kind in which tracheotomy was success- fully performed by Mr. Smyly, see the Medical Press, vol. ii. p. 320. [Note to 3d Edition.) $ Med. Chir. Trans, vol. xiL FOREIGN BODIES IN THE LARYNX AND TRACHEA. 2 63 Inflammations originally affecting the fauces may extend to the rima glottidis and larynx ; and in this way death is often suddenly caused by the obstruction occasioned to respiration, although the pri- mary disease was not one, of the proper air passages. Thus, in small-pox, pustules may be formed upon the parts in question ; and in scarla- tina or diphtherite, aphthous ulceration ; or a false membrane may descend into the windpipe. In the treatment of those diseases, a great deal of attention must accordingly be paid to the state of the air passages ; and it is to be recollected, that our great object must be, to prevent the affection from extending to these parts, as we have but little control over it when so much progress has been made. The diseases alluded to, are considered under their proper heads. In some of these secondary affections of the larynx, we have had occasion to observe how inadequately the symptoms or morbid ap- pearances explain the effects produced. We once attended a child in small-pox, which went favourably through the disease up to the filling of the pustules ; and, upon the last occasion of our seeing it alive, cried without hoarseness, and appeared to be going on as well as could be desired under the circumstances. In about four hours afterwards, a spoonful of water was placed in its mouth, which was rejected through the nostrils ; and, without cough or convulsion, death instantly took place. The only remarkable morbid appear- ance was a dotted abrasion of the margin of the rima glottidis, — the part appearing, precisely, as if small portions of the mucous membrane had been cut off in dots with a sharp instrument. The lesion did not resemble ulceration, but rather that abrasion of the conjunctiva of the eye which we sometimes see in strumous children, the cornea beneath remaining clear. There were no pustules upon or near the epiglottis ; nor any appearances in the brain sufficient to account for death.* We mention this case for the purpose of show- ing how apparently slight a cause may produce, in children, sudden and most unexpected dissolution. VII. FOREIGN BODIES IN THE LARYNX AND TRACHEA. Children are very liable to obstructions of the respiratory function from this cause ; and as the diagnosis of such a case is difficult and important, it is necessary that we should notice it, although the sub- ject does not especially belong to the province of the child's physician. The affections with which we are most likely to confound accidents of this kind are, hooping cough, spasm of the glottis, and croup ; and, in fact, many of the symptoms are those belonging to the latter disease. The child will be suddenly attacked with a paroxysm of difficult breathing and spasmodic cough, so severe as to threaten instant suf- focation, — the dyspnoea being greater during expiration than inspi • A case similar to the above, so far as the rima glottidis was concerned, was read by Dr. Falloon before the Surgical Society of Ireland: but in it there were symptoms resembling croup, and the dotted ulceration extended into the trachea and bronchi. 264 DISEASES OF THE RESPIRATORY ORGANS. ration. These paroxysms recur at intervals, during which the child will probably breathe hoarsely, bat may in other respects appear tolerably well, During one of the paroxysms, the foreign body may be forcibly expelled from the mouth, when the symptoms will shortly cease ; but if the case continue without relief, bronchitis will probably ensue, and the patient perish from that disease, or by sud- den suffocation. The means of diagnosis chiefly to be relied upon, are the history of the case, and the stethoscopic signs. If a healthy child has been suddenly attacked with spasmodic cough whilst eating, or playing with some small article (as a bead, button, &c.) which has simulta- neously disappeared, a presumption is afforded that some foreign substance has got into the trachea. The stethoscopic signs are chiefly valuable at the commencement, before inflammation of the bronchi has set in. When the foreign body is fixed in the larynx, as is likely if it be a fish-bone or other pointed substance, the healthy respiratory murmur will be plainly distinguishable throughout the whole extent of the thorax, which will also return a clear sound upon percussion. Some mucous rale maybe audible in the upper portion of the trachea, owing to the accumulation of fluid in consequence of irritation. When the foreign body is moveable, — as a button, plumb-stone, &c, would be, — its motion up and down the trachea will be occasionally heard, as well as a valve-like sound produced by its being driven in expiration against the rima glottidis. There may also be perceived, at times, a temporary interruption to respira- tion in one lung, when the body happens to be impacted in the cor- responding bronchus, — the respiratory sound again returning when the obstruction has been removed by a violent expiration. It is said that the foreign body is most likely to pass into the right bron- chus, and that hence it is in the right lung we shall most frequently observe the obstruction of respiration.* The treatment indicated in these cases is unquestionably broncho- tomy, which, if the body be in the larynx, or loose in the trachea, may be looked upon as affording a fair prospect of success. The subject, however, must be gravely considered, before resorting to so formidable an operation ; and we must carefully collate the physical signs, with the history, both of the accident and of the previous state of the child's health, before we decide. The diseases, likely to pro- duce error, sometimes invade very suddenly ; but there is generally * We can never be too careful in investigating the history of sudden laryngeal affections : one among several instances in point, which came within our own ob- servation, it may, perhaps, be well to mention briefly: a child of three or four years old was suddenly seized with symptoms of croup, and actively treated ac- cordingly, for some days, when, as it was not becoming better, our opinion was sought for. It then appeared, upon close examination, that about the time of the first seizure the child had been playing in the kitchen, whilst the servants were dining upon herrings. The discovery of this circumstance led to the diagnosis of the real nature of the case: bronchotomy was recommended, and after considerable delay performed ; but too late to save the patient. After death, however, a herring- bone was found sticking in the ventricle of the larynx. See also a case by Dr. Evanson, in the 5th vol. Dub. Med. Journal. SPASM OF THE GLOTTIS. 265 some appearance of illness previously, and their invasion is usually- accompanied with signs of general fever and disturbance of the sys- tem, which are wanting immediately after an accident. Foreign bodies, (as pieces of meat,) stopping in the fauces, and pressing upon the epiglottis, may produce all the distressing symp- toms occasioned at the first passing of any substance into the larynx, and may occasion sudden suffocation. In this case, relief may be given by passing in the finger and removing the obstruction, or by pushing it down the oesophagus by a probang ; but frequently, the body is beyond the reach of the finger, and the emergency' is so great as to admit of no delay, so that the only resource, and means of saving the patient, is the instant performance of bronchotomy. The nature of the operation, and other considerations belonging to it, fall within the limits of general surgery. VIII. SPASM OF THE GLOTTIS. A good deal of confusion appears to exist among medical writers, with regard to the application of this term, — partly owing to its being now applied to a disease which was formerly described under sundry names ; and partly to its being made to include, in common parlance, affections which perhaps have nothing in common, except the occasional occurrence of very sudden death. The disease described by Sir Henry Marsh as " spasm of the glottis,"* appears to be identical with — "the acute asthma of Millar," "Die krampf- hafte Engbriistigkeit of the Germans," " the inward fits" of Under- wood, " the peculiar species of convulsion" of Dr. John Clarke, "the cerebral croup" of Mr. Pretty," the laryngismus stridulus" of Good, and " the thymic asthma" of Dr. Kopp, and other late German writers. By others it has been confounded with the early stage of croup, or that mild threatening of the disease which occasionally occurs in irritable children, and has thence been denominated " spas- modic croup." In common parlance the term has been made the asylum ignorantix in all cases of sudden and unaccountable death occurring among children. A striking picture of the disease, as we understand it, is given in the able paper of Sir Henry Marsh, already cited. It occurs during the first two or three years of life, and appears to be frequently con- nected with dentition, and a deranged state of the digestive system, or of the general health, produced by impure air, fever, unsuitable nourishment, &c. At the commencement, the child, without perhaps showing any previous indications of illness, will be observed to awake suddenly from sleep, as if alarmed ; to struggle for breath, exhibiting all the signs of obstructed respiration, and, after repeated efforts, to recover with a long and sonorous inspiration, like that in hooping cough. Subsequently, the paroxysm may occur when the child is awake, especially if it be frightened or vexed. During the fit, the face often becomes swollen and purplish. After some time, * Dublin Hospital Reports, vol. v. 23 266 DISEASES OF THE RESPIRATORY ORGANS. as the disease advances, the hands and feet become slightly swelled, and the fingers and toes rigid, the thumb being frequently drawn into the palm of the clenched hand. We have observed the spasm to affect the extensor muscles, and to produce a permanent spread- ing and extension of the fingers, which, so far as our experience goes, appears to betoken less serious lesion of the nervous system than the opposite condition. As the disease advances, the health becomes considerably deranged, the bowels are out of order, stools green and slimy or curdy, child pale and unhealthy-looking. If neglected, general and fatal convulsions may supervene. The patho- gnomonic of the disease, according to Dr. Cheyne,* is crowing inspiration, with purple complexion, not followed by cough. We have noticed cases in which the crowing inspiration had a consider- able degree of permanency, and was not confined merely to the period of occurrence of the fit. The duration of the disease is very various : the child may be cut off suddenly in a paroxysm, by suffo- cation, or it may have attacks at intervals for several months, and yet recover. The pathology of spasm of the glottis is still very obscure. Sir Henry Marsh considers it to be primarily a spasmodic affection of the muscles of the glottis, and that it is only when the disease increases in severity, and when general convulsions arise, that the brain, or its membranes, become the seat of disease. He suggests that the primary lesion may exist at the origin of the pneumogastric nerve. He found the disease usually to occur in children of a stru- mous diathesis, and frequently, though not universally, to be com- plicated with painful dentition. Clarke and Cheyne conceived the seat of the disease to be in the brain. Kopp refers its cause to hy- pertrophy of the thymus gland, occasioning pressure upon the heart, lungs, and great vessels. More recently, Dr. Hugh Ley has pub- lished a lengthy essay upon spasm of the glottis, or laryngismus stri- dulus, as he terms it, in which he refers its cause to enlargement of the bronchial, or deep cervical lymphatic glands, producing pressure upon the recurrent nerves, and consequent paralysis of the muscles supplied by them. Without going into a consideration of these va- rious theories, it will be sufficient to say, that the affection is too constantly curable, and too frequently yields to a removal of specific irritations, as from dentition, deranged bowels, or indigestible aliment, to admit of its being referred to a cause decidedly organic. That enlargements of the bronchial, cervical and thymus glands are occa- sionally met with, as complications, we have no doubt, but when we recollect that the subjects of the complaint are usually of a deli- cate and strumous habit, such appearances are not to be looked upon as of much importance in relation to its special pathology. These remarks equally apply to other hypotheses having for their basis organic lesions ; and, therefore, we are inclined to adopt Sir Henry Marsh's view, and consider spasm of the glottis as essentially a spas- modic affection, but one liable to many organic complications, both * Treatise on Hydrocephalus. SUDDEN DEATH. 267 accidental, and consequent upon the continuance of irritation which it occasions in the system. The treatment of spasm of the glottis recommended by writers varies much, according to their views of its pathology. Our expe- rience of the frequent complications of the disease with difficult dentition, derangements of the digestive system, and with marks of a scrofulous diathesis, as well as its occasional dependence upon ex- posure to impure air, (the spasms, in a case of Sir Henry Marsh's, recurring whenever the patient was brought back to a newly-painted house,) have hitherto induced us to adopt the following plan : We would endeavour by all suitable means in our power to re- move complications, and restore the general health. When the bowels are deranged, alterative aperients should be used. If we observe teeth approaching the surface, the gums over them should be divided. If the child be suckling, all artificial food should be in- terdicted, a fresh and healthy nurse should be provided, and removal into pure air effected. When there is no manifest complication, small doses of sulphate of quinine or iodine may be given as tonics. Sir Henry Marsh found much advantage in the employment of the tinctura fuliginis of the old pharmacopoeias. All causes of excite- ment or irritation should be avoided; and during the fit, the child should be held up, and exposed to a draught of cool air. Every indication of an approaching affection of the head should be jealously watched, and treated according to circumstances.* Those who refer the disease to a hypertrophied condition of the thymus gland, advise a different mode of treatment, directed towards the lessening of congestion in that organ, viz., " a very low diet; abundant and often repeated local bleedings ; issues on the chest ; frequent energetic purgatives ; with a choice of mercurials, antimo- nials, cicuta, digitalis, animal charcoal, and iodine."? If we are justified, and we think we are, (at least in the absence of more certain knowledge,) in adopting Dr. Gooch's principle, of viewing the effects of remedies as tests for determining the differences of morbid conditions, our own experience tells us that the alterative and tonic plan we have recommended is the proper one ; and that the disease ive have described will always be aggravated by treating it, in the first instance, as an inflammatory or congestive affection. If, in its progress, it should be complicated with congestion within the head, depletion may become necessary, according to the indica- tions which will be considered when we are treating of head affec- tions ; but even then, the cachectic character of the primary disease must not be forgotten. We have stated that death sometimes takes place in children with unaccountable suddenness, and that such cases are usually referred to Spasm of the Glottis. For any thing we know to the contrary, at * See chapter on Affections of the Head, f Dublin Medical Journal, vol. ix. p. 521. 268 DISEASES OF THE RESPIRATORY ORGANS. present, it may be that the term is rightly applied ; but we wish to point out that the disease which we have been just describing, under the title of Spasm of the Glottis, has distinct characters and symp- toms, which mark it as different from the class of cases to which we are now alluding. We shall briefly state the particulars of the last instance of the kind which has fallen within our notice as the simplest mode of illustrating our views. A child of eight or nine months old was apparently recovering well from hooping cough ; its bowels were not materially deranged, it sucked well, and the cough was becoming less frequent and severe. The only remarkable circumstance was, that alarm was two or three times excited among its attendants, by the sudden occurrence of an unusual agitation in its breathing ; which, however, was so transient that no very clear account of its nature could be obtained. On the day of its death, it appeared lively, and better than usual ; but towards evening, while lying on its mother's lap, without cough, convulsion, or struggle of any kind, it suddenly expired. A careful examination was made of all the cavities, about eighteen hours after death, but without discovering any morbid appearance whatsoever. There was here no crowing inspiration, purple complexion, or other mark of obstructed respiration, or suffocation, which are so many pathognomonics of the disease we first described. We know of many occurrences similar to that just narrated. Pro- fessor Montgomery has lately given an account of some which fell under his notice.* He relates two in which there was some enlarge- ment of the thymus gland, and refers the fatal result to the pressure of that organ upon the trachea and great vessels and nerves. That this is not the constant cause of the event (we can scarcely call it a disease), we are perfectly certain ; for, in the foregoing case, the thymus gland was in a normal condition. It is probable, however, that there may be more than one occasional cause, and every observation upon the subject is interesting. As to the treatment, we have little to offer — the child is generally dead before we hear of its being ill ; but if our attention be directed to any unaccountable agitation in the breathing of an infant, we would be disposed to treat it upon the plan, already recommended in this section, for improving the general health. If there be any ap- pearance of enlargement or fulness in the region of the thymus gland, and that the condition of the child warrants us in supposing this to be of an inflammatory or congestive nature, a leech may be applied over the sternum, and subsequently some slightly irritating liniment rubbed upon the part. If we have reason to suppose the enlarge- ment to be scrofulous, the internal use of iodine will probably be of service. If we happened to be with a child at the moment of seizure, the performance of tracheotomy would undoubtedly be warrantable. IX. HOOPING COUGH (PERTUSSIS). This affection being one of those which regularly occur but once * Dublin Medical Journal, vol. ix. HOOPING COUGH. 269 in the same individual, and that generally at an early period of life, it must be considered as a disease of childhood, although the memory of every practitioner will furnish him with instances of its invasion of even elderly subjects. The common notion is, that hooping cough is infectious, and that it is always propagated by infection ; but this has been doubted by many French and German writers, as Billard, Gardien, Wendt, Stoil, &c, who consider it as rather of an epidemic nature. This, like other questions of the kind, it is next to impossible to determine, as we have absolutely no means of distinguishing between an epidemic and conta- gious propagation of disease. It is quite certain, however, that hooping cough prevails most at particular seasons of the year, viz., at the close of winter and commencement of spring; and thus, whether or not it be spread, in individual instances, by contagion, it manifestly possesses epidemic characters. Girtanner* has advanced the notion, that the disease owes its origin to a specific miasm, analogous to that of marshes ; but for this opinion, we may at least say, that there is no foundation of fact. Symptoms. — Hooping cough commences, like an ordinary catarrh, with feverishness, thirst, coryza, tenderness of the eyes, and a fre- quent, dry cough. These conditions, which include no diagnostic marks of the disease, constitute the stage of incubation, and usually continue from four or five to ten days, although in some instances this stage is but little marked. At the end of the period of incuba- tion, the cough changes its character, and assumes the peculiar con- vulsive form which belongs to the disease. It occurs in paroxysms, or kinks, at intervals varying from half an hour to three or four hours, and is accompanied by long and noisy inspirations, with a crowing and whooping sound. This is pathognomonic of the disease, and has given it a name in most languages.! In some varieties, however, as when the patient is an adult, or a very young infant, the whoop may not be distinctly marked. During the paroxysm, the patient usually shows all the signs of impending suffocation — the face and neck become red, swelled, and often livid ; the vessels of the head are full, and a tensive pain is experienced in the forehead ; the eyes water, and appear as if start- ing from their sockets ; the pulse becomes quick ; the patient is greatly agitated, and lays hold of any fixed object which may be within reach. After this state has continued for a few minutes (more or less), the contents of the stomach are generally discharged, together with a large quantity of mucus, whereupon the coughing ceases, and the patient gradually recovers tranquillity. In severe cases, discharges of blood may take place, during the paroxysms, from the nose, eyes, lungs, or stomach, and even, (it is said,) from * Christoph. Girtanner Uber die Krankheiten der Kinder. Berlin, 1794. f In the old English works it is called Kink^ough ; by the Scotch, Kink-hoast ; by the French, Cuqueluche (explained by Billard to signify a congh coming from a person whose head is covered with a hood) ; by the Germans, Slick-huslen, Keich- /tuslen, and in some parts, Esels-husten , the whoop being likened to the braying of an ass. 23* 270 DISEASES OF THE RESPIRATORY ORGANS. the ears. Involuntary discharges may also occur from the bladder and bowels. Occasionally the patient falls down in a faint, from the extreme violence of the fit. The paroxysm returns with some degree of periodicity ; but it is often brought on irregularly by a full meal, exposure to cold, or any excitement. When the second stage has fairly set in, the symptoms of catarrh, in favourable cases, abate, and the fever is often very slight, — the patient being lively, and inclined to eat, during the intervals. The skin, however, is usually somewhat hotter than natural, and the child pale, and obviously out of order. The second stage of pertussis appears to have a definite duration — in favourable cases, about three or four weeks — at the end of which it begins naturally to decline in severity, the secretion of mucus becoming more abundant, the cough looser, the paroxysms less violent and fatiguing, and the intervals longer, until at length, in two or three months from the first onset, the disease ceases altogether. The duration of the second stage, however, though it probably cannot be very much shortened by art, admits of being considerably extended by many accidental circumstances, as taking of cold, &c. ; and relapses of the convulsive cough are liable to occur, even after the patient has appeared for several days to be altogether free from the disease. Pathology. — Morbid anatomy has thrown no light upon the proximate cause of hooping cough ; and accordingly, as is always the case in the absence of exact knowledge, the subject has been deluged with a flood of hypotheses, — none of which, however, can claim to be more than plausible guesses : many are merely a re- stating of ignorance, in obscure, and therefore (according to the notion of some) scientific words. The fact is, the simple disease is probably never fatal ; and therefore, any appearances which we may meet with in the dead body are the results of complication — e. g., marks of inflammation in the lungs or brain. We shall now merely allude to some of the opinions in question. By Cullen, hooping cough was placed among the neuroses, and con- sidered as a specific irritation of the nervous system. Hufeland, Pal- damus, Jahn, Breschet, and others, supposed the particular lesion to be in the phrenic and pneumogastric nerves. Lobenstein-Lobel believed it to exist, primarily in the diaphragm, and that the irrita- tion was subsequently communicated to the nerves just mentioned.* Webster locates the disease in the brain itself. Watt, Marcus, Albers, and Guersent, look upon it as a simple bronchitis ; Desruelles, as a bronchitis followed by cerebral irritation — a broncho-cephalite, as he terms it. To a similar view, Dr. Johnson also appears to incline.t Dr. Butter designates the bowels as the seat of the primary lesion Autenrieth believes the origo mali to be a determination of morbid matter towards the bronchi, and hopes to divert it away by exciting morbid pustules upon the skin. Holzhausen and Clarus found, in the body of a boy who had died of hooping cough,the phrenic nerves * See Wend I, op. cit. t See his able article, "Hooping Cough," Cyclopaedia of Practical Medicine. HOOPDsG COUGH. 271 loose in texture, and somewhat swollen ; the trunks of the vagi like- wise looser, thicker, and broader than natural ; the great sympa- thetic and splanchnics, especially the latter, of a firmer consistence than usual ; and the cceliac plexus firmer and somewhat elevated.* But, in point of fact, there is no part of the body which has not been found diseased after hooping cough, and assigned as its seat by those who argue post hoc, ergo propter hoc ; as an example of which we may mention, that Girtanner lays some stress upon his having found the parts of generation in a morbid condition upon these occasions. We shall not add to this tangled web of opinions by any specula- tion of our own, but freely confess our entire ignorance as to the intimate nature of the affection. All we know is, that the symptoms in the first stage show the bronchial mucous membrane to be in a state of irritation, if not inflammation ; and that in the second they assume a distinctly spasmodic character. Diagnosis. — The diagnostics of hooping cough are, the whoop and the paroxysmal character of the cough, by which, when it is uncomplicated, it may be readily distinguished from all other diseases. Prognosis. — In simple pertussis, occurring in a healthy child, the prognosis is favourable ; but should always be modified by a due regard to the liability to occurrence of dangerous complications, which is so great as to cause the deaths under the head of hooping cough to constitute a formidable item in bills of mortality. Those complications are most likely to occur, and to be dangerous, in very young children, in those just weaned, or suffering from dentition or other causes of delicate health ; and in those of a naturally unsound constitution. All these collateral circumstances should therefore be taken into account, in giving our prognosis, and the danger of the sudden supervention of another disease distinctly adverted to. Treatment. — The treatment in simple, uncomplicated hooping cough, must be one rather of prevention than cure. Our chief ob- ject should be to avert inflammations or congestions of important viscera, as the lungs, brain, or digestive apparatus. During the stage of irritation of the bronchial membrane, we must keep down the general and local fever, by quietude, low diet, and such eva- cuants as the symptoms may demand. A mild emetic of ipecacuan will almost always be serviceable, and will generally accomplish another indication, by freeing the bowels.f Should it not do this, * Wendt, op. cit. f The prescriptions of Fothergill and Pearson will, either of them, answer well under the above mentioned circumstances. The former is — R. Pulv. e. Chel. Cancr. ^ss. Tartar. Emet. gr. ij. Accurate misceantur — gr. i. — gr. ij. indies. The latter- ly. TincturEe Opii, guttam. Vini Ipecacuan. gtts. v. Carb. Sodae, gr. ij. Ft. Pulvis 4ta quaque hora sumendus. 272 DISEASES OF THE RESPIRATORY ORGANS. however, we may administer one of the aperients recommended in Chap. V. The child, during the first stage, should certainly be con- fined to its apartment, which should be well ventilated, but kept moderately warm ; and we should not be led to deviate from this rule by the popular notion, that change of air is good for the disease. The notion is quite true in the latter stages, when the cough is ob- viously spasmodic, and kept up more by habit, than by any actual irritation ; but it leads to very injurious consequences, when acted upon during the irritative period. The state of the lungs must be carefully watched throughout, and the first symptoms of an inflam- matory kind, met at once by bleeding and leeches. Should no un- toward circumstances, however, interfere, the first stage will pass on without a necessity arising from active treatment ; the bronchial irritation will gradually subside, and the cough assume the spasmo- dic character. It is at this period, when the fever has abated, and the appetite is beginning to return, with, at the same time, a complete freedom from wheezing, or other indication of pulmonary affection during the in- tervals, that we shall find change of air productive of benefit, and that we shall be enabled to employ any of those antispasmodic me- dicines which are in general repute. We must, however, still ob- serve great caution. Fine weather should be selected for bringing the child into the open air, and it should always be well clothed and protected from the cold. Something perhaps may be done in breaking the habit of the dis- ease, by tonics or antispasmodics, and a vast variety of such have been recommended — too great a variety, indeed, to allow of our putting much faith in any single specimen. Cantharides, with bark, has been much recommended, and, when used in suitable cases, will sometimes be found serviceable.* We have also found belladonna useful, in doses of an eighth of a grain, three or four times daily. Oxide of zinc was recommended by Guersent, in doses of a grain, every hour; cicuta, by Butter and Stork; extract of tobacco, by Stoll, Hufeland, and Thilenius ; wild rosemary, by Linnaeus and Wahlborn ; arsenical solution, in doses of a drop daily, by Dr. Fer- riar, &c.,&c. ; but it is needless to encumber our pages with an enu- meration of more specifics, as their very multiplicity affords a strong presumption in favour of their inefficacy. Autenrieth, arguing upon his theory of the nature of the disease, — viz., that it was a deter- * The following formula was much employed by the late Dr. Beatty of Dublin : B. Tinct. Cinchon. Comp. Jv. Cantharid. 1 Opii Camphor, aa. ^ss. M. 3ss — 3i. ex cyatho decocti hordei ter indies. Burton, the original proposer of cantharides in hooping cough, trave it in powder, as follows : R. Cantharid. Camphor, aa. ^i. Extract. Cinchon. 5»ij. Tere simul — gr. viij. 3tia vel 4ta quaque hora. HOOPING COUGH. 2 7 « mination of peccant matter upon the lungs, has advised the deriva- tion of this matter toward the surface of the body, by the employ- ment of tartar emetic ointment, so as to bring out a crop of pustules ; but this is merely a clumsy and unmanageable mode of counter- irritation, and is not suitable in child's medicine. After all that has been said and written respecting specifics for hooping cough, perhaps as good a medicine as any, during the de- cline of the complaint, will be one of the expectorant mixtures pre- scribed in Chapter V.* During the whole progress of a case of hooping cough, we must be alertly upon the watch for the first signs of local inflammations. The most common of these is bronchitis, the symptoms and treatment of which are detailed under their proper head. Here we have only to say that when it does supervene or threaten, it must be met by active depletion and loss of blood, general or local, according to the symptoms; and from this practice we are not to be deterred by any preconceived ideas as to the nervous or spasmodic nature of the dis- ease. We cannot too often repeat, that the great danger of pertussis arises from the likelihood of the supervention of local inflammation re- quiring active and prompt treatment. Other local affections, very apt to complicate hooping cough, are hydrocephalus, or convulsions, and the probability of their occurrence should never be lost sight of. The symptoms and treatment of these affections will be adverted to in their proper place; but we may mention that clenching of the hands, the thumbs being turned into the palms, drowsiness, screaming out during sleep, and, as Dr. Johnson justly remarks, "greater irritability of the stomach than we can account for, or than is natural during hooping cough," are marks which always call for our most strenuous exertions for the aversion of head affections. Remittent fever, and severe derangement of the bowels, is a com- mon complication of the second stage of pertussis, and is not unfre- quently dangerous, or even fatal. The fever, and the increase of the cough and hurry of the respiration, which commonly attend upon it, may often lead us to mistake this complication for bronchial inflam- mation. The diagnosis must be derived from the absence of direct signs (as the auscultatory) of pulmonary disease ; the occurrence of distinct remissions ; the condition of the mucous membrane, &c, — all of which have been dwelt upon, when treating of remittent fever. The liability to the occurrence of derangement of the bowels, should warn us against the indiscriminate and wanton use of purgative or other irritaUng medicines, in the treatment of hooping cough. Many simple cases of the affection have been, no doubt, hampered with dangerous complications, by this unhappy practice. For the manage- ment of derangement of the bowels and remittent fever, we must refer to the chapter devoted to those subjects. When hooping cough happens to attack a child while undergoing the process of dentition, very special attention to the case is demanded. * Nos. 15, 17, 19. 274 DISEASES OF THE CEREBRAL SYSTEM. At this period, both the abdomen and head are peculiarly likely to be engaged; and we shall best prevent these occurrences by carefully watching the state of the gums, and treating them according to the principles laid down in the chapter upon Dentition. CHAPTER X. DISEASES OF THE CEREBRAL SYSTEM. I. FUNCTIONAL DISEASES. The peculiarities of structure to be observed in the nervous system of the infant have been already pointed out, and sufficiently account for the facility with which disturbance of that system takes place during childhood. The great susceptibility to impressions, in consequence of the large mass of brain* and the readiness with which the balance of the cir- culation is deranged, in consequence of its great vascularity, fre- quently give rise to a state of morbid irritation or congestion, which, though not constituting organic disease, may soon lead thereto. We shall consider separately the disorders of the cerebral system con- nected with inflammatory action, and those existing independently of inflammation. The latter may give rise to very serious symp- toms, or even lead to a very fatal result, as we witness in certain cases of irritation, congestion, convulsions, &c, &c, of which we now proceed to treat. We recognise the symptoms of morbid irritation, or erethysm of the brain, (as Dr. Whitlock Nicol calls it,) when we perceive an unusual degree of acuteness in the sensations of a child ; while it is fretful, unquiet, or affected with wakefulness. Noise and light are disliked, the eye being as over-sensitive as the ear, and often winking before a bright light ; or the lids are spasmodically closed. The hand is occasionally clenched, or the thumb thrown across the palm; and frequently, sneezing is present. The temperature of the body, and state of the pulse, are both natural, though occasionally the skin may be hot or the pulse raised ; but the signs of determination of blood to the head are absent. If the spinal marrow be engaged in the irri- tation, the head is thrown back; or there may be some degree of opisthotonos present, with occasional twitchings or convulsive move- ments of the limbs, and great sensitiveness of the whole surface. Wakefulness is a very prominent character of nervous irritation * M. Billard, however, has noticed that affections of the spinal cord are more frequent in the young infant than those of the brain ; and M. Ollivier states that the symptoms of the former are much better marked than those of the latter — the functions of the brain being as yet so little exercised, in consequence of its imper- fect structure, that their disturbance scarcely attracts notice. FUNCTIONAL DISORDER. 2 75 ill the child, and should always arrest attention. When obstinate, it is a dangerous sign, often preceding inflammation of the brain, par- ticularly in children predisposed to hydrocephalus, or who are labour- ing under fevers, as measles, scarlatina, &c, &c. In the latter disease, especially, this symptom is often as distressing as it is dangerous. Somnolency is an occasional symptom of sympathy of the brain, with an overloaded state of the stomach, or costive condition of the bowels ; and a tendency to drowsiness, or even stupor, will often vanish on the exhibition of a brisk cathartic. The presence of worms may occasionally give rise to similar symptoms. The common cause of morbid irritation in the brain are, debility, or the excitement produced by stimulants improperly given ; a deranged state of the bowels, the injurious effects of low, damp situa- tions, and ill-ventilated apartments; or moral impressions, such as fear, anger, &c. We have already pointed out the relation between this state and the process of dentition (p. 162). In all these cases, irritation is very prone to pass into inflammation, and thus hydro- cephalus may be established. Treatment. — Our first effort must be to ascertain and remove the cause of this affection ; our next, to apply such means as are cal- culated directly to, allay the morbid irritability of the nervous system. The state of the bowels primarily demands attention, as also the cha- racter of the secretions. Care must be taken to regulate the diet, which should be nutritious without being stimulating ; and removal to a healthful situation, if necessary, or, at all events, free exposure in the opon air (while exposure to noise or a bright light are avoided), is essential in restoring the balance of the nervous system. Cold to the head (which should be daily sponged with vinegar and cold water), while the feet are occasionally immersed in warm water, or the warm bath employed, are measures directly calculated to allay the irritable condition of the brain, and in particular to restore sleep, when wakefulness is present. In some alarming cases of this description, we have seen tranquillity quickly restored, and sleep in- duced, by the use of the warm bath, while cold was, at the same time, assiduously applied to the head, and the application continued until the child appeared to grow faint. In this form of cerebral affection, the judicious use of narcotics is of signal service ; but they need not be resorted to until the other means mentioned have been tried. In acute cases of morbid irritation, where the symptoms ap- proach those of inflammation, our treatment must be more active — leeches, cold to the head, active purgatives, or counter-irritation, being employed ; and such should always precede the use of narcotics in these cases. Co?igestion is not an unfrequent condition of the brain during in- fancy, and may be present immediately after birth ; but the symp- toms are very often obscure. We consider that congestion is present, however, when a child is stupid and heavy ; the head looking full, and being, perhaps, hotter than usual ; with the veins distended, and dark-coloured, or the countenance livid ; and the pulse slow, or it may be irregular. The pupils are usually dilated, the eyes looking 276 DISEASES OF THE CEREBRAL SYSTEM. vacant, or they are with difficulty fixed on the same object. The state of the fontanelles (as we remarked in our Chapter on Diagnosis), affords an important source of information ; and this, though seldom set forth in books, is always to be looked to by the practical physician. A permanently elevated and convex condition of the fontanelle, joined to the above symptoms, leaves no doubt of the existence of congestion of the brain. Cerebral congestion is liable to occur at the commencement or towards the conclusion of the exanthems in the child, and is always to be regarded as a serious symptom. Congestion may lead to inflam- mation, but is less likely to do so than irritation ; more particularly in young infants, in whom Billard remarks that inflammation is much less liable to follow congestion of the brain, than when either the stomach or lungs are the seat of this affection. Congestion more frequently leads to effusion, and in some cases this occurs very rapidly. We have seen a child suddenly seized with an attack of convulsions, accompanied by signs of congestion, and dying comatose in less than twenty-four hours. Venous congestion of the pia mater, with copious effusion into the ventricles, were the appearances found after death. Mere irritation seems, however, capable of producing similar results — effusion being found, but with little signs of congestion ; and inflammatory action at times runs this course so rapidly, that doubts must be entertained as to whether such had previously existed. Golis speaks of attacks of this description, which he calls " the water stroke," — effusion and death taking place in a few hours. He looks upon this as a variety of hydrocephalus, the inflammation and effusion being almost coincident ; and hence he designates it as hyper-acute. This form of the complaint may be idiopathic ; but is generally brought on by the sudden suppression of some accustomed discharge, or the repulsion of one of the exanthe- mata. Effusion. — No signs, exclusively indicative of effusion, appear to exist, as is now acknowledged ; for those usually enumerated may be present without effusion having taken place, while effusion is occasionally found where no such signs are present. When, how- ever, the head gradually enlarges, with the fontanelles full, we may consider that effusion is the cause ; or in more rapid cases, insensi- bility, with muscular relaxation, debility or paralysis, generally indi- cates the presence of effusion. We have seen cases in which the head enlarged during the presence of febrile symptoms, and those of cerebral excitement, but without dilated pupil, coma, or paralysis ; and which we were inclined to look upon as cases of hypertrophy of the brain, that again subsided under the use of antiphlogistic measures. Treatment. — This will consist, in cases of congestion, in the assiduous application of cold to the head, while heat is at the same time applied to the extremities, or the general warm bath employed. The bowels should be emptied out by purgative enemata ; and occa- sionally leeches may be required ; but they should be used with caution, and are better applied to one of the extremities, or the back FUNCTIONAL DISEASES. 277 of the neck, than directly to the head. Sinapisms, or blisters, will be more frequently necessary, and they should be first used on the extremities ; but afterwards counter-irritation, applied directly to the head, is most serviceable. Hydrencephaloid Disease. — The attention of the profession has been directed, by Dr. Marshall Hall,* to a train of symptoms occa- sionally met with in children, and similar to some that occur in con- gestion or hydrocephalus ; but which differ from these in certain respects, particularly in being induced by a state of exhaustion ; and which, therefore, require a plan of treatment opposite to that neces- sary for an inflammatory affection. Dr. Goocht has also treated of this subject ; and it has been alluded to by Dr. Abercrombie. The disease is called hydrencephaloid, to distinguish it from inflamma- tory hydrocephalus. It can hardly be looked upon as a disease, however, but rather as a condition of the system leading to symp- toms of oppression of the brain, unconnected with an inflammatory origin, but which may succeed to an inflammatory affection, when depletion, particularly bloodletting, has been carried too far. From such source, Dr. M. Hall saw it generally arise, and found it con- nected with congestion. Dr. Gooch saw it arise from a delicate state of constitution, independentlv of this source, and found the ven- tricles distended with fluid, but the vessels of the brain remarkably empty. The symptoms are, drowsiness, with occasional delirium; the pupils are dilated, the eyes being kept usually half-closed, and there ' may be squinting or blindness ; the pulse is feeble, but may be quick, slow, or irregular ; the surface is cool, particularly the face and extremities ; the breathing becomes hurried and unequal, and the child, if unassisted or mismanaged, dies comatose or convulsed. The treatment consists in supporting the strength by nourishing diet and stimulants, as beef-tea or arrow-root, and giving aromatic spirit of ammonia, or brandy, (from five to ten drops for a dose,) until reaction is established, when the use of stimulants is to be cautiously withdrawn. Should much restlessness be present, small doses of opium are to be given, or the warm bath employed. Purg- ing or vomiting, if present, is to be checked. In this disease, we must be careful to avoid putting cold to the head, or raising the child suddenly up, and keeping it in an erect posture. By attention to these particulars, childr^i may be saved, who are said to be dying from hydrocephalus, bi who must have irretrievably perished had antiphlogistic measures been employed. The necessity for taking the entire condition of the patient into account, in affections of the head, and not merely looking to the cerebral symptoms, is admirably illustrated by these cases. Convulsions may be induced by any of the morbid conditions of the nervous system of which we have spoken, or may be merely sympathetic. Convulsions are not, generally speaking, so dangerous * See Dr. M. Hall on a Morbid Affection of Infancy, &c. | See Gooch on Diseases of Women, p. 355. 