NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service THE ECLECTIC PRACTICE IN DISEASES OF CHILDREN. B Y JOHN M. SCUDDER, M. D. PROFESSOR OF THE PRINCIPLES AND PRACTICE OP MEDICINE IN THE ECLECTIC MEDICAL INSTITUTE OF CINCINNATI; AUTHOR OP "A TEEATISE ON THE DISEASES OF WOMEN," "THE ECLECTIC MATERIA MEDICA AND THERAPEUTICS," " THE ECLECTIC PRACTICE OP MEDICINE," "THE PRINCIPLES OF MED- ICINE," "SPECIFIC MEDICATION," "SPECIFIC DIAG- NOSIS, "THE USE OF INHALATIONS, ETC. REVISED EDITION. CINCINNATI: PUBLISHED BY THE AUTHOR 1884 Entered according to Act of Congress, in the years 1869 and 1881, BY JOHN M. SCUDDEK, In the office of the Librarian of Congress. ^ PREFACE; In presenting a new work for approval, the author hopes that it may be as favorably received as the former ones, and that its readers will find it a trustworthy guide in the treatment of the diseases of childhood. The dedication should have been " to the children of this country," as the endeavor has been to free the practice of medi- cine from everything harsh and revolting, and to substitute those gentle means and appliances which, while successful in counter- acting disease, entail no present or future suffering. The practice of medicine in the past has been a chapter of horrors, which the truer civilization of the present will not tol- erate. " We may endure the sufferings of disease, with some degree of equanimity, but we will not have those sufferings in- tensified by medicines." This is the feeling of the better class of people, and especially of parents with regard to their children. If the author has aided to establish a better system of med- icine, and the present work fulfills its mission of rendering the treatment of the diseases of childhood certain and pleasant, he will be well repaid for his labor. It has been the object to make the descriptions succinct and explicit, stating what the author believes to be true, and avoid- ing theories. Thus, while the entire list of diseases has been studied, the work has been kept in that moderate compass that renders it of easy reference to the busy practitioner. viii PREFACE. With regard to the treatment recommended, the author offers the voucher of an extended and successful practice. It varies greatly from the treatment of the standard works of the day, or the teachings of the schools, but upon it he proposes to risk such reputation as he may have made as a teacher or writer. But few quotations have been made, and in these cases due credit has been given. While acknowledging no special obli- gations to any writer, the author begs to make that general acknowledgment to all who, writing on medicine, have revealed the germs of new truths, or have been instrumental in freeing old ones from the chaff in which they were enveloped, that they might be seen and applied. In this revision the author has added the results of the last twelve years' experience. The first part, on infantile therapeu- rapeutics, has been entirely re-written, and forms a good materia medica. In the third part, the treatment has been mostly re- written, and the reader will find here the most successful treat- ment of the day. It is small doses of pleasant remedies for direct effect, which we believe will be the practice of the future. Cincinnati, June 15th, 1881, TABLE OF CONTENTS. PART I. INFANTILE THERAPEUTICS. PAGE. Chapter I.—Action of Remedies in Childhood, . . .17 Differences between the Adult and Child, . . 17 On account of the Nervous System, . . 17 Circulatory System and Blood, 19 Digestive Apparatus, . 20 Excretory Apparatus, . 20 Direct Medication, .... .21 Chapter II.—Form in which Remedies should be administered, 22 Solutions Preferred, . . . . . .23 The Dose of Medicine,.....24 Classification of Medicines, . . . . .25 Remedies which Influence the Nervous System, . . 26 Gelseminum, Belladonna, Rhus, Bryonia, Lobelia, Pulsatilla, Nux vomica, Quinine, Opium, Phosphorus, Camphor, iEther, Chloroform, Chloral, Bromide of Ammonium, Carbonate of Ammonium, Iodide of Ammonium, Ferro cyanuret of Potassium, iEnothera, . Asafoetida. Remedies which Influence the Circulation, 41 Aconite, Rhus, Veratrum. Lycopus, Gelseminum, Lobelia, Eupatorium, Digitalis, Spiritus iEtheris Nitrosi. Podophyllin, Hamamelis, Cactus, Apocynum Canabinum, TABLE OF CONTENTS. Remedies which Influence the Temperature, Baths, Veratrum, Acids, Food, Rhus, Alkalies, Air, Gelseminum, Cod Oil, Exercise, Bryonia, Phosphorus, Aconite, Baptisia, Sulphur, Remedies which Influence the Respiratory Apparatus, PAGE. . 49 62 Aconite, Veratrum, Bryonia, Ipecacuanha, Lobelia, Phytolacca, Stillingia, Lycopus, Drosera, Sanguinaria, Euphorbia, Phosphorus, Senega, Scillae, Sticta. Rumex, Grindelia, Nitric Acid. Eupatorium Perfoliatum, Remedies which Influence the Digestive Apparatus, 69 Emetics, Ipecacuanha, Nux vomica, Hydrastis, Chamomilla, Malt, Oxide of Zinc, Chionanthus, Cathartics, Colocynth, Chelidonium, Dioscorea, Iris, Amygdalus, Hamamelis, Podophyllin, Apocynum, Leptandria, Sulphate of Manganese,Pepsin, Santonine, Aloes, Uvedalia, Remedies which Influence the Urinary Apparatus, . . 82 Mentha Viridis, Sweet Spirits of Nitre, Rhus aromatica, Gelseminum, Acetate of Potash, Curcubitacitrullus, Eupatorium pur. Santonine, Agrimonia, Hydrangea, Benzoate of Lithia, Belladonna. Apis, Local Applications to the Loins, Remedies which Influence the Skin, 87 Baths, Diluents, Asclepias, Saffron, Belladonna, Eupatorium. Antizymotics, Acids, Baptisia, Phytolacca, Antiseptics, Thymol, Carbolic Acid, Permanganate of Potash, Antirheumatics, Macrotys, Sticta, Bryonia, Apocynum, Phytolacca, Acids, Sedatives, Stimulants, Inunctions, Nepeta, Serpentaria. Sulphurous Acid, Sulphate of Soda, Sulphate of Iron, Sulphurous Acid, Rhus, Apis, Senega, Sulphur, Arsenic. . 95 Hydrochloric Acid, Chlorate of Potash, 100 Chloride of Lime, Chloride of Lead, Liquor Sodje Chlorinatse, Salicylic Alkalies. 102 Acid, TABLE of contents. Antiperiodics, .... . Quinia Sulph. Alstonia Constricta Arsenic, Cinchonidia, Uvedalia, Nitric Acid, Anti-erysipelatous, .... , Veratrum, Tinct. Muriate of Iron , Rhus, Apis, Sulphite of Soda, Restoratives, • • ■ . Air, Iron, Cuprum, Light, Phosphorus, Silica, Exercise, Sulphur, Soda, Food, Cod-Liver Oil, Lime. Tonics, PART II. CARE AND MANAGEMENT OF INFANTS. Chapter III.—Washing the Child, . Clothing the Child, How often should the Child be Washed ? Attention to the Cord, Ulceration of the Umbilicus, Excoriation and Chaffing, . Does the Child need Medicine after Birth Difficulties in Nursing the Child, . Food for the Child, Composition of Milk, Liebig's Food, . . . ! A Wet-Nurse, Weaning the Child, Sleeping, .... Regular Habits, .... Moral Government, PART III. DISEASES OF CHILDHOOD. Chapter IV.—General Symptoms of Disease, . Physiological Marriage, .... Life Line, ..... Temperature, Pulse, Respiration, Xll TABLE of contents. Chapter V.—Febrile Diseases^ Pathology of Fever, Febricula, .... Intermittent Fever, Masked Intermittent, Remittent Fever, Slow Infantile Remittent Fever, Congestive Fever, Continued Fever, Typhoid Fever, Spotted Fever, Epidemic Cerebro-Spin. 1 Meningitis, Diphtheria, .... Eruptive Fevers, Variola—Small-Pox, Varioloid, . Variola Vaccina—Cow-Pox, Spurious Vaccination, Can Syphilis be transmitted by Vaccination? Preservation of Vaccine, . Rubeola—Measles, Malignant Rubeola, Scarlatina, .... Angincsa, Maligna, Pertussis, .... Parotitis, .... Dyscrasias, .... Infantile Syphilis, Poisonous Bites and Stings, Chapter VI.—Diseases of the Respiratory Apparat Physical Diagnosis, .... Coryza, ..... Chronic Catarrh, . . " Pharyngitis, . : Tonsillitis, ..... Croup, .... " Mucous, .... " Pseudo-Membranous, . " Spasmodic, table of contents. (Edema Glottidis, Bronchial Catarrh, ; i , Bronchitis; Asthenic, . . Acute, . . . Chronic, . . Pneumonia, ..... Phthisis Pulmonalis, Chapter VII.—Diseases of the Digestive Apparat Dentition and its Derangements, Lancing the Gums, Care of the Teeth, Second Dentition, .... Stomatitis Simplex, Aphthae, . . : Stomatitis Ulcerata, Gangrenous, . . „ Sore Throat, . : : . Cynanche Maligna, .... Chronic Sore Throat," Gastrodynia, .... Gastric Irritation, . . . Gastritis, ..... Infantile Dyspepsia, : . . Colic, ..... Diarrhoea, .... Muco-Enteritis, .... Cholera Infantum, Tabes Mesenterica, . Dysentery, s Constipation, Prolapsus Ani, . : Intestinal Worms, .... Diseases of the Liver, Congestion of the Liver, Strumous Enlargement of the Liver, . Jaundice, ..... Peritonitis, . . . , Hernia, ..... MV TABLE OF CONTENTS. Chapter VIII.—Diseases of the Urinary Apparatus, Acute Nephritis, Chronic Nephritis, . . . Albuminuria, . : . . Diabetes, ..... Ischuria, ..... Enuresis, ..... Urinary Calculi, .... Imperforate Urethra, . . Phymosis, . . . • . Paraphymosis, .... Urethritis, ..... Hydrocele, . . : . . Infantile Leucorrhcea, . . : Onanism, ..... Chapter IX.—Diseases of the Nervous System, Determination of Blood to the Brain, . Congestion of the Brain, Phrenitis, ..... Acute Hydrocephalus, Chronic Hydrocephalus, ; Spinal Meningitis, . , . Curvature of the Spine, : . , Epilepsy, Convulsions, ..... Chorea, ♦ Trismus Nascentium, . . . Night Terrors, . Paralysis, ..... Chapter X.—Diseases of the Eyes, Ophthalmia Neonatorum, . t Diseases of the Appendages of the Eyes, Furuncle, ..... Ptosis, ..... Trichiasis, ..... Diseases of the Lachrymal Apparatus, Ophthalmi Tarsi, .... Catarrhal Conjunctivitis, . . Opacity of the Cornea, TABLE OF CONTENTS. XV PACK. Chapter XI.—Diseases of the Ears, 2 9 436 Examination of the Ear, . . . a . 437 Foreign Bodies in the Ear, . . . . 438 Earache, : . ; . . . . 438 Otitis, ..... e 439 Otorrhoea, 0 . „ . . 442 Deafness, ...... • 444 Chapter XII.—Diseases of the Skin, . 448 Exanthemata, . . . ♦ e . 449 Erythema, . . . i . u . 450 Roseola, ...... , 451 Urticaria, . . » . . , . 453 Erysipelas, . J 455 Vesiculae, ..... . . 458 Milaria, ...... , 458 Eczema, ..... . : 458 Herpes, ...... » 461 Scabies, . . ! , . . . 463 Builds, ...... , 466 Pemphigus, ..... . . 466 Rupia, ...... 5 467 Pustulae, ..... . . 469 Ecthyma, ....!« . 469 Porrigo, ..... . . 471 Papulae, ...... . 473 Lichen, ..... . . 473 Prurigo, ...... : 475 Naevus Materni, s . , . 0 . 476 DISEASES OF CHILDREN. FA.RT I. INFANTILE THERAPEUTICS. CHAPTER I . It is generally admitted that there are sufficient differences in tne action of remedies upon the adult and child to demand a careful study of the subject. While all practicing physicians are impressed with this fact, every one will admit the difficulty of making the distinction, so that the student of medicine will readily appreciate it. This is especially true of the older treatment by indirect-remedies, which, used as in the diseases of the adult, were very uncertain in their action ; but in the special or specific medicines the difference becomes less and less, as we thoroughly understand their action. These differences may be appropriately classified under the heads of: Their Action upon the Nervous System—upon the Organs of Circulation and the Blood—upon the Digestive Tract, and upon the Excretory Organs. The Xeryous System.—The nerve centers of the child are immature and more easily influenced for harm than in the adult. We notice, first, that they are very easily excited (irritative), and in consequence there is determination of blood. The immature structures do not resist this morbid influence well, hence we have excitation of function—restlessness, wakefulness, undue expendi- ture of nerve force, deranged circulation and nutrition, and con- vulsions. 9 18 DISEASES OF CHILDUKX Second, That there is a greater tendency to impairment of circulation (stasis), giving rise to congestion and consequent func- tional lesions. In this case structural changes take place rapidly, and prove a frequent cause of death. Not only is there this tendency in disease to affect the nervous •system of the child, but many remedies influence the nervous system in these ways. As we progress in the description of remedies, we will have occasion to study this action, and will here merely cite the well-known influence of opium as an example. This fict, though it leads us to great caution in the use of remedies, and to a careful observance of those symptoms which experience has shown to foreshadow these nervous disturbances, points out the course of therapeutic study likely to prove most valuable. As all processes of life are, to a greater or less extent, under the influence of the nervous system, Ave may so guide them by medicinal action upon the nerve centers as to remove disease. This subject should also be studied with reference to infantile hygiene Rest to the nervous system is of the highest importance to the young child ; especially is this the case, when from disease or other cause there is an imperfect performance of the functions of digestion, nutrition, or secretion. What I mean by rest here is, an avoidance of all causes of irri- tation or excitement, whether physical or mental. In a case there will be some more or less easily removed physical irritation, which it is the duty of the physician to point out to the mother, and if necessary to give instructions for proper management. Frequently we find such irritation of the skin, from want of cleanliness, or more frequently from too frequent and hard rubbings with an irritant soap. The most common physical irritation is from con- fining the child with its clothing, and thus preventing a healthful change of position and the natural movements of its limbs and body. In the proper place I will describe what I deem a proper clothing for the child. Most persons fail to appreciate that the child is a sentient being, capable of receiving mental impressions and being pleas- surably or painfully impressed by them. If I should sav that (he child is more impressionable than the adult, receives more pleasure, suffers more pain, and that both influence the powers of life more, I would but state the ease as it presents itself to those who have most thoroughly studied children. The child is helpless, wholly dependent upon the care of its mother and grows. infantile therapeutics. 19 into conscious life in an atmosphere of love. It responds pleas- urably to care for its welfare, and suffers acutely from neglect. We frequently meet with parents who seem to have no mental balance ; now they are the most loving, then they are harsh passionate, and wholly without reason. In sickness, and when occasion offers to give advice, the injury, both to the physical and mental welfare of the child should be pointed out, and the influ- ence of the physician thrown in favor of a systematic effort tin- self-government. In some diseases, rest to the nervous system is absolutely essen- tial to life; in all it is of much importance. We will, therefore, carefully guard our own association with the child, that it may not be a source of irritation, calling the attention of parents to it, and prescribing remedies with reference to it. The good old times of physic, when a child could be thrown upon his back, his nose held, and the nauseous dose forced down his throat, as we would drench a horse, have passed by, for parents have learned quite as soon as physicians that it is not necessary to a cure. The Circulatory System and Blood.—Derangement of the circulation forms a very important part of most diseases of children. Very slight and temporary diseases present often marked change of pulse, while in the more grave affections it forms the basis of both functional and structural lesions. But while the circulation is thus easily deranged by causes of disease, it is readily reached and easily amenable to remedies. Possibly there is no part of the practice of medicine that will give more satisfaction than the use of remedies for this purpose. The blood of the child seems less subject to zymotic influences than the adult. Typhoid and typhus fever are of very rare occurrence, and epidemic dysentery and like affections pass the little ones by. On the contrary, the susceptibility to the eruptive fevers is greatest in early life. Lesions in blood-making are common in childhood, especially those that form the basis of that protean disease, scrofula; true, the lesion may be primarily of the lymphatic system, (Principles of Medicine,-p. 236), but it manifests itself in imperfect elabora- tion of the blood. Deficient blood-making, though not more common than in the adult, is less easily influenced bv medicine. Possibly because the digestive processes can not be stimulated by the same active tonic medicines. 20 DISEASE*, OF CHILDREN. The Digestive Apparatus.—The digestive tract is very sus- ceptible to the action of irritants, which unfavorably influence or arrest the processes of digestion, giving rise to crude and im- perfect products, and deterioration of the blood; not only this, but the influence upon the sympathetic nervous system is very marked, and is sometimes extended to the cerebro-spinal centers. A very common as well as marked example of this is, convul- sions from irritation of the stomach or intestinal canal. I have seen the most severe and persistent convulsions produced by the administration of some of the vermifuges, and even from castor oil. There is a less marked influence upon the nervous system from irritation of the intestinal canal, though frequently not less inju- rious. I speak of that which manifests itself in the form of nervous irritability, restlessness, and sleeplessness, which, as we have already seen, are to be carefully avoided. As the vegetative functions are in a very active condition, the child suffers more from deprivation of food than the adult. It has always seemed to me that the most serious error in the treat- ment of diseases of children, was the use of such means as would impair the power of the stomach to digest food, and destroy the appetite. Making no provision for a supply of nutritive material, the waste of the body would be stimulated to excess, and the child's life rapidly exhausted; using a homely simile, "it v\as burning the caudle at both ends." The Excretory Apparatus.— As there is less waste of tissue, the excretory organs are not so active as in the adult, neither do they possess the power of sustained activity under the influence of medicines. While it will be found quite as easy to temporarily increase excretion, it requires much care to sustain these processes. Overstimulation frequently leads to such exhaustion that excretion is almost wholly arrested, and the little patient dies, poisoned bv its own excreta? I do not know of any one point in infantile therapeutics that is more essential than this, in the more grave diseases. Given a disease that will require one or two weeks for its progress and we may see how essential it is that the daily waste of tissue should be promptly removed. And we can never afford to hazard the successful termination of such disease, for the uncertainty of aborting it by over stimulation of the excretory organs. INFA NTILE THERAPEUTICS. 21 DIRECT MEDICATION. In the treatment "of the diseases of childhood especially, I prefer direct or specific medication, as I do in the treatment of the adult; but I find more directness of action in the ease of the child, possibly because it is more free from the effects of a false civilization. The old methods of indirect medication may be employed when nothing better is known, but in the majority of cases the follow- ing rule will be found to yield the greatest success: •'' Never give a dose of medicine unless you see clearly the indication for that particular medicine, and have a reasonable certainty that its action will be beneficial." Of course, this cuts off hap-hazard medica- tion, or treating the name of a disease, and if persistently followed, will lessen the amount of medicine administered several hundred per cent. We have not yet specifics for every disease, possibly for no disease in its totality, but we have specifics for pathological con- ditions, and, properly employed in the order in which these pathological conditions take precedence, they offer a direct and very certain treatment for diseases. In the employment of remedies we find greater success from doing one thing'at a time, and, as a general rule, from the use of single remedies or very simple combinations. If we properly appreciate the different parts of a disease, we will find that they hold the relation to one another of cause and effect; that there are some primary, and others secondary and dependent upon the first; and in the use of remedies we give those first that meet the primary lesion, and follow with such as reach the indications of cure in the order named. In the treatment of diseases of children, as elsewhere, there is the constant tendency to view the sum of pathological processes as a unit, and to meet this at once. Though a physician knows well, if he reflects, that recovery will occupy days, he gives remedies to accomplish it in hours. All the remedies that would seem to be indicated in the whole treatment are given the first and each succeeding day. The true method is, to make a thorough analysis of the disease, and separate it into its component parts; determining also the order of these. Then remedies are selected, not with reference to the name, but with their application to correct a clearly under- stood pathological change of function or structure. 22 DISEASES OF CHILDREN. As an example, I may take infiammmation of the lungs. On analysis we find it to consist of an accelerated circulation, increased temperature, arrested excretion, difficult respiration, and cough, and more or less excitation of the nervous system. In addition to this, there is impairment of the digestive functions, and a gradually increasing lesion of the blood, and the processes of waste and nutrition. Such analysis tells us what the disease really is, and points out a specific or direct treatment. The accelerated circulation is controlled by the use of veratrum, to which gelseminum is added if there is much nervous irritation. The action of these is aided by the general bath, hot foot-bath, and a mush-jacket to the chest, which also relieves the irritation of the respiratory organs. Following this, if necessary, gentle diaphoretics, diuretics, and laxatives are employed to stimulate secretion. If the inflammatory process does not yield, the use of inhalations of the vapor of water, or a specific, like small doses of ipecacuanha, completes the cure. In the meanwhile any gastro- intestinal irritation, or other lesion, passes away as the circulation becomes normal and secretion is established. Very many times it requires but the remedies that control the circulation, for with this the entire series of morbid phenomena gradually disappears. C H A P TER II. FORM IN WHICH REMEDIES SHOULD BE ADMINISTERED Success in the treatment of diseases of children will depend much upon the form in which the remedies are administered The first object is to have the proper medicine; the second, is to intro- duce it into the circulation without exciting any morbid process. It matters little with what skill the disease is diagnosed, or the remedies selected, if they fail to gain entrance into the blood. I doubt not that any physician can call to mind cases which will verify this statement. FORM OF REMEDIES. 23 The form of a medicine, then, is very important, and deserves our careful consideration. The remedy should not be objectionable to the taste, if it is possible to avoid it; for the unpleasant taste excites disgust, followed by more or less nausea, and during this but little if any absorption takes place. If now such remedy is repeated every one, two, or three hours, the disgust and nausea may be rendered persistent, and the remedies fail to produce the desired effect, because they do not get into the circulation where they may act. Many remedies undergo decomposition if retained in the stomach any considerable time, and either lose or change their medical properties; hence, another reason for proper attention to the form, as well as some other accessories to their proper administration. Next to having the remedy in a pleasant form is, to have it in solution or readily soluble in the gastric fluids. To pain entrance into the blood it must be in perfect solution, and as time is an important element in treatment, it is well to see that the remedy has these desirable qualities given it before it is introduced into the stomach. I prefer tinctures or solutions, and usually administer them with water. A very good method is to prepare the remedy in a glass of water, so that the proper quantity will be contained in a teaspoonful. I find that the slight taste is not objectionable, and to the child it docs not look like medicine. If the child is old enough to observe, I prepare it in his presence, showing the bottles, the steps of the process, and then have him taste it and have his opinion of the result. In this way I find no difficulty in competing with homoeopathy as to the pleasantness of medicine. The mixing of medicines in compounds, using some syrup as a vehicle, and attempting to disguise the taste with peppermint, cinnamon, or something worse, is too disgusting now for the well- trained adult, and I do not wonder that it is objectionable to the child. I am very free to confess, that rather than have my children dosed with nauseous medicines, however good might be the physician, I should take the infinitesimal nothing of the homoeopath, and trust to nature for a cure. Powders are generally more objectionable than mixtures, not only on account of their taste, but the difficulty in swallowing them, and their unpleasant influence in the stomach. They are also frequently less soluble, and are absorbed with greater difficulty. Syrups are not so objectionable in taste, yet frequently the 24 DISEASES OF CHILDREN. sugar undergoes decomposition in the stomach, producing irrita- tion. They are, however, very uncertain in their composition, and hence should be dispensed with. Occasionally we may employ the more powerful medicines by the use of homoeopathic pellets. They are easily prepared, but the dose is minute and not definite in quantity. I have used aconite, veratrum, gelseminum, strychnia, morphia, and others in this form. Occasionally we may administer a remedy endermically when it can not be given by mouth. I have thus used quinia in inter- mittents and remittents, morphia, atropia, aconite, and some others. I do not recommend it however with any but the first two, and the use of these will hereafter be described. THE DOSE OF MEDICINE. % The dose of medicine should be as small as will give the desired result. The harsh and immediate action of medicine is not usually desirable, but rather that gentle influence which is in the direction of healthy action, and which may appropriately be termed physiological. It is now generally admitted that the doses of medicine have been much too large, and that much in- jury has been occasioned by this over medication ; but there is no necessity of going to the opposite extreme of homoeopathy. In this, as in other things, there is a happy mean, which when found gives the best results The doses recommended in this work are the maximum. The minimum, though not infinitesimal, would generally be regarded as too small to produce an effect. The human body, however, is a very delicate mechanism, and its processes most easily influenced, and we may readily believe that it may be acted upon by anything of positive quality and appre- ciable quantity. A considerable experience in the treatment of diseases of children, has convinced me that the various processes of life are influenced with more certainty, and with far less liability ot injury through the sympathetic system of nerves, and that a very gradual influence is far more desirable than a speedy one. Another very important point in infantile therapeutics is that the medicinal influence be continued until the desired result is obtained. In other words, that, as the ultimate object is to be slowly obtained, and that by repetitions of the remedy, gradually 17 CLASSIFICATION OF REMEDIES. 25 increasing its influence from dose to dose, the doses should be so frequently repeated as not to lose the influence of one before another is given. Medicine should never be left for the sick to be given in drops, especially with children, who would suffer most from deviation in this respect. Let the remedy be added to some vehicle—water is the best—so that the dose will be a teaspoonful. I have had one patient poisoned from neglect of this rule, and others injured, hence I place much stress upon it. There is, however, another reason for such dilution which may have some bearing : and that is, the medicine is placed in a form that it can be more readily absorbed. • CLASSIFICATION OF REMEDIES. The classification of remedies is a work of no little difficulty, if we are to study them according to their specific action, which is the only method that will advance the practice of medicine. In the treatment of diseases of children, at least, we will abandon the old methods of large doses with their poisonous effects, and substitute the small dose of pleasant medicine, kindly in its in- fluence upon the body, and directly antagonistic to the processes of disease. The old practice never gave good success. It added additional pangs to the suffering, new wrongs to those existing, prolonging the duration of disease and increasing its mortality. A purely expectant practice has proven far more successful; good nursing with diet and rest has given much better success; the water-cure has yielded better results, and homoeopathy has proven an incal- culable blessing to the suffering little ones. Whilst we administer remedies for the most part according to specific indications—special symptoms pointing out the remedies —some are given for their well-known physiological action, and because they influence special parts in a well-known way. A large number of our remedies may be classified according to their action upon special parts or functions, and I can not but think that such grouping will be of advantage. We will, therefore, study our remedies as—1. Those which in- fluence the nervous system; 2. Those which influence the circu- lation; 3. Those which influence the temperature; 4. Those which influence the respiratory apparatus; 5. Those which in- fluence the digestive apparatus; 6. Those which influence the 26 DISEASES OF CHILDREN. urinary apparatus and its secretion; 7. Those which influence the skin and its function ; 8. Those which oppose the malarial poison—antiperiodics; 9. Those which oppose the process of zymosis—anti-zymotics ; 10. Those which oppose the process of sepsis—anti-septics ; 11. Those which oppose rheumatism—anti- rheumatics; 12. Those which oppose the poison of erysipeloid— anti-erysipclatous; 13. Those which oppose the syphilitic poison— anti-syphilitic, and 14. Agents that promote the processes of nutrition and increase life. REMEDIES WHICH INFLUENCE THE NERVOUS SYSTEM. Gelseminum, Quinine, Bromide of Ammonium, Belladonna, Opium, Carbonate of Ammonia, Rhus, Phosphorus, Iodide of Ammoifium, Bryonia, Camphor, Ferro-cyanuret of Potassium, Lobelia, iEther, Oenothera, Pulsatilla, Chloroform, Asafoetida Nux vomica, Chloral, As has been already remarked, " the nerve centers of the child are immature and more easily influenced for harm than in the adult." It might also be stated that the nervous system of the child suffers more from disease, and remedies influencing it assume a more important place in infantile than in adult thera- peutics. It would sometimes seem as if the old doctrine—" that all diseases have their origin in wrongs of innevration "—was more than truth; at least, our acting upon it would be more nearly right than he who is always " acting upon the bowels." The influence of the nervous system, even the brain, upon the processes of vegetative life, is much more marked than in the adult, and the relief of a wrong of innevration will many times occur, when remedies directed to the disease as classified have no effect. Instances will continually come up in practice, when single remedies like Rhus, Gelseminum, Belladonna, Bryonia etc., are sufficient for the cure of seemingly complex diseases. The evidences of disease here will soon become plain to the careful observer, as he studies the position of the body, its move- ments and expression, the expression of the face, its color the expression of the eyes, color, dryness and moisture, dilation or contraction of pupil, temperature, and the frontal, orbital and facial expression of pain. We do not claim that this is to be learned in a day or a year, but it will be learned in a satisfactory degree by him who gives it his attention. CLASSIFICATION OF REMEDIES. 27 If now, we take some common examples, we may see the truth of the above. For instance, here is a patient (a grave case of disease) who is restless, starts in sleep, cries out suddenly and shrilly ; we look at the face, which is contracted, especially about the eyes or base of the brain ; the eyes are bright, and evidently the little patient suffers pain, as shown by the contraction of the frontal and orbital muscles. We give Rhus in small doses, and all the unpleasant symptoms fade away. Here is another, suffering from fever or inflammation, which shows a flushed face, bright eyes and contracted pupils, with increased heat; there is restlessness, sleeplessness, it may be threatened convulsions, and thinking of the usual means, it is a bad case. We admisister Gelseminum with Aconite, and there is speedy and marked amendment. In still another, we find the patient dull, sleepy, comatose; the eyes dull, pupil dilated, and it may be a dull or dusky coloration of skin. We give Belladonna and these unpleasant symptoms soon pass away, and the patient convalesces. In another, the twitching of the facial muscles, the sudden movement of the head, and the involuntary movement of the extremities indicate the tendency to convulsions; the face is pale, brow contracted, circulation feeble, and we administer bromide of ammonium with a certainty of removing the unpleasant symptoms. Gelseminum. Specfiic Indications.—The face is flushed, eyes brioht, pupils contracted, temperature increased, nervous system excited, patient restless and wakeful. J)ose.—I$j Tinct. Gelseminum, gtt. v. to gtt. xx., water oiv.; a teaspoonful every hour. When the irritation is very great and the patient is threatened with convulsions the dose can be increased. Homoeopathic Indications, (3d to 6th decimal).—Bad effects from fright and fear, fright causes diarrhoea; vertigo with loss of sight, chilliness, accelerated pulse, double vision ; great heavi- ness of the eyelids; paralysis of the eyelids and other parts; pupils dilated ; dull expression of countenance ; difficult articula- tion and deglutition ; neuralgia, sharp, shooting pains through the face, eyes and head. Scarlet fever with great nervous excitement, tonsils swollen and very red, pulse rapid.—Ehrmann. We use a saturated tincture of the green root; all other prepa- rations are imperfect or wholly worthless for the purposes for which we employ it. The difficulty in describing this, as well 28 DISEASES OF CHILDREN. as some other remedies, so that the practitioner can employ them with success is, the very great difference in the quality of the article, as sold by different druggists. Gelseminum exerts an influence on the circulation like vera- trum and aconite, but less marked, and not so certain, and it is not for this purpose that I employ it. It has a specific action upon the cerebro-spinal nerve centers, relieving irritation and determination of blood to these patts. This is a use that renders the Gelseminum a remedy of great value in treating the diseases of childhood. The action is so certain and definite, that we prescribe the remedy with great satisfaction. Given, a case of fever or inflammation, in which the child is uneasy, irritable and restless, the face is flushed, the eyes bright, the pupils contracted, and head hot, Gelseminum removes in a few hours all the un- pleasant symptoms. It is also one of our most valued antispasmodics. Its use is in those cases in which the convulsions are due to irritation of the cerebro-spinal centers. In a case of acute disease, the child presenting those involuntary twitchings of the muscles which indicates the approach of convulsions, there being the flushed face, bright eyes, and irritability, Gelseminum wards off the ap- proaching spasms, and relieves the child of them when they have appeared. Gelseminum also has an important action on the urinary organs, which it is well to notice here. Occasionally a case of dvsuria will be met with, consequent upon irritation of the neck of the bladder or spasmodic stricture of the urethra. Gelseminum will overcome the obstruction and cause a flow of urine, in a majority of cases. Belladonna. Specific Indications.—The patient is dull drowsy, comatose, dull heavy headache, the face dull and expres- sionless, the eyes dull, pupils dilated or immobile, capillary circu- lation sluggish, as marked by deep color of skin or redness that is effaced by pressure of the finger, which leaves a somewhat per- sistent white line. Passage of large quantities of limpid urine involuntary passages of urine. Dose.—fy, Tinct. Belladonna, gtt. v. to gtt. x., water Siv. • a teaspoonful every one to three hours. Homoeopathic Indications, (3d to 6th decimal).—Throbbino- headache, with congestion of blood to the head, vertio-o, pulsa- CLASSIFICATION OF REMEDIES. 29 tion of the carotids, worse from motion, light and noise are intol- erable; furious delirium, illusions, hallucinations, with flushed face and redness of the eyes; wishes to strike, bite or shriek, pupils dilated, eyes brilliant and staring; smooth, shining redness of the skin, hot, burning and itching; sore throat, with sensa- tion of a lump on swallowing, and great dryness of the throat ; involuntary discharges of feces and urine from paralysis of the sphincters; pains come on suddenly, and leave just as suddenly. —Ehrmann. Belladonna causes contraction of capillary blood-vessels, doubt- less by stimulation through the sympathetic nervous system. Hence it is the remedy for congestion. Stasis of blood, or con- gestion, occurs in dilated capillary blood-vessels; indeed this condition of the capillaries is the cause of congestion. This action of Belladonna was first observed by Brown-Sequard in some of his physiological investigations. While this influence is exerted upon the entire circulation, it is most marked upon the circulation of the nerve centers. Thus we regard Belladonna as specific to congestion of the brain and spinal cord, and the dullness and coma which are symptomatic of it. In this respect Belladonna is the opposite of Gelseininum, which removes irritation and lessens determination of blood, the condition being an active one. Rurs Toxicodendron. Specific Indications.—The patient is restless, starts suddenly in sleep, sudden sharp cry, contraction of muscles about eyes and at base of braiu, sharp frontal pain, especially in left orbit, small pulse with sharp stroke, tongue shows small red papillae at the tip, erythematous flushing of sur- face, small vesiouke about mouth and sometimes upon the skin. Dose.—K) Tinct. Rhus, gtt. v., water .5'iv.; a teaspoonful every hour. Homoeopathic Indiations, (3d to 6th decimal).—Great debility, feeling of soreness and lameness of the muscles, especially when at rest. Rheumatic pains, drawing and tearing in the muscles and joints. Stiffness of the joints, relieved by continuous motion. Paralysis of the limbs. Bad effects from getting wet. Putrid taste in the mouth, metallic taste. Very restless sleep before midnight. Violent stretching and yawning. Diar- rhiBa, stools watery or of bloody mucus, frothy or white. Invol- untary stools at night while asleep. Dysentery with nausea and 30 DISEASES OF CHILDREN. tenesmus. Involuntary discharge of urine. Typhoid fever, dull stupid expression of the face, muttering delirium. Tongue dry, red, smooth. Restlessness. Involuntary passage of stools and urine, great exhaustion. Erysipelas with intense itching and burning. Scarlet fever or small pox before the eruption itches a great deal, with restlessness. Pustulous eruptions.—Ehrmann. This has a very extended use in the treatment of diseases of children. Commencing with the cases in which cerebral disease is a prominent complication, or indeed the principal element of disease, We find that this remedy relieves the excitement, pro- motes normal innervation through the sympathetic, and thus restores the circulation, waste and nutrition of the brain. It not only releives the brain and spinal cord, but it exerts a marked influence upon the circulation of blood, upon the temperature, upon waste and secretion, and upon nutrition. It presents us one of the most marked examples of the truth of the therapeutic maxim, " where a remedy is specially indicated, it will favorably influence every function of life, and sometimes do every thing that needs be done to effect a cure." Thus a malarial fever having the pronounced indications for Rhus will be cured by it better than by Quinine. An inflamma- tion of the eyes, of the lungs, of the bowels, of the urinary appa- ratus, or of any part, yields readily to Rhus, when it is specially indicated. It is a remedy frequently demanded in erysipelas and erysipeloid diseases, in zymotic and typhoid fevers, and in many endemic and epidemic diseases of children. Its use in the eruptive fevers, and in diseases of the skin will be named hereafter. Bryonia. Specific Indiadions. Headache in right side, with flushed right cheek; pain in serous cavities, with tension of muscles, and moderate tenderness on pressure; sharp, lancinating pain, with tension of tissues; hacking cough with pain; dry skin, sensitive ; hard pulse, with moderate fullness, sometimes corded ; rheumatic pain. Dose.—Pv Tinct. Bryonia gtt. v. to gtt. x., water 5iw a tea- spoonful every hour. Homoeopathic Indications (3d to 6th decimal).—In rheumatism and other complaints, marked aggravation on the slightest motion feels best when quiet; typhoid fever, with dry mouth and lips tongue is dry, rough, and cracked, and of a dark brown color • CLASSIFICATION OF REMEDIES. 31 delirium at night of the business of the day; patient wants to go home ; urine dark with pinkish sediment; pneumonia and pleu- risy, with sharp stitching pains on motion or breathing deeply ; cough worse in warm room.—Ehrmann. Bryonia will be found a prominent anti-rheumatic, and also a remedy for pain, especially when the pain is increased by pressure. Physiologically it has been found to exert a special influence upon serous membranes, and when our little patient complains of pain in the articulations,abdominal pain with tenderness, pleuritic pain, headache, with tenderness of the eyes and temporal regions, ten- sive pain in the ears, we think of this remedy It is a prominent remedy in disease of the respiratory apparatus —the cough irritative, hacking or rasping, pleuritic pain, sore- ness as if the parts were bruised, or soreness and tenderness of larvnx and supra-sternal notch. It does not matter whether the disease is pneumonia or bronchitis, the Bryonia acts well. I wish especially to call attention to the abdominal pain and tenderness in typho-malarial fever, and in some zymotic diseases, as calling for this remedy. It may also be associated with Ipecac or Euphorbia in cholera infantum, when there is abdominal ten- sion and tenderness, or swelling and pain of articulations. Bromide of Ammonium. Specific Indications.—Sudden move- ments of body or extremities, jerking of the tendons, twitching of the facial muscles, want of accommodatoin in the eyes, eyes turned upward ; face unusually pale, and pulse small, though I should not be guided by this. Doxe.— Fov u child one to two years of age, I would prescribe, 5j. to oij. to water r^iv.; a teaspoonful sufficiently often to control the symptoms and give rest. I employ bromide of ammonium to relieve the irritation of the brain and spinal cord, which gives rise to convulsions. It may be used to prevent the occurrence of convulsions when threatened, or to prevent their recurrence when arrested by other means. Regarding the remedy as a stimulant to the nerve cen- ters, we would use it when there was evidence of an enfeebled circulation of blood to the brain. There are a few cases of whooping cough in which bromide of ammonium will be found curative. In these there is an epilepti- form movement of muscles of the extremities associated with 32 DISEASES OF CHILDREN. the cough, and even the convulsive movements of the chest may be distinct. When convulsive disease has assumed a chronic form, as in epilepsy, I regard the bromide of ammonium as one of our most certain remedies. Its influence in childhood is more marked than in the adult. And its curative action is of course greater at the commencement of the disease than when it has continued for several years. I have employed it in a large number of cases of epilepsy, with very good success, a permanent cure re- sulting in a fair proportion. Pulsatilla. Specific Indications.—The child is restless, weary, cries frequently, sobbing even in sleep, face pale and ex- pressionless, pulse small jfnd feeble. Dose.—R/ Tinct. Pulsatilla gtt. v., water 5iy., a teaspoonful every three or four hours. Homoeopathic Indications, (3d to 6th decimal).—Mild, yield- ing disposition, with inclination to shed tears. Vertigo when stooping or lifting up the eyes. The pains of pulsatilla con- stantly change their position, flying from one part to another. Painful inflammation of the eyes, styes, lachrymation in the wind. Dryness, burning and itching of the eyes and lids, with inclina- tion to wipe something away. Fistula lachrymalis. Obscura- tions of the cornea. Otalgia, darting, tearing pains. Discharge of mucus or pus from the ear. Measles with loose, rattliiur cough, photophobia, thick and yellowish coryza.—Ehrmann. Lobelia. Specific Indications.—The pulse is full and oppressed, breathing difficult, rattling of mucus in chest, dull expressionless face. Dull eyes, somewhat swollen, threatened convulsions rest- lessness with uneasiness of bowels. Dose.—The dose will vary from the usual gtt v. to water .^iv. a teaspoon ful every hour, to that which will prove nauscant or emetic. To relieve restlessness and pain, and improve the circula- tion and respiration the old prescription—Fy Tinct. Lobelia Sem. 5) , Com p. Spirits Lavender 3iij., Simple Syrup 5iss.—will ue found very good. Homoeopathic Indications, (3d to 6th decimal).—Nausea and vomiting, with flow of saliva; sensation of a lump in the throat impeding swallowing; asthma with burning feeling in the chest and tightness; urine deep red color.—Ehrmann. infantile therapeutics. 33 Many of our readers will recall the old treatment of convul- sions in which Lobelia played so important a part as an antispas- modic. Compound Tincture of Lobelia and Capsicum (King's antispasmodic) was advised in all cases, and physicians would often wonder why, when the little fellows were so thoroughly drenched with this mistiness, the convulsions would sometimes persist even to a fatal termination. It was the old error of prescribing for names instead of conditions. The Lobelia is a powerful antispasmodic, the conditions being as above named — an oppressed circulation. It is a stimulant to the brain and spinal cord, to the respiratory system, and to the ganglionic nerves. If the condition of the nervous system in convulsions is such as to require a stimulant, then Lobelia is a remedy. To quiet irritation of the nerve centers and give rest, the remedy must be given in doses less than nauseant, and, as above remarked, it may be combined with an aromatic, or alternated with Aconite or Xux. It also relieves irritation of the stomach upon which the restlessness manv times depends. Xux Vomica. The child is restless, draws up its legs, con- torts its body, screams violently, wakes suddenly from sleep with crying, face flushes—intestinal irritation, colic, increased nervous sensibility. The face is pallid, sallow, yellowness about mouth, tongue pallid, nausea and vomiting, child uncomfortable, restless, sleepless, pallid, expressionless face and tongue, food distresses it, urine free but high colored, colors the napkins. Dose.—Py Tinct. Xux gtt. j. to gtt. iij., water .^iv.; from one- fourth to one teaspoon ful every half-hour or hour. Homeopathic Indications, (3d to 6th decimal).—Irritable ; inclined to find fault, disinclined t*> talk; wants to be let alone; nausea and vomiting ; constipation, large difficult stools; uneasy feeling as if the bowels ought to move; ineffectual efforts to pass the feces ; painful hemorrhoids; loss of appetite ; restless sleep, wakes at 3 a. m. ; eructations and heart-burn ; violent hiccough ; colic of whisky and coffee drinkers ; can not bear the clothing tight around the waist ; incarcerated hern-ia ; dysentery, stools small and frequent, with ineffectual urging; retention of urine; suitable to persons of sedentary habits.—Ehrmann. Xux undoubtedly relieves irritation of the brain and spinal cord, when the circulation to these centers is enfeebled. One 3 34 DISEASES OF CHILDREN. might think, from its kindly action upon the intestinal canal and associated viscera, that the relief depends wholly upon this, but I am satisfied that it is not so. When the face is pallid and the pulse feeble, I have seen it relieve the patient from threatened con- vulsions, give rest and good sleep. In infantile paralysis, imperfect movement, and want of de- velopment of the extremities, it is a remedy to be thought of if the circulation is feeble. When the respiratory movements are feeble, in malarial disease, I would suggest Xux. It is not so important in retention of urine as santonine, }>ut it may occa- sionally be used with advantage. It is the tonic of childhood, or rather the stomachic; for it is kindly received by the stomach and is not as objectionable to the taste as the most of bitters, while it increases the appetite and the power to digest food. When there is great depression of the nervous system, without fever or inflammation, it may be used with advantage. As an adjuvant to quinia in periodic disease, especially in intermittent fevers, strychnia will serve a good purpose, and in some old cases, where quinia has been used to excess, we may arrest the periodic disease by its use. Quinia Sulphas. Specific Indications.—There is distinct periodicity in the disease. When administered the pulse should be soft, the skin soft or inclined to moisture, the tongue moist and cleaning, and the nervous system moderately free from irritation. Dose.— The antiperiodic dose of quinine may be stated at one grain for each year, a grain being the dose for a child six months old. This proportion will continue up to the sixth, eighth or tenth year, when it will stop uutil after puberty. In many cases the antiperiodic influence of quinine may be obtained from a minute dose, or, as we frequently use it, from its application to the skin by inunction. Homoeopathic. Indications, (3d to 6th decimal).—Great debility resulting from loss of fluids, as in diarrhoea, hemorrhage, etc.; ailments which have a marked periodicity ; metorrhagia, with paleness of the face and coldness of the skin ; pulse impercepti- ble; ringing in the ears; diarrhoea, painless and debilitating, stools undigested, worse after eating or at night ; intermittent fever, followed by profuse and debilitating perspiration ; sensi- tive to the least draft of air.—Erhmann. INFANTILE THERAPEUTICS. 30 Many wrongs of innervation will be found to have distinct periodicity, whether they take the form of pain, restlessness, sleeplessness or tendency to convulsive action. In malarial re- gions the practitioner is continually on the watch for this, and even an obscure periodicity is thought to demand quinine, and its right use is followed by most satisfactory results. Quinine has been regarded as a tonic and a nerve stimulant, but these actions arc doubtful unless there is the specific indica- tion. The inunction of quinine is frequently followed by in- creased appetite and digestion, a restful nervous system and better excretion, and patients recover rapidly from cholera infan- tum, slow forms of inflammation and obscure diseases, but I think in each of these cases a careful examination would deter- mine the malarial influence and periodicity. Euoot. Specific Indications.— Dullness, stupor, dull eyes, expressionless face, pulse slow and oppressed, tendency to con- gestion, hemorrhages. -Do.sc.—Py Tinct. Ergot gtt. v., water oiv.; a teaspoonful every hour to three hours. Homoeopathic Indications, (3d to 6th decimal).—(neat anxiety, fear of death. Wild, staring look, distortion of the eyes, vision obscured. Sunken countenance, eves sunken. Spasmodic dis- tortion of the mouth and lips. Female complaints, especially in thin individuals. Vomiting of bile, with great weakness. Dry gangrene, beginning in the toes. Very debilitating diarrhoea. Cholera.—Ehrmann. The influence of Ergot upon the system is very similar to Belladonna, and as there is no other place where it can be more properlv described, we will place it here. I have employed it in cases where there was an oppressed condition of the nervous svstem, with a tendency to coma, a labored respiration, and full oppressed pulse. In those cases in which, with such symptoms, there are convulsions, it will be found particularly useful. I should prefer Belladonna in febrile diseases; Ergot is non-febrile. Iodide of Ammonium, specific Indications.—Headache with dizziness, unsteadiness of walk, feeble or sluggish circulation. /)n;«>.—11 Iodide of Ammonium grs. x. to 5s*., water .Viv.; a teaspoonful four times a day. The indications for this remedy are occasionally met with in •.)<> DISEASES OF CHILDREN. diseases of children. Sometimes the lesion of brain is purely functional, but at others it will be found strumous or syphilitic. In the latter cases, I employ this and the iodide of potassium, where the tongue is broad and pallid ; Donovan's solution when it is small and red. Camphor. Specific Indications.—Pallid, expressionless face, pain, sleeplessness, with tendency to exhaustive discharges. Dose.—Py Tinct. Camphor gtt. v., water r^iv.; a teaspoonful frequently repeated. Homoeopathic Indications, (°>d to 6th decimal).—Coldness of the skin, at the same time patient does not wish to be covered. Sud- den prostration with diarrhoea. Retention of urine, with con- stant pressure on the bladder and desire to urinate. Pulse small, weak, and slow.—Ehrmann. .Ether. Specific Indications.—Pain, or convulsive action, the face being pallid and cool, and circulation feeble. It is a Very good remedy for the relief of headache from an enfeebled circu- lation. Dose.—Py JEther 5j-, simple syrup 5].; ten drops to 5ss. may be given with a little water. As an anaesthetic it may be em- ployed with a napkin in the usual way of administering chlo- roform. With the indications named it will sometimes promptly relieve pain, give rest and sleep. It will also control convulsions, though the dose for internal administration is usuallv greater than that named. It is also sedative at least to the extent of lessenino- the frequency of the circulation. It is now regarded as a safer anaesthetic than chloroform, and many physicians use it exclusively. Some emplov it with an equal amount of chloroform, its action being quicker. It may be used by inhalation to relieve pain, arrest convulsive action, and prevent its recurrence, as well as for complete anaesthesia when surgical operations are to be performed. A spray of aether is us(.(j to produce local anaesthesia, i" minor operations, also as a refrioe- rant in cast's of inflammation. Chloroform. Specific Indications.— Pain. Convulsions. Gall stones. Surgical operations. We prefer chloroform as an ainvsthetic because of its speedier action, its more agreeable effect on the patient, and the o-reatcr INFANTILE THERAPEUTICS, ■!■ t ease of its administration. We have used it for thirty years without having a fatal case, and think that with care it is one of the safest remedies. Who can say as much for any of the agents in common use. Say Opium, Aconite, Veratrum, Gelseminum. The first I will guarantee has killed thousands, where one has been lost by chloroform. Chloroform is administered as an anaesthetic by using a folded napkin or handkerchief, cupping it, and sprinkling the fluid in the cavity. This is held over the nose in such manner that the vapor may be inhaled with a sufficient quantity of air. Especial attention is given to the respiration, which, if free, assures us that the patient is in no danger. If it becomes slow, difficult, or ceases, the inhalation is suspended, the child is turned quickly, and two or three smart blows on the chest or buttocks restores the respiratory function. We use chloroform by inhalation to relieve intense pain, and to arrest convulsions. Of course it is not often demanded for the first, and its use in the second case is frequently temporary— we control the convulsions for the time being, until the indicated remedy can be given, and has time to act. This is much better practice than to allow the convulsive action to continue whilst we are vainly striving to get a medicinal action through the stomach. One of the most powerful antispasmodics at our command is found in chloroform. In the majority of cases it will be found safe as well as certain, but there is a class in which I think its use dangerous. There are cases in which there is congestion of the brain, and especially an impairment of innervation through the sympathetic nervous system, and a sluggish general circula- tion, with tendency to congestion of all important organs. It is somewhat difficult to diagnose such a condition ; but the begin- ner will do well to reject the remedy when the breathing is labored, the pulse not much increased in frequency, when the eves are congested and the lips present a continued dusky or pur- plish appearance. Chloroform has been administered in very large doses with safety, though I do not think they should be recommended. As much as a teaspoonful has been given at once to a child two years of age, and repeated. A half teaspoonful is quite fr< quently named as a dose. I think that ten drops will usual). produce the effect desired, and order the vehicle in such propor- 38 DISEASES OF CHILDREN. tion as to give this quantity in a teaspoonful. Simple syrup. glycerine, or mucilage, are good vehicles for its administration. Chloral Hydrate. Specific Indications.—To relieve pain, promote sleep, arrest convulsions, and relieve the cough of ner- vous irritation. It is contra-indicated when the circulation* is sluggish, when there is atendency to congestion, pallid bluish lips, pale leaden tongue, dull eyes, and enfeebled respiration. Dose.—The dose will vary from one-half to five grains, for a child two years of age, and it may be given with syrup and water, as—Py Chloral grs. xx., simple syrup f>ss. water 5iss.; dose a teaspoonful. The element of danger in the administration of Chloral must never be overlooked. Adults have died from a dose of but ten grains, whilst as much as three hundred grains have been taken with safety. If, however, the rule given above is observed, I think its use will be safe. It must be regarded as a temporary remedy only, and when the present emergency is passed it must be suspended for permanent remedies. * Opium. Specific Indications.—The pulse is small and open, waves short, the face pallid, eyes dull, pain, sleeplessness. Homoeopathic Judications, (3d to 6th decimal).—Mania; delir- ium tremens; frightful or pleasing visions, alternating with stupor; steady stertorous breathing, with half open eves; bad effects of fright; congestion of blood to the brain, with strong- pulsations; staring look, glassy immovable eyes ; apoplexy with deep snoring breathing, mouth open ; paralysis without pain ; trembling and twitching of the limbs; constipation, stools in round, black, hard balls; all ailments accompanied by sopor.— Ehrmann. Opium is a remedy that should be employed with verv t>reat care in diseases of children, though it need not be discarded. There are some cast's, in which a judicious use of opium will calm irritation of the nervous system when all other means have failed, and in which this influence is essential to the preservation >f life. The danger from the use of opium is, that its influence on the brain be such as to impair its circulation and nutrition. It first stimulates the nerve tissue and increases the circulation to it • and, secondly, exhausts the nerve tissue and causes congestion. INFANTILE therapeutics. 39 The safest use of opium is in small closes to obtain its stimulant action, the remedy to be frequently repeated to continue the in- fluence. Occasionally a case occurs in which the little patient is very much exhausted, and suffers pain from this cause, there being neither fever nor inflammation. In such cases opium may be used with advantage. The only trouble in such cases as it might be used with benefit is, that it tends to arrest secretion, and if arrested we have again a return of blood poisoning. Occasionally opium is given in the form of some soothing svrup, cordial, or other preparation to quiet children, until we have a condition of chronic poisoning. The symptoms are very marked—general emaciation, languor, a withered, sallow coun- tenance, red and swollen eyelids, derangement of the digestive organs with loss of appetite, and constipation of the bowels, with white stools. For young children the safest preparation is the compound powder of ipecac and opium of our Dispensatory. I generally add five grains to an ounce of water, sweeten with sugar, and have it given in doses of half a teaspoonful frequently, until the patient is relieved. Ammonium Carb. Specific Indications.—The pulse is feeble, circulation to the surface imperfect, skin pallid or dusky, respira- tion difficult, restless and sleepless. Homoeopathic Indications, (3d to 6th decimal).—Suitable for weak and nervous persons of sedentary habits. Scarlet fever when the rash is only faintly developed, with drowsiness, stupor, dry mouth, right parotid gland swollen, burning in the throat. — Ehrmann. Ammonia is an excellent diffusible stimulant, and may be employed in any case in which this action is desirable. The ses- quicarbonate of ammonia is a good form, and may be given in doses of one-half to three grains, in sweetened water. It is espe- cially in the prostration from acute disease that it will be found serviceable. Phosphorus. Specific Indications.—In acute disease there is a low grade of inflammation, with feeble circulation, and cerebral anemia; urine contains mucus, sometimes pus, and is passed with difficulty. In chronic diseases, an enfeebled nutrition of the brain, imperfect retrograde metamorphosis and combustion, with cacoplasfic or tubercular exudations. 40 d:;:-:as:-:3 of children. Dose.—In acute diseases—Py Tinct. Phosphorus gtt. j. to gtt. v., water .^iv.; a teaspoonful every one to three hours. In chronic disease 1 prefer the hypophosphites : hypophosphite of lime gr. ss. to gr. j. three times a day ; or the compound syrup of the hypo- phosphites, one-fourth to onerhalf teaspoonful after meals. HoiiuC'jpathic Indications, (3d to 6th decimal).—Very weak, empty feeling in the abdomen ; heat up the back; constipation, long, hard, and dry stools, which are expelled with difficulty ; sour eructations and sour vomiting; desire for cold food and drink, which is vomited as soon as it becomes warm in the stom- ach ; vomiting of blood ; watery diarrhoea, coming away in a gush, followed by a sense of weakness ; sharp, shooting pains in abdomen ; hoarseness, loss of voice, croup, bronchitis ; hard, tight, dry cough, which is very exhaustive, worse from lying on the back or left side; expectoration salty, bloody yellow, purulent or of sour taste ; more expectoration in the morning; pneumonia, respiration oppressed, quick and anxious; circumscribed redness of the cheeks; phthisis pulmonalis, particularly in tall, slim per- sons; pulse rapid.— Ehrmann. Ferrocyanide of Potassium. Specific Indications.—It. chronic disease there is marked irritability of the nervous system, with restlessness and broken sleep; the pulse and respiration have their frequency increased; mucous membranes are pallid and lax with increased secretion, bowels irregular and tumid. Do.se.—Py Ferrocyanide of Potassium 5j-, water .^iv.; a half teaspoonful to a teaspoonful three or four times a day. This remedy may be used in catarrh, chronic pharyngitis, threatened tuberculosis, or intestinal diseases simulating tabes mesenterica. Though named in this class of diseases—imperfect nutrition with tendency to aplastic deposits—the remedy is in- dicated by the peculiar nervousness, with enfeebled circulation and nutrition of the brain. CExothera. Specific Indications.—A sallow, dirty skin, tis- sues full and expressionless, dull face and eyes, large sallow tono-ue feeble innervation with broken sleep and tendency to cry on the slightest annoyance. Dose.—K Tinct. (Enothera gtt. x., water .^iv.; a teaspoonful everv three or four hours. Asafcetida.—This is one of the oldest antispasmodics in use and is a very good remedy in some diseases of children. The INFANTILE THERAPEUTICS. 