24 278 DISEASES OF THE CEREBRAL DISEASE. an affection as might be at first imagined ; nor is the degree of danger directly proportionate to the violence of the attack, as slight convul- sive movements may indicate a more serious affection than violent convulsions. When very violent or often repeated, however, a fatal termination, or an incurable state of paralysis, may result.* Very young infants are liable to a spasmodic affection, to which nurses give the name of inward Jits. The infant smiles often in its sleep, and rolls about its eyes ; the mouth being occasionally drawn down, with slight twitchings of the lips, and at times there is some surrounding blueness. This state, which can hardly be called one of convulsion, is usually induced by over-distension of the stomach or bowels, from the presence of flatulency or undigested food ; and will be relieved on removing its cause by the exhibition of a mild aperient, or a few drops of turpentine, or spirit of ammonia, in an aromatic water. Symptoms. — During a severe attack of convulsions, all the voluntary, and many of the involuntary muscles, are spasmodically contracted. There is starting of the eyes, or distortion of the eye- balls ; the tongue is protruded, and there is foaming at the mouth. The head and face are often red at the commencement of the attack, but become purplish towards the conclusion, as likewise at times does the whole body. The respiration is obstructed or laborious ; and the hands are, in general, firmly clenched, as well as the limbs being in violent motion. The attack may be momentary, or continue but for a short time ; or the convulsions may be frequently repeated, and last for many days. As the paroxysm subsides, the convulsive movements become less frequent, and less violent ; the muscular contractions relax ; the natural appearance returns, and the child becomes able to cry, having taken a full and deep inspiration. A calm sleep often follows, attended by a free perspiration ; and the child awakes refreshed, and apparently quite recovered. The convulsive attack may be much milder than that just described. Only one limb, or one side of the body, may be convulsed ; and this may alternate occasionally, or several times in succession, with a similar condition of the opposite side. The face alone may be affected, or only slight twitchings of this part, or of the limbs, be present, with some blueness about the mouth, and perhaps distortion of one of the eyes. Neither fever nor disturbance of the mental faculties necessarily attend an attack of convulsions ; but when they do, or the circulation is much accelerated previous to the attack, an inflammatory affection is to be apprehended. Convulsion attends on a directly opposite state, however, — one of depression or debility, — as has been described under the head of hydrencephaloid disease. Convulsions may come on suddenly, without any previous warn- ing, or there being any derangement in the child's health, to account for the attack. Generally they occur in children who are in delicate health, and hence their nervous system in a state of morbid irritability. * According to M. Billard's experience, the convulsive attacks of young infants arise most frequently from an affection of the spinal cord or its membranes. FUNCTIONAL DISEASES. 279 Under these circumstances, very slight causes will occasionally induce an attack ; as any sudden fright, the irritation of teething, pain, flatu- lency, constipation, the ingestion of unwholesome food, the presence of worms, or the sudden suppression of an eruptive disease, or accustomed discharge. Some precursory signs, however, often attend ; and these, in general, indicate a highly irritable state of the nervous system. In addition to the characters already enumerated, as belonging to this state (see p. 274), we observe, in particular, when convulsions threaten, some unusual appearances about the eyes, which are frequently fixed, or in oscillatory motion, the pupils suddenly contracting or dilating ; or there may be want of consent between the pupils, — one being dilated, while the other is contracted ; or difficulty in fixing the eyes together on one object. The condition of the hands and feet specially deserves attention. There are frequent twitchings of the fingers or toes ; the hand is clenched, and the thumb pressed stiffly across the palm ; or the wrist is bent downwards, as well as the foot, and the toes drawn in. Sudden animation is often followed by langour, and the breathing is irregular ; in particular, a long and deep inspiration often follows short catchings of the breath. There is alternate flush- ing and paleness of the face ; or the countenance looks pinched up, and a peculiar blueness is observed about the mouth. Prognosis. — As delicate and irritable children are more easily thrown into convulsions than those that are robust ; so we must look upon convulsions as more dangerous in the latter, especially when connected with inflammatory diseases. The worst cases that we have seen, Occurred in such ; but in any instance, the attack may prove fatal, if violent, and hence our prognosis must be always guarded. As convulsions can never be looked upon as purely idio- pathic, much will depend on our being able to ascertain and remove then causes ; and this should form, the object of our treatment, not merely an attempt to palliate or control the convulsive motions. Treatment. — Having endeavoured to remove or mitigate any source of irritation, — as by freeing the bowels when loaded, dividing the gums if requisite, or using antiphlogistic measures to subdue inflammatory action when present, much does not require to be done for the convulsive attack itself, as this generally tends to pass away of its own accord. Attempts to stop the convulsions by opiates, stimulants, &c, will always do harm, unless where the symptoms clearly arise from irritation or exhaustion. The child's clothes should be always loosened, the head elevated, cold air admitted, and the face sprinkled with cold water. The application of cold to the head is the remedy of most general utility, and most effectual in abridging the paroxysm and preventing its return. The use of heat to the feet, or the warm bath, at the same time, is of signal service, adding much to the efficacy of the cold applications. The mode of applying cold now universally adopted in cases of convulsion, is by pouring a stream of water on the head, from a vessel held at a little distance over it, and continued until the attack subsides. Leeches are occa- sionally required, if much febrile excitement or oppression of brain 230 DISEASES OF THE CEREBRAL SYSTEM. are present. It is often difficult to move the bowels in such cases ; but purgatives, which are in most instances requisite, will act more easily after leeching has been practised. Purgative enemata, with turpentine, often give speedy relief. When much restlessness or nervous irritation is present, small doses of Dover's powder are often of great service ; but in convulsive attacks attendant on inflammatory action, great injury may be done in attempting to control the con- vulsions by narcotics. Still more particular must we be to avoid the use of stimulants, sometimes employed as antispasmodics, but which always aggravate or renew the convulsions in such cases. It is when debility is the cause of convulsions (as in the hydrencephaloid disease), that stimulants, as ammonia, brandy, or turpentine, must be resorted to. After convulsions have once attacked a child, they are liable to recur ; and care must be taken to avoid every exciting cause, and all means must be employed to improve the general health and strength ; in delicate children, change of air, and tonic medicines, are essential. [Very violent attacks of convulsions not unfrequently result from the presence of irritating or indigestible substances in the stomach : in these cases we have found little benefit to result from the use of any of the usual remedies until the cause of irritation in the stomach is removed by an emetic ; upon the full operation of which we have, in repeated instances, known the convulsions to be imme- diately suspended. — C] II. INFLAMMATORY AFFECTIONS. The brain, or its membranes, may be attacked with acute inflam- mation in the child, as well as the adult ; but this form of inflamma- tion is comparatively rare in children, or occurs only in those that are robust and plethoric. The more common forms of cerebral inflam- mation to which the child is subject, present, in general, a low or insidious character ; they appear to partake much of the nature of scrofulous inflammation, as seen elsewhere, and indeed most fre- quently occur in strumous children. It is not easy to determine what the peculiarity is ; but we agree with Br. Cheyne, that hydro- cephalus consists, in many instances, of " a diseased action of a pecu- liar kind, but of what, we can as little explain, as we can the nature of scrofulous action." One peculiarity in this form of morbid action is, its tendency to throw out fluid, or cause effusion ; and hence the name hydrocephalus or dropsy of the brain. This effusion of water, however, is not essential to the symptoms which are usually looked upon as constituting a case of hydrocephalus : for all these may be present, without water being effused ; or water may be found, where the chief of these were wanting. The symptoms seem to depend truly on that morbid condition of the brain, or its membranes, which gives rise to the effusion ; but the latter is only an accidental , though frequent, consequence of this morbid action. Effusion may even be found where no inflammation had existed ; or be induced by debility, INFLAMMATORY AFFECTIONS. 281 or the exhaustion brought on by excessive evacuations. The more slow the disease is, and the less it partakes of the acute inflammatory character, the more certainly, in general, will water be effused, and the greater will be the quantity. The cause, then, why effusion of fluid is so much more common in the child than in the adult, ap- pears to be the greater liability to this peculiar form of inflammatory action, and the greater latitude that there is given to the effusion of fluid, in consequence of the expansile properties possessed in the young cranium. The substance of the brain may be the seat of mor- bid action, leading to ramollissement and effusion, with disease of the membranes ; or the softening of the brain may result from the disease going on in the membranes, when this is protracted and leads to effusion.* The arachnoid membrane is that usually affected ; and it has been remarked by Martinet, that the arachnoid at the base of the brain is more frequently the seat of inflammatory action in the child — that of the convex surface in adults. Each of these varieties is distinguished by particular symptoms. The connexion between hydrocephalus and strumous affections has been long remarked, and Dr. Gerhard, of Philadelphia, points out a peculiar form of the disease, which he denominates tubercular, and has accurately described in two valuable papers,' published in the 13th and 14th volumes of the American Journal of the Medical Sciences. M. Ruz has farther stated, that in several cases in which tubercles were found in the cerebrum or cerebellum, he detected small, white, semitransparent granulations in the arachnoid mem- brane, especially at the base of the brain ; and similar granules were discovered in other situations, as the peritoneum, pleura, &c, &c, while tubercles- were uniformly present in the lungs. The curability of hydrocephalus seems to depend much on the nature of the morbid action giving rise to the symptoms — the acute inflammatory form of the disease being amenable to active depletion ; while in the low, or strumous variety, depletion is ill borne, and recovery uncertain. That described as the tubercular appears to be. the most hopeless form of this species of the disease. As morbid anatomy has not yet enabled us perfectly to clear up this subject, or to determine with certainty, by the symptoms, the precise lesion of the brain present, we shall still treat of hydrocephalus under its ancient appellation, — not forgetting, however, that it is not a mere passive dropsy, as was formerly thought ; and recollecting that it is not always an acute inflammatory disease, as has been more recently taught. * Abercrombie seems to regard an inflammatory affection of the central portions of the brain, ending generally in softening of its substance, as the essential lesion in hydrocephalus, whether there be effusion or not. Lallemand pretends to dis- tinguish between the affection of the substance of the brain and that of the mem- branes ; but this can be attempted only in the early stages of the two affections — which may, however, exist together ; while the direct communication by blood- vessels is such, that an affection of either structure may, from the commencement, give rise to symptoms connected with the other. 34* 282 DISEASES OF THE CEREBRAL SYSTEM. Hydrocephalus may be acute or chronic; and its progress is usually marked by certain alterations in the condition of the patient and the symptoms, which have led to its division into stages or periods. These are often well marked ; but we must not always expect to find them distinctly formed. It has been attempted to connect the peculiarities of the symptoms in each stage, with the particular pathological condition supposed then to exist ; and the state of the nervous or vascular systems is that usually taken as the type of each period. Thus we have, first, the period of increased sensibility of Cheyne, with the quick pulse of Whytt ; or the period of inflamma- tion of Golis. Then we have the second stage, or that of diminished sensibility, according to Cheyne, with the slow, irregular pulse of Whytt ; and looked upon as the period of effusion by Golis. Again, we have the last stage, characterised by the pulse rising once more, and becoming rapid, but feeble ; when convulsions or palsy attend. Differences are also to be observed in the mode in which hydro- cephalus makes its attack : this is modified by the form in which the complaint presents itself, and the condition of the patient at the time. In healthy children, we sometimes see hydrocephalus set in with violence, — there being sudden fever, or severe convulsions, at the onset ; the disease presenting a highly inflammatory character. This form of attack, however, is that less frequently met with ; and hydro- cephalus most commonly commences in a gradual or obscure manner. The premonitory symptoms are not sufficiently peculiar to command attention : but generally the digestive organs are observed to be deranged in a particular manner, and the nervous system much dis- turbed ; and these conditions will not be found to yield to the use of purgatives, or other medicines, as readily as might be at first expected. During the progress of febrile disorders, or after the occurrence of one of the exanthemata, particularly scarlatina, hydrocephalus is liable to make its attack in a secondary form, — approaching insidi- ously during the progress of the complaint, or appearing suddenly on any rapid subsidence of the symptoms. During the progress, then, of any infantile fever, or protracted disease, as scrofulous affections, hooping cough, painful dentition, or disorders of the bowels, as be- fore observed, we should be on the watch for cerebral symptoms ^ and on any unusual irritability of the little patient, particularly an irritable state of the stomach, not otherwise to be accounted for, we should apprehend that the head was becoming engaged, and narrowly watch all the symptoms. In such cases, the symptoms of the early stage are often absent ; and convulsions or palsy, will be the first unequivocal sign of an affection of the head. Symptoms. — In the most acute, and therefore best marked form of hydrocephalus, the symptoms indicative of cerebral disease set in with severity after a short period of previous indisposition, which is very liable to be overlooked. The child is seized with severe pain in the head, which usually appears to be referred to the forehead or temples ; the head is hot, and face red ; the vessels are distended, and throbbing; there are frequent flushings; the .eye is unusually INFLAMMATORY AFFECTIONS. 283 brilliant;* light is disagreeable, and noise distressing; the child starts on the slightest touch or sound ; and there is increased sensi- bility of the whole nervous system. The fever sets in violently and suddenly, the intermissions being very short and irregular ; the pulse is, at first, full and rapid ; the breathing is hurried or oppressed. Much derangement of the diges- tive organs is present, the bowels being obstinately costive, and the discharges very unnatural, when obtained, which it is, in general, very difficult to effect, even by the strongest purgatives. The urine is usually scanty, or suppressed, and may be white. The state of the stomach, in particular, is characteristic of the disease ; the irritability is excessive and peculiar, vomiting being induced by any movement, especially an attempt to sit upright, while there are no corresponding symptoms of gastric derangement ; for though the appetite is gone, the thirst may not be remarkable ; and the tongue is white and furred, but not red or pointed. Pain in the abdomen usually attends the complaint, and some tenderness on pressure over the epigas- trium ; but these fall far short of what indicate an abdominal inflam- mation. The complaints made of the head, and the expression of the coun- tenance, dispel all doubts as to the nature of the case. Pain in the head is loudly complained of, or the child (when unable to speak) clasps its hands round the head, while occasionally the screams are frantic; and alternately with these, there is a heaviness, or unwilling- ness to be stirred. During the periods when there is absence of the look of pain, or terror, that accompanies the more violent symptoms, the eye appears to be set, or vacant, with that look of dejection that belongs so peculiarly to cerebral disease. This is the form of hydro- cephalus that runs its course most rapidly, but regularly ; and in it the stages are most distinctly marked. The pulse, from having been strong and quick, becomes slow, weak, and irregular in its beats, or unequal : the great slowness and inequality now become remarkable ; but it is liable to be accelerated on any motion. Golis speaks of the pulse as being sometimes slow in the first instance ; but this is rare in the acute form of the complaint, although in the low or strumous variety, the pulse is at first almost always slow. Corresponding alterations take place in the other symptoms. Pain in the head is less complained of during the second stage : but this is not always so ; and there still continue occasional screams, or exclamations of suffering. The head droops or sinks upon the pillow, and is with difficulty raised ; and the fontanelle is often found at this period full or prominent. Heaviness or torpor prevails : the child lies in a coma- tose state, with its eyes half-closed ; and a slight paralysis of one of the upper eyelids is often present. The pupils are dilated or im- moveable ; and strabismus not unfrequently attends. An oscillatory * Dr. Armstrong, in his Lectures, says there is a "combined expression of phy- sical brightness and intellectual dulness in the eye;" and describes the •* inter- course" which naturally subsists between the eye of the infant and that of the mother or nurse, as being in this case lost. He lays much stress on these circum- stances, as indicative of cerebral inflammation in the child. 2S4 DISEASES OF THE CEREBRAL SYSTEM. condition of the pupil may precede this state, with impaired or double vision. We have seen the pupil dilate on exposure to the light, and contract on its removal. The sickness of stomach now diminishes, or may be altogether absent, and some appetite occasionally returns ; but the child emaciates remarkably, the bowels continue obstinately costive, and there is incessant picking of the mouth and nose. The hands, which are often raised to the head, are observed to be tremu- lous in their movements ; the child moans ; and the state of debility is indicated by frequent sighing. This condition may continue for one, or even two weeks ; but the symptoms of the third stage now begin to manifest themselves, and add new distress to the scene. Convulsions, in all forms and degrees, may be present, from the most violent general convulsion to mere spasmodic twitching of the muscles of the face, or vibratory motions of the eyeballs. A rigid state of the muscles may be present ; and violent spasms of one side may continue to recur after the other has become paralysed : or the child will wave one hand in the air, or toss one leg about, while the other limbs lie immoveable. There is frequent grinding of the teeth, and movement of the lips and tongue. The whole appearance indicates extreme distress. The child lies moaning, or raving, yet insensible. The eyes are turned upwards, and constantly fixed in that position (a most alarming symptom); or the half uncovered eye- ball discloses a conjunctiva duly suffused, the pupil dilated, and the cornea dim and coated with a filmy matter. The skin is partially covered with profuse perspiration, while in other parts it is dry or burning hot. The pulse becomes excessively rapid, more so than in almost any other disease ; but this apparent effort at reaction soon gives way : the pulse grows gradually weaker ; the breathing be- comes unequal ; and the coma more profound. The child lies in a state of utter prostration, the abdomen being drawn in, and the limbs relaxed ; and dies in a state of collapse, or a violent convulsion pre- cedes death. The duration of this final or third stage is very vari- able, occasionally lasting for a week, or even fortnight ; at times not enduring for more than a few hours. The more common form of hydrocephalus is much less acute, and therefore the symptoms less strongly marked. Great lassitude, lan- gour, and irritability first begin to give character to the child's indis- position. It is restless ; dislikes light or noise ; is very averse to exertion ; totters in its walk, or drags one limb after it : and is soon fatigued in an attempt to sit up for any length of time, which it is unable to do. There is heat of head, and pain ; the pain being occa- sionally complained of in the eyes or back of the neck, and alternating with pains in the limbs or abdomen. There is some fever ; the con- junctiva of the eye is injected, or the pupil contracted. There is grinding of the teeth during sleep, and starting or screaming on being awakened ; but the intellect seems to be little disturbed ; for the child, though unwilling to be spoken to, replies correctly to questions asked. A sudden stammering, or faltering in the use of a particular word, is always to be Looked on as a serious symptom. The peculiar IXFLAMMATORY AFFECTIONS. 285 irritability of stomach, and derangement of bowels before noticed, are present ; and the somnolency, deep sighing, the peevish shrill scream,* and peculiar expression of the countenance, so characteris- tic of hydrocephalus, complete the picture. The disease passes through its stages as before described, but not always in a marked manner : in particular, the pulse may be invariably fast throughout. The urine, which is scanty or suppressed, occasionally causes distress in passing. We should recollect that it may be retained, and an aggra- vation of the cerebral symptoms be induced by an over-distended state of the bladder. We have seen some cases in which a very copious flow of urine had preceded the establishment of the disease. In that variety of the complaint, described as the tubercular, but which is nothing more than the strumous variety in its most exqui- site form, the symptoms appear to observe a very uniform order in their course ; beginning with vomiting, then headache, and consti- pation. Somnolency is succeeded by delirium ; or they alternate with each other — coma now sets in, and convulsions follow. The expression of the countenance is very peculiar, and the respiration is observed to be accompanied by a kind of sign in expiration. The pulse, which is at first slow, becomes very much accelerated before death. A peculiar circumstance in the progress of hydrocephalus, and one well worthy of note, is the occasional remission or total disappear- ance of all alarming symptoms for a short period towards the conclu- sion of the disease, so that a child recovers the use of its speech and senses, noticing objects, and asking or answering questions ; but this remission (or " lighting up before death," as the nurses express it), is of short duration, a deeper state of insensibility than before sets in, and the expectations of recovery which the inexperienced or over- sanguine may have held out, are for ever put an end to. Chronic Hydrocephalus. — The head gradually enlarges in size in this form of the disease ; and the headache, fever, and other symp- toms which belonged to the more active stage subside ; or, as more generally happens, the disease arises insensibly without any ante- cedent acute stage. The head sometimes attains an immense magni- tude — the sutures being separated, the fontanelles transparent and full, with a distinct fluctuation perceptible on pressure, while the face retains its natural size, and gives to the physiognomy a very peculiar expression. In a few instances, instead of general enlargement of the head, a fluctuating tumour may be felt near the occiput. This is surrounded by the investments of the brain, so that upon pressure the fluid compresses the cerebral substance, and thus gives rise to coma or convulsions. The senses become blunted, and the intel- lectual powers impaired ; or altogether suppressed, as the disease advances. Muscular power is much enfeebled, so that the patient is unwilling or unable to move about ; and the enormously distended ♦The peculiarity of this cry seems to have been first pointed out by M. Coindet, of Geneva, by whom it was assigned as evidence of effusion having taken place ; but erroneously. 2S6 DISEASES OF THE CEREBRAL SYSTEM. head can no longer be supported, but droops upon the shoulder or the chest. This gradual diminution in the sensitive and locomotive powers, while the head increases in size, marks the progress of chronic hydrocephalus in the child after it has passed the first year of its age. Convulsions not unfrequently occur, and several of the other symptoms enumerated under acute hydrocephalus, but in a mitigated form. A variety of hydrocephalus, analogous to the chronic, may exist in the infant at birth, constituting the congenital hydrocephalus of authors. In these cases, the head is occasionally so much enlarged as to afford a serious impediment to delivery. In Arachnitis, confined to the base of the brain, there is fever, general languor, and depression. Pain is complained of in the fore- head or temples ; but the intellectual faculties are undisturbed. The head is hot ; the child moves it from side to side, or sinks it heavily on the pillow. Vomiting attends, and more or less of drowsiness is present. Spasm now begins to appear ; and in this affection, in particular, generally affects the mouth, the eyes, or the upper extre- mities. Frequent working of the tongue and lips, or motions of the lower jaw (machonnement) are observed ; or the hands and arms are convulsed at intervals, or for a long time together. A sudden, and often complete loss of the intellectual powers and senses, as well as of the general sensibility, at the same time occurs. We have often to notice in this affection, as we did in hydrocephalus, the occurrence of remarkable, but deceitful remissions of the symptoms. But con- vulsions again occur ; coma sets in ; the pupils become dilated ; the pulse very slow : and a state of complete relaxation of the limbs pre- cedes death. This affection is often accompanied by spinal arachnitis : which we judge of by the stiffness of the muscles at the back of the neck, and the pain complained of in this part. The head is often observed to be retracted, or moved from side to side : the former circumstance being considered as indicative of that part of the arachnoid which covers the pons Varolii being in particular implicated in the disease ; the latter, that the inflammation has attacked the upper part of the medulla oblongata. Children are not exempt from arachnitis of the upper surface of the brain, though this affection occurs less frequently with them than the other variety. In one remarkable case which we witnessed, a thick, tenacious layer of lymph was effused on the arachnoid of the anterior lobes of the brain. The child had been seized suddenly with severe convulsions ; the head continued hot, face red, and eyes suffused ; high fever followed, with delirium, violence of temper, general convulsive movements of the limbs, coma, paralysis, and death on the fourth day. A brother of this child was seized in a similar manner, when about the age of the former patient : but was seen early, and under the use of active depletion, the disease was arrested in its first stage. Pathology. — After the pathological remarks made at the begin- ning of this section, much does not remain to be said of the morbid conditions of the brain connected with hydrocephalus. These will INFLAMMATORY AFFECTIONS. 287 vary according to the form and duration of the complaint. If the disease run a rapid course, and be of the acute inflammatory kind, little or no fluid may be effused ; and even the membranes may appear to be only slightly injected. In other cases, where water is not found, it appears to have been absorbed before death, as the ventricles are found dilated, though empty; and we know that such at times occurs with other dropsical effusions. The water effused in the very rapid attack already alluded to (p. 276), is usually found to be turbid or whey-like. Flocculi of lymph are occasionally seen in the serum; but in general, the water is limpid, of a light straw- colour, and not exceeding a few ounces in quantity. The average extent of the effusion may be estimated at four or five ounces ; occa- sionally it amounts to seven or eight, but in some cases of chronic hydrocephalus to much more, the fluid being generally of a deep citron colour. The mere circumstance of a small quantity of serum being found in the ventricles after death, is not to be looked upon as a proof that hydrocephalus had existed during life ; for such usually takes place previous to death in cases of protracted illness, or may be induced by the very means taken to avert it; as we doubt not, we have seen done by excessive depletion injudiciously employed in the cerebral affections of children. The fluid effused in hydrocephalus is usually situated in the lateral ventricles, which are in consequence distended, the dilatation being most remarkable towards the digital cavity. The foramen is often considerably enlarged ; but, in gene- ral, little fluid is found in the third or fourth ventricles. This effu- sion into the ventricles constitutes the hydrocephalus interims of the old writers — an unnecessary distinction, as it does not appear to have been established that hydrocephalus externus exists. The serum effused in hydrocephalus is often not coagulable by the action of heat or acids, or only very slightly so ; but this is not uniformly the case. In consequence of the distension of the cerebral substance, consequent on the effusion, we find the superior convolutions of the brain much flattened and depressed, or it may be stretched into a thin covering, a sense of fluctuation being perceptible on removing the skull. The vessels on the surface of the brain may be in a state of congestion, or the pia mater injected with blood ; but this is not a frequent appearance. The arachnoid on the convex surface is usually dry ; but beneath that, at the base of the brain, fluid is often found effused. When this is the seat of morbid action, the arach- noid will be dull, opaque, or covered with layers or granules of lymph ; but that lining the ventricles is often unchanged, though much fluid be effused. Laennec speaks of extensive tubercular deposition throughout the brain ; and Dr. Gerhard describes tuber- cular deposition on the membranes. We have certainly seen some cases of this description. The substance of the brain in acute hydro- cephalus is generally softer than natural, except in some cases which run a very rapid course. Ramollissement is most generally found in the central parts of the brain, in the fornix, corpus callosum, or the digital cavity. In chronic hydrocephalus there is incomplete ossifi- cation of the bones, with separation of the sutures, or in some cases 28s DISEASES OF THE CEREBRAL SYSTEM. total absence of bony matter ; and in other cases, again, especially some that were congenital, a great expansion of the cranial bones has been observed. Of the secondary lesions, or complications, found after death in hydrocephalus, a morbid condition of the intestinal mucous mem- brane, or the liver, has been most frequently remarked ; and this coincides with the fact already noticed, of hydrocephalus originating so often in derangement or disorders of the digestive organs. The lungs, also, are not unfrequently found inflamed. Diagnosis. — The circumstances most characteristic of this disease, and which distinguish it best from others, are, — the particular ex- pression of countenance ; the peculiar cry or scream ; the variability and successive changes, in the character of the pulse ; the irritability of the stomach ; the costive state of the bowels, with a peculiar green appearance of the evacuations when obtained, and the suppression of urine, — cerebral excitement being succeeded by convulsions, coma, or paralvsis ; all which signs have been dwelt upon in describ- ing the symptoms of the disease. The occurrence of one or more of these symptoms, during the existence of infantile fevers, should lead us to apprehend hydrocephalus, which may occur either as a sequel to any of them, or commence, itself, with symptoms so similar, that the disease may be established before its existence is suspected, — there being, in fact, often no means of accurately distinguishing between simple remittent fever and the first stage of hydrocephalus. The same may be said of those disorders of the cerebral system which we have described under the name of functional ; for the establish- ment of a diagnosis between any of those and hydrocephalus, we must refer to our detail of the symptoms of both, and recommend a careful collation and comparison of these in every individual case. We must often, however, expect great difficulty in ascertaining, in any particular instance, whether convulsions, or symptoms of irrita- tion of the brain, or of the hydrencephaloid disease, are purely func- tional, or must be referred to organic lesion. Whenever doubt exists, it will probably be encountering the least hazard to consider that the latter is present. The symptoms of chronic hydrocephalus are so well marked, as sufficiently to distinguish it from other diseases. With respect to the other varieties of the complaint, as the various forms of arach- nitis, &c, their diagnosis from each other must be attempted by a comparison of all their symptoms ; a matter always of much diffi- culty. The Prognosis must be in all cases guarded, but, even in those apparently the worst, need not be hopeless. We have seen that the most alarming symptoms may exist, without these being certain proof of any irreparable lesion ; and, notwithstanding such symptoms, recovery may take place. When the cerebral symptoms have come on insidiously, however, at the sequel of a previous disease, in a child of a strumous habit, or one having a family predisposition to the disorder, much danger is to be apprehended, and the result is most frequently fatal. The more acute the inflammation, on the contrary, INFLAMMATORY AFFECTIONS, 2g9 the greater in general is the chance of cure, and the better is active depletion borne, — such cases usually occurring in healthy children. Recovery may also be generally effected, when the disease sets in subsequently to scarlatina, if we are prepared to meet the case, as the symptoms are often very sudden and acute. That form of the disease which is connected with inflammation of the arachnoid at the base of the brain is very dangerous, as alterations of structure, and the growth of false membranes, are so liable to occur. That variety of chronic hydrocephalus which succeeds to an acute attack, is almost always fatal ; but its more common form, when once established, does not seem of itself directly to shorten life, — the patient generally dying of some other disease : Golis thinks this form of the complaint may frequently be cured. When coma, convulsions, or delirium, attend upon chronic hydrocephalus, or an acute attack supervenes, the disease generally proves fatal. Congenital hydro- cephalus is almost invariably incurable. The condition of the secretions, and the pulse serve, in particular, to guide us as to our prognosis in any particular case. When the bowels become easily moved, while the evacuations grow natural, the flow of urine increases, or a copious warm perspiration breaks out, we have very favourable signs ; and with these, some running at the nose is occasionally observed. As to the pulse, Cheyne says, ' that so long as it continues steady, while the breathing is natural, we should not be deterred by other symptoms, however formidable, from entertaining expectations of recovery.' When the pulse falls suddenly, however, and remains slow, until it again arises with ex- traordinary rapidity, while the breathing becomes unequal and irre- gular, we augur very unfavourably, seeing that the case runs on through the usual stages. We must be careful to distinguish between the gradual diminution of the pulse, indicative of a subsidence of fever, and this sudden fall or protracted slowness connected with the second stage of the disease. As careful must we be to distinguish between those deceitful and temporary remissions in the symptoms already alluded to, and the protracted improvement of some days' duration, which we may rely upon as indicative of recovery. So long, however, as the pupil continues dilated, or is very slow to con- tract, we must dread relapse, even though recovery may have appa- rently taken place. The spontaneous occurrence of a cutaneous erup- tion has in some instances appeared to expedite recovery, in pro- tracted cases ; but a particular kind of eruption, consisting of almost imperceptible vesicles, is occasionally observed to occur on the face or upper parts of the body, towards the end of the disease, and is to be looked upon as an unfavourable sign. Continental writers men- tion this eruption as a constant attendant on hydrocephalus, but it is seldom noticed in this country. Treatment. — In undertaking the treatment of a case of hydro- cephalus, we must be guided by the form of the complaint, and the stage or period at which we see it. In the acute attack, when re- cently seen, our treatment must be actively and perseveringly anti- phlogistic. Bloodletting, purging, and cold applications to the head, 25 290 DISEASES OF THE CEREBRAL SYSTEM. with subsequently the use of counter-irritation, constitute our chief resources, and their full employment will often prove successful. In the low form of hydrocephalus, or when the disease is chronic, active depletion is not admissible, though the moderate use of antiphlogistic measures may be occasionally called for ; but we cannot expect here to effect a cure, merely by active depletion, as may be done in the other form of the complaint. Leeches occasionally, and in all cases cold to the head, followed by active counter-irritation, while we keep the bowels open, or try to improve the secretions by alterative doses of mercury, appear to be the means on which most reliance is to be placed, in these forms of the complaint ; while we at the same time take care to support the strength by a sufficient supply of light but nutritious food. Bloodletting should be carried to such an extent, when first em- ployed in the acute variety, as to make a decided impression : and general bloodletting may require to be repeated, but the substitution of leeches will frequently answer. In the less acute or more pro- tracted form of the disease, a frequent repetition of the leeches may be required ; although the application of a large number on any one occasion would not be advisable. When the hydrocephalic symp- toms occur during the existence of disease of the lungs, or particu- larly of the digestive organs, the application of leeches over the seat of the original disorder will often more effectually relieve the head than if they were applied directly thereto. Mercury has been employed specifically in the treatment of hydro- cephalus, but its use has been much overrated. In the acute form, the constitutional action of mercury, after bloodletting, has certainly aided in cutting short the disease, as we see occur in other internal inflammations ; but in the low or strumous variety of the complaint, the production of salivation does not appear to exercise any special influence in controlling the symptoms ; for though these may be mitigated thereby, the case will generally proceed to a fatal ter- mination. Small doses of calomel, given so as to act as an alterative, appear to effect all the good thatt can be looked for from mercury, in this form of the complaint ; which good seems to arise from the improvement thus effected in the condition of the digestive organs. In chronic hydrocephalus, Golis regards this plan of treatment, aided by counter-irritants to the head, as the best that can be pursued, and states that it is often successful ; but condemns the employment of the large doses of mercury commonly in use. Corrosive sublimate has been occasionally employed with success. In either of these forms of hydrocephalus, however, and even in the second stage of the acute variety, we much prefer the use of iodine to that of mercury, and have seen some cases of its signal success. Iodine, to be effectual, however, must be largely employed, both internally and externally. The combination of iodine with mercury, in the proto-ioduret, would seem to present particular ad- vantages. The ointment of bin-iodide of mercury appears eligible for producing speedy and effectual irritation over the scalp, while it INFLAMMATORY AFFECTIONS. 091 at the same time has a tendency to affect the constitution, so as to induce salivation. The tonic or stimulant properties of iodine have also their advan- tage in the treatment of hydrocephalus, under these circumstances ; and its diuretic power may enable us to dispense with digitalis, squill, &c, &c., — once of much repute, but little to be relied on in the treat- ment of this disease. Digitalis is an unmanageable medicine in affections of the head, and its diuretic powers particularly uncertain in hydrocephalus. It should never be employed in the acute form or earlier stages of the disorder ; but in chronic hydrocephalus, or that variety occurring in connection with anasarca after scarlet fever, frictions with tincture of digitalis, or squill, extensively appliedover the surface of the body, appear to have been practised on the Continent with some success. Purgatives are of great service in the early stages of hydrocepha- lus, especially when presented in the acute form; but their employ- ment requires judgment and caution. In general it is very difficult to move the bowels in this complaint, and the most active purgatives may be required ; but in consequence of the irritable state of the stomach, we shall often be obliged to resort to enemata to effect this purpose. Purgatives after bloodletting, however will often produce free evacuations, although they had before failed to move the bowels. When irritation of the intestinal mucous membrane is present, we must be careful to avoid active aperients, and rest satisfied with mild enemata. Antimonials will be found of much service in mitigating increased cerebral action, and have been used with advantage in the early stage of hydrocephalus by Cheyne and Mills. Vomiting should, however, be guarded against ; but Laennec has proved that tolerance of tartar emetic can be attained in affections of the head. James's powder is a more manageable preparation, and may be given alone, or combined with calomel or cathartics. Opium, employed after bloodletting and purging, alone, or in com- bination with antimony or ipecacuan (as Dover's powder), is often of great service, particularly in the second, or even third stage of the disorder, by lessening the frequency of the convulsions, allaying pain, and even rendering the pulse more full, and less irregular. The use of opium, when once commenced, should not be suddenly discontinued ; but when contraction of the pupil ensues from its employment, this is to be looked on as a sign that the use of the medicine has been carried far enough ; nor should we attempt to control the convulsions sometimes attendant on the inflammatory stage, by opium, independently of antiphlogistic means. During the progress of hydrocephalus, we must not forget the necessity for supporting the strength ; and in the advanced stages, light bitters, tonics, or even stimulants may be required. Strong coffee or tea will at times dissipate coma, rouse the circulation, and restore warmth to the skin. Direct stimulants, as ammonia, ether, camphor, or musk, will in come cases be required ; and particular efficacy has been assigned by some practitioners to certain medicines, as the calamus aromaticus, serpentaria root, arnica montana, &c; 292 ERUPTIVE FEVERS. but their utility is not sufficiently established. A large blister applied over the head is often of great service at this period. When distinct intermissions are to be noticed in the progress of the complaint, indicated by alternations in the heat, and chills of the surface, flushings and paleness of the face, with excitement and depression of the animal powers, M. Piorry specially recommends the use of Peruvian bark, given in the form of enemata, and to the extent of from two scruples to two drachms at a time. The period for exhibiting the bark is during the time of intermission, when the face is pale and system low ; and the bark in substance was found to be much preferable to quinine. In the treatment of chronic hydrocephalus, principal attention must be paid to support the strength, while we at the same time improve the general health. Counter-irritation must be freely and frequently applied to the head, and setons or issues inserted in the neck. Warm baths* are of much assistance ; and we may avail ourselves of the alterative action of mercury, or the specific influence of iodine, in attempting to cause absorption of the effused fluid. Antiphlogistic measures may be occasionally necessary ; but should never be intemperately employed. Compression of the head has been used to assist the action of the absorbents in diminishing the effused fluid ; or this has been in some cases evacuated by puncture, tapping the head having been resorted to with success in a few instances.! To prevent the occurrence of hydrocephalus in children predis- posed thereto, we should place them in a dry, warm, and elevated situation ; avoid all causes of mental excitement, in particular early or excessive exercise of the intellectual faculties ; and as medical measures, pay especial attention to the state of the bowels and regu- lation of the diet. An issue kept open in the arm or neck, during childhood, has undoubtedly exercised a control in averting hydro- cephalus in families predisposed to the disease. CHAPTER XI. ERUPTIVE FEVERS — (EXANTHEMATA). I. MEASLES — (RUBEOLA; MORBILLl). This exanthem consists in a fever, in which the mucous membrane of the air passages is chiefly affected, and which, after about three days' * In Continental practice the use of medicated baths is much relied on in the treatment of chronic hydrocephalus. Alkaline solutions seemed to be preferred by Golis ; but Recamier and Andrieux recommend tartar emetic (one ounce gradually increased to four or five in each pailful of water), which appears, when thus em- ployed, to cause a copious flow of urine, the patient growing thin, and the size of the head at the same time diminishing. f Cases are recorded by Dr. Conquest, see Lancet for 1830 ; by Mr. Lizars, in Edin. Med. and Surg. Jour.; by Dr. Vose, in the Med. Chir. Tran. vol. ix. ; and others. MEASLES. 