41 objection tj it is its offensive odor and taste, which render it diffi- cult of administration. Its action seems particularly beneficial wl en the spasmodic or convulsive action arises from an irritation of the stomach, or parts associated with it. It is a gentle stimu- lant to the gastro-intestinal mucous membrane, and relieves irri- tation of it. The tincture of asafoetida with simple svrup offers the best means of administration. The dose of the tincture will be from ten to twenty drops. REMEDIES WHICH INFLUENCE THE CIRCULATION. Aconite, Rhus, Podophyllin. Veratrum, Lycopus, Hauiainelis, Gelseminum, Lobelia, Cactus, Eupatorium, Digitalis, Apocynum Canabinum, Spiritus ^Etheris Nitrosi. Lesions of the circulation are met with in almost all forms of disease, and in many are a principal element, so that if the cir- culation is brought to a normal standard and kept there, the dis- ease passes away. Readers will recall the teaching that there is in a majority of cases a first element of disease (basic element), upon which the disease is based, and which if taken away, the other wrongs disappear of themselves. This is frequently the case with the circulation. Here is a fever or an inflammation with a pulse of 120 beats per minute, small, and upon this as a base, we have a temperature of 104°, arrested secretion, irritation of the nerve centers, and symptoms point to the development of a typhoid condition. Aconite is given in the usual small dose, and as the pulse comes down to the normal standard, the tem- perature comes down, secretion is established, the nervous irrita- tion and pain pass away, the appetite returns, and the patient convalesces. But one remedy has been used, yet everything necessary has b<^en accomplished. The association between frequency of pulse and temperature will be recalled, for every ten beats of pulse an increase of one degree of heat. If the pulse increases in frequency the tempera- ture increases, as the pulse comes down the temperature comes down. With a high temperature every process of life is im- paired, the cause of disease is intensified, and molecular death is rapid. As the temperature comes back to a normal standard the various functions are better performed, nutrition commences, causes of disease are less active, and the body frees itself from devitalized material. 42 diseases of children. Increased frequency of pulse intensifies inflammatory action, and looks toward death of the part. In inflammation of the respiratory apparatus, increased frequency of pulse causes in- creased frequency of respiration, cough, determination of blood, pain and unrest. We control the inflammatory process as we control and obtain a normal circulation of blood. Aconite. Specific Indications.—The pulse is small and fre- quent. (The indication is short but explicit). The remedy in- fluences special parts, as the throat, the larynx, bronchial tubes and intestinal mucous membranes, the indication being irritation with determination of blood Dose.—Py Tinct. Aconite gtt. iij. to gtt. v., water .^iv. ; a tea- spoonful every hour. Homceopcdhic Indiccdions, (3d to 6th decimal).—Chill, followed by hot, dry skin, quick, full pulse; great restlessness and thirst, fear and anxiety of mind, sudden sinking of strength; congestion to head, chest, and heart; anxious, labored breathing.—Ehrmann. The pulse is small and frequent; it seems plain enough and yet it is sufficient for all our purposes. If it is a fever the tempera- ture will be increased in proportion to the frequency of the pulse, and the remedy will then reduce the temperature as it brings the circulation down to the normal standard. If, however, it be the cold stage of a fever, or an Asiatic cholera, it will in- crease the warmth of the body as it gives a natural circulation. The frequent small pulse is the indication in inflammatory dis- ease when there is marked irritation and determination of blood, (an active condition), but the remedy serves an equally good purpose if the circulation of a part is enfeebled—the pulse being small and frequent. Looking at the action of re me lies in the usual way, this seems very strange—a paradox—but there is much in nature that we have not unraveled. If we observe the action of Aconite in fever, we find that as the pulse diminishes jn frequency it in- creases in freedom, and there is a better circulation. If we note its action in cholera we observe that as the pulse loses its fre- quency it gains volume and freedom, and there is a better circu- lation of blood. If we note its action in active inflammation we notice that it lessens determination of blood, quiets the irritation checks the rapid circulation in the capillaries where it is too active, and increases the circulation where it is slu<>Vi.sh. If as infantile therapeutics. 43 we think, it acts upon and through the ganglionic system of nerves, we can account for all of this by saying that it gives right innervation. I have been in the habit of saying that Aconite was a stimulant to the heart, arteries and capillaries, be- cause whilst it lessened the frequency it increased the power of the apparatus engaged in the circulation. In noting the special parts and tissues, influenced by Aconite, we may commence with the tonsils, the fauces and pharynx, where its influence may depend somewhat upon its topical action when swallowed. It has a direct influence upon the larynx, and is one of our best remedies in acute laryngitis and croup; indeed I would very much rather trust my patients with Aconite alone, than with all the old materia medica. Its influence upon the mucous membrane of the bronchia, even to the air cells, is very marked. The topical action of Aconite upon the stomach relieves irrita- tion, and frequently puts this organ in condition to receive remedies and food kindly. It acts directly in relieving irritation of the intestinal canal from stomach to rectum, and proves one of our most efficient remedies in diarrhoea and dysentery, as well as in acute diseases of the associate viscera. It will be noted that Aconite has a wide range of use, especially in diseases of children. It may be called, par excellence, the child's remedy, for the indication—small and frequent pulse—is a common condition in the acute diseases of children. I can almost ats. Lav- ender 5'ijv Syrup oiss. Mix. Give in small portions, frequently repeated, just short of nausea. This will be found an admirable form for the remedy, as it is readily taken, is kindly received by the stomach, and it relieves nervous irritation and gives rest. A description of Lobelia would not be complete without refer- ence to its old use as a nauseant. For this use in diseases of children, I prefer the acetous tincture to other preparations. It is prepared in the proportion of four ounces of the herb lobelia to the pint of dilute acetic acid, or vinegar ; or the acetous tinc- ture may be formed into a syrup by the addition of two pounds of sugar to the pint. Given in nauseant doses, lobelia relaxes the respiratory pass- ages, and thus gives temporary ease to the breathing. In croup, in asthma, in bronchitis, and in whooping-cough, this action is very important. Continuing this nauseant influence there is increased secretion from the mucous membrane of the respiratory passages, and it is thinner and less tenacious than the secretion during the inflammatory process. The engorgement of the vessels is somewhat relieved by the secretion, and the mucus is removed with greater ease. In administering the nauseants for this purpose, thev should be repeated so frequently as to keep up a continued action ; for if given at long intervals, the alternation of relaxation and de- termination of blood proves injurious; and to obtain this action, they should never be given to produce speedy emesis ; indeed emesis is not desirable in any case, unless to remove accumula- tions of mucus already secreted. Eupatouium. When the pulse is frequent, full and free, and the skin inclined to be moist, the Eupatorium will be found a good remedy in bronchitis or pneumonia. Phytolacca. This remedy exerts a special influence upon the fauces and pharynx—the throat—and when this is inflamed or INFANTILE THERAPEUTICS. 65 irritated, and is a source of cough or respiratory difficulty, we think of Phytolacca. A pallid tongue with red spots, sore mouth, sore throat, enlarged lymphatic glands or soreness or pain of mammary glands, associated with disease of the respira- tory apparatus, call for Phytolacca. Stillingia. Specific Indications.—Sense of rawness and tick- ling in the throat; sense of irritation behind the fauces or the velum pendulum palati; burning, itching of the larynx, which causes a short cough and inclination to hawk and free the throat; croupal cough and voice. Dose.— Py Tinct. Stillingia gtt. x., Simple Syrup r>ij., one- fourth to one-half teaspoonful. I like the Linamentum Stillingia (ly Oil of Stillingia 5>j-, Oil of Cajeput oi., Oil of Lobelia .jss., Alcohol rjj. Mix) in doses of one-half to one drop on sugar. Stillingia is one of our best remedies for the relief of cough, when it is caused by a sense of irritation of the throat. We use it in chronic bronchitis, in acute bronchitis when secretion is established, and especially in laryngeal disease, and croup. Even the external application over the larynx will cure croup, and is much safer than the old treatment. Usually I administer Aconite internally and apply the Stillingia liniment to the throat. Lycopus. The pulse is frequent and somewhat full or hard, the cough paroxysmal, expectoration of muco-pus, difficulty in urination, hemorrhage from lungs or kidneys, deposit of tubercle. Dose.—As a cough medicine I administer it in drop doses on sugar; for other purposes—R Tinct. Lycopus gtt. x. to 5'j-j Alcohol 5**-, water 5'iijss ; a teaspoonful every one to four hours. I like the action of Lycopus very much in chronic bronchitis, pneumonia, or tendency to phthisis pulmonalis. It relieves the cough, quiets pain, gives rest, diminishes the temperature, and brings the pulse down to a normal standard. It will also give good results in chronic inflammation of the kidneys, bladder and u ret lira. Sancuinaria. Specific Indications.—A sense of burning and constriction in the fauces or pharynx, with irritative cough and difficult respiration. The patient is nervous and restless, redness of nose with burning and thin acrid discharge, spots of bright redness on face or on chest, redness and burning of the ears. Dose.—The dose will depend upon the action wanted. Many 5 66 DISEASES OF CHILDREN. times I use it in very minute doses—Vy, Xitrate of Sanguinaria gr. ss, water iv.5; a teaspoonful every two or three hours, (or Tinct. Sanguinaria gtt. ij. to gtt. v., water Siv.) In other cases I • would use the acetous tincture in full doses to nausea for a tem- porary effect. N Homoeopathic Indications, (3d to 6th decimal).—Congestion of blood to the head, with ringing in the ears and flushes of heat. Sick headache, beginning in the morning with vomiting of bile, worse from motion, stooping, noise or light. Periodical headache. Coryza, with loss of smell. Nasal catarrh. Xasal polypus. Ulcerated sore throat. Tongue feels sore as if burned, coated white. Sensation of emptiness in the stomach soon after eating. Croup. Asthma. Pneumonia with very difficult respiration, cheeks and hands livid, pulse soft and easily compressed.— Ehrmann. Like the Lobelia, for the old use, I prefer the acetous tincture of sanguinaria to any other preparation. It is prepared with two ounces of the ground root to one pint of dilute acetic acid, or vin- egar. A syrup may be prepared in the same manner as named for the Lobelia. Sanguinaria is rarely used alone; but in combination with Lo- belia it gives us our most efficient nauseant expectorant, and is the remedy we prefer in cases of mucous and pseudo-membranous croup. In small doses, so that it does not produce nausea, it be- comes a stimulant expectorant, and will check secretion from the bronchial mucous membrane. Nitrate of Sanguinaria. The nitrate of sanguinaria is one of the few really good concentrated preparations. It is rarely used in the form of powder, being too acrid ; but, combined with simple syrup, in the proportion of one grain to four ounces, it furnishes a very desirable remedy. Its action is rather that of a stimulant to the respiratory apparatus, and it should not be used in nauseant doses. The dose of the syrup will be ten drops for a child two years of age. Euphorbia. This remedy, which is fully studied with those which influence the digestive apparatus, has an action very much like ipecac, and may be used to quiet irritation of the bronchial tubes and to check profuse secretion. Dose.—Py Euphorbia Hypericifolia gtt. v. to gtt. x. water 5iv.; a teaspoonful every hour. INFANTILE therapeutics. 67 Phosphorus. This remedy, which has been fully studied in other relations, influences the respiratory apparatus in a direct manner, stimulating a better innervation and circulation. It may be prescribed in low grades of inflammation of the luno-s and bronchia in minute doses as—Py Tinct. Phosphorus gtt. j. to gtt. iij., water 5iv.; a teaspoonful every hour. Senega. Specific Indications.—The cough is deep, succussive ; much rattling in the chest; free expectoration of mucus, or inuco- pus; skin is harsh and dry and the epidermis desquamates, or it is relaxed and the surface looks dull and dead. Dose.—The Syrup Senega may be used in doses of one-fourth of a teaspoonful, as a stimulant to the respiratory apparatus. Or the tincture may be employed, as—R Tinct. Senega gtt. v. to gtt. xx., water rjiv.; a teaspoonful every one to three hours. The stimulant influence of Senega upon the throat and bron- chial mucous membrane is well known, and is probably its most important use. For this purpose I prefer to use it in the form of tincture to that of syrup as commonly employed. In chronic bronchitis with profuse secretion, it may be combined with small doses of Ipecac and Veratrum. Its influence upon the kidneys and reproductive organs needs to be studied, and I have no doubt some important uses will be found for it. I have employed it in squamous disease of the skin, and like its action very much ; it is one of a very few remedies that influence these diseases. Scill.E. Specific Indications.—Cough with secretion of a yel- lowish muco-pus, mucus rattling in the chest, scanty urine, feeble circulation. Dose.—R Acetum Scillae ryss., Syrup 5iss.; from one-fourth to one-half teaspoonful every one to three hours. Ilomceopcdhic Indications, (3d to 6th decimal).—Whooping cough, sounding loose, with sneezing and watering of the eyes and nose. Catarrhal affections, with loose sounding cough ; more expectoration in the morning. Wheezing breathing. Pneumo- nia. Pleurisy. Asthma. General anasarca. Hydrothorax. Fre- quent desire to urinate, with profuse discharge of pale urine.— Ehrmann. Sticta. Specific Indications.—The patient complains of pain in the shoulders extending to neck and back of the head; the 68 DISEASES OF CHILDREN. child will be observed to draw its shoulders upward, throw the head backward and move it uneasily. There is a harsh, dry cough, evidently from irritation and not to remove secretion. Dose.—Py. Tinct. Sticta gtt. v., water Siv.; a teaspoonful every one to three hours. Homoeopathic Indications (3d to 6th decimal.) Dry coryza, with constant desire to blow the nose. Chorea, constant invol- untary motion of the feet. Excessive dryness of the nasal pas- sages and soft palate; deglutition painful on this account. Dry, hacking cough.—Ehrmann. Sticta is a very fine remedy when the indications are clear as above. Why a pain in the shoulders, neck and to occiput, call for sticta, is more than I can tell, any more than I can tell why a sick person should have a pain in his shoulder ajid back of neck and head. But all we want to know in medicine is, this relation between a definite symptom or symptoms, and the curative ac- tion of a remedy. Sticta is an excellent remedy for cough, re- lieves irritation, and improves respiration, acts kindly upon the stomach, and is one of our best anti-rheumatics. Rumex. Specific Indications.—Cough with sensation of full- ness in the chest, sighing, yawning, efforts to take a full inspi- ration. Dose.—Py Tinct. Rumex gtt. v., water 5iv.; a teaspoonful every one to three hours. We employ Rumex in cases of bad blood, with disease of the skin ; in such cases it is certainly one of the most valuable alter- atives we have. In these cases we not only use it internally, but as a local application. In scrofulous disease, with deposit in glands and cellular tissue, with tendency to break down and fee- ble repair, I think the Rumex unequaled. Here, also, we use it internally and locally. Grindelia. Specific Indiccdions.—The breathing is labored and asthmatic; the cough hard with rattling of mucus; sense of soreness and rawness of chest; chronic ulceration, with feeble venous circulation. Dose.—R Tinct. of Grindelia oj., Glycerin, Svrup aa. Sj.; one- fourth to one-half teaspoonful every two or three hours. Grindelia may be employed as a cough lemedv in fleshv chil- dren with feeble circulation, and in asthma with secretion but INFANTILE THERAPEUTICS. 69 want of power to expectorate. It is a stimulant to the respira- tory apparatus and to the respiratory function. Locally (in the proportion of oj. to water Oj.) it may be used in the cure of old ulcers, scrofulous ulcers, and as a means of discussing scrofulous enlargements. Hypophosphites. The compound syrup of the hypophos- phites will prove an admirable remedy to relieve irritation of the lungs with atony, checking cough, and giving increased respira- tory freedom. At the same time it improves digestion, blood- making and nutrition. The hypophosphite of lime is one of the most certain remedies I have ever employed in the early stages of pulmonary tuberculosis. REMEDIES WlIrCH INFLUENCE THE DIGESTIVE APPARATUS. It cannot be too often impressed upon the physican, that a good condition of the digestive apparatus is of first importance in the treatment of any form of disease. If stomach and bowels are in fair condition we are careful not to disturb them. If there is anything wrong with them, the first object of treatment is to right this wrong. That system of medicine which irritates the stomach and keeps it in a state of unrest is intrinsically bad, increasing the suffering of the sick, prolonging disease, and greatly increasing the mortality. That system of medicine which disturbs the bowels, causing irritation or atony, wrongs the sick, intensifies suffering, and increases the death rate. If any one will call up his past experience in this direction he will realize the truth of these statements. How have you felt when suffering from nausea and vomiting, or even from gastric irritation short of this? Did you find it conducive to comfort, to rest, to appetite, digestion and normal functional activity? How would you like a teaspoonful of Lobelia or Sanguinaria before each meal—as a steady diet? How have you felt when suffering from a good old fashioned diarrhoea of six to ten evacuations a day? Is this conducive to comfort, to rest, to appetite, to normal functional activity? When you are on the outside of two or three grains of Podophyllin, one or two drachms of compound powder of Jalap, or a teaspoonful of Cascara, was it comfort- ing to the inner man, and did it give strength to the legs and ability to work? If a well man does not take kindly to these 70 DISEASES OF CHILDREN. sensations, and finds that they impair his life, and all his func- tional activities, what must it be with the sick man, woman or child? These are questions which one should put to himself, and then see that they are answered. If we think of the function and relations of this apparatus we can'see additional reasons for the rule I have named. It is the inlet for all the fluid and the foods required by the body, and these are required for sustaining the life. In the olden time it was thought that the sick person required no nourishment, but we now know that the sick may be starved, and are fre- quently starved to death. A certain digestive power is necessary, even though we are careful to furnish food that requires but little digestion, and this requires a reasonably good condition of stomach and intestinal canal. If one only thinks of the administration and absorption of medicines he will see the necessity of the rule. Unless the stom- ach is in fair condition medicines are not kindly received and ab- sorbed. The right remedy may be selected, which, if it gained entrance to the blood, would do that which is needed for the cure ; it is given, but wholly fails because absorption can not take place. The sympathies of the gastro-intestinal canal are very numer- ous and very sensitive, indeed it seems to be the center of morbid sympathies. If a distant part is involved in disease, the stomach speedily suffers; if the body at large is diseased, the stomach suf- fers. It is abundantly supplied with ganglionic nerves, and the solar plexus, the center of this system, lies immediately behind it, and is almost directly influenced from it. It is thus related to the circulatory, respiratory, and excretory apparatus. EMETICS. The act of emesis seems natural to the nursing child, relieving the stomach of repletion and nourishment that fails to digest. This would point out the first indication for emesis, to relieve the stomach of food that can not be digested, or that is undergoing decomposition. For this purpose there is nothing better than warm water given freely, and its action in some cases of emergency assisted by tick- ling the fauces with the finger. A solution of common salt is also very good in such cases, and leaves no bad influence. The second indication for the use of an enietic is, when there are morbid accumulations in the stomach, from undigested and INFANTILE THERAPEUTICS. 71 decomposing food, or from an increased secretion of gastric mu- cus. It is met with occasionally in the first stages of severe dis- ease and is an unfavorable complication, for such condition of the stomach precludes the taking and digesting of food, and the proper appropriation of remedies. Frequently, in such cases, the medi- cines given will be ejected from the stomach two or three times a day, or may not be tolerated at all. The third indication for the use of an emetic is, for the removal of material from the respiratory organs. This is generally mucus, occasionally mucus and pus. The emetic is only employed in this ease, when we have such evidence of the loosening of the mucus as will lead us to believe that it may be removed in this way. Emetics are employed in nauseant doses to aid in soften- ing, diminishing the plasticity, and loosening such accumulations. The fourth indication for the use of an emetic is, to rouse the nervous system from severe depression, and restore a uniform cir- culation of blood. For this purpose it is employed in scarlatina maligna, in the severer forms of rubeola and variola, and occa- sionally in other diseases. Ipecacuanha. I administer ipecac to fulfill the second indica- tion of an emetic. It is given in the form of powder, mixed with warm water, and assisted in its action by warm water or some warm tea. The dose for a child two years old, will be from three to five grains; for an infant, half to one grain. Acetous Tincture of Lobelia and Saguinaria.—R Lo- belia, Sanguinaria, Modes, aa., oTp; distilled vinegar, Oij.; alcohol, Sij,; make Oij. of tincture by percolation; dose from five to thirty drops. To fulfill the third and fourth indications for an emetic, I pre- fer this preparation to any other that I have employed. It is repeated every five, ten, or fifteen minutes, until thorough emesis is produced, and its action is aided by warm drinks. After the use of any emetic, the child should have warm drinks for some hours, but it is not necessary that they should be ob- jectionable to the taste ; a thin corn meal gruel or common tea, or hot water, does very well. 72 DISEASES OF CHILDREN. CATHARTICS. The employment of cathartic medicines for every ailment, and in all conditions, was not only an absurd, but a very injurious practice. It arose from a misconception of the use of the intes- tinal canal. Instead of being a cloaca or drain for the effete materials of the body, it performs the most important part of the process of digestion ; as an excretory organ its function is less than the skin, and two-thirds less than the kidneys. Cathartics act upon the entire digestive tract, and in a manner subversive of natural processes. As the function of digestion is so important to health, furnishing the material for the nutrition of all structures, we should be very careful how we interrupt it and set up unnatural actions. The frequent use of cathartics depends somewhat on the em- pirical benefit that follows their use in slight diseases. A person has a headache, a cathartic is taken, and the next day he is well; or he has an indigestion, and a cathartic preventing his eating for the time being, makes him feel better in a day or two; or he has caught cold, and an active cathartic, acting as a derivative, gives relief. But in these cases the influence is more apparent than real, time and abstinence from food being the important requirements. It may be asserted that a person in the habitual use of cathar- tics can not enjoy good health, and that the occasional use is injurious in the same proportion. I hold that they should never be employed unless there is a special indication for their use which indication we will now consider. The first indication for the use of a cathartic is, to remove accumulations from the bowels that are proving irritant. These are more frequently of undigested food with the natural secre- tions. The symptoms are, an uneasiness of the child, manifestly from the abdomen ; impaired or arrested appetite, and digestion • a uniformly coated tongue, usually with a yellowish shade • and occasionally a peculiar puffy, expressionless appearance of the face. A cathartic is never indicated when the child is well, though the bowels have not moved for days. The second indication for the use of a cathartic is, to produce revulsion or counter-irritation in case of serious disease of im- portant organs. Thus, in the past, it was the principal means of reaching a determination of blood to the brain, inflammation of INFANTILE THERAPEUTICS. 73 the brain, congestion of the brain, and occasionally inflammation of other parts. Our means of cure, and especially of reaching these diseases, have so increased that this use of cathartics will be rare. The third indication for tRe use of a cathartic is, to promote the absorption of dropsical effusions. Even this use is becoming obsolete by the discovery of specific medicines for this purpose, without disturbance of the digestive tract. Cathartic medicines are employed in small doses to stimulate the digestive tract, and increase its innervation and circulation. They increase the secretion of the digestive fluids and thus im- prove digestion, and at the same time increase the activity of its excretory glandulae. For such purpose the remedy is thoroughly triturated with sugar, or sugar of milk, and the dose is below that which would prove laxative. Used in this way, some of this class furnish the most certain and efficient alteratives. Amygdalus. Specific Indications.—There is irritation of stomach with nausea, vomiting, sense of heat and burning. The tongue is elongated and pointed, with reddened tip and edges. Dose.— We prefer an infusion of the fresh bark of the green twigs in half teaspoonful doses, but the tincture may be used in the proportion of gtt. x. to gtt. xx., water r>i\\, (a little ice may be added), in doses of half to one teaspoonful every fifteen to thirty minutes. The peach-tree bark will be found an excellent remedy to relieve irritation and determination of blood, with its attendant nausea and vomiting. As it relieves gastric irritation it will be found to give rest to the nervous system, and a better circulation of blood. Rheum. Specific Indications.—There is nausea, vomiting, un- easy sensation in stomach, irregularity of bowels, diarrhoea, with light colored discharges. Dose.—fy, Tinct. Rheum gtt. v. to gtt. xx., water. ,^iv ; half to one teaspoonful every half hour or hour, or compound powder of Rhubarb Sj., boiling water 5'iv.; make an infusion and strain, and give in half teaspoonful to teaspoonful doses. Homoeopathic Indications (3d to 6th decimal.) Sour smelling diarrhoea in children. Colicky pains before or during stool. Difficult dentition. Longing for various things, but the first morsel satisfies.—Ehrmann. 74 DISEASES OF CHILDREN. Rhubarb is an old and favorite remedy with our school. The old compound powder in infusion was used to relieve irritation of the stomach, check nausea and vomiting, and cure diarrhoea. For the first purpose it was used in small doses frequently re- peated; for the second it was continued in teaspoonful doses until the discharges had the color of the medicine, then less frequently. Diarrhoea from cold was readily relieved by it, and it would cure the simpler cases of cholera infantum or summer complaint. The tincture will sometimes be found an excellent stomachic, improv- ing digestion as well as relieving irritation. Lobelia. In very minute doses Lobelia allays irritation of the stomach and checks nausea and vomiting. When the tongue is broad and full—atonic—the remedy will sometimes (minute doses) act as a tonic and improve digestion. Its action as an emetic has been referred to. Ipecacuanha. Specific Indications.—There is irritation of stomach, small or large intestine, with determination of blood. Xausea, vomiting, diarrhoea, dysentery; the discharges in each case being somewhat violent and painful. Violent and expulsive cough, with sense of irritation and burning; mucus or muco-pur- ulent expectoration ; globular sputa, rusty ; hemorrhage. Dose.—Py Tinct. Ipecac gtt. v. to gtt. x., water §iv.; a tea- spoonful every hour. Homccopjcdhic Indiccdions (3d to 6th decimal.) Constant sensa- tion of nausea, with vomiting of mucus, bile or blood ; the nau- sea continues after vomiting. Colic and diarrhoea, stools look like yeast, smelling sour. Suffocative attacks of breathing, res- piration oppressed, anxious, quick ; cough, with rattling of mucus in the bronchial tubes. Intermittent fever, nausea and vomiting predominate; chill with thirst, followed by fever; cases in which quinine has failed.—Ehrmann. Ipecac is a favorite remedy in disease of the stomach and in- testinal capal. It relieves irritation and quiets nausea, checks vomiting, and improves the functional activity of the stomach. It is a very certain remedy in diarrhoea from irritation, wilh de- termination of blood, or muco-enteritis, from the simplest form to the severer cases of cholera infantum. It is also a prominent remedy in dysentery, quieting irritation, relieving pain, and lessening the frequency of the discharges. In all of these cases we generally use it in combination with Aconite. INFANTILE therapeutics. 75 Euphorbia IIypericifolia. Specific Indications.—Diarrhoea, sense of heat in stomach and abdomen ; abdomen is hot to the hand, some tenesmus with discharges, which are at times acrid. Bronchitis, with thin, acrid secretion. Dose.—Py Tinct. Euphorbia gtt. v. to gtt. xx.; water Siv. ;a teaspoonful every one to three hours. The Euphorbia is a most excellent remedy in the treatment of cholera infantum and in diarrhoea, filling a similar place to Ipecac. In some years it will be found preferable to this remedy, in other years the Ipecac will prove the best. Colocyntii. Specific Indications.—Wandering pains in the abdomen, seemingly in the course and from contraction of the intestine; the intestines are felt to change their position; noise from the movement of the intestinal contents; tormina and tenes- mus; dragging from the umbilicus; frequent desire to stool from pressure in the rectum, with burning sensations. Dose.— Py Tinct. Colocynthgtt. ij. to gtt. v. water Siv.; a tea- spoonful every one to three hours. Homoeopathic Indiccdions, (3d to 6th decimal).—Violent pain in the abdomen, causing the patient to bend double; diarrhoea, worse after eating or drinking, stools frothy, smelling acid or putrid; dysentery, discharges of mucus and blood with tenesmus, morbus coxalgia ; when there is a sensasion as of being encircled with an iron band; urine viscid; general shortening of the ten- dons.—Ehrmann. With the symptoms as above named, Colocynth is an excellent remedy for diarrhoea and dysentery, and for colic' It relieves pain, checks the discharges, and promotes normal functional ac- tivity. In infantile colic, with free, acrid discharges, it will be found an admirable remedy if the dose is very small, gtt. j. to water 5iv., or a Homoeopathic dilution is used. Hamamelis. This remedy has been fully studied, and we notice it here as a remedy which gives tone to stomach and intes- tinal canal, allaying irritation and promoting functional activity. It may be used when the child persistently throws up its food mixed with mucus; in diarrhoea with large, light colored dis- charges, and when there is prolapsus ani. If the abdomen is full and doughy, the remedy (distillate or Pond's Extract) may be used as a local application, and if there is relaxation of the 76 diseases of children. perineum with prolapse of the bowel, it may be locally applied to the parts. Chionathus. Specific Indications.—Fullness in right hypo- chondriuin; pain in hypochondria, extending to umbilicus; pain in right shoulder; yellow (jaundice) coloration of eyes and skin ; colic with excessively green discharges from the bowels; high colored urine, coloring the clothing yellow. Dose.—The dose will vary from gtt. v. in water 5iv., a tea- spoonful every one or two hours, to gtt. j. to gtt. v. at a dose. The Chionanthus will be found a most valuable remedy in the treatment of jaundice, and those painful affections of the bowels, associated with irregular action of the liver. When the child suffers with infantile dyspepsia, and there is fullness in the region of the liver, it may also be employed. LTvedalia. Specific Indications.—Enlargement of the spleen ; full abdomen, doughy; enlargement of the liver (liver-grown); enlargement of any part, the circulation being feeble and the tissues atonic. Dose.—For children I only recommend it as a local application, the affected part being thoroughly rubbed with the ointment of Uvedalia, or with one part of the tincture to two or three parts of cod-liver or sweet oil. With the indications named there is no remedy equal to it. I have seen the enlarged spleen in the malarial fevers of infancy as early as the third month, and it will be found more frequently than physicians suspect. With this disease of the spleen the patient can not easily be cured of the fever, or if the fever were stopped he would still suffer from impaired blood-making (lukae- mia). It is also valuable in chronic inflammations of any part, the circulation being feeble, and tissues atonic. Nux. This remedy, fully described in the first class, has a direct action upon the gastro-intestinal canal. It is indicated by evidences of atony, and an enfeebled circulation. Nausea and vomiting with a pallid, expressionless face, is speedly relieved by minute doses, as gtt. j. to water 5*iv. We use it in the cure of diarrhoea, when the discharges are large, the abdomen full and relaxed, and when there is pain simulating colic. It is one of our best remedies for infantile colic, if there are INFANTILE THERAPEUTICS. 77 no evidences of irritation and determination of blood. The pulse is feeble, the extremities cool, and abdomen full. It is an excellent stomachic, and if an indigestion depends upon' an enfeebled innervation and circulation, the patient will be benefited by it. A sallow, expressionless face, yellowness about the mouth, slight yellowness of the eyes, and clay-colored dis- charges are indications for Xux. In cholera infantum we say that Xux is the remedy when there is atony of the bowels, with feeble circulation. Aconite where there is irritation with determination of blood ; Ipecac or Eu- phorbia being associated with either. Ciielidonium. Specific Indiccdions.—Fullness in hypochon- drium, tongue much enlarged and somewhat pale; mucous mem- branes full and pale ; skin full and sallow, sometimes greenish ; tumid abdomen; light colored feces; no abdominal pain ; urine pale, but cloudy and of high specific gravity. Dose.—Py Tinct. Ciielidonium gtt. v. to gtt. xv., water 5iv., a teaspoonful every two or three hours. Homoeopathic Indications, (3d to 6th decimal).—A fixed pain under the inner and lower angle of the right shoulder blade, in chest or liver affections ; orbital neuralgia of the right side, with profuse lachrymation ; great sense of tightness around the neck above the larynx, hindering deglutition ; constipation, stools like sheep's dung; gallstones with jaundiced complexion; reddish or greenish urine. Podophyllin. Specific Indications.—The tongue is full, face full, abdomen full, veins full; enfeebled innervation through the sympathetic; dull pain, dull headache, dizziness. Dose.—In diseases of children I prefer a second decimal tritu- ration, which may be given in doses of from one-eighth of a grain to one grain. In older children granules containing 1-40 of a grain of Phodophyllin with 1-8 grain of Hydrastia will some- times prove beneficial as a stimulant to the stomach and intestine. Homeopathic Indications (3d to 6th decimal.) Depression of spirits. Giddiness, with sensation of fullness over the eyes. Difficult dentition, very offensive stools, moaning during sleep, half closed eyes and rolling the head from side to side. Diarrhoea, especially in the morning or soon after eating. Prolapsus ani. Prolapsus uteri. Pain in the ovarian region. Suppression of the menses, with bearing down sensation, better when lying down. 78 DISEASES OF CHILDREN. Pain in the sacrum, with uterine troubles. Whooping cough, with constipation and loss of appetite.—Ehrmann. We employ Podophyllin and Podophyllum as a stimulant to the sympathetic nervous system, improving, innervation to all parts supplied with ganglionic nerves. The indications for its use in wrongs of the digestive apparatus are those of atony—full expres- sionless tongue, full abdomen, impaired functional activity. In gastric and intestinal dyspepsia, with these evidences of atony, a trituration of Podophyllin will be found an excellent remedy. The liver may be stimulated by it, the portal circulation improved, and the spleen relieved of its overflow of blood. We employ it as a remedy for diarrhoea when the abdomen is full and doughy, the discharges light in color, mucous, or contain- ing undigested food. Of course the dose is small, much smaller than most physicians use. Some cases of cholera infantum are cured with a trituration of Podophyllin, when the ordinary treat- ment has wholly failed. Hydrastis. Specific Indications.—The mucous membranes are flushed ; papillae of tongue prominent and red; uneasiness in stomach; loss of appetite; impaired digestion; mucoid matter with stools; circulation to surface and extremities feeble. Sore mouth, with increased mucus secretion, thick and tenacious saliva ; sore throat, with muco-purulent secretion; sore eyes, with muco- purulent secretion. Dose.—I prefer for use the yellow alkaloid Hydrastis or Ber- berin, which is very soluble; one grain to four ounces, make a very good tonic, and is about the strength we would use as a wash for the mouth and throat or as a collyrium. Homoeopathic Indications (3d to 6th decimal.)—Sensation of sinking at the epigastrium with palpitation of the heart; loss of appetite and fainting paroxysms; yellowish leucorrhcea of a very tenacious character, sometimes offensive; malignant and cancer- ous forms of ulceration; cancer of the breast; constipation with gastric disturbance, flatulence; small-pox when the pustules are dark colored and there is great prostration, the face is very red and facial oedema quite marked ; throat very sore.—Ehrmann. Dioscorea. Specific Indications.—Abdominal pain, shifting, paroxysmal, relieved by pressure or by supporting the abdomen and keeping the patient still. Skin soft, and feels as if perspira- tion were about to start; extremities cold; uneasy sensation in INFANTILE THERAPEUTICS. 79 lower part of the chest with sense of constriction in epigastrium. Dose.—Pys Tinct. Dioscorea gtt. v. to gtt. x., water 5iv.; a tea- spoonful every fifteen minutes to an hour. Dioscorea is an excellent remedy in infantile colic, if it pre- sents the symptoms named, but it will not do to use it when Xux or Colocynth are indicated. It is also an excellent diaphoretic, but when used for this purpose I administer it with hot water. .. Children will frequently show the evidences of cold, with tendency to cough, and the respiratory movement will be observed to be short, as if there were some obstruction in the lower part of the lungs. The Dioscorea is a good remedy in this case. Apocynum. This remedy has been studied in the second class, as it influences the circulation. We employ it here as a stimu- lant to the entire gastro-intestinal tract, the indications being a full, tense abdomen, the skin glistening, with oedema of some part. In very small doses it increases the activity of the bowels, and overcomes constipation, and if the dose is a little too large will cause; diarrhoea. It will be found an admirable remedy in acute hydrocephalus, as it is in the chronic form of the disease. Irritation of the nervous system, with prominent eyes, fullness of the fontanells, or opening of the sutures. A very common indi- cation for Apocynum is oedema of the eyelids, or that wrinkled appearance that the eyelids present when they have been swollen. Chamomilla. Specific Indications.—Infantile dyspepsia with irregularity of the bowels; diarrhoea with flatulence and colic, discharges contain curdled milk or other undigested food; the person is irritable and restless and the surface alternately flushed and pale. Dose.—Py/ Tinct. Chamomilla gtt. v., water .^iv. ; a teaspoonful every one to three hours. Homoeopathic Indications, (3d to 6th decimal).—Great sensi- bility to pain, making the patient cross and uncivil; children crying and fretting, must be carried about in order to be appeased ; diarrhoea which smells like rotten eggs, and looks like chopped eo-gs and greens, especially during dentition ; one red cheek while the other is pule, with great irritability and thirst; flatulent colic of infants.—Erhmann. 80 DISEASES OF CHILDREN. Iris. Specific Indications.—Fullness of thyroid gland, enlarge- ment of lymphatic glands, fullness of spleen, grayish or coppery coloration of skin, chylous discharges from the bowels. Dose.—Py Tinct. Iris gtt. v. to gtt.' x., water §iv. ; a teaspoon- ful every one to three hours. Homazopathic Indications, (3d to 6th decimal).—Sick headache, with vomiting of mucus, tasting sweet; fullness and heaviness of the head, head and face cold; colic relieved by benduig for- ward; brown and very offensive diarrhoea, with cutting pains, nausea and vomiting, emmission of foetid flatus.—Ehrmann. Leptandria. Specific Indications.—Fullness of abdomen, doughy sensation to touch ; tongue full, pallid, and covered with pasty fur ; stools pa pescent and light colored; tawny, dirly skin, dirty eyes, Do.se.—Leptandria triturated one to ten may be given in half grain doses, or the tincture may be used with glycerine or syrup so that the patient will get from one-fourth to five drops at a dose. Homazopathic Indications, (3d to 6th decimal).—Black fluid stools, great urging, with difficulty in retaining the stool ; cutting pains about the umbilicus; stools like tar; chronic diarrhoea, worse in the afternoon.—Ehrmann. Sulphate of Manganese. Specific Indiccdions.— A pale, leaden tongue, dirty, with pendulous abdomen and sluggish bowels; jaundice with enlarged liver, fullness and weight in right hypogastrium, dropsy. Dose.—For administration to children I prefer a second deci- mal trituration, of which one-half to one grain may be given every three hours. Malt. Specific Indiccdions.—The digestion of calorifacient food is imperfect, nutrition is impaired, and there is a tendency to scrofulous or tubercular deposits. Dose.—Any of the good extracts of malt may be used in doses of one-fourth to one teaspoonful three times a day. Or instead of this an infusion of malt may be prepared and given to the child with its food, or immediately after eating. It is believed that malt contains a similar ferment to the saliva (ptyalin), and to a less extent to the pancreatic fluid (pancreatin). The first has an especial influence upon starch, changing it into grape sugar; the second will peptonize proteids, emulsify fats and infantile therapeutics. 81 convert starch into sugar. When these processes are imperfect and children suffer from impaired nutrition, and cacoplastic or aplastic deposits, malt has been found to give good results. Pepsin. Sp^ecific Indications.—Gastric digestion is impaired, and nutrition is imperfect; there are eructations of food and gas, chylous or lienteric diarrhoea, abdomen full, urine cloudy. Dose.—Of a good pepsin one-fourth to one half grain may be given with or after the taking of food. Oxide of Zinc. Specific Indications —The tongue has a pasty coat, breath bad, eructations of food, waterbrash, gastro- dy uia; secretions of mouth become so acrid that they excoriate the mucous membrane and lips, and produce soreness of the nipple. Dose.—It may be used in pill form (granules), the dose being one-tenth to one-fourth grain, or it may be employed in the second decimal trituration in doses of one grain. Homazopathic Indications (3d to 6th decimal.)—Weakness of memory. Indisposed to converse. Great sensitiveness to noise. Hydrocephalus. Soreness of the eyes, lids and inner angle of the eyes, great itching. Paralysis of the upper eyelid. Otalgia, discharge of fetid pus from the ear. Great burning in stomach after taking sweet things. Great greediness when eating, can't eat fast enough. Xausea and vomiting. Metallic taste in the mouth. Patient can't keep still, must be in motion all the time. Varicose veins which give rise to fidgetiness of the limbs. Puerperal convulsions. Scarlet fever when there is retrocession of the eruption. Child unconscious and motionless. Involun- tary jerking and twitching of the muscles. Grinding of the teeth. Screaming spells. Occiput very hot and forehead covered with cold perspiration. Pulse thread-like and difficult to count. —Ehrmann. Santonine. Specific Indications.—Fullness of the upper lip, white line around the mouth, picking at the nose, foul tongue, fetid breath, full pendulous abdomen, tendency to retention of urine. Dose.— As a remedy for worms I usually combine it with Podophyllin as in the following—R Podophyllin gr. j., Santo- nine gr. x., Sugar, or Sugar of Milk oj.; triturate thoroughly and make twenty powders, of which one may be given night and 6 82 diseases of children. morning. In retention of urine I have it triturated with sugar, so that the child may have a dose of one-eighth to one half grain every one to three hours. Santonine is one of the best remedies we have to expel the ascaris lumbricoides, and to so influence the mucous membrane that the intestine will not bo a habitation for these vermin. The combination with Podophyllin is very good when there is atony with increased secretion of mucus, but if there is irritation of the intestine, the remedy may be triturated with sugar and a minute portion of Ipecac. Tn retention of urine in childhood it is par excellence the remedy, and I have not known it to fail in an experience of twenty years. It is not a question of how or why it influences the bladder, but the fact that when there is retention of urine from one to three doses of Santonine will cause its passage. Aloes. Specific Indications.—There is atony of large intestine and rectum, mucoid discharges, prolapsus ani, pruritus ani, ascaris vermicularis. Dose.—The remedy is a very nauseous one, and it is difficult to use it on this account. A second decimal trituration may be given in doses of one grain, or even a trituration of one to ten may sometimes be used. To remove the ascaris vermicularis, and break up the conditions under which it propagates itself, I have found that the following prescription does well: Py Tinct. Aloes, Comp. Tinct. Cardamom, aa. .^ss., Syrup r>j. ; dose, one- half to one teaspoonful until it acts upon the bowels. Homoeopathic Indications (3d to 6th decimal.)—Sensation of weight or heaviness in the rectum; morning diarrhoea, very urgent, must go at once; rumbling and rolling in the bowels be- fore stool; hemorrhoids protruding, feeling hot and sore; when urinating sensation as though something had passed'from the bowels; stools consisting of jelly-like mucus. REMEDIES THAT INFLUENCE THE URINARY APPARATUS. We find in practice that, in a majority of acute diseases the function of the kidneys will be re-established so soon as the cir- culation is controlled. Hence, in the common diseases of child- hood diuretics are not required. It is principally in the malarial fevers, and in zymotic diseases that they will be demanded. In INFANTILE THERAPEUTICS. 83 c.ironic disease, with deficient waste and excretion, they become our most important remedies. Here, as in the adult, we recognize the two actions, hydragogue and depurant. In the first, the water of the urine is increased; in the second, the solid constituents are increased. The first mav be used to lessen the volume of the circulating fluid, to remove irritations of the urinary passages by diluting the urine, and to promote the absorption and removal of dropsical deposits. The second, increasing the solids of the urine, are used to depurate the blood of worn-out and imperfectly-formed material. Thev also stimulate the processes of retrograde metamorphosis, and thus facilitate the "breaking down and removal of tissue, and indi- rectly its renewal. We might give a long list of remedies influencing the urinary apparatus, but a few will serve our purpose, as in diseases of children especially, the kidneys will do their work if the general conditions are right. The agents we will study are:— Sweet Spirits of Nitre, Mentha Viridis, Cucurbita Citrullus, Acetate of Potash, Gelseminum, Rhus Aromatica, Eupatorium Pur., Santonine, Agrimonia, Hydrangea, Apis, Belladonna, • Benzoate of Lithia, Local applications to .the Loins. Sweet Spirits of Nitre. I name this remedy first, because it has been employed so extensively, and with good advantage, in diseases of childhood. In this case it is not only diuretic, but. to a slight extent, sedative—lessening the force and frequency of the pulse. It is only in the simplerformsofdisea.se that I would recommend it. To two ounces of water, in a glass, add a tea- spoonful of spirits of nitre, keep covered, and give a teaspoonful' every two hours. This is the dose for a child from one to two vears of age. Mentha Viridis. Though not usually regarded as of much importance by the profession, and as having but feeble diuretic properties, I think in diseases of children it will be found one of the most certain of remedies. It has this advantage, that, pre- pared in strong infusion and sweetened, it is quite palatable, and it may be given freely without danger. I o-ive it alone and in combination. With sweet spirits of nitre a very powerful hydragogue action may be obtained. If there is irritation of the urinary apparatus, I generally add tincture of 84 DISEASES OF CHILDREN. Gelseminum in small doses. If the pulse is excited I give Ve- ratrum at the same time. Or, if there is congestion with ten- dency to coma, Belladonna. Cucurbita Citrullus. An infusion of watermelon seeds is a very mild unirritating diuretic in diseases of children. The only difficulty we find in using it is, that children will not drink unless they are thirsty, and in sickness they are very particular what they drink, and may not like watermelon-seed tea as a sub- stitute for water. Acetate of Potash. Specific Indications.—The tongue is full, pallid, slightly leaden, and coated with a pasty fur; the abdomen is full and doughy, and the skin dirty. Dose.—Py Acetate of Potash 5j., water .^iv.; a teaspoonful every two or three hours, with as much fluid as the patient can be persuaded to take. Of the class renal depurants, Acetate of Potash is the most effi- cient. It is employed to increase the solids of the urine, and remove the waste from the blood. When given in large doses, and for some time, it breaks down feeble tissues, and thus hastens the removal of worn-out material. But having such action, it may be carried too far, to the weakening and breaking down of sound tissue, or to the removal of material faster than it can be replaced. It is a good remedy in its place, but used to excess it is injurious. In many cases it may be added to the child's drink, so that the necessary quantity will be taken in the course of the dav, without its knowledge. For a child two years of age the medium quan- tity will be half a drachm, each twenty-four hours. Citrate of potash, bitartrate of potash, nitrate of potash, and acetate of soda may be used for the same purposes. Santonine. We think of Santonine as a vermifuge only, yet it has other desirable properties. One of them is. its influence over the bladder in retention of urine. In some diseases there is sometimes a tendency to retention which ordinary remedies will not reach, and which at last proves fatal. Santonine thor- oughly triturated with sugar, in doses of from half to one grain every two hours, affords very certain relief. It is also very effec- tual in relieving burning, scalding, tenesmus, and other unpleas- ant sensations of the urinary passages. infantile therapeutics. 85 Eupatorium. Specific Indications.—There is a sensation of weight and dragging in the loins, retraction of testicles, frequent desire to urinate, scanty secretion of urine. Dose.—fy Tinct. Eupatorium gtt. x. water Siv.; a teaspoonful every one or two hours. When there is a continued scanty secretion of urine, though the general wrongs have been looked after, Ave may think of the Eupatorium. The indications as given above, will be found a good guide to its administration. Gelseminum. Gelseminum has been studied in our first class, and we notice it here as a remedy directly influencing the kidneys, relieving irritation and determination of blood. The indications for it are, sharp pains in the loins and back, frequent desire to pass urine, which is passed in very small quantities Avith tenesmus. It is not only a remedy for irritation and determination of blood to the kidneys, but for irritation of any part of the urinary passages as Avell. In cystitis it is a favorite remedy, as it is in irritable (spasmodic) stricture of the urethra. Eryngium. Specific Indications.—Frequent desire to pass water, Avith Aresical tenesmus, contraction of abdominal muscles, drawing up of the thighs, scanty urine, acrid, irritating the ex- ternal parts. Dose.—1$5 Tinct. Eryngium gtt. v., AvaterSiv.; a teaspoonful every one to three hours. Eryngium is an admirable remedy to relieve irritation of the bladder, and I have no doubt that it exerts quite as strong an influence upon the pelvis of the kidneys.and ureters. It also increases the secretion of urine, Avhich is less acrid and irritant, Belladonna. This remedy has been fully studied, and Ave notice it here as a remedy for congestion or enfeebled circulation of the kidneys, and for diabetes and incontinence of urine. In cases where the patient complains of fullness, Aveight and drag- ging in the loins Ave prescribe Belladonna. When the urinary secretion is too free, the urine of low specific gravity, the admin- istration of Belladonna internally, or the application of a Bella- donna plaster to the loins is good treatment. In incontinence of urine this remedy has gi\Ten most excellent results, especially in those cases where there Avas inability to hold the urine during the day, and a dribbling aAvay which soiled the clothing. 86 diseases of children. Rhus Aromatica. This agent is highly recommended for incentinence of urine, especially for nocturnal incontinence. It is also used in irritable bladder; in chronic cystitis and urethritis; in phospburia, and when there are mucoid discharges in the urine. Dose.—Py Tinct. Rhus Aromatica gtt. v. to 5j-, water §ij.; a teaspoonful every two or three hours. Agrimonia. Specific Indications.—Renal colic, pains ex- tending from the hypochondria to the loins, and thence doAvn to the bladder. Irritable kidneys; irritation of kidneys or the urinary passages, Avith cough; cough attended Avith expulsion of urine. Dose.—Ft Tinct. Agrimonia gtt. x. to gtt xxx., Avater §iv. ; a teaspoonful every one to three hours. Hydrangea. Specific Indications.—Irritable bladder and urinary passages, urine passed with difficulty and Avith tenesmus, blood in the urine, strangury, irritation of urinary passages Avith cough. Dose.—Py Tinct. Hydrangea gtt. a\ to gtt. x., water 5iv.; a teaspoonful e\*cry one to three hours. Apis. Specific Indications.—Itching of the genitals; itching along the urethra ; burning in the bladder; itching of the anus ; itching and burning of the skin ; eyes itch and burn; child wants to rlib them frequently. Dose.—R Tinct. Apis gtt. ij. to gtt v., water 5iv.; a tea- spoonful every hour to three hours. Homoeopathic Indications (3d to 6th decimal).—Burning and stinging pains with scanty secretion of urine; breathing labored, with fever without thirst; dropsy without thirst, and Avaxy ap- pearance of the skin ; (edematous swelling of the face, especially about the eyes; hydrocephalus, Avith sudden shrill cries; boring of the head in the pillow, squinting, grinding of the teeth, urine scanty, tAvitching on one side while the other is paralvzed.__ Ehrmann. With the indications as above named the Apis Avill be found an admirable remedy. I have seen it start a free secretion of urine in a few hours, Avhen it bad been nearly arrested. It relieves irritation of the nerve centers, gives rest, improves the circula- tion, and especially removes hyperesthesia of the cutaneous nerves. INFANTILE THERAPEUTICS. 87 Benzoate of Litiiia. Specific Indications.—There is diffi- cult urination, discharge of mucus, muco-pus or phosphates with the urine; the skin is doughy or Avaxy ; the tongue dirty ; the breath fetid, and general evidence of imperfect Avaste and nutrition. Dose.—It may be given to a child two years old to the amount of one grain each day in the water the patient takes. Homoeopathic Indications (3d to 6th decimal).—Urine scanty, of dark brown color, and strong urinous odor; nocturnal enuresis; rheumatism, Avith strong smelling urine; hypochondriasis, sore throat and diarrhoea, with the above characteristic urine.— Ehrmann. REMEDIES THAT INFLUENCE THE SKIN. It is hardly necessary to call attention to the importance of a healthy skin, as associated with good health, and to its impairment as a frequent cause and constituent of disease. This organ not only removes a large amount of nitrogenized Avaste, but it also regulates the temperature, and assists in the respiratory function. If its function as a regulator of the temperature (safety valve) is impaired, we will have a Avrong of this condition of life which Avill work a Avrong of every function of life. If it fails to do its, Avork of excretion, the blood must suffer from the retained ma- terial, unless the kidneys and bowels do vicarious Avork. Impair- ment of the skin thus imposes additional labor upon the lungs. In studying the pathology and therapeutics of the skin avc must not forget its intimate relationship with mucous membranes. The skin and mucous membrane may be regarded as one piece— folded in, forming the internal lining or envelope, covering the body as an external envelope. The sympathy between the two is so intimate that wrongs of the skin Avork wrongs of mucous membrane, and wrongs of mucous membrane Avork Avrongs of skin. An impairment of the functions of the skin may Avork such wrong of mucous membrane as to imperil life. We see this illustrated in some of the simpler eruptions upon the skin. A child suffers from heat, or some of the simpler forms of erythema or urticaria, but as long as it is out freely upon the skin, the functions of the body are AA'ell performed. From some cause the eruption disappears (goes in), and at once the child is very sick, has bronchial irritation, croup, or intestinal irritation with diarrlnjea. A cure in such cases avi'11 come from bringing 88 DISEASES OF CHILDREN. the eruption to the surface, prevention of disease will come by keeping the eruption on the outside. The remedies we will study in this connection are the following: Baths, Sedatives, Rhus, Diluents, Stimulants, Apis, Asclepias, Inunctions, Senega, Saffron, Nepeta, Sulphur, Belladonna, Serpentaria, Arsenic. Eupatorium, Sedatives. In proportion to the frequency of the pulse and the increase of temperature is the arrest of secretion. If, there- fore, there is a frequent pulse, the first step toward obtaining a normal action of the skin is, to bring it down to the normal standard. The arterial sedatives thus become the most import- ant diaphoretic means. With small and frequent pulse Aconite is our best diaphoretic ; with a full, frequent pulse it is Veratrum ; with an oppressed pulse Lobelia, etc. In a large number of cases of fever and inflammation, if proper means are used to lessen the frequency of the pulse and bring the temperature to a normal standard, secretion from the skin is established in proportion as these effects are obtained. If secretion does not start as the pulse comes down, very mild diaphoretic remedies will be sufficient to accomplish the purpose. With a frequent pulse and high temperature no diaphoretics will act. Stimulants. There are cases where, from a feeble general circulation, and an enfeebled skin, secretion can not go on. This Avill be known by the dull color, Avant of elasticity, coldness, and want of sensibility. In such cases anything that Avill stimulate the general circulation, and will stimulate the skin and its circu- lation, will improve functional activity. I have used in such cases something like the folloAving, Avith good results: Py Tinct. Lobelia 5j-, Com p. Tinct. Lavender oiij-, Syrup Siss.; give in teaspoonful doses, mixed with hot water every hour. ty, Tinct. Ipecac gtt. x., Comp. Tinct. Cardamom ?»ss., Syrup 5iss.; tea- spoonful every half hour or hour, Avith hot Avater. An infusion of ginger or of Asarum canadense may sometimes be giA'en. Baths. We have already studied the use of baths, as a means of rectifying wrongs of the temperature, but Ave can not learn too much about these means, and a little repetition will INFANTILE therapeutics. 89 not be injurious, and Ave uoav want to know how they influence secretion. The success of Eclectic practice has, I think, depended quite as much upon the skilled use of the bath, as upon the administra- tion of internal remedies, and from the days of Beach great stress has been put upon " bathing the sick." It came in at a time when Avater was thought to be injurious, whether applied to the surface or given as drink, for Avater and mercury were antagonistic elements, and mercury the sick must have. In simple opposition, therefore, if for no other reason, Ave Avashed our patients frequently, and gaA'e them as much Avater as they could drink. -The Alkaline Sponge Bath.—" The alkaline bath," was the one most generally recommended and used, and this Avas a potash, not a soda bath. In early days it Avas made by adding Avood- ashes to water (broke Avater) so as to render it slightly slippery ; now Ave use bicarbonate of potash. It has a very kindly influ- ence upon the skin, softening it, lessening the temperature, pro- moting a better flow of blood and increased secretion. In some cases soda may be substituted for the potash with advantage, but as a rule the old alkaline bath is the best. There are cases in which the skin is influenced better by simple soap and water. The Acid Sponge Bath.—When the tongue and mucous mem- branes sIioav a deep-red or dusky color, and the skin also shows dusky redness, an acid bath Avill sometimes be preferable. If the ordinary bath is used it seems to leave the skin drier and harsher than it was. If we now add a portion of vinegar to the Avater, it softens the skin, lessens the temperature, and aids secretion. Cold Wet-Sheet Pack.—In recent disease where the attack is acute and the patient strong, the cold Avet pack may be used to advantage. The temperature is increased, the pulse frequent and strong, and the skin dry. The only objection to it is, the fear of the parents that some harm may follow, and the indisposi- tion of the child to have such liberties taken Avith it. Resolving on a cold wet pack, Ave have the little felloAV stripped, a sheet of proper size wrung out of cold Avater and Avrapped around him, and then tuck him in his crib or bed, with plenty of covering Half an hour to one hour is about the time Ave should allow him to be in it, when he may be thoroughly dried Avith rubbing, and have dry Avarm clothing put on. 90 diseases of children. Local packs may be used to any part which is suffering from increased heat and arrested secretion. The point Ave place stress upon is, that there shall be a vigorous circulation. It Avill not do to trust to the reaction to obtain a good circulation and temper- ature, though sometimes the reaction from the cold is sufficient for this. Hot Wet-Sheet or Blanket Pack.—When the skin is feeble, its circulation impaired, and especially Avhen Ave Avant to bring an eruption upon the surface, Ave use the hot blanket pack. Some- times an internal congestion will demand speedy means of relief. In the eruptive fevers, if the eruption fails to make its appear- ance the patient becomes dull, sleepy or comatose, and the skin has a dull pallor or is dusky—here the hot pack is a good thing. In using this, a blanket is Avrung out of hot'water, and applied around the child, Avhich is then Avarmly covered in its crib; in some cases mustard may be added to the Avater to make it more stimulant. As the child does not like the hot application any better than it does the cold, and Avill not bear it hot enough for benefit, Ave sometimes apply the hot blanket over a thin under- shirt and drawers ; it can then be very much hotter. Local hot packs are employed when parts are feeble, and have a sluggish circulation. The Hot Foot Bath.