293 duration, results in the eruption of a red rash over the surface of the body. Symptoms. — Measles commences with the ordinary signs of fever — langour, shivering, heat of skin, thirst, &c. ; and at the commence- ment cannot be distinguished from common catarrh, or other febrile affection. As the disease advances, the catarrhal symptoms become very distinct ; there is dry, hoarse cough (often much resembling that of croup); frequent sneezing; suffused and watering eyes; swoln and feverish face ; alternations of heat and chills ; quick pulse ; thirst, and scanty secretion of urine ; with hot, dry skin. There is occasion- ally vomiting or purging, but sometimes constipation of the bowels. These symptoms occur, with greater or lesser severity, in different cases ; being sometimes very slight, and scarcely attracting attention ; at others, exceedingly severe, — being accompanied with delirium, and the affection of the lungs amounting to actual inflammation. There is usually, towards evening, an exacerbation of all the febrile conditions. After the symptoms enumerated have continued for three or four, or in some cases for so many as seven or eight days, the eruption begins to appear in the form of round, red dots — showing first upon the forehead and face, and subsequently upon the body and limbs. On the fifth day, the whole surface is usually covered with the erup- tion ; which begins to decline on the face, on the sixth, and has usually disappeared altogether upon the tenth day from the commencement of the fever, or sixth from its own first appearance. The eruption is not confined to the skin ; but extends also to the mucous membrane, as we may observe by inspecting the fauces and mouth, upon which, reddish, slightly elevated spots will be discernible about the fourth or fifth days. The rash consists at first of separate elevations, giv- ing a sensation of hardness to the fingers ; subsequently, these run together into raised patches, of an irregular or semi-circular form. These patches are in healthy measles of a lightish red colour, and contrast strongly with the sound skin between them, which retains nearly its natural hue. At the termination of the disease, the cuticle covering these elevations becomes detached in the form of scales ; and during the desquamation, a troublesome itching is occasioned. Billard describes the eruption of measles as not feeling elevated above the surface, which is decidedly contrary to the fact.* Variations from the course of the eruption, as we have just de- scribed it, may occasionally occur; e. g., it may be accelerated or retarded in its course, or be combined with an eruption of miliary vesicles. In favourable cases, the violence of the fever abates as soon as the eruption appears ; but frequently the cough will continue without much fever for a considerable period. Pathology. — With respect to the cause and intimate nature of measles, or indeed of any of the other diseases included in this chapter, we are in a state of total ignorance ; and yet, to the philosophical physician, they are the most remarkable of any to which * Traite des Maladies des Enfans, p. 102. Paris, 1828. 25* 294 ERUPTIVE FEVERS. the human body is liable. They are, indeed, well ascertained to be subject to certain definite laws, to a degree of strictness unknown in any other affection, — and which almost confirms to them the cha- racter of natural and necessary movements in the system, rather than of accidental diseases. These laws are ; first, that the proper period for the occurrence of the exanthemata is in the commencement of life — a rule to which we certainly meet with exceptions ; but not to an amount at all cal- culated to weaken the generality of its application. Secondly, that they occur but once in the same individual ; and to this the excep- tions are extremely rare, although not totally wanting. Thirdly, that they run a certain definite course as to order of symptoms and duration, to occasion any deviation from which, a very considerable disturbing force is required. Fourthly, that they afford the only certain examples of the propagation of disease by contagion ; but that, at the same time, they are in their own essence decidedly of an epidemic nature, — occurring at certain seasons of the year, usually in spring and the commencement of summer ; and at those times often arising in communities, independently of any traceable contagion. Fifthly, they have the power of suspending each other's action, although apparently owing to some degree of relationship or connection : thus epidemics of measles and small-pox commonly occur simultaneously ; but the progress of small-pox, after it has been received into the con- stitution, may be suspended by an invasion of measles, and may subsequently resume its course after the latter has terminated : and vice versa. A consideration of the foregoing laws, whose existence is univer- sally admitted, cannot but strongly force upon us the conviction, that in them we might hope to find some principia for the establishment of a true and comprehensive pathology. In the exanthemata, for example, we have instances of disease occurring, we may say with certainty, to all individuals ; and thence affording the presumption that by their operation a certain necessary change is effected in the system. Their usual occurrence at certain seasons, and their occa- sional suspension of each other, favour the same presumption ; as well as the immunity from future attacks conferred by them. The capability of being communicated by inoculation, belonging to some of them, also gives the means of experimenting upon disease, and so testing conclusions at which we might arrive by other channels : and we have also in them an opportunity, which is to be found under no other circumstances, of investigating the subject of contagion. To do more than hint at the foregoing views, would be, at present, out of place ; but our notion of their importance, induces us to ex- press regret, that the (perhaps too complete) abandonment of the doctrines of the humoralists, by leading to an almost exclusive con- sideration of the effects rather than of the working of disease, has somewhat diverted attention from the study of the exanthematous fevers. In enumerating the laws just stated, we have recorded nearly all that is known respecting the pathology of these affections. A latent MEASLES. 295 period probably exists between the time of receiving the infection, and the appearance of the fever ; but the duration of this is not well ascertained, and is differently stated by authors — the average is probably about eight or ten days. Diagnosis. — Measles is to be distinguished by the regular occur- rence of the stages, and of the eruption, as we have described them. During the febrile stage, the disease can only be guessed at from collateral circumstances, — as exposure to infection, or the existence of an epidemic. The eruption must be discriminated by its peculiar characters, and by its occurring in connection with the febrile stage. The varieties of strophulus or red gum, have been sometimes mis- taken for measles ; but may be recognised by the absence of fever and catarrhal symptoms. Prognosis. — Measles, by itself, is not a dangerous disease : but in forming a prognosis, we must take into account the liability to complication with other diseases, as inflammation of the lungs or brain ; and also the sequelae likely to remain in the form of ophthal- mia, scrofula, diarrhoea, or phthisis. These, though not properly parts of the disease, are so likely to be called into action in patients predisposed to them, that we should always watch measles jealously, and speak guardedly of its termination : we must also be influenced in our opinion by the character of the prevailing epidemic ; which may at times assume even a malignant cast, and at others be ex- traordinarily mild. These circumstances, and the state of the patient's general health at the period of receiving the infection, must all be taken into account in forming our prognosis. Treatment. — In simple measles, the treatment must be rather preventive than remedial, and should be directed to the allowing of the disease to run its course without interruption or attempts at acceleration. Perhaps we cannot have a better plan than that adopted by Sydenham with the children of " the most virtuous Countess of Salisbury," viz. : " I ordered them to keep their beds two or three days before the eruption, that the blood, according to its own genius, might cast out through the pores the particles that were easily sepa- rated, which occasioned the disease ; but I did not permit that they should have any more clothes on, or fire, than they used to have when they were well. I forbad the eating of flesh, and allowed them oatmeal and barley broths, and now and then a roasted apple ; and for their drink, small beer, and milk boiled with three parts of water ; and when the cough was troublesome, as was usual, I pre- scribed a pectoral ptisan,* to be taken often."! So far as positive treatment is required, little more is necessary. If the bowels be confined, a gentle aperient (as No. 21 or 28, p. 126-7,) may be ad- ministered ; but in ordinary cases, no active purgatives are required. Every thing heating should be avoided; and in this country, as in the days of Sydenham, particular attention is required, in order to * For a suitable expectorant mixture, see p. 113. -j- Sydenham. Pechey's Translation. London, 1734. 296 ERUPTIVE FEVERS. prevent the attendants from giving ardent spirits and stimulant drugs, with the view of " striking out the eruption, and driving the disease from the heart." The tenderness of the eyes belonging to the disease will, probably, make light disagreeable to the patient ; and if so, the room should be partially darkened, but at the same time free ventilation should be provided for. When there is much heat of surface before the eruption has appeared, we have found great advantage from sponging the body with warm vinegar and water ; and the same process will also materially relieve the dis- agreeable itching attendant upon the desquamation of the cuticle at the close of the disease. So much for the management of simple measles. Anxious atten- tion must, however, be directed towards any symptoms of local inflammation which may arise. The state of the respiration must be carefully watched, and the chest regularly examined ; and should any symptoms of bronchitis or pneumonia be discovered, very active treatment, perhaps even a repeated use of the lancet, may be required. Any symptoms of an attack in the head, as headache, remarkable intolerance of light, or convulsions, must also be narrowly looked after, and treated according to the principles laid down in the chapter on those affections. Local inflammations and congestions commonly appear as a kind of metastasis, suddenly setting in simultaneously with a sudden premature disappearance, or partial fading of the eruption ; and when such is the case, an important part of the treat- ment must be directed to the bringing out again of the rash. We have occasionally seen this effected, and the local affection quickly relieved, by placing the lower extremities and hips of the child, for five or ten minutes, in a bath of as high a temperature as could be borne. The partial hot bath, when used in this way, will almost always be found of service ; but we must be very cautious in attempt- ing to recall the eruption by the use of any internal stimulants. Most commonly these are contraindicated by the existence of active inflammation ; and in such cases the proper plan is the reduction of the latter by suitable depletion. It is not to be forgotten, however, that cases do occur in which the retrocession of the rash is occasioned by debility, either belonging to the type of the prevailing epidemic, or occurring accidentally in an individual patient. In such a case, we shall find the child cold and stupid, with pallid, shrunken features, and perhaps petechia?. When the chest is the seat of the metastasis, our diagnosis will be much aided by the employment of auscultation ; but it is often an extremely difficult point to decide as to whether the state of depres- sion, in which we may find a child, be dependent upon inflamma- tory congestion, or debility. These are matters, however, which fre- quently embarrass the most experienced physician, and can only be learned by long-continued personal observation of disease. When debility is obviously present, wine and stimulants (as the mixture No. 6, p. 98,) will be required ; and in such cases we have found advantage from the application of a blister, or stimulating em- MEASLES. 29? brocation ; but the rules laid down in the section treating of these remedies (p. 107), must be strictly adhered to. Severe purging is not an uncommon sequela of measles, and was treated with bloodletting by Sydenham, upon the theory that it arose u from vapours of inflamed blood rushing upon the guts." The theory is valuable, as being calculated to remind us of the existence of inflammatory diarrhoea, with tenderness of the abdomen, and fever ; but we are not to suppose that bleeding is necessary or ad- visable in every case of purging after measles. Most commonly it will be removable by alterative aperients (as No. 29, p. 127,) when the discharges are foul ; or it may require astringents, if the stools be watery, and the abdomen drawn in and empty. Varieties of Measles. — An eruption precisely similar in appear- ance to that of measles is occasionally seen, especially in young infants, and runs through a regular course, but without catarrhal symptoms. This has been denominated Rubeola sine Catarrho. It requires no particular treatment, being merely a local affection ; but it is generally believed by authors that it does not, like true measles, confer an immunity from future attacks.* Many rashes of this kind, sometimes denominated Roseola, sometimes distinguished by the above-mentioned name, occur during infancy and childhood, dependent upon dentition or derangements of the digestive organs ; but unless accompanied by the specific fever, and running the regular course, they are not to be looked upon as measles. Rubeola nigra is mentioned as another variety of measles, in which the rash assumes a peculiarly dark hue. Sydenham attributes this appearance to the employment of stimulants and a hot regimen. He observes, that it only happens to grown people, and requires prompt measures of depletion. We have seen this character given by the conjunction of petechise with the eruption of measles, when a typhoid epidemic was prevalent — under which circumstances, a stimulant regimen and treatment will be demanded ; in short, a management similar to that required in other low malignant fevers. Inoculation of measles has been proposed by Dr. Home, of Edin- burgh,! and was performed by him with blood drawn from a por- tion of skin affected with the rash. It has been performed by others in the same way, and also with lymph from one of the miliary vesicles which occasionally appear in the disease. In both ways, the affection appears to have been communicated, but not with much certainty, and the practice has not met with any general approval. * During an epidemic of measles which occurred in this city during- the latter part of last year (1839), we observed the Rubeola sine Catarrho under peculiar cir- cumstances such as we do not recollect to have seen noticed by any author. In one family of four children all underwent an eruption accurately resembling measles, in its external character and period of duration ; but without any fever or other constitutional derangement. All these individuals were attacked with genuine measles in the course of a week after the disappearance of the first eruption, and all passed through it favourably. We observed a similar occurrence in other isolated cases. [Note to 3d Edition.] f Medical Facts and Experiments, by Francis Home, M.D. London, 1759. 298 ERUPTIVE FEVERS. II. SCARLET FEVER (SCARLATINA). This name is applied to an eruptive fever, which about the second day results in the appearance of bright red patches upon the skin and mucous membrane of the mouth and throat, commonly declining about the fifth day. The symptoms vary so much with the type of the fever in different attacks and epidemics of this disease, that we must describe them under separate heads, as constituting distinct varieties of the affection. a. Symptoms of Simple Scarlatina. — These are, at first, the ordinary symptoms of fever, viz., — lassitude, shivering, succeeded by heat, thirst, quick pulse, and occasionally nausea, headache, or even delirium. These vary much in degree in different cases, from the slightest disturbance of the constitution to severe fever. About the second day (according to Sauvages and Cullen, not until the fourth), the eruption appears in the form of red spots — first upon the face and neck, and subsequently these coalesce and spread over the trunk and extremities. On the third day the eruption is at its height, and then appears in the form of a continuous bright redness upon the extremities, and of large irregular patches upon the trunk of the body. It has been likened by Huxham to the colour produced by smearing over the skin with the juice of raspberries. The red- ness is paler in the morning, and assumes its greatest brightness towards evening. The skin subject to it is dry and very hot, but it gives to the touch no feeling of elevation, only a slight sense of roughness. It may, however, occasionally be intermingled with miliary vesicles, or papulae, especially when the patient has been subjected to a stimulating treatment or regimen. The eruption may also be seen upon the inside of the mouth and throat, which assumes a bright scarlet colour : the tongue, if clean, exhibits the same hue, or the papillae appear through the coating of fur, and their redness, as well as that of the tip, affords a strong contrast to its white or yellowish colour. Dependent upon the occurrence of the eruption in the fauces, there is always more or less sore throat. On the fifth day the eruption usually begins to decline, and in a day or two after altogether disappears — its departure being attended with a general desquama- tion of the cuticle from the whole surface of the body. The foregoing is a description of the mildest form of scarlatina, which Sydenham terms but " the name of a disease." If, however, as that admirable physician states, it be treated " too learnedly," or if the invasion be in its own nature more severe, all the symptoms may be materially aggravated, and a dangerous disease presented to us. By some, such an aggravation of character has been considered to constitute a distinct variety, which they have described under the name of Scarlatina rfnginosa ; but the distinction is unnecessary, the difference being rather in degree than in kind, and the slighter cha- racter of the symptoms being convertible into a severer, merely by mis- management ; or peculiarity of constitution. The symptom of sore SCARLET FEVER. 299 throat, to which the term anginosa refers, is common, in a greater or lesser degree, to all forms of scarlatina. The principles of treatment, also, must be the same ; whether the disease be mild or severe ; provided only it be inflammatory, and there should be no difference, except in the degree to which we may find it necessary to work them out. We conceive, in short, that less confusion will be created, and a right understanding of the treatment facilitated, by considering as identical in nature, and only different in degree, all cases of the disease which possess inflammatory or sthenic characters, thereby including under one head the Scarlatina, Sim- plex and Jlnginosa, of most writers, and Dr. Armstrong's Inflamma- tory Variety of the Scarlatina Maligna. All the symptoms, then, which we have described may exist in an aggravated degree ; the fever may be more violent, with quicker pulse, greater headache, and more frequent delirium. The skin may be much hotter, amounting sometimes to 106° or 108° F. There may be considerable derangement of the digestive functions, with oppression at the praecordia, vomiting, and dark stools. The soreness of throat, which in mild cases demands little attention, may be very severe and distressing, with pain and stiffness about the neck, painful deglutition, hoarseness, and a viscid secretion of mucus, causing much suffering by the efforts constantly excited for its expulsion. Upon looking into the throat, we may find considerable redness and swelling, and often, portions of lymph thrown out upon the tonsils and uvula, which may at first be mistaken for ulcers or sloughs of the mucous membrane, but are not so, as upon their removal by gargling, the latter will be perceived to be whole and unbroken. When the symptoms run to the height which we have just described, there is usually much nervous excitement, and the supervention of in- flammation of the brain or other viscus is to be dreaded. Thus, after delirium and high cerebral excitement, the patient may suffer collapse, and ultimately sink into a state of coma, showing that con- gestion has taken place within the head. In other cases there may be diarrhoea and vomiting, with tenderness of the abdomen, indica- ting an inflammatory condition of the alimentary canal ; or there may be fatal inflammation of the respiratory organs. Fatal gangrene of the throat may also supervene even upon the most inflammatory at- tacks of scarlatina ; or acrid discharges may take place from the nos- trils, causing sores about the lips and corners of the mouth. These latter circumstances may occur as a sort of secondary attack, upon the eighth or ninth day, after the patient has, apparently, got through the disease : thus, being somewhat analogous to the secondary fever of small-pox. In severe attacks, there may be irregularities in the eruption : it may appear too soon ; or it may be retarded ; or, lastly, it may recede, or become faint too soon after its first appearance. When the fever has been violent, the desquamation is occasionally very remarkable, the whole cuticle peeling off the hand or foot in the form of a glove or sock. As sequelae of scarlatina, we frequently have dropsy, either in the cellular membrane, or in the cavities ; also, abscesses in various situa- 300 ERUPTIVE FEVERS. tions ; ophthalmia ; suppuration from the ears ; and various forms of scrofula. The dropsy most commonly affects the cellular membrane, especially of the hands, feet, and face ; but it sometimes takes place in the cavities. A dropsical swelling of the hands and feet may follow very mild cases of the disease, setting in a week or ten days after the disappearance of the rash. It is attended by symptoms of an inflammatory kind, the pulse becoming quick, the stomach deranged, with costive or irritable bowels, nausea, and scanty, high- coloured urine. When the face is affected, its pallor, and the swell- ing of the eyelids, give the patient a peculiarly bloated and unhealthy aspect, More rarely, effusion takes place into the head, chest, or abdomen ; and it is then also of a more dangerous character — some- times rapidly occasioning death. The urine in dropsy after scarlatina, is generally albuminous, and coagulates upon the application of heat. b. Symptoms of Malignant Scarlatina. — Under this head, we shall consider the asthenic forms of scarlatina, or those in which the fever is of a low, typhoid type, whether that be occasioned by pecu- liarity in the prevailing epidemic, or bad state of constitution in the individual patient. Such forms of disease have been described by authors under different names, as Angina or Cynanche Maligna, An- gina Gangrenosa, or putrid ulcerous sore throat. Malignant scarla- tina is a most formidable disease, often sweeping away all the chil- dren of a family, in spite of the most judicious and zealous attentions of the physician. In many cases the symptoms are, at first, similar to those already described ; the patient being seized with severe headache, shivering, quick pulse, and other indications of fever, which, however, soon assumes a typhoid character. The pulse becomes very rapid and irregular, the heat of surface unequal ; and a low muttering delirium, with great restlessness, sets in. In other instances Huxham* describes the patient as " moving about for a day or two, neither sick nor well, as it were, but under uneasiness or anxiety, till they were obliged to lie for it." There is usually great dejection of spirits, sudden pros- tration of strength, and heaviness about the breast ; the countenance is pale, sunk, and dirty ; the eyes red and heavy ; the tongue loaded with a brown fur, or unnaturally clean, and of a fiery red colour. There is commonly nausea ; often severe and protracted vomiting and purging ; the discharges from the bowels, and the urine are much deranged — the former being, in children, usually loose, dark- coloured, and fetid ; the latter scanty, brown, and turbid. There is hoarseness, pain in swallowing, and painful swelling of the glands in the neck. The fauces appear somewhat swollen, and at the com- mencement, of a dark red hue ; but whitish or ash-coloured sloughs soon appear upon the tonsils and uvula, and the breath and odour of the body become very fetid. The rash in malignant scarlatina is irregular in its character and occurrence, being often faint or of a dark livid red colour, or interspersed with the petechias, but it may * Essay on Fevers, &c. London, 1757. SCARLET FEVER. 301 assume a bright scarlet hue. It also sometimes disappears soon after its first coming out, and it may return again in some hours or days. As the disease proceeds, all the symptoms are aggravated : there is extreme despondency and low delirium, or the patient sinks into a state of stupor. The sloughs in the throat spread and become dark-coloured and obviously gangrenous ; the voice is hollow and hoarse, and the breathing accompanied by a peculiar rattling, as if from strangulation. The patient is constantly harassed with efforts to spit up the sloughs, mixed with mucus, and often with blood. The disease extends to the nostrils ; and an acrid, ichorous discharge is emitted, which excoriates the lips and cheeks of the child, and, according to Huxham, even the fingers and arms of the nurse. The swallowing of this matter, also, appears to cause irritation in the bowels, and a species of dysentery. Towards the end, the breath- ing becomes difficult, the tongue black and dry, and discharges of blood occasionally take place from the several passages, the patient sinking exhausted at different periods, varying (according to his original strength, or the violence of the malady) from the third or fourth day to the second or third week : total insensibility or con- vulsions may precede dissolution. In some instances malignant scarlatina will prove fatal upon the second or third day, or even earlier, without the occurrence of death being explainable either by the progress of the gangrene of the throat, the amount of the typhoid symptoms, or the existence of any local congestion. Life, in these cases, appears to be at once extinguished by an intense impression upon the nervous system in a manner analogous to, but equally unexplainable with, what occurs in cholera, and more rarely in the cold stage of intermittent fever; the vital principle being, as it were, suddenly discharged from the body. Dr. Armstrong* also relates cases in which " children, and even adults, some time after exposure, now and then die suddenly, from the oper- ation of the contagion, without any appearance of efflorescence or of sore throat. They are attacked with convulsions, or with the symptoms of apoplexy, and frequently sink into insensibility and death in a few hours." c. Scarlatina of the Throat. — Dr. Tweediet has given a name {Scarlatina Faucium) to this variety of the disease, with which every practitioner must be familiar. It occurs chiefly among adults, and occasionally attacks those who have gone through the more regular form of scarlatina. It is, in fact, an appearance of the eruption in the mouth and throat, without any efflorescence upon the surface of the body. It is often attended with a good deal of fever, and may be followed by desquamation of the cuticle. It also appears to be capable of communicating an infection which will produce other forms of the disease. Pathology. — Scarlatina is subject, although perhaps not so strictly, to the same general laws as regulate the other eruptive fevers. It ♦ Practical Illustrations of the Scarlet Fever. London, 1818. t Cyc. Pract. Med. Art. Scarlatina. 26 302 ERUPTIVE FEVERS. occurs most frequently in the earlier periods of life ; but as persons are not so certainly exposed to it during these periods as to measles, so the instances of its occurrence after puberty are more numer- ous than in the latter exanthem. In the circumstances of affording immunity against future attacks — of naturally running a definite course — of being, to a certain extent, spread by contagion, and of suspending the action of other exanthems, it is also generally ac- knowledged to obey the laws already enumerated. Attempts have been made to communicate it by inoculation, but these have not hitherto been successful. We have stated that scarlatina is, to a certain extent, spread by contagion ; and it is well known to practitioners, that the different varieties which we have described may all owe their origin, and be distinctly traced, to the same source of infection. Like its kindred diseases, however, it is unquestionably of an epidemic nature, occur- ring usually about the end of summer and autumn, especially in wet and cold seasons, and prevailing until the commencement of spring. From the extraordinary difference in character between the mild and malignant varieties, these have been supposed by some to be dis- tinct diseases ; but this is disproved by the fact just stated, that the same source of infection may produce either form. The difference appears to lie partly in the habit of the patient, but chiefly in the constitutio anni, the epidemic taking a mild character when simple inflammatory diseases prevail, and running into an opposite form when the morbid tendency is low or typhoid. Looking upon the subject in this way, the simple scarlatina is to be considered as the true type of the disease, and the malignant as something superin- duced; just as the simplest wound may be attacked with erysipelas, when it happens to be rife in the locality, or when the subject is at the time in an unhealthy condition. The post-mortem appearances in persons who die of scarlatina are various, according to the complications which may exist of inflamma- tions or congestions in the several cavities. In the malignant form there is every evidence of a depraved and broken-down condition of the blood, putrefaction occurring rapidly, and livid spots and wheals existing even before death. Purulent matter is also occasionally found in the joints, without traces of inflammation, but as if deposited directly from the blood. We have stated that sudden death may occur at an early period ; and then we may fail to discover any morbid characters apparently capable of causing dissolution. Dr. Currie* relates the case of his own daughter, in whom death was occasioned by ulceration of the glottis, symptoms resembling those of croup attending. Diagnosis. — The only affections with which scarlatina is likely to be confounded are measles and roseola. From the latter it may be distinguished by its regular, and longer duration, and by the pre- sence of the sore throat, and efflorescence within the mouth ; from the former by the period of appearance of the rash, by the characters * Med. Reports. Liverpool, 1804. SCAKLET FEVER. 303 of this, and by the sequelae — all of which have been sufficiently- dwelt upon. Prognosis. — This depends both upon the nature of the particular epidemic, and the condition of the individual patient. The simple scarlatina, though it may be attended with severe symptoms, is not in itself a fatal disease ; and when there is no complication of internal inflammation ; and the rash is of a bright red colour, comes out abundantly, and remains the usual time, we may hope for a favour- able result : but still the sequelas to which we have alluded are always to be dreaded, and often constitute far more formidable affec- tions than the primary disease. Among these, glandular swellings and other forms of scrofula, are most to be dreaded ; dropsy, espe- cially of the cavities, is also highly dangerous. The malignant form is always attended with great hazard, the favourable signs are, a plentiful, bright eruption (although even this may exist in very bad cases) ; florid redness in the throat, and dis- position of the sloughs to separate ; general scaling off of the cuticle ; and some degree of strength being kept up. Lividity or disappear- ance of the eruption, petechia?, ulcerations about the lips, spreading of the disease in the throat, convulsions, stupor, and general pros- tration of strength, are among the most unfavourable signs. The mortality of different epidemics varies in a most remarkable manner; in some, scarcely a death occurring, — and in others, whole families being carried off. The danger appears to be greater to adults than to children, and to females than to males. Of 3S fatal cases, which occurred in a total of 644 treated at the London Fever Hospital, 13 were males, and 25 females.* Treatment, a. — In simple Scarlatina. — This must be regulated by the greater or lesser severity of the symptoms, the principle being to favour a development of the disease and prevent disturbance from accidental occurrences. In the mildest cases, the patient must be kept in bed, but not oppressed with an unusual quantity of clothes. The apartment should be cool and well ventilated, cooling drinks given freely, and abstinence from animal food and everything heat- in* strictly enjoined. A gentle emetic is almost always of service, by checking the fever and relaxing the skin, and also by clearing the throat of viscid mucus. Its action will be advantageously fol- lowed by a purgative ; but we do not go the full length with Dr. Armstrong, in recommending the continued use of aperients ; nor do we place as much reliance as he did, upon what he calls the bold administration of calomel. When the hepatic secretions are deranged, small doses of mercuryt will, unquestionably, be useful ; but we have long since ceased to think that calomel is a cure for febrile dis- eases. Currie strongly advocated the affusion with cold water, in inflammatory scarlatina ; and when the patient is strong and plethoric, with a hot skin, the weather being also warm— when, in short, there is no likelihood of a want of reaction, this measure will be * Cyclopaedia of Practical Medicine, article Scarlatina, f As in the pulv. rhei comp., No. 29. 304 ERUPTIVE FEVERS. attended with the best results. We can commonly, however, substi- tute for it sponging with cold or tepid water and vinegar; and this is in every case safe, and generally highly useful, bringing down the heat, and affording much comfort. Tepid affusion, and the warm bath, have also been highly spoken of, in the treatment of scarlatina ; but we have, ourselves, more experience of the benefits derivable from sponging. Bleeding has been recommended by some, and in certain epidemics (as that described by Morton), has been found advantageous. The weight of authority is, however, against its general employment ; and even by its patrons, it is recommended to be practised very cau- tiously. When visceral inflammation sets in during the course of scarlatina, and when we have the good fortune to discover it early, bleeding is certainly required, as it would be in ordinary fever under similar circumstances ; but it is only as a matter of necessity that we must have recourse to it ; for we believe that it is likely to prove injurious so far as the fever itself is concerned, delaying its regular course, and increasing the tendency to dangerous sequelae. If we are obliged to take blood, in consequence of inflammation of any organ, the quantity must be altogether left to the judgment of the practitioner ; enough should be taken to control the inflammatory tendency — but, if possible, not one drop more.* Nitre we have found to be of service in the early stages of scarla- tina, as a cooling and useful febrifuge. It may be given in doses of from one to three grains, freshly dissolved in cold water or whey. Gargles can seldom be used with children ; and with them, as Dr. Armstrong justly remarks, mild emetics will be the best gargles, clearing the throat, and removing the viscid secretion, which often furnishes a serious obstacle to respiration. In infants, the latter cir- cumstance requires that careful attention should be paid to the main- tenance of a free passage for the air, as the obstruction produced by viscid phlegm has been known to prove fatal. When gargles can be employed, the best in ordinary cases is barley water and honey, acidu- lated with vinegar; or half a drachm of muriatic acid to an eight- ounce mixture. When the fauces are covered with masses of lymph, or small ash-coloured sloughs, a more stimulating gargle will be use- ful, and an excellent one will be, a mixture of five ounces of infu- sion of roses, an ounce of honey, and a drachm of tincture of capsi- cum. The gargle recommended by Fothergili in mild cases was sage tea and vinegar. If we can get the patient to inhale the steam of hot water and vinegar, it will often afford much relief. When the cuticle is desquamating, at the close of the disease, the tepid bath will be found useful, and very comfortable to the patient. At this period, exposure to cold must be carefully guarded * For the sake of the audi alteram partem, we give the following quotation : "We gladly take this opportunity of asserting, from considerable experience, that copious bloodletting is the best remedy in severe cases of scarl. anginosa ,■ and that the greater the tendency to malignancy is, the more boldly must it be employed. This change in the treatment of scarl. maligna, has naturally followed that of its congener typhus," Edinb. Medical and Surgical Journal, vol. xix. p, 44S. SCARLET FEVER. 305 against, and the child not let into the open air without additional clothing. These means, and keeping the bowels relaxed, and the kidneys in action, by small doses of the compound powder of jalap, we have found, in our own experience, the most efficient in preventing those dropsical effusions which form so disagreeable a sequela of scarlet fever. There is often considerable debility at the close of the disease, and convalescence is not unfrequently tedious, obliging us to have recourse to tonic medicines, as mineral acids, or quinine ; but mildly nutritious food will commonly be sufficient for the purpose ; and any thing in the way of stimulants, as wine, &c, should be given with very great caution, as, in the weakened state of the system, they are extremely likely to excite dangerous local inflammations. Dr. Armstrong recommends mild fresh ale, in preference to wine ; and, if any stimu- lant be required, it will usually answer well. The hair very generally falls off, after scarlatina ; and when we find any tendency to its doing so, it will be well to have the head shaved, and tepid shower baths used, as soon as the patient acquires strength enough to bear them. Any special symptom, as diarrhoea, occurring during or after scarlatina, must be treated according to the particular indications belonging to it. b. Treatment in Scarlatina Maligna. — When the disease exists under the form which we have described as the truly malignant, the acute stage is extremely short, and often scarcely appreciable, — typhoid symptoms manifesting themselves almost from the very onset. It is important to recollect this in the treatment, as it is only in the short stage of excitement that any measures of depletion are warrant- able. Even Dr. Armstrong, who so strenuously advocated active means, admits that their use, except in the early stages, would be inevitably fatal. What are the measures of depletion proper even for this stage, comes next under consideration. Fothergill,* who was the first accurate describerof the disease in this country, utterly discounte- nanced bleeding, purging, and nitrous medicines; his plan consisting of gentle emetics in the first instance, and subsequently aromatic cordials, with anodynes when diarrhoea existed ; and, as a local application, he recommended the mel iEgyptiacum. Huxham adopted somewhat of a similar plan, only, in addition to the emetic, using enemata to unload the bowels, and sometimes very mild laxatives, before em- ploying aromatics or tonics. Mineral acids, also, appear to have been in estimation with him. Bleeding he was decidedly opposed to, in the truly malignant forms ; although, carried to a small extent, he thought it might be useful when the disease had a more sthenic character. Currie styled bleeding and purging, fatal practice ; and also condemned his own remedy, affusion with cold water, in malig- nant scarlatina. Dr. Armstrong advocated bleeding, upon the theory that, in the first stage, the apparent debility was produced by an op- pression of the circulation, in consequence of a congestion of blood in * Works, by Lettsom. London, 1784. 26* 306 ERUPTIVE FEVERS. the venous system ; he also supposed that calomel had a special effect in equalizing the circulation, and accordingly he prescribed it in very large doses. These two measures, with active purging, and the saline warm bath, constituted his plan of treatment. Those, however, who read his Essay carefully, will easily perceive that he was not free from misgivings as to his practice ; and it is equally obvious, that he considered the mere circumstance of the disease being severe and vio- lent as a sufficient sanction for the use of severe and violent remedies. Such a notion, though popular and common, is altogether inconsistent with an enlarged view of disease, and justifies the apologue of D'Alembert, — the physician being then, truly, a blind man armed with a club, who, as chance directs the weight of his blow, will be certain of annihilating either nature or the disease. A fever being likely by its violence to produce speedy death, is no palliation of the guilt of a physician who administers a medicine in poisonous doses, even though he may be ingenious enough to construct a theory explaining, satisfactorily to himself, the secundum artem character of the murder he commits.* We are, on these accounts, as well as from the views our own experience has led us to adopt, obliged to differ considerably from many of Dr.. Armstrong's positions, although fully impressed with the importance of some of them, and with the general ingenuity of his essay, — circumstances which, of course, only call for a more distinct warning against the dangers into which his theories might lead the inexperienced. Without going at any greater length into the opinions of others, we shall now state briefly our own ideas as to the proper treatment of the disease* , If any thing gives a chance of cutting short a typhoid fever, we believe it to be the sudden shock produced upon the nervous system by the operation of an emetic ; and accordingly, our first step usually is the administration of a medicine of this nature. Where the patient is much excited, and no irritation of the bowels present, we prefer the tartarized antimony: when there is much feebleness, we usually employ ipecacuan ; and this drug often operates advantageously upon children, by freeing their bowels, after its emetic action has been accomplished. With respect to actual aperients, we think they are often required and beneficial, — the discharges being depraved in character, and frequently destitute of bilious matter. They should, however, be of a mild kind, as the manna mixture (No. 2&, p. 123) ; or if we desire to give a mercurial, the compound rhubarb powder (No. 29, p. 127). If the affection of the throat be very distressing, occasioning much difficulty in respiration, before the appearance of sloughs, we may think it advisable to put leeches to the neck, or be- hind the ears; and if intense headache and stupor exist at the very commencement, the adoption of a similar measure may be justifiable, upon the grounds of local congestion being presumed to exist within the head. This is the utmost extent to which we can ourselves con- * For such practitioners, we know no better advice than that of the judicious Huxham, — "at least to peruse the sixth commandment." SCARLET FEVER. 3o7 scientiously go, in recommending depletory measures in scarlatina maligna : but it is right to state, that some experienced practitioners hope for benefit from a small bloodletting , if it can be performed at the very onset. When an epidemic invades a family of children, we may have an opportunity of trying this practice in cases arising during our attendance upon those earlier attacked ; but it is, at best, an experiment, and must be tried with great caution. Our practice, in addition, during the stage of excitement, is to immerse the patient in a warm bath, strongly impregnated with salt, as Dr. Armstrong directs, and subsequently to rub the skin with warm dry flannel, especially when irregular distribution of heat exists • when, also, bottles of warm water, or heated bricks, should be applied to the cold extremities. When the stage of excitement has passed, support will be required,, and such nourishment as the patient can take, as broths, must be given ; and if collapse approaches, wine and other direct stimulants will be demanded. By some, these latter have been much employed in the treatment of malignant scarlatina. Dr. Peart recommends carbonate of ammonia, in large doses (five or six grains, every second or third hour), as a sort of specific for the disease. We think, however, that stimulants should only be given when the patient is actually in a state of exhaustion, — - as, in the weakened state of the circulatory system, they are very likely to occasion local determinations of blood, of a peculiarly dangerous character. We would, therefore, be de- sirous of using only such tonics as are unlikely to produce a heating or excitant effect, and, on this account, prefer the mineral acids, with, small doses of sulphate of quinine. Local treatment should attract our principal attention in bad cases of scarlatina, the local disease causing much distress, and probably sometimes perpetuating a destructive reaction in the system. WTien the case is met with early, the dusky red, erysipelatous inflammation existing in the fauces, without ulceration or sloughing, we would recommend the free application of a strong solution of nitrate of silver (ten grains to the ounce), to all the parts concerned. It can be best applied by means of a piece of lint sewed to the finger of a leather glove, which latter is to be placed upon the forefinger of the operator. When sloughing or ulceration has set in, we have found the best applications to be the mel iEgyptiacum ; or a linctus made of five grains of sulphate of copper, and half an ounce of honey. If gargles can be used, the capsicum gargle already mentioned may be prescribed. Dr. A. T. Thomson recommends one composed of 12 drachms of the chloro-sodaic solution of Labarraque to 1 vss. of water and 5ss. of honey. Fumigations of chlorine and other gases have been recommended, but are not much employed in practice. The application of blisters in this disease, at least to children, is, we con- ceive, contraindicated by the tendency to gangrene which exists, and which is likely to be communicated to the blistered surface. There is one measure, in the treatment of malignant scarlatina, of which we have not yet spoken, although it is probably the most im- portant and efficient of all. We allude to the free admission of fresh 308 ERUPTIVE FEVERS. air. In children living in crowded apartments, we have witnessed the most marked change in the condition of the throat to be imme- diately produced by free exposure to air ; and in every possible case, we would recommend the practice to be adopted. If a patient be fortunate enough to become convalescent from scarlatina maligna, the greatest delicacy of management is required, in order to prevent local congestions, or other dangerous sequelse, from occurring. While sufficient mild nourishment is given, a care- fully antiphlogistic regimen must be observed, every thing stimulant or heating being avoided, and gentle laxatives administered, so as to prevent any accumulations in the bowels. By such a plan, we shall also best prevent the dropsical effusion which is likely to follow the sthenic form of the disease. When this latter sequela has once set in, it requires purgatives, and sometimes bloodletting, being usually of an inflammatory character, as is evinced by the state of the pulse, skin, and secretions. Convalescence from any form of scarlatina is often tedious ; and the patient should never be pronounced out of danger, until a state of perfect health be regained. Prophylaxis. — Dr. Hahnemann, of Leipzig, the originator of the homoeopathic doctrine, has put forward the opinion that belladonna possesses the power of preventing the reception of the infection of scarlatina. His plan is to dissolve three grains of the extract of bella- donna in an ounce of distilled water, and give two or three drops twice a day to a child under a year old, and one drop more for every year additional, during the time of exposure to infection. His views have been corroborated by several German physicians ; but we cannot speak of the plan from any experience of our own. III. SMALL-POX (VARIOLA). This eruptive fever, though once the agent of destruction to entire nations, has now, thanks to the genius of Jenner ! almost ceased to engage the attention of physicians. Its continued existence, how- ever, should not be forgotten, nor any neglect of the proper precau- tions against its ravages be induced by security, even though that has been now enjoyed for nearly forty years. We shall consider the disease as it occurs in the mild or distinct ; the severe or confluent : and the modified forms. a. Symptoms of Distinct Small-Pox. — Natural small-pox runs through a regular course of three distinct stages, viz. — 1, of incu- bation ; 2, of maturation ; and, 3, of decline. The space of time between th£ reception of the infection and the first invasion of the febrile symptoms, although probably a definite one, has not been absolutely agreed upon by writers; the average period, however, appears to be about fourteen days. The commencement of the fever is commonly well marked, being for the most part a sudden and severe rigor, followed by excessive heat, pain in the head and back, nausea, pain at the pit of the stomach, weakness and giddiness, with disposition to heavy sleep. In children, we have observed the first SMALL-POX. 3og appreciable symptom to be a convulsive fit ; and this was considered by Sydenham to be a favourable sign. The symptoms just enumer- ated are those belonging to other eruptive or ordinary fevers, and can only be inferred to belong to small-pox by a knowledge of ex- posure to contagion. On the fourth day,* inclusive, from the commencement of fever, the second stage begins. An eruption of small, red, elevated pim- ples shows itself, first upon the face, and neck, and subsequently upon the rest of the body, being completely out in a period varying from twenty-four hours to two or three days. The eruption is not confined to the skin, being often extended to the mucous membrane of the mouth and throat, and sometimes to the tunica conjunctiva of the eye. Its appearance is usually accompanied by a considerable abatement of the febrile symptoms, and sometimes by profuse sweat- ing. The pimples quickly grow larger and higher, their increase in size being attended with pains in the jaws, and general redness of the skin. In two or three days from their first appearance, they become vesicular, the vesicle being formed of distinct cells, contain- ing a straw-coloured fluid, and depressed in the centre: their seat is in the true skin. From day to day, the redness and swelling of the skin increases, and is accompanied with pain ; the face becomes swollen, so that the eyelids are usually closed ; the hands and fingers also swell. The distinct cells in the vesicles gradually run together, and, losing the central depression, they acuminate and form pustules, filled with a thick, opake, yellowish matter. This process, called maturation, is completed about the eighth day from the commencement of the fever; and the pustules are then about the size of a pea; yellow, and in some places rough, and the intervening skin of a florid red colour, resembling the hue of a damask rose. On the eleventh day, the swelling and inflammation of the skin on the body and face de- cline, and the pustules upon these parts dry up, and form scabs, which fall off about the fourteenth or fifteenth day, leaving behind, in some cases, the peculiar marks of the disease — in others, merely discoloured spots, which soon disappear. The pustules on the hands remain a day or two after the others, and often break, and leave troublesome sores. b. Symptoms of Confluent Small-Pox. — These are, in the first stage, similar to those of the distinct form, but more severe and violent, the fever running higher, and being accompanied by con- siderable nervous excitement, often amounting to delirium. The eruption appears generally, upon the third day, coming out earlier than in the milder form; but Sydenham observes, that when the fever is of extraordinary violence, there may be no eruption until the fourth or fifth day. The febrile symptoms do not so markedly abate upon the commencement of the second stage, as they do in the dis- tinct variety, but continue with greater or lesser severity. At first, * This is Sydenham's account. Dr. Gregory, in the article " Small-Pox,'* Cyc. Pract. Med., states the duration of the fever to be forty-eight hours. 10 ERUPTIVE FEVERS. the eruption has nothing peculiar in itself; but, in a day or two, it will be perceived that the pustules are not rising so high, or filling so much as usual ; and by degrees those upon the face run into one another, and form one continuous bag, containing a thin sanious fluid, instead of pus. The face becomes considerably swollen ; and as the conflu- ence takes place, it loses its red colour, and becomes pallid and doughy. About the eighth day, the covering of the pustules changes to a dusky colour, or it bursts, and dark brownish fetid scabs are formed. In either case, the surface becomes rough ; and at length, towards the twentieth day, large scales fall off, disclosing ulcerations of the true skin, which ultimately leave permanent pits and seams. It is principally upon the face that the confluence of the pustules takes place ; and the danger of a particular case is chiefly to be inferred from the condition of the face, both as to the number of pustules upon it, and their more or less unhealthy appearance. During the course of confluent small-pox, children are commonly affected with diar- rhoea, which appears to be analogous to the salivation to which adults are subject during the stage of eruption. In the distinct form, we have stated that the fever abates consider- ably upon the coming out of the eruption, and does not, under ordi- nary circumstances, return again during the course of the disease. This, however, is not usually the case in the form we are now consider- ing — as about the tenth or eleventh day from the commencement, when the scabs are forming, an attack of secondary fever often sets in. This is attended with a variety of distressing symptoms : the skin becomes dry and hot, with quickened pulse, white tongue, and thirst ; the head is often affected at this time, violent delirium or coma being present, or that peculiar affection of the nervous system, re- sembling delirium tremens, which is occasionally observed to attend upon severe accidents, as burns or scalds, &c. The chest is also liable to be effected, especially the pleura, which is not uncommonly the seat of sudden and fatal inflammation. The abdomen, it is said, is not so commonly the seat of disease in small-pox as either of the other cavities. Boils and abscesses may, also, form in various parts of the body, and may be accompanied with glandular swellings and petechias, or hemorrhages from some of the passages. Gangrene of the genitals is not an unfrequent occurrence, and usually proves fatal. A. destructive ophthalmia, invading all the texture of the eye, and often causing sloughing of the cornea, is also a common com- plication. c. Symptoms of Modified Small-Pox. — Variola has occasionally occurred epidemically, in a peculiarly mild form, and has been, under such circumstances, described by the older authors as " stone- pox," " horn-pox," or " siliquose-pox." The disease, also, although usually obedient to the general law of the exanthemata, of occurring but once in the same individual, does sometimes recur ; and in about the same ratio of frequency, it visits those who have been protected by vaccination. When it recurs under these circumstances, it assumes the modified characters, which we shall now describe. The first stage of modified small-pox differs little from that of the SMALL-POX. 311 natural form, the fever being often very severe, and presenting no peculiar characters. There is, however, considerable difference in the eruption, which is seldom very copious, and usually begins to decline about the fifth day. The fever mostly abates upon the appearance of the eruption, and the pocks do not advance to matu- rity, but dry up and become hard and horny, by the fifth day. When they fall off, a mottled red condition of the skin remains, and some- times a slight pitting continues visible for a considerable period, or even may be permanent. Although the pustules may sometimes be numerous, and even run together, becoming partially confluent, still the fever is seldom high after the first stage, and there are rarely any dangerous complications. That the disease is actually small- pox is, however, proved by its being the result of exposure to con- tagion, and also by its being capable of communicating a severe form of the disease by inoculation. Pathology. — Small-pox obeys the general laws of exanthema- tous diseases. It is, however, less a disease of childhood than any of the others, probably because it is more usually propagated by contagion, and possesses rather less of an epidemic nature. The contagious character is very well marked-, but appears to be most strong during the stages of maturation and decline. The type of an individual case does not always appear to influence the disease pro- duced by infection from it, in another patient, as the mildest cases may communicate the most severe form, and vice versa. With respect to the type of the disease, much variation is produced by the pecu- liar constitution of the patient, and also by the epidemic constitution of the year or season. Certain persons, but those very few in num- ber, appear to be altogether insusceptible of variolous infection. The morbid appearances observable in those who die of small- pox are, for the most part, those proper to complications which arise during the progress of the case — being inflammatory conditions of the brain, or respiratory organs : ulceration of the bowels is some- times met with ; but the abdomen is comparatively seldom the seat of lesion. When the disease has been peculiarly malignant, and the fever typhoid, marks of putrescency will be observable in the rapid approach of putrefaction, and the existence of livid wheals and petechia upon the surface of the body. The larynx and trachea sometimes present peculiar appearances — being covered with a quantity of dark-coloured, viscid secretion, and the mucous mem- brane being thickened and pulpy, or even in a sloughy and disor- ganised condition. We have already particularised, at p. 263, an instance of fatal ulceration of the rima glottidis supervening upon small-pox. Diagnosis. — The characters of the fever and eruption sufficiently distinguish small-pox. It can only be confounded with varicella, or chicken-pox, which is to be known by its shorter and milder course. The modified small-pox can, however, scarcely be distinguished from varicella, and is by some considered to be identical with it. Prognosis. — This must be entirely regulated by the form of the disease, and by the absence or presence 1 , and character of complica- 312 ERUPTIVE FEVERS. tions. Confluence of the pustules is always a sign of danger ; as is also a large number of pustules upon the face, and there remaining flat and pale, instead of filling well, and being surrounded with a bright red areola. Hoarseness, or croupy cough, is unfavourable, as indicating an affection of the larynx. The state of the system must be taken into account, and also the age. Healthy persons, neither very plethoric nor delicate, will escape best ; while infants and very young children are more liable to suffer complications than those of a more advanced age. Any evidences of a debilitated system, as petechia?, hemorrhage, gangrene, &c, are very unfavourable signs. Certain periods of the disease appear to be particularly critical : these are stated by Sydenham to be, in the distinct form, the eighth, and in the confluent the eleventh days, from the commencement of the fever. In making a prognosis, even in mild cases of small-pox, we must recollect the liability to dangerous sequelae which always exists ; various forms of scrofula, and severe ophthalmia, for example, being likely to follow attacks apparently very favourable in their primary states. The average mortality of small-pox may be stated at about one-fourth of those who are attacked ; and when we reflect upon the small probability of any individual escaping from the frequent epi- demics which raged before the happy recovery of Jenner, we must be led to form a frightful estimate of the destroying power of this for- midable disease. Treatment. — The principle upon which the treatment of every form of small-pox should be conducted is, in a word, the prevention of any circumstance which may be likely to disturb or interrupt its natural course. Any steps, on the one hand, which may heighten the fever, as a hot regimen and apartment ; or which, on the other, may diminish the strength to the degree of causing debility, as inor- dinate evacuations, — will produce such disturbing effect, and should be carefully avoided. The happy medium desirable to be attained is the restraining of the fever, so as to prevent the occurrence of local congestions or inflammations, and at the same time to leave a suffi- cient degree of strength to enable the patient to pass through what may be a tedious and debilitating disease. To furnish rules for the attainment of these objects, we cannot do better than give the substance of Sydenham's plan of treatment, which has never been improved upon, and which, if we consider the state of opinion existing at the time of its promulgation, may be safely recommended to the student as a model of the observation, reasoning, and practice of a true physician. "As soon," says Sydenham, "as" the signs of this disease show themselves, I keep the sick from the open air, and forbid them the use of wine and flesh, and allow them small beer gently warmed, with a toast, for their ordinary drink, and now and then I permit them to drink as much of it as they will. I order them, for their victuals, oatmeal and barley broth, and roasted apples, and other things, which are neither too hot nor too cold, nor of too hard a digestion. I forthwith prohibit a hotter regimen, and the use of all manner of cordial medicines, * * * for I have more than once ob- SMALL-POX. 3 13 served, in young people of a sanguine complexion, that a hot regimen and cordials given on purpose to force out the small-pox before the due time, have so little promoted their coming out, that, on the con- trary, they have given a check to it * * * till at length, by allowing small beer, and taking off part of the load of clothes wherewith he was roasted, I have made a convenient way for the pustules to go out ; and so I have put the patient out of danger, by God's assist- ance.'' He also discountenanced confinement of the patient to bed in mild cases before the fourth day : " for bloody urine, purple spots, and other mortal symptoms, come upon people merely because they are too soon confined to their beds." After the fourth day, he recom- mended opiates at bedtime, for the purpose of allaying irritation ; and their employment is sanctioned by our knowledge of the benefit often derived from them in the treatment of that low form of delirium at- tendant upon burns and scalds, — a state, similar to which, so fre- quently accompanies small-pox. In addition to this treatment, should there be no diarrhoea present, it will be advisable to free the bowels gently by injections or mild aperients, as the manna mixture (No. 25, p. 123), or the powder of rhubarb and magnesia (No. 27, p. 126). Sydenham was not solicitous about restraining the diarrhoea which sometimes attends, considering it to be critical. When the fever ran high in plethoric persons, Sydenham recom- mended bloodletting : with children this measure is not so frequently called for ; but if we meet with very high febrile symptoms, and especially if any tendency be evinced to local imflammation in the head or chest, we must draw sufficient blood, either from the arm or by leeches, to moderate those symptoms. Our dread of subsequent debility must always be moderated by the recollection that over- action, which is particularly liable to occur in this disease, frequently produces prostration of strength, and that the reduction of such over- action in time, may be the most efficient means of husbanding the patient's powers. It is, however, not to be forgotten that the ex- tensive suppuration, which ought to take place in the maturation of the pustules, requires that the strength should not be wantonly taxed. In the distinct form, after the coming out of the pustules, Syden- ham continued the same antiphlogistic regimen, but allowed the patient to rise from bed for a few hours every day, unless the weather was cold, or there was a large eruption, when he kept the patient continually in bed, but with no more clothes upon him than when he was in health, so as to avoid, if possible, the production of per- spiration. When the disease is going off, mildly nutritious food may be given; and if there be restlessness, an occasional anodyne ; but stimulants are not often required, and must always be resorted to with extreme caution. The state of the bowels should be watched throughout this stage, and mild laxatives administered, when necessary. When the disease is confluent, greater care is required in the com- mencement, to prevent the fever from attaining a dangerous height ; but the principles of treatment are identical with those which we 21 314 ERUPTIVE FEVERS. have just laid down. When the secondary fever has set in, it must be met by diluent drinks, occasional aperients, and, if there be irri- tation and restlessness, opiates ; — bleeding is seldom safe at this late period. Among children, Sydenham justly remarks, opiates are not so often advisable, as they would tend to stop the diarrhoea, which is not to be unnecessarily interfered with, being, in fact, a sort of critical evacuation. In bad cases, the access of secondary fever is sometimes quickly followed by extreme debility, coldness of the ex- tremities, petechiae, and, in short, the whole train of typhoid symp- toms. A similar state is sometimes produced by the drain of matter from the pustules, when these are very numerous ; and sloughing sores upon parts of the body exposed to pressure, may also attend. Under these circumstances, wine, tonics, and stimulants are called for, and furnish the only means of supporting the patient's strength. The pustules do not require any particular local treatment ; they should be left to themselves, except so far as anointing them with a little cold cream, or oil of almonds, when they become hard — or dusting over the surface with starch, or other dry powder, when they are discharging thin, sanious matter. The hands of children should be muffled, to prevent them from breaking the pustules upon their faces, which the extreme itching would otherwise lead them to do. The hair of the head, also, should be clipped, as otherwise it is apt to become matted with the discharge, and then to occasion great irritation and pain. The different complications and sequelae must be treated upon ordinary principles ; but it is particularly necessary to guard against the effects of ophthalmia. When this inflammation occurs it must be promptly checked by the application of leeches, or such other remedies as may be required, otherwise there will be considerable risk of destruction of sight. There is nothing particular to be said upon the treatment of modified small-pox : the principles of its management are similar to those already laid down. Inoculation for Small-Pox. — It would be exceeding our limits to go at any length into a consideration of this subject, as it is now happily superseded by vaccination. The practice was first intro- duced into Great Britain from Turkey by Lady Mary Wortley Mon- tague, and was found materially to diminish the perils of small-pox. It has since been discountenanced by judicial decisions,* in conse- quence of the equal security afforded by vaccine inoculation, and the additional advantage possessed by the latter measure in not consti- tuting artificial fomites of variolous infection. The mode of inoculating is similar to that of vaccinating, which shall be treated of at length. The manner in which the disease runs its course, when introduced in this way into the system, is as follows : * The King v. Burnet, and the King v. Vantandillo. 4 Maule and Selwyn, pp. 271-73. More recently the production of small-pox, by inoculation or wilful exposure to infection has been made punishable with one month's imprisonment, by the 3d and 4th Vic. c. 29. s. 8. [Note to 4th Edition.] CHICKEN OR SWINE-POX. 3l - On the third day after inoculation, the wounds show some slight marks of irritation, and a minute pimple is perceptible. On the fourth day, this is converted into a vesicle with a depressed centre, and the patient begins to feel an itching and slight uneasiness in the part, which upon the sixth day is increased to pain and stiffness, extending towards the nearest lymphatic glands. About the seventh or eighth day, rigors and other febrile symptoms, as nausea, head- ache, pain in the back, &c, occur, and in the course of forty-eight hours afterwards, the eruption appears. The number of pustules is generally very limited, and they usually run their course precisely in the same manner as the natural, distinct pox. In some cases, however, the result is not so favourable, death occasionally occur- ring 5 — shortly after the introduction of inoculation into Great Britain, and its adoption with two of the Princesses of the blood, the practice did actually receive a check in consequence of its producing fatal results in three remarkable instances. We have introduced a notice of the subject here, on account of its weight as a pathological phenomenon ; but as matters stand at pre- sent, it is the unquestionable duty of every practitioner to discourage the practice of variolous inoculation, both as being opposed to the spirit of the law, and as being a measure hazardous to the commu- nity, by keeping alive the infection of a most baleful disease. For a full consideration, however, of all the bearings of the question, we must refer to our chapter on Vaccination. IV. CHICKEN OR SWINE-POX "( VARICELLA). This mild exanthem may be said to be peculiar to the period of childhood, as it very rarely affects adults. It has been divided by authors into four varieties — viz., V. Lentiformis vel Lymphatica, V. Coniformis, V. Globularis, V. Corymbosa : the division is based upon the varying characters of the eruption, but is of no practical importance. Symptoms. — We have always observed the eruption of chicken- pox to be preceded by more or less fever ; the patient usually under- going a rigor, succeeded by the ordinary febrile symptoms, for a day or two before the appearance of the rash. Such is also the opinion of Dr. Willan* and of Dr. Copland,! although it is asserted by some writers that febrile symptoms are unusual. The eruption first appears upon the back, neck, and breast, the face being comparatively free. It very early (indeed, usually from the very commencement,) assumes a vesicular character, coming out suddenly in form of little blisters, about the size of split peas, and rilled with a transparent, straw-coloured, or yellow lymph. These vesicles may be lenticular, conoidal,or globular, or may run together in clusters, thus constituting the four varieties. If they happen to be punctured, or are broken, the fluid is discharged, and the cuticle * On Vaccine Inoculation. f Dictionary of Practical Medicine. 316 VACCINATION. falls evenly on the cutis, there being no elevation or hardness in the latter tissue. Successive crops of vesicles come out, which is cha- racteristic of the disease, not occurring in any of the other eruptive fevers. There is usually a slight degree of redness of the skin around the vesicles ; and they are commonly accompanied with itching, which mostly causes them to be broken early. About the fourth or fifth day, they begin to dry up, being converted into brown, gummy scabs. These crumble off in the course of a week or ten days, some- times leaving slight pits, but more generally, mere discolorations of the skin. Pathology. — Chicken-pox obeys the general laws of the exanthe- mata : its contagious nature, however, is not so clearly made out as that of the others, as it has not been satisfactorily proved that it can be communicated by inoculation. It has been supposed by some to be merely a mild variety of small-pox ; and this question, which is a curious and interesting one, shall be discussed in the chapter on Vaccination/ Diagnosis. — Chicken-pox is to be distinguished from small-pox (supposing it not to be a modified form of that disease), by its mild- ness ; by the rash early assuming a vesicular character, the vesicles not being depressed in the centre, and coming out in successive crops. It must be confessed, however, that it is not easy to discriminate it from some forms of modified small-pox. Prognosis. — This is always favourable, — no danger existing except from accidental complications. Treatment. — Very little is required, it being merely necessary to keep the child in bed for two or three days, and to prohibit animal food or heating drinks. Towards the close, a mild laxative may be given, and the return to ordinary food and habits gradually effected. CHAPTER XII. VACCINATION.* Edward Jenner, of Berkeley, to whom mankind is indebted for a knowledge of the great blessing of vaccination, became acquainted (in consequence of his residence among the dairies of Gloucester- shire), at a very early period of his life, with traditionary accounts of the security afforded against small-pox, by the casual introduction into the system, of a disease occasionally prevalent among the cows in that county. The description of the original disease will proba- bly be best given in his own words. " It has obtained," he says, " the name of cow-pox. It appears on the nipples of the cows, in the form of irregular pustules. At * The matter of this chapter is now republished from a paper by Dr. MaunseU, in the 4th volume of the Dublin Medical Journal. VACCINATION. 317 their first appearance they are commonly of a palish blue, or rather of a colour somewhat approaching to livid, and are surrounded by an inflammation. These pustules, unless a timely remedy be applied frequently degenerate into phagedenic ulcers, which prove extremely troublesome. The animals become indisposed, and the secretion of milk is much lessened."* From these pustules, infection is soon communicated to the hands of the milker. Inflamed spots appear about the joints and extremities of the fingers ; these assume the form of circular vesicles, with elevated edges and depressed centres, and of a " colour distantly approaching to blue." From the irrita- tion and friction to which the vesicles are usually exposed, they most commonly ulcerate, and often pass into phagedenic sores. When this is the case and the points of infection are numerous, considerable fever and disturbance are excited in the constitution. The axillary glands become inflamed, and there is headache, quick pulse, rigors, &c. Reasoning from a great number of individual instances which fell under his notice, and from the general opinion of the country, Dr. Jenner came to the conclusion that persons affected in the man- ner described, became insusceptible of the infection of small-pox. In a happy hour the idea struck him that it might be possible to ex- tend the protection, by the artificial communication of the disease from one individual to another ; and accordingly, on the 14th of May, 1796, he made the first vaccine inoculation. The subject was a boy named James Phipps ; and the matter was procured from a sore on the hand of Sarah Nelmes, a dairy-maid, who had been infected casually in the course of her occupation. On the 1st of July following, the experiment was tested by inoculating the boy with variolous matter, taken directly from a pustule. This was again repeated, after some months, " but no sensible effect produced on the constitution." Similar experiments were tried upon others; and in June, 1798, Jenner published his first work upon the subject. His hypothesis at this period was, that cow-pox and small-pox were modifications of the same disease, and that the origin of both was to be found in the cutaneous inflammation to which horses are subject, and which, when it affects their heels, is termed grease. He con- ceived, however, that although a disease resembling cow-pox might be communicated to a human subject directly from the horse, still it failed to afford protection unless it has intermediately passed through the system of the cow. In every instance he thought the disease in the cow could be traced to infection, either from another animal of the same species, or from the matter of grease, communicated by the hands of a milker. By after observations it has been ascertained that the grease, at its commencement, and before its characteristics have been destroyed by friction, is a vesicular eruption, very similar in appearance to that which occurs upon the nipples of the cow. It is also stated that Mr. Gardner succeeded in producing the vaccine disease in the cow by a direct inoculation from the eruption in ques- tion ; and that Dr. Loy, and Dr. Sacco of Milan, were able to pro- * Inquiry, &c, 3d Ed. p. 4. 27* 318 VACCINATION. duce it, from the same source, directly in the human subject.* In Jenner's " Inquiry," and indeed generally in the early stages of the investigation of cow-pox, we find the term pustule applied to cha- racterize its form. The disease, however, is strictly vesicular,t but the mistake was owing to the peculiar circumstances under which it was usually observed in the cow ; its situation, upon the nipple, never allowing it to run its course uninterruptedly, and the natural inflammation being usually much increased by friction. When the infection was communicated casually to the human subject, a similar interference with its progress almost invariably occurred, and in the first cases of inoculation was not sufficiently guarded against. On this account a very considerable febrile disturbance was frequently ex- cited in the system ; not by " the first action of the virus," but by the subsequent existence of corroding ulcers, and this indisposition was erroneously considered necessary to the success of the inocula- tion. Another error consequent on the supposition of the pustular origin of the eruption was the employment of purulent matter or ichor from an ulcer, for the propagation of the disease. The saga- city of Jenner, at a later period, discovered both these mistakes : he continued, however, to the last, to apply the term pustule, and has not in any part of his works given a very satisfactory account of the appearances and progress of the complaint, so that it was some time after the discovery before its exact characters were ascertained and recorded. In describing these, we shall avail ourselves freely of the descriptions given in the papers of the National Vaccine Board, and of those contained in Dr. Labatt's excellent Address to the Medical Practitioners of Ireland. About the third or fourth day after vaccination, a small red pimple is formed on the site of the operation. This is hard to the touch, and slightly elevated : if it be examined through a magnifier, a slight efflorescence will be seen to surround it, and sometimes a minute vesicle will be discovered on its apex. The tumour gradually enlarges, and about the fifth or sixth day the vesicle becomes appa- rent to the eye. It is circular in its form, elevated at the edges, but with a depressed centre ; and when at its greatest size, is sometimes indented by one or two concentric furrows, resembling, to use the simile of Mr. Bryce, a worm coiled under the skin. It goes on increasing in size until the tenth or eleventh day, when it is usu- ally about four lines in diameter. The size, however, varies accord- ing to the mode of inoculation ; if it has been performed by puncture, it is generally small ; whereas, when several scratches have been made, two or three vesicles frequently form, and subsequently run together. The colour of the vesicles is at first a light pink ; some- times with a bluish shade, which gradually changes to a pearl colour. * Life of Jenner, by Dr. Baron. t It may be well to keep in our minds the strict definitions of these two forms of cutaneous eruption : — Vesicle : a small orbicular elevation of the cuticle, con- taining lymph, which is sometimes clear and colourless, but often opake and whitish, or pearl-coloured. Pustule : an elevation of the cuticle, with an inflamed base, containing pus." — Willan. VACCINATION. 319 The centre is darker than the margin, which is firm, turgid, and shining. Internally, the vesicle consists of numerous little cells, filled with clear transparent lymph, and, according to Dr. Willan, commu- nicating with each other. We should think, however, from the difficulty experienced in evacuating the lymph, that the communication is at all eventsnot very free. The quantity of virus varies considerably in different vesicles, and will usually be found to possess activity in an inverse proportion with its quantity. Dr. Joseph Clarke suggested to Dr. Labatt, that this might probablv be accounted for by suppos- ing the increased quantity of fluid to depend, not upon an increase of the specific virus, but upon a discharge of serum excited by the mechanical irritation of the part. On the eighth or ninth day there is formed round the base of the vesicle an inflamed ring, which spreads rapidly, and about the tenth day forms an areola of an inch and a half or two inches in diameter. This areola is intensely red, and is accompanied with some degree of tumefaction and hardness. The redness continues for a day or two, and then begins to fade, gener- ally from the centre to the circumference, sometimes forming two or three concentric rings. After the tenth day, the vesicle begins to decline ; the centre first turns brown, and the whole gradually changes into a hard, smooth crust, of a dark mahogany colour, having, like the vesicle, a concave surface. About the twentieth day, the crust falls off, leaving a permanent circular cicatrix, a little depressed, and marked with small pits, probably equal in number with the cells of which the vesicle had been composed. The vesicle in very young children sometimes appears a little earlier than has been described ; more frequently, however, the de- viation is to a later period. In some instances we have known it to remain dormant for ten or twelve days ; in others, Dr. Labatt has observed it bearing the characters of an ordinary phlegmon until the eighth, tenth, or twelfth day, when it assumed the regular vesicular appearance. In all these cases, if the subsequent stages be regular, slight deviations as to time are of no moment. The progress of cow-pox is sometimes suspended by the interven- tion of other diseases, and after their removal, proceeds regularly with its usual marks. Dr. Jenner relates two cases in which the vesi- cles advanced to maturity, during the existence, in one instance, of scarlatina, and in the other of measles : the areola, however, did not appear until these diseases had subsided. When the vesicle has advanced through all its stages, to the formation of the hard crust, local irritation will sometimes occasion the formation of pus ; this, however, is by no means to be regarded as a regular part of the process, and may usually be prevented by preserving the part from injury. During the early period of the history of vaccination, con- siderable stress was (as has been already observed) laid upon the constitutional affection. Since, however, the nature of the disease has been more perfectly ascertained, and more attention paid to the preservation of the vesicle from injury, it has been found that the general symptoms are usually very slight, often scarcely perceptible. They commonly occur from the seventh to the eleventh day, and 320 VACCINATION. consist in restlessness, slight shiverings, followed by heat, with thirst and headache. In infants there is, occasionally, sickness and vomiting, and the child is peevish, or drowsy and oppressed. Erup- tions are not usual concomitants of vaccination ; but frequently, in children, a slight form of strophulus will be observed. As the sym- pathies of the skin are so active in these subjects, it is of course not easy to determine whether the rash be a consequence of the infection, or an accidental occurrence. One of Dr. Jenner's main positions was, that a constitutional as well as a local affection should follow the inoculation of cow-pox, in order to insure to the patient the full amount of protection. From the extreme slightness of the febrile symptoms, it is often impossible to declare, upon their evidence, that any constitutional disease has been felt, and it therefore becomes a desideratum to have some sure test of the general affection of the system. According to the instructions of the Vaccine Board, we may be satisfied that this has taken place, " when the progress of the vaccine vesicles has been regular and complete ;" and this is, no doubt, prima facie evidence to that effect. In the following case, however, which occurred under our own eyes, the local disease was so regular, although not absolutely complete, in its progress, as to appear to us to furnish grounds for doubting the invariable correctness of this conclusion. A child, four months old, was vaccinated, and had two well-formed and perfectly regular vesicles ; from one of which, on the eighth day, six other children were infected. On the ninth day the child was very feverish, and on the tenth, small-pox pustules appeared. These ran their regular course, maturating about the ninth or tenth day from their appear- ance, and having the characteristic depression of centre. The six children inoculated from the vaccine vesicle, had the vaccine disease perfectly and favourably. In this case, as the small-pox was not modified, we should be disposed to infer, that the constitution was not affected by the vaccination, although the vesicles were sufficiently mature to afford virus capable of exciting a perfect disease in six other individuals. An analogous case is related by Mr. Dawson, in the Transactions of the College of Physicians, London, vol. hi., p. 385, in which, small-pox pustules upon two children furnished matter for the successful inoculation of nineteen persons, although the children themselves suffered no fever, nor general eruption "of pustules, and in a few days afterwards, upon a second inoculation, took the disease regularly. Instances of local small-pox pustules without fever, occurring in persons much exposed to infection, but who have had variola before, may be found in the works of Huxham and many others, and these have been sometimes found to be capable of communicating the disease by inoculation. Notwithstanding, however, " these loops to hang a doubt upon" in individual in- stances, we are strongly inclined to think, that there is a fair pre- sumption of the constitution having been properly affected, whenever the local disease has gone through the regular course exactly as it has been described above, with perfect areola, cicatrix, &c. At the commencement of the vaccine inquiry, small-pox inocula- VACCINATION. g lation was employed as the criterion of a constitutional infection of cow-pox ; at present it is fortunately difficult to procure variolous matter for the trial, and even were it always at hand, the risk of dis- seminating contagion would render its use unjustifiable. When any shadow of doubt exists as to the efficacy of a vaccination, we should of course, always repeat the operation ; but it is not to be expected' that in every successful case, the constitution will be insusceptible of a re-vaccination. Very frequently, the secondary insertion of virus will be followed either by an erysipelatous inflammation of the arm, or by an irregular vesicle, quickly running to a termination, and generally without an areola or permanent cicatrix. Jenner, how- ever, has observed and recorded cases, in which both casual and inoculated cow-pox occurred twice and even thrice in the same in- dividual :* it was also his opinion, that vaccination occasionally took effect perfectly, after small-pox. From these facts it is plain, that re-vaccination cannot completely satisfy us as to the success or failure of the first operation : the local disease may appear a second or third time, or perhaps much oftener, with its characters so well marked, as to furnish, at each repetition, only an additional source of doubt. Owing, however, to the ingenuity of Mr. Bryce, we have a test of the constitutional affection, the validity of which, when it is pro- perly executed, has not, we think, yet been successfully impeached. Reasoning analogically from some experiments upon the inoculation of small-pox, Mr. Bryce was induced to make similar trials with vaccine matter, and found " that if, during the regular progress of cow-pox, a second inoculation be performed, about the end of the fifth, or beginning of the sixth day after the first, (i. e., between thirty-six and forty-eight hours before the areola of the first begins to appear,) the affection produced by this second inoculation, will be accelerated in its progress, so as to arrive at maturity, and again fade at nearly the same time as the affection arising from the first inoculation ; and that this will take place, although the constitutional affection be so slight as otherwise to pass unnoticed. " If we take matter, for example, on the fifth day after a successful vaccination, and insert it into the opposite arm, this second operation will be fol- lowed by a minute vesicle on the third or fourth day, being the eighth or ninth from the date of the first, and will be immediately afterwards surrounded with an areola, becoming, on the fifth day of its own existence, an exact miniature of the first upon its tenth day : both will have finished their course at the same period, that being usually the thirteenth day from the first inoculation, and eighth from the second. The rationale of the acceleration which thus takes place in the progress of the second vesicle, may be explained in a * We had an opportunity lately, through the kindness of Dr. S. Cusack, of seeing a family of four children, who had been vaccinated at the Cow-pox Institution of this city, and subsequently re-vaccinated by Dr. C. In one of them the operation entirely failed ; in two, one of whom was a girl of fifteen, irregular vesicles were excited ; and in the fourth, a child three years old, a perfect disease with an areola followed. In all the children the cicatrices were perfect. 