—Every person thinks that be or she knows all about the use of this simple means, but yet Ave find in practice that not one in ten can use it so as to benefit a child. The adult Avill have a full bucket of hot water, and the limbs covered ; the child will have one or two inches in a shalloAV basin, not very hot, and the limbs exposed up to the body. In the majority of cases the nurse dashes the water upon the child's legs Avith the hands, thus producing rapid evaporation, and of course refrigeration. Necessarily, the desired influence is not produced, and very frequently it has the contrary effect to that desired. So confident am I that the foot bath will be used in this Avay, that I never order it Avithout giving specific directions, and many then misuse as above. Hot Sponge Baths. Sponging the surface AV'th Avater as hot as it can be borne is sometimes a most admirable stimulant to the surface, and very much better than the hot bath. If the skin is very inactive, with a feeble circulation, I recommend the use of hot Avater with a sponge lightly and briskly applied, the patient being covered with a blanket. In the eruptive fevers, when there INFANTILE THERAPEUTICS. 91 is a tardy appearance of the eruption, no better means can be found than this; in some cases the eruption seeming to folloAV the hot sponge. In these cases I am in the habit of directing the nurse to apply the hot sponge to any part that suffers pain or uneasiness, or wherever the eruption may not come freely to the surface. A hot iron wrapped in flannel and Avetted Avith vinegar so as to raise a vapor is a still more active application, and one of the most poAverful stimulants known. It is claimed that a current of electricity is thus generated, and Ave faradize the surface as Avell as stimulate it Avith heat. The Hot Bath.—A general hot bath may be given in any ves- sel large enough to hold the child. The water should have a temperature of 125 degrees at least, and should cover the entire body. The child should not remain too long in it, and Avhen removed should'be Avrapped in a Avarm blanket until thoroughly dry. Common salt may be added to the water, when there is much debility, or a tendency to congestion. With care, such a hot bath may be used with advantage in the early stage of acute diseases. Inunctions.—There are cases Avhere fatty inunctions answer a better purpose than baths. The bath leaves the skin dry and harsh and inactive; the inunction leaves it soft and pliable, and in better condition for functional activity. Sometimes we use lard alone, or, if there is a tendency to aplastic deposits, cod-liver oil. When there is periodicity, or when Ave wish to get the action of quinine it is added to the lard. If we Avish the inunction stimulant, Ave add one of the essential oils in small quantity (they are very active Avhen combined Avith fatty matter). In scarlet feA'cr avo sometimes have the patient rubbed thor- oughly with a bacon-rind or piece of fat bacon. Or, Ave may order it from the drug store as folloAvs:—Py Creasote gtt. xx., Common Salt o**., Lard 5jj. Ammonia added to the lard makes a very stimulant application, and I sometimes order it Avhen the skin is very feeble, or Avhen it is necessary to bring an eruption to the surface, as—Py Bicarbonate of Ammonia or Ilydrochlorate of Ammonia 5ss., Lard Sij- Mix. Diluents. A certain amount of fluid is necessary to the proper performance of function, and I am satisfied that many 92 DISEASES OF CHILDREN. times the sick suffer severely from the want of it, either because the physician does not think it worth his while to look after such small matters, or the condition of disease is such that it can not be introduced. Here Avas one of the evils of the old practice— they used remedies Avhich Avere incompatible Avith Avater, or Avhich kept the stomach in such condition that water could not be ab- sorbed by the stomach. Warm Drinks.— An infusion of catnip, sage, chamomile, ascle- pias, and many other simples, or even hot water, Avill prove diaphoretic, and is sometimes useful in slight ailments. The difficulty in their use is the repugnance the child has to anything unpleasant, and to the quantity necessary to be given to get a diaphoretic influence. If warm drinks can not be taken, or sometimes if they can, Ave think it better to administer cold. I make it a rule to ask if my little patient has expressed a desire for Avater, and advise that it be given frequently if the child has any thirst. Some- times Ave will find that the little one takes it eagerly, and follow- ing its use the irritation and restlessness subside, and it goes to sleep. Again, Ave will find that the frequent giving of cold Avater in moderate quantities lessens the temperature and the frequency of the pulse, and the child is better in every respect. In some cases the child may have lemonade to good advantage, either hot or cold, as it will take it best. In others, whey answers a most excellent purpose, and is taken with pleasure. When the temperature is high, and fluids can not be taken by mouth, I think it Avell, in some cases, to use it by enema. Four ounces of cold Avater thrown up the rectum will lower the tem- perature of the entire body two or three degrees. If there is continued nausea a very small portion of common salt may be added to the fluid used in this way. Asclepias. Specific Indications.—The pulse is strong, the patient has sharp pain in some part, inflammation of serous mem- branes, skin hot and dry but not constricted, urine scanty, pain- ful cough. Dose.—Pv Tinct. Asclepias gtt x., Avater 5iy.; a teaspoonful every hour. Asclepias may be taken as the type of a diaphoretic, acting kindly, and promoting that normal activity, " insensible perspira- tion." The skin softens, the temperature comes down, the pulse INFANTILE THERAPEUTICS. 93 is less frequent, and the nervous system is relieved. It is especi- ally a good remedy in pleuritis or pleuro-pneumonia, and in rheumatism involving synovial membranes. Eupatorium Perf. The Boneset has a direct influence upon the skin, and may be employed to good advantage when the pulse is full and strong, and the skin gives the sensation that perspiration is almost ready to break out. It may be employed alone or in combination Avith the sedatives. Crocus Sativus. Specific Indications.—The skin is dull, mottled and inactiATe, afterwards becomes exceedingly dry and harsh with irritation of mucous membranes. An eruption shows itself beneath the skin, or there has been a retrocession. Dose.—Saffron maybe used in infusion, or the tincture may be given with warm water. True saffron is one of the most certain, as it is one of the kindliest of diaphoretics, and Avhen it can be obtained it should be employed, especially in the eruptive fevers. It Avill be found very much better than the old remedies, Avhich irritate the stomach and bowels. Xepeta C atari a. Specific Indications.—The skin is dry and harsh, mucous membranes of the air passages irritable, urine scanty, more or less pain in abdomen. Dose.—Catnip may be given in sAveetened infusion in irritation of the respiratory and intestinal mucous membranes, or the tincture may be added to water in the proportion of gtt. x. to gtt. xx. in water 5iv., and given in teaspoonful doses. It must not be supposed that because catnip is such a common domestic remedy, it is Avorthless, for it Avill sometimes ansAver a better purpose than the stronger and harsher medicines. Used with the sedatives it gives excellent results in fevers complicated Avith irritation of mucous membranes. Serpentaria. Specific Indications.—The skin is inactive, harsh, desquamation of epidermis, epidermis feels rough and dead, Aveight and dragging in the loins, scanty urine, fullness of chest, difficult respiration. Dose.^fy Tinct. Serpentaria gtt. v. to gtt. x.; Avater §iv.; a teaspoonful every one to three hours. 94 diseases of children. Belladonna. Though a remedy which is studied with especial reference to the nervous system, it also influences the skin directly, and is thus one of our most important remedies. The reader Avill remember the statement that " it causes contraction of capillary blood-vessels, and thus overcomes congestion." This is its most important action, and this it does in the skin and kidneys as Avell as in the brain. Congestion of the skin is known by the deep coloration, dusky red, or Avhen bright red, and the redness is effaced by pressure, a persistent Avhite line is left. In the eruptive fevers its influence is to bring the eruption to the surface. This is shown in the simpler eruptions, erythema and urticaria, and in the severer eruptive fever—scarlatina. Dullness of mind and disposition to sleep are almost always associated Avith congestion of the skin, but in some cases there Avill be marked impairment of the capillary circulation of the skin before the brain suffers. Rhus. This remedy exerts a direct influence upon the skin, being indicated by bright redness and burning pain. It is a rem- edy in hives, with burning and itching; in scarlet fever Avhen the skin is hot, dry and burning; in erysipelas Avhere there is vivid redness Avith burning pain. Of course Ave are not altogether guided by symptoms from the skin, though these Avould be sufficient. The sharp stroke of pulse, frontal headache, and prominent red papillae on tip of tongue will be additional indications. Apis. Apis is indicated by itching of the skin or outlets of the body. It is a most valuable remedy Avhen thus indicated, as in "heat," hives, scarlet fever, prurigo, erysipelas and some cases of eczema. Senega. Senega is a stimulant to the skin, and may be em- ployed where there is a feeble circulation, coldness of the extrem- ities, and dry, harsh, dead epidermis. Sulphur. This remedy, which is fully studied under the head of restoratives, exerts a direct influence upon the skin, improving its nutrition and functional activity. Dryness and separation of the epidermis, vesicular or pustular disease, or change of color Avill indicate it. It has been used both locally and as an internal remedy, and in both Avays proves beneficial. INFANTILE THERAPEUTICS. 95 Arsenic. Specific Indications.—Inactive skin, wants elas- ticity; dull, sallow, or pallid color; eczematous eruption; feeble circulation ; periodicity not cured by quinine. Dose.—For children, in ordinary cases, I prefer a second or third decimal dilution, though I sometimes use the pellets wetted with Fowler's Solution, or with a first Homoeopathic dilution. In skin disease where a stronger action is wanted we prescribe__ Pv Fowler's Solution gtt. v. to gtt. x., water giv.; a teaspoonful every four hours, or three times a day. Homoeopathic Indications (3d to 6th decimal).—Great restless- ness and anxiety with burning pains, violent thirst with frequent drinking of but little water at a time; vomiting and diarrhoea, stools watery, offensive, and undigested, dysenteric stools ; patient Avants to be in a Avarm room, or Avarmly covered ; attacks of anguish, with fear of death ; face pale and haggard, great exhaus- tion ; suppression of the urine or bloody urine ; oppressed breath- ing, oedema of the eyelids, urticaria, eczema, pityriasis, falling out of the hair, trembling, stiffness and contraction of the joints; aggravation of Symptoms after midnight, on lying down with the head Ioav, and in the cold air.—Ehrmann. ANTI-ZYMOTICS. We have been in the habit of classifying such remedies as oppose the putrefactive process in blood as anti-septics, but it is better perhaps to study them as antizymotics. Zvmosis is more like a process of fermentation ; as Dr. Dunglison defines it, it is "any epidemic, endemic, contagious, or sporadic affection, Avhich is produced by some morbific principle acting on the organism similar to a ferment—as the major exanthemata." The symptoms of zymosis are prostration and impairment of life, and those that are usually designated as typhoid. The tongue is dirty, or the coatings are brown or deep colored; in the first case the tongue is moist, and in the second it is inclined to be dry. In both cases sordes accumulate around teeth and gums, and the discharges from the body become peculiarly offensive. The causes of zymosis it is claimed, act similarly to if not as ferments, setting up in any fluids of the body septic processes Avhich produce material like the original. Thus the poison of typhoid fever introduced into the body Avill grow a condition of disease like the original, and Avill generate a poison similar to 96 DISEASES OF CHILDREN. that introduced. We notice the same in erysipelas, in zymotic dysentery, in diphtheria, and in other diseases. An anti-zymotic is a remedy, therefore, which, introduced into the body (blood), will antagonize such ferment, and arrest the process that is going on to the destruction of life. In the case of some of these remedies, Ave can see how they act, for they will stop the process of fermentation outside of the body as Avell as within. But in others, Ave can not tell Iioav this is accomplished, because the remedy has no chemical action, and is used in very minute doses. But whether Ave can account for this action or not, if experience proves that definite results follow the administration of a remedy, Ave should be satisfied to give it Avhen indicated. It Avill also be noticed that Ave have a group of these remedies, all antidoting the process of zymosis, yet each having an indi- vidual action, and not being interchangeable one for the other. Indeed, they are so different in their construction that we Avould hardly expect them to act in a similar manner. As Ave can not interchange them, and must have the right remedy, if Ave Avish good results, Ave Avill be especially careful in examining the symptoms that point to the remedy. The remedies Ave will study under this head are :— * Acids, Sulphurous Acid, Hydrochloric Acid, Baptisia, Sulphate of Soda, Chlorate of Potash. Phytolacca. Acids. We have studied these under the head of remedies that influence the respiratory function, to Avhich the reader is referred, but it is Avell to examine them in this relation. The indications for their use is, a deep-red color of tongue and mucous membranes, the tongue being usually dry and contracted, coated brown, or slick and like raAV beef; deep redness of parts, when blood comes freely to the surface, may also be noted. As muriatic acid is studied separately Ave will notice here that acetic and lactic acids will sometimes fulfill the indication. We give the first in the form of a good sharp cider, Avhich is also a mild stimulant; and the second as Avhey, formed by curdlino- milk. Both of these Avill be taken kindly by children, when muriatic acid Avould be refused. Hydrochloric Acid. Specific Indications.—The tongue is dry and contracted, and the color deep-red or dusky-red. Coat- infantile therapeutics. 97 ngs of tongue are inclined to be broAvn, growing darker as the ♦ lisease advances, and there is dark sordes about the teeth. Dose.—It is added to Avater so as to make a pleasant drink, a little syrup being added, and given ad libitum. Homoeopathic Indications (.'3d to 6th decimal).—In typhoid fever, Avhen the patient has a tendency to slide down towards the foot of the bed; great debility; diarrhoea with great itching and soreness of the anus; hemorrhoids excessively painful to the touch, bleeding profusely; involving discharges of feces while urinating; sad and silent during the menses; early and profuse menstruation; scarlet fever, rash intensely red Avith great dizzi- ness ; sore throat, foul breath, acrid discharge from the nose.— Ehrmann. With the indications named no remedy Avill give better satis- faction than this acid. In some cases it seems to do everything that is necessary in the case. It lessens the frequency of the pulse, brings the temperature down, relieves irritation of the nerve centers, places the stomach in better condition for the reception and digestion of food, softens the skin, and aids secre- tion. It makes no difference where or Avhat the disease is, if the remedy 1s indicated it proves beneficial. Sulphurous Acid. Specific Indications.—The tongue is of normal redness and moist, but dirty, the coating is pasty and sometimes looks like fecal matter, the tongue is dull and atonic and has no papillae, the fauces and phaynx full and relaxed, and the mucoid secretion brownish and dirty, moist sordes about the teeth, fetid breath. Dose.—This is a feeble acid and may be giAren in doses of gtt. v. to gtt. xx., and the following prescription Avill be very good for children from two to five years: Py Sulphurous Acid %}., water 5iij. ; a teaspoonful every three hours. Sulphurous acid is a valuable remedy in diphtheria, cynanche maligna, malignant scarlet fever, in some cases of small pox, and indeed in any contagious or zymotic disease Avhere the above in- dications are found. It is not only a good remedy when admin- istered internally, but it is also an excellent local application in diphtheria and cynanche, and Avhere a part shows a tendency to brake down. 7 93 DISEASES OF CHILDREN. Sulphite of Soda. Specific Indications.—The tongue is broad and pallid, the coating pasty, white and dirty, frequently the breath is fetid. Dose.—The dose for a child will be from one to five grains, ac- cording to age, repeated every three hours. If one will test the sulphite of soda Avhen indicated as above, he will become a convert to specific medication. It acts kindly and directly, not only in controlling zymosis, but on the circula- tion, temperature, nervous system, and in establishing excretion. It is a fair example of the therapeutic maxim, " Avhen a remedy is indicated by a special symptom or symptoms, it proves curative in any form of disease." Chlorate of Potash. Specific Indications.—Fetid odor, as from cynanche maligna, fetid lochial discharge, as from decom- posing animal matter. As a local application it is indicated by bright redness of parts. Dose.—For internal administration to children the dose Avill vary from one-eighth of a grain to one grain ; as a local applica- tion a solution of grs. x. to grs. xx., in Avater rjiv. Chlorate of Potash has been so extensively used that there is less need of recommending it to readers, than of caution against its abuse. When indicated it is a most excellent remedy, none better; but when not indicated, especially Avhen tissues are dull and dusky in color, and the patient has a feeble circulation, it may do serious damage. It should be used with great care in the eruptivTe fevers, or when there is irritation of the kidneys, for it Avill sometimes im- pair the functions of these organs to such an extent that the patient will suffer, or may die from uraemia. Baptisia. Specific Indications.—The face is full and purplish, like one who has been exposed to severe cold ; the tonoue and mucous membrane of fauces and throat are full, and bear the same purplish or leaden discoloration. Dose.—Py Tinct. Baptisia gtt. x., Avater 5iv.; a teaspoonful every hour. Homoeopathic Indications (3d to 6th decimal).—Typhoid symp- toms, dull headache, soreness as if in the brain, sleeplessness can not go to sleep because "she can not get herself together;" great dryness of the mouth and tongue, tongue coated, dry and broAvn • infantile therapeutics. 99 putrid, offensive breath, very fetid stools, preceded by colicky pains in the hvpogastrium.—Ehrmann. The symptoms indicating this remedy are so clear that one can hardly go astray. The first sight of the person is frequently sufficient—the full, discolored face, like one that has been long exposed to cold—if not* the bluish or purplish coloration of tongue and mucous membranes, is sufficient. It exerts an ad- mirable influence in typhoid disease, whether fever or inflamma- tion, in some cases of diphtheria and cynanche, and in zymotic dysentery. When the indications are strong it Avill sometimes do everything that one could expect of medicine—lessening the frequency of the pulse, reducing the temperature, relieving the nervous system, putting the stomach in good condition for the reception of food, and establishing secretion and excretion. Phytolacca. Sj)ccfic Indications.—There is sore mouth; small blisters raise on the tongue, mucous membrane of the mouth and fauces; apthae; sore throat; diptheritic exudation; soreness and rawness of the mucous membrane of the nose; sore lips, they look blanched, and the epidermis separates; enlarge- ment of parotid and submaxillary glands ; the cervial lymphatics are enlarged; disease of the breasts; orchitis. Dose.—Py Tinct. Phytolacca (fresh root) gtt. v. to gtt. x., Avater ivv.; a teaspoonful every one to three hours. Homoeopcdhic Indications, (3d to 6th decimal).—Syphilitic and mercurial rheumatism ; nightly pains in the tibia, Avith nodes and irritable ulcers on the leg; sensation of roughness and raAvness in the throat; feeling of a lump in the throat, causing a continu- ous desire to swallow; deep ulcers on the tonsils or base of the tongue; very offensive odor, and great pain on swallowing; habitual constipation, feeling of fullness in abdomen before stool; capacious flow of urine; albuminous urine; inflammation, swell- in^ and suppuration of the mammae.—Ehrmann. Phytolacca is one of the most certain remedies in the materia medica, meeting the most grave forms of disease. It is indicated in a large number of cases of diphtheria, and seems to antidote the zymotic cause, and in some seasons will cure nearly every case. It is also the remedy for parotitis, or mumps. We pre- scribe it for infantile sore mouth Avith most excellent results, as Ave do for the sore nipples of the mother which are associated Avith it. It has a verv favorable action in scrofula Avhen it manifests itself in the cervical lymphatics. 100 diseases of children. ANTISEPTICS. We will embrace in this group those agents Avhich destfoy septic poisons, and arrest the processes of sepsis outside of the body. The classification may not be the best, but I hope it Avill not create confusion. The anti-zymotics are really antiseptics, though as Ave are in the habit of studying a group of diseases as produced by zymotic poisons, and their influence upon the body as zymosis, it is quite as well to think of the internal remedies which meet this as anti-zymotics. In medicine, cleanliness takes precedence of godliness, and many times the need of antiseptics may be prevented by strict attention to cleanliness. There is an intimate relation between " dirt and disease," especially if the dirt is the Avaste of the human body, or that which it subsists upon. Soap and Avater Avill stand first in the list of antiseptics. ^-^C^^^J^^f. Good air is a requisite of good lffe,£md many germs of disease overtake people and gain entrance to their bodies through bad air. The air is defiled in many ways, and all these should be thought of and avoided. The sick should have their supply from such sources as Avill give it as pure*as possible. Whilst air is admitted to the room, from Avithout, provision should be made for the egress of the air that has been used. An open fire-place Avith a fire is the best means of ventilation in ordinary houses; if stoves must be used, they should have the doors open so as to permit a draught. Fecal matter is especially poisonous in zymotic disease, and should be removed from the room at once, and the A'cssels thoroughly cleansed and possibly disinfected. When removed, care should be taken that it is not emptied wdiere it will defile the Avater supply, either by running into the well, or into some stream Avhich supplies other persons. We Avill study the following antiseptics :— Thymol, Sulphate of Iron, Chloride of Lime, Carbolic Acid, Sulphurous Acid, Chloride of Lead, Permanganate of Potash, Liquor Sodne Chlorinatae. Thymol. Thymol, in Aveak solution in alcohol and water is used as an antiseptic dressing to Avounds and in surgical opera- tions, or to abscesses Avhen they are discharging. Thvmol may also be used to disinfect the chamber utensils, and dressings for wounds. In some cases the object is to prevent infection by INFANTILE THERAPEUTICS. 101 septic germs, in others it is to arrest putrescence in a feeble part. It nyiy be used of the strength of—Py Thymol gr. ij. to gr. iv., alcohol "yss., Avater 5'iijss. Carbolic Acid. Carbolic acid may sometimes be used Avith adA'antage to arrest the process of sepsis in injuries and surgical operations, and as an excitant to feeble parts. Usually Ave pre- scribe—Py Carbolic Acid 5j., Glycerine 5j., Avater 5v. Mix. In this strength Carbolic Acid is an excellent dressing for burns and scalds. We employ this acid in full strength to destroy Avarts, working it down to the base of the growth Avith a pine pencil. It causes suppuration, and in this the growth is permanently removed. Sulphate of Iron. Sulphate of Iron in solution is a fair disinfectant for privies, drains, Avater closets, chamber utensils, etc., though it is not as good as the other named. Sulphurous Acid. This remedy, studied Avith the anti- zymotics, is also a most excellent antiseptic; boAvels may be cleared Avith it, a diseased surface sponged with it, dressing thoroughly disinfected Avith it, and finally, if used Avith a spray apparatus, the air may be disinfected. The old method of burning sulphur in a room answers an ex- cellent purpose. It is easily done by holding a pan, containing the sulphur, over the chimney of a coal oil lamp. In the olden time they sprinkled the sublimed sulphur o\Ter a pan of live coals. In cases of very severe small-pox I haA'e .seen the air so freshened by burning sulphur that the patient Avas improved Avithin an hour. Chloride of Lime. I like the old antiseptic, Chloride of Lime, quite as Avell as any for the disinfection of water closets, drains, seAvers and privies, and sometimes to purify the air of rooms. This agent should be fresh, and as they hoav put it up in pound and half pound cans, it can be procured and used of full strength. For use in the house it may be placed in a saucer and sprinkled with vinegar. Liquor Sodje Chlorinate. The officinal solution of chlo- rinated soda is a valuable disinfectant and antiseptic. It is especially useful to cleanse vessels, surgical dressings and band- ages Avater closets, drains and seAvers; used with an atomizer or 102 DISEASES OF CHILDREN. spray apparatus it will purify the air of a room and destroy dis- ease germs. In severe diphtheria, in scarlatina maligna, and small-pox, its frequent use is of advantage to the patient, and prevents the spread of the contagion. Chloride of Lead. Take of Nitrate of Lead half a drachm, dissolve it in a pint of boiling Avater; disolve tAVO drachms of common salt in a bucket of water, and pour the tAVO solutions together. The clear, supernatent fluid Avill be a saturated solu- tion of chloride of lead. " A cloth dipped in this solution and hung up in a room will sweeten a fetid atmosphere instantane- ously ; or the solution thrown doAvn a sink or water closet or drain, or OA*er a heap of refuse, Avill produce a like result." It is a cheap disinfectant and antiseptic, and may be used freely at but little expense. Permanganate of Potash. We rarely employ the perman- ganates internally on account of their irritant action upon the stomach. But as a local application to arrest the septic process, and to prevent rapid destruction of tissue, it has no superior. It is used in superficial and phlegmonous erysipelas, suppurative skin diseases, in the treatment of superficial inflammations Avhen parts manifest debility, in the treatment of abscesses, and other suppurations the result of inflammation, and the treatment of wounds and injuries. The solution for external use will be made in the proportion of from one-half to one drachm of the salt to one pint of water. When the tissues are greatly debilitated it mav be used as strong as ten grains to the ounce of Avater. ANTI-RHEUMATICS. We have a peculiar inflammatory process which Ave call rheu- matic, and a variety of pain Avhich Ave also call rheumatic, and both of these are due to a special cause. Not only have we rheumatic inflammation and rheumatic pain, but we frequently find the rheumatic cause influencing other diseases. What this cause is, is not accurately known. It has been thought to be lactic acid generated during retrograde metamorphosis, or by decomposition or mal-digestion of food. Whether lactic acid or not, it is certainly a product of retrograde metamorphosis or food decomposition, and may be acid in one case, an ammonia product in another, and neutral in another. Whatever it is, Iioav- ever, it is specific in its nature, and is met by specific remedies. INFANTILE THERAPEUTICS. 103 We might have studied this group of remedies under the head of "rheumatism," but I think it will serve our purpose better to examine them here, especially because we employ them in dis- eases that Avould not be called rheumatic. Then again, these remedies have other actions that are important, and we can see them all to better advantage. The group of anti-rheumatics will be as follows:— Macrotys, Sticta, Salicylic Acid, Bryonia, Apocynum, Alkalies. Phytolacca, Acids, Macrotys. Specific Indications.—Muscular pain, pain is in- termittent, as if due to muscular contraction, parts swollen tense, pain someAvhat throbbing (no evidence of suppuration), pains in inguinal region and groins, lumbar pains. Dose.—Pv Tinct. Macrotys gtt. a'., water 5iv.; a teaspoonful eA'ery one to three hours. With the indications as above named Macrotys is a very cer- tain anti-rheumatic. As there is fever and inflammation, Ave usually associate it with the Veratrum. In some seasons it seems to be indicated in almost every case of rheumatism or rheumatic pain, so that avc arc inclined" to think that it will cure eArery case, and possibly the next year the disease has so changed that it will relieve none. Bryonia. This remedy has been fully studied, and we notice it here only as it influences rheumatism. The indications are sharp pain, the serous membranes are involved, the pain is ten- sive, the pulse is full and hard, and the patient inclined to cough. Apocynum. Apocynum AATas studied under the head of reme- dies which influence the circulation. The indications for it in rheumatism and rheumatic pains are—oedema of feet, eyelids or other part, and puffiness or oedema of part affected. Salicylic Acid. Specific Indications.— The tongue is full, leaden-colored or purplish, the temperature high, but without dryness of the skin ; the breath is sometimes fetid ; the tongue is broad with leaden pallor. Dose__The best form to administer Salicylic Acid to children is as a Salicylate of Potash, say—Py Salicylic Acid gr. x. to grs. xx. Acetate of Potash .vs., water 5iv. ; dose half teaspoonful 104 DISEASES OF CHILDREN. to one teaspoonful every two or three hours. As a local applica- tian it may be solved with Borax or Chlorate of Potash, the first being the best antiseptic, as—li Salicylic Acid grs. v. to grs. x., Borax or Chlorate of Potash grs. x., water 5iv. Where the case is properly selected Salicylic Acid lowers the temperature, controls the circulation, and the specific gravity of the urine is markedly increased. But when not indicated it irritates the nervous system. As a local application Ave employ it in the treatment of nasal catarrh, and in diseases of the throat with inuco-purulent secretion. It is a good local remedy in some cases of cynanche maligna, malignant scarlatina and diphtheria. In these cases it is used with a spray apparatus. With Borax it may be used as a dressing to Avounds and superficial inflamma- tions, if the parts are relaxed and atonic. Phytolacca. This remedy, studied under the head of anti- zymotics is also an anti-rheumatic, if the indications for it arc present: Pale tongue, sore mouth, vesicular eruption on tongue and about the mouth, enlargement of lymphatic glands. Sticta. Sticta Pulmonaria, studied under the bead of remedies that influence the respiratory apparatus, is a most excellent anti- rheumatic if the folloAving symptoms present : The neck is stiff and painful, the head draAvn back or to one side, pain in shoulders extending to neck and occiput. Acids. If one has read the medical journals of the past twenty-five years, he Avill be surprised at what seems to be a fashion in the selection of remedies. For months, the medical journals will teeniAvith articles in favor of acids in the treatment of rheumatism, and reports of cures ; and then it all seems to change, and alkaline salts are just as strongly recommended, and quite as many cases reported. It is all rheumatism, and nothing is said about a difference of cases, and Ave might suppose it Avas all chance. Yet the cases cured by acids could not be reached by alkalies, and vice versa. We have no doubt of the cures in both cases, for it is a fact that acids will relieve rheumatism, as it is equally the fact that the cause of rheumatism may be antagonized by alkalies. But these are not the same conditions of disease. Lemon juice is anti-rheumatic when the tongue is markedly red infantile therapeutics. 105 and the papillae prominent; the coating of the tongue is usually thin and white. Alkaline Salts. If the tongue is broad and pallid, we use an alkaline salt, and sometimes it is all that Ave require to cure any rheumatism. It is usually bicarbonate of soda to the ex- tent of one-half to one drachm daily for children two years old. If the tongue has a leaden pallor, nitrate or acetate of potash are the better remedies. ANTIPERIODICS. If physicians will, not concede anything else, they will con- cede that the group of remedies called antiperiodic, and quinine especially, has specific action. They will go further, Avhen pressed, and admit a Avell defined and positive indication for this group of remedies. Pushed a little further, and they will admit the certainty of its action Avhen thus clearly indicated. This is Avhat Ave claim with reference to all remedies Avhich have been carefully studied, and Ave believe that any one may satisfy himself that Ave live in a Avorld of law, medically as Avell as physically, the same causes always producing the same effects. The indication for the antiperiodics—periodicity of disease—is so clearly defined in many cases, that he avIio runs may read. There are exacerbations of the disease, whatever it may be, and there are remissions or intermissions in it. The most common type of periodic disease is intermittent fever or ague, a chill or cold stage, a hot stage, a sweating stage, and period of intermis- sion. There is usually regularity in the recurrence of them, so that the disease having made one " revolution," the time of each may be predicted. It would be interesting and profitable to know the cause of periodic disease—the malarial poison—not that it Avould enable us to treat it better, but that Ave might the better avoid it, or possibly remove it. But in so far as the administration of reme- dies is concerned, the essential thing is to determine periodicity as the basis of diseased action. Whilst physicians Avill admit the positive action of antiperiodics in malarial disease, and claim thmt they are as nearly " specifies" as anything Ave have in the materia medica, they will yet confess to a great many failures. These failures prove to them that u there is no certainty in medicine;" the quinine cures the ague 106 DISEASES OF CHILDREN. to-day, it fails to-morrow; it cures Smith, Jones continues to shake (?). Here the diagnosis has been half made. In the one case tire periodic cause, Avhatever it may be, Avas the basis of the disease ; ■ in the other case it Avas but a part, and there was something else at the bottom. There are many cases in Avhich the antiperiodic cannot act, because of some morbid conditions of the body; correct these wrongs, and at once it acts kindly. Proper prepara- tion for the action of the antiperiodic is many times essential to its success. The remedies Ave will study in this connection are :— Quinia Sulph. Arsenic, Alstonia Constricta, Cinehonidia, Uvedalia, Nitric Acid. Quinia Sulphas. Specific Indications.—There is distinct periodicity in the disease, Avhatever else may be its character, the periodicity being marked by exacerbations and remissions, or intermissions. Dose.—In the ordinary use of the remedy the antiperiodic quantity Avill be one grain for the first year, two grains for the second, and so increase one grain each year up to the fifth or sixth, Avhen the dose will vary according to the strength and deA'elopment of the person. In some cases very minute doses prove antiperiodic; in others its limited absorption by the skin when used as an inunction, or applied to the skin Avith alcohol, is sufficient. Periodicity being the indication, we Avant to knoAV if the patient is in such condition that the remedy Avill act, and will act kindly. In this case, as in many others, a remedy must gain entrance to the blood before it can antagonize the disease. We put it in the stomach in an insoluble form—the stomach must first furnish an acid menstruum for its solution, and then reverse the process of osmosis to cause its absorption. If either of these fail, the agent Avill not prove curative ; indeed, Ave might as well put it in the patient's shoes. Again, the remedy acts kindly in a certain condition of body unkindly in other conditions, and a knoAvledge of these is essen- tial to its right use. We say thmt if the pulse is soft, the skin soft, inclined to moisture, the tongue moist and cleaning, and the nervous sy.stss., Simple Syrup .^iijss., Mix. ; dose from one-half to one teaspoonful. To improve the appetite and aid digestion it may be adminis- tered in connection with iron, cod-liver oil, etc. It is not bitter, 116 DISEASES OF CHILDREN. but quite pleasant to the taste, and sits very kindly upon the stomach. In chronic diseases of the respiratory apparatus it is a favorite remedy, having a specific influence in removing irritation and improving functional activity of all parts supplied by the sympa- thetic system of nerves. Iron. Iron is a most efficient tonic and restorative in child- hood. It can be so prepared as to be readily taken and Avell appropriated by the stomach. As a general rule, it should not be administered while there are evidences of fever, or during the progress of inflammation. And in the treatment of chronic disease it will rarely be of benefit so long as the secretions are locked up. I prefer the folloAving preparations: Py Tincture of Muriate of Iron oij., Glycerine or Syrup o'iv.; dose a teaspoonful three or four times a day. Py Citrate of Iron 5«s., Water Sj. ; dissolve and add Glycerine or Syrup §iij , mix ; dose, a teaspoonful three or four times a day. Phosphorus. Phosphorus may sometimes be employed Avith advantage as a restorative. Different preparations are in use, but I think the best are the Hypophosphite of Lime, Hypophos- phite of Soda, and Compound Syrup of the Hypophosphites. Of the first, the dose will be one grain ; of the second one or two grains; and of the syrup, one-third of a teaspoonful three or four times a day. The indications for the use of phosphorus are, a pale, doughy condition of the skin, cold extremities, abundant pale urine of low specific gravity, and deficient innervation. Sulphur. Though not regarded as a tonic, or even as a restorative, I regard sulphur as a very important restorative in some exceptional cases. It is not \-ery easy to indicate the cases in which it is most useful, but they are those in Avhich there is a deficiency of heat and impairment of muscular poAver. I use it in doses of three to five grains, associated Avith cod-liver oil, or other fatty material. Cod-Liver Oil. This is a very important restorative in many cases A\diere the nutritive powers are impaired. It furnishes material for combustion, and thus saves the nitrogenized food INFANTILE THERAPEUTICS. 117 and tissues from being burned. It also furnishes food for the nerve centers in a form readily appropriated. Coddiver oil, Avhen the stomach will receive it kindly, is easily digested, and increas- ing the temperature and the innervation of the body, all the functions are better performed. The dose of cod-liver oil for a child two years old, will be a teaspoonful three or four times a day. Cuprum. Specific Indications.—The skin has a taAvny or dirty hue, sometimes greenish, the tongue is pale, and the gums blanched, the pulse is small and soft, and more frequent than usual. Discharges from the bowels lack color, and if there is diarrhoea, they are pale and like rice Avater. Dose.—Py Tinct. Acetate of copper (Rademacker's) gtt. x., Avater §iv.; a teaspoonful four times a day. Sometimes Ave get the restorative action of copper by having the patient take it in the shape of a greened pickle—a small portion three times a day. Homoeopathic Indications, (3d to Gth decimal).—Spasmodic affec- tions, Avhooping cough Avith spasms, long continued paroxysms of suffocation, cough, much rattling of mucus; epilepsy ; violent diarrhoea with cramp in the stomach and chest, much flatus with the stool, nausea and vomiting of frothy mucus, sometimes green, metallic taste; pulse small, soft, almost imperceptible; scarlet fever Avhen the rash suddenly disappears, folloAved by stupor and delirium or convulsions.—Ehrmann. Silica. Specific Indications.—The skin is rough, the epider- mis desquamates, and the hair is harsh; teething is slow, and the tissues feeble. Dose.—I employ the third decimal trituration as a remedy; usually I order an oatmeal or cracked Avheat diet, or the use of bread from unbolted flour. Homoeopathic Indications (3d to 6th decimal).—Headache with great sensitiveness to a draft of air. Must have the head covered. Great inclination to perspire. Hardness of hearing. Otalgia with stitching pains. Nasal catarrh Avith offensive odor and loss of smell. Inflamed glandular swellings. Fistulous ulcers. Ulcers burning, putrid, indolent. Carbuncles. The skin heals badly; a slight injury inclines to suppurate. Bones swollen, inflamed. Caries. AVeakness of the joints, especially the ankle. Feet perspire very much, and smell \'ery offensively. Phthisis 118 DISEASES OF CHILDREN. pulmonalis, with great sensitiveness to a draft of air, and profuse night sweats. Soda. This remedy has been studied in two or three places, and Ave only need say here that Avhen the tongue is continuously pallid and broad, it will be found a good remedy. It improves the appetite, digestion and blood-making, and the nutrition of tissues. Lime. Specific Indications.—Acid fermentation in the stomach, food does not digest Avell, colic, green acrid discharges from the bowels, inflammation of cellular tissues, boils. Dose.—When Ave Avish to influence the digestive tract Ave use lime-Avater with the milk. If it is for inflammation of the cellular tissues, or boils, Ave may use lime-Avater, or minute doses of sul- phide of lime. PART II. CARE AND MANAGEMENT OF INFANTS. CHAPTER III. The young of man is the most helpless of all created beings, requiring constant care from the hour of birth until its second or third year. But it is especially for a short time after birth that it is thought to need extra attention, and Avhen it very frequently gets an officious interference that renders it uncomfortable, and frequently leads to disease. Many of the prejudices and Avhims of the olden time still re- main, and some of them, indeed, receive the tacit support of the physician. It is Avell to educate the public mind to the truth in these things, and though the physician may find it a thankless task at first, it Avill bring its return in an increased confidence and respect. Works on obstetrics point out the things to be done, and how to do them. It Avill be our business here, at least to some extent, to point out some things that should not be done, and other things that are not done properly. Washing the Child.—A physician should not have the least hesitation in telling a nurse how to Avash the child, if she sIioaa's ignorance in regard to it. Avery common plan is, to rub the child with lard freely, and then with an ordinary cloth, and poor soap and lukeAvarm Avater, to Avash off the grease and secre- tions upon the skin. It is a difficult job, and the child is rubbed until its skin is irritated, and still not cleansed, and it is ren- dered fretful and uneasy for days. (119) . -:... 120 DISEASES OF CHILDREN. The true way is, let the person Avashing the child rub it thor- oughly with the lard, and then with a piece of soft flannel, or even cotton, wipe the child clean. Then with soap and water, and a soft cloth or sponge, it may be gently yet thoroughly washed. The drying had better be done by gently pressing the towel or cloth upon the skin, rather than by rubbing. This makes all the difference possible in the feelings of the child and its future comfort. And as the skin has a very close sympathy with other parts, in addition to being an extremely sensitive part itself, Ave can readily see that, in some cases at least, it will be a means of avoiding serious disease. Clothing of the Child.—I object most decidedly to many parts of the infant's dress, as usually made; and I have no hesi- tation in giving my objections words, whenever and Avherever I am brought into contact Avith these errors. The bandage of the child is always pinned too tightly. The child no more needs this swathing than the adult; its abdominal muscles are just as strong, and just as capable of performing their functions. But there is something worse than the mere suffering which folloAvs such confinement. The bandage extends upward so as at least to embrace the floating ribs, hence the insertion of the diaphragm, and often much higher. Here there is a more or less serious impairment of the respiratory function, as the baud is more or less tightly applied. We not only have suffering and restlessness upon the part of the child from this, but occasionally such impairment of the lungs as will lead to a fatal result. There is another lesion that may be directly attributed to this. I allude to infantile constipation. It comes on gradually ; it is attended with colic, and sometimes Avith infantile dyspepsia. True, in many cases it does not produce any present marked inconveniences, but it lays the foundation for future constipation, hemorrhoids, prolapsus ani, and, as I believe, for hernia. The child needs such band only for the purpose of retaining the dressings of the cord, and to give Avarmth. One thickness of soft and elastic flannel, not so wide as to extend upward on the thorax, or down to be Avet Avith the excretions, will answer this purpose. Being elastic, it maintains its place Avithout being applied so tightly. Its skirts are usually as badly made. The Avaist is made of cotton stuff, usually stiff and harsh, and so Avide as to prevent CARE OF INFANTS. 121 any warmth from the flannel attachment. As frequently put on it chafes the child under the arms, and is unpleasantly bulky and cumbersome about the body. The diaper is as bad or Avorse than the remainder. If the parents are in good circumstances, and it is a first child, it will be of linen diaper; at any rate it will be harsher than there is any need for. Let this be Avetted and dried several times Avithout washing, and Ave have a cause of irritation that would make the adult Avince if obliged to wear it. I have seen scores of cases in Avhich irritation and chafing about the genitals, the perineum, nates, and thighs, Avas the result of such treatment. Yet the mother could not imagine why her child should be so affected. While I do not insist that they should be Avashed after each discharge of urine, though it Avould be better and pleasanter for the child if they Ave re, I object to their being used until they smell and are as foul as it is possible for so much linen or cotton to get. If children are delicate, the absorption of these excre- tions must prove \Tery detrimental. When a child shows such irritation as.I have named, recom- mend that the diapers be made of canton flannel, Avhich is soft, unirritating and pleasant, and that they be rinsed in clean Avater every time they are soiled, before drying and using. How often should the Child beWashed?—The question might be put in a different Avay—not so much how often, but how much should the child be Avashed? Some are/washed a very great deal; indeed, some poor innocents have their lives soaked out of them. It Avould be a mercy to the children to put a feAV monthly nurses, and not a few mothers, through a similar course of soap and water, as afterAvard they would hardly be so free with it. I have seen children washed out of the Avorld in a few months, and sometimes in a feAV Aveeks, and have had to put a stop to it a number of times. The child is very sensitive to cold, and being entirely divested of clothing, and having the evaporation of water from the surface for some minutes, is too much for many. To Avash a child properly, the nurse should have a blanket or other woolen material of sufficient size to wrap the child entirely up. Then a portion of the body should be washed at a time, the child being kept well covered in the meanwhile. Even with this care it is not necessary that the child be washed every day. 122 diseases of children. Washing is done for cleanliness, and need not go further than that; and when children are feeble it had better fall short of it than exceed it. Attention to the Cord.—The question is usually asked, how long Avill it be before the cord falls off? aiid Avhat shall Ave do with it in the meantime? It usually requires from five to nine days for the separation of the cord, and cicatrization of the umbilicus, and occasionally it is prolonged beyond this. It is important that the cord be tied sufficiently tight to pre- vent any hemorrhage. True, it is but rare that there is any severe hemorrhage, yet I have had such in my practice.' But a small amount of blood discharged causes the cord to adhere to the cloth, and the mass becomes hard and unpleasant; if not irritant to the child. I ahvays recommend the young physician to examine the cord before it is dressed, and if not certain in regard to this point, to apply a second ligature. The cloth Avith which the cord is dressed should have its upper surface oiled (in obstetrics Ave say oil Avhen Ave mean lard), so that it may not adhere if it should become necessary to remove it. Every day Avhen the child is dressed, it should be placed in such a position that there will be no strain upon it. And in Avashing the child, the cord and cloth should be removed, so as to Avash beneath it. In the majority of cases, irritation and inflammation about the umbilicus is the result of tension npon the cord, upon the dress- ing becoming hard and irritant from bleeding, or other cause, from a too tight band, or from the excretions passing up so as to soil the dressings of the cord, and subsequent Avant of cleanliness. No traction or other means should be used to remove the cord, as it will be separated in due time by the natural process of absorption. When separated it is Avell to apply a soft cotton cloth, folded, that the recent cicatrix may not be disturbed by the rubbing of the child's clothes. If the part seems someAvhat tender, a cloth spread with mutton suet or simple cerate may be applied. Ulceration of the Umbilicus.—Occasionally avc are called to prescribe for ulceration, or rather a AArant of cicatrization of the umbilicus. Sometimes there is considerable redness and evidences 'of inflammatory action, and the child is feverish and fretful. I generally prescribe one of three things. In the majority of CARE of infants. 123 cases, that the part be powdered with subnitrate of bismuth twice daily. If there is much inflammation, that it be dressed with stramonium ointment. Or, if there is an erysipelatous redness, order a solution of permanganate of potash, one grain to the ounce of water. If the child is feverish and restless, Ave would give Aconite, one drop to the ounce of Avater, one-half of a teaspoonful every hour. Excoriation and Chafing.—Various parts of the infant's body may be chafed, and become excoriated, and painful. I have already mentioned the chafing that comes from Avant of attention to the diapers of the child, and want of cleanliness. It is quite easy, by inspection, to determine the nature of the difficulty, but it is not always so easy to give immediate relief. The use of Colgate's Glycerine Soap to Avash the child, and strict attention to cleanliness, Avill sometimes be all that is neces- sary. Occasionally dusting the inflamed parts with scorched flour Avill answer the purpose. The common, idea is that some- thing "greasy" is necessary, and frequently ointments will haA*e been used before the physician is spoken to. Mutton suet, if Avell prepared, ansAVers as Avell as any ointment, if Ave except the glycerole of starch, Avhich is an excellent application in such cases. The most certain, as Avell as the speediest cure, has fol- lowed the use of subnitrate of bismuth in fine powder, dusted over the parts, tAVO or three times a day. Does the Child need Medicines immediately after Birth?—Many persons believe that the young child needs some- thing to act upon its bowels. And for this purpose they propose to give it urine and molasses, lard and molasses, or sometimes castor oil. Others think it should have a Avhisky or rum mix- ture, to Avork the mucus out of its throat. The truth is, the less the child is interfered Avith the better it Avill get along. Nature makes provision for all of its wants, and an action of the bowels is provided for in the first milk of the mother. The child Avill have a sufficient opportunity to take medicine, Avithout commencing thus early, ajid it Avill be good policy to impress this upon the mother and nurse. There is no need of saffron tea to keep off the jaundice, or make the child a better color, Xo need of German chamomile 124 DISEASES OF CHILDREN. to strengthen its stomach, or of pap or panada, or of any of the hundred and one things that people like to force upon the child. Whait it wants is Avarmth and quiet, and not food or medicine. Nature furnishes food at the proper time, and furnishes it exactly adapted to its Avants. Difficulties in Nursing the Child.—Occasionally Ave find a child that will not nurse, at least it persistently refuses, and accompanies its refusal by energetic remonstrances. This seems, in some cases, an excellent illustration of original sin, though, doubtless, there is some good cause, other than this, if Ave but knew it. If the child is fed the difficulty increases as time progresses; for, becoming accustomed to the spoon or bottle, he is less in- clined to take the breast. The proper Avay is, not to feed the child, but, by kindness and perseverance, get it to nurse. The child should be applied to the breast Avhen in a good.humor, and not Avhen crying; sometimes it Avill be an advantage to Avet the nipple with the milk, as an extra inducement. In some cases the difficulty is Avith the mother, not with the child The nipples are retracted, or not properly formed, and the child is unable to obtain a sufficient hold to draAV the milk. In this case a breast-pump, applied for a moment, will draw the nipple out so that the child can nurse. If a breast-pump is not at hand, it may be accomplished Avith an ordinary pint bottle; fill it with hot water, and pouring it out quickly, apply to the breast. The sore nipple that is so frequently met Avith, and that proves such an annoyance and source of difficulty in nursing, is best cured by Avearing a leaden nipple shield, and small doses of Phy- tolacca Avith or Avithout Aconite. If sheet-lead can be readily obtained, this may be easily fashioned into a cup that will accu- rately fit the nipple. If not, a piece may be hammered from ordinary bar or other lead. We Avant it to fit accurately and pleasantly, so as to bring it in contact with every part of the nipple. It should not be too heavy, as it is to be constantly worn, except when the child is nursing. It has often seemed strange to me that Avith so simple and certain a means of cure, such suffer- ing should be permitted. Food of the Child.—The natural food of the child for the first eight months, is the mother's milk, and it is rarely the case, when the mother is healthy, that any other food will be required. CARE OF INFANTS. 125 If the mother is healthy, and still fails to supply the amount necessary, the probabilities are that there is a deficiency of some kinds of food. Frequently it will be of farinaceous foods, which, if prepared in palatable form, give an increase of good milk. Occasionally the fault will be found in a lesion of digestion, and the employment of the bitter tonics and restoratives will answer the purpose. When the child can not have its natural food Ave have to advise a substitute. That most readily obtained and easily prepared is the milk of the cow. In its natural condition it is too rich in some of the elements of food, too poor in others. The constitu- ents of human, cow's and goat's milk are as follows: HUMAN. COAV. GOAT. Water......................................................883.6.........861.0.........868.0 Butter...................................................... 253......... 38.0......... 33.2 Casein...................................................... 34.3......... 68.0........ 40.2 Sugar of Milk and Extractive Matters.......... 48.2........ 29.0......... 52 8 Fixed Salts................................................ 2.3 ........ 6.1......... 5.8 To prepare the milk of the cow for food for the child during the first Aveeks of life, one-third the quantity of water should be added, and one drachm of sugar to the pint of milk, and the Avhole boiled. After the first month, the proportion of water may be lessened to one-fourth, and after the child has passed its sixth month it may be given pure. Those avIio have had occasion to use artificial food in raising children, prefer the milk of the goat to the cow, and there is no doubt but that it is more easily appropriated by the child. In France, goats are frequently trained so that they Avill lie down and permit the child to nurse directly from the udder. Liebig's food is a most excellent substitute for the mother's milk, being much better than the milk of the cow. It contains the elements of human milk in a form easily digested by the child. It is composed of Wheaten Flour, two ounces; Barley- malt Flour, two ounces; and Biearbonate of Soda, thirty-one grains. In preparing it for use, the following directions are observed : Take a heaping tablespoonful of the poAvder and mix it with two tablespoonfuls of water ; then add to it ten tablespoonfuls of milk, and heat the Avhole over a gentle fire (do not boil). When the mass begins to thicken, remove it from the fire, and stir for five minutes. Then place it over the fire, and heat again, 126 * DISEASES OF CHILDREN. with stirring, until it becomes quite fluid, and then suffer it to boil. In the preparing of the food, do not use too much heat, or haste, as it Avill prevent the necessary chemical change taking place. Use a gentle heat, and only allow it to come to a boiling temperature at the end of the process. In employing artificial food, Avhether milk or that just named, it it better that it be given with a nursing bottle, rather than with the spoon. There is more than one reason for this direc- tion, but one good reason is sufficient. The act of sucking calls into use the muscles connected with the salivary glands, and ex- cites those glands, hence there is good insalivation of the food. Maw's nursing bottles are decidedly the best, though they require more care to keep them clean and in order. But the ordinary nursing bottle will ansAver if it is Avell looked after. Milk should neATer be alloAved to stand in the bottle, which should be emptied and rinsed every time it is used, and kept in a vessel of Avater, or at least partly filled with water. In this Avay it is kept clean and sweet. Everything connected with the food of the child should receive the greatest care, and should be frequently scalded. A very slight decomposition in the milk, from sourness of a vessel, Avill give the child an indigestion, and may seriously derange the functions of the stomach and boAvels. These facts can not be too forcibly impressed upon those avIio haATe the nursing of children in this Avay. The food of the child should ahvays be given at the tempera- ture of the body, and this Avill require the employment of heat at all periods of the day. A nursery lamp answers this purpose very well, but there is a much simpler means aA7ailable Avherever coal-oil or gas is employed for light. It is a nursery attachment, which may be attached to any lamp or gas-burner, and Avhich Avill hold a cup steadily over the blaze, Avhere it Avill quickly heat. These are made by Messrs. Tifft & Howard, 406 Pearl street, New York, of Avhom they may be ordered by mail, if they can not be obtained nearer. It seems very important, when trying to raise a child by the milk of the coav, to be able to determine Avhether the milk ob- tained is good. There is a very simple method, Avhich will give this information to any one. AIIoav the milk to stand for six hours, skim it, and if, upon holding it to the light, the skimmed CARE, OE INFANTS. .127 milk has the natural color, it is good. But if it is blue, or green, or varies in appearance in any Avay, the milk should be rejected as not fit for the purpose, and another coav's milk should be tried. I need not say that it is important that the child should have one coav's milk, and I am satisfied that it is much better if the coav is fresh. As the child attains to the end of its first year, it will require additional food to the mother's milk. If it is strong and healthy it may be gradually accustomed to the ordinary diet of the family ; farinaceous food being preferred to animal. If, Iioav- ever, the digestive organs are not strong, it will be better to con- fine it to a milk diet, or to food prepared Avith flour and milk, or with sago, tapioca, etc. A Wet Nurse.—Next to the mother's milk as food for the child, the milk of another Avoman is the best, and Avhen a choice can be had, preference should always be given to a Avet-nurse, Mothers have a prejudice to overcome in agreeing to this; yet, as it is manifestly for the child's benefit, and as its chances of living are one hundred per cent, greater, it is a duty to make the sacrifice for the child's benefit. When Ave have really tried it, having a wet-nurse in the house, and having the care of baby, will not be found nearly so objectionable as anticipated. The nurse should be selected with reference to her health, the a"-e of her milk, and with reference to her character and associa- tions. We do not expect perfection in a Avoman who is obliged to take*this position, and must make many allowances. As a general rule, Ave Avill find the health of persons in the loAA-er Avalks of life much better than those Avho enjoy more of this world's goods and comforts. The general appearance of the patient will usually tell the story at the first glance. Such per- sons are rarely scrofulous, at least to that extent that it Avould be objectionable, and if they are, they carry the marks in old cica- trices, and enlarged glands. What avc are most fearful of is a syphilitic taint, secondary syphilis. We may not be able always to determine this, for it mav exist in the system, without having as yet shown itself in the" usual symptoms. A person suffering from secondary syphilis in the early stage will show maculae, and if the tongue is exam- ined Ave will find the evidence in recent or old indurations. The danger of getting a person afflicted with syphilis is not 128 DISEASES OF CHILDREN. great, except in large cities, and even here the pleasures and profits of a life of shame are so much greater than attends the position of a Avet-nurse, that they are not frequent applicants. When there is doubt of the capacity of the applicant to fur- nish a sufficient supply of milk for the child, the breasts may be examined. If round and firm, of usual size, and a Avell devel- oped nipple, there will be but little doubt in this respect. It is important that the nipple be free from sores or abrasions, as this not only prevents free nursing, but it is the source from Avhich vices of constitution are most frequently transmitted. It is best that the milk of the wet-nurse be as young as the mother's. When other things are right, three or four weeks, or even as many months, may be permitted. I do not see any ob- jection to the milk being too young, if it has passed the first Aveek. As regards the character of the wet-nurse, Ave would like to have it as good as possible, as Avell as her associations. Still, beggars can not always be choosers; we Avant to save the life of the child, and Avet-nurses are not too plenty, and Ave may, by kindness and good offices, improve both character and associations. Weaning the Child.—Almost all the Avorks that speak of weaning the child, name tAvelve months as the period the child should nurse. This, however, is English and continental authority, and is not always adapted to this country and our habits. If a child is Avell developed, and has cut its teeth thus far Avithout trouble, there is no reason, so far as it is concerned, Avhy it should not be weaned. Of course it is essential that for a couple of months it has been accustomed to eating, and has digested its food well. I do not think Aveaning is prudent until Ave have the conditions named. If, as in some cases, the milk of the mother is found to disa- gree Avith the child, it may be Aveaned at a much earlier period, and Avill thrive better on the milk of the cow, or the other foods named, than if permitted to nurse. Not unfrequentlv the moth- er's milk undergoes a change from the eighth to the fourteenth month, that renders it poorly adapted to the Avants of the child, and gives rise to various symptoms of infantile dyspepsia, and to irritability of the bowels. The re-appearance of the menstrual discharge sometimes pro- duces a very marked effect upon the milk, and in nearly all eases CARE OF INFANTS. 