322 VACCINATION. few words : the phenomena of the ordinary cow-pox before the eighth day, or in other words until the appearance of the areola, are strictly local ; when this appears, we may look upon it as a visible sign of the specific fever (or perhaps we should rather say action), being in operation in the system, and as a consequence of this general action, we find that a specific areola appears around any local vesi- cle of the same disease that may at the time actually exist upon the surface of the body, although that disease may not be in existence sufficiently long, according to the known laws of the disease, to be itself the cause of this phenomenon. The proper time for putting this test in practice, has been mentioned to be from thirty-six to forty-eight hours before the appearance of the first areola ;* this is the latest period at which we can expect it to succeed, " as it is necessary that the secondary affection may have proceeded some length, and that a small vesicle containing virus may have been formed by it, before the constitutional action from the first inocula- tion begins, otherwise no areola, but merely a slight degree of hard- ness will take place from the second puncture. "t We defer it to the latest period, in order to afford the strongest possible contrast be- tween the progress of the two inoculations. In estimating the value of this test, it is to be recollected, that from unskilfulness in the per- formance of the operation, or from some other accidental cause, the second vaccination may not take effect at all ; with common care, however, this is unlikely to happen, as, by taking the virus from the first vesicle, we are sure of its being in the very best state for com- municating the disease. Upon the whole, we think it is a plan which should, if possible, always be adopted, at least in private practice ; for we are aware, that in this country it would be very difficult to procure in public institutions a sufficient number of at- tendances on the part of each patient, to enable us to carry it pro- perly into effect. Having considered the disease as it exists, in its most perfect state, it will now be well, before entering upon the much disputed subject of its value, to attend to the modes adopted for its artificial propa- gation, and the circumstances requiring attention during the process. First, then, as to the age and condition of the person to be vacci- nated ; it is agreed by all writers that the most favourable time for communicating the disease to an infant is between the ages of six weeks and two months, which, as Mr. Marshall % observes, "is prior to the irritation of teething," and is also subsequent to the extreme irritability of first infancy. Should circumstances require it, however, there is little risk in vaccinating a child immediately after its birth, as has been repeatedly done with safety and advantage when small- pox was near, and sometimes even when the mother was suffering under that disease. It is very desirable that no fever, specific or otherwise, should exist * This, in ordinary cases, will be on the sixth day, but where the first vesicle has been slow, we must, of course, defer the second operation, f Bryce, 2d ed. p. 189. % Popular Summary of Vaccination. VACCINATION. 323 in the system at the time of vaccinating, and also that the surface of the body should be free from eruptions, as in either case the local disease will probably be imperfect, and the constitutional affection be very likely to be suspended, or perhaps altogether prevented. It has been observed, however, both by Jenner and Bryce, that chronic eruptions are sometimes benefited by the introduction of the vaccine disease ; and their existence is not sufficient to prevent us from vac- cinating, although it would certainly be calculated to make us more suspicious of the case, and ought to induce us to repeat the operation upon a future occasion. The probability of exposure to small-pox contagion would of course make us more anxious to anticipate it, if possible, by a milder dis- ease ; and indeed we are not aware of any other conditions than those alluded to, either of the body or season, that could make us hesitate about submitting an individual to vaccination. A most important point in the conduct of vaccine inoculation is the employment of active virus, which we can of course only pro- cure from perfect specimens of the local disease. In the early periods of the practice, much confusion and disappointment arose from an imperfect. understanding of the stages of the affection; and some mischief was done before Jenner discovered the necessity of always employing matter in a limpid state. Later observers all pretty well agree in recommending the virus to be taken, not merely when in a limpid state, but before the areola has begun to form ; and accordingly, the vesicles are now almost universally opened for infection on the eighth day. If the progress of a vesicle be slow, but at the same time regular in other respects, we may safely employ matter taken a day or two later, provided the areola has not appeared. Having selected a vesicle at the proper period, we make, with the point of a lancet, three or four slight punctures in its elevated margin, from which minute drops of transparent lymph will soon be observed to exude. This may be either taken upon the lancet, and at once inserted into the skin of another individual, or may be collected and preserved for future use.* In the preservation considerable attention is required, in order to prevent a destruction of the specific proper- ties of the virus, either by decomposition, or by exposure to the ac- tion of the atmosphere. To effect these purposes, various contri- vances have been devised ; one of the best is, to receive the lymph upon a small square of glass, allow it to dry, and then, covering it with a similar piece of glass, fold both up in a portion of moistened bladder or gold-beaters' skin. For more immediate use, it may be taken upon thin pointed blades of quill or ivory; these should be charged with lymph two or three times, being allowed to dry between each charging, and then enclosed into a packet with gold-beaters' skin. When it has been desired to keep the virus for a considerable length of time, it has been allowed to ascend from the punctured vesicle into glass capillary tubes, or into glass tubes with bulbs, the * If it be not convenient to employ the virus immediately, we may keep it on the lancet, but only for a few hours, as the latter very soon rusts. 324 VACCINATION. air having been rarified in the latter by the application of a lighted taper : in either case, the tubes are to be hermetically sealed imme- diately on their being charged with matter. Mr, Bryce ascertained, that although the fluid found in the vesicle after the formation of the areola seldom produced a perfect disease, still the dry crust of a ma- ture cow-pock always succeeded. He explained this apparent ano- maly by inferring that the crust is actually the limpid virus in a con- centrated state ; and that the fluid occasionally found in the vesicle, after the crust has begun to form, is merely the product of irritation, and not specific. At all events, a solution of the crust is found to produce a true cow-pock ; and by keeping it dry in a well-stopped phial, its activity can be preserved to a very extended period. We may now consider the manner of communicating the infection, which, in every possible instance, should be done with liquid virus taken directly from a vesicle. The best site for the operation is over the insertion of the deltoid muscle, as being the part of the arm least likely to be disturbed by muscular action. It may be performed either by scratch or puncture ; the last by stretching the skin, and introducing the point of the charged lancet obliquely between the cuticle and cutis, keeping it in the wound for a few seconds, and then wiping it repeatedly over the puncture. In the insertion by scratch, which we think much preferable to the other, and which, when well done with fresh lymph, scarcely ever fails, a very blunt, but clean lancet, answers best : this should be charged with virus in the manner already described, and its edge then drawn repeatedly, but very lightly, over the cuticle, so as to make five or six scratches, each about the eighth of an inch in length. Upon these the lancet should be rubbed until the lymph has been completely wiped from its point. When done properly, no blood should flow from these scratches ; they should merely become red, like those accidentally made with the point of a pin. They require no application ; and by exposure for a few minutes to the air, the small quantity of serum which exudes from them becomes hardened into a thin scab. At least two points of insertion should always be made, and by some it is recommended to make two in each arm. This, however, is unnecessary, unless we require a large stock of infection ; and the chances of the vesicles being preserved entire, will be much diminished by the attention of the nurse being divided between both arms. At all events, one vesicle should always be allowed to run its course entire ; and when only one point of inoculation has succeeded, that should not be punctured for the supply of virus. According to the hypothesis already stated, of the disease being strictly local at its commence- ment, we may conceive it possible to prevent the constitutional affec- tion by removing the lymph, on the absorption of which its excite- ment is altogether dependent. When, instead of the recent infection, we have to employ that which has been preserved dry upon glass, we must take upon the point of a lancet the smallest possible portion of cold water, (a very low degree of heat with moisture is sufficient to decompose the virus,) and rub it on the lymph until the latter is completely dis- VACCINATION. 32 5 solved. The solution is then to be collected on the lancet, and used precisely as the recent matter. When employing points of ivory, or other material, we must first make a slight oblique puncture with a lancet, and into it insert the point, which is to be allowed to remain for a minute or two, and then to be wiped frequently over the puncture. When capillary or other tubes are used, the matter must be expelled from the broken tube with a blow-pipe, and then inserted in the same manner as if it were recent. Crusts, as recommended by Mr. Bryce, are prepared for use by solution in a drop or two of cold water. Lancets employed in the operation, it is scarcely neces- sary to say, should De kept perfectly clean and free from rust, as they might otherwise produce sores which would materially interfere with the disease we wish to establish. In performing the operation, the great cause of failure appears to us to be the occasioning of a flow of blood; there should be merely sufficient to colour the wounds — more than this would, in all probability, wash away the minute portion of fluid virus usually employed. Medical treatment is seldom required during the progress of cow- pox ; nothing, in fact, is necessary in ordinary cases, except a little attention towards the preserving of the part from friction: when, unfortunately, this cannot be accomplished, inflammation is some- times excited, which must be treated according to the ordinary rules of surgery. Dr. Jenner's practice in these cases consisted in the application of a drop of Goulard's extract to the broken vesicle, or occasionally a plaster of strong mercurial ointment. With a little care all injury may be avoided, and we have seldom seen the em- ployment of any surgical means, more active than a poultice, required. As for internal treatment, we have never known any thing necessary, excepting, now and then, the exhibition of a mild aperient. In concluding this portion of the subject, we must not let it escape our recollection, that there are idiosyncrasies of constitution which resist our best directed efforts for the communication of cow-pox, and that a similar circumstance has been observed with respect to small-pox. When we meet with suck a case, we must, of course, after a fair number of trials with fresh and active virus, leave the patient to chance ; and after some lapse of time make another attempt, upon the probability of a change having taken place in the system. The term imperfect or spurious vaccination is frequently to be met with in books, and has been the cause of no small degree of confusion in practice, although, at the same time, it has frequently afforded the practitioner an excellent asylum against the storms now and then arising out of failures in the protective powers of the vaccine disease. This portion of the subject has received much attention from Dr. Willan, by whom the different appearances consequent upon imperfect vaccination have been divided into three varieties — pustules, ulcerations, and irregular vesicles. Their causes have also been referred, by the same author, to three classes — impurity of the virus, occasioned either by heat, or being taken at a late period, or 28 326 VACCINATION. by exposure to air, moisture, rust, &c. ; secondly, the system of the person inoculated being under the influence of any fever ; and thirdly, his being affected with some chronic cutaneous disorder. With respect to the two first varieties we may as well cut the knot, and save much minute and tedious description, by at once refer- ring to the characters of a cow-pock, as already laid down, and which there can be no difficulty in distinguishing from a pustule or an ulceration. Should either of these, then, follow vaccination, it must be considered not as a variety of vaccine disease, but as much an accidental occurrence as if the slight wound were attended by phlegmon or erysipelas.* With the irregular vesicles, however, the case is different, as they, in many instances, closely resemble the true disease, and in some have even furnished virus capable of exciting it perfectly in other individuals : three sorts have been observed by the distinguished physician already mentioned, which we shall describe pretty nearly in his own words.t The first is a pearl- coloured vesicle, set on a hard, dark red base, slightly elevated. It is globate, and less in size than the genuine vesicle, its top is flat- tened, or sometimes a little depressed, but the margin is not rounded or prominent. The second appears to be cellular like the genuine vesicle, but is somewhat smaller, and more sessile, and has a sharp angulated edge. The areola in both of these is usually more diffuse than in the regular disease ; in the second it is sometimes of a dilute scarlet colour, and radiated. The areola appears round these vesi- cles, on the seventh or eighth day after inoculation, (sometimes earlier,) and continues more or less vivid for three days, during which time the scab is completely formed. The scab is smaller and lighter coloured than in the regular disease, and falls off sooner, leaving a smaller and less permanent cicatrix. The third irregular appearance is a vesicle without an areola, which usually takes place if the person has previously had small-pox, or is at the same time labouring under some fever. The two first forms of irregular vesicles will, no doubt, appear to the student to have no very marked characters by which an inexperienced observer could distinguish them from those of a more genuine nature ; and the confusion, we apprehend, will not be diminished, when we find Dr. Willan admitting that they will in some cases afford full security against small-pox, although in others, that disease will take place after them, at different intervals, and under a particular form. The true state of the case we believe to be, that the cow-pox is, like other diseases, liable to some slight variations in its symptoms, and that, in many instances, the too enthusiastic partisans of vacci- nation made use of these to help them out of the dilemma in which the occasional failure of the practice involved them. Whenever * We are aware that Dr. Willan supposed that there was a real vaccine pu&tule, capable, in " a few instances," of communicating by inoculation the genuine vesicle. We have ventured above to state our own opinion, conceiving that the adoption of it will afford a simpler rule of practice, and remove some difficulty from the subject. f Willan on Vaccine Inoculation. VACCINATION. g 07 small-pox occurred to a person who had been vaccinated, a ready- answer to all their doubts was furnished by the supposition of his having been the subject of irregular vesicles. In other instances, as, for example, when the areola is deficient, we must adopt Mr. Bryce's notion, and suppose the disease to be merely local, and not to have affected the constitution. An excellent rule, however, is, in all cases in which a shadow of doubt remains upon our minds as to the effi- cacy of the inoculation, always to repeat the process, and avail our- selves of the valuable and ingenious test of Mr. Bryce. In approaching the consideration of the vaccine controversy, we are fully aware of the extraordinary difficulties common to it, and every other subject involving, in any degree, the inscrutable principles of contagion. As we have now, however, an experience of the effects of vaccination in various parts of the world, during a period of thirty-five years, we should hope that without bewildering ourselves in abstruse reasoning, it will be possible to find, among medical records, numerical evidence sufficient to warrant us in placing our conclusions high upon the scale of medical probabilities : a rank that, it is never to be forgotten, is the very highest that can be obtained for any portion of a science whose data are influenced by the varying and unascertained laws of vitality. Of the import- ance of any measure that would diminish the ravages of small-pox it is not now necessary to speak, as it has been long since practically acknowledged by the adoption of variolous inoculation. Of the ad- vantages of the vaccination over this latter, supposing it to be equally preventive of small-pox, it is scarcely more necessary to adduce proof. We may mention, however, that cow-pox is only propagated by actual inoculation, while every case of inoculated small-pox be- comes a new fomes for the dissemination of infectious miasmata ; that cow-pox never terminates fatally, nor ever excites scrofula or other chronic constitutional diseases, but, on the contrary, has been observed occasionally to be beneficial in some cases of obstinate cutaneous eruptions; "while inoculated small-pox not only frequently produces blindness and other deformities, and developes scrofula in the con- stitution, but has been estimated by Dr. Willan to be fatal in the proportion of 1 to 250 cases, and by Dr. Jurin, in the large ratio of 1 to 50. So little too was the general advantage promoted by this practice, however beneficial it might be to individuals, that it has been ascertained, by the calculations of Dr. Heberden,that, from the increased exposure to infection, the general mortality of small-pox rose, after the introduction of inoculation, from 70 to 95 in 1000.* So much for the personal merits (if we may so speak) of the two diseases. We shall now inquire, first, whether vaccination affords any protection, and if so, to what extent ? Secondly, has the present vaccine disease lost any of its properties by having passed through a * We quote these numbers from the Edin.Rev. vol. ix., not being able, just now, to lay our hands on Dr. Heberden's paper. 328 VACCINATION. number of human constitutions ? And, thirdly, has the general em- ployment of vaccination been found to increase the mortality of other diseases of infancy ? With respect to the first part of the first query, we can have no more conclusive reply than is furnished by the cases recorded in Dr. Jenner's work, and which were made by him the groundwork of his reasonings upon the subject. One of the shortest of these may be quoted in the author's words, and will serve as a specimen of the rest : — " John Philips, a tradesman of Berkeley, had the cow-pox at nine years of age. At the age of sixty-two I inoculated him, and was careful in selecting matter in its most active state. It was taken from the arm of a boy just before the commencement of the eruptive fever, and instantly inserted. It very speedily produced a sting-like feel in the part. An efflorescence appeared, which on the fourth day was rather extensive, and some degree of pain and stiffness was felt about the shoulder ; but on the fifth day these symptoms began to disappear, and in a day or two after went entirely off, without pro- ducing any effect on the system. ,y A vast number of cases present- ing the general features of the foregoing were observed by Dr. Jenner and his friends, and form a body of evidence that could not be resist- ed, at a period when every mind was prejudiced against the new doctrine, and that would now only be weakened by an impertinent attempt at corroboration. With respect to the objections to those cases urged by Mr. Brown, of Musselburgh, (the chief opponent of vacci- nation, in the present day,) viz., that the individuals were either insusceptible, or that the protective impression was kept up by con- tinual exposure to infection from the cow, it will be necessary merely to remark, that, as in the instance quoted, many of the persons men- tioned by Jenner were for years removed from the influence of cow- pox infection, and that if we suppose them to be accidentally insus- ceptible, the exceptions will be so numerous, as to become of necessity converted into a rule. An account has already been given of the circumstances under which Jenner put his theory to the test of expe- riment, the whole, we think, proving as demonstratively as the subject will admit, that the general tenor of the vaccine disease is to destroy the constitutional susceptibility to small-pox contagion. We shall now, merely to show that we are not dependent for proofs upon the observations of others, cite one of those striking examples of protec- tion, many of which must fall under the observation of every person in the constant habit of vaccinating. About four years since we vaccinated with the same virus three children of the same family, and who were in the habit of occupying one bed. Small-pox was prevalent in the neighbourhood, and two of our patients were seized with rigors a few hours subsequent to their vaccination ; each had a very severe attack of small-pox ; the third, who at night constantly slept between these two, had a perfect vaccine vesicle, and completely escaped the other disease. In attempting to reply to the second part of our first query, a number of the most disputed parts of the subject, will naturally come under our consideration. We shall first examine a few of the most VACCINATION. 339 prominent and authentic statements as to the numerical effects of vaccination upon mortality, and in doing so. cannot avoid expressing our regret at the total neglect in which the important subject of medical statistics is suffered to lie by the government of these coun- tries. In every other civilised state of Europe, the medical or political inquirer can obtain from the highest sources authentic records of facts, without which, their doctrines, that so especially involve the happi- ness of the human race, are but vain speculations. In England, on the contrary, the only fountain of knowledge is the London bills of mortality, and in this division of the empire we are without even the scanty stream of information which they supply. All that could have been derived from the bills of mortality on the subject of small- pox and vaccination, has, however, been given to the public by Dr. Jurin and Sir Gilbert Blane, and incomplete as it is, affords highly gratifying conclusions, which we shall endeavour to weave in with some of the more accurate records of other states. From an exami- nation of the bills during a period of forty-two years, Dr. Jurin* found that one in fourteen of all who were born died of small-pox; by Frank, Siissmilch,t and Black, the general mortality of the human race from this disease was estimated at about eight or nine per cent. Duvillard states that of 100 born, only four reached the age of thirty without undergoing small-pox, and that the mortality among adults affected was one in seven or eight, but among infants so much as one in three. For the purpose of comparing the effects of small-pox inoculation and of vaccination, with the unchecked effects of natural small-pox, Sir G. Blane t has constructed, from the bills of mortality, four tables of periods of fifteen years each, showing the ratio borne by the mortality of small-pox, to the total mortality. These are as follows : — in the first period, which was that immediately preceding the introduction of inoculation : From 1706 to 1720 the proportion was one in 12*7 or 78 in 1000. In the second and third periods, when inoculation had made con- siderable progress, the proportions were, From 1745 to 1759, 1 in 11-2 or S9 in 1000. From 17S4 to 179S, 1 in 11 or 90 in 1000. In the fourth period, when vaccination had been some years in use, viz. : From 1804 to 1S18, only 1 in 18-9 or 53 in 1000. By calculations founded upon these tables, Sir G. Blane has esti- mated the saving of lives during the latter fifteen years, in London alone, at 23,134, a result very gratifying, but still alloyed by the reflection, that it is but a fragment of the good that, might have been done, were it not for our own, almost national, caprice, and childish refusal of the slight constraint upon personal liberty that would ac- crue from the legal enforcement of vaccination. From Sweden, for * Account of Success of Inoculating the Small-Pox, &c, 1723-6. t Gottliche Ordnung, &c. Berlin, 1742. % Med. Chir. Trans, vol. x. 2S* 330 VACCINATION. example, where the authority of government is interposed in favour of the measure, we are furnished with the following interesting document : In the year 1779 small-pox destroyed 15,000 persons.* 1784 - - - 12,000 1800 - - - 12,800 1801 - - - 6,000 1822 ... 11 1S23 ... 37 III Prussia, also, (according to Dr. Casper,t) the most marked advantages have followed the introduction of vaccination. In the years 1S20 and 1821 the deaths from small-pox were 3137, in a population of twenty-three millions, making one in 7204 inhabitants. In Berlin alone, the average annual number of deaths from small- pox, during the twenty years preceding 1802, was 472; during twenty years succeeding 1802, it was 175; since 1812 it amounted only to 50 ; since 1S17 to 12 ; and in 1821 and 1S22, there was only one death from this cause in each year. During the ten years pre- ceding 1823, the deaths from small-pox, compared to every 1000 births, were as nine ; before the introduction of cow-pox, they were as eighty-three ; whence it would appear that seventy-four lives in every 1000 were preserved by the practice of vaccination. But it would be superfluous to multiply these statements ; the foregoing have been taken almost at random from the chaos of records upou the subject, existing in every journal, in almost every language ; and surely, to use the enthusiastic words of Blane, these are " benefits which could never have been dreamt of by the most sanguine philan- thropist," and which must overwhelm us " with a sense of unrequit- able obligation to the individual who first disclosed and promulgated the secret." Such have been the gross numerical results of vaccination, which would appear of themselves sufficient to obtain universal support for the practice. The arguments, however, of the anti-vaccinists, have never been drawn from the only source of any value in an uncertain science — a general average of facts ; but have invariably been built upon isolated occurrences which we shall probably find to be fully entitled to the character of exceptions. At the commence- ment of vaccination, the new disease was confidently put forward, as a complete and perfect preventive of small-pox, and was implicitly received as such by its partisans. This notion was so far fortunate as favouring the rapid and extensive adoption of the practice, and as such was wisely countenanced by its discoverer. From the cautious style, however, of many passages of his work, it is not diffi- cult to perceive that Jenner, though a parent fond of his offspring, * B. Hawkins on Med. Statistics, p. 143. t Review of J. L. Casper on Med. Statistics, in Edinburgh Medical and Surgical Journal, xxvi. 171. VACCINATION. g 31 had sufficient of that foresight of difficulties, so peculiarly character- istic of genius, to enable him to perceive, that like every thing human, his discovery was not altogether infallible. Signs of this spirit may be observed in the anxiety which he exhibits to prove, that the occurrence of small-pox, whether casual or inoculated, does not perfectly extinguish, in the constitution, the susceptibility to that dis- ease.* It appears to us obvious, that without wishing, at the time, to moot the question, he perceived that if the possibility of small-pox occurring twice, was once established, its occasional appearance after vaccination, would excite neither surprise nor alarm. In the wri- tings of the anti-vaccinists, this view of the subject was altogether overlooked, and all their conclusions made to depend upon the assumption, that small-pox inoculation furnished a perfect and com- plete protection against the future occurrence of the disease. That it did not do so, will be proved to the satisfaction of the most skepti- * cal, by an examination of the cases detailed in Jenner's own work : and those alluded to in Moore's History of Small-Pox, and in the 9th vol. of the Edinburgh Review, p. 62, not to speak of the numer- ous cases scattered through all the periodicals, and those with which the memory of most practitioners will furnish them, either of the actual re-occurrence of small-pox itself, or of those other diseases, as scarlatina, measles, &c, which may be supposed to furnish reason- able analogies. To exhibit the ratio in which small-pox has occurred secondary to itself or to vaccination, and also its mortality under such circum- stances, it will be useful to examine some numerical records. In the year 1825,t 419 persons were admitted into the London Small- Pox Hospital ; 2C3 had no protection, and of these 107 died ; two had been inoculated with small-pox, of whom one died ; and 147 had been vaccinated ; among the latter the mortality was 124 During the year 1818, small-pox was epidemic in Edinburgh, and 556 cases were seen by Dr. Thomson§ of that city. Of these 205 had no pro- tection, and 50 died, or 1 in 4; 41 had previously had small-pox, several being deeply marked ; 30 other cases of secondary small-pox were reported to Dr. T., and of the whole 71, 3 died, or 1 in 23; 310 of Dr. TVs patients had been vaccinated, and in only one did the small-pox prove fetal. In Norwich,|| during the year 1819, 3000 * Inquiry, &c. p. 116. t Dr. George Gregory, in Med and Phys. Journal, vol. Iv. { The announcement of this mortality excited, at the time, co nsiderab e alarm, which was, however, quieted by a Report of the Vaccine Board, and a le Ate from Sir H. Halford to Mr. Hobhouse, (vide Medical and Physical Journal, ut :*«/»«,) showing, from Dr. Gregory's own admissions, that in not more than oneoi ^ the twelve cases, was there evidence of perfect vaccination. There is also a difference between the tot and the separate numbers, the tot being 419, ^. lle *£* + ^'S; make only 412. We have, however, inserted the report, as alt hough it may be considered one of the most unfavourable that has been ever made upon the > subjec the mortality it shows from small-pox after vaccination is only eighteen*. • * ™° that from secondary small-pox is fifty, and that from the uninfluenced disease upwards of forty per cent. § On Varioloid Diseases. U Cross on Varioloid Epidemic, Lond. 1820. 332 VACCINATION. individuals caught small-pox, of whom 530 died ; it was estimated that there were in that city 10,000 persons who had been vaccinated, and that of these 2 in 100 caught small-pox ; only six of them, how- ever had it in a perfect form, of whom two died. The disease also •proved fatal to one individual who had previously undergone vario- lous inoculation. These numbers speak for themselves, and when contrasted with the natural small-pox mortality, of 1 in 5 or 6, loudly and unanswerably proclaim the great advantages of vaccina- tion. It appears, however, that although the mortality of small-pox in those who had undergone cow-pox was very trifling, still a con- siderable number of the vaccinated actually underwent the disease, but only when variola prevailed as an epidemic, as inoculation alone has not been found sufficient to overcome the preventive influence of vaccination. The reader will naturally be led to inquire, why, in the same epi- demic, the disease is found to be so mild in the vaccinated, and so severe and fatal in the unprotected. The reason is obscured by the same veil that envelopes the cause of the usually singular occurrence of some diseases, and which, in all probability, will never be pene- trated by human eye. The fact, however, is, that small-pox secon- dary to itself, or to vaccination, becomes very different in many of its symptoms from the uninfluenced disease ; and it is upon this power of modifying, when it cannot altogether prevent, that the claims of cow-pox as a protective agent must now be rested. The observations and experiments of Dr. Willan,* enabled him to form some conclusions upon this modifying power, the substance of which it may be useful to state : 1st. inoculations with vaccine and variolous matter, performed upon the same person at the same period, or with an interval of not more than a week, were both found to prove effective to a certain extent, so far as to produce a vaccine vesicle, and variolous pustules, each respectively capable of communi- cating their peculiar infection to other individuals ; 2d, that when variolous matter was inserted on the ninth day after vaccination, its action seemed to be wholly precluded ; and, 3d, that when the two diseases took effect as mentioned above, they always modified and restrained each other, an irregular vaccine vesicle being produced : and a variolous eruption of " hard, distinct, shining pustules, which have butlittle inflammationTound them,'and which seldom maturate, 5 ' resembling strongly those varieties of variola, called by the older writers " stone-pox," " horn-pox," " siliquose-pox,"t &c„ &c. It is this modified disease, then, which occurs in almost every in- stance in which small-pox attacks a person who had previously been the subject of cow-pox inoculation. That a similar mild form of small-pox sometimes occurs naturally, and in an epidemic form, may be inferred from the descriptions in old works of those eruptions named above. Jenner also mentions an epidemic of a peculiarly mild nature, which spread through several towns of Gloucestershire, * On Vaccine Inoculation, 1806. f For an accurate and interesting description, see Thomson on Varioloid Dis- eases. VACCINATION. 333 and was witnessed by himself. A similar variety was described under the name of pearl-pox, by Dr. Adams,* who hoped to substi- tute it for the ordinary sort, by successive inoculations from the mildest cases. The mildness, however, appears to depend upon the constitu- tion of the individual epidemic; as it was found by Willan, and others, that inoculation from pustules, modified by vaccination, pro- duced occasionally the worst forms of the disease. This modifying influence appears to be possessed by small-pox itself, and to affect its secondary attacks ; it is supposed, however, by Thomson and Bryce,t to be less efficient in tins respect than cow-pox ; and the same opinion appears to be entertained by Dr. Mohl, of .Copen- hagen,;}; as he records 31 fatal cases out of 153 of secondary small- pox. Before leaving this part of our subject we must (though with ex- treme reluctance) notice the remarks of Dr. Gregory, in the 12th vo- lume of the Med. Chir. Transactions. We confess, in our anxiety to avoid controversy, we should have evaded doing so altogether, were it not that Dr. G. has subsequently informed us,§ that his paper has excited the favourable attention of the profession ; and that the paper itself, from its dubious style rather than its sound arguments, is well calculated to produce an injurious effect upon the minds of casual readers. In the first place, then, with respect to the increasing num- ber of cases of small-pox after vaccination — when it is considered that the number of the vaccinated to take small-pox is every year increasing, the surprise, probably, will be lessened; and perhaps alto- gether removed, when we find that Dr. G.'s cases were "after pre- sumed as well as real vaccination." Again, as to the manner in which variola is modified by vaccination, Dr. G. alleges that neither the eruptive fever, nor quantity of the eruption is usually lessened, nor the effect of the poison upon the brain and nervous system ren- dered less fatal. As to the first assertion, it will be best met by the Doctor's own account of fifty-four out of fifty-seven cases being " discharged in perfect health ivithin fourteen days from the period of their admission." || In proof of his second position, respecting the fatal effect of the modified disease upon the brain, he has adduced two cases. One of them, however, is that of a drunken " labourer in lead works," and the other of death from erysipelas following venesection for ophthalmia in a woman who had gone through small- pox, but in whom (according to himself) " vaccination was not trust- worthy." In three other cases out of the five fatal he admits that one had no cicatrix, and the other two had cicatrices large and irre- gular. Amidst the dark hints of Dr. Gregory, the partisans of vacci- nation will generally find some gleams of encouragement. He tells * Popular View, &c. London, 1807. f Thomson, Op. eit. pp. 60 and 202. % De Variolidibus et Varicellis. Copenhagen, 1827. § Medical and Physical Journal, vol.lv. || By the way, if Dr. G. discharged fifty-four cured out of fifty-seven, it is not easy to understand by what process of arithmetic he had a remainder of five fatal cases . Vide Trans, p. "334. 134 VACCINATION, us, for example, that George Ferriman,who had been inoculated for small-pox, was admitted into the hospital with "pretty severe" modi- fied variola, and that with him were admitted his two children, who had been vaccinated, both labouring under a " very slight" form of the same disease ; and again, that the large majority of his patients had been vaccinated in the country, and "had large, irregular, and therefore imperfect ^cicatrices." Another observation was contained in the paper now alluded to r and was more developed in subsequent papers,* which, we fear, has been the occasion of much disturbance in the public mind. It was, " that the majority of cases of small-pox, after vaccination, which have occurred at the small-pox hospital, have been persons between the ages of 15 and 21." Upon this was afterwards built a revival of Mr. Brown's opinion, "that the influence of cow-pox on the sys- tem wears out in the progress of life, and requires periodical renew- als."! Mr. B. thought that the influence wore out in six years, Dr. Gregory extended the period to ten. A brief allusion to Mr. Brown's conception of and practice in the vaccine disease will enable us very shortly to dispose of his share in the argument. He contends that if you only have a vesicle with an areola, you may depend upon the production of whatever effect cow-pox is capable of: again, in his practice he surrounded the punctures with a stripe of flannel, used gentle violence, made the child lie on the inoculated arm, and took no virus until the areola was formed. J Dr. Gregory asserts that he has not been able to re-vaccinate children under ten years, and that the same age is the earliest at which he has seen small-ppx among the vaccinated. He admits, however, that he has met resistance after twenty-five years ; and as to the table in his first paper, like many an edged tool, it cuts both ways, having a descending scale from the age of twenty, as well as an ascending one to it. Dr. Mohl, of Copenhagen, in some degree advocates the same opinion, at least he thinks that the modifying influence is somewhat weakened by time, but his scale is liable to the same objection as Dr. Gregory's : he found, Under 3 years - Cases. 5 ... 14 Between 5 and 10 - - 102 10 and 15 - - 173 15 and 20 - - 1S7 20 and 25 - - 156 Above 25 - - 21 653 Dr. Thomson found the modified disease to occur, on the other hand, at every period after vaccination ; and Jenner, with his usual foresight, " selected in his first work cases in which the disease (cow- * Medical Gazette, vol. viii. t Med. Chir. Trans, vol. xii. p. 336. % Inquiry, and Edinburgh Medical and Surgical Journal, 1819. VACCIXATIOxV. 33s pox) had appeared at a very distant period, previous to the experi- ments made with variolous matter, to show that the change produced in the constitution is not affected by time." The periods he alludes to are from 25 to 53 years, so that we think, if the gentlemen who have taken up the other side of the question have no better proofs than those they have as yet advanced, we may safely set down their allegations as not proven. Dr. Jenner's hypothesis of the identity of variola and the variolse vaccinae (to use his phrase) has been already alluded to ; whether it be true or false is a matter rather curious, than of any practical utility. ^ It will be enough to say, that the present phenomena of the two affections are materially different, and it is probable that an attempt now to trace their affinity would only result in rendering the obscurum, obscurius* A novel and interesting idea has, however, been more lately started by Dr. Thomson, viz., that varicella, modi- fied small- pox, horn-pox, swine-pox, stone-pox, &c, are all only varieties of the common small-pox. A modification of Dr. Thomson's views has since been proposed by Lichtenstadt,t of Breslau, viz., that varicella was originally a mild offshoot from variola, which has become gradually so weakened by transmission, as now to be inca- pable of producing small-pox ; but that it still occasionally arises directly from that disease, as at first. Dr. Thomson's hypothesis owed its origin to some inoculations performed by the late distin- guished Dr. Hennen, with matter taken from an eruption which appeared upon his son, and was supposed at the time to be vari- cella. By these experiments, eruptive diseases of different degrees of severity, varying between the mildest varicella and severe small-pox, were communicated to several individuals; at the same time Dr. T. observed, in different parts of Edinburgh, natural and modified small pox, and chicken-pox, " co-existing in the same situations, and ap- pearing in their progress to produce one another." A variolous epidemic was existing in Edinburgh at the time, and from the fore- going circumstances he was led to conceive, that all its various ap- pearances in the different classes of persons whom it attacked, might be produced by the operation of one and the same contagion. On the other hand, Dr. Mohl, of Copenhagen,! has observed varicella at periods when there was no variolous epidemic, and again has seen it to occur sporadically at the same time with, but independently of, the other disease. The question appears to turn upon the exact defini- tion given to varicella, and we must confess that no description that we have seen would enable us to form a diagnosis between it and the vesicular variety of small-pox. An able revie wer§ has laid down, * The correctness of Jenner's views has been completely proved by the interest- ing experiment of Mr. Ceeley, of Aylesbury ; for a detailed account of which see the Medical Press, vol. ii. p. 120. Mr. C. succeeded in communicating small-pox to young cows by inoculation, the affection thus produced in these animals being, in all respects, similar to the true vaccine disease, and capable of being re-com- municated to the human subject. [Note to 3d Edition.] f Hufeland's Journal, June, 1820. X Op. cit. § Edin. Med. and. Surg. Journal, April, 1820. S 36 VACCINATION. with a good deal of confidence, what he conceives to be certain dia- gnostic marks, the substance of which we shall give, but indeed with little hope of their being available in practice. The eruptive fever, he says, in varicella, is slight ; Dr. Will an, however, has often seen it attended with convulsions ; secondly, the eruption is vesicular from the beginning, or at least from the early part of the first day, not papular, as vesicular variola always is at first ; thirdly, the tuber- cular basis of the vesicles is absent in varicella ; yet Dr, Willan found " the -sensation communicated to the finger, like that from a round seed flattened by pressure,"* and the reviewer admits that chicken- pox sometimes acquires a tubercular base at a late period, while variola as often loses it : fourthly, varicella is to be known by the thinness and fragility of the covering of its vesicles, and by being found between the skin and the cuticle, while variola always exists in the true skin. With every disposition to acknowledge the talent shown in the review in question, we cannot but express our opinion, that the foregoing characters are rather the result of meditation in the closet than of observation by the bedside, and that as far as we have been able to see, ourselves, or examine into the opinions of others, the theory of Dr. Thomson appears to us to be still unim- pugned. Having now, we trust, entered, sufficiently in detail, upon the points embraced by our first query, it is time to return to the other two, which, however, will not require so lengthy a discussion. The second inquiry proposed was — Has the present vaccine dis- ease lost any of its properties by having passed through a number of human constitutions ? The answer must, in a great, measure, depend upon the case already made out for the actual protective properties of cow-pox at the present time. In addition, we may mention that it is in the power of every person to satisfy himself that the vaccine vesicle of to-day is, in all respects, an original for the delineations of the same disease given by Jenner, in 179S ; that we have no analo- gies in favour of deterioration, e, «•., measles, scarlatina, plague, &c, are identical with the same maladies, according to the descriptions of the old authors ; and that as small-pox itself has not lost its virulence from time alone, we can have no solid reason for supposing that the same agent could have a material effect upon its opponent. Our third query was — Has the general employment of vaccina- tion been found to increase the mortality of other diseases of infancy ? The affirmative of this question was advanced by Dr. Watt, of Glasgow, in the appendix to his Essay on Chincough, and in the Edinburgh Med. and Surg. Journal, vol. x., and his views passed current, both at home and abroad, until Mr. Roberton, of Manches- ter,-^ detected a fatal error in his calculations. Dr. W. found, from the Glasgow tables, that from six years subsequent to 17S2, the deaths, under ten, were 53-48 per cent, of the total deaths, whereas in the six years previous to 1S12 they were 55*43 per cent. Hence * On Vaccine Inoculation, p. 95. f On Mortality of Children, 1827. VACCIxVATION. . 3 he inferred that the mortality of children had not improved, and that as a manifest diminution had taken place through the abatement of small-pox, this must have been compensated by a corresponding increase of deaths from other diseases of children. In his inference Dr. Watt did not take into account the diminution that had taken place in the general mortality, nor the increase of the population • and accordingly we shall find, by referring the infantile deaths to the' latter, both as found in Dr. W.'s tables, that in the early period the average annual mortality was one in 26-7, and the deaths under ten, 53-48 per cent. ; that is, among every 1000 of the population there' died annually 37-45, of whom 20-03 were under ten ; and that in the latter period the annual mortality was one in 40-8, and of the deaths, 55-43 per cent, were under ten; that is, in every 1000 inhabitants 24-51 died annually, of whom 13-58 were under ten ; showing in reality a decrease of deaths among children to two-thirds of what they were in the former period.* In corroboration of this view, we may quote Dr. Casper, who found that in Berlin, during the twenty years before 1799, the deaths under puberty were to the births as 51 to 100, while in the eight years succeeding 1814, they were only as 42 to 100 ; and that in the first period the deaths from measles and scarlatina were 14§ to 1000 ; in the second, only 12£ to lOOO.t In conclusion, we shall advert to one other point, upon which we conceive a misconception has arisen. It has been asserted, that cer- tain writers upon political economy declared themselves hostile to vaccination. We believe they did no such thing, but that the accu- sation was founded upon the opinion which they expressed, that the limits'of increase in population were determined by those of the pro- duction of food, and that the numbers of mankind must maintain a ratio to the quantity of food that is to support them, notwithstanding the havoc of a pestilence ; or the diminution of mortality produced by a powerful agent of health. As well as we recollect, Malthus has, in his late editions, expressly cleared himself from the imputa- tion ; but without at all entering into the doctrine of population, it must be obvious that no man in his senses, treating upon the means of improving the happiness of the community, could advocate the designed continuance of a disease that frequently leaves those who survive its attack, burdens to themselves and to society. If the political economists proposes to keep down the numbers of mankind, it must be by checking their production, in the first instance, not by cutting them off prematurely after they have been produced. * The coup de grace has been given to Dr. Watt's error by an ingenious paper read lately before the Glasgow Med. Soc. by Mr. Cowan of that city, f Op. citat. 29 338 CONSTITUTIONAL DISEASES. CHAPTER XIII. CONSTITUTIONAL DISEASES. I. SCROFULA. A pull discussion of this subject properly belongs to the province of writers upon the general practice of physic ; and it would, therefore, be out of place, in the present work, to devote a lengthened space to it. As, however, a scrofulous predisposition appears in many cases to be coeval with the existence of the individual subject to it, and as it may be kept dormant by proper management, or again, by an opposite course, may be induced in those not originally possessing it, so we feel it necessary to consider briefly its general nature, and the principles to be held in view in its treatment, whether preventive or remedial. Symptoms and Marks of a Scrofulous Habit. — These have been laid down with great confidence, (although often with con- siderable difference of detail,) by systematic writers, ever since the time of Galen. Any value, however, which we may be dis- posed to attach to them must be modified by the recollection, that scrofula can be excited by certain fortuitous occurrences in individuals who have no especial natural tendency towards it, and consequently we may meet with actual scrofula in persons who do not exhibit the ordinary characteristics of the strumous diathesis. These characteristics, as most universally agreed upon, are — a white and transparent skin, which, from its thinness, making the colour of the blood particularly visible through it, often gives the appearance of a blooming or hectic complexion ; fair, or red, and soft hair ; large and well opened eyes, with dilated pupils ; thickness and liability to chapping of the upper lip and alae nasi ; large head and joints, but contracted chest; fingers long, and swollen at the extremities, with hooked nails ; the muscular parts flabby and ill developed ; the general surface of the skin delicate and subject to irritations, as from chafing or chilblains, and the whole constitution irritable and prone to febrile excitement from slight causes. The feelings and intellect often partake of the corpo- real irritability — the person being ardent and warm-tempered, sometimes with a remarkable quickness and precocity of talent. In many cases we shall find the strumous diathesis existing in indivi- duals of small stature and weak or deformed bodies ; but its charac- teristics will often be present to a considerable extent, in persons large and well formed. Occasionally we shall find the skin, not de- licate and transparent, but thick, sallow, and liable to eruptions, the person then usually having a heavy, stupid aspect, with full and drooping eyelids. As might readily be anticipated, the condition of SCROFULA. 33g the constitution just described is likely to be accompanied by an imperfect performance of the functions of organic life. The circula- tion is usually languid and feeble, and the digestion so frequently deranged as to lead some writers to consider a peculiar form of dys- pepsia as one of the most characteristic features of the strumous habit.* The collection of symptoms, however, to which the term strumous dyspepsia has been applied, we are rather inclined to de- signate as tuberculous fever. It is, in fact, nothing more than infan- tile remittent fever in a slow form, which, although often dependent upon the presence of worms or other source of irritation in the intes- tinal canal, may (much more frequently than is supposed) be occa- sioned by the development of scrofulous tubercles in some part of the system. The disease is well described by Dr. Todd in his paper already alluded to, but we object to his naming it dyspepsia, as being likely to have the eifect of directing the attention exclusively to the abdomen as the seat of mischief ; whereas we have reason to be- lieve that the primary irritation may exist in the head or other parts. Dr. Todd admits that hydrocephalus and various other affections, may show themselves in strumous dyspepsia, but he considers these as secondary irritations, while our view differs from his, and from that generally adopted, in the essential point, that we believe symp- toms identical with those of infantile remittent fever frequently attend upon a primary localization of scrofulous action in the brain and other parts as well as in the abdomen. For a description of the symptoms of tubercular fever we must refer to our section upon re- mittent fever at page 242, there being usually no appreciable differ- ence between the affections. A great many other marks of scrofula will be found in express treatises upon the subject, but those we have given form the main and striking features of the strumous diathesis .t When the disease is actually called into existence, it may affect, although with different degrees of frequency, almost every tissue in the body ; and, indeed, it appears that any morbid condition occur- ring in a person with scrofulous diathesis, will be likely to be more or less modified by its influence. The susceptibility of different tissues to its invasion varies according to the age of the individual ; children — to whom our observations have immediate reference — most commonly suffering the effects of scrofula in the mucous mem- branes, glands of the neck, and those of the mesentery. We have, however, seen true tubercular phthisis, with very extensive cavities * See article Indigestion, by Dr. Todd, in Cyc. Pract. Medicine. f This term and that of scrofulous diathesis or habit, we use throughout this article in precisely the same sense as Dr. (now Sir James) Clark, employs the term Tuberculous Cachexia, in his admirable Treatise on Pulmonary Consumption and Scrofula, a work which, though published in 1835, we had not the pleasure of seeing until after the publication of the first edition of the present vol, but which we now refer to with peculiar satisfaction, as containing opinions identical with those which we ventured to advance upon the various subjects included in our chapters upon Physical and Moral Education. Upon these, as upon all other sub- jects to which he has directed his attention, Sir James Clark has shed a light from which we should have been delighted to borrow. [Note to 2d Edition.] 340 CONSTITUTIONAL DISEASES. in the lungs, in children under five years of age. The affection of the mesenteric glands has already been considered (as a disease peculiar to childhood), under the head of Tabes Mesenterica ; and we shall now advert to the affections of the glands of the neck, and of the mucous membranes of the eye, ear, and of the vagina. We shall do so briefly, however, as they are, by no means, peculiarly dis- eases of childhood. a. Scrofula as it affects the Glands of the Neck. — These glands are seldom affected in children under two years of age, and are most commonly subject to the disease between the fifth year and puberty. When first affected, which often appears to be in consequence of irritation from eruptions on the scalp or behind the ears, or as a sequela of measles or scarlatina, the glands swell, and feel to the touch firm and fleshy. Their texture, however, is not at this period much altered, quicksilver passing readily through their vessels, as has been proved by the injections of Sommering. By degrees, and often very slowly, the gland becomes larger and harder, parts of it sometimes being as firm as cartilage, and finally a process of soften- ing takes place in particular spots, which, if then examined, would be found to contain a soft, yellowish-white, and cheesy, tuberculous matter. The softening continues until a species of curdy, yellowish pus is formed, which slowly makes its way to the surface, often through several apertures, when an open scrofulous abscess results. The natural tendency of scrofulous glands, or tubercles, is to soften and produce a whey-like, purulent fluid : but they may attain a very large size, still continuing hard, and finally be absorbed without any suppuration, probably in consequence of some improvement in the state of the general health. Most commonly, several glands are affected simultaneously, or in quick succession, a chain of tumours being often formed along the entire side of the neck, or beneath the jaw from one side to the other. After a scrofulous abscess has burst, a slow process of enlargement goes on in the opening, and an indolent sore is formed, which con- tinues, frequently for a very long period, to discharge a thin fluid, containing curdy flakes and occasionally small masses of tuberculous matter. The sore is characterised by a thin, overhanging, livid margin, with pale and flabby, or indistinct granulations. There is seldom any pain or uneasiness. The sore remains indolent for a long time ; or sometimes heals in one part, and breaks out afresh, or spreads to another. When cicatrices are formed, they are wrinkled, and irregular in appearance, often crossed by projecting bands of skin, and producing much deformity.* b. Scrofulous Ophthalmia. — Strumous children are exceedingly liable to inflammation of the tunica conjunctiva of the eye, which puts on the following characters. The edges of the eyelids are at first slightly red and thickened, and the secretion of the Meibomian glands altered, so as to cause glueing together of the lids during sleep. * The disease sometimes, but more rarely, attacks other glands, as those of the groin or axilla ; its progress, however, being similar to that just described. SCROFULA. 341 On everting the lids, we find the conjunctiva covering them some- what redder than natural ; but the same membrane upon the eyeball has, at this time, probably nothing remarKable in its appearance, except its being traversed by a few enlarged vessels. The inflam- mation slowly increases, and the conjunctiva becomes gradually more vascular, — the eye watering, and being very intolerant of light. This latter symptom is usually so remarkable, that the disease may be known, even without looking at the eyes, by the stooped position in which the patient carries his head, for the purpose of diminishing, as much as possible, exposure of the eyes to light. As the disease goes on, a marked disposition to the formation of pustules is evinced. They appear upon the margins of the lids, and in the Meibomian follicles, in which situations they run into ulcera- tion, and produce great irritation and distress. Pustules are also formed upon the conjunctiva of the eyeball, or upon the cornea, a pencil of red vessels being developed in connexion with each. When this happens upon the cornea, a troublesome ulcer is likely to follow ; a general dulness of that texture is also usually produced ; or a per- manent opacity of a part of it, to a greater or lesser extent, which may end in total blindness. We have frequently observed, in children, a form of ulceration of the cornea, notice of which we do not recollect to have seen in works upon the subject ; it is a removal of a patch of the conjunctiva which covers the cornea, without the production of any opacity. It appears exactly as if a small portion of the mem- brane had been removed by a sharp chisel, leaving a distinct facet, sometimes level, and in other instances concave. An experienced eye will easily detect this lesion, by the peculiar reflection of the rays of light which it occasions ; but frequently we can actually see the defect only by looking at the part in profile. This condition may remain unaltered for a considerable length of time ; and so far as our experience goes, local applications, especially those of a caustic nature, are always injurious. c. Scrofulous Disease of the Ear. — The lining membrane of the external auditory passage is often the subject of inflammation in scrofulous children. The affection is quite analogous to that of the eyes, consisting in a slow inflammation of the membrane, attended by the formation of pustules, and protracted discharge of unhealthy, and often fetid pus. This form of disease is always to be looked upon as dangerous, as the inflammation may slowly extend to the internal ear, causing ulceration of the tympanum, and destruction of the auditory bones, thus producing incurable deafness. It also not unfrequently extends to the petrous portion of the temporal bone, and thence into the cavity of the skull, when convulsions and death are the certain and sudden result. p Ulcerations behind the ear, in the angle between it and the head, are common attendants upon the affection of the passage, and are often to be looked upon as a beneficial source of derivation with regard to the latter: they should, therefore, not be incautiously meddled with. ' . • ... - .. d. Scrofulous Discharges from the Vagina. — Children of a stru- 29* 342 CONSTITUTIONAL DISEASES, mous habit are liable to purulent or muco-purulent discharges from the vagina, which require to be understood by practitioners, who are often consulted respecting them, in consequence of unpleasant suspicions arising as to their being of a specific nature, and having been communicated by infection. Looked upon in this light, such discharges may become the subjects of legal investigation ; and in every such case, no opinion should be given without the most care- ful examination as to their real nature. Other marks of a scrofulous diathesis will commonly be present, but they may not be very decided- ly so ; and the occurrence may appear to be a good deal connected with a deranged condition of the bowels. It is a very obstinate affection, and only yields to improvement of the general health. Pathology of Scrofula. — A consideration of this subject involves questions of considerable difficulty, into which we cannot here enter at length, and shall therefore merely state what appears to us to be the most rational views upon the subject. It does not appear that scrofula is the product of any peculiar virus, as direct attempts to propagate it by inoculation have been unsuc- cessfully made by Kortum,* Goodlad,t Hebreard,J Le Pelletier,§ &c. We must, therefore, abandon this opinion of the older physicians, and seek for another more accordant with the present state of our knowledge. From what we have already stated, it appears that the constitu- tions of some individuals are decidedly predisposed to the occurrence of scrofula ; and that marks are recognisable, whereby we may esti- mate the existence of such predisposition. These marks are all such as denote a preponderance of the white tissues and fluids of the body over the red, — or, in other words, of the lymphatic over the arterial and venous system. Our physiological knowledge leads us to the inference, that the strength, and vitality, and capability of resisting disease, possessed by animals, (at least, warm-blooded animals,) is in a direct ratio with the preponderance of the red tissues and fluids in their bodies over the white ; that, in fact, the white tissues have naturally a lower degree of those qualities than the red, — and the more they abound in the system, in relation to the others, the less power will there be for struggling against morbid conditions. It appears, also, that individuals who do not naturally possess the marks of a strumous diathesis, may become scrofulous by the opera- tion of certain external causes, and that these are such as favour the production of a preponderance of the white over the red tissues, e.g., confinement, in a damp, unhealthy situation, with defective diet and a diminution in the supply of solar light and fresh air. Whoever looks upon the blanched aspect of hand-loom weavers, or of the youthful inhabitants of cellars, in some of our confined streets, will be at no loss to understand the operation of these causes in producing, at least, a diminution of the redness of health ; and medical men * De Vitio Scrofuloso, Lemgov. 1798. f On the Lymphatic System, Lond. 8vo. % Dissert, sur les Tumeurs Scrof. Par. 8vo. 6 Sur la Maladie Scrofuleuse, Par. 1830. SCROFULA. 343 know that such individuals are very prone to scrofulous disease Animals, also, taken into confinement from a wild state, frequently fall victims to scrofula — most of our parrots, monkeys, and tame rabbits, dying of tubercular consumption : while again, in the vege- table kingdom, an analogy is furnished with regard to the effects of want of light and air, in causing increase of the white tissues, by the appearance of any plant which has grown in a dark, confined situa- tion. If, then, we have the marks of a scrofulous predisposition, identical with those of a preponderance of white tissues, and if we find also that the same causes which produce the latter state, may also produce the former, we have some warrant for inferring that the scrofulous diathesis is nothing more than a state of general ill-health occasioned by a deficiency in the proper supply of red blood, and consequent preponderance of white fluids and tissues ; and that the different forms of scrofula are probably but local exhibitions of irri- tation, modified by the predisposition in question ; but which irrita- tions, if occurring in a healthy subject, would in all likelihood either be repelled without injury, or merely produce common inflamma- tion. Upon these principles, we can account for the hereditary transmis- sion of the disease, and for its occasionally passing over generations. It accords with any knowledge we possess respecting reproduction, that peculiarities of structure have a tendency to be communicated from parent to offspring ; therefore, we should expect the deficiency in red tissues, constituting the scrofulous diathesis, to be bequeathed by a strumous father or mother to their child, and accordingly we find that it frequently so happens. On the other hand, we know that fortuitous circumstances may produce a like condition of the two sets of tissues in individuals not born with it ; and so we see how scrofula may arise independently of hereditary descent. Again, every one is aware of the increase of ruddiness and strength effected in delicate persons by active exercise in the open air, — this ruddi- ness being nothing more than an evidence of an increase in their store of red blood; hence we know why scrofula may pass over a generation better circumstanced as to air and employment than that which preceded it ; and we are also taught to hope that, by suitable means, much may be done, both in the prevention and cure of this scourge of the human race.* * Mr. Carmichael in his admirable clinical lectures, while he rejects the idea of scrofula being occasioned by any peculiar poison transmissible from parent to child, says : — " No doubt numbers come into the world predisposed to the disease ; but these are the children of sickly or debilitated parents ; no matter from what cause their debility may have arisen. Thus the offspring of the valetudinarian — the dissipated debauchee — the drunken sot — or the old gouty man of pleasure, may be esteemed predisposed to scrofula. Even the children of old men, though healthy, appear to be in this predicament. A few years since, I was consulted on account of two children, a boy and a girl, under ten years of age --the one had caries of the vertebrae — and the other hip-joint disease in its second stage. 1 he lady under whose care they were, who was herself apparently fifty years of age, told me that these children were her brother and sister —seeing some surprise in my counte- nance, she added, ■ but by different mothers. My father, when eighty years ot age, 344 CONSTITUTIONAL DISEASES. With respect to the essential character of scrofulous disease, the most certain is the production of tuberculous matter, which is defined by Dr. Carswell* to be " a pale yellow or yellowish-grey, opaque, unorganised substance, the form, consistence, and composition of which, vary with the nature of the part in which it is formed, and the period at which it is examined."! The seat in which this matter is commonly deposited has been also shown, by the same author, to be the mucous system, although it was formerly supposed to be the cellular tissue. His view, however, appears to us to corroborate the opinions already advanced, as to the pathology of the disease : the mucous systems require, for the discharge of their functions, a large share of red blood, and a high degree of vitality; consequently it is to be expected that they will suffer soonest and most severely from any minus state of the constitution in these particulars. Although the deposition of tuberculous matter is a sure evidence of scrofula being present, still we must admit the disease to exist, although no such formation may have taken place. In the affections of the eye, ear, and vagina, for example, there is no tuberculous matter deposited ; yet we cannot doubt that they are strumous, both on account of the manner of their progress, and of the constitutions of the individuals whom they affect. It has been supposed by some, that tubercle always had its origin in inflammation : and were it not that the authors of this theory have endeavoured to form for it an unlawful and dangerous union with practice, by recommending depletive measures for the cure of tuberculous disease, we should pass it over as one of those idle disputes about words unfortunately so common among physicians. Our opinion upon the subject may be inferred from what we have already stated ; we believe that irritations which would produce no effect upon the healthy, originate tubercle in the scrofulous; and also that lesions capable of exciting inflammation in the former, would excite tuberculous deposition in the latter. The cure of in- flammation in the healthy, however, is to be effected by the abstrac- tion from their system of red blood; while the cause of the scrofulous disposition we believe to be a deficiency in the same fluid — conse- quently, it cannot be cured by making that deficiency more consider- able, and therefore, (in a therapeutical sense, at least,) is not to be looked upon as inflammation. thought proper to marry a second time; the family he had by his first wife are, like myself, all stout and healthy (indeed she appeared the very personification of stout- ness), while the family he had by his second wife, like those you see before you, are all mere sickly blights.' I then inquired if the mother of the latter was healthy, and was told that she was a remarkably fine healthy looking woman, and nursed three children herself — the inference is obvious." Mr. C. also strongly advocates the opinion, that close intermarriages between blood relations tend much to the production of a scrofulous progeny. See the Medical Press, vol. iii. p. 3. [Note to 3d Edition.] * Illustrations, &c. London, 1833. f Mr. Carmichael conceives the tubercle of the lungs to be essentially different from the matter of scrofulous tumours ; according to his opinion, the former is to be considered as an independent parasitic formation. See his lectures in the 3d vol. of the Medical Press, passim, [Note to 3d Edition.] SCROFULA. 345 Preventive Treatment— Viewing the scrofulous diathesis as a minus state of the red fluids and tissues, the obvious means of pre- venting the development of the evil effects of this condition must be, to restore the system to its healthy balance, and so to preserve it. How this is to be attempted has been already considered at some length, in the chapters upon the Management and Education of Children, and need not be again dwelt upon. What we want to accomplish is, the establishment of a good state of health ; and this can only be arrived at by a careful working out of the principles laid down in those chapters under the heads of focd, clothing, &c, &c. In cases of a marked scrofulous predisposition, we may recom- mend, in addition, a residence at the sea-side during three or four of the summer months, which, without supposing the sea to possess any specific, antistrumous qualities, must certainly be looked upon as likely to produce very beneficial tonic effects. No specific medi- cal treatment is required or warranted for the prevention of scrofula. Curative Treatment of Scrofula. — This is to be based upon principles precisely similar to those of the preventive treatment. The general health must be improved by means suitable to the par- ticular case, and all causes of local irritation must be, as far as pos- sible, removed. The means of working out these principles must, of course, vary according to circumstances. When the digestive system is out of order, it must be improved by alterative medicines, and perhaps gentle aperients ; but nothing in the shape of drastic purgatives should ever be administered to scrofulous subjects. The improvement we want to effect in the digestive system is, the esta- blishment of a good appetite and digestion ; and this will, in most cases, be done, with greatest certainty, by preventing errors in diet, giving a sufficient quantity of light nutritious food, partly of the animal kind; but never oppressing the stomach: when wine or malt liquors can be taken without exciting fever, they should be allowed ; but with children such articles are seldom required, and often do harm by their stimulant effects. Constant exercise, and free exposure to the air, and solar influence, but with a sufficiency of warm clothing, are essentials in the treatment of scrofula ; and if residence near the sea during the summer months, or short sea- voyages under comfortable circumstances, can be accomplished, much good may be expected to result. Residence in a mild and equable climate during the winter, is also desirable ; but very warm latitudes are not suitable for the scrofulous, and the want of many British comforts (as fires, comfortable beds, well-aired linen, &c), incident to a residence on the Continent, renders a removal to the southern parts of Europe a matter of very questionable prudence with persons suffering from these disorders. As to medicines, we know of none that possess specific antistru- mous properties ; and in addition to the mild alteratives already alluded to, we would only recommend a trial of such as are con- sidered to possess tonic properties, keeping a careful watch, however, over their effects, and never pushing them in the hope of their being specific cures, after they have appeared to disagree with the system. 346 CONSTITUTIONAL DISEASES. The tonic which we have found most beneficial, and approaching nearest to a specific, is certainly iodine ; and this we would give in almost every case of scrofula, under the restrictions and in the mode recommended at p. 99.* Sarsaparilla will also be found of service, and may be given in conjunction with iodine ; as may also the light bitters when the state of the stomach requires treatment. As for the numerous specifics recommended in this disease, e. g., muriate of baryta, hemlock, iron, &c., we consider them to possess no more peculiar virtues than as they may happen to have tonic, or anodyne, or the like qualities, which may be useful in particular cases.t Local Treatment of Scrofula. — When scrofulous glands enlarge slowly and remain indolent, we believe it is better to use no local treat- ment, and especially to avoid exciting them by frictions with greasy sub- stances. We cannot have much hope of dispersing them by such means ; and if we could do so, without at the same time changing the scrofulous disposition in the constitution, there is reason to fear that, by removing what furnishes a sort of counter-irritation upon the external surface, we may be only favouring the development of the disease in some internal organ. When there is much pain or irritation in the tumour, we may have occasion to apply a leech or two, and use * The use of ioduretted baths has been much recommended by M. Lugo!, in the treatment of scrofula. We give his formula for baths for children between four and seven years of age: Hydriodate of Potash. Troy grains. 60 to 72. Water. Iodine. Quarts. Troy grains. 36. 30 to 36. f In a letter lately addressed to the Royal Academy of Medicine, of Paris, by M. Coster, the virtues of iron, as a preventive of the development of scrofula, are highly extolled. Two years ago, M. C. placed a number of dogs, rabbits, &c, in the cir- cumstances most favourable to the development of the scrofulous diathesis. Thus, many of the unfortunate animals were shut up in dungeons, without light, or space for motion, and exposed to a moist cold by means of wet sponges which were hung up in the cages. Some of the animals placed in these conditions, were fed on their ordinary diet; others were fed with ferruginous bread, containing half an ounce of carbonate of iron, to the pound. All the former became ill, the greater part tuber- culous, but not one of those fed on bread containing iron presented a trace of tuber- cles.— Bull, de VAcad. Jan. 31, 1840. [Note to 3d Edition.] M. Coster has since published his Experimental Researches on the generation and prophylaxis of tubercular diseases at greater length (see Gazette des Hospitaux, and translation in the Medical Press, vol. vi. p. 247). The views of JM. C. regarding the nature of scrofula are very similar to those we have put forward above. He considers the disease to be constitutional, and the result of a special organisation, either hereditary or acquired. "Tubercles," he correctly observes, " wherever situated, do not constitute the disease; they are but the expression, the manifesta- tion of a pathological disposition, so universal that it influences every molecule of the system, communicating to the entire economy, as to each of its constituent atoms, a mode of existence peculiar to itself, and often cognisable in the physical and moral condition of the individual." The intimate nature of this pathological disposition M. C. does not profess to explain, nor does he offer any theory to ac- count for the operation of iron in modifying it. We confess, the moderation and soundness of his arguments, as well as the detail of his experiments, and the few trials of his plan which we have had an opportunity of making, all combine to in- duce us to doubt the correctness of our former opinion as to the non-specific proper- ties of iron. M. Coster has, to say the least, made a case to warrant its careful and extensive trial, both as a preventive and curative agent. [Note to 4th Edition.] SCROFULA. 347 emollient warm applications, for the purpose of relieving the tension. If matter be formed, it becomes a question whether or not an opening should be made for its escape. We believe this should not be done unless there is more than ordinary pain or tension, or the skin is mani- festly on the point of bursting. It is hoped by some that an early opening may be the means of preventing any unsightly scar; but it does not always do so ; and on the other hand, large tumours have been altogether absorbed without breaking, even after the for- mation of matter. After the abscess has been opened or has burst, if the discharge be considerable, we may cover it, for a day or two, with a poultice, and subsequently dress it with a bit of dry lint or finely-carded cotton, avoiding all greasy applications. The ulcer when indolent, as it usu- ally is, may be stimulated by touching its edges with nitrate of silver ; and if irritable, the same treatment, followed by a poultice of bread and water, or hemlock leaves, or sea- weed, will be found serviceable. The healing of these ulcers is commonly very tedious, and will not be perfectly accomplished unless an improvement is effected in the constitution ; or scrofulous disease breaks out elsewhere. After the ulcer has healed, a hard tumour will sometimes remain ; and if this be perfectly free from pain, or other sign of irritation, we may attempt its removal by the employment of small blisters, or frictions with discutient ointments. It is at this time that the different oint- ments of iodine may be safely used ; but if any pain or irritation arise, they should at once be discontinued. In treating scrofulous ophthalmia, much attention should be directed to the state of the constitution ; but local management will also be found of considerable importance. In the first place, a broad, green silk shade should be placed upon the patient, in such a way as to stand out well from the forehead, and admit the access of air to the eyes, while it intercepts the direct rays of light. This management of the shade is of great consequence ; as those usually employed, which are small and lie close to the eyes, do more harm than good. When there is much redness or pain, a poultice of bread and cold water, or of alum curd, enclosed in a muslin bag, should be placed over theclosed eye atnight. The best eye water is asolution of sulphate of zinc, or alum (three or four grains to the ounce) in rose water. If the lids stick together at night, much relief will be afforded by anointing them at bed-time with a small portion of dilute citrine ointment, or of oxide of zinc ointment, made with five grains ot the oxide to two drachms of lard, and with the addition of ten drops 01 a VheTthe affection is indolent, small blisters behind the ears will often be of service. If the conjunctiva becomes granular m old cases, the application of caustics will be required, as the sulphate of copper, "SSer, nothing is done, if we do not improve Ohe state of the wstem bv the general means already laid down. We have in a ver™t number of instances, tried the experiment of treating the general health alone, using nothing local except the shade and a 348 CONSTITUTIONAL DISEASES. poultice of cold bread and water ; and we are certainly of opinion that a greater number of cases will be cured in this way, than if the most careful local treatment were combined. We have not unfre- quently seen ulcers, and even considerable opacities of the cornea, disappear altogether under the use of iodine, without any local treat- ment whatsoever. Scrofulous disease of the ear requires no direct local treatment, except cleanliness ; but will often be benefited by exciting coun- ter-irritation behind the ear; the best way to do which is, to place a piece of woollen thread, smeared with blistering ointment, in the angle between the ear and the scalp. In scrofulous discharges from the vagina in children, we have re- peatedly tried stimulant and astringent lotions and injections, without effect. We believe they can be efficiently treated only by general means. II. RICKETS (RACHITIS). This disease, which is now, happily, becoming rare, was once so prevalent in these countries as to be termed the English disease, a name {Die Englische Krankheit) which it still retains among the Germans. It does not affect the young infant, but commonly appears about the period of the first dentition, — at least, its effects become then, for the first time, manifest, when the child commences to support the weight of its body upon its limbs. Symptoms. — Before any local characteristics of the disease make their appearance, the child's health will be observed to be deranged : it is peevish and languid ; the skin becomes dry and rough ; the flesh soft and flabby ; the countenance pallid and delicate ; the appetite uncertain, and occasionally depraved (unnatural food being sought for) ; the digestion is at the same time impaired, the bowels being irregular, and the stools and urine unhealthy in their appearance ; the abdomen is large, while the rest of the body and the limbs be- come emaciated. Along with these symptoms, a general febrile excitement is present, similar to that which has been already de- scribed under the name of remittent fever, and which, in the last section, has been named tuberculous fever. After these symptoms have been manifesting themselves for some time, the head will be observed to be unnaturally large, and the forehead prominent, while a defective ossification of the bones of the head will be proved by the open state of the fontanelles and sutures. The ends of the long bones at the ankles and wrists become swollen into knobs, which seem larger than they really are from the contrast with the shrunken limbs ; the sternal ends of the ribs may be also enlarged and spongy. That the bones are softer than natural, and incapable of supporting the weight of the body, or the action of mus- cles, is shown by the bending of the legs, thighs, and arms, and nar- rowing of the chest by the straightening of the ribs and projection of the sternum forwards. As the disease goes on, the pelvis and spine partake in the deformity, which may be carried to such a pitch as to RACHITIS. 34 9 destroy life by interrupting the performance of the functions of the different viscera. The teeth also share in the general disease of the osseous system, coming out slowly, and prematurely suffering decay. It has been observed, that the mental faculties of ricketty children are, usually, quick and precocious ; but this is not at all uniformly so, and is probably no characteristic of the disease being explainable by the greater degree of attention likely to be paid, by its adult rela- tives, to the conversation of a delicate child, which is unable to join in the active sports of younger companions. A species of acute rickets has been noticed by authors, in which all the bones of the skeleton are said to have become softened in the space of a few weeks. Pathology. — The immediate cause of rickets is a deficiency in the earthy matter of the bones, which consequently do not possess the natural and requisite firmness. " Dr. John Davy found 100 parts of the dry tibia of a healthy subject of fifteen, to yield 46-4 of animal matter, and 53-6 of earthy ; while the same quantity of the dry tibia of a ricketty child contain 74 parts of animal, and 26 of earthy sub- stance/'* The various marks of disease in the cavities and viscera, which are found in the bodies of those who die ricketty, are merely accidental, and not to be considered as in any way essential to the disease. The remote cause of rickets are identical with those which pro- duce scrofula ; so much so, that by some it is considered as merely a form of that disease. It certainly is often combined with unequi- vocal marks of a scrofulous diathesis, and to make any difference in the general pathology of the two affections is probably but disputing about words. Bad nursing, unhealthy, ill-ventilated, damp dwell- ings, deficiencies in cleanliness, food, exercise and exposure to light and air — anything, in fact, which prevents a healthy nutrition, may produce rickets. It appears also to be endemic in certain localities, and to be sometimes transmitted by hereditary descent. Diagnosis. — There can be no mistake about the disease, when its local characters appear. Its early symptoms, however, may be similar to those of tabes mesenterica, or simple remittent fever, and can only be determined to belong to rickets, by the result. Prognosis.— This is favourable when the disease is noticed early, and the cause admits of being removed. Danger is to be appre- hended when the deformity is so considerable as to impede any of the vital functions ; and even if it does not reach this extent, it may be sufficient to cause a life of protracted misery, and liability to dis- ease About the age of puberty, a marked improvement often takes place in the health of ricketty persons ; and in those who, with an originally healthy constitution, have been subjected to the disease bv bad nursing, a most surprising improvement will often take place in the form of the limbs, during recovery. Of course, any disease affectin- a child while in a ricketty condition may be expected to be particularly severe, in consequence of the deficiency of strength in the general system. * Cyc. Pract. Med. Art. Rickets, 30 350 CONSTITUTIONAL DISEASES. Treatment. — We have little to say, under this head, beyond what we have already said respecting the treatment of scrofula, and in the chapters upon the Management and Education of Children. Attention similar to that recommended on those occasions must be paid to the ricketty child, with the view of improving its health, which is the great principle to be followed out in the preventive or remedial treatment of rickets.* Any symptoms of fever, derange- ment of the bowels, &c, which attend, must be met by suitable means ; and during the treatment we shall frequently have occasion to employ gentle, alterative aperients. When the digestive system has been set to rights, tonics, both internal and external, will be re- quired : among the latter, the tepid salt water bath, and friction will generally prove serviceable ; and among the former, iodine and the different preparations of iron hold the first place. For the modes of administering these medicines, we must refer to the chapter on Therapeutics. In holding and carrying a ricketty child, the greatest attention should be pain to the avoidance or undue pressure upon any part, especially the chest. It must be remembered that the bones are in a flexible and pliant condition, and that pressure carelessly continued in the same situation, will be very likely to alter their shape. When recovery is taking place, and the child is sufficiently old, well-regu- lated gymnastic exercises will often produce very good effects in ex- panding the chest, and straightening the limbs and spine ; but they should be used very cautiously, and always with due regard to the delicate health and impaired strength of the patient. Dupuytren was in the habit of placing the child with a deformed chest, with its back against a flat resisting body, and then pressing with the expanded palm of the hand upon the sternum, so as to flatten the thorax from before backwards, and increase the convexity of the ribs from side to side. By repeating this practice from day to day, it is possible to effect much improvement in the shape of the chest ; but force suffi- cient to cause pain should never be employed. All instruments for straightening the limbs, or supporting the spine, are worse than useless, as they prevent the action and development of the muscles, which afford the only true means of restoring strength and symmetry. III. SYPHILIS. The venereal disease may be communicated to the young child in three ways: — 1st, the fcetusmay be contaminated, while yet in the womb of its mother ; 2d, the infant may receive infection from the nipple of a diseased nurse ; and, 3d, it may be infected during its birth, the * Ricketty children sometimes show a remarkable fondness for common salt, which should be indulged to a reasonable extent. This reminds us of having omitted, in speaking of the food of children, to dwell upon the necessity and advan- tage of giving a sufficient supply of this condiment. Sufficient salt should always be put in the broths, and given with the animal food allowed to children, as it con- tributes much to the healthy performance of digestion, and is also a powerful pre- ventive of intestinal worms. s SYPHILIS. 