129 impairs its value. But as this, in the usual course of events, does not appear until the child has attained the age of one year to eighteen months, it is not often that our attention will be called to it. When, from such reason, there is evident change in the milk, and it giA'es rise to gastro-intestinal or other disease, Ave will advise Aveaning the child. When the mother becomes pregnant Avhile nursing, the milk very generally suffers after a time. It is necessary in this ease that the child be weaned, not only for its oavh sake, but for the mother's* for nursing a child Avould interfere with the natural progress of gestation. The objections to Aveaning the child are of two kinds—with reference to the mother, and Avith reference to the child. The first objection Avould seem trivial, if Ave did not so often Avitness the health of t';.e mother completely broken doAvn by frequent child-bearing. It is the popular impression, and to some extent it is true, that so long as a Avoman nurses her child, she will not have her menstrual periods, and so long she Avill not be in dan- ger of becoming pregnant. Frequent pregnancies are a very great burden to a Avoman, especially if she has not the proper assistance in the care of her family, and Ave need not AAonder that she prefers to nurse one child for two or three years, rather than have another added to her cares. The objections upon the part of the child are with reference to its health, and its poAvers of digestion and assimilation in main- taining a separate existence. In some families every child has to pass through a second summer of cholera infantum, which requires great care, especially Avith regard to its food. In such cases it is best for the child to nurse eighteen months, or even two years. In other cases the infant is far from robust, and its develop- ment is sIoav ; it cuts its teeth tardily, does not digest food well, and is liable to attacks of gastro-intestinal irritation. Here, also, nursing the child should be prolonged. When it is determined to wean the child, there is much dis- cussion of how it is to be done, as it is no easy matter in many cases, and, as usually managed, very troublesome in most. Trying to " taper off," as a drunkard tries to quit drinking, giving the child a little now and then, or depriving him of it in the day-time, giving it to him at night, is just about as efficient in the one case as in the other. At the end of a Aveek the child 9 130 DISEASES OF CHILDREN. is no nearer weaned than Avhen it commenced; but in most cases is farther from it, for it has been Avorried and tantalized until it has a stronger desire for.the breast than before the Aveaning commenced. It is also a poor plan to put bitter or nauseous things on the nipple, thinking to disgust the child, and make it reject the breast. While it answers occasionally^ it fails in the majority of cases. It is objectionable, also, because it makes a bad impres- sion upon the child's mind, and it feels that it has been deceived, and wronged. • The only true Avay is, to stop giving the breast at once, and convince the child that this is right. In the day there Avill be but little trouble, and if the father or some friend Avill take care of the child for two or three nights, the trouble Avill be all over. The moral effect of sucV a course upon the child will be a decided benefit, and will give the mother a power of control that she could not otherwise possess. Sleeping.—The young child should be accustomed to regular periods of sleep during the day, indeed, all its habits should have great regularity. As it groAvs older it does not need so much sleep, and after it has passed its first year, it will not usually require more than one sleep in the day-time. At night the child should have its separate bed. I think it very objectionable for the child to sleep Avith its parents. Expe- rience has proven that the young yield vitality to the older, and the sound to the unsound. This Avould be a verv cogent reason if either of the parents suffered from ill health. But beyond this it is not Avell for the child to breathe the emanations from the bodies of other persons, as it must, if thus confined, and fre- quently covered so as to almost exclude the air. Another, and a very important reason is, that if alloAved to lie Avith the mother all night, it will obtain a habit of frequent nursing that Avill proA'e detrimental to its oavii health and to the health of.the mother. Many times an infantile dyspepsia mav be traced to this source. Let the child lie in its crib or cradle at the bedside, and Avhen it requires nursing the mother can take it in the bed witli her and give it the breast, placing it in the cradle again afterward. A child cared for in this Avay Avill be much less trouble to the mother, in addition to the advantage to its own health. CARE OF INFANTS. 131 Regular Habits.—There are few persons that can be con- vinced how readily a child may be trained to regular habits, in all things, unless they have seen it. Very frequently they will not believe the evidence of their own eyes, but account for it by saying, that it is owing to a difference in children, some being good, others being bad. The truth is, that a child is just as sensible to impressions as the adult, and is just as ready to yield obedience if it is asked in a proper manner. Beyond this is the fact, that habits in childhood are very readily formed, and very persistently maintained. This is as true of bad habits as of good. During the first three months the child should be accustomed to taking the breast about every three hours, and at very regular intervals. As it grows older it Avill not require it more than four times during the day, and once at night. One-half the slight illnesses, and tlie irritability and fretfulness of childhood might be avoided in this Avay. Nursing the child Avhenev7er it cries, simply to keep it quiet, is a most pernicious habit, and will very certainly lead to ill health, usually in the form of infantile dyspepsia and colic. And yet this is a very common habit, and will require much effort upon the part of the mother to break it up. The time of. getting up in the morning, of being Avashed and dressed, of taking the morning sleep, of the afternoon sleep, should all be as regular as the clock. I knoAv that the physician will be met by many objections Avhen he urges this ; the most common being, that the mother has other duties besides taking care of her child, and the attention it requires can not always be given at the minute. The fact is, hoAvever, that duties regularly performed become light by the side of those irregularly done. No one ever accomplishes much, unless the work is pursued by system. So in this case, it is a saving of time to do things promptly to the minute, and have the child in good humor and take its long refreshing sleeps, rather than from neglect, to haA*e it irritable and fretful, difficult to get to sleep and hard to keep asleep. There is no necessity of rocking a child when sleeping, indeed but little necessity of their being rocked at any time. If they are accustomed to go to sleep at a certain time, all that is required is to give them the breast, and put them in the crib or the bed. Americans might learn a valuable lesson from our German citizens in reo-ard to the management of young children. They 132 DISEASES OF CHILDREN. put them in the crib and cradle and cover them warmly, and keep them there, except Avhen nursed. There seems to be no trouble about it, the child is comfortable, is accustomed to that method of living, and takes it as quietly as if it were its natural mode of existence. When it becomes old enough to play, a tassel, Avith some simple toys, is suspended Avithin reach of its hands, and with them it Avill amuse itself for hours at a time. When old enough to sit alone, it is accustomed to amuse itself in a similar Avay. MORAL GOVERNMENT. As the health of the child -will depend to a considerable extent upon the condition of the nervous system, especially of the brain, the physician Avill frequently have to givTe the mother instructions in regard to its moral government; especially will this be the case when the child is suffering from chronic disease, which is aggravated by irritability, displays of temper, and the various cryings and frettings so common in badly-regulated households. True, in these cases he is not able to effect as much by good advice as he Avould like; yet, there are other cases in Avhich he may, by a feAV judicious words of counsel, direct the mother, who is willing, Iioav to train her child, so as to conduce to her happi- ness as Avell as its own. In this respect, the experience of a mother has higher \Talue than any other person, and I Avill give the short chapter from Chambers' Infant Treatment, by the lady editor of that Avork: " During the first few Aveeks of life, happiness is solely derived from the healthy operation of the bodily functions. Until the senses begin to act so as to convey impressions to the brain, there can be no pleasure drawn from external circumstances. The activity of the senses, and the enjoyment produced, will be in proportion to the state of the health. An infant avIio is continu- ally in pain, either crying, moaning, or in a state of repletion, or of exhaustion from the consequences of suffering, Avill be but little attracted by the light, sound, or motion Avhich first engages the senses of infancy. In no other instance, perhaps, are the influ- ences of the physical condition so immediate and so evident. An infant, even of three Aveeks old, Avill exhibit a haggard, grief-AVorn countenance, sunken eyes and shrunken face, painful to those Avhose experience tells them Avhat these signs indicate. But the CARE OF INFANTS. 133 fair, plump, contented look of the healthy babe, speaks a lan- guage of comfort, prophetic of the approaching dawn of intellect. " The general irritability caused by disordered functions, ren- ders the impressions upon the senses even more painful than pleasurable; the disposition for enjoyment bestowed by the feel- ing of health is denied ; the mother's voice, her smile, are asso- ciated Avith pain as much as with pleasure, and the affections are imperfectly and tardily aroused. As weeks pass on, habits form, and instead of a habit of contentment, there is one of fretfulness. An infant so constituted is either reared Avith an indifference to its continual crying and fretfulness, or with the apprehension Avhich causes its nurse to be continually seeking Iioav she may quiet or prevent its cries. At the age when food alone appeases it, the babe is always eating or sucking; as it groAvs older, sugar, cake, etc., are superadded, with the addition of noises or rough exercise, and but too frequently some sedative or composing draught, which the mother believes herself obliged to adopt in order to procure the child needful repose, or the servant surrep- titiously administers to relieve herself from incessant fatigue. When the time arrives that restraints and guidance should be adopted, the fear of farther irritation by contraction leads to a system of bribes, deceit, and coaxing; all the lowest sentiments of human nature are appealed to; and at two years old Ave have a selfish, willful, ill-tempered child, with violence apportioned to its strength, and intelligence prompted by ill feelings. It is not to be supposed that these moral disorders belong exclusively to bad health. A healthy child may be selfish, willful and ill- tempered at tAVO years of .age, if injudicious treatment have cultivated the lower sentiments; but the healthy infant is predis- posed to receive happy impressions, and enjoys the condition called good temper—a term which in infancy is synonymous Avith good health. The nurse has feAver temptations to mismanagement, and the affections and intelligence being more healthful ami activre, moral mismanagement actually produces less permanent injury. "There can not, then, be too much value attached to the physical condition of an infant; to the condition of the parent while pregnant and while nursing, and to the regulation of every particular connected Avith the health of her offspring. This being the first object, both in point of time and importance, the next consideration is the means of developing the moral and intellectual faculties." PART III. DISEASES OF CHILDHOOD. CHAPTER IV. The diseases of childhood do not differ in their pathology from the diseases of the adult. In each disease, there is a de- pression of the vitality, either of the Avhole or of a part, and though there may be increased functional activity in some par- ticular functions or part, Ave must never take it as an indication of an increased vitality or of a real functional increase. The animal body in early life is immature in all its parts, and Avliat change there may be in the character of diseased action, is in part dependent upon this. The tenacity to life is just as strong in the child, in many cases even stronger than in the adult. Possibly, this increased tenacity of life, will counter- balance the immaturity of organs, in all children Avho possess vitality sufficient to reach adult years. There is this fact to be taken into consideration in all our estimates of infantile disease: That there is a certain proportion of children, Avho are not born Avith sufficient vitality to live longer than the second year, and some, indeed, Avho have not the capacity to live this long It is not Avorth our Avhile here to discuss to any considerable length avIiv this is so, but it concerns us to knoAV that it is a fact, and to know Iioav Ave may determine it. It is a Avell-known fact in vegetable physiology that imperfect or unsound seed Avill not produce perfect plants; and that Avhen the seed-bearing plant requires to be fertilized by the pollen of another, an unsoundness of this Avill lead to deterioration ; that in breeding animals, sound and robust young are not expected (134) PHYSIOLOGICAL M \RRIAGE. 135 from immature or unhealthy parents; and that peculiarities and imperfections Avill be increased from generation to generation, by propagating from animals thus impaired. In our civilization there is a continual breeding in, with refer- ence to physical and vital imperfections, and hence to save the integrity of the species, it is necessary that the imperfect young should die before they have arrived at an age to transmit their physical imperfections. Physiological Marriage.—Prof. William Bvrd Powell advanced the theory, that persons of similar temperaments could not have healthy offspring, or in some cases, Avould not be capa- ble of begetting children ; even two very healthy persons, physi- cally and mentally Avell-developed, and Avith each the capacity to live the allotted time of man, might have children that Avould not live to the age of two years, or in some cases Avould not have the capacity for independent existence at all. The principles of this discovery, if discovery it is, are thus briefly stated by Prof. Powell: " Laav I. When the constitutional similitude of the respective sexes is such that a qualified observer can not detect an appre- ciable difference, sterility Avill be the result of their marriage. Illustration : Washington and his Avife were, respectively, san- guine, and it is known that sterility was the result. Between General Jackson and his wife there Avas a nominal difference of constitution; he Avas bilious sanguine, and she Avas bilious; nevertheless they Avere physically the same, both being exclu- sively vital, and it is knoAvn that sterility was the result. The first Napoleon and Josephine Avere, in person, greatly different, and in constitution they Ave re nominally as different, and yet there Avas no physiological difference. He was sanguine enceph-- alo-bilious lymphatic, and she Avas bilious encephalic, conse- quently they Avere, respectively, compounded of equal varieties of vital and non-vital conditions, and it is knoAvn that sterility was the result of their alliance. "Law II. When the constitutional similitude of the respec- tive sexes is less than complete, or is appreciably different, progeny will result, but it will be dead-born, imbecile, scrofulous, deaf, blind, or otherwise imperfect. Illustration: I can furnish three hundred examples of this law, but as they arc not histori- 136 DISEASES OF CHILDREN. cally known, they would be of no value in this relation. I can cite one, hoAvever, Avhich is historically known, viz.: the first Napoleon and his second Avife. Her temperament Avas bilious encephalo-sanguine, and his temperament I have indicated. There was betAveen them an appreciable difference of constitu- tion, and the result of this difference Avas one son ; but the dif- ference was too small to secure to him a normal viability, for he died of a scrofulous affection of the lungs, at the age of eighteen years. It is most indisputably the fact, that a considerable differ- ence of constitution' must obtain betAveen the respective parties to a marriage, to secure to offspring a soundly viable constitu- tion. To discover the least difference consistent with a physiolo- gical marriage Avas indispensible, but before discoA'ering this the conviction became forced upon me that my discovery could not become of general utility without the discovery of a laAV of universal application. By a great amount of observation and study, I succeeded in discovering the desired laAV, and it is of easy application, and Avill universally secure a physiologically legitimate offspring, and the greatest possible happiness to the parents. Those, therefore, who make domestic happiness, and a really useful progeny, conditions of marriage, must observe the folloAving laAV : "Law III. One of the parties must be exclusively vital—that is, must be either sanguine, bilious, or sanguine-bilious (the last being a compound of the two former, is also vital), and the other party must as certainly be more or less non-vital, that is, more or less lymphatic or encephalic. All marriages, in contra- vention of this laAV, are physiologically incestuous, and the con- sequences will be vicious in proportion to the delinquency. " Law IV. The greatest dissimilitude of constitution that can obtain betAveen the sexes, when they are respectively of the same species, is that Avhich obtains between a vital and a non-vital temperament—and this is the most favorable to progeny. But marriages of this character are greatly impracticable in any country. It is a very remarkable fact in the physiology of hu- man procreation, that a high degree of constitutional dissimil- tude is about equally unfavorable to progeny. It has been seen that a high degree of similitude entails a scrofulous diathesis, and with a high degree of dissimilitude, as when one party is white and the other negro, the progeny is invariably scrofulous, I believe." TEMPERATURE, ETC. 137 Life Line.—To determine Avhether a child has the power to live to adult years, is of much moment if it is practicable. Most persons judge by the general appearance, and by the functional activity of the important organs. A physician in active practice for a number of years, will be able to form a very good opinion in most cases, but will occasionally be seriously in error. I have been accustomed to place much reliance upon a meas- urement of the base of the brain, which determines its depth. Let the meatus auditorius externus represent the floor of the cranium, which it does only approximately, and a line drawn from the occipital protuberance to the external angular process of the os-frontis Avhere it articulates Avith the malar bone, repre- sent the superior part of the basilar brain, as marked by the tentorium cerebelli. The measurement betAveen the tAvo is approxi- mately the depth of the base of the brain. If the measurement is one-half inch or more, the child has the capacity to live to adult years, and will pass safely through any ordinary sickness. If the measurement is from three-fourths of an inch to an inch, it will live Avhen it Avould seem hardly possible. But if the life line fall beloAV the measurement of one- half inch, the power of living is feeble, and the child will succumb to the slightest ailments, and with one-fourth or even one-third of an inch, Ave may safely say that life is not possible. As a physician's success will, to a certain extent, depend upon his poAvers of prognosis, such knoAvledge as this Avill prove of much importance. It tells us when Ave may rely on treatment to effect recovery, and when the best treatment will fail of success. For the general pathology of. disease, and the principles upon which Ave base our practice, the reader is referred to my " Prin- ciples of Medicine." TEMPERATURE. PULSE. RESPIRATION. In an abnormal condition of the system, the first things to be considered are, the temperature, pulse and respiration. Pulse and respiration are more readily affected, and to a greater extent, than the temperature, but the latter affords a more correct diag- nosis of the patient's condition than the former. The pulse may deviate from a healthy standard, from some trivial cause as that of anger, slight indigestion, and sometimes sleep will produce a change, but under such circumstances the trouble will be of no 138 DISEASES OF CHILDREN. moment and soon subside. However, should a change of tem- perature occur and remain for a time, a general abnormal condi- tion will prevail. Too much importance, then, can not be attached to the study of the temperature, and a thorough knoAvledge in disease of the body thermoneter. TABLE Showing the Temperature, Pulse and Respiration at various Ages. PULSE. RESPIRATION. Temperature above normal age, at birth, 1.5 120 to 150 40 to 60 1st month, .5 120 40 1st year, .25 105 to 130 30 to 40 15th year, .21 75 to 85 20 21st year, .0 70 to 75 16 to 18 Deviations from this table have been found Avithout any con- stitutional disturbance, but they Avere feAV, and so far as tests have extended it is accurate. Temperature.—Exercise and diet, as Avell as climate, may affect and cause the temperature to vary, but it will be but a tem- porary change when thus disturbed. Should it, however, deA'iate, and remain so for some hours, Ave may expect an abnormal con- dition of the system. If, on the day following Ave note an in- crease in the temperature, running as high or higher than that of the day preceeding, the question of disease is beyond all doubt. In measles there is usually a high temperature three or four days preceding the eruption ; in scarlet fever it is less a day, perhaps; in variola two days; in Avhooping-cough, the first indication of the disease is, a change in temperature usually running quite high; in diphtheria it precedes the soreness of throat. Increase of temperature calls for sedatives and cooling remedies. Decrease of temperature demands stimulants and sustaining treatment. The following things are to be taken into special consideration : The hour at Avhich the temperature rises or falls. An increase of temperature, beginning a little earlier each day, is cause for alarm, beginning later is encouraging. A decrease, beginning earlier each day is a good indication, beginning later, it is to be closely Avatched; also the duration of temperature. Should a high temperature prevail and remain Avithout a decline for some time, it is to be regarded as very unfavorable. LikeAvisc a low temperature, remaining so for a time or continuing to decrease, is to be considered a most dangerous symptom, being of greater danger than a corresponding rise would be—the danger lying TEMPERATURE—PULSE. 139 in the great depression, and probable Avant of vital force neces- sary to accomplish a reaction. The daily fluctuations of tem- perature should be carefully noted, going frequently from one point to another, and not remaining stationary any given time. The food of the child has an influence on the temperature; after a good nourishing meal, there Avill be a rise in the index of the thermometer; if there is no rise, the food does not contain sufficient nourishing properties. This rise will not exceed .5, unless in a case nearing starvation, Avhen it may be increased. A too simulating food Avill produce a rise of one degree in the temperature; after digestion there will be a decrease of tempera- ture uutil the normal standard is reached. , Pulse.—As previously said the pulse is more easily disturbed than the temperature, and an increase may be occasioned by the most trivial cause. The position of the body influences the pulse, it being augmented Avhen the body is in a standing posi- tion, and decreased Avhen lying down. Joy, grief and anger will A'ary the pulsations of the body; food likeAvise affects it. Hence, an accelerated pulse must not ahvays be regarded with alarm; but Avhen such a condition supervenes with general constitutional disturbance, it demands investigation. In studying the pulse Ave Avant to note the frequency, regularity and fullness. Referring to the table Ave find that in a healthy adult there are from 70 to 75 pulsations per minute ; Ave note the fact on the living body, and finding it to correspond, Ave next observe the regularity, Avhether the pulsations are uniform in volume and time, or Avhether there is an irregular action of the heart, causing the pulse to intermit. Fullness of pulse is ascertained by the sensation imparted to the finger from the current of blood as it passes through the artery. If a large portion of the pulsation is felt, Ave get fullness, but if the finger discovers but a small portion of it Ave have the reverse; likeAvise Ave detect a hard pulse, soft pulse, and a wiry pulse, and measure them according to the standard of increase, decrease and perversion. With children it is more difficult to obtain accu- rately the number of pulsations to the minute, but the general character of the pulse is to be taken into consideration in order to determine the departure from a normal condition. If possible observe the pulse Avhile the child is sleeping. The pulsations will be more accurate than when the little sufferer is awake and irritable. 110 DISEASES OF CHILDREN. Respiration.—In disease Ave not only desire to know the number of respirations per minute, whether there is an increase or decrease, but Ave must as fully understand the character and source of respiration ; Avhether it occurs with regularity, or Avhether it is panting and short; Avhether it is abdominal or thoracic, and whether a full inspiration can be taken Avithout causing pain. Note, if any, the difference in the character of respiration Avhen the child is sleeping and Avhen awake; also the sounds, if any, produced by respiration. Observations made during sleep are generally more accurate than made Avhen the child is aAA'ake, as any exertion quickens the-respiration. CLASSIFICATION OF DISEASE. It is most convenient, and at the same time the most suc- cessful plan to study disease as it influences particular parts or functions. We thus get all the diseases of a part in a group, and are able to learn better the differential diagnosis between them, and also between them and others of different parts. There are certain diseases that are general in their character, and have their cause principally in the blood, or in functions intimately associated Avith it—as blood-making, nutrition, and retrograde metamorphosis. This will naturally form the first division. We may then study diseases of the digestive organs in a group, next, diseases of the respiratory organs, then diseases of the kidneys, of the skin, of the locomotive apparatus, of the nervous system, and of the organs of special sense. CHAPTER V. FEBRILE DISEASES. Fever is a disease involving to a greater or less extent every function of the body. Continuing for a time, it impairs the tissues, in some cases to such an extent that the further continu- ance of life is impossible. The functional derangement is studied by the rule of excess, defect and perversion, though in all cases the change is in reality an impairment, and is associated with depression of vitality. FEBRILE DISEASES. 141 In analyzing a simple fever, we find it composed of: 1st. An excess in the frequency of the pulse, an excess in the temperature of the body, and an excess of innervation. 2d. A defect of excre- tion by the skin, the kidneys, and the boAvels, and a defect of digestion, assimilation and nutrition. 3d. A perversion of the blood and of some functions. Pathology of Fever.—The doctrine of the humoralist that fever is a disease of the blood, offers the best explanation of the phenomena of fever, and leads to the most certain methods of treatment. We must not forget, however, that Avith such de- rangement of function, especially of Avaste and excretion, and its complement nutrition, the solids of the body are being diseased from day to day. In some fevers, the cause of the disease has been influencing the functions of nutrition and waste for a considerable time before the outbreak of the fever, and during this time all the tissues Avhich have been formed are more or less diseased. In such a fever, complete recovery does not take place until all such tissue is removed. Thus, in typhoid fever, Ave find the disease continuing until the sdft tissues have been removed to a A*ery considerable extent; and in those exceptional cases, Avhere the patient does not lose flesh during the progress of the disease, a perfect recovery does not take place; the reason is obvious—the imperfect tissues remain in their place, and to that extent the nutritive process fails. The old tissue is incapable of functional activity, and hence the imperfection Avith Avhich all the processes of life are performed. If Ave regard the cause of fever, as acting in and from the blood, as consisting of some morbid material, either generated within the body, or introduced from Avithout, but always acting to impair the quality of this fluid, and consequently depressing every functional activity, Ave have a plain and very simple pathology. We can readily see how such condition of the blood should occasion the disturbance of the circulation that Ave witness, and Iioav this abnormal circulation should be the cause of the diminished functional activity of every part of the body. Based upon this view of the pathology of fever, the treatment becomes also simple and straight-forward.- The rapid but im- perfect circulation of the blood is corrected by certain special medicines, called sedatives. The excretory organs can then be 142 DISEASES OF CHILDREN. stimulated by remedies that act directly upon them to increased activity, and any morbid material thus removed. We are then in a position to call the digestiAe organs into action, and obtain normal nutrition of tissue. Lastly, Ave have a class of remedies Avhich directly influence zymotic processes and products, and in some cases at least, are antidotal to the cause of disease. In other Avords, they are agents which, Avhen introduced into the blood, combine with and modify or destroy all those activities which are unnatural to and not under the control of the vital forces. As before remarked, Ave must not lose sight of the structural changes Avhich go on during the incubation and progress of the fever, and Avhich impair the integrity of the tissues. But the treatment for this is as distinct as for the other. This imperfect tissue must be removed, and the nutritive process must be stimu- lated to its repair. The remedies which increase excretion favor retrograde metamorphosis, and the tAVO go on together. A tonic and restorative treatment, Avith a good diet, completes the treat- ment, and the tAVO go on harmoniously together. As the old tissue is removed by the first, hcav material is prepared, and formed into tissue in its place by the second means. We have thus, as Dr. Chambers tersely expresses it, a real " reneAval of life." Classification of Fevers.—We may divide the fevers of childhood into four ATarieties. The evanescent, or febricula ; the periodic or malarial fevers, divided into tAvo varieties, intermit- tent and remittent; continued fever, and the eruptive fevers. FEBRICULA. Occupying a prominent place in the diseases of childhood, if Ave regard the percentage of cases, is this little fever. I call it little on account of its brief duration, and the little danger that attends it. In the apparent symptoms it may be, and frequently is, a very high or active fever, and gives rise to much uneasiness on the part of parents. Causes.—The causes of febricula are numerous, but Avhy they influence the system in this Avay is not well known. Probably, the most frequent cause is the action of cold arresting secretion from the skin. The similar arrest of secretion from the kidneys ' physiological marriage. 143 or bowels may produce the same effect. In other cases, an indis- cretion of diet, followed by imperfect digestion, introduces into the blood an imperfectly-formed material, Avhich must be removed. Pathology.—Taking the humoral vieAV of this disease, Ave regard it as being produced by a morbid material in the circula- tion. In the first case, from retained excretions; in the second, from mal-digestion. This view is borne out by the history of the disease—always terminating by the re-establishment of secre- tion, and by the treatment, Avhich is always successful Avhen it attains this end. We do not Avish to ignore the existence of the nervous system in this vieAV, for it is influenced by the cause of fever, and in some cases its morbid action is capable of generat- ing such a blood-poison, but usually this is but a minor element. Symptoms.—The symptoms of febricula are those common to all fevers. The patient has a chill of longer or shorter duration, but not usually of much severity. Preceding this chill, it will be observed, sometimes for a few hours, that the child is dull and languid, cross, or that it Avants to sleep more than usual. Following the chill, the pulse increases in frequency, and the temperature becomes higher, the secretions are checked, and there is more or less excitement of the nervous system. The febrile reaction conies up rapidly, and usually attains its greatest intensity in from two to four hours. It may continue to the termination of the disease as a continued feArer, or it may be broken up into exacerbations and remissions. The natural duration of the disease is from one to three days, the fever gradually declining for the last third of the time, and finally terminating by the establishment of free secretion. Occasionally, during its progress, the excitation of the nerATous system becomes very great, and the child suffers severely from this, and in some cases, may have convulsions. In other cases there is determination of blood to the brain. Diagnosis.—There is no difficulty in determining that the child has fever, for all the symptoms are very clearly defined. But it is not so easy, always, to determine the character of the disease. The points that I rely upon to effect this diagnosis are tiicse: though the skin is hot, it is never dry or harsh; the tongue is uniformly moist, and the mucous membranes of natural color; though the pulse is frequent, it is not otherwise much 144 diseases of children. changed, but gives a sensation to the finger of normal fullness, and freedom of circulation. As the reverse of this is shown in the more persistent fevers, the diagnosis is quite plain. Prognosis.—The prognosis is favorable whether the patient has treatment or not, and Ave can safely say that the disease will terminate favorably by the close of the third day. Treatment.—If secretion is arrested, Ave Avant to look to that, and usually but little additional treatment Avill be necessary. For the excited circulation and to favor diaphoresis, add Aconite gtt. v. Asclepias, gtt. x. to xv., to half a glass Avater, and give in teaspoonful doses every hour until a good action has been ob- tained. If there is irritation of nervous system, alternate Gelse- minum Avith the sedative, gtt. x. to xv. to Avater §iv., a teaspoonful every tAvo hours. If the child is vigorous, a Avarm bath may be given once a day, but if delicate the dry rubbing or the employment of some oily preparation is far better. INTERMITTENT FEVERS. It is only in those sections of county Avhere the malarial poi- son is intense, that young children have ague; and during the first six months, they rarely have it, even in these localities. After the child has passed the age of two years, the system seems more easily impressed, though not so easily as after the age of puberty. Cause.—The cause of intermittent fever is generally conceded to be a poison generated by the decomposition of vegetable mat- ter, and receives the name of " vegetable malaria." Pathology.—There is no doubt but that the cause of inter- mittent fever acts upon the blood, and from it upon other parts and functions. There is always a period of incubation in Avhich * the morbid material, AvhateA'er it may be, is increasing. Finally it produces depression of the vital powers, and a chill. Then the vitality of the system seems concentrated for its removal, and Ave have the febrile reaction, succeeded by the sweating stage, in Avhich secretion is re-established. The system thus freed from the poison enjoys a period of com- parative health (the intermission), but the germs of the poison TEMPERATURE, ETC. - 145 still remaining in the body, it is gradually reproduced, and there is another period of depression, reaction, and secretion. Thus it may continue for an indefinite time, the system never freeing itself entirely from the cause of the disease. Symptoms.—An intermittent fever in the child, presents the same symptoms, and in the same order as in the adult. There is a period of depression for a short time, in which the child is dull, its face pallid, the extremities cold, and the lips and finger nails bluish. The chill is thus introduced, and increases in intei - sity for a longer or shorter time. The child is seen to be cold, has more or less rigors, its pulse is small and increased in fre- quency, and the secretions locked up. Continuing thus for a short time (from fifteen minutes to tAvo or three hours), the symptoms of the chill gradually pass away, the surface becomes Avarm, loses its bluish appearance, the pulse increases in frequency, and the symptoms of nervous depression pass aAvay. But going beyond the point of healthy reaction, the surface becomes hot and more or less dry, the pulse increased in frequency from tAventy to forty beats per minute beyond the healthy standard, and is also changed as to freedom, and is more or less hard, and the nervous system is excited, with a gradual increase in the febrile symptoms. The fever attains its maxi- mum intensity in from tAvo to six hours, and there is then a like gradual decline to the sweating stage. This stage of an intermittent is announced by the diminished frequency of the pulse, and disappearance of nervous excitement. The temperature of the body is reduced, and the child breaks out into a free perspiration, and there is also increased secretion from the kidneys. There is then a complete intermission, the child presenting no evidences of disease for twenty-four, forty-eight, or seventy-two hours, as the fever is quotidian, tertian, or quartan in type, except in some rare cases in Avhich it assumes the form of a double quo- tidian, there being tAvo revolutions of the fever each day. This period being passed, there is again a recurrence of the phenomena of chill, febrile reaction, SAveating stage, and inter- mission, until finally the fever Avears itself or the patient out, or is arrested by medicine. With Nervous Complication.—In some cases the nervous svstem suffers severely. There is very great depression during 10 14fi diseases of children. the chill, with tendency to congestion. And during the febrile reaction there is dullness, Avith tendency to coma. In other cases there is very great excitation of the nervous system, Avith deter- mination to the nerve-centers. And this will sometimes con- tinue during the intermission. In some cases the ague is attended with convulsions. With Inflammatory Complication.— In other cases Ave notice a very high febrile reaction, the fever being prolonged beyond the usual time. The sweating stage is imperfect, and during the intermission the child still suffers, the skin is dry, the urine scanty, and the pulse somewhat hard. With Gastric Complication.— In still other cases, the stomach and associate organs seem to suffer severely. In some the stomach is very irritable, and there is nausea and vomiting during the chill and early part of the febrile reaction. And even in the remission, the irritability of the stomach remains, so that digestion is imperfectly performed, and medicine is not received kindly, and is absorbed sloAvly and Avith difficulty. In another class of cases the tongue is pale, broad, and coated with a Avhite, or, yellowish-Avhite, tenacious fur. The appetite is capricious, digestion imperfect, and nutrition of tissue is not well performed. Medicine is received with difficulty, and if ab- sorbed at all, slowly, and does not act kindly, or produce its usual influence. In still another class of cases the mucous membranes are darker, even dusky, and the coatings of the tongue are also dark-colored. Digestion is imperfect, and of course nutrition is to a considerable extent suspended. In the severer cases there is a tendency to septic decomposition. And in all, the usual antiperiodic treatment fails to arrest the disease. Treatment.—During the chill the child must be kept Avarm ; this may be aided by giving Avarm drink occasionally, and there is nothing better, especially if the child craves drink, than hot lemonade, sweetened just enough to make a pleasant drink, and let it be taken at pleasure. It Avill proATe a grateful and efficient remedy. As soon as reaction takes place, give the required seda- tive Avith any other remedy that may be indicated. Aconite, if the pulse is small and rapid and there are no complications. Veratrum, if the pulse is full and bounding and with gastric INTERMITTENT FEVER. 147 complication. Asclepias is the child's diaphoretic and an essential part of the treatment, Avhen the skin is harsh and dry ; Gelse- niinum is ahvays to be thought of Avhen the pupils are contracted and face flushed, with irritation of nervous system. If there is dullness with a tendency to sleep, indicating congestion, Bella- donna in small doses, gtt. iv. to viii. to Avater 5'iv., a teaspoonful every half hour or hour, according to the severity of the case, Avill prove a fine remedial agent. As soon as the pulse and tem- perature begin to decline and secretion is established, the anti- periodic is to be given. In uncomplicated cases carbazotate of ammonia is preferable to quinia ; it may be given even during the fever with perfect safety. The dose is small, from one-eighth to one-sixth of a grain, triturated with sugar of milk and giA'en eATery three hours. When complications exist, and particularly if there is considerable depression, quinia is preferable to any other antiperiodic. It may be given in from one to two grain doses, repeated every two hours during the intermission. After the chill is broken, and especially in malarial localities, it is best to continue the antiperiodic for three or four days, giving it less frequently, hoAvever, in one grain doses twice daily, repeating it en the seventh day. Quinia is the antiperiodic, though there are other remedies that act in the same manner, but less efficiently. I prefer to give a sufficient quantity in a single dose, rather than in broken doses. This for a child two years old, Avill be from tAvo to three grains. It is giA'en best in a cold infusion of green tea. If the chill is broken, it may be repeated for tAvo or three days in one-grain doses. For some days afterwards, it Avill be Avell to continue the Veratrum or Aconite, and in a malarial country repeat the antiperiodic every seventh day. In the nervous complication, with dullness, and congestion of the neiwe-centers, I use Belladonna, associated \v4th Aconite, as in this formula: B/ Aconite, Belladonna, aa. gtt. v. Avater 5iv«; a teaspoonful every hour during fever, and every three hours during the intermission. Rhus tox. will be found indispensable in some nervous compli- cations; giATe it in alternation or with the Aconite. Stimulant frictions to the skin, as with a combination of some of the essential oils with lard, is an aid to the treatment. This means is continued until the symptoms are no longer marked during the intermission, and then quinine isgiA'cn as before. 148 DISEASES OF CHILDREN. In the second form—with irritation of the nervous system and determination of blood—I prescribe: B/ Tincture of Gelseminum gtt. x. to xx. ; Aconite or Veratrum gtt. v.; Avater §iv. A tea- spoonful is given every hour Avhile there is fever, and every tAvo hours during the remission. If the symptoms have been very severe, the acetate of potash may be given for a day or tAvo be- fore the administration of the antiperiodic. In the case of inflammatory intermittent, the administration of the special sedatives, until a complete SAveating stage and inter- mission is produced, Avill frequently be all that is required. In the more persistent cases, gently opening the boAvels, and the use of a solution of acetate of potash, Avill be necessary. The im- portant point in all of these cases is, not to give the quinine until the system is thoroughly prepared for its reception. The gastric complication gives the greatest trouble, as there is not only imperfect digestion and nutrition, but medicines are not absorbed from the stomach. In the first case named, I should give the patient Nux in small doses every hour, and the usual doses of Aconite Avith Gelseminum. The child may have a hot foot-bath once or tAvice a day, or sometimes a general hot bath. Cold applications over the stomach Avill usually ansAver a better purpose than counter-irritants. In severe persistent cases the folloAving local application will relieve Avhen all other means fail: Take of cinnamon, cloves and alspice aa., sufficient quantity, cover with good whisky and Avater, equal parts, and make an infusion, strain and keep it hot, Avring flannel cloths out of this and apply to the epigastric region ; it Avill quickly relieve and refresh the little sufferers. When the tongue is broad, and coated Avith the pasty coat, I advise the administration of sulphite of soda in doses of tAvo to four grains, every two or three hours. When this condition is very marked, and the disease has continued for some time, a thorough emetic is the shortest road to a cure. In the meamvhile, the child should have Veratrum in small doses regularly, and if there is nervous irritability, Gelseminum. When there is the dusky discoloration of the mucous mem- branes, the patient Avants Baptisia and Aconite every hour, and the quinine should be given in the form of an elixir, prepared Avith muriatic or nitric acid and simple syrup. This will supply the required acid; and render the antiperiodic ready for immediate absorption. REMITTENT FEVER. 149 Where quinia can not be giATen by mouth, I frequently arrest the disease by its endermic use. Especially in the nervous and gastric forms of the disease, this method will be found beneficial. I order : B/ Quinia Sul. oj.,* Adeps, or Avarm olive oil, 5jj. Let the child be thoroughly rubbed with this, twice daily ; brisk friction while it is being employed is of great importance. I have not failed of success in any case, Avith this method, where the internal treatment had been pursued as I have recommended. MASKED INTERMITTENT. In the diseases of children, as with the adult, Ave meet with many cases, in which, if the periodic influence is not the cause of the disease, it continues it, and prevents success from the ordinary treatment. Many of these cases are very obscure, nnd it Avill require that the practitioner be impressed Avith the im- portance of closely looking for the malarial complication, that it be detected. Almost all of the inflammatory diseases may hi thus compli- cated, and Ave frequently find it at the bottom of persistent gas- tric and intestinal disturbance, and of lesions of innervation, and especially of nutrition. In the adult Ave find the majority of masked intermittents in the form of neuralgias. The treatment of these cases Avill be the same as for an ordi- nary intermittent, and quinia, one to two grains in the form of an elixir, may be given Avith an acid; or carbazotate of ammonia or Alstonia may be given, in the fijlloAving doses: grains two of the first eATery tAvo hours ; from one-sixth to one-fourth grain of the second every three hours, and one to three grains of the last four times a day. REMITTENT FEVER. » The fevers of childhood are almost always remittent in form. A continued fever, being of very rare occurrence. Thus Ave Avill have remittent fever from the ordinary malarial cause of this disease in the adult, and also from the various causes Avhich may give rise to fever. The disease is divided into two varieties, regular infantile remittent, and slow infantile remittent fever. The first possesses all the elements of a fever, and runs a regular and uniform 150 DISEASES OF CHILDREN. course; while the second is defective in many of its symptoms, and is irregular in its course and duration. We will consider the regular form of the disease first. • Causes.—As just remarked, the causes of infantile remittent fever are of tAvo kinds. In a certain proportion of cases, it is as distinctly malarial, as in the same form of the disease in the adult. I knoAV of no means of determining this cause, other than that it prevails in localities and at times when the adult remittent fever is noticed. The ordinary cause of continued and typhoid fever in the adult-—animal malaria—will produce a species of remittent fever in the child. The ordinary causes of simple fever, cold, arrest of secretion, imperfect digestion, defi- cient waste of tissue, Avhatever may be their origin, will give ris3 to this disease. Pathology.—The febrile poison, Avhatever may have been Its source, seems to act primarily upon the blood. During the incubation of the disease, which occupies a longer or a shorter period of time, the solids of the body become to some extent involved through impaired nutrition. Thus, when the febrile symptoms are fully announced, there is the double lesion, a morbid material in the circulation and impaired vitality of the blood, and imperfect material through all the tissues of the body, from the depraved nutrition. For the first days of the fever, the lesions seem principally of function, but as the disease is protracted, the solids of the body become more and more affected. This is in three Avays—by the impairment of the vitality of tissue, by the febrile-reaction—by imperfect waste, leaving Avorn-out and dead tissue in its place— and by imperfect and faulty nutrition, whereby feeble and im- perfect tissues are formed. Post-mortem examination shows a deterioration of the blood, and in some of the Avorst cases, the red-cdrpuscles of the blood are much broken down. There is usually some evidences of congestion and infiltration, especially of organs which have suffered from irritation during the progress of the disease. The tissues are but little softened in the majority of cases. The local lesions are principally inflammatory in their character, and owing to complications. Symptoms.—In the majority of cases there is a forming stage of from one to six days. During this, the child seems dull and REMITTENT FEVER. 151 listless at times, at other times is cross and fretful. Sleeps at unusual times during the day, but not soundly, and is restless and uneasy at night. The appetite fails, the boAvels are irregu- lar, and occasionally slight febrile exacerbations occur. The chill is not usually so marked as to attract notice. The child seems very quiet and dull, draws up to the fire, and wants to drink more than usual. Lasting but a short time, febrile reaction conies up quickly, and in a couple of hours presents its most marked symptoms. The skin is hot and somewhat dry, the pulse frequent and hard, the mouth dry, and the tongue coated white; the urine is scanty, the bowels constipated, and there is considerable nervous irritation. The fever varies considerably, as regards the remissions. In some cases there is but one remission, and that usually in the morning; in others there are two, and in others three, and in still others the fever is broken up into short febrile exacerbations of irregular duration, so that there may be a dozen or more in the course of tAventy-four hours. As the disease progresses, the symptoms increase in severity, the febrile reaction is higher and more prolonged, and the re- missions less marked. The important functions are also involved to a greater extent, and the patient more and more debilitated. Remittent fever is frequently complicated, and, as a general rule, the greatest danger to life is from this. The more common complications are, of the brain, the digestive organs, and of the respiratory apparatus. With Disease of the Brain.—There are tAvo principal lesions of the brain, noticed early in the disease. These are— irritation Avith determination of blood, and congestion. In the first case, the child is noticed to be more than usually restless and fretful, its eyes are bright, and it is continually wanting drink, and various things that it sees. In a short time it is noticed that the face and scalp are flushed, the head is hotter than usual, the eyes are bright, with contracted pupils, and the restlessness has increased. The disturbance thus commenced may go on to the development of inflammation, or after lasting for some time—three or four days—may terminate in congestion and coma; or in other cases, the excitement may eArentuate in the production of convulsions. In the second case, the child is dull, and has a tendeney to sleep much, but sleeps with its eyes partly opened. The eyes are 152 DISEASES of children. dull, pupils frequently dilated, and the face has a heavy, expres- sionless appearance. As the case progresses, coma comes on, and gradually deepens until it becomes impossible to arouse the child from it. With Derangement of the Digestive Organs.—The common lesions of this apparatus are—irritation of the stomach, and atony of the stomach with morbid accumulations. The irritable stomach is readily recognized in most cases. The child can not take food, drink, or medicine, Avithout nausea and retch- ing. The tongue is elongated and pointed, tip and edges more or less reddened, and the coating—usually Avhite—confined to its center. In the second case thej'e is also nausea and efforts at vomiting, food is not digested, and medicine produces sickness and is not absorbed. The tongue is unusually pale, broad, and covered with a pasty Avhite coat. In both of these oases, the disease runs its course more rapidly. Not only on account of the sympathetic derangements that Aoav from such gastric disturbance, but also because digestion is arrested, and all our means of cure are inefficient because not absorbed. With Disease of the Respiratory Apparatus.—In the Avinter and spring, infantile remittent fever is frequently compli- cated Avith disease of the respiratory organs. In the majority of cases, it is nothing more than an irritation, with a more or less troublesome cough. In others, a Avell developed bronchitis, and in others, a lobular pneumonia is set up. The symptoms are usually very plain. The child has cough, with increased frequency of respiration, and sometimes slight difficulty in breathing. At first there is dryness of the bronchial mucous membrane, aftenvard increased secretion. Where these symptoms are marked, a physical examination of the chest should be made, to determine the character of the trouble. Diagnosis.— The diagnosis of an infantile remitttent fever is easily made. From febricula, Ave determine it by the dry skin, hard pulse, and dry or broad and pale tongue. From continued fever, by the regular appearance of remissions. From inflam- matory diseases, by the absence of local symptoms; for even \tfien complicated, the local symptoms are distinctly secondary. • remittent fever. 153 Prognosis.—The prognosis is favorable. Unless the compli- cations are severe, there is little danger of a fatal termination in • . . . viable children. As heretofore noticed, a certain proportion of children are won-viable, and will die of any disease, or even Avithout any disease, before they have passed the age of child- hood. The mortality to be expected in the course of ordinary practice will be from two to five per cent., depending upon the fact just stated. Treatment.—The treatment of a remittent fever is usually very simple, and also very successful. The first object is to reduce the pulse to the normal standard, and get a free and equal circulation of blood. The second, to remove any irritation or other derangement of the nervous system. The third, to estab- ish secretion, and get a good condition of the digestive apparatus. The fourth, the employment of agents to antagonize the malarial or other cause of disease. The first indication is very surely accomplished by the use of the special sedatives, and the accessory means—a general bath once or tAvice daily, and the hot foot-bath. I usually prescribe : B/ Tincture of Aconite or Tincture of Veratrum Viride gtt. v. to gtt. x., Avater §iv.; a teaspoonful every hour. The action of these remedies should not be looked for at once ; they require time, but it is noticed that under their use there is a continuous amendment in all the symptoms. In the course of forty-eight hours, the febrile reaction has to a considerable extent subsided, the pulse is but little abovTe the normal standard, and the circu- lation is free and uniform; and Ave are ready to look after the second indication. As a general thing, Ave will not need to use any special reme- dies to relieve the nervous system, for any irritation or other disturbance will pass aAvay with the febrile reaction. The special cases that demand treatment will be named hereafter. The third indication is also frequently fulfilled by the action of the special sedatives, without other means. But Avhen secre- tion is not established as Ave should like, we put the little patient on tincture of Asclepias 5'. to water §iv., a teaspoonful every hour, Avhich, Avith a hot mustard foot-bath, will soon establish secretion from the skin. More frequently we will Avant to stimulate the action of the kidneys, as being the most important excretory oro-an. For this purpose I prefer a solution of acetate of potash. 154 diseases of children. % Secretion from the boAvels should be obtained by minute doses of Podophyllin, as named in the first part of this Avork, or other laxative. Or, if there is simply retention of feces, it may be overcome by the use of mild laxatives or enemata. Purgatives should not be used unless there is a special indication for their employment. The fourth indication of cure is accomplished in the strictly malarial cases, by the administration of quinine in doses of one to tAvo grains every two hours, given with an acid. I never give quinine to child or adult until I have so prepared the system for its reception that it will act kindly, and as a curative agent. With the action of the sedath'es, and secretion beginning to be established, it may be given with a considerable degree of cer- tainty. With the subsidence of the disease, and the establishment of convalescence, but little medicine will be required. I think it advisable to give the sedatiA'es in quite small doses, for two or three days after the fever has entirely passed away, as the child convalesces more rapidly under their influence. In some cases, a restorative aids recovery. Elixir of Guarana, gtt. x. four times daily, or Comp. Spirits of Lavender, ansAvers a very good purpose. Or in some cases, dilute muriatic acid 5'j. to simple syrup 5ij., half a teaspoonful in Avater as a drink, every three or four hours, Avill ansAver a good purpose. Determination of blood to the brain is arrested by the adminis- tration of Gelseminum, which, in this respect, is specific in its action. I usually ghre it in combination Avith the sedatives, pre- ferring, when the fever runs high, to dispense with the Aconite, and increase the quantity of the Veratrum. In the majority of cases, ten drops to the four-ounce mixture, is sufficient. But Avhen the determination is active, and likely to progress to in- flammation, I prescribe tAventy drops to four ounces of Avater. When there is danger of convulsions from the same cause, Gel- seminum may be relied on Avith great certainty to prevent it. The dull, congested condition, Avith tendency to coma, is an- tagonized by the administration of Belladonna, Avhich is also specific in its action. I generally prescribe it with Aconite, in the folloAving proportion : B/ Tincture of Aconite, Tincture of Belladonna, aa. gtt. at., AArater oiv.; a teaspoonful every hour. The hot stimulant foot-bath, and occasionally counter-irritation to the spine, will be beneficial. But the dry rubbing, in both REMITTENT fever. 155 mild and severe cases, will frequently be all that is desired. It arouses the inactive condition of the system, restores the capillary circulation, and with the internal use of Belladonna, the cure is complete. The rubbing or dry bathing must be done gently but thoroughly, fi\Te minutes being sufficient time to operate, repeat- ing it every hour and a half or tAvo hours, the hand movements being from the base of the brain doAvn to the sacrum, the arms, thorax and abdomen operated on in the same manner. I have removed the congestion in very severe cases with no other remedies than these. The Belladonna wants to be given in small doses. Children being very susceptible to its influence, from gtt. iv. to viii. added to half a glass of Avater, and given in teaspoonful doses every half hour Avill give excellent results. The irritation of the stomach is met by the use of cold or Avarm applications to the epigastrium, and heat and stimulants to the extremities as the external means. Internally, Nux or Ipecac may be given, and they will do the work best if given with as little fluid as possible. To accomplish this the preparation of Nux should be made stronger than usual, about gtt. v. to the ounce of water, and give gtt. xv. every half hour. Ipecac will operate charmingly in severe cases, if given in doses varying from one-tenth to one-sixth of a grain according to age of child. If there is nausea with flatulence, Colocynth alternated Avith the Ipecac Avill be the remedy ; or subnitrate of bismuth, in mint water. These are continued until the irritation is removed. At the same time, small doses of Aconite may be given for its seda- t'iAre effect, and also for its influence in controlling the irritation of the solar plexus of nerves, Avhich attends the gastric irritation. Much care will be required in these cases, to prevent a reneAval of the gastric irritation, as the disease progresses, especially to give our remedies in such Avay that they Avill hot be likely to produce it. In the second case, Avith atony and morbid accumulations, if the symptoms are marked, the shortest method Avill be to gh'e a prompt emetic. This is not a pleasant means with children ; but when the symptoms are grave, it is the most successful method. Tn malarial localities the emetic is usually a first consideration, as it is Avorse than useless to give the child other remedies until the stomach has been placed in a condition to receive them. The acetous emetic tincture or an infusion of gentian-root is preferable to use. In the same cases it Avill be absolutely essen- 156 diseases of children. tial to use : B/ Podophyllin gr. 1-20, Leptandrin gr. 1-15, sugar of milk sufficient to make one grain of the powder. Dose, one every three hours during the first day, and three, one at morning, noon and night, during the second day. In other cases, sulphite of soda in five grain doses, may be administered every tAvo or three hours, or if the tongue is red and dirty, sulphurous acid. As a general rule, disease of the respiratory organs Avill yield readily to the treatment for the fever. If an inflammation is developed, I advise the mush-jacket to the chest. And if there is much cough, some simple remedy to relieve this. B/ Cam- phorated Tincture of Opium, Syrup of Lobelia aa: 5ss., Simple Syrup Siii- M. Dose from x. to xx. gtt. three or four times a day. Or, B/ Chlorate of Potassa 5ss., Tinct. Aconite gtt. x., Tinct. Opium 5ss., Simple Syrup 5iv. M., and give a teaspoonful four times a day. SLOW INFANTILE REMITTENT FEVER. This disease is not only sIoav in its progress, but also obscure in its symptoms, so that many times it is very difficult to make a correct diagnosis. As before remarked, more or less of the symptoms of fever are Avanting, and others are quite irregular. Causes.—In a part of the cases that come under our notice, the cause is undoubtedly the malarial poison that produces other forms of periodic disease. This may be taken for granted, when it occurs in a malarial region, or if the child has been exposed to this cause, hoAvever temporarily. In other cases, the disease is produced by derangement of the digestive organs^ by imperfect nutrition and waste, by deficient excretion, and indeed by any of the many causes of diseased action. Pathology.—As with the other fevers, this must also be re- garded as primarily a disease of the blood, but as it advances, all the functions are impaired, and there is also a continued deterio- ration of tissue. An arrest of nutrition is a prominent feature, so that Avaste continuing, the child becomes very much reduced in flesh. There are no special evidences of diseased action, found upon post-mortem examination, unless there has been some local com- remittent fever. 157 plication, which generally manifests itself during life, by Avell pronounced symptoms. Symptoms.—For a week or tAvo the mother notices that the child is not so Ave 11 as usual. Its appetite is variable, its temper capricious, is fretful and irritable, is sometimes dull, Avants to sleep at unusual times, but does not sleep easily or Avell at regu- lar times, is restless and uneasy at night, tossing about in the bed, and wants to drink frequently. These symptoms slowly in- crease, and the parents finding it is not the temporary ailment from cold or teething that they supposed, call a physician. He hears the history of the case as above, and an examination confirms the symptoms. Ke also finds that the pulse is not natural, but has a sharper beat, is a little more frequent, and has an unusual hardness in some cases, is softer and more easily com- pressed in others. The tongue shows evidence of disease in its change of form and its coating. In a feAV cases it is contracted, and presents a dusky redness, and the coating, if any, has a shade of broAvn. In the larger number of cases it is more or less, pallid, frequently broader and seemingly larger than common; in both cases the coating is a dirty or yelloAvish Avhite. The boAvels are irregular, and the feces unnatural. In some, the feces are dark-colored, brownish, or greenish, in state of effer- vescence, and have a peculiar fetor. This is more frequent with the dusky-red tongue, and is generally said to indicate acidity of the prima vice; Avhether this is so or not, it is best remedied by the administration of an acid. In other cases the feces are light- colored, papescent, and have not the natural feculant odor. The skin is dry, and in bad cases gives a parchment-like sensa- tion to the hand. Frequently, the extremities are cold, and in some cases the temperature of the child is lower for a considera- ble portion of the day. The urine, if it be observed, will usually be found free, pale, and of Ioav specific gravity, although the Avaste of tissue is going on rapidly. In some cases it is highly colored, stains the clothes, and possesses in an eminent degree, the urinous odor. At some period of the day, slight febrile symptoms are devel- oped, and continue for one or two hours. But they are not very Avell marked, and frequently escape notice. As soon, however, as the attention is drawn to it, the periodicity of the disease Avill be noticed. 158 DISEASES OF CHILDREN. Continuing on thus for Aveeks, the child becomes much reduced in flesh, and it no longer has the strength to sit up, or make an effort at play. Finally, if not arrested, or it is not naturally removed, some local complication is set up, which runs an acute course, and causes a fatal termination. Diagnosis.—The diagnosis of slow infantile remittent fever is made by exclusion. The evidences of disease are very marked, but what the disease is, is obscure. The patient is examined with reference to local lesions. Is there disease of the brain or nervous system, of the digestive organs, of the respiratory sys- tem, or of the excretory organs? We determine there is not. It is then a disease of the blood, and a lesion of nutrition and Avaste, and the symptoms observed will readily determine its periodicity. Prognosis.—The prognosis is favorable if the disease is diag- nosed, and a proper treatment adopted. But in its advanced stages it Avill not bear a harsh or very active treatment, but, on the contrary, requires time and patience. The vitality of the patient is so exhausted, and the functions are so impaired, that they require gentle and judicious stimulation to obtain the de- sired action. Treatment.—I place the patient upon the use of Aconite alone, if the pulse is soft and feeble, giving it in the usual doses. If the pulse is hard, I associate Veratrum Avith it in the propor- tions already named. I regard the action of the sedatives as very important in these cases, improving the circulation, both as to frequency, freedom, and an equal distribution of blood. No disease Avill better illustrate the fact that these remedies called sedatives, are really stimulant and tonic to the heart and blood- vessels. The sedatives are continued for one, tAvo, or three days alone, or with but little other medicine, and aided by the general bath and hot foot bath. A salt-Avater bath answers a very good pur- pose to stimulate the surface. We find that the circulation be- comes better, the skin less dry, boAvels more regular, innervation better, indeed, that every function has improved slightly under their use. If there has been marked dullness and hebetude of the ner- vous system, the combination of Belladonna and Aconite should REMITTENT FEVER. 159 be employed. If there is irritation of the nervous system, Gel- seminum, or Rhus, as indicated, should be substituted. These means of meeting special indications, should not be neglected. With the influence upon the system named above, Ave may give remedies to call the excretory organs into action, if it seems necessary. The administration of small doses of Podophyllin, triturated as heretofore named, with one-fourth or one-half a grain of Sulphate of Hydrastia, three or four times a day, in- creases secretion from the intestinal canal, and improves the ap- petite. Acetate of potash, to the extent often grains daily, will give free excretion by Avay of the kidneys. Whether Ave use these means to increase secretion or not, Ave find a very important aid to the cure in quinine. I consider the patient prepared for its administration*Avhenever the pulse be- comes soft, the skin soft and moist, and the tongue moist and cleaning. Usually, I give from tAvo to three grains at one dose, and afterward repeat it, one grain each day, for three or four days, or may be a Aveek. When quinine by mouth is objected to, or there is any other reason for not giving it in this way, I use it by inunction. I am satisfied that in some cases this use is decidedly preferable to the other, being more certain, as Avell as pleasant. I have the child thoroughly rubbed once or tAvice a day Avith an ointment of one drachm of quinine to two ounces of lard. In some cases Ave find the tongue broad, pale, and covered Avith a pasty coat. If these symptoms are very marked, the mouth being nasty, and the breath fetid, I think the speediest method is the administration of a thorough emetic, and its repe- tition if necessary. In place of this I give the sulphite of soda in the usual doses, repeated every two hours. Rhus, Belladonna, Gelseminum, Apis, Arsenicum, and other remedies, will find a place in this disease according to indications. When the mucous membranes present the dark-red or dusky appearance, a very marked effect folloAVS the use of muriatic acid. Some very persistent cases, that ha\7e been intractable to the ordinary method, Avill yield readily to the same treatment with the acid addition. As a general rule, Avhen the disease is soon arrested in its course, convalescence is steady, and tolerably rapid. Where it is not, Ave may put the patient upon the restoratives named in the treatment of the preceding form of fever. 160 DISEASES OF CHILDREN. CONGESTIVE FEVER. There is a form of fever in childhood that may be properly called congestive, resembling in many of its symptoms the con- gestive remittent fever of the adult. It might have been passed by Avith the brief notice given in remittent fever, complicated with congestion of the brain; but it Avould leave the student of medicine at a loss, Avhen he was called to cases Avhich, though distinctly febrile, presented the predominant symptoms of con- gestion. Pathology.—The causes of this may be the same as produce any form of fever; the congestive character of the disease de- pending upon the condition of the patient, rather than the causes of the disease. In the majority of cases, hoAvever, there is some- thing in the cause which seems to paralyze the vegetative or sym- pathetic nerves, and Avhich occasions the congestion. In some seasons, and in some localities, Ave find a tendency to this form cf disease. Post-mortem examination evidences the local engorgements of blood, in discoloration, and transudation. In the severer cases, the blood is more broken doAvn, and the tissues more softened, than in ordinary fevers. Symptoms.—As a general rule the chill is protracted and better marked than in the fevers described. Indeed, in some cases it Avill last the greater part of the tAventy-four hours, not presenting so much a coldness as a dullness and hebetude. As the febrile reaction comes up, the child is not excited, but sleeps or dozes with its eyes partly open, and a full and expres- sionless appearance of the face. This continues until the fever commences to decline, when the child arouses up and seems more lively and better. This condition of the nervous system con- tinues throughout the disease, gradually increasing as the fever becomes more intense, becoming a profound coma in the severer, and especially in the fatal cases. The pulse is full and someAvhat labored, or in some cases the casual observer Avould notice but little change from its normal state, beyond its frequency. There is distinct evidence of an impaired capillary circulation, in the fullness of loosely connected tissues and the dusky redness or lividity. The circulation be- comes more free during the remission, and the symptoms of con- gestion pass away. CONGESTIVE FEVER. 161 I have noticed the lesion of the nervous system, Avhich is so constant as to be a part of almost every fever. But there are also local congestions, which become very marked. The respiratory apparatus suffers in this Avay in many cases. It is noticed that the child has a slight cough, attended with some difficulty in breathing, and occasionally removing a frothy mucus. In a few hours the breathing becomes labored, there is a marked rattling or blowing sound in the chest. The cough fails to raise anything, though it is evident there is increased secretion, and the evidences of imperfect aeration of the blood become Avell marked. Continuing on in this Avay, Ave find all the symptoms' increasing rapidly, and sometimes death will ensue in twenty- four to forty-eight hours. In other cases there is evident congestion of the abdominal viscera, and arrested function of stomach, liver, intestinal canal, etc. The symptoms are not so distinct as in the preceding ease; yet the prostration of the little patient, the fullness and evident' uneasiness in this region, are pretty good evidence. Add to this that the respiratory function is oppressed, and the breathing' principally thoracic, Avith an absence of the physical signs of disease of the lungs, and the diagnosis becomes quite plain. Congestion of the kidneys is announced by a rapid increase of coma, attended by a scanty or arrested secretion of urine. Diagnosis—There is usually but little difficulty in making the diagnosis of this disease. « The evident impairment of the circulation is manifested by the pulse, and by the appearance of the patient. The dullness and hebetude, and the development of coma, are very characteristic. The local lesions are very readily determined, as named above. Prognosis.—If not properly treated, the prognosis is not so favorable as in other forms of fever. It frequently runs its course to a fatal termination by the fourth or fifth day. But if attention is given to this feature of the disease at the commence- ment, with our special remedies, the mortality Avill be but little greater than in other forms of fever. Treatment.—There are two methods of overcoming this con- gestive condition, both of them good, though differing entirely in their character and mode of action. The first of these methods is by active emesis, the second by the specific action of Belladonna. 11 162 diseases of children. There are some cases in Avhich I should prefer the employment of an emetic. In a case Avhere the symptoms of congestion bad developed rapidly, and especially where there Avas marked coma, the action of the emetic would be the most speedy, and probably the most certain. The acetous emetic tincture is the best emetic in such cases, being very thorough in its action, and also giving the stimulant influence upon the circulation. I ad- minister it in doses of gtt. x. to xx. every ten minutes, with some stimulant or aromatic infusion, and continue to repeat it until very thorough emesis is induced, and a free circulation of blood follows. The nervous prostration and coma are usually overcome by this action, and in many cases, after such thorough emetic, the disease Avill run the usual course of a simple remittent fever. Should the symptoms of congestion return, the emetic may be repeated every day, or even tAvice daily. In these severe cases I like the action of the hot blanket pack, as an adjuvant to the other treatment. To a kettle of hot Avater add an ounce of mustard, Avring a blanket out of it, and Avrap the child up in it, placing it in bed, and covering Avarmly. In half an hour the Avet blanket may be replaced by a hot dry one, in which the child can remain until the means employed are successful. Another very efficient means of revulsion is—heat three, four, or five bricks on the fire until they are hot enough to vaporize Avater, yet not to burn the clothing; wrap them in cloths Avrung out of equal parts of vinegar and water, and place them at the feet, legs and body of the child, covering the Avhole loosely with a blanket, which should be well tucked in at the feet and around the child's shoulders, to prevent the escape of the Aapor. It is very efficient as described, but may be rendered more poAverful by the addition of tincture of Capsicum to the vinegar and Avater in which the cloths are Avet. The above may be called the indirect method of treatment, and, as will be seen, requires considerable skill, and much attention from the nurse. For, Avhen improperly used, it may do as much harm as it would do good if used rightly. The direct method is Avholly different, but to persons in the habit of active medication Avill hardly seem sufficient for the purpose. The remedy with which I propose to overcom'e the congestion, is Belladonna, in small doses. I generally administer it with Aconite. B/ Tinct. Aconite, Tinct. Belladonna, aa. gtt. v., Avater §iv.; a teaspoonful every hour. Had I not seen the congestive fever. 163 specific action of Belladonna in such cases so frequently, I would not be willing t.o give it this recommendation. But if my ex- perience is to be depended upon, the remedy is most reliable, and Avill give entire satisfaction. In this connection a very important part of the treatment will be stimulants and restoratives, and I shall refer to Elixir of Guarana, Comp. Spirits of Lavender and beef essence. They have filled the requirements so often that I consider them indis- pensable in these prostrating diseases. Usually, in these cases, I continue the same remedies through- out the treatment, as there is still some tendency to congestion or feebleness of the capillary circulation, especially of the brain. In congestion of the respiratory apparatus, in addition to the means named, or Avhen it is a special lesion, other parts not suf- fering so much, I depend principally upon small doses of Lobelia internally. For a cliild three to six months of age Ave may prescribe: li) Tinct. of Lobelia (seed) 5j-, Compound Tinct. of Lavender 5ij-, Simple Syrup 5ij. Dose, half teaspoonful every fifteen minutes or half hour. For the local application I direct a cloth, sufficiently large to cover the anterior surface of the thorax, spread with lard and dusted Avith Comp. Powder of Lobelia and Capsicum. This is changed once or twice daily until the complication is removed. In congestion of the abdominal viscera I order hot stimulant fomentations to the bowels, occasionally preceded by dry cupping if the child is of some age, and an enema of an infusion of Bay- berry, to which is added one drachm of tincture of Lobelia. The enema as named, is of especial importance in those severe cases in Avhich the danger is imminent and speedy relief essential. In congestion of the kidneys I apply hot fomentations across the loins, sometimes preceded by dry cups, and move the bowels freely by the use of an enema of Comp. PoAvder of Jalap and Senna. In those cases in Avhich there is a constant tendency to congestion of these organs, but in which the urine is not sup- pressed to any considerable extent, Santonine, gr. one-sixth to one-fourth every three hours, Avill prove effectual. In all other respects the fever should be treated in the same manner as named for infantile remittent. In those cases in Avhich the abdominal organs are principally affected, the sulphate of quinia combined Avith Avartu oliAre oil, and the abdominal organs thoroughly bathed with it and rubbed gently three or four times 164 diseases of children. daily, will give prompt relief. Too much importance can not be attached to this kneading and friction process, it supplies a long needed Avant in medical treatment, particularly in congestion and some other diseases, as marked beneficial results, after re- peated trials in practice, have proven. In those cases Avhere an acid is required, I Avould always combine the quinia with it, adding aromatic elixir to form a pleasant preparation. The sul- phite of soda Avill also prove a very important remedy in some of these cases—the tongue presenting that peculiar broad, pale, pasty condition, heretofore named as indicating it. CONTINUED FEVER. As heretore noticed, continued fever is not of frequent occur- rence in early life; and, up to the fifth year, the common fevers of children are those already described. Indeed, with but ex- ceptional cases, Ave will not meet Avith continued fever, except in those years in Avhich it is the prevailing disease of the adult, being endemic or epidemic. At such times the cause of con- tinued fever is very intense, and influences the child as Avell as the adult, A continued fever is never sthenic in childhood. In the majority of cases it Avill present the symptoms of synochoid, or common continued fever, and only Avhen the cause of typhoid fever is intense, do Ave have this form of the disease Avith the intestinal complication. Typhoid symptoms, i. c., the evidences of de- pression and sepsis of the blood, is, hoAvever, of tolerably fre- quent occurrence. Causes.—We accept the usual theory, that this class of fevers is caused by an animal poison, or malaria. What it is exactiy Ave do not know, but that animal matter in certain states of de- composition will produce fever of this kind, is very clearly proven. The fever poison may be generated by decaying animal matter, or by a person suffering from such disease, and being introduced into the circulation through the lungs, or the ordinary methods of absorption, sets up a process of change Avhich gives us the phenomena of fever. Pathology.—As just stated, the- cause of continued fever is an organized body undergoing decomposition. It may be per- ceptible to the senses, or it may be in gaseous form, but it pos- CONTINUED fever. 165 sesses the property of setting up a like change in any material that possesses its elements with Avhich it may come in contact. The theory of Liebig is, that the fever poison resembles yeast in this respect, and that it not only sets up a process of decom- position in the blood, but develops a material similar to itself out of its elements. The evidence of this action is so marked and so Avell known that it is not now a matter of controversy. The fever poison possesses varying degrees of intensity, just as yeast is Aveak and active. Like this, also, it possesses the poAver of setting up these changes in minute as Ave 11 as in large quantity. When the fever poison is active Ave find it producing fever of a grave character, which either runs its course rapidly to a fatal termination, or is prolonged and attended with great prostration. On the contrary, when the fever poison is mild, the fever, though it may be protracted, is not of a grave character. These fevers are characterized by the length of their forming stage, or period of incubation. During this time the fever poi- son is insidiously undermining the poAvers of life. Digestion is influenced by it, as is assimilation and the formation of blood. EvTery molecule that is formed into tissue during this period, re- ceives the impress of the poison in an imperfect development; and it is not until the patient is divested of all these imperfect tissues that real convalescence commences. Post-mortem examination reveals the same lesions that are found in the adult. There is marked change in the blood, both of the albumen, fibrin, and red globules. It does not coagulate firmly, does not change readily Avhen brought in contact Avith oxygen, and the microscope shows the red globules more or less broken doAvn. There is no special lesion of structure, except in those cases in which the glands of Peyer are involved, and these haAre presented the characteristic symptoms of typhoid fever during life. Symptoms.—One of the most marked features of a continued fever, is the long duration of the forming stage, which frequently embraces from one to three Aveeks. During this time the child Avill be dull, uneasy and fretful at times, Avill sleep more during the dav, and Avill be restless and Avakeful at night. Its appetite will be impaired, the boAA'els irregular, and the skin dryer than usual. The tissues become soft and flaccid, and it loses strength in a marked degree. 166 diseases of children. The chill is usually protracted. In many cases an entire day, sometimes, indeed, two days will be occupied Avith alternate slight chills and febrile exacerbations. SloAvly the fever becomes estab- lished, and, to the ordinary observer, it does not seem so severe as in the simple febricula, or infantile remittent, but the experi- enced practitioner sees in the prostration of the nervous system, the feeble circulation of the blood, the parchment-like skin, and the marked debility, evidences of a grave lesion. Day by day, as the fever advances, the strength becomes more impaired; the pulse is more frequent, is smaller and harder, or more frequently soft and easily compressed ; the skin is dry and harsh, and manifestly inactive; the urine is tolerably free, but is pale, frothy, and has an unpleasant odor ; the stools are also fre- quently papescent, and have an unpleasant odor; the nervous system is markedly implicated. In some cases the patient is very restless and irritable, the eyes bright and the pupils dilated ; but in the majority the patient is dull, the face is expressionless, the eyes dull, and the child dozes Avith its eyes half open. Passing on toAvard the eighth or the tenth day, we notice that the child's mind Avanders, though there is never the manifest delirium that Ave Avitness in the adult. In other cases the dull- ness has passed into coma, Avhich gradually deepens until it ter- minates the life of the patient. The tongue sIioavs distinctly the character of the disease. In a majority of cases it is contracted, its movement is impaired, and the coating upon it has a tinge of broAvn. In this case the tongue and mucous membrane of the mouth are of a dull-red or dusky hue, which once observed will ahvays convey to the mind the evidence of depravation of the blood. In a much smaller number of cases, the tongue is broad and pale, and covered with a pasty white coat. In the first case, as the disease advances, the tongue becomes dryer, less mobile, fissured, and the coating of a deeper broAvn, until finally, in the severer cases, it is dry, black, and fissured, can not be protruded or hardly moved in the mouth, and bleeds Avhen it conies in contact with anything, or even when movement is attempted. I am of the opinion that this condition is due rather to the harsh medication so frequently adopted, than to the disease. When the symptoms above are most marked, the passages of the nose and the throat are' also involved, and in consequence CONTINUED FEVER. 167 there is a dry whistling respiration, sometimes with much diffi- culty. The lips also are dry, fissured, bleed, and form dark un- pleasant-looking crusts. The symptoms of typhoid fever have the addition of the intes- tinal lesion. Early in the disease the bowels become lax, Avhich by the fourth or fifth day is a marked dirrrhoea; there is also the evidence of pain in the boAvels, and tenderness on pressure. A peculiar pinched appearance of the face is frequently seen, and may almost be regarded as pathognomonic of this condition. As the disease advances the intestinal complication is the most marked feature. The diarrhoea is very intractable, Avith evident pain and uneasiness before the evacuations. The dis- charges present an unpleasant appearance and an unusual fetor. Occasionally there is tympanitis. The natural duration of the disease is from three to four Aveeks, though in some cases it may terminate fatally by the end of the first Aveek, and by appropriate treatment it may be aborted in the early part of its course. During this period it may be com- plicated with local diseases, as named under the head of infantile remittent, but as they present very nearly the same symptoms, and possess the same pathological character, they need not be further described. ^ Diagnosis.—We determine the character of this fever, first, by the long duration of its forming stage, and the nervous pros- tration at the period of chill and commencement of febrile reac- tion. As it progresses, the continued febrile reaction, Avithout remission, gives it a distinctive character. The typhoid form of continued fever is diagnose! by the ap- pearance of diarrhoea early in the disease, with tenderness on pressure about the umbilicus, and evident intestinal uneasiness, if not pain. In these cases, also, the fever is of an asthenic type, and there is especial prostration of the nervous system. Prognosis.—The prognosis is not unfavorable if the disease is properly treated; but under the old antiphlogistic treatment the mortality Avas sometimes large. Indeed, if patients are care- fully nursed, and have proper food, the disease being allo\Ared to run its regular course, the mortality Avill not be more than ten per cent. Treatment.—The object of treatment in this disease is tAVO- fold—to shorten its duration, and relieve unplea'sant symptoms. IQS DISEASES of children. In some feAV cases we may save life, but they must be few, as the mortality is but small, and some of the deaths are unavoidable, as the disease involves all the tissues of the body, Avhich must be remoA'ed before convalescence is completely established. With pimple functional lesion Ave might expect to arrest the disease at once; but avc are doing well to accomplish it by the seventh to the ninth, or sometimes the twenty-first day. I As heretofore named, the first indication of cure is to correct the functional disturbance, for this must precede the removal of structural lesions. The derangement of the circulation of blood js manifestly first in order, and if avc can correct it, other indica- tions of treatment will be readily accomplished. I prescribe in this case, as in other fevers, the special sedatives, as: Py Tinct. Aconite, or Tinct. Veratrum, gtt. v., water 5iv., ji teaspoonful every hour. This is continued to the complete establishment of convalescence, Avhatever additional means may be etiploycd. If there is irritation of the nervous system, with flushed face, restlessness, sleeplessness, and other evidences of determination of blood, Ave give Gelseminum in combination with the sedatives ; but if on the contrary there is dullness and hebetude, the patient being drowsy, sleeping Avith the eyes part open, and as the dis- ease progresses tending to coma, Ave use Belladonna instead, as: B/: Tinct. of1 Belladonna, Tinct. of Aconite, aa. gtt. v., water 5'ia\, a teaspoonful every hour. The patient has a sponge bath once or tAvice daily, always used carefully so that the surface Avill not be chilled. Sometimes Ave find it better not to employ the bath after the first two or three days, on account of the prostration that folloAvs. The hot foot- bath is both an aid to the action of the sedatives, and valuable to relieve irritation of the nervous system and produce sleep. When there is great Avakefulness Ave render it more stimulant by the addition of mustard or capsicum. * There are some chses, though in most seasons but feAV, in Avhich decided benefit will follow the use of an emetic in the early stage of the disease; indeed, occasionally it offers the only safe course. The cases are thyse in Avhich the tongue is broad, covered with a heavy yellowish Avhite fur, especially at its base. The breath is frequently fetid ; there is nausea and retching, ajjd medicines are rejected by vomiting, or, if retained, are not absorbed. In such cases deterioration of the blood goes on remittent fever. 169 rapidly, and typhoid symptoms are developed early. A thorough emetic of acetous emetic tincture, or Ipecacuanha, removes ac- cumulations from the stomach, stimulates it to better action, and prepares the way for the successful administration of other remedies, and the digestion of food. There is yet another condition in which an emetic can be em- ployed with marked advantage. I allude to those cases in Avhich there is marked nervous prostration, with dull eyes, expression- less countenance, tendency to sleep, Avhich Avill soon pass into coma. In these cases the action of the emetic arouses the nerv- ous system, and at the same time gives a better and more equal circulation of blood. When the tongue is pallid, usually with a whitish pasty coat, I like the action of the alkaline sulphites. The sulphite, or hyposulphite of soda is in most common use, and may be given in doses of five grains every three hours to a child tAvo years old. It may be commenced at the beginning of the treatment/.aiid used Avith the special sedatives. It is discontinued when the condition for Avhich it has been given is removed. Frequently a day will make such a difference in the patient, especially after the remedy has been given for three or four Jdays, that we will find it necessary to put the patient upon the use of an acid. When the mucous membranes are dark-red, or dusky, the tongue being in a majority of cases dry and contracted (occasioir- allly it is moist), I give the muriatic acid from the commencement of the treatment, using the formula heretofore given: B/ Dilute Muriatic Acid, 5ij-, Simple Syrup, 5ij. Add it to Avater so as to make it pleasantly acid, and give as a drink. The child can hardly take too much; usually about one teaspoonful of the mixture every tAvo hours Avill be the proper quantity. There are some cases in Avhich irritation of the stomach, will be an unpleasant feature in the early part of the disease. Not only so, but it will aggravate all the symptoms, prevent the action of remedies, and cause the disease to run a more rapid course, and increase its fatality. This irritation should be arrested early. So important is this, that it will take precedence of all other treatment, I generally prescribe a cold application—cloths Avrung out of cold Avater, or its opposite—hot fomentations applied over the Avhole abdomen. An infusion of the bark of the young limbs of the peach-tree, in small doses, is very efficient in quieting this irritation. In other 170 diseases of children. cases, the subnitrate of bismuth, in mint Avater, may be employed. An infusion of the compound powder of rhubarb, given in small doses, has ansAvered a good purpose, sometimes continuing the remedy until it produces a slight laxative effect. In this case, Aconite alone of the sedatives may be used, with the addition of Gelseminum, if there is irritation of the nerve- centers, or Ipecac if there is intestinal irritation. The dose is five drops of the Aconite to four ounces of Avater. Cathartics are not employed in this fever, unless there are special indications for their use. This would be, evident accu- mulations in the intestinal canal, and irritation from this cause. The usual evidence from the tongue, is its uniform yellowish coat, extending from base to tip. With the means already named, judiciously selected to meet the indications of the case, we find the patient progressing favor- ably. The disease yields, day by day—the pulse becomes less frequent, but is greater in volume and in freedom of circulation— the irritation or depression of the nervous system passes aAvay, and the secretions are gradually established. In a majority of cases, no other medicines will be required, as Avith proper nursing and food all symptoms of febrile disturbance Avill have passed aAvay by the seventh to the fourteenth day. In a feAV cases Ave will find it necessary to stimulate secretion from the skin and kidneys, after the sedative has produced its effect. The Comp. Powder of Ipecac and Nitrate of Potash, Avill be found a good remedy for this purpose, and Avill also act very kindly on the nervous system, and promote rest and natural sleep. Occasionally Ave are called to take charge of cases of fever which have run the (irst part of their course, and have some- times been aggravated by the medicines employed. All forms of fever will, if severe, or badly managed, present much the same lesions and symptoms; these being of an asthenic or typhoid type. In diagnosis, as Avell as in our therapeutics, Ave group them in four classes—with reference to the circulation—with reference to digestion and the formation of blood—with reference to the nervous system—and Avith reference to waste and excretion. The action of the heart is rapid, but imperfect, and though the blood apparently moves faster, there is deficient circulation in the capillaries. Here small doses of the special sedati\'es exert a most marked influence. As the pulse becomes less fre- CONTINUED FEVER. 171 quent under their influence, the action of the heart is stronger and more regular, and the blood circulates more freely, and is more equally distributed. In the majority of these cases Ave prefer the use of Aconite, but are governed even in this ad- vanced stage by the rules already laid doAvn. It is of very great importance to the success of treatment at this advanced stage, that the stomach be placed in condition to receive and digest small portions of food, for the real danger is, many times, from starvation—a failure of vital power, from a want of nutrient material to sustain it. One of tAvo conditions will usually present—the tongue Avill be contracted, dry, fissured, and coated brown or black; the lips, also, Avill be dry, and occasionally covered with an unpleasant crust. The mucous membrane of the mouth, tongue, nose, etc., is dark-red or dusky. In this case, Ave administer dilute muri- atic acid, as heretofore named, giving it as a drink, and as freely as the child chooses to take it. In the other case, the tongue is broad, pallid, and moist, and covered with a pasty fur. Here we give sulphite of .soda, in the usual doses. For the use of the anti-zymotics the reader is referred to page 95. To improve innervation, and get its general influence upon the system, I like the action of quinine used by inunction. In- ternally, it is not kindly borne at this stage of the disease. We find also, that this fatty inunction improves the condition of the skin, and also increases the general vital poAver of the child. The food of the child will be boiled milk, Avith sufficient salt to make it pleasant. It is more kindly received and better di- gested, if taken quite Avarm, the heat acting as a stimulant to the stomach. Children take food, because they have an appetite or desire for it, and, not as the adult sick may, because their reason sIioavs the necessity of it. In disease, Avhen there is no appetite, but on the contrary, disgust for food, they can not sometimes be persuaded to take it in the usual manner of taking food. In such cases, instead of letting them suffer from the AArant of it, I have the milk given as a drink, e\Ten sometimes mixed with one or tAvo parts of Avater. The necessity of this attention to giving food should be forcibly impressed upon the mother. If the child will not take milk, Ave may have preparations of arrow-root, sago, tapioca, maizena, etc., or occasionally a beef essence will answer a good purpose. A good way to make a beef tea for a child, or even an adult, is as folloAvs: Cut a lean and 172 DISEASES OF CHILDREN. tender piece of beef in small pieces, rejecting all the fat; put in a tin or porcelain-lined vessel and cover with cold Avater; set on the stove and bring it sloAvly to the boiling point, letting it boil for half an hour. We thus get the elements of the beef in a fluid form, and with the necessary salt it will be quite palatable. The attention to the skin, by the quinine inunction, or an occasional stimulant bath, with brisk friction, will be all that Ave can do to get secretion from this organ. As a general rule, it Avill not be good policy to stimulate the kidneys by special means, at this adA'anced stage of the disease. Occasionally, Avhen con- valescence is being established, Ave may administer a saline diuretic in small quantity, to facilitate the removal of Avaste. The tincture of muriate of iron, recommended to aid convalescence, strengthens and increases the action of the kidneys. As a gen- eral rule, the boAvels had better not be interfered with. But where there is irritation from accumulations in the intestinal canal, a gentle purgative of compound poAvder of rhubarb will ansAver a good purpose. In those cases in which the tongue is broad and pale, minute doses of Podophylliii, triturated as here- tofore described, may be used with advantage. Occasionally Ave associate one-fourth to one-half grain of hydrastis Avith it. In some few cases, there is tardy passage of urine, or complete retention, and if this is not seen to, it Avill lead to a fatal termi- nation. The use of diuretics, as generally advised, is bad prac- tice. Instead, I prescribe santonine, triturated with sugar, in doses of one-sixth to one-fourth gr. every hour, until the patient is relieved. Its action in this respect is specific. In some other cases, the urine is suppressed, producing at first irritation of the nervous system, then coma, Avhich gradually deepens until the child dies. In other cases, convulsions ensue, and the patient dies of them. In this case, also, I do not depend upon diuretics. Instead, I have hot fomentations applied assidu- ously across the lions. Usually the fomentation is of vinegar and water"; but if there is evident congestion, it may be rendered stimulant. SPOTTED FEVER. Though not a disease of childhood exclusively, yet it has pre- vailed among children more than adults, and deserves considera- tion here. Indeed, if Ave Avere to reject all the diseases which attack the adult as Avell, Ave would have but a small list remaining. SPOTTED FEVER. 173 Spotted fever has prevailed in this country to a very considera- ble extent since 1862. In some localities it seemed endemic, Avhile in others it Avas decidedly epidemic. Whether or not it is contagious has been in dispute; some contending that it is, others that it is not. My own opinion is that spotted fever is, in ordinary cases, contagious, like typhoid fever; that when very malignant, with marked symptoms of putrescency, a fever poison is evoh'ed which will affect persons Avho come in contact Avith it. There is, again, an epidemic form in which the conta- gion is as marked as in typhus fever. Many have supposed that spotted fever was a neAV disease, bearing no relation to diseases knoAvn and described by authori- ties, and have been at a loss Iioav to treat it. The fact is the disease has appeared several times previously, and bears a \'ery close relationship to typhus fever, with the addition of a sub- acute cerebro-spinal meningitis. This fever first made its appearance in this country in the toAvn of Med way, Massachusetts, in the year 1806, and preArailed to a considerable extent in New England from that time up to 1815. At this time it presented the same symptoms, Avas as malignant, and attended by the same mortality. The same disease is noticed by historians as having prevailed over the greater part of Europe in 1505, 1528, 1556, and at vari- ous times up to 1805; and Ave can trace it under the names of hospital, jail, putrid, or spotted fever, in almost all parts of the world during the last century, folloAving in the train of the great European armies, among which it made the most destruc- tive ravrages, and by avIioiu it Avas spread over the greater part of Europe. Cause.—The cause of spotted fever is undoubtedly an animal poison of very great activity, resembling in many respects the fever poison or malaria of typhus. We do not knoAV definitely Iioav it Avas produced in this country ; yet in all previous epidem- ics it has been traced to crowding, bad ventilation, and especially to the decomposition of human excreta. Pathology.—In its pathology this fever does not differ very materially, save in its malignancy and rapidity, from that last considered. The fever poison, Avhatever it may be, Avhen once introduced into the blood, reproduces itself more or less rapidly, and finally causes the death of this fluid. In some cases the 174 DISEASES OF CHILDREN. virulence is such, that Avithin forty-eight or even tAventy-four hours, the blood is completely broken doAvn, dies even before the vital functions have ceased. Post mortem examination reA'eals a breaking doAvn of the blood in greater degree than in typhoid fever. There is also extravasation of blood, and especially of its coloring material, so that parts Avhich were congested during life are much discolored, as are the most dependent parts of the body after death. Parts that have suffered from local congestion are also softened, some- times so much so that they may be readily separated and broken with the handle of the scalpel. The spleen is engorged Avith dark grumous and broken doAvn blood, and is frequently enlarged. The liver is also dark-colored, SAVollen, and friable. The lungs seem to have suffered in like manner, are filled Avith blood, ami the bronchial tubes contain a dark-colored offensive mucus. The surface of the body presents in some cases a remarkably spotted or ecchymosed condition. The discolorations are purplish or almost black, and most numerous on the most dependent parts of the body. A close examination reveals that they are true ecchymoses or vibices. Symptoms.—The symptoms vary in different cases and in different localities, but may be divided into two prominent classes, as folioavs : First. For two or three days the patient is listless, dull, and stupid, the face is flushed and dusky, eyes tumid, some pain in the head and back, loss of appetite, tongue dusky-red and coated Avith a dirty-white mucus, skin dry. This is the forming stage of the disease, and instead of lasting as long as named, will, in the severer cases, not be longer than twenty-four hours. Following this there is a tolerably well-marked chill, lasting for two or three hours, and attended Avith great prostration. Febrile reaction follows, sometimes high, at others not very Avell marked. In the one case the surface becomes intensely hot and flushed, the pulse 120 to 140 in the adult, and so that it can scarcely be counted in the child, sharp and hard, with great irri- tability and restlessness, though there is marked dullness of the intellectual functions. The thermometer marks a temperature in these cases of from 104 to 109 degrees. The urine is scanty and the boAvels constipated. Frequently there is difficult respi- ration, some cough, and sibilant rales. SPOTTED FEVER. 175 In from tAvo to six days an eruption appears upon the surface, very closely resembling measles, but more clearly defined. If the patient recovers they commence fading out by the end of the hVst twenty-four hours, but do not disappear entirely for some days. If the disease progresses unfavorably, they become dusky, and at last livid and associated Avith vibices. As their color be- comes darker the nervous system of the patient becomes more oppressed, his mind Avanders; and, becoming livid, he sinks into a stupor from which he can not be aroused, and Avhich in a short time terminates in death. In the second case there is but little reaction, the pulse running up to 90 or 100 in the adult, 110 to 120 in the child, and op- pressed. There is tendency to coldness of the extremities, the skin being harsh and dry. or sometimes moist and atonic. The eruption appears the first, second, or third day, and is a dusky-red, not readily effaced Ivy pressure. There is marked dullness and hebetude from the commencement, and frequently the patient is almost entirely unconscious a feAV hours after the appearance of the eruption. It runs a very rapid course in most instances, terminating fatally by the third to the sixth day. The eruption becomes dusky and livid, petechia ap- pear, the tongue is dry and broAvn, sordes on the teeth, urine and faeces very offensive, coma or Ioav muttering delirium, and gradu- ally increasing difficulty of respiration. Diagnosis.—The diagnosis is not always easily made at the commencement of the disease; yet this is not so important, be- cause the symptoms sIioav it to be a grave form of disease, of a congestive and malignant type. The extreme febrile reaction in the one case, associated as it is Avith dullness and hebetude of the intellectual functions, the dusky discoloration of the tongue and mucous membrane of the mouth, are characteristic symptoms. In the other case, the great prostration, feeble reaction, dull- ness and tendency to coma, the appearance of the dusky erup- tion, etc., sIioav the nature of the disease. Prognosis.—The disease varies in malignancy and mortality in different sections of country and at different times. So that Avhile uiuler one class of circumstances Ave s'lould regard the prognosis as favorable in a large majority of cases, in another it would be unfavorable. Much Avill depend upon the time when the patient is seen. If quite early in the progress of the disease, very severe cases may 176 DISEASES OF CHILDREN. be conducted to a favorable termination. While, if the disease is alloAved to progress unchecked for a day or tAvo, or is aggra- vated by injudicious medication, the more mild cases will be rendered unmanageable. Treatmknt.—There are three plans of treatment that I think may be relied upon, and I Avill state them plainly, endeavoring to point out the special cases Avhere a preference should be given to one over another. Taking the majority of cases I think I should value them in about the order in Avhich they are stated, relying upon the first plan especially in very bad cases. Make an infusion of Capsicum one part, Bayberry six parts, having it as strong as the patient can take it Avith comfort Then give the acetous emetic tincture in doses of from one-fourth to one-half teaspoonful eATery ten or fifteen minutes, with as much of the infusion as the child will drink. We do not wish to pro- duce immediate vomiting, but desire to get the general influence of Lobelia upon the system, so that if it is not well tolerated by the stomach, Ave lessen the dose, and apply a stimulant fomenta- tion over the epigastrium, to aid its retention. Continuing it in this way for one hour or more, Ave notice that the depression of the fever is being replaced by the influence of the Lobelia, and Avhen this becomes marked, Ave carry it to free and thorough emesis. In the meanwhile, the child being placed in bed between blankets, hot bricks Avrapped in flannel wrung out of an infusion of Capsicum with vinegar and water, are placed at the feet, by each thigh, and by each side of" the trunk, at such distance as to be in no danger of burning the child. Have the blanket loose over the body, but Avell-tucked doAvn at the feet and around the neck, to prevent the escape of the vapor. After a' free and vigorous circulation is established, the body may be rubbed dry with a flannel, and Avrapped in a dry blanket. In the second method of treatment Ave desire to obtain the stimulant influence of Lobelia or Ipecacuanha upon the circula- tion. I Avouhl order them in this form: B/ Lobelia Seed (powdered), gr. xx.; Capsicum 5j- Mix and divide in eighty powders. These may be administered as often as every fifteen minutes, every half hour, or hour. Occasionally they a\ ill pro- duce slight nausea, Avhich is not objectionable, providing it docs not go so far as retching or the rejection of the remedy. Ipecacu- anha is giveu in doses of one-fourth to one-half grain every hour, always less than Avill produce vomiting, and is thus con- SPOTTED FEVER. 177 tinned until reaction is Avell established. I like the action of the Lobelia the best, though the Ipecac has been used with considera- ble success. To aid these, an enema of an infusion of Bayberry, Lobelia and Capsicum, may be employed Avith good advantage. I am satisfied that I have seen the patient aroused by this means, so as to obtain the influence of other remedies by the stomach, Avhen Avithout this, it Avould have been impossible. Dry cupping to the spine, is sometimes of advantage, but in the majority of cases, I Avould prefer the stimulant vapor-bath, as first named, and friction with Comp. Tinct. of Capsicum. The third method of treatment is based upon the specific action of Belladonna to overcome congestion and stimulate the circu- lation: This has not been as thoroughly tested as Ave Avould Avish, yet some very favorable reports have been made of it. In Cali- fornia, the Atropia has been employed; we have always used the the tincture of Belladonna. For a child two years old, I should order: B/ Tinct. of Belladonna gtt. v. to x.; Tinct. of Aconite gtt. v.; Avater oiv. Of this, give a teaspoonful. every half hour, until its influence in arousing the nervous system and overcom- ing the congestion is noticed, afterward every hour, until the circulation becomes free, and the dangerous symptoms have passed aAvay. In either case I should employ the sulphite of soda, or sul- phurous acid, in the usual doses, as soon as this first influence Avas established, and continue it until the dirty coat was entirely gone. But if at any time, the tongue becomes dry and dark, I would substitute the dilute muriatic acid. The Comp. Powder of Leptandrin may be given in from one to two grain doses four times a day with remarkable efficacy. It acts mildly, but efficiently, upon the glandular system, and re- moves morbid and Avorn-out material from the intestinal tract, leaving it free from irritation. Quinia may be used by inunction, early in the disease, and its use in this Avay continued to the complete establishment of con- valescence. I do not think that its internal administration in the early stages of this disease, has been attended with any good effect, but, on the contrary, has frequently increased the depres- sion of the nervous system. Tincture of muriate of iron may be occasionally given alter- nately with the sulphite of soda, so as to obtain the good influ- 12 178 DISEASES OF CHILDREN. ence of both. In a majority of cases, it will be well to put the patient upon its use for some days after other remedies are suspended. EPIDEMIC CEREBRO SPINAL MENINGITIS. Closely associated with spotted fever, and also with diphtheria, is the disease known by the name of epidemic cerebro-spinal meningitis. These three bear a very close relationship, in that each presents very similar lesions of the nervous system, both during the progress of the disease, and in the sequelae. In all three there is the evidence of the action of a blood poison, and the breaking down of the blood, and in each, death may be the result of the lesion of the nervous system, or of the lesion of the blood. In this country, within the last ten years, the three diseases have prevailed in an epidemic form, one succeeding another, and in some cases seeming to merge into one another. We had first the epidemic diphtheria, next the epidemic spinal meningitis, and last the spotted fever. Pathology.—The profession are not agreed as to the path- ology of epidemic spinal meningitis, though it is now generally regarded as bearing a very close relation to typhus and typhoid fevers, epidemic dysentery, etc. I think there is no doubt but that it is produced by an animal poison, which, gaining entrance to the blood, gives rise to the phenomena of fever, and acting from the blood, specially affects the cerebro-spinal centers, pro*^ ducing the peculiar lesions that characterize this disease. What this poison is, Ave are unable to say, neither are Ave able to account for its origin or propagation, in many cases. That the disease is contagious, in its severer forms, I am Avell satisfied, but this is also true of typhoid, especially of typhus, and, at times, of nearly all diseases which present that grouping of symp- toms called typhoid. In some instances, it has seemed as if there Avere an endemic influence causing the disease. In others, it has been distinctly epidemic. There is yet much mystery in regard to epidemic influences, and until the subject has been more thor- oughly studied, it will be useless to theorize upon it. Symptoms.—The cases of cerebro-spinal meningitis may be divided into two classes, the distinction being very marked. CEREBRO-SPINAL MENINGITIS. 179 Occasionally, Ave Avill find it prevailing in both forms, at the same time, in a locality ; but more frequently it will maintain the one form in all the cases, at one place, or during one season. We may call these tAvo classes the rapid and the slow cerebro- spinal meningitis, as this expresses the greatest difference in the symptoms. In the first, or rapid form of the disease, there is but a short period of incubation, rarely exceeding a day. The patient feels dull and prostrated, and if old enough to complain, it is of pains in the back, head and limbs. The chill is usually well marked, the extremities being cold, the surface shrunken and pallid, and occasionally, severe rigors. It will be noticed that during the chill there is greater dullness of the mind and prostration than should attend an ordinary chill, and the patient seems to suffer severely. In the course of one or two hours, the chill passes aAvay and febrile reaction succeeds. The surface becomes flushed, and the temperature is increased. The pulse increases in frequency to 120 or 140 beats per minute. The face is flushed, the eyes in- jected and suffused, and the head is Avarmer than other portions of the body. The tongue and mucous membrane of the mouth are usually dusky, and the tongue coated with a yelloAvish-Avhite pasty fur. During the first few hours, sometimes for a day, the patient complains of pain in the back, and muscular pains in Ararious parts of the body, and though there is great dullness of intellect, yet the patient is restless and uneasy. It will also be noticed that moving the child increases the suffering, sometimes so much that Ave are obliged to let it remain in the one position. By the second day, the patient has sunk into a stupor, from which, it is difficult to arouse it. The surface is markedly flushed and dusky ; the pulse very frequent and wiry, in the majority of cases, but in some it is open but oppressed. Respiration is diffi- cult, and the patient shows marked evidences of imperfect aera- tion of the blood. The characteristic symptom is a fixure of the spinal column, the head being dnnvn. backward, or to one side ; or the disease may show itself in the same Avay in the dorsal or lumbar regions. Occasionally, Ave notice evidence of partial paralysis this early in the disease. At other times, convulsions come on early, or the disease is announced by them. Thus it progresses rapidly to a fatal termination, the patient 180 DISEASES OF CHILDREN. rarely lasting longer than four or five days, if not relieved, and sometimes it terminates fatally within forty-eight hours. In the other form of the disease, the forming stage may last from one day to a Aveek, presenting the usual symptoms of dull- ness and hebetude, and arrested function. The chill is not very marked, though it may last for the greater part of a day, or be made up of slight chills and febrile-reactions, of short duration. Reaction comes up slowly, and is not fully established before the end of the first tAventy-four hours. The temperature is increased, the pulse increased in frequency and hardness, the patient restless and fretful, and if old enough, complaining of pains in the back, head, limbs, or not unfrequently, simply of a hurting, Avithout being able to locate it at any one point. The secretions are arrested; the skin becomes dry and harsh, the urine scanty and high colored, and the boAvels constipated. The tongue in some cases is contracted and reddened, Avith a coat having a shade of brown ; in others it is broad, pallid, and cov- ered with a pasty white coat. Usually at first, the face is slightly flushed, the eyes bright, the pupils contracted, and the mind active. The patient is uneasy and restless, and does not sleep well. The child maintains one position, and the fixure of the back is marked, and if moved, so as to bend the spinal column, it cries out with pain. Thus, day after day, the fever continues, sometimes presenting the symptoms of a remittent, at others of a continued feA'er. There is a gradual increase in its severity, and necessarily an in- creasing debility of the child. Occasionally the feATer Avill run A'ery high about the sixth to the tenth day, and there Avill be evident delirium. Passing into the third week, the symptoms assume a typhoid condition, Avhich gradually increases as time passes. I do not think that at this time there are any distinctive symp- toms, but the tenderness on pressure over the spine, and the pain when the child is moved, except, possibly, the greater excitement of the nervous svstcm, which in this case replaces the dullness of typhoid. But sooner or later in the disease, this excitement is replaced by <'<>ma, which sometimes becomes a marked feature in fatal cases. A peculiarity of the disease is, that having run the course I have described, for two, three or four Aveeks, the symptoms gradu- ally give way to treatment; the fever is arrested, secretion SPOTTED FEVER. 181 established, the child sleeps avcII at night, takes food and seem- ingly digests it, but further than this there is no advance to re- covery. There is no increase of the strength, indeed, no increase of flesh, and thus Aveek after Aveek Avill pass by without an appre- ciable change. After a time, however, it will be noticed that the child is failing, and in two or three Aveeks it dies—but of Avhat it is impossible to say. I have knoAvn of many cases that had a duration of three or four months, and an exceptional case that terminated fatally at the commencement of the eighth month from the date of attack, there being no time during which the child Avas able to sit up. Diagnosis.—In the first form of the disease, the symptoms are of a very grave character from the commencement, and v/e are able to trace their relationship to spotted fever and the more malignant cases of diphtheria. The pains in the back and head, the severe muscular pains, are characteristic, and even Avhere the child is too young to describe its sufferings, its appearance Avill evidence it. The pain, or expression of suffering, upon moving the body, is the evidence of spinal disease. In the second class of cases, the disease comes on insidiously, and there may be but little, if anything, to arouse the suspicion of the practitioner that he has more than an ordinary fever to treat. But after aAvhile his attention is attracted to the pain when the child is moved, and the greater irritability of the nerv- ous system and restlessness than is common in ordinary fevers. Prognosis.—I do not regard the prognosis as unfavorable if the disease is seen in time, and a proper treatment is adopted. Taking the disease as it ordinarily prevails, it is probable that the mortality will vary from ten to twenty per cent. We must not forget the fact that in some situations the cause of the disease is very intense, and it exhibits very great malignancy. Indeed, in some localities, many times, death Avould have commenced be- fore the physician was called to the patient. Treatment.—In the first form of this disease, I would strongly advise that the treatment be commenced Avith athorougli emetic, of some preparation of Lobelia. In this case as in spotted fever, Ave desire the general influence of Lobelia, as Aveli as the act of emesis, or in other Avords, Ave want the act of emesis as the result of its general action. The acetous emetic of our 182 DISEASES OF CHILDREN. dispensatory, or the Comp. Powder of Lobelia and Capsicum, are good preparations for this purpose. Give in five to ten drops doses with warm Avater, repeated every five or ten minutes, and Avhen the system is brought fully under the influence of the remedy, Avhich will be in one or two hours, then more freely until emesis results. In many cases it will be necessary to folloAV emesis Avith a cathartic. This is particularly requisite in malarial localities. The intestinal tract is in the same morbid condition as the stomach, and must be aroused ere Ave can hope for a satisfactory response from our sedatives or other indicated remedies, Avhen quick action is desired. I like the action of Rhaninus P. best, prepared as follows : B/ Tinct. Rhamnus P. 5j., Tinct. Taraxicum 5j., Simple Elixir 5J. M., and give from gtt. xv. to xxx. every two hours, until there has been good action. If slow action is desired Ave can use the Leptandria compound gr. ij. every two or three hours. Then comes our sedatives, Aconite or Veratrum, Avhichever is indicated ; Veratrum, if the patient has a full bound- ing pulse, and Aconite if it is small in volume and easily com- pressed. Of the former, gtt. x. to half a glass of Avater; of the latter, gtt. v. to water 5iv. Marked cerebral irritation or coma will generally be present in a major portion of cases, and in the irritative ones, Rhus tox. is a prominent remedy; given, a case with excited circulation, frontal pain, prominence and redness of papillae, and tip of tongue, and Ave have the true indications for the remedy. In these cases, then, Ave would think of Rhus and give it curativelv. We have another class of symptoms that pre- sent great vascular excitement, contracted tissues and pupils, face flushed, and extreme restlessness ; here avc would substitute Gelse- minum for Rhus and get its specific action ; gtt. v. of the Rhus to Avater 5iv., and xv. of the Gelseminum to the same quantity of Avater, Avill be the right proportion ; give in teaspoonful doses every hour. In the opposite cases Ave have dullness and hebe- tude, patient sleeps with eyes partially unclosed, tissues are sodden and the whole system is in an atonic condition. From five to ten drops of Belladonna added to half a glass of water and given eA'cry half hour or hour, according to the severity to the case, Avill remove the congestion and leave the system in better condition for the action of other remedies. If there was large pulse, tongue broad with dirty coat, sweetish taste in the mouth Avith pallor of mucous membranes, I should SPOTTED FFVER. ' 183 prescribe sulphite of soda, grains tAvo to four every three hours ; but with deep redness of mucous membranes, slick tongue, and typhoid symptoms, the patient Avants muriatic acid. In such cases I should associate Baptisia with the acid In septic condi- tions they are definite agents and as such produce definite results. "\\ ith the system prepared for the antiperiodic, Ave may give it cither by mouth or by inunction. Where the soda is indicated I prefer giving the quinine by inunction. In the other cases I should giA7e an acidulated elixir of quinine. Where there is a torpid circulation of the skin, I should associ- ate it Avith a stimulant, as follows: B/ Quinia Sulphas 5J-, Cap- sicum gr. x. to 5ss., Adeps .^ij.; mix thoroughly. This may be used Avith brisk friction two or three times daily, and if the tem- perature of the extremities is lowered, apply dry heat or friction with the hand. In the second case, the treatment need not be so active. I am not certain, however, but that in many of these cases Ave might obtain much advantage from the action of the emetic in the first two or three days. Indeed, I am satisfied that in two cases I arrested the disease by4his means. But Ave would think more particularly of Rhus and Macrotys, plus the required sedative, in these irritative cases, though even the sedative is not ahvays necessary, Rhus doing the Avork nicely. Indications for Gelseminum will be met Avith that remedy sub«- stituted for Rhus. If Ave get an indication for a certain remedy in a large number of cases, Ave then have an epidemic remedy, and with the sedative is all sufficient. Two or three remedies rightly chosen, have, in some of the severest types of disease of this character, ahvays given me good results. The general sponge-bath, sometimes with hot Avater, Iavo or three times a day, Avill be found an important aid. If the .bowels are torpid they may be stimulated to action by a gentle laxative, or by an enema. If the secretion of urine is scanty and high colored, some diuretic infusion, as of mentha viridis, with small portions of sweet spirits of nitre, may be given. DIPHTHERIA. Diphtheria was the first of these epidemics, making its appear-' auce in some sections as early as 1 *•")•">. From then, up to 1864, it prevailed in most parts of our country. It Avas thought by 77 184 DISEASES OF CHILDREN. many to be a new disease, though a reference to authorities will show that several epidemics of the same have occurred before, and that it Avas AvelI described, and received its name from French observers in the last century. Cause.—The cause of diphtheria is undoubtedly a specifie animal poison, though how generated or propagated we are unable to tell. It prevails as an endemic or epidemic disease, and is rarely if ever found in isolated cases. I have no doubt that it becomes contagious, like other similar diseases, Avhen it occurs in its most malignant form. There seems, sometimes, to be a very close relationship betAveen diphtheria and scarlatina, and cases have been recorded Avhere an eruption attended it. In this, as in some other diseases, the anomaly may have been a mistake in diagnosis, rather than a difference hi the disease. Pathology.