351 mother at the time labouring under primary symptoms of the disease. By most authors it has been supposed, that the two latter are the only modes by which the child can be infected ; but, strange as it may appear, the first mentioned has been, in our experience (which has not been inconsiderable), by far the most usual ; and we have not in our recollection any case decidedly proving the occurrence of the third. Whether or not this is explainable by the supposition of Jahn, that the vermx caseosa effectually prevents contamination by the skin, we shall not at present attempt to decide. Transmission by the nipple of the nurse we have frequently ob- served, and have known a whole family to be infected in this way, — the nurse having first received the disease from the mouth of a syphilitic nurseling. The most ordinary manner, however, in which syphilis is communicated to an infant, is by the first mode ; and it happens, commonly, in one of the following ways. One or both parents may have the disease at the time of the conception of the child, or they may have had it previously, and perhaps, at the period in question, present no sign of ill-health whatsoever. Under either of these circumstances, a child maybe born, apparently healthy, and continue so for an uncertain period, (varying from a fortnight to five or six months.) when marks of syphilis may show themselves : the most usual period for the disease to appear is, according to our experience, from the third to the fifth week. In this way the symp- toms may be developed, in several successive children of the same parents ; but usually, such cases are alternated with miscarriages, or premature births of children, dead, and covered with syphilitic erup- tion ; or all these occurrences may take place in the same family : for example, a woman may miscarry once or twice ; may then pro- duce a dead syphilitic child ; and subsequently give birth to one, apparently healthy, but showing disease when it has attained the age of four or five weeks. There is no regular succession in the occurrence of these different events, as they indifferently precede or follow each other. During the whole period of the production of these diseased children, both parents may appear perfectly healthy, and one of them may never have had any sign of the disease. We have in our recollection many instances in which miscarriages, premature births, and syphilitic children have continued to succeed each other, although the mother had been always healthy, and the father had no trace of disease, perhaps, for years before his marriage. We have now be- fore us, notes of the case of a syphilitic child, whose mother had been infected by a former husband, and, to all appearance, cured, five years before its birth, — the father of the child (her second husband) being in good health. Our experience would enable us to adduce many curious facts, bearing upon this subject, which, however, would be unsuitable in the present work ; and we shall now proceed to consider, The Symptoms. — We have stated that children may suffer from syphilis, while yet in the mother's womb ; in which case they are generally born premature and dead, often putrid. The appearances on the body of the child are not generally of a decided pathogno- 3 52 CONSTITUTIONAL DISEASES. monic character; we have seen an eruption of copper-coloured blotches ; but more usually there is merely a desquamation of the entire cuticle. When the child is dead, it has commonly been so for some weeks before birth, and has consequently become so putrid as to prevent our recognising any marks except those of decomposition. We have not, therefore, in the mere fact of the birth of dead and putrid children, evidence sufficient to enable us to pronounce upon the existence of a syphilitic taint in the constitution of the parents ; and, unless the history throws distinct light upon the case, it can only be satisfactorily cleared up by the birth of a living child, and its subsequently showing symptoms of syphilis. Under these circum- stances, the child appears healthy for an uncertain period (from a fortnight to five or six months) after birth. The first distinct symp- tom usually is the occurrence of a peculiar mode of breathing through the nose, known by nurses as the snuffles. At the commencement, this is attributed to cold, and seldom attended to until the eruption appears : in the interim, however, the child's health is much affected, and without any apparent reason. It has no bowel complaint, and is not undergoing dentition, but yet wastes away, and is feverish, fretful, and pallid. In about a fortnight, an eruption comes out rather suddenly, at first upon the lower extremities and buttocks, and subsequently upon the face and body. The practitioner seldom sees the child until this eruption has been for some time in existence, and has changed from its original charac- ters. It appears, however, first in the form of copper-coloured blotches, about the size of a split pea, and slightly raised above the level of the skin ; these are in a slight degree moist upon the surface, and, in situations exposed to the air, they soon become scaly, and subsequently, are converted into dark-yellowish scabs. Where por- tions of skin are naturally in contact, as between the buttocks, in the wrinkles of the neck, &c, scales are not formed — but raised, condy- lomatous sores. As the disease advances, the skin, in the interspaces between the scabs, becomes, throughout, of a copper colour ; and perpendicular fissures are formed in the lips, giving the mouth a very peculiar and characteristic appearance, which cannot be verbally described, but, to those familiar with the disease, is in itself diagnostic of its real nature. The voice at this period becomes feeble and stridulous ; the inside of the mouth often covered with aphthse ; extreme emaciation attends ; and, if medical aid be not afforded, the child is reduced to a state of excessive debility, and dies, covered with disgusting scabs and ulcerations. Such is the ordinary course of the disease ; and so far as we have observed it, the syphilis of children presents little variety of form. In one case, we saw well-marked syphilitic iritis in a child about a year old, whose father had at the time a tubercular eruption ; the mother stated herself never to have had any syphilitic complaint. Syphilis of children may be, to all appearance, cured by treat- ment, and will again return : this may occur several times, at inter- vals of a month or two, each relapse being milder than the preceding one, until, at length, the taint is worn out of the system. When the infection has been communicated in the second mode, SYPHILIS. 353 viz., from sores upon the nipple of the nurse, ulcers will, in the first instance, be formed in the mouth of the child, but subsequently the characters are similar to those we have just described. The ulcers in the mouth are often overlooked, or considered as aphthous : we are not able to assign to them any characteristic marks whereby they may be diagnosed. The Diagnosis of the disease is to be derived partly from its his- tory ; but in investigating this, the greatest caution is required, as a hint of any suspicion upon the subject might, in many instances be productive of the most unhappy domestic results. The tact of the physician will therefore be called into play, for the purpose of elicit- ing the information he requires, without committing himself to an opinion, or exciting unpleasant suspicions in the minds or those with whom he is dealing. To persons experienced in the management of the disease, the characters of the eruption, as just described, will usually be sufficient to declare its nature, and obviate the necessity for minute inquiries into its history ; but knowledge of this kind can- not be acquired, except by long-continued personal observation of patients. The snuffles of syphilis have nothing at first to distinguish them from those of common catarrh ; and in this stage it cannot be diagnosed, except by a knowledge of its having previously occurred with other children of the same family. The disease with which the eruption is most likely to be confounded is common itch, which, in the delicate skin of the child, may assume a frightfully severe form. It is to be known from syphilis by its pustular character, by the itchiness which it occasions, and by the absence of the copper colour of the skin, and the peculiar fissured appearance of the mouth. Itch is also commonly communicated to the attendants of the child, in whom its characters will be too well marked to admit of any mis- take : and by an observation of this circumstance, the diagnosis will be often much assisted. The Prognosis is always favourable, when the case is seen early and properly treated ; few diseases being more under the influence of medicine. If left to itself, however, syphilis infantum is certainly fatal. We are also to recollect that even when treated in the most judicious manner, it is liable to relapse, perhaps more than once, after an appa- rently complete cure. The Treatment is exceedingly simple, — mercury being always required, and when judiciously exhibited, seldom failing to produce a beneficial effect. A question has arisen as to the propriety of giving mercury directly to the child itself, or indirectly through the nurse : the former is the plan we always adopt, — the child bearing the medicine well, and experience having taught us that the latter method alone is not sufficient to effect a cure. The expediency of putting the parents under the influence of mer- cury, with a view to the prevention of a recurrence of the disease in future children, involves several distinct considerations. If either parent exhibits unequivocal marks of syphilis, there can be no doubt of the propriety of adopting suitable means of cure. Frequently, however, we shall find no existing symptoms of the kind ; and then 30* 354 CONSTITUTIONAL DISEASES. we are to consider, whether it will be advisable to mercurialise one or both. If both have been formerly infected, it is our opinion that both should take mercury : if one has been affected, and the other apparently not, there is more difficulty in the case. If it be the female alone who has had the disease, as in the case of the widow whom we have already alluded to, we think it will probably be sufficient to treat her : but under opposite conditions, we are not so much inclined to hope for success from treatment merely of the male. In other words, we are inclined to suspect that a taint may be communicated to the female parent, without its being rendered manifest by any outward marks. The subject, however, is in great obscurity, and requires many more observations for its elucidation. Our plan of treating a child is, to administer from one to two grains of hydrargyrum cum creta, two or three times a day (according to the age), until the eruption and snuffles disappear. The child usually fattens under this treatment ; and salivation is never produced, at least we have never seen it, in a child under three years of age. Should the mercury affect the bowels, which sometimes happens, we must combine with each dose from half a grain to a grain of Dover's powder, or of the powder of chalk and opium. The time required for treatment is from six weeks to two or three months, and the medi- cine should always be continued for two or three weeks after every symptom has disappeared : even when this precaution has been observed, the disease may return, and the mercurial treatment must be, again and again, resumed. The sores about the anus, and in other similar situations, will often be benefited by the application of black wash, or of dilute citrine ointment ; and when they become very indolent, it may be necessary, towards the termination of the treatment, to stimulate them with nitrate of silver, or sulphate of copper. In addition to the foregoing treatment, when the mother is suckling her own child (and, for obvious reasons, it never should be given to a strange nurse), it will be well to treat her with alteratives, — as, for example, sarsaparilla ; but unless she labours under actual syphilitic symptoms, the giving of mercury to her should not be thought of until the child is weaned, as by affecting her general health, it would be likely to deteriorate her qualities as a nurse. IV. PURPURA. A form of this affection is not uncommonly met with among the children of the poor, in large cities, and has been noticed by Heberden in his Commentaries. It has been included by Willan among the ex- anthemata ; but the mode of its appearance, without distinct preceding fever, as well as its duration and course, sufficiently distinguish it from those diseases, with which indeed it has nothing in common, except that it engages the cutaneous surface. The form of purpura which we have observed in children is that denominated by Willan purpura simplex. Symptoms, — It appears in the form of purple spots, varying from PURPURA. 355 the size of flea-bites (for which they are often mistaken), to that of a shilling, or even larger. These are not elevated above the sur- face, but consist of small extravasations of blood in the tissue of the skin : they are not productive of any local uneasiness whatsoever. The appearance of the spots is not preceded by any distinct febrile reaction ; but the child will be always found to have been somewhat out of health previously ; it has been pallid and delicate-looking, with a quickened pulse, and more or less derangement of the bowels ; and frequently the subject, for some time, of an attack of remittent fever. Often, the child will be brought to us for some other disease, and we shall be the first to notice the purpural appearance, which has been previously considered by the parents to be merely the effect of flea-bites. Should the disease run on, in consequence of injudicious treatment, or of a continued exposure to its original cause, slight pressure will produce vibices ; larger extravasations of blood will be formed upon the surface ; hemorrhages will take place from the various passages, and the case, in short, will become one of true purpura hemorrhagica. Pathology. — This disease, if not identical with scurvy, is at least very analogous to it, and the proximate cause of both is probably the same. Into a consideration of this subject, however, involving, as it does, the whole dispute between the humoralists and solidists, it would be out of place here to enter ; and we shall only mention the conditions which we have seen most frequently associated with the purpura of children. The subjects of the disease have been always, according to our observations, living in situations unhealthy, damp, and imperfectly supplied with light and air ; their diet has also been scanty, or unsuitable to their age. Dr. Graves justly ob- serves,* that he has usually found that such children were fed upon salt provisions, as bacon, salted herrings, &c. ; and without making any inquiries upon the subject, we shall frequently perceive, by the peculiar odour of these patients, that the latter article has been a chief constituent of their diet. The chief point in the Diagnosis of purpura simplex is, to dis- criminate the spots from flea-bites : these latter may be recognised by their redder colour, and by the central puncture produced by the bite, as well as by their more rapid disappearance from the skin. When a suitable dietetic and general treatment can be adopted, the disease, if uncomplicated, readily yields ; but purpura always indicates a bad state of constitution, and betokens evil, when it occurs in the course of other disorders. The Treatment must consist less in the administration of medi- cines than in the improvement of diet and regimen. In place of tea and salted provisions ; milk, fresh meat, and vegetables should con- stitute the child's food : it should live in an airy situation, and be made to exercise freely in the open air during a large portion of each day The surface of the body should be sponged, night and morn- ing, with tepid vinegar and water, and the strictest attention paid to cleanliness. * Dub. Med. Jour. vol. iii. 356 CONSTITUTIONAL DISEASES. With respect to medical treatment, the bowels, if deranged, should, in the first instance, be set to rights ; and for this purpose some mild alterative aperient (see pp. 126, 127), will usually be required. We have sometimes given, with advantage, small doses of quinine with the mineral acids ; and Dr. Graves has found benefit to arise from the administration of citric acid, to the amount of half a drachm daily. Usually, however, attention to the bowels, with regulation of the diet, &c, will be sufficient to effect a cure without any further medi- cal interference being required. V. PEMPHIGUS GANGRENOSUS (BURNT HOLES). A variety of pemphigus to which the epithet gangrenosus has been applied by Dr. Stokes the elder,* is not uncommonly met with among children, and constitutes a very dangerous disease. It occurs usually within the first five years of life, chiefly among the children of the poor, who live in damp, unhealthy situations ; and it sometimes assumes an epidemic character. Our account of the Symptoms we shall take, in a good measure, from the essay of Dr. Stokes, who first accurately described them, adding any thing which our own experience may suggest. " The approach of this disorder is sometimes, though rarely, denoted by a livid suffusion, like that of erysipelas, slightly elevated. It more fre- quently happens, however, that the complaint comes on in perfect health. One or more vesicles appear, mostly larger than the best distinct small-pox : these increase for two or three days, burst, and discharge a thin fluid, having a disagreeable smell, limpid in most cases, sometimes whitish, and sometimes yellowish ; the latter less dangerous : usually, the weaker the child's constitution is, the thinner is the matter.f Before or after breaking, the vesicles run together ; the sore becomes painful, with loss of substance, and a thin, fetid, ichorous discharge ; the edges of the ulcer are undermined, and it spreads quickly." We have sometimes observed the sore to put on a very peculiar appearance, being clean, but perfectly destitute of granulations, without any surrounding inflammation, and seeming exactly as if a portion had been scooped out of the sound skin with a sharp gouge. The surface of the sore, is, in other cases, livid and sloughy, true gangrene actually taking place in it. " The most usual seats of the disease are, behind the ears, some- times on the hands or feet, on the private parts, (seldom on the arm- pit,) the breast, folds of the thighs, lower belly, on the inside of the mouth or lips. If the sores are behind the ears, they destroy the connection of the posterior cartilage with the cranium ; they spread to the meatus auditorius : to the eyes, the sight of which seemed, in a few cases, to have been destroyed one or two days be- fore death ; and they sometimes extend to the vertex. * Dub. Med. and Phys. Essays, vol. i. Dublin, 1808. f Dr. M'Adam, in one case, found this matter so acrid as to corrode sound skin upon which it had dropped. See Dub. Med. and Phys. Essays, vol. i. 1803. BURNT HOLES. 357 "The constitutional disturbance, that accompanies this disease, seems principally the effect of irritation. When the vesicles burst the child begins to grow peevish and fretful, pale, loses its appetite and the flesh becomes remarkably flabby. The periods of the dis- order are not very regular; but it often 'happens, about the eighth day, that the pulse sinks, the lividity spreads over the whole sore the fetor and discharge increase greatly. The smell is so strong as often to be perceivable at a distance from the bed. The discharge in one case, where the ulcers affected the arm-pits and breasts, was such that the linen was completely loaded several times a day. " Death takes place about the tenth or twelfth day, often preceded by convulsions, sometimes by extreme debility. Patients are apt to relapse soon after the sores are skinned over. " The causes of this malady are rather obscure. It seems exclu- sively confined to children. Dr. M'Donnell saw twenty cases before the year 1795 ; all the patients were under four years old. Dr. Spear observed, that it was confined to children from the age of three months to that of five years ; but it has been observed, near Dublin, in children of nine years old. It attacks the finest children in preference ;* the children of the poor more frequently than those of the affluent ; and those who live in damp situations seem more peculiarly subject to it than others. The disease is more prevalent in summer than in winter. It appears to be infectious, though ob- scurely so, in general ; but in the year 1800, Dr. Spear observed it to spread epidemically." Diagnosis. — The eruption of pemphigus at the commencement bears some resemblance to that of varicella ; but the progress of the vesicles, in the former case, to ulceration, and in the latter to desicca- tion, soon establishes the difference. Excoriations behind the ears, and in the angle between the thigh and pudenda, occasionally pro- duce very troublesome sores ; but they are to be distinguished from pemphigus by their origin, not in vesicles, but in simple chafing of the skin ; neither are they so rapid in their course, nor attended with such severe contitutional disturbance. The Prognosis in pemphigus gangrenosus is unfavourable, and the more so in proportion to the amount of constitutional disorder. The most unfavourable characters are, rapid spreading of the sores, and supervention of gangrene ; also paleness and fetor of the dis- charge. The Treatment of this disease has usually been directed princi- pally to its local manifestations ; and Dr. Stokes, with considerable trouble, procured and published the particulars of the composition of an ointment, which appears to have been extensively and success- fully employed in its management by the Irish peasantry. The essential ingredient in this ointment, Dr. S. found to be the leaves of the scrofularia nodosa (great Jigwort,phogr am, or rose noble) — an officinal preparation of which has been latterly introduced into * This does not accord with our own experience, as we have usually seen the disease in ill-fed, delicate subjects. 358 CONSTITUTIONAL DISEASES. the Dublin Pharmacopoeia. His practice was, in the first instance, to apply a carrot poultice, or one formed of porter and oatmeal, to the sores. After about eight hours, this was to be removed, the parts affected very gently wiped with lint, and the scrofularia oint- ment, previously melted to the consistence of honey, applied by a soft feather, and with the utmost gentleness, to the whole surface of the sore. After smearing the ulcer with the ointment, it should be dressed with the same ointment, with the addition of one-eighth part of wax. The dressing should be repeated, in severe cases, every fourth or sixth hour. With respect to general treatment, Dr. S. says, " I believe it to be necessary that the child's bowels should be kept open. I also direct the internal use of yeast, which I am of opinion is of service, but cannot decidedly prove it to be so." We entirely concur in the foregoing plan of local treatment, and have found considerable advantage in the employment of the scrofu- laria ointment ; but our own experience would decidedly lead us to the adoption of a very careful general treatment. Change of locality, and free ventilation of the patient's apartment, should, if possible, be effected at the very commencement. The bowels should be regu- lated by alterative aperients, which commonly bring away dark- coloured and offensive stools. The diet should be nutritious, but not stimulating ; and if the child be suckling, a fresh and healthy nurse should be procured. As soon as the bowels have been set to rights, we commonly administer quinine ; and if there be no diarrhoea, we may combine it with one of the mineral acids. We have seen a comparatively chronic form of the disease among children, in which we have found the most decided benefit to attend upon the employment of iodine. A disease has been described by Mr. Kinder Wood, in the 7th vol. of the Med. Chir. Transactions, under the name of " a very fatal affection of the pudendum of female children," which appears to us to be merely a form of pemphigus infantilis, and to require treat- ment founded on principles precisely similar to those we have just laid down. All Mr. Wood's cases occurred between the first and sixth years ; and of twelve which he saw, only two recovered. One of the most remarkable symptoms which he observed, and which we may consider to be peculiar to the affection of the pudendum, was retention of urine. This appeared to be in a great measure volun- tary, the patient being unwilling to encounter the pain of making an attempt at passing water : it accordingly required a vigilant atten- tion on the part of the attendants. In a fatal case quoted by Mr. Wood, " the abdominal and thoracic viscera were found to have been free from disease." SCALDING OR CHAFING. 359 CHAPTER XIV. DISEASES OF THE SKIN. The cutaneous system, during the periods of infancy and childhood, is subject, as in the adult, to many important forms of disease. Seve- ral of these we have already considered under other heads, and of those remaining unnoticed there are a considerable number which, presenting no remarkable peculiarities in the young subject, require no special attention in the present work. It would also be, mani- festly, out of place to enter at any length into a consideration of the difficult and obscure subject of cutaneous diseases, or to attempt even a sketch of the manifold classifications invented by authors, with the design, hitherto unaccomplished, of introducing order and perspicuity into this intricate branch of medicine. We shall, therefore, content ourselves with a few short practical sketches of certain affections of the skin necessary to be understood by the child's physician, either from the frequency of their occurrence, or the peculiarities of their diagnosis or treatment during the early stages of life. Having laid down this limited plan for our guidance, we shall not adhere to any particular nosological system, but without mystifying ourselves and our readers by attempts to ascertain the various meanings attached to the same appellations by different authors, we shall endeavour to attain intelligibility by the employment, as far as possible, of terms of a general signification and popular use. I. ERYTHEMA INTERTRIGO (SCALDING OR CHAFING). This affection, which is a species of exanthem, very frequently occurs in infants and young children, showing itself on the groins, upper part of the thighs, scrotum, neck, between the buttocks, behind the ears, and on other parts where opposite surfaces of the skin are in continual contact, or subject to friction, being often occasioned, in the first instance, by neglect on the part of the nurse, and inattention to cleanliness. It appears in the form of red blotches, irregular in shape, not defi- nitely circumscribed, varying much in size, and commonly lasting from eight to twelve days. There is but little general fever ; but the child is fretful, and the local inflammation is sometimes considerable, being accompanied by severe itching, and the exudation of a faint- smelling sero-purulent fluid. If the affection continues unrelieved, the skin becomes hard and chapped, and troublesome excoriations follow A form of erythema may sometimes be seen upon the cheeks of children during teething; at first appearing merely as a bright red blush, and subsequently leaving the skin rough and fretted. The Diagnosis of erythema intertrigo is not difficult Erysipelas and syphilis are the diseases with which it is most likely to be con- 360 DISEASES OF THE SKIN. founded ; but from the former it may be distinguished by its super- ficial character, and by the absence of any severe constitutional dis- turbance. Its common seat about the groins and buttocks may cause it to bear some slight resemblance to syphilis ; but the coppery colour of the latter, together with the snuffles and other symptoms belonging to it, furnish abundant means of discrimination. The treatment of this affection is very simple, consisting almost entirely in a removal of the exciting cause by strict attention to clean- liness, and keeping the parts dry. When the inflammation is con- siderable, fomentations with warm water, or decoction of chamo- mile flowers, will be useful. When the discharge is troublesome, the parts may be washed, two or three times daily, with tepid spirits and water, and subsequently dusted over with finely powdered starch. The administration of a mild alterative aperient, as the powder of rhubarb and magnesia (p. 126) will usually complete the cure. II. URTICARIA (NETTLE RASH). Young children are not unfrequently affected with this eruption, which, though unimportant in its own nature, may, by the sudden- ness of its attack, occasion considerable alarm. It is most likely to occur in hot weather, and often seizes children during sleep, from which they then awake restless and screaming. Upon examination, the body and lower limbs will be found covered with raised patches or wheals of irregular shape and pale colour, resembling those caused by the stinging of nettles, and accompanied by excessive itchiness. It may often be traced, as in adults, to some irregularity of diet. Nettle rash is an affection of very trifling importance, and in the child usually requires but little treatment. A tepid bath will relieve the itchiness and heat, and a slight aperient will commonly remove the exciting cause of the disease. III. SCABIES (ITCH). This disgusting disease is very frequently met with in young infants, whose tender skins are extremely susceptible of the infection. Its nature is, however, often mistaken, and it is chiefly upon this account that we are led to notice it. Itch is commonly communi- cated to young infants from the hands or breast of the nurse, and it, therefore, first appears upon the buttocks and lower limbs, or upon the back of the neck, the hands often continuing completely free from spots. Owing to the delicacy of the skin it is attended with much more inflammation than in adults, and sooner assumes a pus- tular character. The pustules, also, break earlier, and thus give rise to larger and more doubtful looking ulcers and scabs. These circumstances, together with the severe constitutional disturbance which itch often occasions in the young child, frequently perplex and deceive the practitioner, and we have not unfrequently known it to be mistaken for a syphilitic eruption. CRUST A LACTEA. rtfil The diagnosis will commonly be made quite clear by an inspec- tion of the nurse, on whose skin the true characters of the disease may, in almost every instance, be readily recognised. The treatment may be disposed of in very few words; it con- sists, as in the adult, of the internal and external use of sulphur. With children, however, this powerful medicine must be cautiously used ; not more than a drachm of the ointment should ever be applied at one time, and the application should be made successively to different parts of the body. The plan which we adopt is to direct a portion of sulphur ointment, about the bulk of a hazel nut, to be rubbed, at bedtime, upon a fourth part of the surface of the body, and the child to be placed in a tepid bath for ten minutes on the succeeding morning. The process is to be repeated, each night, upon a different portion of the body, until the eruption has entirely disap- peared ; at the same time half a drachm of sulphur electuary should be given every second night to more grown children ; but for those at the breast it will be sufficient to give the nurse, each night, a tea- spoonful of the flower of sulphur. IV. CRUSTA LACTEA. The disease of which we propose to treat under this name has been variously denominated by system-mongers, according to their peculiar fancies in the matter of classification. Thus, it is termed, by Willan, Porrigo larvalis ; by Bateman, Impetigo larvalis ; by Rayer, Eczema impetiginodes; and by others, Tinea muciflua,granu- lata, &c, &c. ; but unfortunately by none of these learned appellations are we made at all the wiser as to the nature and treatment of the affection. The eruption usually occurs during teething, and appears to be much connected with that process ; it commonly commences on the forehead, by the breaking out of a number of small, yellowish pus- tules, more or less confluent and crowded together upon a red surface. These pustules excite great itchiness, and are quickly broken, dis- charging a viscid fluid that subsequently concretes into thin greenish- yellow scabs. The scabs are frequently rubbed off, and, when they form again, are tinged, of a dark colour by the blood which follows the furious scratching of the child. Fresh crops of pustules appear around the scabs which quickly extend to the scalp and over the face, sometimes covering the latter as with a mask, and justifying the epithet larvalis. When the scalp becomes engaged, the lym- phatic glands at the back of the neck enlarge and occasionally sup- purate. The ears seldom escape, and patches of the eruption will also often appear upon the neck and breast ; upon the head, the discharge from the pustules is caught by the hair and concretes into small, irregular, friable masses, somewhat resembling the bruised yolk of a hard-boiled egg. At the termination of the disease, the skin of the face remains, for some time, red and tender, but scarcely 31 352 DISEASES OF THE SKIN. ever retains any permanent marks. Owing to the extreme itchiness, and the irritation occasioned by the continual efforts of the child to scratch its face and head, sleep will usually be much disturbed, and a state of uneasiness and fretfulness kept up : it is, however, often wonderful how little the general health may be affected in this dis- ease, and how well the process of dentition, and the functions of digestion and nutrition may be performed during its continuance. Still our observation does not lead us to coincide, unconditionally, with Dr. Underwood, who says, he " never saw an infant much loaded with it but it-has always been healthy, and cut its teeth re- markably well." We have certainly seen it produce severe and dangerous constitutional disturbance, although such cases are excep- tional, and the prognosis is, in general, highly favourable. This disease does not appear to be contagious, although Alibert mentions an instance in which it was propagated by inoculation. The treatment of crusta lactea should, we think, be of a very simple kind. We have little faith in the numerous lotions recom- mended by authors, and ointments of all sorts we have invariably found to be injurious. In the early stages, when there is considerable inflammation, and the discharge is copious and acrid, bathing, several times during the day, with tepid water or a decoction of poppy-heads, will give relief, and when the scabs are hard and extensive, poultices oi linseed meal will be necessary for their removal. The hands of the child should be muffled at night, and it should be carefully watched in order to prevent it from scratching its face and head, but the utmost attention will usually be insufficient for this purpose. When the severity of the inflammation has subsided, and the disease ceased to spread, we have derived much advantage from lightly touching the raw surfaces, from which scabs have been rubbed, with a pencil of lunar caustic, or brushing them over with a camel's hair pencil moistened in a solution of that substance. This application removes the itching more effectually than any other of which we are aware, and thus often enables the child to enjoy a night's quiet rest. The internal treatment should be such as maybe indicated by the state of the general health ; the employment of mild alterative aperients combined with antacids (Nos. 27, 28, and 29) will usually be productive of much benefit. When the disease becomes chronic, tonics will probably be required, among which none is more suitable than the hydriodated solution of iodine (No. 10). In this stage we have also found the tepid, or, when the season is suitable, the cold salt water bath, very serviceable. In every case, the strictest atten- tion should be given to the regulation of the diet, and the restriction of all articles of a stimulant or acescent character. V. HERPES CIRCINNATUS (RINGWORM). This affection is very common among children after the period of infancy. With some -individuals it is an annual visitant, making its SCALD-HEAD. 363 appearance, regularly, every spring, during the period of childhood. The vesicular ringworm is an eruption of small, globular vesicles crowded closely together, and arranged in the form of a ring or crescent ; the portion of skin included within the figure is healthy and of its natural appearance, and commonly measures from half an inch to two inches in diameter. The vesicles are filled with a trans- parent fluid, and the skin upon which they are set is of a red colour, especially towards the outer margin of the circle. The breaking out of the eruption is attended with itching and smarting, which con- tinue during its progress. In five or six days, the redness begins to disappear, the vesicles become turbid and finally burst, their place being then occupied by thin scaly scabs, which desquamate, between the 10th or 15th day from the commencement, leaving the skin be- neath of a bright red colour. Sometimes the smaller vesicles do not burst ; but the fluid within them being absorbed, a slight desquama- tion of the cuticle takes place. Several patches of ringworm usually appear at the same time, or they may be evolved in succession during a period of several weeks ; their most common sites are the forehead, backs of the hands and wrists, the ham, and the back part of the forearm near the elbow. Very little constitutional disturbance attends the eruption, which does not seem to be contagious, although it is often seen at the same time upon several individuals in a family or school. This, however, may be accounted for by the disposition of the disease to appear at a particular season of the year. The name of vesicular ringworm, must not lead to its being confounded with pustular ringworm of the scalp (porrigo scutulata), which is a dis- ease of a very different character and much more troublesome nature. The Herpes circinnatus or vesicular ringworm, though troublesome from its appearance and itchiness, is seldom followed by any perma- nent, disagreeable results. The treatment consists in little more than guarding the affected part from the ill effects of scratching. At the commencement, the best application will be a fold of lint wet with cold water, and covered with a piece of oiled silk — the common Avater dressing. Should this not relieve the itchiness, the spots may be brushed over with a solution of nitrate of silver. Alterative aperients should at the same time be given, and, during the process of desquamation, the tepid salt water bath should be frequently employed. VI. TINEA CAPITIS (SCALD-HEAD).. No words can convey a keener satire upon the imperfection of the medical art, than would a simple enumeration of the names and enkhets invented by various authors for the disease of scald-head, and a con ras of that multitudinous catalogue, with the beggar y account o haemal knowledge of means whereby we can reasonably exnect to accomplish the removal of that distressing affection. Chap- ters and volumes have been composed upon this unhappy subject; 364 DISEASES OF THE SKIN. the finest distinctions between the varieties of scabs and sores have been pointed out ; the most learned and unintelligible names have been constructed from all languages ; the art of the apothecary, and the fancy of the quack have been strained for the invention of oint- ments, lotions, and depilatories, and yet, we believe, no systematic writer, at the present day, points to any line of treatment to which we can look with a confident hope of its being sufficient for the cure of any particular case of the disease. Still we do not believe tinea capitis to be hopelessly incurable ; and we are further of opinion, that the obstinacy with which it has hitherto been found to resist treatment, has been referable less to its own nature than to the want of patience on the part of medical practitioners, and the variety of remedial experiments which they have consequently been led to in- stitute. In the observations which we now propose to make, we shall not attempt to follow out the tedious descriptions of the syste- matic writers, or to temovethe obscurity with which their whimsical epithets and divisions have enveloped the subject ; but, without enter- ing into nice distinctions,shall endeavour to convey a general view of the characters of the disease, and thereupon to found rational prin- ciples of treatment. Tinea Capitis is a disease rather of childhood than of infancy, commonly occurring about the sixth or seventh year. It may, how- ever, make its appearance at a much earlier age. It is highly conta- gious, and is very readily communicated among children using the same combs or brushes, or wearing the same head dress, so that when once introduced into a school or other assemblage of young persons, it is very likely to contaminate almost every individual. Besides contagion, there would appear to be other causes that favour the production of tinea, and which are well worthy of attention. We find, for example, that it is comparatively uncommon in the board- ing schools used by the children of the higher classes, while it is a very common visitant of institutions in which any considerable num- ber of the children of the poor are assembled. When we inquire into the circumstances of these assemblages, we shall usually find that the children are the offspring of very destitute parents ; that they have been neglected and ill fed during infancy, and are conse- quently defective in constitution, and often scrofulous. Their habits in such institutions, are also, very generally, unfavourable to health; they are kept during a great portion of the day in a sedentary pos- ture, and in a crowded schoolroom ; their sleeping apartments are over filled ; their food ill suited to their tender years, and their cloth- ing often insufficient upon some parts of the body, as the head or feet ; cleanliness, too, is frequently but superficially practised among them. Such are the circumstances under which tinea most com- monly appears, and we can scarcely refuse to admit that they must be considered as at least among the causes that favour its pro- duction. The external characters of tinea vary considerably in different cases ; such variation, apparently, depending partly upon the dura- SCALD-HEAD. one tion of the disease, and partly upon the constitution of the patient, inus we shall have, in one case, the scalp covered with clusters ot minute, oozing, red prominences, some of which are covered with ary yellowish scabs, while others are indented with pits or cups filled with pus, presenting a honeycombed appearance and exhaling adis- agreeable odour, similar to that of the urine of cats. These characters nave been described by authors under various names, as porrigo, or tinea, favosa or lupinosa ; favus dispersus ; true porrigo, &c. In another instance, the scabs will be found to be thick and firm, and to assume somewhat of a definite circular shape, whence many other names are derived; as porrigo, scutulata; pustular ring- worm, favus confer tus, &c. Again, when the scabs are united into one firm incrustation, cover- ing the head like a cap, the names of tinea Crustacea, porrigo lar- valis, and impetigo larvalis, &c, have been applied to the disease ; while it is by some termed tinea granulata, when the hairs are matted and glued together by the scabs, into separate tufts. In a fifth case we may have the discharge less abundant and less viscid, in consequence of which the scabs will assume a thin and scaly character ; or the discharge may dry into a branny powder which can be easily separated from the scalp. In these cases which are most common among scrofulous children, the hair falls off in patches, and becomes weak and light coloured. When it assumes this appearance, the disease has been called indifferently tinea fur- fur ans, tinea asbestina, porrigo furfur a cea, ecpyesis porrigo, &c. Lastly, as a consequence of tinea, the scalp may become, entirely or in part, devoid of hair, the skin being free from ulceration or scab, and smooth, shining, and white. This baldness is described by some writers as occurring without any previous morbid appearance ; but we do not believe this statement to be correct: in most of the cases which have fallen under our notice, the loss of hair was known to have been preceded by an eruption of pustules, though in some in- stances these were so minute as to attract but little attention. It is this state which is described in books under the title of alopecia ; porrigo deca Ivans ; trichosis area, &c. Tinea is always attended with extreme and harassing itchiness, which is augmented by the numerous pediculi produced under and among the scabs. The severity of the local irritation is generally shown by the swelling and inflammation of the lymphatic glands, at the nape of the neck, which often suppurate. The cellular tissue beneath the scalp will also, in severe and neglected cases, become the seat of collections of matter, and the inflammation may extend to the periosteum, and even to the bones of the cranium. It is attempt- ed to be argued by some writers, that the disease is merely local. This opinion we consider to be altogether incorrect ; at all events there can be no doubt that if it be not occasioned, it is constantly attended by very considerable constitutional disturbance. Rayer correctly observes that tinea is often complicated with chronic in- flammation of the gastro-intestinal mucous membrane, and that, 31* 366 DISEASES OF THE SKIN. when it becomes inveterate, the intellectual faculties are frequently- diminished in vigour, and a sort of premature old age appears to be induced. The nails of the feet and hands sometimes exhibit remark- able alterations, increasing in thickness, and becoming rough and yellowish in colour. It may be collected from what we have already stated, that we consider the p?