—I have not changed my opinion of the path- ology of diphtheria, first published in 1861, and upon Avhich the treatment of the majority of our physicians has been based. I quote it as then Avritten, desiring to keen it on record as being the first announcement of a doctrine that is uoav generally ad- mitted as correct. " I hold diphtheria to be a general as well as a local disease, as is proven by the languor, listlessness, torpor of the nervous system, and derangement of the excretory organs, which, as a general rule, precede all local disease; all being symptoms of perversion of the blood, and almost invariably indicating the establishment of febrile reaction. We also find the evidence of the perversion of the blood in the heavily coated tomrue. which is ahvays more or less discolored at the commencement of the disease, and ahvays in severe cases, exhibiting the broAvn- ish tinge, Avith more or less sordes upon the teeth as it pro- gresses ; in the diphtheritic deposit Avhich is markedly different from the exudations from highly-vitalized blood ; in the secre- tion of urine in severe cases being abundant, in all cases dis- colored, frothy, more or less clouded with a peculiar, somewhat cadaverous odor—Avhat the ancients would have termed illy-con- cocted; in the evacuations from the boAvels, obtained by cathar- tics, which are frequently large, dark, and almost invariably fetid ; and especially in the condition of the blood itself, when the disease has attained its maximum, which is dark, is not changed DIPHTHERIA. 185 by exposure to air, forms a loose and easily broken-down coagu- lum, or does not coagulate at all. " Post-mortem examination in those cases that have run a reg- ular course, i. e. that have not been terminated by an extension of the disease to the larynx, shows us the blood broken down to a considerable extent, more or less discoloration of tissues from extravasation of the coloring matter, and softening of the tissues. These facts, it appears to me, prove conclusively the opinion given above." There are some cases in Avhich the disease seems almost wholly local, yet these are mild. Other cases Avill present the evidences of local disease first, and it Avill only be after some days that the serious character of the general lesion Avill be manifest. Symptoms.—As above named, the symptoms of the forming stage are similar to those of fevers and inflammations generally. For a day or two, sometimes for a week, the patient is listless and languid, does not play with the usifal zest, is fretful at times, does not sleep well, especially at night, drinks frequently, and has a variable appetite. FolloAving this is a slight chill, lasting one or two hours; not unfrequently it is so light that it is not noticed by the parents. FolloAving this, febrile reaction conies up slowly, and varies greatly in different cases. In some the fever is acute, and is a marked feature of the disease. In others the symptoms of fever are but slight—an accelerated and soft pulse, arrested secretion from the skin, kidneys, and boAvels, and an increased temperature of the body, as marked by the thermometer, though it is not so perceptible to the hand. As the disease progresses the fever assumes an asthenic or typhoid character, and there is evidently a serious lesion of the blood. In a feAV cases the fever is high from the commencement, and continues to present sthenic symptoms during its entire progress. The patient complains or sIioavs signs of sore throat at the commencement of the disease. There is difficulty and pain in deglutition, the child SAvallows frequently to moisten the throat, and there maybe slight difficulty in breathing. On examination Ave find the mucous membrane of the fauces, tonsils and pharynx somewhat SAvollen, sometimes of a vivid red color, at others dusky or livid, and occasionally presenting a blanched appear- 186 DISEASES OF CHILDREN. ance. On some of these parts we will notice the characteristic exudation—spots of an ashen-gray or white lymph upon the sur- face of the mucous membrane. They are usually small at first, not larger than a grain of Avheat, or at farthest a three-cent piece. They are usually grouped together, two or three or more at a point, Avhich is more SAvollen or discolored than adjacent parts. There may be but one of these points of exudation, or several. As the disease progresses the swelling becomes more marked, and the points of exudation more numerous. The patches likeAvise increase in size, sometimes coalescing, so as to uniformly cover quite a large surface. For tAvo or three days, in the majority of cases, the throat is dry, sometimes, indeed, during the entire progress of the disease. Then secretion is established from the mucous follicles, and some patches of exudation being removed, there is a free secretion from the denuded surface. The salivary glands also become more active, and the saliva is tenacious, thick, and ropy; and alto- gether the secretion is large, and requires frequent efforts at removal. Occasionally cases present themselves in which this seems to be the most unpleasant symptom. In the later stages of the disease, Ave may distinguish two classes of cases. In the first the dryness continues, and the parts become stiff and immobile, so that after a time deglutition be- comes almost impossible, and respiration is rendered very difficult and labored. Extending upAvard to the posterior nares and nasal cavities, these are closed by the swelling; and descending to the inferior portion of the pharynx and epiglottis, these and asso- ciated parts are SAvollen and rendered incapable of motion, and the child dies, partly from Avant of food alid drink, and partly from imperfect aeration of the blood. In the second class of cases, secretion commences about the second or the third day. By the fifth day it is quite free, some portions of the exudation are being detached, and the exposed surface secretes pus. In very severe cases this ulceration pro- gresses in every direction, but is mostly superficial. The tissues seem to have lost their vitality, and the muscles their poAver of contraction, and they hang feeble and pendulous and infiltrated with serum, Avhen the connectiAre tissue is loose. Thus Ave have paralysis of the throat in the second as Avell as in the first case. This also extends upward to the nose, sometimes presenting the distinctive characteristics of diphtheria throughout. In some DIPHTHERIA. 187 of these the discharge will be profuse, in others it is retarded, becomes dried, and thoroughly closes up the passages. In other cases the disease extends doAvnward and involves the pharynx. Here the child presents all the symptoms of croup— the Avhistling respiration, croupal cough, loss of voice, and gradu- ally increasing difficulty of breathing. The occurrence of the laryngeal complication is sudden, and it runs a rapid course. Thus, if not relieved by remedies, it will usually terminate fatally Avithin forty-eight hours. Diagnosis.—piphtheria is readily diagnosed by the specific character of the sore throat. Where there is the peculiar ashen exudation upon the free surface of the mucous membrane, there is a case of diphtheria, no matter Avhat the other symptoms may be. Wiien there is no such exudation the disease is not diph- theria. I admit that in some exceptional cases the patches of exudation may be throAvn off very early, and Avhen the patient is first seen there Avill be simply an ulcerated sore throat, but in all there is the exudation at some period. Prognosis.—As is the case with all endemic and epidemic dis- eases, it prevails Avith different degrees of severity in different places and at different times. Thus one physician may meet Avith it in a form so malignant and running its course so rapidly, that a majority of the cases Avill prove fatal. While another will see it in a mild form, and Avith but simple treatment a large ma- jority recover. Thus Avith some there has been a mortality of twenty to fifty per cent., with others of not more than tAvo or three per cent., both pursuing the same treatment. Of course, in laryngeal complication the prognosis Avill be more doubtful. Treatment.—Diphtheria being a disease of the blood, the treatment will in all cases be general, with the addition of local treatment in severe throat complications. Should nausea prevail, Avith heavily coated tongue, I Avould preface the treatment Avith the administration of a thorough emetic ; this Avill arouse the system and place the stomach in condition to receive other remedies. In my experience Avith this disease, in the greater number of cases taken from the commencement, I find Phytolacca to be the most frequently indicated. It has a specific influence upon the blood, the glandular system, and the throat. We may use it with the indicated sedative, or, as I prefer, iu alternation with 188 DISEASES OF CHILDREN. Tinct. Aconite or Veratrum gtt. v. to x., Avater 5iv.—Tiuct. Phytolacca gtt. xx., Avater 5iv-; dose, a teaspoonful alternately every hour. If there is an excess of saliva, make a solution of potassa chlorate oss. to half a glass of Avater, and give the child a tea- spoonful four times daily. If there is fetor with ulceration, Thymol may be given both internally and used with the spray. B/ Thymol gr. viii., Glycerine, water, aa. 5ii. M.; a teaspoonful once in three hours, and spray the throat three or four times a day. With enlargement of the glands a local application of Phyto- lacca and glycerine will be excellent treatment. Tavo drachms bf the first to an ounce of the last; saturate a flannel bandage and apply to the throat, reneAving tAvo or three times a day. Dusky color of face and mucous membranes, with typhoid symptoms, indicates Baptisia, which may be given in the usual doses Avith Aconite. Children of scrofulous habits Avill improve nicely on Lachesis, and Lycopodium may be given Avhen there is a low grade of fever, Avith diminished secretion of urine. Cases may arise where, in the latter stage of the disease, it Avill be necessary to use an emetic, but it will be in laryngeal compli- cations, and must be used Avith care. We may use the acetous emetic tincture in small doses, just sufficient to produce nausea and gradual emesis. Following the sedatives and antiseptics must be the sustaining treatment. The temperature must be carefully noted at different periods during the day, and if it. decreases, stimulants must be administered frequently, and in small quantities. Should high temperature prevail, Ave want to think of cooling remedies in addition to our sedatives. In malarial localities, Avith the system prepared for the antiperiodics, quinine should be given early in the disease. If there is no gastric irritation, but an alkaline condition, the better Avay will be to give the acidulated elixir. With an atonic condition, or congestion, I prefer the olive oil preparation with thorough friction. In the matter of local applications, there are tAvo remedies that I prefer to all others : they are Phytolacca and compound Stillingia Liniment. As previously alluded to, the Phytolacca will be an essential part of treatment in all cases with enlarged glands, using it in combination with glycerine. The^ Stillingia liniment is a stimulant and an excellent counter-irritant, and may be used in both throat and lung complications. Satu- DIPHTHERIA. 189 rate a flannel cloth, and apply three times a day. It exerts a marked control over the croupal symptoms, when applied over the larynx. In mild cases Ave may use the hot vinegar pack. If there is stupor and tendency to coma, or pain in the throat Avith difficulty in SAvalloAving, give Belladonna. Sepsis with deep redness of mucous membranes and slick tongue, Avants muriatic acid. If the tongue has a dirty coating, with pungent breath, and the excretions look as if fermented, the patient Avants sul- phurous acid. We may use the first as an acidulated drink, add- ing tAvo or three drops to half a glass of water, and let the child drink at pleasure. We get a much better action from the acid in this Avay than Ave should if syrup Avere added. Of the sulphu- rous acid, oss. to water 5iv., and given in teaspoonful doses every tAvo hours, Avill give marked benefit. Occasionally Ave have a case calling for sulphite of soda. We recognize it by the pasty- Avhite coat on the tongue, palliditv of mucous membranes, and a general atonic condition of the Avhole system. The dose will be three grains every two hours. Noav come our cases of unusual severity : the patient is debil- itated, and the throat ulcerating with a sickening fetor. The disease has extended up into the nares, and the lips are parched, and mav have sordes upon them. Treatment must be prompt and decided, and Ave turn Avith confidence to bichromate and permanganate of potash. The former avc Avould use more par- ticularly in those cases of a croupy nature, accompanied by diffi- cult, Avheezy breathing, and great depression. From ten to fif- teen grains may be dissolved in half a glass of Avater, and given in teaspoonful doses every tAvo hours, alternating with Veratrum. Of the latter salt, Ave wi 11 add from five to ten grains to four ounces of Avater, and give a teaspoonful every two hours. As adjuvants, I would recommend gargling, if the child is old enough, and spraying with the atomizer, or inhalations. Water medicated with chlorate of potassium, salicylic or carbolic acid, thvmol, chloride of calcium, with muriated tincture of iron, and the vapor of hot vinegar, may be employed Avith success. (Moths must be kept at hand to absorb all discharges from the mouth, and burned immediately ; and the lips and mouth sponged with a solution of thymol or chlorate of potash. The little patient must be kept as quiet as possible, and the food will necessarily be of the most sustaining character, as beef essence, milk, and cus- tards of sea-moss farina. 190 DISEASES OF CHILDREN. With this, as in other similar diseases, the general bath and the hot foot-bath are employed. In the majority of cases a stim- ulant bath will be preferable, as of salt Avater with brisk friction, or the addition of capsicum or mustard to the Avater. The hot mustard foot-bath is a very valuable means, and may be used tAvo or three times daily, and for half an hour at a time. It is espe- cially important in severe cases, indeed in any case, that the ex- tremities be kept warm. I have often thought that in some it Avas just the difference between death and recovery. Let the feet and legs be cold for six hours, in a severe case, and the throat disease Avill have advanced beyond the reach of medicine. In the application of stimulants I prefer Capsicum, and the use of dry heat Avill be the best means. It is a very good plan to say to the nurse, " If complaint is made of any part, sponge it Avith hot water,'and cover at once Avith hot dry flannel." Where the larynx becomes involved, and the symptoms of croup developed, the treatment must be prompt and thorough, if Ave expect to sa\Te life. To give temporary relief, I direct the inhalation of vinegar and Avater sufficiently often to give ease, using at the same time hot fomentations assidulously applied to the throat. When the case does not seem to be progressing rap- idly, I place the patient upon the use of Aconite and Phytolacca alone, using the Stillingia liniment as a local application over the larynx. If, hoAvever, it is progressing rapidly Ave may give the patient small doses of acetous tincture of Lobelia and San- guinaria, so as to keep up continuous slight nausea; and Avhen the patient is brought fully under the influence of the remedies, it is carried to free emesis. So far as my experience goes, Iioav- ever, Ave have much better results if Ave folloAV the direct indica- tions, and give the small doses. ERUPTIVE FEVERS. The eruptive fevers are caused by a specific contagion gene- rated during the progress of the disease, and propagated by con- tact, by inhaling the gaseous exhalations, or by the absorption of the poison from the clothing or the excretions. The poison is capable of being disseminated by the atmosphere to a limited extent in ordinary cases; but Avhen severe, and in numerous cases, it sometimes affects the atmosphere for considerable dis- ERUPTIVE FEVERS. 191 tanccs, especially in the direction of the prevailing winds; in these cases the disease assumes an epidemic character. In the most of these diseases the virus may be transmitted by inoculation. Indeed, in any Avay by Avhich it is brought in con- tact Avith the body, so that it may be absorbed into the blood, the disease may be disseminated. The causes of these diseases vary in intensity in different sea- sons, and in different localities, so that at one time they will be remarkably mild, and at another time very severe, even malig- nant. It is pretty evident that the condition of the atmosphere, as regards heat and cold, moisture or dryness, and especially its electrical condition, has much to do Avith the intensity of these, as well as other diseases. It has been noticed that the eruptive fevers, as Avell as some other diseases, prevail in cycles, the periods being usually about seven years. This has been accounted for in the ease of the class under consideration, by the fact that all the material for such disease is used up in its progress of jtwo or three years, and its reappearance depends upon the presence of a new population not protected from it. A peculiar feature of these diseases is, the immunity from them produced by one attack. It seems that in each of these cases, the cans'.; of the disease destroys all the material capable of being influenced, or all susceptibility to the influence in the first attack. As a general rule, the immunity from the influence of the cause a second time, is perfect after the first attack, and the person may be exposed without the least danger. There are some rare cases, hoAvever, in Avhich the person is not thus protected, and in which it may recur one or more times. These fevers differ from all others, therefore, that an attack protects the individual from ever having the disease again, even though being exposed to the same cause. They differ also in the specific character of the eruption, which is a part of the fever. Liebig thus accounts for the disease and its protective influ- ence : u When a quantity, hoAvever small, of contagious matter, that is, of the exciting body, is introduced into the blood of a healthy individual, it Avill be again generated in the blood, just as yeast is generated from Avort. The condition of transforma- tion Avill be communicated to a constituent of the blood ; and in consequence of the transformation suffered by this substance, a body identical with, or similar to the exciting or contagious 132 DISEASES OF CHILDREN. matter, Avill be produced by another constituent substance of the blood. The quantity of the exciting body neAvly-produced must constantly augment, if its further transformation or decomposi- tion proceeds more slowly than that of the compound in the blood, the decomposition of Avhich it effects. * * * In the abstract chemical sense, reproduction of a contagion depends upon the presence of two substances, one of Avhich becomes com- pletely decomposed, but communicates its oavu state of transfor- mation to the second. The second substance thus thrown into a state of decomposition is the newly formed contagion. * When the constituent removed from the blood is a product of an unnatural manner of living, or Avhen its formation takes place only at a certain age, the susceptibility of contagion ceases on its disappearance. The effects of vaccine matter indicate that an accidental constitution o f the blood is destroyed by a peculiar process of decomposition, Avhich does not affect the other con- stituents of the circulating fluid." As in the case of sthenic-fevers, the cause, in these diseases, seems to influence the blood almost in direct ratio to the func- tional disturbance. Thus, with an active fever, and arrested secre- tion, the poison seems to be generated in increased quantity. In some cases the influence of the contagion does not cease Avith the formation of the specific virus, but originates a septic decomposition of the blood, giving rise to putro-adynamic symp- toms, Avhich frequently result in death, sometimes even before the appearance of the characteristic eruption. VARIOLA-SMALL-POX. Small-pox, like other of the eruptive fevers, is caused by a specific contagion, generated during the progress of the disease in the human body. This contagious matter may be propagated by contact with the person or with articles of clothing, or indeed anything that has been in contact Avith him, and by inhaling an atmosphere impregnated Avith the poison. This atmospheric cause varies in different cases; in some extending but a short distance from the person, frequently confined to the room ; in other seasons extending considerable distances in the direction of the prevailing Avinds. The disease is, so far as Ave knoAV, always produced by the one cause, the specific virus of small-pox, and is never generated VARIOLA. 193 anew or Avithout this. While it is thus contagious, it also be- comes endemic and epidemic by peculiar states of the atmosphere. It also prevails in cycles, as heretofore stated,\some of these being mild, others severe. More commonly, perhaps, we have one or two years in each cycle, in Avhich the disease is severe, then others of a milder type. The virus of small-pox acts upon the blood, giving rise to such changes in this fluid as produce all the phenomena noticed, and generating Avithin it a virus similar to itself. Finally, this is thrown upon the surface in the form of pustules, and the blood being freed from it convalescence ensues. We may, in this dis- ease, study the pathology of all fevers, as this presents all the phenomena of a fever, with a cause tangible to our senses. We may trace the incubation of the virus in the body, as it gradually increases and influences all the functions of life. The gradually increasing prostration terminating in a chill; the febrile reaction following this, the eruption of the small-pox pustules, and finally the subsidence of the disease Avhen the virus is thus Avhtlly removed. Symptoms—Small-pox is divided into two classes, the discrete and confluent, though these are differences in its severity, not in its character. In discrete small-pox the pustules are not so nu- merous but that they have room for full development upon the skin. In confluent small-pox the points of eruption are so numerous, that as they are developed into pustules they croAvd upon each other and run together, so that on large portions of the surface nothing is seen but the eruption, and, as it matures, the formation of a single crust. In the discrete form the premonitory symptoms are not severe. The child will be fretful, restless in its sleep, and, if old enough, will complain of feeling tired. The chill is tolerably Avell marked, though not severe, and lasts from one to two hours. The febrile reaction comes up pretty actively, though it bears a closer resemblance to febricula than to the severer fevers. The eruption generally makes its appearance during the latter part of the second and during the third day, and at this time the fever has attained its highest point. By the fourth dav the fever will have subsided, to a considerable extent, and from this to the tenth or twelfth day, is so slight as to give but little annoyance. At this time, Avhen maturation is complete, a secondary fever is developed, Avhich, for a few hours, is pretty active. This passing 13 194 DISEASES OF CHILDREN. off, secretion is established, the appetite and digestion are restored, and the child convalesces rapidly. In the confluent form the premonitory symptoms are noticed earlier. The child appears depressed, its appetite is poor, it is restless and fretful during the day, and does not sleep soundly at night. As we approach the period of chill these symptoms are more marked, and the child presents evident symptoms of suffer- ing. The chill, in this case, is usually Avell marked and pro- tracted, the temperature is really lowered, the pulse increased in frequency, the skin contracted, presenting the cutis anserina, and in many cases there are marked rigors. The febrile reaction comes up rapidly in most cases, and runs high. The surface is hot and dry, the pulse frequent, full and hard, the urine scanty, the boAvels constipated, the mouth dry, the tongue coated with a Avhite fur, the face flushed, the eyes bright, with great restlessness and irritability. The child expresses evidences of suffering that can not be mistaken, and avc suppose it has all the aches and pains that are pathognomonic of small- pox in the adult. The fever continues on Avithout abatement, rather increasing than otherwise, until the eruption makes its appearance. The symptoms of suffering pass away after the first day, and there is usually not so much restlessness, though occasionally the irrita- tion of the nervous system continues to be a marked feature, and there may be convulsions and occasionally eATident delirium. About the time the eruption is making its appearance the throat seems to be stuffed up, and there is free secretion from it and the mouth. In some cases this becomes quite severe, the throat is SAvollen, and the secretion profuse and tenacious, Avhich render deglutition and even respiration difficult. The eruption appears on the third day, at first on the face, then the trunk, and finally the extremities, usually not being fully out before the end of the fourth or the fifth day. In most cases there is a slight abatement of the fever after the eruption has made its appearance, presenting frequently a morning remission and evening exacerbation. It varies greatly in intensity in differ- ent enses. In some it is very active in all its symptoms, and children are frequently delirious. In others it presents the usual symptoms of an infantile remittent. In the more malignant cases it is asthenic in character, and the symptoms are of a typhoid type. VARIOLA. 195 About the tAvelfth day from the chill, or ninth from the erup- tion, a secondary fever makes its appearance, and lasts from one to three days. Usually it is very active, and the child suffers more from the fever than at any time during the progress of the disease. Maturation being complete, Avhen this fever declines, the secretions are re established, and the child sIoavIv convalesces. Having described the general symptoms of the disease, Ave must now study the eruption. When it first appears it simply presents a small red spot, resembling somewhat a flea or mosquito bite. These look as if slightly elevated, and when Ave place a finger upon one it feels hard, as if a small shot were imbedded in the skin. On the second day the redness has increased in size, the elevation is more perceptible to the eye, and a minute point is seen in the center from which the future pustule is to be de- veloped. On the third day the red spot has increased in size still more, and in its center is seen a small vesicle, distinctly rounded in form, and filled with a clear, limpid serum. On the fourth day this has increased in size, is flattened, seems to be tied doAvn in its center—umbilicated—and the lymph is becoming yellowish and opaque. On the fifth day it has attained about one-half its size, is yellowish and opaque, distinctly umbilicated, and stands on a SAvollen base, and presents a red areola. Continuing to increase in size it attains its maturity by the ninth day, Avhen it is three-eighths to one-half inch in diameter, the red areola being about as much larger; it is yelloAvish and opaque, and distinctly umbilicated. The tumefaction of the base, Avhen the points of eruption are numerous, is such as to give a uniform SAvelling of the surface. Thus, in the severer cases, the eyes are closed, and the features so effaced that the person could not be recognized. When maturation is thus completed, some of the pustules burst and discharge a portion of their contents. In all it desic- cates, and forms a crust or scab, which is retained in contact with the skin by the epithelial investment of the pustule. In from three to nine days this gives way and the scabs are throAvn off. The parts, Avhere they are developed, present a bluish or livid appearance, which slowly passes away in some five or six weeks, though it can be noticed for as many months Avhen the person is exposed to the cold. In some eases a process of ulceration is set up at the base of the pustule, and the true skin is destroyed, to a greater or less 196 DISEASES OF CHILDREN. extent. This causes those depressions that Ave call pitting, and Avhich are never effaced. Small-pox may be complicated with inflammation of any organ or part. These are not very common, and are usually recognized Avith ease. There are some irregularities in its progress, hoAvever, that should be studied with care. In one, the disease having progressed to the fourth day, avc find the skin swollen, and as- suming a dusky appearance; yet the eruption does not come out, or appears sparsely. At the same time we find the child becom- ing comatose, and also that this is influencing every function of life, until finally death results. In a second, the eruption having made its appearance, recedes; the skin is SAvollen and dusky, and coma comes on, as in the preceding case. In malignant small-pox—that in olden times received the name of black small-pox—the skin seems swollen and dusky from the commencement. When the eruption makes its appearance it also is discolored, and the pustules, instead of being yelloAvish, have a shade of broAvn or black, or in some cases are black. This is associated with the broAvn tongue, sordes on the teeth, frequent small pulse, and other typhoid symptoms. Diagnosis.—The diagnosis of small-pox is not difficulty The symptoms preceding the chill for some two or three days,—this being marked, and followed by high febrile reaction, in Avhieh the child evidently suffers much pain,—are sufficient to arouse our suspicions. The eruption of red points, hard under the finger, is the diagnostic evidence at this time. Afterward the umbilicated pustule and its regular and sIoav development, distinguish this from all other eruptions. Prognosis.—I regard the prognosis of small-pox as favorable, except in those exceptional cases last described. Of course, some children Avill succumb to eA'en its milder form, because they have not vitality to live through any disease. The mortality attend- ing small-pox seems to have lessened in the ratio that the people are protected by vaccination, thus proving that the virus gains intensity as developed from a large number of persons at the same time. Treatment.—It is contended by the majority of Avriters that small-pox is a self-determined disease, and has a regular course to run, and that this can not be modified or shortened. In this VARIOLA. 197 respect it is said to resemble typhoid and other continued fevers. I admit the resemblance, and contend that its course can be both modified and shortened, as Ave have proven to be the case with continued fever. We have the evidence of this in the history of inoculation. Here the small-pox virus Avas introduced into a system not pro- tected, but by a system of diet and means to promote the secre- tions, it Avas caused to run a very mild and also a short career. If the small-pox virus is generated within the blood, and this is the cause of the disturbance Ave Avitness, that disturbance Avill be less, just in proportion as this is developed slowly and re- moved by the excretory organs. There is no doubt but that the virus of small-pox may be removed by the excretory organs in very considerable quantity. We have already seen that the development or activity of such blood poison Avas in the ratio of the frequency of the circulation and other functional derange- ment. If, therefore, avc control the circulation, and establish function, Ave will lessen the rapidity with Avhich the virus is generated, and arrest the septic decomposition that accompanies it; and if, at the same time, Ave stimulate excretion by the skin, kidneys, and boAvels, Ave Avill remove considerable portions of it, and thus lessen the eruption upon the skin. It will be observed that the theory is good, and is based upon facts constantly witnessed in other diseases. Experience, also, which is the test for every new doctrine, confirms these views. The treatment, then,Avill be the same as for any other form of fever. We put the patient upon the use of Aconite or Veratrum, in the usual doses, aiding their action by the general sponge-bath and the use of the hot foot-bath. If there is much irritation of the nervous centers, Avith determination of blood, we add Gelse- minum; but if the patient is dull and torpid, and inclined to coma, Belladonna is used instead. The most pronounced symptom in the first stage of small-pox is the severe pain, and this suggests remedies that relieve pain. Macrotys has been employed for a half century in these cases, and so marked is its action that many have called it a specific in small-pox. Bryonia will be found an excellent remedy Avhen the patient complains of pains in the chest, with severe cough, or uneasiness in the boAvels with tenderness, or pain in the articu- lations. Rhus is an admirable remedy in some cases, and Avill be indicated by burning pain, by pain in the forehead, and also 198 DISEASES OF CHILDREN. by pain in the neck and occiput, the tissues being very sore and painful Avhen pressed. Among the remedies to bring the erup- tion to the surface, when it is tardy, there are none better than Belladonna when the patient is dull and inclined to sleep, and Rhus Avhere it is restless, uneasy and Avakeful. By the second or third day of the treatment Ave may add a portion of the tincture of Asclepias to the sedative mixture, and commence the administration of a solution of Acetate of Potash 5ss., to Avater Siv.; a teaspoonful every three hours. This is used Avhen the fever is active and the disease sthenic in character. The boAvels are kept in a soluble condition by the use of laxa- tives, but cathartic medicines of an irritant character are very objectionable. Citrate or carbonate of magnesia, manna, phos- phate of soda, or castor oil, may be used, or in place of them Ave may depend upon enemata. In some cases we find the tongue broad and much furred, the breath bad, and the stomach in such condition that it can neither digest food nor receive remedies kindly. Generally this may be regarded as an unfavorable commencement of small-pox, and demands prompt treatment. When marked, I would strongly advise the use of an emetic, so given as to obtain a thorough action, then continuing the treatment as above named. Where this condition is not so marked, the sulphite of soda may be employed, in doses of five grains every two hours until removed. Even when an emetic has been used, it will be Avell, in some cases, to follow it with the sulphites. In the case named, where the eruption is tardy in its appear- ance, Ave may use the hot-pack or the emetic, or both. In giving a hot-pack, in this case, I have an ounce of mustard added to a couple of gallons of Avater, and Avhen hot Avring a blanket out of it quickly and envelop the child, covering Avarmly with dry blankets or comforts. In the majority of cases it Avill be more convenient to use the stimulant vapor by means of hot bricks, as heretofore named. The emetic of Lobelia is the most poAverful means Ave have, if properly used. It is given so as to produce its general influence, and then carried to thorough emesis, as Avas named in congestive and spotted fever. So also in those cases in which there is a retrocession of the eruption. Theemetic arouses the nervous system, throAvs off the cause, and re-establishes a free and equal circulation of blood. It may be used alone, or associated with the hot stimulant bath. VARIOLA. 199 If the disease sIioavs evidence of a septic condition of the blood, no class of remedies will give better results than the sulphites. The sulphite of soda is probably the best, and may be used freely, the indication being a broad pallid tongue, coated Avith a dirty Avhite fur. If the tongue is red, moist, and covered with a glu- tinous nastiness like fecal matter, sulphurous acid Avill be the remedy, giving it in teaspoonful doses every three hours. Sul- phur may also be burned"in the room to purify the air, and the bed utensils may be disinfected in the same Avay, or by the use of chlorinated soda. In some eases, and these very severe ones, Baptisia Avill be indicated from the commencement. The full leaden or purplish face, like one Avho has been exposed to severe cold, is the best indication for the remedy. Sometimes the patient shows this fullness and unpleasant color over the entire surface, and even the mucous membranes Avill bear the tint. Baptisia is added to the sedative mixture in the proportion of gtt. x. to gtt. xv. to Avater Siv. It is an admirable remedy, and I should hardly know how to treat these unpleasant cases Avithout it. Occasionally muriatic acid, or a good sharp cider, or Avbey, will serve a good purpose; the last making a very good diet drink in these cases. Chlorate of potash Avill sometimes be indicated in small-pox, but in this, as in other cases, we folloAV our nose—the bad odor being the indication. To relieve the unpleasant condition of the throat during the first davs of the eruption, we order a gargle of sulphite of soda, chlorate of potash, or Baptisia, Avhen the child is old enough to use remedies in this Avay. With younger children these remedies may be used Avith a spray apparatus, or by inhaling the vapor from them when heated. Usually, Avhen no apparatus is at hand for using inhalations, Ave will find the vapor of vinegar and water to ansAver a good purpose. To prevent pitting I depend wholly upon cleanliness, keeping the room darkened to obviate the irritant action of light. Using glycerine soap, I have the exposed parts Avashed with a soft sponge several times a day, so as to keep them clean and soft. Occasionally a soft and thin cloth, Avet with equal parts of glyce- rine and Avater, may be used when parts sIioav considerable irri- tation. With quite a large experience in the treatment of the disease, the results of this method have been very satisfactory. 200 DISEASES OF CHILDREN. The sedatives are continued during the Avhole progress of the disease, so as to control febrile reaction ; and generally Avhere the treatment as given is pursued, there Avill be but slight secon- dary fever. When this comes up, however, it is controlled by increasing the frequency of the dose. Throughout the progress of the disease, which is exhausting in its character, especial pains should be taken to prevent irri- tation of the digestive organs, and to support the strength by appropriate food. When the child is nursing the mother's milk is sufficient, and is the best food. At a more advanced age, boiled milk, slightly salted, taken hot, Avill be more kindly re- ceived and better digested than most other food. In some cases it will be necessary to support the strength of the patient by the use of the bitter tonics and iron. Quinine Avith Hydrastine, in doses of one-half grain, is generally our best prescription. This may be aided by the muriated tincture of iron with glycerine, as heretofore named. When the mucous membranes present a dark-red or dusky appearance, the dilute muriatic acid Avill answer the best purpose. VARIOLOID. Varioloid is small-pox modified by the vaccine disease. In some persons the coAv-pox is but partially protective, or it may be wholly protective at first, but as time passes, the susceptibility to the virus of small-pox is gradually reproduced. Upon Lie- big's theory, the material in the blood, upon which the small-pox poison acts, is reproduced in smaller quantity. Varioloid is small-pox in every sense. It is produced by the specific contagion of small-pox, and in turn it generates a virus which will give rise to the fully developed disease in a person not protected by vaccination. It differs only in that the symp- toms are milder, and it runs a shorter course. The symptoms are usually those of the discrete form of small-pox. The febrile action subsides Avith the appearance of the eruption, or in the severer cases is remittent in character, and not severe. The pe- riod of maturation is generally but seven days, and the secondary fever is short and mild. The desiccation and removal of the crusts or scabs is also rapid, so that by the tAvelfth to the fif- teenth day the surface is pretty Avell freed from them. VARIOLA VACCINA. 201 It is not necessary to give the treatment of varioloid, as it would be but a repetition of that just given under the head of small-pox. VARIOLA VACCTXA—COW-POX. Prior to the year 1721, no prophylaxis against small-pox Avas known in Europe, if Ave except the practice of buying the small- pox that prevailed at a very early period both in Wales and Scotland, and Avhich, in fact, was inoculation. The practice of inoculation, according to the statements of the Jesuits, Avas em- ployed immemorially in China, and by the simplest method, that of passing a needle charged with the virus through the skin Avhen it was pinched up by the finger. The practice of inoculation was introduced into England in 1721, by Lady Mary Montague, Avho had Avitnessed its success in Turkey, and had a son successfully inoculated. The practice met with much opposition, as all innovations upon established cus- toms and prejudices do, and it Avas not until about the year 1750, that it received the cordial support of the medical profession. At first a stimulant and heating treatment Avas pursued, as Avas the case in small-pox, and the mortality Avas considerable. After- ward a " refrigerant and reducing" plan Avas adopted, which was attended Avith much success, and from this time the practice came to be regarded with favor. The vaccine disease or coAV-pox, as a prophylactic against small-pox, Avas discovered about the year 1775, by Dr. Jenner, though he did not publish it until 1798. He noticed, Avhile first studying medicine, that in the dairy districts of Gloucestershire, there Avas a current opinion that persons Avho had been affected Avith a peculiar eruption knoAvn as coAV-pox, Avere protected against the contagion of small-pox, and might go among it and nurse persons affected with it, Avith perfect immunity. His mind was strongly impressed with these facts, and he commenced their investigation. It Avas not until 1796, hoAvever, that he became sufficiently convinced to attempt the propagation of the disease by inoculation, or as Ave say, by vaccination. His first case Avas entirely successful, the disease Avas transmitted, the pustules formed as described, and tAvo months aftenvards, upon being inoculated Avith small-pox virus, it was found not to have the slightest influence. 202 DISEASES OF CHILDREN. Dr. Good, in his study of medicine, Avriting about the year 1822, gives the following account of the discovery, which, as a matter of historical interest, I quote: "The disease attracted attention in the county of Dorset, about forty or fifty years since, as a pustular eruption derived from infection chiefly, shoAving itself on the hands of milkers Avho had milked coavs similarly disordered. It had been found to secure persons from the small- pox ; and so extensive Avas the general opinion upon this subject even at the time before us, that an inoculator, avIio attempted to convey the small-pox to one Avho had been previously infected Avith the coAV-pox, Avas treated with ridicule. A formal trial Avas made, hoAvever, and it Avas found that no small-pox ensued. About the same time, a farmer of sagacity, of the name of Nash, duly attending to these facts, had the courage to attempt artifi- cial inoculation on himself; and the attempt is said to have suc- ceeded completely. Similar facts and numerous examples of them Avere accordingly communicated to Sir George Baker, Avho, having engaged not long before in a most benevolent, though highly troublesome controversy respecting the cause of the en- demical colic of Devonshire, Avas unwilling, notAvithstanding his triumph, to tread again the thorny paths of provincial etiology. Gloucestershire, hoAvever, another dairy county, had Avitnessed the same disease Avith similar consequences; and the same opinion generally preATailing in distant districts of both counties, afforded proof that the poAver thus ascribed to coAV-pox Avas not Avholly visionary. " Dr. Jenner, then resident at Berkley, in Gloucestershire, pursued this hint Avith great judgment and unabated ardor. He AA'as at first foiled by not distinguishing between the genuine coAV-pox and an ineffective modification of it, or a spurious dis- ease of nearly similar appearance, to Avhich the same animal is subject, but Avhich is no preservative against the small-pox ; and found another difficulty in determining the period of time Avithin which the vaccine virus maintains its prophylactic poAver. Hav- ing at length made himself master of the distinctive characters of the genuine A'esicle, he ventured to publish the discovery in 1798, and to recommend inoculation with the virus of vaccinia as a substitute for variola." The discovery Avas not received by acclamation, and its discov- erer hailed as a benefactor of his race, as many persons avouUI imagine ; but, on the contrary, it Avas met by ridicule and denim- VACCINATION. 203 ciation, and Dr. Jenner lost business and property, and narrowly escaped personal injury several times at the hands of a mob. The medical profession Avas as sIoav to admit the truth of the discovery, and as fast to cast obloquy on the discoverer, as the people; and it Avas many years before the doctrine and the man were admitted to be orthodox. The disease of the cow is of rather rare occurrence, even in England, and hardly ever manifests itself except Avhen cattle are gathered together in herds. We have no authentic account of it ever having prevailed out of England, and feel sure that it has not occurred in this country. The supposition that it is small- pox modified by passing through the coav is an error reproduced every few years, generally to make a sale for vaccine virus from some particular person. Dr. Jenner thought that he had traced the cause of the disease of the cow to the grease of horses. In regard to this Dr. Good remarks: "It Avas fortunate for Dr. Jenner, and the triumph of his discovery, that a minuter attention to the subject gave sufficient proof that there Avas no foundation for this opinion ; and that Avhatever be the prophylatic poAver of the matter of the disease called grease, this disease is by no means the origin of the natural cow-pox, and has no connection with it." Vaccination.—Vaccination is not so easy an operation as thought by the majority of physicians! True, it is very simple, and there should be no reason for Avant of success, Avhen good virus is used ; yet an extended acquaintance Avith physicians of all schools, proves that from its imperfect or careless perform- ance, it fails fully one-half the time. The causes of failure are tAVo-fold. In one case the skin is not so abraded as to bring the virus in contact with the true skin, where it may be absorbed. In the other the punctures are so deep as to cause a free Aoav of blood, and the virus is Avashed aAvay. A very simple and good method is, exposing the arm at the insertion of the deltoid, make the skin tense with one hand, and holding the lancet in the other at an acute angle with the arm, make many slight punctures over a part as large as a three cent piece, elevating the epidermis Avithout much bleeding. Noav take the virus, softened to the consistence of cream, and spread on the punctures, either letting it dry by exposure to the air, or cov- ering- it with adhesive plaster, before the sleeve is draAvn down. 204 DISEASES OF CHILDREN. When there is a failure with the lancet used in this way, try the Chinese method. Charge a fine needle Avith the virus, raise a portion of the skin betAveen the thumb and finger and pass the needle through. An instrument has been devised for this pur- pose, which answers well, being speedy, certain, and not painful. It consists of a small cupped stylet, throAvn by a spring; the virus being placed in the cup, and the spring draAvn back, it is discharged into the skin Avith a single stroke. Formation of the Vaccine Vesicle.—As a general rule, the punc- ture disappears the second day, but about the fourth or fifth day, a minute inflamed spot is seen. This gradually increases in size, and is swollen and hardened, and forms the base of the vesicle, Avhich is seen first about the sixth day. At first it is spherical and filled Avith a transparent limpid fluid, but as it increases in size it becomes flattened, and Avhen it attains maturity the center is loAver than the circumference. It requires twelve or fifteen days from vaccination for the full development of the vesicle, Avhich uoav presents the folloAving appearauce : It is regular in its outline, being usually ovoid, though sometimes circular in form. The vesicle is uniform in its elevation, usually about one-eighth of an inch, is flattened, or even depressed at the center, and has a peculiar pearly-gray color. It stands upon an indurated and inflamed base, which forms a red areola of from half an inch to an inch outside of the vesicle. About the twelfth day of the vesicle desiccation commences, and in four or five days is complete, though the scale or scab is not loosened for some time. The scar left by vaccination is peculiar, yet is simulated by spurious vaccination. It remains Avhite, the skin seeming to be deprived of its rete mucosum or colored layer, is depressed, the outlines being clean cut and well defined, and presents many7 little pits or depressions into the true skin. Generally there is slight febrile reaction about the eighth day, when the vesicle has attained its maturity. Occasionally there is a marked chill, nausea and vomiting, and for a few hours the child is quite sick. Sometimes the irritation of the arm extends to the axillary glands, and these become enlarged and painful, and in some exceptional cases they have been knoAvn to suppurate. Spurious Vaccination.—Any deviation from the course above described may be designated as spurious, and will not prove pro- VARIOLA VACCINIA. 205 tective. Regular in form, uniform and even border, flattened and of equal elevation, slight depression in the center, pearly-gray in color, uniform period of development about nine days, gradual and even desiccation, and slow detachment of the crust. This is the vaccine eruption, and is so distinctive that I think it need not be mistaken. Spurious vaccine matter is produced in several Avays. It may be from decomposition of the vaccine lymph, by keeping, especi- ally when moistened, and carried in the pocket, Avhere the tem- perature will be high. I Avas acquainted Avith an example of this kind, in Avhich a suppurative disease in some half dozen children was produced by such lymph. The most common cause, as I believe, is the use of second crusts from the \raccine vesicle. In many cases the vesicle having fully developed, the lymph commences to desiccate, but before completion the par- tially-formed scab is rubbed off or is removed by some accident. But another one shortly forms, principally from pus secreted as the result of the irritation. Of course, if this should be used for vaccination avc Avould introduce pus instead of vaccine lymph. If the general health Avas deteriorated in such person, and the blood was bad, and they Avere suffering from any cachectic dis- ease, the results of such vaccination might be very unpleasant. For in some of these cases the pus possesses a peculiar septic property, that Avill cause extensive ulceration. I am satisfied that this Avas the case in the spurious vaccination (from the army) that Avas propagated through many sections of our country, and was regarded by some as syphilitic. In every case that I could trace, the soldiers vaccinated had been in the hospital, with health broken down by the fatigues, privations, and sometimes dissipations of the army. Even when the vaccination was good and protective, which Avas not often the case, a suppurative in- flammation followed at the site of the vaccine vesicle, and the scabs formed contained pus from bad blood. I had a very marked example of such spurious vaccination, in my own practice. A daughter of mine, in perfect health, Avas visiting her grandmother, and a case of small-pox having oc- curred in the village, people became excited, and almost the entire population Avas vaccinated. A young lady employed in the house, having a very perfect vaccine vesicle, the child Avas vaccinated with lymph from her arm, and it also took well, and developed regularly, and Avas as perfect as Avas possible. But, a 206 DISEASES OF CHILDREN. couple of days before coming home, while playing with other children, she struck her arm, and the partly-formed scab Avas detached. But a new one forming, it looked well when I ex- amined it, and as there could be no doubt of the health of both the parties, I concluded that I Avould use it in my practice in place of others. The Avinter course of lectures had just com- menced, and, as usual, I vaccinated a majority of the students, using this virus. It did not produce the characteristic vaccine disease in a single instance, but quite a number bad very sore arms. Four Avere so severely affected as to be confined to their rooms, and in one the local ulceration and infiltration of tissue AAras such that I feared the gentleman would lose his arm, if not his life; but, having a good constitution, he recovered. This unpleasant experience has caused me to be very careful in the use of vaccine, and, under no circumstances, will I em- ploy a second scab, Avhether the first has been detached naturally or by some injury. Can Syphilis be Transmitted by Vaccination ?—I ansAver this question in the negative, to this extent—that the use of vaccine lymph will never convey the disease. To make the ansAver plainer, Avhere the vaccine disease runs its regular course, and the vesicle formed presents all the characteristics of that de- scribed, tlie lymph from this is like pure gold, and is not influ- enced by any constitutional peculiarity or any disease of the patient. But if it varies from this standard, is irregular in form and elevation, and yclloAvish or pus-like in color, then disease may be transmitted, for it is not vaccine, but something else. Or, if running the normal course of the vaccine disease, there is after- ward irritation and ulceration, pus being formed, this may be in such quantity in the scab, especially at its base, as to be a cause of disease. Or if the first scab is detached by injury, the second one, being formed principally of pus, the use of this for vacci- nation may transmit disease from one to another. For many years the medical Avorld, following the lead of Ricord, denied that secondary lesions Avere transmissible. Hence, syphilis could not be transmitted as above, unless there Avas a primary source at the part of vaccination, Avhich could only occur by careless handling of a person having the primary dis- ease upon the genitals. But it is now conclusively proven, and even Ricord admits, that certain secondary lesions may be trans- RUBEOLA. 207 nutted by inoculation, and among these are pustular eruptions. Thus Ave have an additional reason for care that the lymph we use is the normal and regular product of good vaccination. This we can ahvays determine, while it would not be possible for us to learn or discover constitutional taints upon the part of many patients. That our population is being slowly and insidiously infected Avith syphilis, through vaccination, as some would have us be- lieve, has no foundation in fact. On the contrary, the spread of the disease depends upon the licentiousness of the people, especi- ally the young men of the country, and the Avant of laAVS regulat- ing houses of prostitution. Preservation of Vaccine Lymph.—Vaccine lymph undergoes spontaneous decomposition, or at least loses its specific properties in a period varying from tAvo to eight weeks. Hence extra pre- cautions are required to preserve it from season to season. It is most convenient to vaccinate from the crust or scab, and this is most commonly used. For a short time it may be kept betAveen two pieces of wax, or inclosed in this manner, additional security may be given by an envelope of tin-foil. But when Ave wish to keep it through the summer, Ave eiwelop the scab in tin-foil, pressing it down tightly, so as to render it Avater-proof, and drop it into a bottle of glycerine. I do not know how long it might be preserved in this Avay, but I have kept it in an active condi- tion for a year. RUBEOLA—MEASLES. Measles is a disease of childhood, though it may occur at any age, and becomes more dangerous as the person is advanced in years. Like the other eruptive fevers it is caused by a specific contagion developed during the progress of the disease, and may be propagated in the same Avay, by contact or by breathino- an atmosphere impregnated with the poison. Like the others, it also prevails in cycles of from five to seven years. In some sea- sons and localities it Avill appear in a very mild form, while in others it Avill be more or less malignant. Svmptoms.—From seven to fourteen days after exposure, the disease is ushered in with a chill, sometimes slight, at others amounting to a rigor. Occasionally for a day or tAvo before this the child manifests catarrhal symptoms, has a slight cough, and 208 DISEASES OF CHILDREN. may complain of pain in the head and back. Following the chill, febrile reaction conies up, but varies greatly in different cases. In some it is quite active, Avith a flushed hot skin, frequent, full hard pulse, and considerable irritability of the nervous system.* in all cases the catarrhal symptoms are so prominent and constant, as to be regarded as almost pathognomonic. About the time of the chill, the child seems to have taken a severe cold, sneezes frequently, stuffing up of the nose, Avith increased secre- tion and discharge, redness and watering of the eyes, increased sensibility to light, hoarseness, and a troublesome dry bronchial cough. The febrile reaction is usually remittent, and continuing to increase gradually to the second, third, or fourth day, then de- clines after the eruption has fully made its appearance. The eruption conies out first on the face, neck and breast, then on the balance of the trunk, and finally upon the extremites. The single point of eruption is much the color of a musquito bite, ovoid or irregular in form, especially irregular in its border, and the color is gradually shaded off to the color of the skin. The points of eruption generally coalesce, so as to present larger patches or blotches. In very severe cases, the whole surface will be thus covered so as to present but little of sound skin. The eruption is slightly elevated, and rough when the finger is passed over it, and pressure momentarily removes the color. It requires from twenty-four to seventy-two hours for the full appearance of the eruption. It retains about the same degree of redness for one or two days, and then slowly declines, so that about the sixth to the ninth day from the chill, it has passed aAvay. During the one, tAvo or three days in which the eruption is coming upon the surface, the fever is higher than before, and sometimes the little patient is quite sick, even in the ordinary form of the disease. Then it declines, sometimes slowlv re- appearing at times until the efflorescence has entirely passed away ; at others, the little patient will be free from it in the course of a day. With the appearance of the eruption the bronchial irritation and cough are markedly increased in some cases, and become very troublesome. There is also more or less difficulty of breath- ing, which sometimes depends upon determination to, or conges- tion of the bronchial tubes, and at others upon similar lesions of the parenchyma of the lungs. The part affected, and also RUBEOLA. 209 the character of the lesion, may be determined by physical examination. Ma lion ant Rubeola.—As named above, measles prevail with varying degrees of severity, from the very mild to the most malignant. We will also find that all the cases of a season re- seinble one another—Avhen the disease is mild, all cases are mild—Avhen it is severe, all cases are severe. Of the cause of this malignancy Ave know but little, further than that the conta- gious virus once attaining malignancy, propagates itself in the same Avay. In one class of cases .the eruption is tardy in its appearance; the fever running a pretty active course, with considerable bronchial disturbance, the third, fourth, fifth, or sixth day passes Avithout its full appearance. The surface seems slightly SAvollen and flushed, and in some places the eruption is seen indistinct as if struggling to make its appearance. In the children of my oavu family, the eruption made its appearance, respectively, in five, eight, and thirteen days from the chill. Necessarily, in such cases the blood must become impaired by the long retention of the rubeolous poison, and the symptoms presented will be more or less of a typhoid character. In another class of cases, the symptoms of malignancy are manifested early in the disease. The pulse is smaller and faster, the skin flushed, but dry and husky, and the tongue covered with a dirty fur with a tinge of broAvn. The nervous system suffers especially in these cases. In some there is great excitement for the first day or tAvo, even delirium, or occasionally convulsions, afterwards coma. But in the majority of cases dullness and hebetude are marked symptoms, the child dozes with its eyes partly open, and early coma comes on and gradually increases until the child can not be aroused from it. In all of these severe cases the eruption is more or less dusky, and Ave may judge very closely of the severity of the disease by this. It Avill also be a guide in the treatment. Means that brighten the color of the eruption are beneficial, but if the duskiness increases, avc may be satisfied that our treatment is productive of no benefit. Retrocession.—There may be a retrocession of the eruption of measles, at any time after it has appeared. In the milder form of the disease, this increases the fever and the bronchial 14 210 DISEASES of children. irritation, and though unpleasant is not dangerous. But in other cases Ave will find the nervous system suffering severely from the retrocession, and if it continues the blood also becomes impaired. In these cases dullness, stupor, and coma folloAV one another rapidly; the skin is dusky, the temperature increased, and the tongue soon becomes brown, and sordes appear upon the teeth. These symptoms are of a grave character, and unless prompt means are employed to bring the eruption again upon the sur- face, it may terminate fatally in a short time. The Sequels of Measles.—An irritation of the bronchial tubes and larynx, Avith a harassing cough, is very frequently left from measles. In some cases this seems to be the result of cold taken during the progress of the disease, or more frequently, shortly after the child has commenced getting about. The cough is very harassing, causes restlessness and broken sleep, affects the appetite and digestion, and indeed, all of the vital functions. Continuing, the bronchial irritation produces structural change, and after a time deA^elops true phthisis. A less common sequel of measles, is a subacute inflammation of the conjunctiva, principally confined to the lids, and finally terminating in granular lids, or ophthalmia tarsi. In some other cases, otorrhcea results, and proves very stub- born. Deafness, partial or total, may also be produced by measles. The partial deafness is usually OAving to disease of the Eustachian tubes, though it is sometimes of the middle ear. Diaonosis.—The marked catarrhal symptoms is the principal diagnostic feature in the early stage of this disease, as the severe pain is in small-pox, and the sore throat in scarlet fever. We distinguish the eruption by its irregular form, coalescing in blotches, not presenting the hardness of small-pox, or the vivid redness of scarlet fever. Prognosis.—The prognosis in measles is favorable; even in the malignant cases, if properly treated, there should be but a small mortality. It is true that in some epidemics in large cities, the disease is very severe and typhoid in its character, yet I think that the great mortality attending it is to be attributed to the medication as much as to the disease. RUBEOLA. 211 Treatment.—The treatment of measles is usually very simple. Bathe the patient's feet for half an hour in hot Avater, and give internally an infusion of two parts of Asclepias and one of Lobelia herb. It need not be given to produce nausea, though to the extent of slight nausea it favors the appearance of the eruption. After the eruption has made its appearance I fre- quently continue the same remedy in small doses, to relieve the bronchial irritation and check the cough. In place of this Ave may put the patient upon the use of Vera- trum or Aconite, in small doses, with gtt. x. to gtt. xx. of Lobelia to Avater Siv., using the general sponge-bath at first, and the hot foot-bath to favor their action. This is not associated with Avarm teas and stimulants as so commonly used, but on the contrary the patient is kept quiet in bed, not too Avarmly covered, and is allowed cool drinks. If the cough is \rery troublesome, Ave may give an infusion of dried red clover, or from the pocket ease, Tinct. Drosera gtt. x. to gtt. xx., water 5i\\, a teaspoonful every three hours. If there is anything specific in medicine it Avill be found in the use of Drosera in the cough of measles and in Avhooping cough. O loo In some cases Ave find the patient very restless, starting in sleep, Avith shrill cry, and Ave fear convulsions. The pulse is small and sharp, and the skin dry, contracted and burning. The remedy here Avill be Rhus, and its action is very prompt and kindly. Gelseminum, Bryonia, Apis, Phytolacca, Eupatorium, and other remedies, Avill find a place in the treatment of this dis- ease, being guided by the special indications as heretofore given. When bronchial irritation is great, or passed into the state of inflammation, Ave will find the use of an inhalation of the vapor of water, either alone, or medicated Avith Lobelia, or with some of the narcotics, will answer a better purpose than the usual inter- nal remedies. A mush poultice applied to the chest in older children, and continued until the irritation is relieved, ansAvers a good purpose. But with young children I prefer a cloth spread Avith lard, and sprinkled Avith the emetic poAvder of the Dispensatory. Much care is required after the disease has subsided in order to confirm convalescence. The clothing should be warm, and the child not permitted to expose itself to draughts of air. If this is attended to and the secretions kept free, there is no more danger from measles than from any other disease. 212 diseases of children. Iii malignant rubeola we will have to give the case closer atten- tion. The first evidence of the character of the disease in young children will be manifested in the stupor and tendency to coma. This will be met by the use of Belladonna with Aconite, in the doses heretofore named. Though the case seems grave to trust to such small doses, yet a considerable experience has given me great confidence in Belladonna as a specific against congestion, especially of the nervous system. With this I put the patient upon the use of the anti-zymotics, to antagonize the septic condition of the blood; either of these remedies may be indicated. Sulphite of soda, if the tongue is broad, pallid and dirty ; sulphurous acid, if it is deep-red and moist, and covered with a glutinous nastiness; muriatic acid, if it is deep-red, contracted, dry and coA7ered Avith a broAvn coat; Baptisia, if the patient sIioavs that full livid face as of one ex- posed to se\Tere cold; and chlorate of potash, if Ave ha\re the peculiar odor as from cynanche maligna. When the eruption is tardy in making its appearance, the patient being depressed, Avith stupor or coma, Ave may place great dependence upon the action of an emetic. Or Avhen a retroces- sion of the eruption takes place, with the same symptoms, it is the most certain means of treatment. I prefer in these cases the acetous emetic, and give it so as to get a gradual influence upon the system, then carry it to thorough emesis. This may be folloAved by the Aconite and Belladonna, and the sulphite of soda, as named above. To arrest the harassing cough that so frequently remains after the eruption has disappeared, I prefer either the infusion of clover hay, as before named, or the Tinct. of Drosera 5ss., to Avater 5iv., a teaspoonful every four hours. These remedies Avill be found much better than the ordinary cough medicines in use. SCARLATINA. This is essentially a disease of childhood, and feAV persons will take it after the age of twenty. Unlike measles, it is also milder, as the patient is older. It is propagated by a specific contagion, either by inhaling the exhalations, or contact with the clothes of the patient. In some seasons it becomes epidemic; doubtless because the poison is so intense as to be propagated readily and at a considerable distance, and the condition of the atmosphere SCARLATINA. 213 is favorable to the ready propagation of a zymotic disease. Scar- latina has been divided into three forms : S. Simplex, S. Angi- nosa, and S. Maligna, differing in their intensity, severity of symptoms and fatality. In some seasons the disease will present the character of the first exclusively, in others it Avill be of the anginose form, and again every case will be malignant. Symptoms.—From six to eight days elapse after exposure be- fore the disease makes its appearance, and it is usually ushered in Avith a chill. In scarlcdina simplex the chill is not very Avell marked, and lasts but a short time. The fever folloAving presents the common symptom?, increased heat of skin, arrest of secre- tion, frequent pulse, loss of appetite, etc. In the course of from six to tAventy-four hours, the eruption makes its appearance, in the shape of patches of efflorescence upon the fiice and neck, then extending to the body. If the eruption is minutely ex- amined, it will be found to consist of an infinite number of small red points, the rose-colored ground being simply the base upon which they stand. Soreness of the throat, with slight difficulty of deglutition, appears at the commencement, though not usually severe, or accompanied Avith tumefaction. For eighteen to forty- eight hours after the appearance of the eruption the fever con- tinues as before, but then rapidly abates, and in from three to five days the redness disappears, and is followed by branny desquamation of the cuticle. In scarlatina anginosa, the chill is usually marked, there is nausea and vomiting, pain in the head and back, thirst, etc. The fever Avhich folloAvs is intense, the skin is dry, husky and burn- ing, the eyes dry and painful, the face congested and tumid, boAvels constipated, urine is scanty, frequently voided and high- colored, with marked irritabillity of the nervous system. Sore- ness of the throat, with difficult deglutition, is complained of from the first, and on examination Ave find the fauces tumid and red, and the tonsils someAvhat SAvollen. The nares are frequently implicated with the angina, and there is consequent stuffing of the nose, Avith difficult respiration and increased restlessness. The eruption sometimes makes its appearance during the latter part of the first day of the fever, but more frequently not until the second or third day; about the third or fourth day it has reached its bight. At the commencement there appears a slight tumefaction of a portion of the surface, which gradually 214 DISEASES OF CHILDREN. assumes a scarlet color, and the minute red points are devel- oped. These patches increase in size until the greater portion of the surface is involved. During the eruption there is an ex- pression of anxiety and suffering ; the child is restless and uneasy, and sleeplessness, which resists the usual means of rest, is caused by the heat and stinging of the surface and soreness of the throat. The throat affection is here the most prominent feature ; the soreness increases, the mucous membrane and subjacent tissue are engorged and tumid, and the secretion from the mucous follicles and salivary glands so viscid and tenacious as to cause great distress. In some cases, ulceration commences by the fifth or sixth day of the disease, and the secretion is difficult of re- moval and exceedingly offensive; occasionally the ulceration assumes a phagedenic form, and speedily terminates the life of the patient. Frequently enlargement of the cer\rical lymphatics commences from the third to the sixth day, and if not promptly treated, terminates in inflammation and suppuration. The fever, under appropriate treatment, commences to abate Avhen the erup- tion has made its appearance, and disappears entirely by the fourth or sixth day, Avhen desquamation commences. As this progresses the surface becomes paler, the epidermis exfoliating in whitish scales, or in large pieces when it is thick. Sometimes desquamation is retarded for tAvo or three weeks. Scarlatina maligna might be divided into two kinds, the dis- tinctive symptoms being marked. In the one case there is marked evidence of prostration from the commencement. The chill is greatly prolonged, and the child seems dull and stupid, the countenance vacant or besotted. Febrile reaction conies up sIoavIv, the body becomes hot, the heat being pungent, but the extremities are cold. The pulse is frequent, but soft and fluent, or else small and wiry. Frequently there is nausea and vomit- ing, sometimes diarrhoea. The tongue is broad, flabby, and coa-- ered Avith a foul, dirty mucus, and the patient has difficulty in controlling its movements. The eruption makes its appearance slowly, the redness being more or less dusky. The throat affec- tion possesses the same characteristics; there is difficult degluti- tion and respiration, the mucous membrane presenting a dusky, tumid appearance. Ulceration is of frequent occurrence, their surfaces being foul, the edges ragged, and a strong tendency to phagedena. Enlargement of the cervical lymphatic glands is very common, with a tendency to the formation of a diffusive SCARLATINA. 215 abscess, and also, if the patient lives, to the formation of sec- ondary abscesses. As the disease progresses the symptoms are all of a typhoid character; there is the dark tongue, sordes on the teeth, feeble pulse, great oppression of the nervous system, tendency to diarrhoea, tympanitis, etc. In the second case, the disease exhibits but few, if any, pre- monitory symptoms. The child is attacked suddenly; the chill lasting but a quarter or half an hour, is not Avell marked, and is succeeded by the most intense febrile reaction. The skin is in- tensely hot, dry, and husky ; the mouth parched and dry; the eyes injected, dry, brilliant and painful. The patient is either delirious or suffers sitch intense pain as to be almost unconscious of what passes around him. There is nausea and vomiting, the irritation being sometimes so intense that nothing can be retained on the stomach. In these cases the patient is frequently ex- hausted by the intense reaction, and dies before the appearance of the eruption, or during the time that nature is trying to throAV it on the surface. In the last two forms of the disease, and sometimes in the simple form, avc observe a want of poAver upon the part of the system to determine the eruption to the surface. In such case the skin appears tumid and dusky, there is tendency to coldness of the extremities, and marked oppression of the nervous system. In such case, prompt measures must be taken to bring the eruption to the surface, or the patient will die. Again, Ave observe cases in Avhich the eruption comes out, but, from some cause, it retro- cedes; in this case the same alarming symptoms manifest them- selves. In other cases, the anginose affection is so severe that it seems that the patient has not sufficient poAver to carry on respiration; sometimes the difficulty depends upon the secretion of a viscid, tenacious mucus. Diagnosis.—Scarlet fever is diagnosed from other diseases of the skin by the rose-colored efflorescence, upon Avhich are the innumerable small red points. A marked characteristic of the disease is the fact that the redness is effaced by pressure, and does not return for some little time. Thus, by taking a pencil or the finger-nail Ave can Avrite our name, Avhich remains for a moment, and then gradually fades out. Prognosis.—In the simple and anginose forms of the disease, the prognosis is favorable. In the malignant form, unless the 21G DISEASES OF CHILDREN. treatment is prompt and effective, the prognosis is unfavorable. In all cases, if the eruption becomes dusky, if coma or typho- mania ensue, or if the tongue becomes brown and foul, it is unfavorable. Sequelae.—Among the most frequent of the sequelae of scarlet feArer, are diseases of the kidneys, consisting of simple exhaustion and Avant of poAver to secrete, chronic inflammation and albuminuria. In the first Ave notice a marked dullness and hebetude, the appetite is poor, the bowels irregular, marked debility and tendency to cachectic diseases, the blood being greatly impaired. In the second, the pulse is hard and frequent, the dryness and huskiness of the skin continue, there is pain and soreness in the back and loins, the appetite is poor, the tongue dry, whitish, and fissured. In the third, dropsy makes its appearance when the child is supposed to be convalescing. Continued disease of the throat, Avith irritation and enlargement of the cervical lymphatic glands, is sometimes observed. Ozaena, Avith weakness and irritation of the eyes, and chronic disease of the ears, attended by purulent discharge and partial deafness, is not unfrequent. Treatment.—In.the treatment of this disease it is Avell to have some Avell-defined line of action—to determine exactly Iioav Ave can benefit our patient. We knoAA', by experience, that the higher the fever, and the longer it continues before the appear- ance of the eruption, the greater the danger, and that the case also becomes critical in proportion to the amount of eruption and arrest of secretion. Thus, in all cases, it is good practice to use such means as will control the primary fever, and favor the early appearance of the eruption. I have already mentioned, when speaking of small-pox, that keeping the secretions free during this period lessened the amount of eruption ; this is the case here; hence depurants are advantageous. Care must be used, hoAvever, not to overstimulate either the skin, the kindeys, or the bcnvels. If the first, Ave Avill have too free eruption, and after- Avard inaction; if the kindeys, secretion may be arrested, or albu- minuria induced ; if the boAvels, it may cause retrocession of the eruption, or very great Avrong of sympathetic innervation. In scarlatina simplex Ave put the patient upon the use of Tinct. of Aconite and Belladonna—the usual doses repeated every hour. The alkaline bath is used sufficiently often to keep SCARLATINA. 217 doAvn the heat of the skin, and render it soft and pliable. If the skin is inactive the bath may be hot; sponging the child with water as hot as can be borne, stimulates the capillary circulation, and brings the eruption, to the surface. This may be done before the fire, covering the patient with a blanket, or it may be done under the bed-covering. It is Avell to say to the nurse, in these cases, " if the child complains of any part, sponge it Avith hot Avater, and cover Avith dry flannel." Generally Ave will find that these means relieve the irritation, the feA'er is lessened, and the eruption comes out early; and con- tinuing these for tAvo or three days, there is but little fever after the eruption has made its appearance. The treatment for the throat will consist of the use of occa- sional inhalations of one part of vinegar to three of water, and a flannel Avrung out of equal parts of vinegar and Avater and ap- plied around the throat, Avith a dry flannel over it; this may be changed every half hour or hour, and as the disease subsides may be replaced with a dry flannel. In some cases no applica- tion to the throat is necessary, patients doing better Avithout it. In some Stillingia liniment may be used once a day. In scarlatina anginosa we adopt pretty much the same treat- ment. If the febrile reaction is high Ave may add Veratrum to our sedative mixture, or Ave may substitute it for the Aconite. We do not expect immediate sedation, indeed it is not desirable, but as the remedies gradually influence the circulation, many of the unpleasant symptoms pass aAvay. In some cases there Avill be marked irritation of the nervous system, Avith determination of blood to the brain. In these Ave replace the Belladonna Avith Gelseminum, continuing it until these symptoms have disappeared. In other cases there will be marked indications for Rhus, in the sharp stroke of the pulse, pain in the forehead, starting in the sleep, shrill cry, etc. This remedy is also indicated by burn- ing of the surface, Avith extreme nervous irritation, and whilst it favors the appearance of the eruption, it promotes functional activity of the skin. Apis will be indicated by itching of the surface, and pinkish coloration of the face. Baptisia Avill be suggested by the full face, someAvhat dusky, and by duskiness of the eruption. The disease of the throat, which in this case is the most promi- nent feature, will demand much attention. The vinegar pack is 218 DISEASES OF CHILDREN. the best external application here, as it Avas in the preceding case, and should be continuously employed. The inhalation also offers the best local application to the affected mucous surface. The simple inhalation of the vapor of water, or of AA'ater and vinegar, or an infusion of hops, of German chamomile or garden tansy, Avill give great relief, and repeated every two, three, or four hours, will be sufficient in many cases for the permanent cure. When additional remedies are deemed necessary, they are best prepared in poAvder with gum arabic and sugar, and alloAved to sloAvly dissolve upon the tongue. We may thus use chlorate of potash, Ilydrochlorate of ammonia, sulphite of soda, borax, alum, etc. Used in this Avay, they relieve dryness of the throat, and the constant desire to SAvalloAV, which is so unpleasant. If there is a marked tendency to enlargement of the lym- phatic glands, I administer Phytolacca, alternated with the rem- edies that have been named. It has been my experience that if remedies are carefully selected, Ave will have but little glandular trouble. Phytolacca is an excellent external application, or in place of this, especially if suppuration is threatened, a solution of salicylic acid and borax, aa. 5j- to Avater Oj. may be employed. Boracic acid in solution, 3j- to Oj. of water, is also a good appli- cation. In the first case of scarlatina maligna, I employ Aconite and Belladonna in the usual doses, using stimulant hot sponge-baths and the hot mustard foot-bath, to aid in restoring an equal and free circulation of blood. The indications for remedies are care- fully noted. Baptisia is frequently indicated by duskiness of the skin and even of mucous membranes; Rhus by the sharp stroke of the pulse, starting in sleep, and contraction about the base of the brain; Phytolacca by the soreness of mouth and SAvelling of the cervical lymphatics; Ipecacuanha by irritation of the stomach and diarrhoea; Nux by the nausea and vomiting, associated with nervous prostration, etc. As typhoid symptoms rapidly develop, Ave select our anti-zy- motic early, sometimes commencing its use at our first visit. The pallid, dirty tongue (not a common case) is met by sulphite of soda ; the red tongue, with glutinous dirty coat, calls for sul- phurous acid. The latter remedy is indicated in a large number of cases, and is not only one of the best for internal administra- tion, but also as a topical application to the throat. In severe cases it may be used Avith a spray apparatus. Muriatic acid may SCARLATINA. 219 be added to the child's drink when the indication is strong— o the deep red tongue. Baptisia has already been named, the in- dications being dusky coloration of face, surface, tongue, and throat Chlorate of potash is indicated by the peculiar fetor, as from cynanche maligna, and may iioav be used as an internal remedy, as a gargle, or as a spray. The throat receives the same treatment as the preceding case Avith the addition of an infusion of Baptisia tinctoria as a gargle, if it can be used in that way; if not, by a spray instrument, or by inhalation of the vapor. I Avould also give it internally, a teaspoonful every tAvo or three hours. If the throat is tumid and dusky, or is ulcerated and sloughy, boracic acid or thymol in solution Avill be found an excellent application. The sulphu- rous acid, one part to four of water, is also very good Avhen used with the spray apparatus. In very severe cases, when there is marked torpor of the nervous system, Avith rapidly approaching coma, I prefer to commence the treatment Avith an emetic. I use the acetous tincture of Lobelia and Sanguinaria. and give it so © 4 o as to obtain a prompt and thorough action. It should relieve the depression of the nervous system, and produce a free and equal circulation of blood. If the eruption should not appear at the usual time, the symptoms becoming grave as named, I should also use the emetic, as I Avould if there Avas a retrocession of the eruption. In this, as Avell as the other forms of scarlatina, in some cases, I prefer fatty inunction to the use of the bath. It relieves the irritation of the skin, keeps it soft, and thus favors some se- cretion. Many physicians direct their patients rubbed with a bacon rind. A prominent Homoeopath of my acquaintance places much dependence upon it. Instead of this I use lard alone in the first forms of the disease, and an ammonia inunction (hyd. ammonia 5j, lard §ij.) in the malignant form. In congestive diseases it has been recommended to sponge the surface with a solution of carbonate of ammonia, or liquor am- monia. Several cases are recorded of malignant scarlet fever, purpura hemorrhagica, and typhus fever, in which it Avas em- ployed with advantage. In using it, one ounce of muriate of ammonia is added to tAvo quarts of hot Avater, and applied freely. The carbonate may be used in the same proportion in diseases of children. 220 DISEASES OF CHILDREN. It must not be forgotten that this, like other diseases, will vary in different years. In one season fatty inunction is one of our most important means, and Avater seems to exert an unpleas- ant influence upon the skin. But in another year, the fatty. matter can not be used, for it seems to close the skin up and pre- vent excretion, and Ave are forced to use soap and Avater for its removal, and afterAvards employ baths. I have had most admi- rable results from hot sponge baths, as I have had from the ammonia just named. I may also note that tincture of muriate of iron has also been used in scarlet fever Avith advantage. It is given after the erup- tion has made its appearance; the combination with glycerine is the best form, and this may also be used as a gargle. It will also be of advantage during convalescence, and Avill tend to prevent dropsy and the other sequelae. The enlargement of the lymphatic glands is a source of much trouble in this form of the disease, appearing frequently when the patient is apparently convalescent. I prefer an application of the Salicylic Acid and Borax aa. 5ss., to Avater Oj., or some- times double this strength. If it becomes evident that suppura- tion Avill occur, no benefit will folloAV from trying to keep it back; indeed Ave would thus endanger diffusive abscess. To hasten suppuration, we apply a poultice of a decoction of cornus, thickened Avith Avheat bran or poAA'dered ulmus, or of equal parts of hydrastis and elm. It is Avell to continue the use of the salicylic acid solution with the poultices, as a preventive against diffusive abscesses and purulent absorption. And should there be symptoms indicating this result, put the patient upon the use of sulphite of soda, and give quinine and iron, Avith stimulants, if needed, and a nutri- tious diet. If the lymphatic inflammation goes on to suppurotian, it is well to open the abscess early, and not let the pus burroAV in the tissue. This not only relieves pain, but it lessens the danger of secondary abscesses. The first intimation of dropsy should be noticed, and appro- priate treatment adopted. Usually Ave will note its appearance in a swelling of the upper eyelids, and sometimes in a night the eyes will be closed. (Edema of the feet is also common, and in either case albumen will probably be found in the urine. In the PERTUSSIS. 221 majority of cases Apocynum, with the small dose of Aconite, Avill be the remedy. If not, we will probably choose betAveen Aralia and sulphate of manganese. PERTUSSIS-WHOOPING-COUGH. This is eminently a contagious affection, though Iioav it is propagated is more than is known. Usually it is contracted only when children are brought in such immediate proximity that the breath or exhalations of the diseased person are inhaled ; this, hoAvever, is not ahvays the case, as the poison seems to contami- nate the atmosphere, so that persons take it wheu at considerable distance from those having it. It is undoubtedly a disease of the nervous system, the parts implicated being the pneumogastric nerve and medulla oblongata at its origin. And yet, post-mortem examination has not sIioavii any more serious lesion of the medulla than evidence of deter- mination of blood, Avhich Ave Avould be likely to find in any case of such prolonged irritation of the parts to Avhich the nerve is distributed. Like other contagious diseases, it runs a very regu- lar course, and gives immunity against a subsequent attack. Symptoms.—Whooping-cough manifests itself at first as a simple catarrh, the cough being gradually developed. Some days elapse before there is anything distinctive in it; and it is not usually Avell marked under from two to four Aveeks. The cough differs from others in that it seems to arise from an ob- struction to respiration, and forcible inspiration is taken, and then there is a series of short expulsions until the air is all ex- pelled. The tendency to cough still continuing, produces great distress, ami more or less evidences of impaired respiration are noticed. The whoop is developed when the cough becomes in- tense, and is the shrill sound formed as the air is drawn through the yet contracted larynx in the forcible inspiration succeeding the cough. The cough is paroxysmal, the paroxysms recurring at longer or shorter intervals, in proportion to the severity of the disease. There is a secretion of glairy mucus in most cases, which is raised at the latter part of the cough, and frequently seems to increase the suffering. If the disease is very severe, and some- times Avhen mild, there is a free yellowish expectoration. There 222 DISEASES OF CHILDREN. is frequently some fever at the commencement of the disease, and it may occur during its progress. Writers divide pertussis into three stages: the first, lasting from five to fifteen days, presents the symptoms of ordinary ca- tarrh ; the second, lasting from three to six Aveeks, presents the peculiar whoop, which gives name to the cough ; and the third, of variable duration, is the period of decline. It is during the second stage of the disease that the symptoms become so aggravated as to demand relief. We sometimes see the paroxysms of cough so severe that the little patient will turn purple in the face, gasp for breath, and even for some time after- Avard exhibit marked evidences of imperfect respiration. Occa- sionally bronchitis sets in and is very troublesome; sometimes there is marked congestion of the lungs; at others, the frequent and seATere paroxysms of coughing prevent necessary rest, derange the functions of the body, and Avear the patient out. In some cases there is a tendency in the disease to recur for months after it has ceased, on exposure to cold, though almost ahvays in a mild form. Instead of impairing the strength of the lungs in feeble children, it seems rather to have increased it, and may sometimes be regarded as of marked advantage to the child. Diagnosis.—In the first stage it is with difficulty recognized, but in the second, the paroxysmal character of the cough, its long continuance Avithout seeming cause, and the peculiar Avhoop, are sufficient for the diagnosis. Treatment.—Except in some rare cases I discard all of the old methods in the treatment of this disease, and rely Avholly on specific means. We get a clear idea of the variability of named diseases in this study, because it belongs to the class of conta- gious diseases, is produced by a specific poison, and has symp- toms so characteristic that it cannot be mistaken, and to the cas- ual observer all cases are alike except as to severity. Yet Ave find that it is not ahvays the same disease, but varies from season to season, and the remedy that cures it iioav may be of no service in the next recurrence of the disease. If one Avill but think, it is just the same Avith other coughs. We have a group of remedies for whooping cough, all of them good, all of them specific, if we haA'e the right indication. They are Nitric Acid, Belladonna, Drosera, Bromide of Ammonium. PAROTITIS. 223 yitric Acid is an old remedy, and a very good one, but will not benefit all cases of Avhooping cough—which are the cases? If the tongue has a violet color, showing over red, the remedy Avill cure Avhooping cough, as it Avould cure ague, or any other curable disease, Avith the same symptom. Belladonna is also an old remedy, and a most excellent one, but it Avould not relieve the nitric acid cases. What cases will it cure? When the patient is dull and inclined to sleep, (the eyes are dull, the pupils dilated,) just as it is the remedy in other diseases showing these symptoms. Drosera is the remedy for the cough of measles. There is something peculiar about this cough which Avill be readily rec- ognized, and it is based upon a peculiar catarrhal condition of the mucous membranes. Whooping-cough may sIioav these very conditions, and if so, Drosera is the remedy. Bromide of Ammonium is peculiarly the epileptic remedy, and if our whooping-cough shoAVs the peculiar convulsive condition, Ave expect to relieve with this agent. What may Ave say then? Why certainly' that Ave ha\Te four classes of Avhooping-coughs, distinct and separate, and which may be diagnosed, and the right remedy selected. PAROTITIS. Parotitis, or mumps, belongs to the class of diseases Ave have been studying, as it is caused by a specific contagion, generated during the progress of the disease, propagated by contact, and Avhen a person has had the disease there is subsequent immunity. In the case of small-pox the contagious material is something tangible ; in scarlatina and rubeola there is a distinctive disease of the skin, and may be such change that it is propagated by the epidermis thrown off, or by the excreta in breath, from skin, kidneys and bowels. But in Avhooping-cough and in mum [is Ave do not know the character of the contagion, or Avhy in the one case it should involve the medulla oblongata, and in the other case the parotid glands. Pathology.—Arising from a specific contagion, to Avhich the patient has been exposed, usually by contact, Ave find the disease manifesting itself in a peculiar inflammation of the parotid gland. I say peculiar, because there is but little exudation of plastic 224 DISEASES OF CHILDREN. material, and but little tendency to suppuration. In some cases, indeed, it seems but little more than an irritation Avith marked determination of blood, Avith some Avatery or serous effusion into the tissues. In other cases the inflammatory symptoms are all Avell developed, and the function of the gland entirely'suspended. Other glandular tissues may be involved. Thus we have a me- tastasis of the disease to the testes in the male, and to the mam- mary glands in the female, and I have noticed disease of the thyroid, and I think of the thymus bodies. Symptoms.—The period of incubation varies from five to twelve days, during Avhich the person has no symptom of the coming trouble. Frequently he Avill go to bed Avell, and aAvake Avith SAvelling about the jaAvs and ears, stiffness of the neck, and Avhen he sits down to his breakfast Avill find both mastication and deglutition difficult. Acids increase the pain, and a very common domestic means of diagnosis is to have the patient try to eat a pickle, Avhen the sharp pain about the articulation of the jaAv soon tells the story. • In some cases the disease will be ushered in with headache and pains in the back and extremities, a Avell marked chill, followed by febrile reaction In these cases the inflammatory action runs high and the pain in and about the parotid space and ear is ex- quisite, and the patient can hardly eat or speak because it in- creases it. The fever Avill continue one or two days, and then pass aAvay with increased excretion, but the parotial inflamma- tion and SAvelling will continue for five or six days, and then slowly pass aAvay. But one side may be involved in the attack, and it is thus claimed that the person may contract the disease again on subse- quent exposure, the other parotid being involved When there is a metastasis to the testes, the patient feels a deep aching dragging pain, with occasional lancinating pains through the organ. The slightest touch or pressure occasions exquisite pain. The testicle is found greatly SAvollen and red- dened; very rarely both are affected at a time, but occasionally one is involved, and as the acute symptoms subside, the other testicle SAvells and becomes tender. In these cases the fever is likely to recur, and the secretions are arrested. Mastitis is not so common, yet I have seen cases in which the breast Avas very sensitive and painful. The th.yroid enlargement SCROFULA. 225 is associated with ovarian irritation in the woman after puberty, and may continue for some months. Treatment.—The patient is put upon the use of Aconite or Veratrum, as indicated, with Phytolacca as the specific remedy in the larger number of cases. A very common prescription is, Iy Tinct. Aconite gtt. v., Tinct. Phytolacca gtt. x., water 5iv.; a teaspoonful every honr. Belladonna replaces the Phytolacca, if there is dullness and stupor; Rhus, if there is sharp pain, frontal headache, and sharp pulse; Gelseminum, if there is in- creased heat of the head, inability to sleep, with general head- ache. In some cases there is a clear indication for sulphurous acid in the red tongue, Avith nasty glutinous coating; and in others the indication is equally clear for sulphite of soda. I do not think it best to make local applications to the swol- len parotids—a flannel cloth tied around the head to insure Avarmth being sufficient. Still, if the pain is very severe, a lotion of—R/ Tinct. Aconite oj- Tinct. Phytolacca 5j-> water Sj-, may be applied every tAvo or three hours. Sometimes a flannel cloth Avrung out of hot Avater, and applied for a few hours, will give relief. If there is a metastasis to the testes, they should be Avell sup- ported Avith a flannel bandage, and in some cases the lotion of Aconite and Phytolacca may be used, and in others of Bella- donna and Phytolacca. In older persons, if the SAvelling per- sists, Ave strap the SAvollen testicle firmly to the abdominal Avail, using adhesive plaster. SCROFULA. Scrofula, or king's evil, is one of the most common diseases the physician has to treat; and manifesting itself in so many differ- ent forms, its symptoms are protean, and its treatment varied and difficult. It is undoubtedly a disease of the blood, though the secretions and nervous system are markedly affected. Cope- land remarks that " The blood in scrofula and tubercles has long been considered popularly, and with much truth, to be of a poorer quality than in healthy constitutions." Simon states that the blood is deficient in solid constituents, especially in fibrin and in corpuscles. * According to Duboise, the blood of scrofulous subjects coagulates slowly, the clot is small, soft, and diffluent; the serum is thin, and often of a reddish color. Under 15 226 DISEASKS OF CHILDREN. the microscope, some of the corpuscles appear devoid of color at the edges only, some entirely colorless. Their size is not mate- rially changed, but they appear flattened, spherical, or cylindri- cal. Hence he infers that there is a deficiency of the salts in the blood of scrofulous persons. Mr. Phillips remarks that, in every case in Avhich he examined the blood of scrofulous subjects, the coagulum Avas relatively small, the serum large, the clot un- usually soft, almost diffluent; in a feAV instances only, it Avas tol- erably firm. In most cases the proportion of globules Avas con- siderably under the healthy standard. The fibrin had not gen- erally undergone much change. The causes of scrofula, Avhether those acting on the parent, or the individual himself at a very early age, or eATen at later periods, Avhether external or internal, whether hereditary, congenital, or acquired, have all a similar tendency, namely, directly to depress, or to exhaust organic ner- vous, or vital poAver ; and thereby to impair vital resistance, to preATent the processes of repair consequent upon morbid vascular action, and to arrest the formative or organizing tendency of the exudations produced by this action. Not only is there a dispo- sition to a dyscrasia—to a solution of vital cohesion, observable in parts near the seat of scrofulosis, but there is also an absence of the formative effort in the fluids exuded by morbid actions in scrofulous constitutions. The state of vital poAver or endoAvment in the several tissues or organs of scrofulous persons, appears in- sufficient both for the healthy or sthenic actions or functions these parts should perform, and for the organization of the fluids or matters effused from their vessels. Hence the changes Avhich the exuded matters undergo neither favor nor are folIoAved by organization, eATen in its lowest grades; and most probably, the fluid itself is exuded from the capillaries of a kind and in a state which indisposes it to organization. Scrofula is said to be hereditary, and so it is in this, that the child inherits a defective vitality, which manifests itself in im- perfect elaboration of the blood, and enfeebled vitality of tissues and organs. Such persons may live for years Avithout any man- ifestations of the disease, simply because there has been no cause acting to further depress vitality, or to determine scrofulous de- posit. Finally, however, from arrest of secretion or other cause, the system is depressed, and an irritation of some part beino- set up at the same time, Ave have full manifestation of the disease. If Ave have correctly stated the pathology of the disease, what 73 SCROFULA. 227 measures may be adopted to remove this predisposition? Some contend that it can not be removed, but Ave have evidence suffi- cient to show that it can be entirely eradicated. To accomplish this Ave resort principally to hygienic measures, such as will stim+ ulate healthy digestion, secretion, and innervation. Remove the child to the country, let it have plenty of out-door exercise with accompanying light and sunshine, give it nutritious food and es^ cIicav condiments, pastry, and SAveetmeats, and the entire consti- tution of the child will undergo a change. Scrofula manifests itself in various ways; Arery frequently the deposit commences in the lymphatic glands; sometimes in the viscera, as of the lungs, liver, brain, etc.; again in the bones, in the muscles, in the skin, in fact in all the tissues of the body. The determining cause of the deposit is undoubtedly an irrita- tation of the part, causing determination of blood. Symptoms.—The symptoms of a scrofulous constitution are not Avell marked, though it has been frequently described as if they Avere. It is true that it occurs most frequently in children of fair skin, blue eyes, light hair, and regular features; but it is so often met with in persons of dark skin, hair and eyes, irregu- lar features, and rough development, that it is impossible to say, by a child's appearance, Avhether it is scrofulous or not. There is, hoAve\rer, in very many cases, such manifest imperfections in assimilation, circulation, and nutrition, and feeble vitality, that Ave arc enabled to recognize the scrofulous constitution. Usu- ally, the previous history of the family Avill throw some light on the matter; but, as Prof. Powell has well demonstrated, the scrofulous constitution may be and often is developed in children by incompatibility of the parents. Scrofula manifests itself Avhen, from any cause, the vitality of the system is so depressed that the blood is not properly elabo- * rated, or the detritus of the system is not removed, either by an imperfection in the process of retrograde metamorphosis, or by failure of the excretory organs. The situation is determined in all cases by the existence of a local irritation or inflammation in or adjacent to the parts affected. Thus, we observe scrofulous deposit and disease of the cervical lymphatic glands, from disease or irritation of the mouth or throat; involvement of the axillary glands, from disease of the arm or breast ; of the inguinal glands from disease of the loAver extremities or genital organs; of the 228 DISEASES OF CHILDREN. mesenteric glands, from disease of the bowels; of the lungs, from irritation produced by cold ; and in the muscles and bones, from the same cause. It might be divided into tAvo forms, as it occurs in the lymphatic glands, or as a deposit in the form of tubercles in the structure of a part, but no practical benefit Avould grow out of such distinction. As Ave have, in other places, de- scribed scrofulous or tubercular affections of the principal organs, Ave will confine ourselves here to a description of it as it affects the lymphatic glands. In many cases the irritation giving rise to the development of scrofula is very manifest, and occasionally demands treatment, but in others it is very slight. The superficial lymphatic glands are then observed to become slightly enlarged and hard, so as to be very perceptible Avlien the finger is passed over them. This occurs frequently in scrofulous children in the superficial cervical glands, Avithout further development, and is considered by many as the best indication of a scrofulous constitution. When the disease has fully commenced, one or more of the glands con- tinue to enlarge, a Ioav form of inflammation sets in, and deposit takes place in the adjacent tissues, Avhich become SAvollen and hard. Now the inflammation becomes more or less acute, the part is reddened, painful, hot, tender on pressure, and the SAvell- ing increases rapidly. Continuing in this Avav for a longer or shorter time, suppuration commences, and the deposit is gradu- ally changed into pus, which in time makes its Avay to the sur- face, and is discharged. This occupies a variable period of time, sometimes passing through all its stages in eight or ten days, and at others occupying as many weeks. In some cases the inflam- mation is acute and the pain severe, but in others it progresses Avithout much redness, heat, or pain. The pus forms sIoavIv in many cases, and there is but little * tendency to its discharge, and in others Aveeks pass over, the part still continuing hard ; and at last, when our patience is nearly exhausted, suppuration occurs rapidly. Sometimes the pus is Avell formed and healthy, and Avhen discharged the part heals readily ; but at others it is Avatery, of a greenish-broAvn color, or clear, Avith more or less flocculent material mixed with it. Occa- sionally the abscess exhibits no tendency to point, but the pus burroavs in the ti.-sues for a long time, unless it is opened. In other cases, Avhen the pus is discharged the abscess does not heal but continues to discharge a dirty, flocculent pus; and if Ave ex- SCROFULA. 229 amine it, we will find the Avails ragged, and often a chain of lym- phatic glands dissected out, and lying at the bottom. The constitutional disturbance varies greatly. Sometimes there is quite brisk febrile action when inflammation first conies up, with loss of appetite, arrest of secretion, and much prostra- tion. In these cases, suppuration is frequently marked with a chill or rigor, and occasionally attended with hectic feA'er and night-SAveats. In other cases, there is no constitutional disturb- ance further than loss of strength, and some derangement of se- cretion, languor, and a peculiar pallid appearance of the surface. Diagnosis.—Scrofulous enlargement is readily recognized from its situation, and from the attendant symptoms above named. Prognosis.—In very many cases the prognosis will be favor- able, as the tendency to the disease is not so strong but that it may be removed by appropriate treatment, and measures calcu- lated to improve the general health. There is no doubt but that by proper care the constitution of a child can be so entirely changed, in the course of time, that the tendency to this disease Avill be entirely removed. There are other cases, hoAvever, in Avhich, though avc may get the patients safely through the present attack, they Avill inevitably die, sooner or later, of this or some analogous affection. Treatment.—When children are predisposed to scrofula, a judicious hygienic plan should be adopted to strengthen the constitution, by improving the functions of digestion, assimila- tion and nutrition. Such children are said to be tender, and hence they are kept in the house a considerable part of the time for fear of colds and sickness, and being Aveakly they are petted; and their appetites pampered; and not spending their time in playr, as they should do, their minds are precociously developed at the expense of their bodies. Instead of this, such children should be accustomed to the open air from an early age. As with plants, the human species can not be robust and stout Avithout fresh air and sunshine. As soon as they commence Avalking they should play in the open air Avhenever the Aveather is suitable. In this way, the constitution is strengthened, and the liability to colds by alternations of temperature much reduced. Sleeping- rooms should in all cases be large, Avell-ATentilated, and exposed to the direct rays of the sun during some portions of the day. 230 diseases of children. Up to the age of eight or ten years, the child's occupation should be out of doors, and Avhether it Avas play or work, it should be of such a character as to bring into action all the muscles of the body. Before this age the child should not be required to study, neither should it be sent to school, there being sufficient time after this for all laudable educational purposes. Regular meals of good, hearty food, with fruits in their season, with a sedulous avoidance of all cakes, sweetmeats, etc., are of the highest im- portance. An observance of these rules, the children being raised in the country, will almost invariably result in a complete change of constitution, and such increased vitality that not only is the predisposition to this disease removed, but the child becomes a vigorous, hearty man or Avoman, instead of dropping into a premature grave from phthisis or some kindred affection. In the treatment of the disease, the indications are to, first, improve the quality of the blood, and raise it above the point at which scrofulous material is effused, and, second, to promote the absorption and elimination of such material as may have been deposited. To accomplish these indications various means are resorted to, according to the condition of the patient. Altera- tives are relied upon to a very great extent, and various agents of this class are employed. By some the ■compound syrup of Stillingia and iodide of potassium are considered the preferable agents, and are used to a very great extent. My ex- perience has not been favorable to these remedies, and I have been compelled to select others. I now use the Phytolacca, Rumex Crispus, Alnus Scrrulata, Iris, Scrophularia, Podophyl- lum, Corydalis, and some tAvo or three other agents, sometimes singly, or two or three combined to suit the indications of the case. Acetate of potash or other saline diuretic is my main dependence to promote absorption and elimination by the kid- neys. I believe it to be as much more efficient than iodide of potassium, as this is over epsom salts ; at the same time employ- ing the bitter tonics, iron, the hypophosphites, and cod-liver oil. Very much depends upon getting proper action of the three principal emunctories—the skin, kidneys, and bowels. Great care is necessary, however, in the severer cases, not to overstimu- late and exhaust these organs. To restore the secretion of the skin, I employ—if it is dry and husky—oleaginous frictions, followed by thorough Avashing with castile soap and Avater; if soft, relaxed, and flabby, I use the bitter tonic baths; if there is SCROFULA. 231 deficient capillary circulation, Avith coldness of the extremities, a sponge-bath of dilute Tinct of Capsicum. As a local application to promote resolution, I have used equal parts of tinctures of Belladonna and Stramonium, and glycerine, or if there is much fever, an equal part of tincture of Aconite,, In other cases, a Avash of equal parts of tincture of muriate of, iron and glycerine may be used, or the part may be painted with the iron, and then folloAved by the lotion named. In some eases Ave obtain good results from the use of the Mayer's ointment or; the black salve. Finely pulverized Indian turnip, made into a poultice, is an excellent application. If there is much heat and; redness, Ave may use fomentations of Stramonium leaves, or a poultice of a decoction of Cornus and Avheat-bran. If it is seen that resolution can not be effected, Ave will employ poultices to facilitate suppuration, and if pus has formed to any extent, iu-.j stead of permitting it to burroAV, we will immediately open the> abscess. The poultice may be continued for a few days longer, until the inflammation has passed off, Avhen it may be dressed ; with Mayer's ointment, or other stimulant application, until it heals. If it does not discharge Avell, and looks ragged, it will be best to use a solution of sesquicarbonate of potash until sup-' puration becomes free. And in those cases in which the healing! process is slow, and the discharge thin and Avatery, it may also! be employed with advantage. In some cases the healing process progresses until the abscess; is nearly closed, but a red, ugly cicatrix is left, from which there' is more or less oozing; or, if it closes, it breaks out frequently, and, after running for a feAV days, again closes, with a thin, blu- : ish cicatrix. These cases are remarkably tedious, and are ATery difficult to cure. I have treated them by employing the zinc paste to entirely destroy the morbid cicatrix, and then healing with some mild stimulating ointment; or, instead of this, Ave may ; sometimes dissect the cicatrix out, and draw the parts together with adhesive straps. In other cases Ave Avill find that a decoc-1 tion of equal parts of Cornus, Rumex, and Alnus, continually applied, and taken internally, will in time overcome the disease.! 232 DISEASES OF CHILDREN. DYSCRASIAS. The definition of dyscrasia by Dunglison, " a bad habit of body," Avould ansAver our purpose very Avell as describing a bad blood and an impairment of nutrition, and from this enfeebled tissues. The older pathologists used the term to express " an ill habit or state of the humors," /. e., of the fluids of the body. It is used to describe a condition of life, and not a special form of diseased action, though Avhatever form this may assume, it possesses the characteristics of the entire group. In scrofula the impairment of the blood manifests itself in the deposit of imper- fect albumen, most frequently in the neighborhood of lymphatic glands. In this the nutritive fluids are impaired, and the tissues formed from them are also imperfect. In addition to this the excretory organs being insufficient for its removal, Ave have it throAvn off in the skin, producing skin diseases ; in cellular tissue, producing Ioav grades of inflammation, and in other tissues giving rise to degenerations and inflammatory affections. Causes.—The causes giving rise to this condition are numer- ous; indeed Avhatever depresses the vital poAvers, either an im- pairment of digestion and assimilation, or retrograde metamor- phosis and excretion, will produce it. Hereditary feebleness of vitality or formative power is very frequently the cause. Add to this imperfect food, deficient ventilation, impure air, Avant of sunshine and exercise, and Ave have the common causes. We have also to take into consideration the fact that bad blood or bad tissue manifests a constant tendency to reproduce itself— indeed, that Avhenever a fluid or tissue has had its vitality thus impaired, it perpetuates the impairment; also, that every point where the disease manifests itself becomes, to a greater or less extent, a depot of supply or depravation. Thus the fluids are being constantly impaired by materials taken into them from these sources. Tn some of these cases, the lymphatics suffer more than other parts, and the lymph being impaired, the blood which is formed from it is impaired to the same extent. Symptoms.—The evidence of bad blood and bad tissue may be found in the general impairment of function, as Avell as in the many local diseases arising from it. Nutrition being imperfect, DYSCRASIAS. 233 the tissues are soft, and have lost their toiie and elasticity ; the circulation is feeble and unequal ; the appetite is variable, and the digestive act imperfect; the tongue being pale, broad, and frequently covered with a pasty Avhite coat. There is a Avant of activity of the excretory organs. The skin is dry, rough, and harsh, or soft and flabby, in neither case per- forming its function well. The urine is changed, containing the triple phosphates or urates, or at times of low specific gravity and deficient in urea ; while the boAvels are irregular, neither acting Avell as a digestive or an excretory apparatus. The local diseases vary in character, but they are alike in giving rise to deterioration of structure, Ioav grades of inflam- mation, a poor, purulent product, and deficient poAver of repair. Treatment.—The indications for treatment are very plain in these cases. We have to get rid of the imperfect blood and im- perfect tissues, and replace them with good blood and good tissue. We get rid of the bad material by increasing the process of retrograde metamorphosis, and stimulating the excretory organs—the skin, the kidneys, and the boAvels. We obtain better blood and better tissue by the use of means that improve the appetite and digestion, and that restore to the blood the materials in which it is deficient, and Avhich stimulate the nutri- tive processes. The selection of remedies to accomplish these objects is not ahvays easy. The processes that we desire to act upon are vital processes, and remedies that increase their activity, if properly used, may depress them, or even arrest them, if used Avithout care. Excretion, or the removal of the bad blood or tissue by the skin, kidneys, and boAvels, occupies the first place. Usually Ave Avill have no trouble in obtaining this influence, if Ave are willing to giye time enough, and employ simple agents in small doses. I prefer the vegetable alteratives in infusion, singly, 'or tAvo or three in combination. The Alnus, Rumex, and Scrophularia are favorites of mine, and I think they will give satisfaction. The skin is reached by the use of baths and frictions. If dry and harsh I prefer fatty inunction, Avith brisk friction, occasion- ally using a small portion of quinine in this way, if there seems need for its tonic influence upon the nerArous system. If relaxed and flabby, stimulant, tonic, or astringent baths are the best. If the boAvels are inactive, minute doses of Podophyllin, 234 DISEASES OF CHILDREN. thoroughly triturated with sugar, answer a very good purpose, but the doses should be so small as not to produce purgation. The kidneys are called into action by the use of acetate of potash, better than by other remedies, the solids of the urine being especially increased. I have regarded this as our most powerful alterative Avith children, being much better than the iodides in such common use. While employing these means the patient is put upon the use of iron, the hypophosphites, cod oil, and the bitter tonics. In many cases the tincture of muriate of iron with glycerine, as heretofore named, will answer the purpose ; or if a stomachic is needed, a small portion of tincture of Xux A'omica or solution of strychnine may be added. Of course a nutritious diet, carefully adapted to the condition of the patient is indispensable, and the selection of this and its preparation, will require the advice of the physician. Add to this good ventilation of and sunlight in the sleeping apartments, and out-door exercise, attention being paid to Avarmth and clean- liness, and Ave have an excellent treatment. INFANTILE SYPHILIS. A child may receive the primary disease from a chancre of the breast, Avhile nursing, or from a chancre of the lips in the act of kissing, or by the use of cloths or clothing soiled by the dis- charges from a chancre. Though examples of each of t'aese are upon record, they are of very rare occurrence. In my practice I have seen one chancre of the breast, Avhich, had the Avoman been nursing, would ha\re communicated the disease to the child, and I have seen three cases of chancre of the lip, in one of which such transmission occurred. In such cases, the presence of the specific sore will be sufficient for the diagnosis, if the physician gives it a close examination. All the symptoms of the primary disease Avill be there, and after a period varying from tAvo months to a year, constitutional symptoms will be observed, if the system becomes infected. But Ave have a more common source of the syphilitic lesion, in the transmission of the disease from one or the other of the parents to the child in utero. This is hereditary syphilis, and is the form Ave desire to study particularly. INFANTILE SYPHILIS. 235 Secondary syphilis may be transmitted by either parent to the child, Avhich Avill be born impregnated by the poison. The fol- loAving are the propositions laid down by M. Ricord regarding its transmission, and they may be received as facts well established : " t. The father and mother may transmit the disease to their child indifferently, if either or both of them be affected. " 2. Transmission may occur from the parents to the child, when they are affected Avith constitutional symptoms, or Avhen a concealed syphilitic diathesis exists in them. " 3. The absence or existence of constitutional symptoms in parents at the moment of impregnation and conception exerts no influence on the form of the disease, which may afterward appear in the child. The distinction established by M. Cazenave be- tAveen congenital and hereditary syphilis, and which is based on the absence of constitutional symptoms in the parents at the moment of generation, or which have been developed in the mother during gestation, is totally erroneous; and indeed M. Cazenave confesses that his opportunities of observing have not been ample. " 4. The character and period of the manifestation of the symptom in the child are governed by the stage to which the disease had advanced in the parents at the moment of generation. The treatment to Avhich the parents Avere subjected may also re- tard, prevent, or modify its appearance in the child. " 5. If the parents are both healthy at the time of generation, and the mother contracts syphilis during gestation, she may transmit the disease to her child. Of this I have seen .several examples at various periods of pregnancy, even to the se\renth month inclusive. " 6. When the venereal poison is transmitted from the mother to the child during pregnancy, infection takes place through the medium of the placenta, and in this case appears to occur after the fourth month of utero-gestation. " If the father alone be diseased at the moment of generation, an abortion may occur at any period of pregnancy. If the mother alone be diseased at the time of conception, the abortion will not take place until after the fourth month. " 7. Children born of a father and mother affected Avith syphilis may escape infection ; for a certain disposition to receive con- stitutional disease is necessary for the child as well as the adult, and this may be absent. 236 DISEASES OF CHILDREN. " 8. Observations made as accurately as possible seem to prove that constitutional syphilis may be transmitted from the child to the mother during utero-gestation." Symptoms.—The most common, as Avell as the most reliable, evidence of hereditary syphilis, after the child has attained the age often years, is the peculiar appearauce presented by the per- manent teeth, especially the upper incisors. These are usually short and narroAV, with a broad vertical notch in their edges, and their corners rounded off. Horizontal notches or furroAVS are often seen, but they as a rule have nothing to do with syphilis. Associated with this condition of the teeth, and earlier as to time, being noticed by the end of the first year, are the folloAving symptoms : " The skin is almost ahvays thick, pasty, and opaque. It often sIioavs little pits or scars, the relics of a former eruption, and at the angles of the mouth are radiating linear scars, run- ning out into the cheeks. The bridge of the nose is almost always broader than usual, and Ioav ; often it is remarkably sunk and expanded. The forehead is usually large and protuberant in the regions of the frontal eminence ; often there is a Avell marked, broad depression a little above the eye-broAvs. The hair is usually thin and dry, and iioav and then (but only rarely) the nails are broken and splitting into layers. If the eyes have already suffered, a hazy state of the corneae, and a peculiar leaden, lusterless condition of the irides, with or without synechiae, may be expected. If, hoAvever, the eyes have not yet been attacked by a syphilitic inflammation, they will present no deviation from the state of perfect health and brilliancy. " The occurrence of well characterized intestinal keratitis is iioav considered by several high authorities as pathognomonic of inherited taint. It is also invariably coincident with the syphi- litic type of teeth; and Avhen the tAvo conditions are found to- gether in the same individual, I should certainly feel that the diagnosis Avas beyond doubt."—Hutchinson. The symptoms present at birth or occurring during infancy vary in different cases. In some cases the child is born shriveled and emaciated, the skin hanging in folds in different parts of the body. The throat is sore, the voice rough and unnatural, and an unnatural discharge is noticed from the nose. Associated with this may be a pustular or squamous skin disease, and INFANTILE SYPHILIS. 0Q7 co[)per-colored discolorations. Occasionally there are unpleasant cicatrices or marks of an intra-uterine lesion. In other cases, and more frequently, the disease first manifests itself tAvo or three Aveeks after birth in the appearance of the syphilitic exanthemata or vesicula. Following this, there is the deterioration of the general health, above named, Avith squamous, papular, and pustular eruptions, and the associate ulcerations of the throat and mouth. At a still further advanced stage, there is disease of the nasal cavities, mucous tubercles about the anus, and finally disease of the bones. Dr. Golding Bird described a characteristic snuffling as one of the most marked symptoms of infantile syphilis. With this, the " puckered mouth, the position of the very characteristic erup- tion round the lips and anus, in addition to the peculiar and fissured appearance of the surface from Avhich the scales have faded, Avill seldom, if ever, fail to convert a suspicion of the dis- ease into positive certainty." Diagnosis.— While it is sometimes easy to make the diagnosis, the symptoms being characteristic, as above described, at others it is extremely difficult. These may be but the symptoms of bad blood and impaired nutrition, as described in the quotation from Hutchinson. Yet Avhenever one form of caitaneous eruption folloAvs another, after a Avhile associated Avith disease of the throat and nasal cavities, and attended by impairment of the general health, Ave Avill have cause to make strict inquiry Avhether there is the peculiar discolorations of the skin or not. Prognosis.—When the symptoms of constitutional syphilis are present at birth, the prognosis is unfavorable; indeed, as a general rule, it is better that such children should die early, for it is almost an impossibility for it to be removed and good health restored. But Avhen it appears some Aveeks after birth, in the form of syphilida, in a Avell-developed child, Ave may expect to effect a permanent cure, if the mother's health is not much impaired. But in most of these cases, the evidence of the syphilitic lesion 0 will still remain as named. The disease makes a permanent im- press on the nutrition of the individual, and may be seen for several generations,'though all its active symptoms are arrested. 238 DISEASES of children. Treatment.—The objects of treatment in hereditary syphilis are : to increase the process of retrograde matamorphosis, and the removal of the broken-down material by Avay of the skin, kidneys, and bowels ; and to improve digestion, assimilation, blood-making, and nutrition, thus reneAving the blood and tissues with healthy material. This must be carefully done, for the influence of the syphilitic poison is to depress vitality, and it is much easier to break doAvn tissue than to replace it. The two processes—Avaste and reneAval —should go on together, the one being the exact complement of the other. Thus, as time passes, the syphilized blood and tissues are replaced Avith neAV material not contaminated with the poison, and in the course of some months the disease is wholly removed. There is no specific against the syphilitic virus; if there Avas its administration Avould suffice. The use of mercury and arsenic temporarily arrests its activity in some cases, but they sometimes render it difficult of cure. When the tongue is small and red, I make the folloAving prescription : R/ Donovan's Solution of Arsenic gtt. x. to gtt. xx., Tinct. Phytolacca gtt. x., water &v., a teaspoonful every four hours. When indicated it sometimes exerts a remarkable influence, clearing the skin, arreeting the ulcerative process, and improving digestion and nutrition. In same cases the mother may be put upon the same remedies in larger doses, as : R/ Donovan's Solution 5j-, Tinct. Phytolacca Sij., Avater 5iv., a teaspoonful three or four times a day. Iodide of Potassium is an admirable remedy when the tongue is broad and has a leaden pallor. Sometimes the gums and mucous membranes sIioav the same pallor. For the child I order: R^ Iodide of Potassium 5j , water 5iv., from half to one tea- spoonful every three or four hours. For the mother, if the child is nursing, the proportions of: R/ Iodide of Potassium 5ss., water Si v., a teaspoonful three or four times a day. Sometimes much smaller doses may ansAver for both child and mother. I prefer to treat the young child partly through the mother, if it is nursed. She maybe placed upon the use of the vegetable alteratives—Corydalis, Alnus, Rumex, Stillingia, etc.— using them in weak infusion, but quite freely. They can be gotten in pleasant form by the use of some agreeable aromatic, as in the following formula: R/ Corydalis Sss., Alnus and Sassafras, aa. Sj , boiling Avater Oiv., put in a covered vessel and keep hot for four hours, then strain and SAveeten to the taste. Any aromatic infantile syphilis. 