*og?iosis in tinea capitis to be unfavourable. It may, however, wear itself out after a continuance of months or even years, and it may terminate, by a destruction of the bulbs of the hair, in that state of baldness to which we haye just adverted. Our pro- gnosis should, nevertheless, refer to the tediousness and obstinacy, rather than to the incurability of the disease. Patience and cleanli- ness, with attention to the general health are, we believe, the grand remedial agents required, and by the employment of these, during six months, the late Dr. J. Crampton,* cured a total of twenty-eight cases which he treated, together, during that period. The treatment of tinea, as it is laid down in the works of syste- matic writers is a mere jnmble of empirical experiments: lotions, ointments, eseharotics, and depilatories of all kinds, from the decoction of flaxseed to the pitch cap, inclusive, have been freely recommended and unsparingly used, and each and all have most impartially failed. To enter into any discussion with respect to the numberless propo- sals of remedies, or even to enumerate them, would lead us far be- yond our limits, and that without conveying the least particle of useful information to our readers. Those who are curious on the subject, we must, therefore, refer to the express works on cutaneous diseases, and shall now content ourselves with sketching the plan of treatment which appears to us most rational, and which we have found to be comparatively, though (we must confess) not absolutely, successful. The treatment, then, must be both constitutional and local ; the former being directed to there-establishment of the general health, by whatever may appear in each case to be the most suitable means. In children who have been leading sedentary lives, who have been poorly and carelessly fed, and whose digestive systems have consequently become disordered, aperients are strongly indi- cated, and those of a saline kind will be found to be particularly useful. In scrofulous children, much benefit will generally be derived from the use of the warm tonic purgatives, as the saline infusion of rhubarb (No. 2S), or the aloetic mixture (No. 35). Dr. Crampton recom- mends purgatives every second morning ; but we must, of course, use our discretion as to the frequency of their repetition, always stopping short of exciting any excessive irritation in the intestinal canal. In almost every case, we shall find advantage from the em- ployment of iodine given in the form of the hydriodated solution * We have to acknowledge the great advantages which we derived from a peru- sal of the paper of this able and lamented physician, published in the fourth vol. of the Transactions of the King and Queen's College of Physicians. In a few pages, Dr. Crampton has conveyed more information in an intelligible form, than is to be found in all the systematic works taken together. SCALD-HEAD. (No. 10), and ill doses suited to the age of the child. Should the henatir system be materially deranged, alterative doses of mZyZy ZK?S2 £ Z5S2&** the *■!■** * Patients wLse tatP 3 £*' V he Sk f WiU alrn0St alwa ^ s be in an unhealthy state being dry, harsh, and supplied irregularly with heat. In such cases no remedial measure is more useful than the warm bath, which may be employed every second or third night. While adopting these means in whole or in part, as may in each case seem advisable, the strictest attention must be paid to the regulation of the diet, which should be light, nutritious, and such as we may find from expe- rience will agree best with each patient. The clothing also should be comiortable, the feet kept warm and dry, and precautions adopted lor preventing an irregular distribution of heat throughout the body. I he sleeping apartment of the child should be airy, and not over- crowded with occupants. In conducting the local treatment, the first indication is the removal oi the scales and crusts, the presence of which upon the scalp keep it in an irritated and filthy condition. The next step must have for its object to soothe and mitigate the inflammation under which the diseased parts more or less suffer. In pursuance of these indications, then, we must at once have the hair taken off by clipping, or shaving when that is practicable. The scabs or crusts must next be removed by washing with soap and water j or where that will not succeed, by poultices of linseed or oat-meal. In some cases the crusts are unusu- ally firm and tenacious, and in order to effect their removal we may find it necessary to employ, for a few days, poultices made of brown soap, reduced to a stiff jelly. When the scabs have been removed by this application, the linseed or oat-meal poultice maybe resumed, and continued as long as the scalp remains in a morbid condition. As the poultice cannot be conveniently used while the patient is taking exercise, the best substitute for it, during such periods, will be the liniment of lime-water and oil, which may be smeared over the head with a brush or feather, and covered with a soft linen cloth. Throughout the treatment we need scarcely say that the head must be regularly washed with warm soap and water, and the utmost attention given to the preservation of cleanliness. If the foregoing plan be pursued steadily and with patience, and recurred to should relapses (as often happens) take place, it will, in many cases, according to our experience, prove successful. Should it fail, after a reasonable trial, the practitioner will probably be justified in resorting to the depilatories, escharotics,and other severe measures, recommended in books, and during their use the disease will no doubt sometimes be removed ; we may state, however, that Dr. Crampton's twenty-eight cases were treated upon a plan similar to that laid down above, during six months, and were all ultimately cured. The topical applications tried by Dr. C. at first, all failed ; among them were ointments of oxides of mercury, lead, and zinc ; of pitch, sulphur, black pepper, and sulphuric acid ; and lotions of 368 DISEASES OF THE SKIN. almost all the metallic salts. We have ourselves tried most of these applications, and some others besides, and have not been much more successful in their use than was Dr. Crampton. In that variety or termination of tinea capitis, in which the hair falls off in patches, leaving the scalp smooth and white, and known among authors as alopecia or porrigo decalvans, it becomes a desi- deratum to discover some means of promoting a new growth of hair. For this purpose a vast variety of applications have been recom- mended and tried ; but we must frankly admit that we know of none possessing the least claims upon our confidence as cures for: baldness. INDEX. Abscesses, 151 Accidents at Birth, 131 Air, 57 Alkalies, 94 Aloes, 130 Alopecia, 365 Angina, 174, 255, 261 Antacids, 94 Antiphlogistics, 103 Anthelmintics, 130, 241 Ani Prolapsus, 212 Antimony Tartarized, 112 Anas, Imperforate, 136 Aphthae, 170 Arachnitis, 286 Artificial Feeding, 40 Ascarides, 239 Asphyxia, 132 Asthma Thymicum, 265 Atelectasis Pulmonum, 135 Atrophia Ablactatorum, 194 Bark, 98 Baths, 119 Ioduretted, 346 Bed, 51 Biscuits, Purgative, 128 Blisters, 107 Bloodletting, 103 Blue Disease, 147 Boiling Water, Swallowing of, 262 Bottle, Sucking, 42 Bow's Opiate Liniment, 93 Bowels, Healthy state of, 55 Training of, 47 Affections of, 190 Brain, 20, 25 Irritation of, 274 Effusion in, 276 Congestion of, 275 Inflammations of, 280 Bread, Ferruginous, 346 Breasts, Swelling of, 158 Bronchitis, 251 Broncho-pneumonia, 252 cephalite, 270 Bronchotomy, 262, 264 , Bryce's Test, 321 Burnt Holes, 356 Calomel, 89 Cancrum Oris, 181 Carminatives, 95 Daiby's, 96 Castor Oil, 122 Catarrh, 250 Bronchial, 251 Causes of Disease, 66 Cerebro-spinal System, 20 Diseases of, 274 Chalybeate Powder, 99 Change of Air, 85 Childhood, 13 Children, Management of, 31 Food of, 42 Still-born, 132 Chicken-pox, 315 Choice of Nurse, 39 Cholera Infantum, 198 Circulatory System, 18 Cleanliness, 45 Climate, 85 Clothing, 47 Clyster, 131 Club Feet, 140 Cold, 48 Colic, 212 Colitis, 221 Colostrum, 35 Constitutional Diseases, 338 Convulsions, 277 Coryza, 250 Costiveness, 55 Cow-pox, 316 Cowhage, 241 Coxe's Hive-syrup, 116 Cradles, 50 Croup, 255 Membrane of, 257 Spasmodic, 258 Cerebral, 265 Crowing Inspiration, 266 Crusta Lactea, 361 Cupping, 106 Cutaneous Diseases, 359 Cyanosis, 147 Cynanche Parotidea, 189 Trachealis, 255 Maligna, 300 Daiby's Carminative, 96 Dancing, 53 Deformities, 135 370 INDEX. Dentition, 158 Treatment of, 164 Diagnosis, 76 Diaphoretics, 116 Diarrhoea, 207 Digestive Organs, 15 Diseases of, 167 Functional, 192 Inflammatory, 218 Disease, 66 Signs of, 77 at Birth, 131 Constitutional, 338 Diphtherite, 174 Dolichos, 241 Doses of Medicines, 83 Dressing of Infants, 33 Dysentery, 221 Ear, Scrofulous Disease of, 341 Early Rising, 51 Eczema, 361 Education, Physical, 31 Mental, 58 Moral, 62 Religious, 65 Emetics, 110 Enema, 131 Enteritis, 219 Eruptive Fevers, 292 Erysipelas, 149 Erythema, 359 Etiology, Q6 Exanthema, 292 Excitants, 98 Exercise, 52 Expectorants, 115 Favus, 365 Feeding, Artificial, 40 Feet, Swelling of, 163 Deformed, 140 Fever, 242, 292 Fingers, Supernumerary,. 141 Fits, 147, 265, 277 Foreign Bodies in Larynx, 263 Food, 35, 36, 42 of Nurses, 39 Fractures, 146 Frenum Linguae, 139 Funis, 33, 47 Gangrene of the mouth, 182 Gardens, Public, 54 Gastritis, 219 Gastro-malacia, 201 Glottis, Ulceration of, 263 Spasm of, 265 Gripes, Watery, 211 Growth, 23 Gums, Lancing of, 165 Gum, Yellow, 153 Red, 157 Gymnastics, 53 Hands, Swelling of, 163 Hare-Lip, 139 Hardening of Cellular Tissue, 151 System, 48 Health, 76 Heat, 57 Heat of Infants, 32 Herniae, 143 Herpes, 362 Hide-bound, 151 Hippo, 111 Hooping-Cough, 268 Hoisting, 52 Huile Purgative, 129 Hydrargyrum, 88 Hydrencephaloid Disease, 277 Hydrocephalus, 282 Chronic, 285 Congenital, 286 Hydrocele, 145 Hypospadias, 137 Icterus, 153 Ileitis, 220 Impetigo, 361, 365 Induration, 151 Infant, 13 External Characteristics of, 14 Digestive Organs of, 15 Respiratary Organs, 17 Circulatory Organs, 18 Cerebro-spinal System of, 20 Senses of, 21 Locomotive Organs of, 22 Growth of, 23 Management of, 31 Heat of, 31 Washing of, 32 Dressing of, 33 Feeding of, 35, 36, 42 W T eaning of, 42 Schools, 65 Indigestion of, 192 Cholera of, 198 Infantile Erysipelas, 149 Therapeutics, 83. Colic, 212 Infusion of Rhubarb, 127 Inflation of Lungs, 133 Inguinal Hernia, 145 Injuries during Birth, 146 Intellect, Development of, 27 Intertrigo, 359 Inoculation, 314, 323 Inward Fits, 265, 278 Iodine, 99, 101 Ipecacuan, 111 Iron, 99 Itch, 360 INDEX. Jacob, Dr Letter from, on Purulent Ophthalmia, 155 Jalap, 128 Jaundice, 153 Larynx, Foreign Bodies in, 263 Inflammation of, 261 Laryngismus, 265 Leeches, 105 Lientery, 211 Light, 56 Locomotive Organs, 22 Lockjaw, 147 Lumbricoides, 239 Lungs, Inflation of, 134 Management of Children, 31 Magnesia, 124 Manna, 123 Maternal Nursing, 36 Maw Worm, 240 Measles, 292 Meconium, 35 Medicine, 35, 54 Mercury, 88 Mesenteric Disease, 228 Mental Education, 58 Milk, Substitutes for, 40 Millet, 173 Mixture, Anti-emetic, 96 Carminative, 96 Exciting, 98 Terebinthinate, 98 Strengthening, 99 Emetic, 112 Expectorant, 113 Antimoniated, 114 Sedative Ipecacuan, 114 Sedative Squill, 115 Polygala,U5, 116 Aloetic, 130 Astringent, 196 Senna, 128 Manna, 123 Moles, 141 Moral Education, 62 Mortality of Infancy, 131 Mouth, Inflammation of, 169 Ulceration of, 169 Gangrene of, 179, 182 Muguet, 173, 191 Mumps, 189 Music, 54 Navel-string, 33, 47 Naevi, 141 Nettle-rash, 360 Nine-day Fits, 147 Nursing, Maternal, 36 Obstacles to, 36 Rules for, 37 Nurses, Management of, 38 Choice of, 39 371 Nursery, 51,57 Medicines, 56 Obstacles to Nursing, 36 Ointment, Sedative, 109 Omphalocele, 143 Opium, 92 Opiate Liniment, 93 Ophthalmia, 153 Ophthalmia, Scrofulous, 340 Paralysis, 147 Pastilles de Manne, 123 Peculiarities of Infants, 13, 66 Penis, Imperforate, 136 Perforation of Bowels, 227 Peripneumonia, 252 Pericarditis, 255 Pemphigus, 356 Pertussis, 268 Pes Equinus, 140 Pleuritis, 255 Pneumonia, 254 Polygala, 115 Porrigo, 361, 365 Potion Calmante, 117 Powder, Chalybeate, 99 Expectorant, 113 Rhubarb and Magnesia, 126 Compound Rhubarb, 127 Jalap and Ipecacuan, 128 Sedative Ipecacuan, 114 Scammony and Chalk, 129 Scammony and Rhubarb, 129 Prescribing, 83 Prognosis, 81 Prolapsus Ani, 212 Public Gardens, 54 Pulse 19 Purging, 54 Purgatives, 122 Biscuits, 128 Purpura, 354 Pustule, Malignant, 181 Red Gum, 157 Refrigerants, 117 Remittent Fever, 242 Respiratory Organs, 17 Diseases of, 250 Retention of Urine, 137 Rhubarb, 126 Rickets, 348 Ringworm, 362, 365 Rocking, 50 Roseola, 297 Rules for Nursing, 37 Prescribing, 83 Rubeola, 292 Sine Catarrho, 297 Nigra, 297 Ruptures, 143 Salivation, 88 372 INDEX. Salt, Use of, 350 Salts, Neutral, 124 Schools, Infant, 65 Scabies, 360 Scalding, 359 Scald Head, 365 Scarlatina, 298 Anginosa, 299 Maligna, 300 Faucium, 301 Treatment of, 303 Scammony, 129 Scrofula, 338 Scrofularia Nodosa, 357 Scrofulous Glands, 340 Ophthalmia, 340 Ulcers, 340 Ear, 341 Discharge from Vagina, 341 Senses, 21 Sedatives, 91 Senna, 127 Sinapisms, 110 Skin, Diseases of, 359 Skin-bound, 151 Sleep, 49 Small-pox, 308 Confluent, 309 Modified, 310 Snuffles, 250, 352 Solutio Iodinii, 102 Somnolency, 275 Spasm of Glottis, 265 Spina Bifida, 137 Spoon-feeding, 40 Squill, 115,116 Steel, 98 Still-born Children, 132 Stimulants, 97 Strengthening Mixtures, 98 Stomach, Affections of, 190 Softening of, 199 Stomatitis, 169 Strophulus, 157 Strumous Dyspepsia, 339 Sucking Bottle, 42 Suppositorium Anthelminticum, 130 Suppression of Urine, 137 Sudden Death, 267 Swelling of Breasts, 158 Hands and Feet, 163 Swine-pox, 315 Syphilis, 350 Syrup, Simple Sedative, 92 Compound Sedative, 93 Tabes Mesenterica, 228 Tape-worm, 240 Tartar Emetic, 112, 114 Teething, 158 Teeth, Permanent, 166 Temperament, 30 Therapeutics, 83 Throat, Scarlatina of, 301 Thrush, 169, 174 Thread-worm, 239 Thymic Asthma, 265 Thymus Gland, Enlargement of, 268 Tinea Capitis, 363 Toes, Supernumerary, 141 Tonics, 98 Tongue-tied, 139 Tricocephalus, 239 Trismus, 148 Tubercle, 344 Tuberculous Fever, 339 Tumours on Head, 146 Turpentine, 98 Umbilical Cord, 33 Hernia, 143 Unguentum Sedativum, 109 Anthelminticum, 130 Urine, Retention of, 137 Suppression of, 137 Urticaria, 360 Vaccination, 316 Spurious, 325 Vaccine Controversy, 327 Vagina, Imperforate, 136 Discharge from, 341 Valgus, 140 Varus, 140 Varicella, 315 Variola, 308 Ventilation, 51, 57 Vernix Caseosa, 14, 32 Wakefulness, 274 Washing, 32, 46 Water, 117 Water, Boiling, Swallowing of, 262 Watery Gripes, 211 Weaning, 42 Brash, 194 Worms, 236 Yellow Gum, 153 THE END. May, 1843. Siatrtratfj Wort® ON ANATOMY, MEDICINE, SURGERY, AND THE COLLATERAL SCIENCES. PUBLISHED BY ED. BARRINGTON & GEO. D. HASWELL ; Medical Publishers and Booksellers, PHILADELPHIA. irnw WOIEKS PILCHER OIV THE EAR. A TREATISE on the STRUCTURE, ECONOMY, and DISEASES of the EAR ; being the Essay for which the Fothergillian Gold Medal was awarded by the Medical Society of London. By Geo. PiLCHER,late Lec- turer on Anatomy, and Lecturer on Surgery at the Theatre of Anatomy and Medicine, Webb St., Borough, and Senior Surgeon to the Surrey Dispensatory. First American, from the 2d London edition, with Notes and numerous illustrative Plates. "This is a most valuable treatise, illustrated with elegant plates, is a standard work, and must have a great sale in its present form. It teils all about the anatomy and diseases of the ear."— N. Y. Herald. STANDARD MEDICAL WORKS PUERPERAL FEVER. THE HISTORY, PATHOLOGY, AND TREATMENT OF PUER- PERAL FEVER AND CRURAL PHLEBITIS. By Drs. 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" We recommend this volume most warmly to the attention of our readers. —London Lancet, No. 937. M This volume may, in fact, be denominated with no small degree of propriety, an ency- clopedia of dyspeptic disorders, and we unhesitatingly commend it, as the most useful and comprehensive treatise on this class of diseases w ith which we are acquainted." — N. Y.Lancet. " We have perused this work with pleasure and instruction. It is decidedly the best compilation in the English language on the extensive class of disorders and diseases comprehended under the" term dyspepsia, united with a very large proportion of original matter, both in the form of able comments on other writers, and practical information derived from the author's own experience. — Johnson's Medico- Chirurg. for Jan. 1842. SEXVIEIOLOGY. OUTLINES OF PATHOLOGICAL SEMEIOLOGY. Translated from the German of Professor Schill. With copious notes by D. Spillman, M.D., A.M., &c, &c. 1 vol. 8vo. 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" The work before us is an excellent compilation of the subject of hepatic affections, functional and structural; and, as such, it is infinitely more valuable to practitioners and students, than any original essay, however ably executed. We cannot do better, therefore, than strongly recommend the work as the best in the English language, on the important subjects of which it treats.— Medico-Chirurg. Rev., October, 1841. "These two works, when united, form, we may safely say, one of the most valuable and attractive volumes on this important class of diseases which have been issued from the press. We may, en passant, remark, that the volume is got up in a very superior style."— N. Y. Lancet, March 26, 1842. CLINICAL REMARKS ON SOME CASES OF LIVER ABSCESS PRESENTING EXTERNALLY. By John G. Malcolmson,M.D. Surgeon Hon. E. I. C. Service, Fellow of the Royal Asiatic Society, and the Geological Society, London, 1 vol. 8vo. HUNTERS TREATISE ON THE VENEREAL DISEASE. With Notes by Dr. Babington. 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It is no small triumph to the author to be able to say that he has introduced almost all that is valuable, and everything absolutely necessary to the student within the compass of 200 pages, and we would deliberately recommend our young friends to read this work."— Br. % For. Med. Rev. GU1VTS. THE GUMS ; with late Discoveries on their Structure. Growth, Connections, Diseases, and Sympathies. By George Waite, Member of the London Royal College of Physicians. 1 vol. 6vo. TEETH. A TREATISE ON THE TEETH. By John Hunter. With Notes by Thomas Bkll, F.R.S. With Plates. 1 vol. Svo. •* The treatise on the teeth is edited by Mr. Bell, a gentleman accomplished in his art. Mr. Bell has studied his subject with the" greatest minuteness and care: and in ap- propriate notes at the foot of the page corrects the author with the air of ■ gentleman, and the accuracy of a man of science. The matter contained in these short notes forms an ample scholum to the text ; and without aiming at the slightest display of learning, they at the same time exhibit a ready knowledge on every point, and an extensive in- formation both of comparative anatomy and pathology.— Med. Gtr-tttt. CONSTIPATION. A TREATISE on the CAUSES and CONSEQUENCES of HABITUAL CONSTIPATION. By John Burke, M.D., Fellow of the Royal College of Physicians, Physician to the Westminster Hospital, ifcc. 1 vol. Bvo. "For some interestine cases illustrative of this work, the author is indebted to Pr. Williams, Dr. Stroud. Dr. Callawav, Mr. Morsran. Mr. Taunton, Pr. Roots, Sir Asilev Cooper. Sir Benjamin Brodie,Mr. Tupper, Mr. Bailer, Dr. Paris. Mr. Dendy, Dr. Hen. U.Thomson,'' kc— Preface. PUBLISHED BY BARRINGTON AND HASWELL. CHEST. LEC iIV^ ES ?," ^.PHYSIOLOGY and DISEASES of the CHEST, chieflvhl » ^ nnc ;P' es 0f Ph ^ cal aHd General Diagnosis, illustrated ch.efly by a rational Exposition of their Physical Signs: with new re- searche son the sounds of the heart. Br Chiles J. b! Williams, M.D. Inird edition, 1 vol. 8vo. " We d s 1r>n y X rUten by a "jan thoroughly acquainted with his sul ]ea."-Lancet. " Wad. HlJ ZyJJ" Work t0 the a V lention of aus C ultators.»-MM. Chir. Rev. workf-'-li ftL? J 7W? / h / S °Pll or r tun| ty of strongly recommending this very valuable "'Of 11 "£■ * orbes s -translation of Laennec. Med.Gaz. * 0IUh ' S sub J ect > We are inclined much t0 P ref er that of Dr. Williams."- LEC 3iS? T 5 1 S 0N THE DIAGNOSIS, PATHOLOGY, AND TREAT- MENT OF THE DISEASES OF THE CHEST. By W. W. Gerhard, M.D., Lecturer on Clinical Medicine in the University of Pennsylvania, etc., etc. 1 vol. 8vo. " A series of clinical lectures — concise, lucid, and eminently instructive. We have no more able expositor of diseases .if the chest than Dr. Gerhard, and any work of his on these Yorklanret' 1 ^ 1313 cerlam of S rateful acceptance by his professional brethren. "-New To our readers, therefore, we recommend the book of Dr. Gerhard as the fullest and mosr judicious manual, in relation to the diseases of the chest, which they can procure."— Western an I Southern Recorder, June, 1842. " These lectures constitute a useful and practical digest of the existing knowledge of the diseases ol the chest (lungs and heart)."— Bulletin of Medical Science. A PRACTICAL TREATISE onlhe PRINCIPAL DISEASES of the LUNGS. Considered especially in relation to the particular Tissues affected, illustrating the different kinds of Cough. By G. HumeWeatherhead, M.D., Member of the Royal College of Physi- cians, Lecturer ou the Principles and Practice of Medicine, and on Materia Medica and Therapeutics, &c. &c. 1 vol. 8vo. PRACTICAL OBSERVATIONS on~DISEASESof the HEART, LUNGS, STOMACH, LIVER, &c, OCCASIONED by SPINAL IRRITA- TION: AND ON THE NERVOUS SYSTEM IN GENERAL, AS A SOURCE OF ORGANIC DISEASE. Illustrated by Cases. By John Marshall, M.D. 1 vol. 8vo. CUTANEOUS DISEASES. A PRACTICAL TREATISE ON DISEASES OF THE SKIN, arranged with a view to their Constitutional Causes and Local Character, &c. By SAMUEL PLUMBE, late Senior Surgeon to the Royal Metropolitan Infirmary for Children, <&c. Illustrated with Splendid Coloured Copper- plate and Lithographic Engravings. ] vol. 8vo. Plombe on Diseases of the Skin. — " This excellent Treatise upon an order of diseases, the pathology pf which is. in general, as obscure as the treatment is empirical, has just been republished, edited by Dr. John Bell, of this city. We hail with pleasure the appear- ance of any new work calculated to elucidate the intricate and ill-understood subject of skin-diseases. The late Dr. Mackintosh, in his Practice of Physic, recommends it as the 4 best pathological and practical treatise on this class of diseases, which is to be found in anv language.'"— P/iil. Med. Exam., Jan. 17, 1838. " Tliis work is one of the most excellent on the Diseases of the Skin in the English language."— West. Jour, of Med. and Phys. Sciences, Jan. 1838. BANDA&ES AND BAWBAGING, THE SURGEON'S PRACTICAL GUIDE IN DRESSING, and in the Methodic APPLICATION of BANDAGES. Illustrated by one hun- dred engravings. By Thomas Cutler, M.D., late Staff Surgeon in the Belgian Army. 2d American from the 3d London edition. " The Author seems to have spared no pains in procuring correct descriptions of all the surgical apparatus, at present employed in bandaging and dressing, both at home and abroad. He has given numerous illustrations, in the form of well executed woodcuts, ana has altogether produced what we conceive to be a very useful, and by no means an ex pen- sive publication."— Medical Gazette. STANDARD MEDICAL WORKS TETANUS. A TREATISE ON TETANUS, being the ESSAY for which the Jackson ian Prize was awarded by the Royal College of Surgeons in London. By Thomas Blizard CuRLiNG,Assistant Surgeon to the London Hospital,&c. " This book should be in the library of every surgeon and physician. It is a valuable work of reference. It does not pretend to originality, for originality on such a subject was not wanted. But a compendium of facts was wanted, and such a compendium is this volume. We cannot part from Mr. Curling without thanking him for the information we have received in reading his work, and for the matter it has enabled us to offer to our readers." — Medico- Chir. Rev. BLOOD, INFLAMMATION, ETC. TREATISE ON THE BLOOD, INFLAMMATION, AND GUN-SHOT WOUNDS. By John Hunter, F.R.S. With Notes, by James F. Palmer, Senior Surgeon to the St. George's and St. James's Dispensary, &c, &c. 1 vol. 8vo. LECTURES ON BLOOD-LETTING. By Henry Clctterbuck, M.D. 1 vol. 8vo. HISTORICAL NOTICES ON THE OCCURRENCE OF INFLAMMA- TORY AFFECTIONS OF THE INTERNAL ORGANS AFTER EXTERNAL INJURIES AND SURGICAL OPERATIONS. By William Thompson, M.D., &c. &c. 1 vol. 8vo. A TREATISE ON INFLAMMATION. By James Macartney, F.R.S. , F.L.S., &c., «&c. Member of the Royal College of Surgeons, London, &c., &c. 1 vol. 8vo. LECTURES ON THE BLOOD, and on the CHANGES which it undergoes during DISEASE. By F. Magendie, M.D. 1 vol. 8vo. ANIMAL (ECONOMY. OBSERVATIONS ON CERTAIN PARTS OF THE ANIMAL CECO- NOMY, Inclusive of several papers from the Philosophical Transactions, &c. By John Hunter, F.R.S., &c, &lc. With Notes by Richard Owen, F.R.S. 1 vol. 8vo. MIDWIFERY, LECTURES ON THE PRINCIPLES AND PRACTICE OF MID- WIFERY. By James Blcndell, M.D. Edited by Charles Sevebx, M.D. 1 vol. 8vo. Just published. " The eminently fluent and agreeable style — the large anil accurate information — the great experien e — and originafmind of Dr. Blundell have secured for him a very enviable reputation as a public lecturer. It is impossible to read these lectures without being delighted — it is equally impossible to avoid being instructed. Weie these discourses more"gent r rall>' diffused and studied here — were their~sound and judicious directions recollected and their salutary cautions observed, we would hear of fewer cases of malpractice. This work forms a complete system of midwifery, with the diseases of ths puerperal slate and o! the infant.''— JV. Y. Lancet. A PRACTICAL TREATISE on MIDWIFERY; Containing the Results of Sixteen Thousand Six Hundred and Fifty-four Births, occurring in the Dublin Lying-in Hospital. By Robert Collins, M.D., Late Master of the Institution. 1 vol. 8vo. "The author of this work has employed the numerical method of M. Louis : and by accurate tables of classification, enables'his readers to perceive, at a glance, the conse- quences of the diversified conditions, in which he saw his patients. Avast amount of information is thus obtained, which is invaluable to those who duly appreciate precision in the examination of c*ses."— J5a/£. Chron. A PRACTICAL COMPENDIUM OF MIDWIFERY; being the Course of Lectures on Midwifery and on the Diseases of Women and Infants delivered at the St. Bartholomew's Hospital by the late Robert Gooch, M.D. Prepared for Publication by George Skinner, Member of the R. Coll. of Surg., Lond. 1 vol. bvo. PUBLISHED BY BARRINGTON AND HASWELL. ARMSTRONG'S LECTURES. LECTURES on the MORBID ANATOMY, NATURE, and TREAT- MENT of ACUTE and CHRONIC DISEASES. By the late John Armstrong, M.D.; Author of '• Practical Illustrations of Typhous and Scarlet Fever," &c. Edited by Joseph Rix, Member of the Royal Col- lege of Surgeons. J vol. 8vo. The British and Foreign Medical Review savs of this work : '•We admire, in almost every page, the precise and cautious practical directions; the striking allusions to instructive cases; the urgent recommendations of the pupil to be careful, to be diligent m observation, to avoid hurry and heedlessness, to be atten- tive to the poor. Nothing can be -more excellent than the rules laid down for all the parts of the delicate management of fever patients: nothing more judicious than the general instructions arising out of the lecturer's perfect knowledge of mankind His prudent admonitions respecting the employment of some of the heroic remedies, as mercury, arsenic, and colchicum, attest his powers of observation and his practical merits." " The pious office of preserving and publishing his Lectures has been performed by Mr. Rix, with singular ability." isrsANiTir. A TREATISE on INSANITY and other DISEASES AFFECTING the MIN D. By James Cowles Prichard, F. R.S. M-D. Corresponding Member of the Institute of France, &c. 1 vol 8vo. " The author is entitled to great respect for his opinions, not only because he is well known as a man of extensive erudition, but also on account of his practical acquaint- ance with the subject on which he writes. The work, we may safely say, is the best, as well as the latest, on mental derangement, in the English language."— Medico-Chir, Jico. A TREATISE ON MENTAL DISEASES, By M. Esquirol. APHORISMS on the TREATMENT and MANAGEMENT of tho INSANE: with considerations on Public and Private Lunatic Asylums, pointing out the errors in the present system. By J. G. Millingen, M.D., late Medical Superintendent of Lunatic Asylum, Hanwell, Middlesex, &c. 1 vol. 8vo. "Dr. IMillingen, in one small pocket volume, has compressed more real solid matter than could be gleaned out of any dozen of octavos on the same subject. We recommend his vade mecum as the best thing of the kind we ever perused."— Dr. Johnson'' s Review. PHYSICAL AGENTS. ON THE INFLUENCE of PHYSICAL AGENTS on LIFE. By W. F. Edwards, M.D., F.R.S., etc. Translated from the French, by Drs. Hodgkin and Fisher. To which are added, some Observations on Elec- tricity, and Notes to the work. 1 vol. 8vo. " This is a work of standard authority in Medicine ; and, in a physiological point of view, is pre-eminently the most valuable publication of the present century ; the experi- mental investigation instituted by the author, having done much towards solving many problems hitherto but partially understood. The work was originally presented in parts to the Royal Academy of Science of Paris, and so highly did they estimate the labours of the author and so fully appreciate the services by him thus rendered to science and to humanity, that they awarded him, though a foreigner, the prize founded for the promotion of experimental physiology. cXiixracAXi xvxsDxcixra. MEDICAL CLINIC; or, Reports of Medical CASES: By G. Andral, Professor of the Faculty of Medicine of Paris, etc. Condensed and Translated, with Observations extracted from the Writino-s of the most distinguished Medical Authors : By D. Spil- lan M.D., etc., etc. ; containing Diseases of the Encephalon, &c. with Extracts from Ollivier's Work on Diseases of the Spinal Cord and its Membranes. 1 vol. 8vo. LECTURES on Subjects connected with CLINICAL MEDTCINE. By P. M. Latham, M.D. Fellow of the Royal College of Physicians and Physician to St. Bartholomew's Hospital. -We stronglv recommend them [Latham's Lectures] to our readers; particularly to pupils attending the practice of our hospitals.' -Land. Med. Gaz. STANDARD MEDICAL WORKS SURGERY. ELEMENTS OF SURGERY, in Three Parts. By Robert Listen, Fel- low of the Royal College of Surgeons in Loudon and Edinburgh, Surgeon to the Royal Infirmary, Senior Surgeon to the Royal Dispensary for the City and County of Edinburgh, Professor of Surgery in the London University, &c. &c. Third American, from the Second London Edition, with upwards of one hundred and sixty illustrative engravings. Edited by SAMUEL D. GROSS, M.D., Professor of Surgery, Louisville Medical Institute. Author of Ele- ments of Pathological Anatomy, etc., etc. 1 vol. 8vo. " We must not forget to mention that the volume is rendered still more attractive by the addition of numerous wood engravings (some of them introduced bv Dr. Gross), all finely executed. These will be found of very considerable advantage to the student, materially assisting him in comprehending the explanation of morbid structure. Another admirable feature, is the printing of the notes in type of the same size as that of the text. This obvi- atesalmost entirely, whatever objections can be alleged asainst fout-notes. r — Western Jour, of Med. and Surg., Dec, 1S42. ,; We are here presenied with a republication of Mr. Liston's admirable and much praised work on Surgery, which has been subject to the alembic of a critical and learned friend, Dr. Gross. He has added ' copious notes and additions,' such as the progress of surgery in the United States demands in order to meet the wants of the surgeon. iProfessor Gross has also given an entire article on Strabismus, and another on Club Feet, which were wholly omitted in the English copies. They miy be regarded important, inasmuch as they give a completeness to an otherwise unfinished treatise". The execution of the book is good; the paper firm, and well secured in the binding. The plates are uniformly well executed, and the impressions distinct."— Boston Med. and Surg. Jour. "In another essential feature this edition is greatly improved. With the principles is taught also with it the practice of surgery; and both morbid structure and operations are doubly described ; first by the author and editor, and next by the graver of the artist."— Bull. Med. Scien. " Mr. Listonhas seen much, thinks accurately, and speaks independently. From a volume written by such a man, more really valuable practical instruction is to be derived than from all the books that were ever compiled."— Western and Southern Med. Recorder. "This is a work of established reputation. It has gone through two editions in Great Britain, and the same number in this country. The aJditiuns of the American edition are copious, and add materially to the value of the work." — Atner. Jour. Med. Sciewes. "The author is bold and original in his conceptions, accurate in deductions, plain and concise in style; a combination of good qualities not often found united in a single volume. The notes and additions, by Prof, Gross, are well arranged and judicious, sup- plying some evident deficiencies in the original work."— Western Lancet. LECTURES OF SIR ASTLEY COOPER on the PRINCIPLES and PRACTICE of SURGERY, with additional Notes and Cases. By Frederick Tyrrell, Esq., Surgeon to St. Thomas's Hospital, and to the London Ophthalmic Infirmary. 1 vol. 8vo. LECTURES ON THE PRINCIPLES OF SURGERY. Br John Hunter, F.R.S. With Notes by James F. Palmer, Senior Surgeon to the St. George's and St. James' Dispensaries, &c. &c. With Plates. 1 vol. 8vo. " We cannot bring our notice of the present volume to a close without offering our testimony to the admirable manner in which the editor and annotator has fulfilled his part of the undertaking. The advancements and improvements that have been effected, up to our own day, not only in practical surgery, but in all the collateral departments, are constantly brought before the reader's attention in clear and concise terms."— Brit. $ For. Med. Rev. JOHN HUNTER'S WORKS. THE COMPLETE WORKS OF JOHN HUNTER, F.R.S., 4 vols. 8vo., comprising his Lectures on the Principles of Surgery; A Treatise on the Teeth; Treatise on the Venereal Diseases; Trea- tise on Inflammation and Gun-Shot Wounds ; Observations on Certain Parts of the Animal (Economy ; and a full and comprehen- sive Memoir. Each of the Works is edited by men of celebrity in the Medical Science, and the whole under the superintendence of Jas. F. Palmer, of the St. George's and St. James's Dispensary. This is the only complete edition of the works of the distinguished physiologist ever published in this country. "One distinctive feature of the present edition of Hunter's works has been already mentioned, viz: .in the addition of illustrative notes, which are not thrown in at hazard, but are written by men who are already eminent tor their skill and attainments on the particular subjects which they have thus illustrated. By this means, whilst we have the PUBLISHED BY BARRINGTON AND HASWELL. views entire of John Hunter in the text, we are enabled by reference to the accompanying notes, to see wherein the author is borne out by the positive knowledge of the present "day, or to what extent his views require modification and correction. The names of the gentlemen who have in this manner assisted Mr. Palmer, are guarantees of the successful performance of tueir task."— Med. Gaz. HYSTERIA. AN ESSAY ON HYSTERIA, being an analysis of its irregular and aggra- vated forms; including Hysterical Hemorrhage and Hysterical Ischuria. With numerous Illustrative and Curious Cases. By Thomas Laycock, House Surgeon to the York County Hospital. 1 vol.8vo. UTERUS. LECTURES on the FUNCTIONS and DISEASES of the WOMB, by Charles Waller, M.D., Bartholomew's Hospital. ON DISEASES of the UTERUS and its APPENDAGES, by M. Lisfranc, La Pitie Hospital. ON DISEASES of the PUERPERAL STATE, by J. T. Ingleby, Edinburgh. 1 vol. 8vo. * We can very cordially recommend them as affording a concise and practical exposition of the pathology ami treatment of a most important class of diseases, and which cannot be too attentively ■United."— If. Y. Lancet. '• The present volume contains a short and succinct practical account of the principal mor- bid slates either of ilie functions or the structure of the womb, the best methods of dis- tinguishing them, and the means which experience has shown to be the most effectual in removing iheni. The reader will find that he obtains, in a small compass, a distinct view of the nature and treatment of each disorder."— Edinb. Med. and Surg. Journ. URINARY DISEASES. URINARY DISEASES and their TREATMENT. By Robert Wil- lis, M.D., Physician to the Royal Infirmary for Children, &c. &c. "We do not know that a more competent author than Dr. Willis could have been found to undertake the task ; possessing, as it is evident from his work that he does ss, an accurate acquaintance with the subject in all its details, considerable per- sonal experience in the diseases of which he treats, capacity for lucid arrangement, and a style of communication commendable in every respect."— Brit. &} For. Med. Rev. AMUSSAT'S LECTURES on the RETENTION of URINE, CAUSED by STRICTURES of the URETHRA, and on the Diseases of the Prostate, translated from the French by James P. Jervey, M.D. EPIDEMICS OF THE MIDDLE AGES. FPIDEMICS of the MIDDLE AGES. From the German of I. F. C. Hecker, M.D., &c. &c. Translated by R. G, Babington, M.D. F.R.S.- No . i.-TIIE BLACK DEATH IN THE 14th CENTURY. ■ Hecker^ account of the ' Black Death,' which ravaged so large a portion of the globe in th fimrlSth century, mav be mentioned as a work worthy of our notice both as . -^ mV,,vinti.re«t"i ^details of this tremendous pestilence, and as exhibiting a t^^^T^^^^^cU^eMa of Practical Medicine-History of Medicine by Dr. Bostock. T ^ T ^ T ^ », , XTT * No. II — THE DANCING MANIA. ., %* a- ,1 u;-tnrv Ins lon» been in need of the chapter which this book supplies; and •Medical Hlstor > ha „ s t ^"° v ° l P n remedied at a better season. On the whole, the the deficiency could no ^ e ^ "nufljett acceptable, as con- volume ought obepopu lar, »° in J £ ° 1C ; imDortant subject which had almost been veying so much "^/" iat '° n .^ especial thanks Buffered to be buried in , obhi on a dw e l ^ nk ™ ion _ The st * le f the translation. ^^£^Tl^t^£o^\t ?eads like an English original,'-^.. Med. Gaz. 10 STANDARD MEDICAL WORKS PHYSIOLOGY AND HYGIENE. ESSAYS ON PHYSIOLOGY AND HYGIENE; viz: I. Reid's Experimental Investigation into the Functions of the Eighth Pair of Nerves. II. Ehrenberg's Microscopical Observations on the Brain and Nerves (with numerous engravings). III. On the Combination of Motor and Sensitive Nervous Activity; by Professor Stromeyer, Hanover. IV. Vegetable Physiology. V. Experiments on the Brain, Spinal Marrow, and Nerves. By Prof. Mayer, of Bonn (with woodcuts). VI. Public Hygiene. VII. Progress of the Anatomy and Physiology of the Nervous Sys- tem, during 1836. By Professor Muller. VIII. Vital Statistics. 1 vol. 8vo. ANATOMICAL EXAMINATIONS. EXAMINATIONS in ANATOMY and PHYSIOLOGY; being a complete series of Questions and Answers; designed and intended as preparatory to Examinations at the different Medical Schools throughout the United States. To which are annexed, Tables of the Bones, Muscles, and Arteries. By Thomas Sydenham Bryant, M.D., Surgeon U. S. Army. "This is a very useful manual of anatomy. We have pleasure in recommendins it to the favourable notice of students. They will find it of immense service in preparing for exami- nations." — N. Y. Lancet. THE LONDON DISSECTOR, OR GUIDE TO ANATOMY; for the use of students : comprising a description of the muscles, vessels, nerves, lymphatics, and viscera of the human body, as they appear on dissection ; with directions for their demonstration. Revised and corrected by Edward J. Chaisty, M.D., &c, &c. 1 vol. 12mo. 8 Although there are several of these dissectins-room companions, there is not one in the whole catalogue that wears better, from its intrinsic value, than the eld London Dissector. With the improvements of litis excellent edition, carefully revised, it will prove a very economical as well as certain assistant ; and it therefore commends itself to the student.''— Boston Med. and Surg. Jour. JUST PUBLISHED, EVANSON 6L ItIAUKTSSLL. PRACTICAL TREATISE ON THE MANAGEMENT AND DIS- EASES OF CHILDREN. By Richard T. Eyanso.v, M.D., Professor of Medicine, —and Henrv Mailvsell, M.D., Professor of Midwifery in the Col. of Sur^s. in Ireland. From the 4th Dublin edition. Edited by D. F. Condie, M.D. ANDRAL, OX THE ABDOMEN. MEDICAL CLINIC: DISEASES OF THE ABDOMEN. By G. A>dkal. M.D., Professor to the Faculty of Paris, Member of the Royal Academy of Mediciue, etc., etc. Condensed and Translated, with Observations, by D. Spillan, M.D., Fellow of the King and Qneeu's College of Physicians in Ireland, Member of the Association of the Fellows and Licentiates of the College of Physiciaus, aud Formerly Physician to the Dublin General Dispensary. STOKES AND BELL. LECTURES ON THE THEORY AND PRACTICE OF PHY- MC By W illiam Stokes, M.D., Lecturer at the Medical School, ^ark Street, Dublin : Physician to the Meath County Hospital, etc., etc., and John Bell, M.D., Lecturer on Materia Medica and Therapeutics : Member of the College of Physicians, Philadelphia, and of the American Philosophical Society, etc., etc. Second American Edition. 2 vols. 8vo. valuable J» tv, n £n,, a , M T ed lh , 6 f ° rm °J \ qu ! te complete system of medicine, equally InVSif ^ k l ? xl V b0 ' ,!: , 1 ? l * e student, and a book of reference to the practitioner." " We ; r Jl. k ^°° k ° f , l ^ e k,nd wh '. ch we would more readil y P la " in thu hands of a student, ?.,?» »r ^ e W0 Jf, ia mor ? readll y refer lhe Practitioner, for a hasty investigation of a sub^ jeet. — Aeu> Eng. Quart. Journ. of Med. and Surg. »«n .f^tf andl ' 8 F" cl ,'r e U i. ,l,g among the best works extant on Practical medicine, will at once commend itself to the practitioners of our country. It is not going too far to declare, that no physician, whether his experience be large or small, should be without this work in his library; and, having it there, he should study its various parts with care and attention."— Western Lancet. '•A second edition of this work of established reputation, is sent out from the press of Messrs. Barnngton and Haswell, Philadelphia. No change in the mind of the medical public, touching the worth of this very celebrated series of medical lectures, has been wrought by tne advent of later publications on the same subjects. It is just as popular as ever, and we believe, at this moment, is exerting a far more extensive influence than was ever predicted by the warmest personal friends of the two learned authors."— Boston Med. and Surg. Jour. The following is from the pen of a distinguished Professor in one of the Medical Schools in the West. " We cordially recommend the joint labours of two such distinguished phvsicians as Drs. Stokes and Bell to the notice of the medical profession. They will be found to em- body the principles and practice of medical sciencedown to the present moment."— Louis- ville Journal. MISCELLANEOUS. OUTLINES OF GENERAL PATHOLOGY. By George Freckleton, M.D., Fellow of the Royal College of Physicians. OBSERVATIONS on the PRINCIPAL MEDICAL INSTITUTIONS and PRACTICE of FRANCE, ITALY, and GERMANY: with Notices of the Universities, and Cases from Hospital Practice: With an Appen- dix on ANIMAL MAGNETISM and HOMOEOPATHY. By Edwin Lee, Member of the Royal College of Surgeons, &c. 1 vol.8vo. " Mr. Lee has judiciously selected some clinical cases, illustrating the practice pursued at the different hospitals, and he has wound up the volume with an amusing account of annual magnetism and homoeopathy — those precious effusions of German idealty, for w Inch we refer to the work itsaM.—Medico-Chirurg. Rev. BOUILLAUD ON ACUTE ARTICULAR RHEUMATISM IN GEN- ERAL. Translated from the French, by James Kitchen, M.D., Philada. MEDICAL AND TOPOGRAPHICAL OBSERVATIONS upon the MEDITERRANEAN and upon PORTUGAL, SPAIN,AND OTHER COUNTRIES. By G. R. B. Horner, M.D., Surgeon U. S. Navy, and Honorary Member of the Philadelphia Medical Society. With En- gravings. 1 vol. 8vo. " An uncommonly interesting book is presented to those who have any disposition to know the tilings medical in Portugal, Spain, and other countries," and" will doubtless 1m> read, also, with marked satisfaction by all who have a taste for travels.— Bost. Med. and Surg. Jour. AN ESSAY ON DEW, and several Appearances connected with it, by William Charles Wells, M.D.,F.R.S., etc. ON DENGUE; ITS HISTORY, PATHOLOGY, AND TREATMENT. By S. Henry Dickson, M.D., Professor of the Institutes and Practice of Medicine in the Medical College of S.C. HINTS ON THE MEDICAL EXAMINATION OF RECRUITS FOR THE ARMY; and on the Discharge of Soldiers from the Service on Surgeon's Certificate : Adapted to the Service of the United States. By Thomas Henderson, M.D., Assistant Surgeon U. S. Army, &c, &c. 12 STANDARD MEDICAL WORKS, ETC. 3mSCEI,X.ANEOUS- Continued. MEDICAL NOTES AND REFLECTIONS. By Henry Holland, M.D.; F.R.S., Fellow of the Royal College of Physicians, and Physician Extra- ordinary to the Queen. THE MEDICAL PROPERTIES of the NATURAL ORDER RANUN- CULACEiE,&c, &c. By A. Tornbull, M.D. Prof. HORNER'S NECROLOGICAL NOTICE OF DR. P. S. PHYSICK ; Delivered before the American Philosophical Society, May 4, 1838. THE LIFE OF JOHN HUNTER, F.R.S. By Drewry Ottley. 1 small vol. 8vo. "In the summing up of Mr. Hunter's character, Mr. Ottley exhibits equal judgment and candour."— Brit. # For. Med. Rev. ESSAY UPON THE QUESTION, 18 MEDICAL SCIENCE FAVOR- ABLE TO SCEPTICISM? By James W. Dale, M.D., of New- castle, Delaware. Pamphlet. METEOROLOGICAL REGISTER for the years 1826-30 ; from Observa- tions made by Surgeons of the Army and others at the Military Posts of the United States. Prepared under the direction of Thomas Lawsok, M.D., Surgeon-General U.S.A. In Press, ARAN'S PRACTICAL MANUAL ON DISEASES of the HEART and GREAT VESSELS. Translated from the French. A TREATISE on BANDAGING and MINOR SURGERY; or, Hints on the Every-day Duties of the Surgeon. By H. H. Smith, M.D., Lecturer on Minor Surgery, Fellow of the College of Physicians, Member of the Phila- delphia Medical Society. Illustratedf by Engravings. PRACTICAL MEDlCiNE. Illustrated by Cases on the most Important Diseases. Edited by John M. Gait, M.D. B. fy H. continue to publish THE SELECT MEDICAL LIBRARY AND BULLETIN OF MEDICAL SCIENCE. EDITED BY JOHN BELL, M.D., AT FIVE DOLLARS PER ANNUM, IX ADVANCE. Each No. of the Library will consist of one or more approved works on some branch of Medicine, including, of course, Surgery and Obstetrics. 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