239 that the patient might prefer can be substituted for the sassafras. In using the vegetable alteratives, I think it best to change them every Aveek, as Ave may in this Avay obtain a stronger in- fluence, and the remedies are less distasteful. With this the physician may give acetate of potash to the ex- tent of three drachms, or iodide of potassium to the amount of from one-half to one drachm daily. At the same time the patient, if past the second summer, is put upon the use of iron and the bitter tonics, and has a full diet in which animal food preponderates. Occasionally Ave will find that the tonic and stomachic is most efficient Avhen com- bined with small doses of Podophyllin, as in the following for- mula : R/ Podophyllin gr. j., Hydrastia, Quinine, aa. gr. xx., divide in tAventy poAvders, and give one three times a day. The compound tonic mixture,* the formula for Avhich Avill be found in the foot note, is an excellent remedy, and may be em- ployed in this case with advantage; or in place of it, Ave may sometimes-use the folloAving: B/ Tincture of Muriate oP Iron Sss., Solution of Strychnia 5j-, Glycerine oiijss., a teaspoonful four times a day. The treatment of the child may consist in part of the adminis- tration of the alterative infusions already named. They should be made pleasant, so that the child Avill take them freely and without disgust. Iron with glycerine, as so frequently recommended, will prove the best stomachic and restorative. If the child is feeble, especi- ally if there is occasional febrile action, I like the inunction of quinine, indeed, I am not certain but Avhat it will be found of advantage in most cases. I am partial to the use of alterative baths in infantile syphilis, and have been able to obtain a very decided benefit from them. * Formula for Compound Tonic Mixture—R Ferri Sulph. 5j.. Soda Phos. 3yj., Quinia Sul. grs. 192, Sul. Acid dil. q. s., Aqua Am- monia q. s., Strychnia grs. vj., Acid Phosph. dil. f.^xiv., Saech. Alba Jfxiv. Dissolve the Iron in 3.j of boiling water, and the Phosphate of Soda in ,^ij., of boiling water. Mix the solutions and wash the precipi- tated phosphate of iron until the washing is tasteless. With q. s. of dil. sul. acid dissolve the quinine in two ounces of water, precipitate the quinine with ammonia, and carefully wash. Dissolve the phosphate of iron and the quinine thus obtained, as also the stry-.-hnia, in the dilute phosphoric acid, then add the sugar and dissolve the whole without heat. 23 240 diseases of children. I generally employ, externally, the same remedies that are used internally. For instance, if Corydalis and Rumex are given, a strong infusion of the same is used as a bath. POISONOUS BITES AND STINGS. Occasionally a physician is called to treat a child avIio has been bitten by a poisonous serpent; but more frequently one who is suffering the effects of the sting of the bee, wasp, or others of like species. The history of the accident in these cases is usually plain, and their symptoms very marked ; so that there is little danger of mistaking the character of the injury. Symptoms.—The symptoms from the bite of a poisonous ser- pent are manifest in a short time. The patient is prostrated, the countenance pale and listless, body bedeAved with a cold perspi- ration, the pulse small, rapid and fluttering, with droAvsiness and disinclination to speak or ansAver questions. The part bitten usually SAvells rapidly, and becomes bluish discolored. In some cases the SAvelling extends to adjoining parts, and finally the whole body is more or less swollen and sometimes discolored. All the symptoms are those of prostration, and we may regard the poison as a depressant, having a somewhat similar action to hydrocyanic acid, and at the same time a blood-poison, setting up a process of decomposition. The poison of the sting of the bee, Avasp, hornet, and others of like species, is someAvhat similar in kind, though in much less degree. Usually Ave Avill find the disturbance principally local, except the irritation of the nervous system from the extreme pain, Avhich sometimes goes so far as to produce convulsions. The part is much swollen, pale at the part stung, but with a red areola, and is exquisitely painful. In some persons, extremely susceptible to the influence of the poison, we Avill have marked prostration from a single sting. Usually, however, the constitutional symptoms are seen when the person has been stung in many places. In these cases the pulse is small and feeble, the extremities cold, the face pallid, a sense BITES AND STINGS. 241 of weight and oppression in the praecordia, difficulty of breath- ing, and sense of general prostration. In one case that came to my kuoAvledge the patient was unconscious for some hours, and seemingly lifeless for a time. As a general rule, these symptoms pass off in the course of twenty-four hours. Treatment.—The treatment for the bite of a serpent will be of a stimulant character. Let the Avound be freely incised, and cupped, or draAvn by the mouth, and aftenvard a strong solution of ammonia applied. Place the patient in bed, covering Avannly, and applying dry heat freely. Give internally the aromatic spirit of ammonia with tincture of asafcetida, in full doses, repeated frequently, Avith as much strong coffee as the patient can drink. The common treatment in the South-AA'est is to give Avhisky freely, to the extent of k pint or more in a short time, for an adult; but I think it doubtful Avhether this is as good as the plan proposed. In the case of a sting I have slices of raAv onion applied to the part, and changed frequently. It is very certain and speedy in its action, relieving the pain, and dispersing the SAvelling, usually in the course of half an hour. If there are a number of stings, it should be applied to every one of them, and bound on firmly. In case the general symptoms are developed, I should recom- mend the treatment given for the bite of a serpent. If convul- sions ensue, chloroform Avill probably prove the best remedy. 16 242 DISEASES OF CHILDREN. CHAPTER VI. DISEASES OF THE RESPIRATORY APPARATUS. The respiratory apparatus consists of the cavities of the nose, the pharynx, larynx, trachea, bronchial tubes, parenchyma of the lung, and the investing membrane—the pleura. Each of these parts may be the seat of diseased action separately, or tAvo or more may be engaged at one time. The diseases are mostly of an inflammatory character, but in addition we have them de- pendent upon morbid innervation, and change of structure de- pendent upon causes other than inflammatory. We diagnose these diseases in part by the general symptoms, as Ave do affections of other parts of the body. But to confirm such diagnosis and render it more exact, we are guided by cer- tain physical signs, manifest to the senses of sight, hearing, and touch. This is called physical diagnosis, to distinguish it from the ordinary means by general symptoms. We purpose giving but a brief space to the subject of physical diagnosis here, merely pointing out the differences betAveen the child and the adult. For further information the reader is re- ferred to special monographs on the subject, or to treatises on the practice of medicine. The information for physical diagnosis is obtained from an examination of the conformation of the thorax, respiration, cough, sputa, and from auscultation and percussion. Conformation of the Thorax.—But little information is obtained from the form of the thorax in acute disease. In some cases of chronic disease, the narroAV and flattened chest, Avith feeble respiratory poAver, Avill be additional evidence of feeble viablility. But it is of more importance if it impresses upon us the necessity of passive and active exercise of the thoracic mus- cles, and increased inspiratory effort to obtain a better develop- ment. There is no doubt but that the movement cure may be applied in this case with great advantage. Respiration.—The respiratory movements of the child are more open and free than in the adult, and at the same time more superficial. Changes in the respiratory movements have less DISEASES OF RESPIRATORY ORGANS. 243 diagnostic value than in the adult, because they may be influ- enced by slight lesions, or by derangements of the nervous sys- tem. Considerable irregularity of the respiratory movement is permitted, without seriously interfering with the function. Respiration normally is both thoracic and abdominal; if it is changed in this respect, it is evidence of disease. Thoracic res- piration is caused by acute inflammation of the liver, stomach, or spleen, or from peritonitis; but the most frequent cause is from an irritable state of the bowels, sometimes met with in severe cases of colic. It is abdominal in pleurisy, pericarditis, and in extreme debility. Respiration is increased in frequency from tAvo causes : First, in consequence of an increased frequency of the circulation, to Avhich it bears the normal relation of one to four; and second, from disease of the respiratory apparatus, the capacity of the lungs being lessened, the respiratory movement is proportionally frequent. A sIoav and free respiration indicates an easy circulation of the blood, sound lungs, and an unimpaired distension of them. If the respiration is large and attended with difficulty, much exer- tion being necessary, it indicates loss of nervous power and approaching coma or stupor. The short respiration, when un- attended with pain, is a very certain symptom of obstruction of the lungs. Difficult respiration is manifested by labored breathing, the inclination being to assume a sitting position, and in the child by the clutching movements of the arms and hands. There are also the additional evidences from imperfect aeration of the blood. Cough.—Cough is an indication of irritation of the respira- tory mucous membranes, and may be produced from disease of any part. The purpose fulfilled by the normal act of coughing is the removal of irritating matters Avhich may be in the air- passages. The irritation of disease gives the sensation of some- thing irritant within the bronchial tubes, hence the cough. The act of coughing removes increased secretion of mucous, and keeps the air-passages free for the performance of the respiratory function. Cough may be sympathetic—depending upon disease of some part other than the lungs, as when it arises from disease of the 244 DISEASES OF CHILDREN. stomach, liver, or other abdominal viscera. Or it may be de- pendent upon the irritation of the nervous centers, especially of the base of the brain, as we have a marked example in Avhoop- ing-cough. The short irritative cough is generally met Avith in the first stages of inflammation of the parenchyma of the lungs. The hoarse and stridulous cough results from laryngeal disease. The hollow, rattling cough is found in bronchitis, with increased se- cretion. A dry cough indicates want of secretion; a moist or mucous cough, increased secretion. Sputa.—While Ave obtain considerable information in diseases of the adult from an examination of the sputa, Ave learn but little in diseases of childhood. The adult raises the secretion by an act of coughing, and spits it out; the child raises it to the larynx, and swalloAvs it. If the sputa is ejected, and can be examined, it Avill give the same information as in the adult. Percussion.—The practice of percussion does not give the same information as in the adult. The Avails of the chest are not so elastic, and the comparative resonance or dullness is affected by minor circumstances in a greater degree. Neither do Ave have solidification of the lungs even in pneumonia, as in the adult Still, resonance on percussion gives the information that the lungs are permeable for air, and there is no structural reason for impaired respiration. And dullness on percussion is evidence of congestion, or of effusion into the structure of the lungs. Auscultation.—We obtain the most certain information in regard to the condition of the respiratory organs from ausculta- tion ; yet should Ave be guided by the statements of Avriters on auscultation, Ave Avould be led into frequent errors. We have no sibilant, sonorous, dry crackling, crepitant, subcrepitant, mucous, or carernovs rhonehi in children, and those Avho auscultate with the ."\-u in its literal signification. They are dry in various degrees, and rhey are mnist in various degrees, Avhich the ear soon learns to appreciate. Dryness indicates an arrest of secretion, and CORYZA. 245 contraction of the bronchial tubes ; as is the dryness, so is this condition. Moist bloAving sounds indicate the establishment of secretion, and in proportion to the moisture, or rattling, is the abundance of the secretion. The sounds also give evidence of the condition of the bronchial tubes, as regards tone. If the sound is well defined or acute, the tubes are contracted, and in proportion as the sound is Avaver- ing and IioIIoav, they are relaxed. Getting the timbre of the sound is the most important part of the education of the ear. The respiratory murmur is A*ery distinctly heard in the child, being once or tAvice as loud as in the adult, so that beginners in auscultation are recommended to commence the training of the ear, and to get a better kuoAvledge of this natural sound, by auscultation of the child. When this sound is present Ave know the parenchyma of the lung is not involved. It is changed in inflammation of the lungs, becoming coarser and less even, and broken by mucous cracklings. It is masked by the moist blov- ing sounds of bronchitis, and these sometimes mask the change in its character—in the latter stages of an inflammation of the lungs. CORYZA. ' A mild form of coryza is of very common occurrence in the child, and Avhile it is mild and demands but little treatment, it is a source of great annoyance to the child, and from the restless- ness that attends it, to the family. The severe form of the disease is a true inflammation of the nasal cavities, and causes considerable constitutional disturbance in addition to the local uneasiness. Symptoms.—In the first form, the nose becomes stopped by accumulations of mucus, and the child draws its breath through the nose with difficulty, and finally is compelled to breathe wholly through the mouth. The adult finds such a state of things sufficiently annoying, but the child can see no reason for it, and no cause Avhy it shall have patience under the infliction, and consequently makes knoAvn its objections in violent crying. The nose may remain stopped in this way for several hours, and it may be repeated day after day for a Aveek or more. Usually it is associated with slight cold, and Avhen this passes aAvay the trouble ceases. 246 DISEASES of children. In the second form there is a similar condition of the nose, and the same restlessness and suffering in consequence. In addition to this the child manifests symptoms of febrile action and arrest of secretion ; the face is flushed, the eyes injected, and the head is hot. The closing of the nose in this case, during the first tAvo or three days, is dependent upon SAvelling of the nasal mucous membrane. After this there is free secretion and discharge, but when this is retained it closes the passages. With the subsidence of the fever and the establishment of secretion, the disease passes aAvay. Treatment.—In the first and simple form, thoroughly rubbing the nose and over the frontal sinus Avith hot lard, or any fatty matter, will giAre present relief. If the child is suffering from cold, the use of an infusion of Asclepias will generally be all that is required. In the second form of the disease the patient is put upon the use of the sedative, Aconite or Veratrum, in the usual doses, and the action is aided by the hot foot-bath. In some cases the dis- charge is acrid, and though the child may not complain of burn- ing, Ave can see by the expression of its face that there is much irritation of the mucous membrane : Ave use Rhus with the Aco- nite. If the child is dull, and Avants to sleep a great deal, Bel-* ladonna is used. If the head is hot, and the face flushed, the remedy is Gelseminum If the tongue is pale, the throat sore, or any enlargement of the lymphatic glands, give Phytolacca. Some cases will present themselves in which marked benefit will be derived from sulphite of soda or sulphurous acid. The first, if the tongue is pallid and dirty, or if there is eczema; the sec- ond Avhen the tongue is red and dirty, and the tissues someAvhat puffy. The use of inhalations of the vapor of Avater and vinegar give great relief, and may be employed several times a day in bad cases. In place of this Ave may use a friction to the nose of tinc- ture of Aconite gtt. x. to gtt. xx., lard Sj.; mix. CHRONIC CATARRH. Chronic catarrh is not of as frequent occurrence in childhood as in the adult, yet Ave meet Avith cases from the age of three years upAvards. In some cases it seems to be dependent upon an CHRONIC catarrh. 247 enlargement of the mucous follicles, thickening of the mucous membrane, and increased circulation. In this case the discharge from the nose is of mucus only. In other cases there is a true chronic inflammation, producing thickening of the mucous mem- brane and superficial ulceration, and the discharge is muco- purulent. Symptoms.—In the first case there is too free secretion from the nose, the constant discharge becoming disagreeable. In addi- tion to this the voice is changed, and has a nasal tone, Avhich is sometimes disagreeable. In some cases the nasal cavities become closed at times, from accumulation of the secretion, and this is very unpleasant to the patient. In the second case there is the free discharge from the nose, but iioav it is frequently fetid, and is othenvise unpleasant. The patient complains of pain over the nasal bones, and frequently a frontal headache, which may be located in the frontal and orbital sinuses. In addition to this, there is the unpleasant nasal tone to the A'oice, and the occasional stopping up of the nose, com- pelling the child to breathe through the mouth. In some cases the disease is confined principally to the superior portion of the cavity, extending backAvard to the posterior nares. In others the posterior nares and the upper part of the pharynx back of the soft palate, are principally involved. This gives rise to a peculiar IioIIoav voice, and occasionally to some difficulty in articulation, and an unpleasant gurgling noise in swallowing. In both of these cases the secretion pours backward, and drop- ping into the pharynx, is ejected by an act of haAvking and ex- pectoration. The general health suffers more or less as the disease continues, especially in the second form. The appetite is impaired, diges- tion deranged, and poor blood is formed, and from this Ave have imperfect nutrition. I do not think such cases are necessarily scrofulous, but as the disease progresses, a condition very similar to scrofula is developed. Diagnosis.—The diagnosis is not difficult, as the continued abundant discharge from the nose, its occasional closure, the nasal tone of voice, and the pain and uneasy sensations in the nose and frontal region, are very prominent. 248 diseases of children. Prognosis.—The disease will rarely if ever get Avell Avithout treatment; but an appropriate general and local treatment, if continued sufficiently long, will effect a radical cure. Treatment.—In many cases a general treatment is necessary to success; in some cases, however, nothing but local means Avill be indicated. The general treatment Avill vary according to the indications, and much care will be necessary to select the right remedy. The possible remedies might be named, as Arsenic, Iron, Lime, Sulphite of Soda, Sulphurous Acid, Hamamelis, Alnus, Scrophularia, Phytolacca, Donovan's Solution, Iodide of Potassium. The relaxed, atonic skin, with feeble circulation, Avill be benefited by arsenic; pallid skin, Avith blue veins, iron; dusky redness of mucous membranes of nose and throat, with occasional erysipelatous flushings of skin, tincture of muriate of iron. Lime is used Avhen there is acid dyspepsia, or a tendency to inflammation of cellular tissue—lime-Avater or hypophosphite of lime; sulphite of soda, if there is eczema of the face; sul- phurous acid, if there is deep redness of mucous membranes, with offensive discharge; Hamamelis, if the tissues are full and atonic; Alnus and Scrophularia, if there is purulent secretion, Avith the formation of unpleasant crusts or scabs; Phytolacca, if the throat is sore, or the cervical glands enlarged; Donovan's solution, if the bones are being involved, the skin dirty, and especially if a syphilitic taint is suspected; iodide of potassium, if there is a broad atonic tongue, with leaden pallor. In some cases I have employed Rhus with Aconite or Vera- trum, Avith most marked benefit. The Rhus has the usual indi- cations, frontal headache, persistent, with burning in the eyes or nose. The Aconite is suggested by the irritable tonsils and throat, and the Veratrum by cough and mucous rattling in bronchia. At the same time the child should have its regular bath every one or tAvo days, using the alkalies Avhen indicated, the tonic bath if the child is ansemic, or the fatty inunction if the skin is dry and harsh. With young children it is someAvhat difficult to make proper use of local remedies. With such I prefer to use them by inha- lation, or Avith the steam or air atomizer. In this Avay they can h« brought into direct contact Avith the diseased structures. When the child is old enough (six years) to use it, the nasal chronic catarrh. 249 douche may be employed (Thudicum's method), the fluid being passed into one nostril and flowing through the nasal cavity and out at the other. The Thudicum apparatus consists of a glass vessel, holding a pint or quart, to the bottom of which is attached a piece of rub- ber tubing six or eight feet long, furnished with a stop-cock to turn on or off the fluid, and a nose-piece to fit in one nostril. The method of using it is as folloAvs : Place the vessel containing the fluid on a shelf or stand three or four feet higher than the patient's head, and place the nose piece in one nostril; iioav let the patient open his mouth, breathing through it entirely, turn on the fluid, and it Avill pass through the nose, and out of the other nostril, as described. A vessel may be placed before the patient to receive it. If such apparatus is not at hand, one may be improvised by taking an ordinary bottle to contain the fluid, and a piece of half- inch rubber tubing six or eight feet long to conduct it to the nose. Place one end of the tube in the bottle so that it may reach to the bottom, apply the mouth to the otfier end, and by suction draAV the fluid through, then compressing it with the fingers, introduce it into the nostril, and proceed as before. It is the ordinary syphon, and Avill continue to discharge until all the fluid in the vessel is removed ; its force Avill depend on the elevation of the vessel. Another method is to use the ordinary rubber-pump syringe, the fluid passing into one side, going through the nasal cavities and out at the other nostril, so long as the patient breathes through the mouth. With either of these, so soon as the patient shuts the mouth the fluid will pass doAvn the throat, or into the larynx if the patient makes an inspiration. Of course the sense of strangulation stops its use until the pa- tient gets breath and starts fairly again. The remedies used by the atomizer will differ someAvhat from those used by the hydrostatic method. I have obtained good results from the use of a solution of chlorate of potash (gr. x. to water §iv.), alternated Avith Pond's extract of Hamamelis; or in place of the preparation of Hamamelis named, Ave may use one part of the tincture to three of Avater. When the discharge is purulent and offensive Ave may use the solution of permanganate of potash grs. x. to Avater 51 v to Sviij., depending upon the con- dition of the mucous membrane. In place of this, a solution of carbolic acid, one part to tAventy, may be used Avith good results. 250 DISEASES OF CHILDREN. Within the past two or three years I have used a solution of Salicylic Acid Avith Borax or with chlorate of potash with excel- lent effect. The strength Avould be, B/ Salicylic Acid gr. x., Borax or Chlorate of Potash gr. x., Avater 5*1 v. The apparatus for atomizing is now so good and so cheap, (the Essex selling for $1.50 and $2.00, the Adams for $2.00,) and the method is so easily employed even with young children, that I give it the preference. It Avill not do to forget the old means in looking after the neAV, and there are cases in which a filtered infusion of equal parts of Alnus, Rumex, and Quercus Rubra, will be preferable to any other remedy. These are cases of profuse secretion of muco-pus, Avith probable disease of bone, and marked development of the nasal voice. With the hydrostatic apparatus, Ave use a solution of common salt Sss. to the pint of Avater, to cleanse the nose and remove the mucus or muco-pus. Not unfrequently considerable quantities of offensive material, with large unpleasant looking crusts, will be brought aAvay*. FolloAving this, use a solution of chlorate of potash, varying in strength from gr. x. to 5j-> to the pint of Avater. In a large number of cases Ave find that these simple means are sufficient for a cure. Occasionally it may be Avell to alternate Avith this an infusion of Hydrastis or Hamamelis, or the distilled extract of Hamamelis diluted Avith one part of Avater. If the discharge is very offensive, Ave employ the solution of salicylic acid and chlorate of potash ; or instead of this, a Aveak solution of carbolic acid may be used. To relieve the pain and unpleasant sensations in the frontal region, I ahvays direct the local application of tincture of Aconite root over the part. It is applied with the finger, and of course is used in small quantity. The use of the voltaic battery, the current being passed from the nape of the neck through to the part in front Avhere the pain points or reversed, relieves the unpleasant sensation, and it is claimed aids in the cure. CHRONIC PHARYNGITIS. Chronic disease of the pharynx, fauces, soft palate, and tonsils is occasionally met with in the child, and is generally of an in- flammatory character. All of these parts may be involved in the disease at once, or one or tAvo may be affected separately. It CHRONIC PHARYNGITIS. 251 is frequently associated with disease of the posterior nares, and occsionally Avith disease of the larynx and bronchia. Causes.—Occurring in persons of feeble vital poAA-er, and consequently poor blood and impaired nutrition, Ave can easily see Iioav any irritation may progress and run into this disease. With such conditions of the system it is most frequently caused by cold, and follows ordinary sore throat. Repeated attacks of tonsillitis, or of sore throat, may give rise to it in persons other- wise of good constitution. It may also be a sequel of diphtheria Avhich has prevailed so extensively during the past ten years. Pathology.—The mucous membrane covering these parts is thickened, the blood-vessels, especially the veins, enlarged, and the mucous follicles increased in size and activity. With this changed and enfeebled condition the transformation of epithelial cells into pus cells, and the reparative material into pus, is easy ; and at a further advanced stage erosion, superficial ulceration, and at last deep ulceration, Avould naturally folloAV this condition of the tissues. Syaiptoms.—It is noticed that the child is easily affected by cold, frequently complaining of sore throat; that it frequently clears the throat by an act of haAvking, and expectorates a mucus or muco-purulent material in considerable quantity. There is also a change in the voice, readily recognized by one Avho has not become accustomed to it like the family. Quite often the child will make an unnatural gurgling noise Avhen it sleeps, or it may be, it Avill snore like an adult. The constitutional lesions vary in different cases, in some marked, and in others slight, but as they are only incidentally related to the disease Ave are describing, it is not necessary to enter into a detailed description. Diagnosis.—The symptoms above named having drawn our attention to the throat as the seat of a disease, Ave make an ex- amination of it, by placing the patient in a good light and de- pressing the tongue. I prefer the use of a hand-mirror to reflect the light, concentrating it in the throat. In using this the patient is placed with his back to the AvindoAV, in such position that avc can catch the direct rays of the sun upon the mirror, and throAV them in the throat. Or, using a lamp, which is more 252 DISEASES OF CHILDREN. coiwenient, it is placed by the side of the patient on a le\rel Avith the head, Avhen the light may be readily thrown into the pharynx Avith the mirror. Making such examination we find the mucous membrane thickened, relaxed, changed in color, and the tonsils enlarged and spongy, and covered by the mucus or muco-purulent secretion. Treatment.—The general treatment named for chronic catarrh Avill be applicable to this case. If called in consequence of a recent cold, (Avhich ahvays increases the throat trouble,) Ave will administer Aconite Avith Phytolacca or Avith Rhus as may be indicated. If the mucous tissues are deep-red and relaxed, sulphurous acid can be giATen Avith advantage, especially if the tongue is dirty and the breath bad. With the dull purplish color of mucous membrane, and sometimes also of face, the patient should have Baptisia. Restoratives are very generally indicated, and Ave select them as heretofore named. Minute doses of Veratrum and Arsenic, Compound Syrup of the Hypophosphites, Cod-liver Oil, the diffent preparations of malt, Hypophosphate of Lime, inunctions with Quinine, etc. If the child is old enough to use a gargle Ave may employ the Hamamelis, alternated Avith chlorate of potash. The Hamamelis may be used in the form of the tincture, Sss. to Avater 5iv., the chlorate of potash in solution, 5j- to water Oj. In place of the Hamamelis Ave may use the Hydrastis, Cornus, Alnus, or Marsh Rosemary. If the child can not use a gargle, the same remedies may be employed Avith the spray apparatus. Occasionally good results may be obtained by using a remedy in poAvder, allowing it to dissolve on the tongue, SAvalloAving slowly. In this Avay Ave may employ the following: R/ Chlorate of Potash 5j., (or Alum gr. xx.,) Tannic Acid gr. v., Gum Arabic powdered, White Sugar, aa. 5ij.; triturate thoroughly and divide into powders of five grains. In place of this Ave might use a pastile or lozenge in the form of Dr. Anton's, which has proven quite available. The formula is given in the foot-note.* * # Cubebs, fresh and finely pulverized, two ounces; Chlorate Potash half ounce; Gum Tragacanth one and a quarter ounces; Refined Sugar TONSILLITIS. 253 A flannel cloth wrung out of cold vinegar and applied around the throat, Avith a dry flannel over it, on going to bed, is a very important aid to the treatment. If the vinegar produces irrita- tion of the skin it should be diluted. When the cloth is removed in the morning, the neok and shoulders should be Avashed in cold Avater, using it freely, but drying with brisk friction. This is the most certain means to prevent the frequent taking cold, which in some cases seems to be the greatest obstacle to perma- nent recovery. TONSILLITIS. Inflammation of the tonsils is a very peculiar disease, in that the tendency to it is hereditary in some families, and that, hav- ing once occurred, there is a continued predisposition to it, and it continues to recur, sometimes during the entire life-time. It is also peculiar, in that an inflammation so active in form should be confined to a small gland, and not extend to adjacent structures. Caises.—Tonsillitis occurs most frequently at the commence- ment or breaking up of Avinter, Avhen the Aveather is very change- able. A slight cold, contracted at such times, will be folioAved by an attack. Pathology.—The tonsils are composed of an association of follicles, terminating on the free surface by tAvelve or fifteen ducts, through Avhich the secretion is passed for the lubrication of the fauces. These follicles are bound together with a rather loose areolar tissue, and the Avhole is invested by a reticulated fibrous capsule, and covered externally by mucous membrane. fourteen ounces; Tincture Collinsonia Canadensis three fl-iid ounces; Tincture Stillingia half fluid ounce; Tincture Capsicum thirty drops; Essence of Peppermint thirty drops. Add the tinctures to a few drachms of the sugar and evaporate, then mix all the ingredients and triturate thoroughly; add of boiling water two and a half ounces; mix and work well in the mortar, and set aside (bottom upward to prevent evaporation) for twenty-four hours', to allow the Avater to soften and incorporate with the gum and sugar. Cut out slices, flatten out with a roller on a pill tile to a uniform thickness, using sugar of milk or starch powder to prevent the mass from adhering to the tile and the roller, and the lozenges to each other. Cut out the lozenges with a flaring tin punch, a full half inch in diameter, so the lozenjre will weigh eight grains. Let them dry until hard before using. Avoirdupois weight is used. 254 diseases of children. The structure is such as to permit very great variations in size. Thus, in simple congestion, they may attain a size three or four times as large as in the normal state, and under inflammatory action Avith exudation, their bulk is still further increased. The looseness of the tissue likeAvise permits organized exudative material to once or tAvice the usual size of the organ, Avithout materially interfering Avith their function, as Ave see in protracted cases of tonsillitis. Symptoms.—Quinsy usually manifests itself first, by soreness and stiffness of the throat, Avith difficult deglutition, and more or less derangement of the digestive functions; occasionally it is ushered in Avith a marked chill, folioAved by febrile reaction. There is ahvays some fever, dryness and constriction of the skin, and general arrest of secretion. In a feAV hours the patient com- plains of pain, and a sensation as if some foreign body were present in the throat, Avith heat and constant desire to SAvalloAV. When fully developed, deglutition becomes so difficult and painful as to occasion extreme suffering, and in some cases it is impossi- ble. A guttural cough with frequent desire to remove the secre- tion from the throat; a hoarse and difficult respiration, and confused Avhispering and guttural articulation, or sometimes entire loss of voice, is observed. In the severer cases it becomes impossible for the patient to lie doAvn, and in many, but little rest is obtained in consequence of the difficult respiration Avhen the will is in abeyance. If Ave examine the throat in this disease, we Avill find the tonsils enlarged and reddened; some- times so large as to entirely close the opening of the fauces. An attack of quinsy continues for a variable length of time; usually from four to twenty days, and terminates sometimes by resolution, at others by suppuration. When it terminates the latter AAray, the gland rapidly enlarges; there is a dull throbbing pain or aching, and a yclloAvish color near Avhere the pus points; usually it readily comes to the surface and discharges Avithout assistance, but sometimes it is very sloAvand requires the bistoury. A condition of chronic inflammation and enlargement frc- quently continues, in those predisposed to the disease. The glamls appear prominent on examination ; the mucous follicles enlarged; the color a dusky-red, and considerable tenderness. Associated with this, Ave frequently have a chronic irritation Avith determination of blood to the entire isthmus of the fauces, and TONSILLITIS. 255 elongation of the uvula, giving rise to a continuous disagreeable cough, derangement of the general health, finally inducing seri- ous disease of the respiratory apparatus Diagnosis.—The diagnosis is very readily effected, as the symptoms pointing to disease of the throat are so prominent as to lead to its examination at once. Upon depressing the tongue one or both tonsils Avill be seen enlarged and reddened. Day by day Ave find the s\Arelling increasing, until, if both tonsils are engaged in the disease, they will have quite closed up the isthmus of the fauces. The deep, throbbing pain in the part, greater difficulty' of respiration and deglutition, with yelloAvish discolora- tion, give information of the establishment of suppuration. Prognosis.—Though these symptoms are sometimes very urgent, and the patient suffers extremely from a sense of im- pending suffocation, not one in a thousand will die of the disease. Yet it has been one peculiarly difficult to influence with reme- dies; and the radical cure of the disease, Avhere there has been a predisposition to it, has been considered impossible, except by total ablation. Treatment.—The use of Aconite with the spray instrument is almost specific in the early stage of the disease. I have em- ployed the steam atomizer, but the Bergsen tubes operated with the rubber belloAvs, the Richardson apparatus in its many modified forms, Avill ansAver the purpose, or the small Essex spray is very good. With the steam atomizer I use it in the proportion of gtt. xx. to Avater §ij., Avith the air spray gtt. x., to water §iv. The spray is used as often as every four hours, for five minutes at a time, until relief is obtained. In many cases I have suc- ceeded in arresting the disease with the one application. It is well to have the patient spit out the Aconite that accumulates in the mouth, as there Avill be too much to SAvallow. When these instruments are not at hand, let the patient inhale the vapor of vinegar and Avater, and apply to the throat the Linamentum Stillingia on flannel. The internal remedy in this case Avill be Aconite alone, using it in the usual proportion, and repeating it every hour. There is no doubt about the specific action of the remedy, even Avhen taken in these small doses, though it is not so certain as Avhen used with the spray. Some- times Phytolacca, Belladonna or Rhus may be added to the sed- 256 diseases of children. ative. If the tongue is red and dirty, and the tissues of the throat red and relaxed, sulphurous acid is a very good remedy. Penciling the tonsils with the strong tincture of Veratrum will also exercise a marked influence on the inflammation, and will sometimes arrest it at once. These means should be persisted in, and if they do not arrest the inflammation they will most frequently prevent suppura- tion. When they prove ineffectual, I am satisfied that there are no means Avhich Avould have given better results, and Ave wait the result of suppurative action with patience. Much relief is iioav given by the use of inhalations, and sometimes by hot fomentations applied to the throat. As a general rule the abscess will open itself, and this avc would ahvays prefer in children. If it does not, and the symptoms of obstruction in the throat be- come alarming, Ave Avill have to lance the tonsils. This is not very easily done, but by guarding the bistoury Avith the finger, it may be accomplished Avithout danger. The treatment for the radical cure of the disease Avill vary in different cases. If the tonsils alone are affected, the general health being good, I think Ave may hope for a cure in the child. For this I rely principally upon the local application of persul- phate of iron ; at first one part to three of glycerine, but increas- ing its strength as the treatment progresses, until it is used of full strength if necessary. Tne continued use of the tincture of Hamamelis, applied to the tonsils once or twice dailv, Avill also give good results. If there is disease of adjacent parts, the treatment advised in chronic pharyngitis Avill be used in addition. When these means fail, avc Avill have to take into consideration the propriety of excision. It is claimed by some, that the remo- val of the tonsils leads to tuberculosis of the lungs, and this claim is based upon considerable experience in sections of coun- try Avhere tonsillitis prevails. Why such a result should folloAV I can not see. The tonsils are removed Avith a tonsillitome, or guillotine, and is easily effected, and Avithout risk. The important part of the operation is to include the Avhole of tonsil in the ring of the instrument, so as to remove it Avhen the knife is throAvn forward. If not Avholly removede, the disease may be reproduced, just as if nothing had been done. If there should be hemorrhage fol- loAving the operation, pencil the part with persulphate of iron, or a saturated solution of alum. CROUP. 257 CROUP. Croup is laryngitis of the child, and yet it differs very mate- rially from that disease in the adult. This difference is owing in part to the imperfect development of the larynx in the child, as compared with the adult, and to a limited extent, the differ- ence in the progress and results of the inflammatory action. Thus it is well to retain the name of croup for the laryngeal affection of the child, to prevent confounding the disease with the laryngitis of the adult. We recognize three forms of croup, mucous, pseudo-membra- nous, and spasmodic. Though alike in some of their features and symptoms, it is Avell to study them separately. MUCOUS CROUP. This is the most common form of the disease in our Avestern country, comprising, probably, tAVO-thirds of all the cases met with. It varies in intensity in different localities, at different seasons, and in different persons. Thus in some places it is a very common disease, in the late autumn and early winter, and in the spring, Avhen Avinter is breaking up; as on the shores of Lake Erie. While in some other sections croup is rarely seen, as in Cincinnati aAvay from the river. Causes.—The cause of this, as Avell as other forms of croup is cold, with its arrested secretion and derangement of the circula- tion. Why it should particularly affect the small surface of mucous membranes lining the larynx, Ave are unable to say, as avc are unable to account for manv things Ave meet Avith in the study of medicine. Pathology.—This is a true inflammation of the mucous membrane of the larynx, though not of an active character. It is sufficient, hoAvever, to cause an increased circulation of blood to it, some impairment of the capillary circulation, and an in- creased activity of the mucous follicles. It might properly be termed follicular laryngitis There is but little thickening of the mucous membrane; in- deed, all there is depends upon the increased distension of the blood-vessels. We have, therefore, to look someAvhere else for i7 258 diseases of children. the cause of the difficult breathing, Avhich is so prominent a symptom. This is partly OAving to accumulations of mucus in the larynx, but principally to contraction of the intrinsic muscles of the organ, from the irritation of the mucous membrane. Thus post-mortem examination does not sIioav the larynx occluded by structural change, as many would suppose. In some cases, it is true, there are considerable accumulations of mucus, but in most the larynx is sufficiently free for respiration, and Ave must conclude that the child has been asphyxiated by the spastic contraction of the laryngeal muscles. * Symptoms.—Frequently for a day or two before the attack the child will have had symptoms of cold, Avith a slight cough. Both the cough and voice are frequently a little hoarse and rough, and Avould be recognized by a person acquainted Avith the dis- ease as croupal. The attack of croup occurs most frequently at night, though it may be in the day time. The child seems to be suffering more Avith its cold during the evening, but still it is not sick, and it is put to bed Avithout, probably, a thought of danger. But along about the middle of the night the parents are aroused by the child starting out of sleep Avith difficult respiration, a hoarse voice, and a croupal cough. The respiration is rough and whistling, the cry hoarse and feeble, except when a great effort is made, Avhen it becomes shrill and piping. At first the difficulty of respiration is intermittent, but after an hour or tAvo it becomes permanent, and there is a peculiar Avhistling or gurgling sound as the air passes into and out of the larynx. As the disease progresses the difficulty of respiration becomes more marked, and the cough is hoarser, has a peculiar metallic tone, and the voice sinks to a Avhisper. If the child sleeps mucus accumulates in the throat, the breathing becomes more and more difficult, until at last the child Avakes with symptoms of asphyxia. At first the skin is dry, its temperature increased and the pulse full and hard. But as the respiration becomes more difficult, a cold clammy perspiration breaks out, the extremities become cold, and the pulse frequent and feeble. The disease runs its course in from tAvelve to tAventy-four hours, terminating in a subsidence of the disease or death. CROUP. 259 Diagnosis.—The hoarse metallic (croupal) cough, with hoarse- ness and change of voice is sufficient evidence of croup, but it does not inform us which of the three varieties it is. in mucous croup, there is the slight febrile action to distinguish it from the spasmodic variety, and the evident presence of mucus in the larynx manifested by the rattling sound heard on auscultation, and Avhen the patient coughs, which distinguishes it from, the pseudo-membranous form. The evidence of increased secretion of mucus in the throat is the diagnostic feature of this disease, though other points of distinction Avill be named Avhen Ave describe the tAvo other forms. Prognosis—Though some cases of mucous croup are Aery severe, and require careful and close attention, yet Ave may regard the prognosis as favorable. I do not think the mortality should exceed from tAvo to five per cent. Treatment.—Three methods of treatment may be pursued, and either of them Avill give success if properly carried out; or, if the practitioner chooses, he may take a part of each and form his oavii treatment out of it. I may premise by saying that the treatment generally adopted, of giving emetics for the purpose of emesis, is the worst that could possibly be done, if Ave except the insane idea of the local application of nitrate of silver, by the folio Avers of Dr. Green. It makes very little difference what emetic agents are employed, if the object is speedy vomiting; for such action is not attended Avith relaxation or sedation in one-half the cases, while the efforts at vomiting throw the larynx into action, cause increased determination of blood, and increased irritation of the intrinsic muscles. There is no more certain Avay to destroy the life of the child than this. Emetic agents, however, may be used in the treatment of croup Avith success, and Ave will consider this use, as the first plan. The objects Ave wish to accomplish are: first, relaxation of the larynx to give better respiration ; second, to produce sedation, and thus lessen inflammatory action ; third, to increase secretion and thereby <;et a material less tenacious and more easily removed, and at the same time deplete the engorged vessels of the part. For this purpose they should be used in small doses frequently repeated, so as to produce nausea and its effects—relaxation and 260 diseases of children. sedation—Avithout emesis. I prefer preparations of Lobelia, but other nauseant emetics may be used Avith good results. The acetous emetic tincture of our Dispensatory will be found to ful- fill all the indications. Aconite alone is the principal internal remedy in the second plan of treatment. I have no doubt of its specific action in this case, even in small doses. I Avould prescribe it in the propor- tion of: I$s Tincture of Aconite gtts. j. to iij., Avater 5iv., a teaspoonful every fifteen minutes. Veratrum may be used in some cases in the proportion of gtt. v. to gtt. x., to wafer 5iv., and alternated Avith the Aconite. The external remedy in this case, as well as in the others, is the application of the Stillingia liniment to the throat over the larynx. It may be applied with the finger or a piece of soft flannel or cotton, and the application repeated every half-hour or hour. In some cases this remedy locally applied is all-suffi- cient for a cure, and relief Avill be noticed within an hour. Occasionally we administer it internally in doses of half a drop to one drop on sugar; it may be repeated every half-hour or hour. In families where croup is of frequent occurence, it is well that the mother should haATe a bottle of Stillingia liniment, and be instructed to use it on the first appearance of hoarseness. The formula for this preparation Avill be found in the first part. I greatly prefer the second plan of treatment. When the breathing is very difficult, hot water may be applied to the throat with flannel cloths assiduously, until relief is obtained. This part of the treatment is of much importance, and requires that the application of heat be constant, and that the surface is not alloAved to be chilled by exposure as the cloths are changed, or by Avetting the clothing. The third plan of treatment is by the use of inhalations, the vapor of Avater or vinegar being the basis, and medicated as the case seems to demand. The steam spray apparatus is an ex- cellent instrument for using inhalations in this case, though if it is not at hand Ave may improvise our means from a tin vessel containing the fluid, and a hot iron to raise the vapor. With the spray apparatus I use the preparation of Aconite, named above for internal use, or equal parts of vinegar and water in the cup, or if the sounds are whistling, lime water. The ordi- nary inhalation Avill be of vinegar and water, or of an infusion of hops or tansy. CROUP. 261 With either of these means the hot application to the throat is important. Or, when it can not be conveniently employed, or Ave are afraid to trust the nurse, we will apply the compound Stillingia liniment, or in place of this, a cloth sufficiently large to cover the throat and upper part of the chest is spread with lard and freely sprinkled with the compound powder of Lobelia and Capsicum, and applied. The old-fashioned snuff plaster, made in the same Avay, answered a good purpose. PSEUDO-MEMBRANOUS CROUP. This form of croup is fortunately of rare occurrence, as it is much more severe than the others, and, if not treated promptly and skillfully, Avill terminate fatally. Causes.— This variety is produced by the same cause, cold, as the other forms, though there is some difference in the general health of the patient, Avhich, in one case, gives increased secre- tion of mucus, and in the other a plastic exudation. Pathology.—This is a true inflammation of the larynx, com- ing on gradually and progressing slowly in the majority of cases, and attended Avith plastic exudation upon the mucous membrane. In this case Ave find the mucous membrane no more thickened than could be accounted for by its injection Avith blood ; and even Avhere loosely attached there is no submucous infiltration. Post-mortem examination sIioavs the formation of a false mem- brane from the one-twelfth to the one-sixth of an inch in thick- ness. This of a grayish-white or yelloAvish-Avhite color, opaque, and of considerable tenacity. Microscopic examination shows it to be composed of mucus, epithelial cells, and an obscure fibrous structure, the result of organization of the plastic exudation. It varies greatly in its tenacity of adhesion to the mucous mem- brane; in some cases it seems almost to form a part of it, and is detached with great difficulty ; in others it is very loosely attached, and may be loosened and removed by simple pressure on the larynx externally. In a large majority of cases this false membrane is not of sufficient thickness to account for the arrest of the respi- ratory function, and Ave must regard the spastic contraction of the muscles of the larynx, from irritation, as one of the causes of death. 262 diseases of children. Symptoms.—The coming on of the attack of pseudo-mem- branous croup may sometimes be recognized for three or four days, or even a Aveek. The child does not seem sick, and is playing about the house as usual, but has some cold, and the parents notice a slight hoarseness of voice and cough. We Avill notice, hoAvever, a peculiar metallic resonance to the voice, cry, and cough, but more especially that there is a dry anc^Avhistling respiration. This is so marked that the breathing may be heard across the room. The attack of croup most frequently comes on at night, as in the other cases. In the evening it is noticed that there is more hoarseness of the voice and the cough is someAvhat croupal, but as the child breathes pretty well and does not seem sick, the parents flatter themselves that it is but a cold, and Avill give no trouble. The mother has told me of going to the child's bed or crib, attracted by the peculiar whistling respiration, impressed that there Avas something Avrong, but fearing ridicule if she sent for the physician. As time passes the child becomes restless from difficult breath- ing, has slight attacks of cough in his sleep, -which are clearly croupal. In another hour or tAvo he aAvakes Avith a start and assumes a sitting position, evidently suffering much from difficult respiration, Avhich is increased by the attacks of coughing. The symptoms are uoav very marked, the respiration is sibilant or whistling, and difficult; the cough hoarse and metallic; the voice roughened or sunk to a Avhisper, and the cry shrill and piping; the skin is dry, the pulse hard and increased in fre- quency ; urine scanty, and the patient restless and uneasy. As the disease progresses there is a gradual increase of all these symptoms, but especially of difficult respiration, which is constant. The cough is spasmodic in its character, and Avhen it comes on the patient suffers very greatly from Avant of air. After a time evidences of asphyxia appear in the bluish lips, distended veins, leaden appearance of the surface, cold extremities, dullness of the nervous system, and finally coma and death. The entire duration of the final attack will be from six to forty-eight hours. Diagnosis..— That it is a case of croup is evidenced by the peculiar cough and the change of the voice and cry; that it is pseudo-membranous croup by the constantly increasing difficulty CROUP. 263 of respiration, the marked dryness and sibilance in the sound of the air passing through the larynx, and in the peculiarly dry and metallic cough. Dryness and metallic resonance, in addition to the croupal cough and voice, are the diagnostic points. Prognosis.—The prognosis is not as favorable as in the other two varieties, and with the best treatment some cases Avill prove fatal. Still I should not be willing to indorse the old state- ment—"a large majority must die"—but think, Avith proper treatment, the majority Avill recover. Treatment.—The indications of treatment in this case are: To produce relaxation of the intrinsic muscles of the larynx, and thus give freedom to the respiration, while Ave pursue the main treatment; to lessen inflammatory action, and obtain free secretion of mucus, for the purpose of effecting the detachment of the false membrane; and finally to effect the removal of this. To fulfill the first indication, avc employ inhalations of the vapor of Avater, or Avater and vinegar or lime Avater, as Avill be hereafter named. With this we direct the continuous applica- tion to the throat of flannel cloths Avrung out of hot Avater, in the meaiiAvhile bathing the throat with the Compound Stillingia Liniment. These are important means, and should never be neglected. There are tAvo plans of accomplishing the second indication. The one is, by the use of tincture of Veratrum viride or Aconite, aided by inhalations of lime Avater, and is a very good treatment and much pleasanter than the use of nauseants. I prescribe the Veratrum in the proportion of gtt. x. to water §iv., a teaspoon- ful every fifteen minutes, until it produces a marked influence upon the pulse, then in smaller doses to continue its effect. Aconite is preferred when the pulse is small and frequent, and is administered in the usual small doses: 1^ Tinct. Aconite gtt. ij. Avater 5iv., a teaspoonful every fifteen minutes. If the child is very sensitive to the action of the remedy the dose should be still further reduced, and if Ave find the lips dry and contracted, and the child grasping at the mouth Avith its hands, it should be suspended and Veratrum substituted. If the tongue is pallid and shows small spots of red, Phyto- lacca mav be combined with the medicine. If the little patient is dull and stupid and Avants to sleep, give Belladonna. If it has a sharp-stroke of pulse, and moves its head restlessly back- 264 diseases of children. ward and forward, throwing it backAvards as if it would bury the occiput in the pillow, give it Rhus. This remedy is also indicated by the shrill cry, as if frightened, and sudden starting from sleep. Gelseminum is indicated by the flushed face, bright eyes, and contracted pupils, with restlessness and great irritation. These remedies are secondary, it is true, but it is a case that re- quires all that Ave cai» do, and if by one of these Ave strengthen the Aconite and Veratrum, Ave give our patient an additional chance. What the physican needs, most of all, is a steady hand. The treatment requires time, and Ave must not get excited. If the patient is groAving no Avorse, avc should feel satisfied for a time ; if there is but a sIoav improvement, as marked byr more ease of respiration, a better circulation, Avarmth and moisture of feet, legs and forehead, Ave will feel encouraged and hold fast to the treatment. The use of lime water as an inhalation is a \'ery important part of this treatment. It is claimed that it alone is sufficient to arrest the inflammatory action and cause the detachment of the membrane; and I have employed it Avith success Avhen other means have failed. The Veratrum and Aconite also have proven very successful alone, and they will fulfill the first tAvo indications. The other and older plan of treatment is by the use of the nauseant emetics, and if properly used will give excellent re- sults. I may add, that if improperly used, i. e., so as to irritate the stomach with retching and ineffectual efforts to vomit, they will hasten the fatal termination. Of these remedies I prefer: 1^ Acetous Tincture of Lobelia, Acetous Tincture of Sunguinaria, aa. 5j., Molasses Sj., Chlorate of Potash, finely poAvdered 5ss., let them be combined with heat, and add the potash. We give this in doses of a teaspoonful every ten or fifteen minutes until nausea is induced, then in smaller doses so as to continue the nausea without vomiting. The greater and more constant the nausea Avithout efforts at vomiting, the greater the success of the treatment. Using the hot applications to the throat, and the inhalations of vinegar and Avater, Ave continue the nausea for some hours, at least until Ave have evidence of secretion, and the commencing detachment of the false membrane. This Avill readily be de- tected by the moist sound of respiration, and a gurgling flapping CROUP. 265 sound in the act of coughing. If the child is breathing pretty freely, Ave may Avait for the removal of the membrane by the cough, as it will be brought aAvay by shreds. But if, with the loosening of it, it seems to be drawn upAvard in expiration, and downward in inspiration, tending to block up the passages, and producing evident symptoms of asphyxia, Ave carry our remedies to thorough and prompt emesis. Generally it Avill be Avell enough to prepare an infusion of the compound poAvder of Lobelia and Capsicum for use at this time, as we will have established a degree of tolerance for the other preparation. Occasionally Ave will meet Avith a case requiring prompt relief. Here the child may be turned on its abdomen, and a finger in- troduced into the mouth, draAving the tongue forward and excit- ing the fauces, will be folloAved by a forcible expulsive effort, and the membrane will be detached. A case of this kind oc- curred in my practice—the membrane became detached and en- tirely stopped the larynx, the child Avas asphyxiated and would have died in five minutes. I snatched it from the mother, turned it on its face, inserted my finger as far down as the larynx; a forcible effort at vomiting ensued, and the Avhole membrane Avas removed at once, being a perfect cast of the laiynx. The child recovered. Success in the treatment of pseudo-membranous croup, Avhat- ever means may be pursued, depends upon keeping the larynx relaxed to permit aeration of the blood, until in the course of time Ave get the detachment of the false membrane. It demands patience and perseverance in the use of the means named, and success will follow. The convalescence of such a case demands much care, as the patient Avill have suffered from imperfect respiration, from the effects of the remedies employed, and the larynx and other mu- cous surfaces Avill be in a debilitated condition. Put the patient upon the use of bitted tonics, as: R Quinia, Hydrastine, aa. gr. vj., make tAvelve poAvders, give one every three hours. The child should be kept Avarm and quiet, in the recumbent position, and guarded from draughts of air, and in addition it should be kept free from excitement. 266 DISEASES OF CHILDREN. SPASMODIC CROUP. In some sections of country this is the common form of croup, though in others the mucous form is of most frequent occurrence. It is not so severe, and ordinarily patients reco\'er Avithout difficulty. Very rarely a case is met with running to a fatal termination. Causes.—The cause of this, as of the other forms, is cold, sudden change of temperature, exposure to an east or north wind, sitting in a draught, irritation of the digestive apparatus, etc. Pathology.—In spasmodic croup there is irritation of the mucous membrane of the larynx with determination of blood, or in some cases a slight superficial inflammation. The irritation is sufficient to excite spasmodic contraction of the muscles of the larynx, hence the symptoms of croup. In many cases the irrita- tion extends to the bronchial tubes as well, and they are more or less contracted. Thus, Avhile the difficulty of breathing is prin- cipally laryngeal, it may be to a limited extent asthmatic. Symptoms.—In this case there is usually but slight symptoms of cold before the attack, though occasionally the child will haA*e a severe cold. Frequently there is slight hoarseness in the even- ing and a little cough, though not sufficient to attract attention. The child is put to bed and sleeps for an hour or tAvo, then be- comes restless, and finally wakes with a start, suffering severely from difficult breathing. Noav the breathing is stridulous, the cough hoarse and croupal, the voice hoarse or Avhispering, and the cry shrill and piping. The skin is soft and moist, the pulse soft and regular, and the nervous system sIioavs no traces of excitement. In a feAV minutes the child breathes easier, and may fall asleep, but the period of ease is short, a paroxysm of cough occurs, and the breathing is as difficult as before. Thus the disease will continue for hours, broken up into exacerbations and remissions, until finally, the paroxysms becoming lighter and lighter, the breathing is Avholly relieved, and nothing is left but a slightly hoarse cough. Diagnosis.—The diagnosis of spasmodic croup may be easily made if Ave notice, first, that there is an entire absence of febrile I croup. 267 symptoms; second, that it is remittent in character and broken up into exacerbations and remissions. There is an absence of the mucous rattling, as in mucous croup, and the extreme dryness of respiration and cough, as in the pseudo-membranous; and neither in the respiration nor cough do Ave detect any evidences of change in the condition of the mucous membrane, as is so distinct in the other tAvo forms. On the contrary, all the symp- toms point to irritation of the intrinsic muscles of the larynx, and the consequent diminution of its calliber, as the true condition. Prognosis.—The prognosis is favorable. For, Avhile in ex- ceptional cases, the impairment of respiration may be so great as to destroy life, in the majority recovery Avould occur Avithout aid from medicine. Treatment.—The treatment of mucous croup may be em- ployed in this case, especially the treatment by the use of nau- seants. I prefer preparations of Lobelia to any other, as this is our most powerful anti-spasmodic. The compound tincture of Lobelia and Capsicum (King's Anti spasmodic Tincture) is a very good form, biit almost any preparation of the remedy will ansAver. It should be given in doses sufficiently large to produce nausea, but always short of emesis. In the milder cases the administration of the compound tinc- ture of oils of Lobelia and Stillingia (Stillingia liniment), in doses of one drop, repeated every quarter or half hour, with its external application to the throat, Avill be sufficient to arrest the disease. In giving this, it is dropped on sugar, Avhich is alloAved to dissolve in the mouth and swalloAved Avithout water. This Avill also be found a good treatment in the milder cases of mucous croup, or in its earlier stages. In families Avhere the children are subject to croup, it Avill save much trouble to provide the mother Avith the remedy, Avith directions for its use. It Avill save many unpleasant trips at night, and be a very great satisfaction to the parents. Spasmodic croup is frequently sympathetic, and repeated at- tacks occur much to the surprise of the physician. There is an irritation of the stomach requiring treatment, or the patient wants sulphite of soda or sulphurous acid to remove an unpleas- ant coat from the tongue, (and a similar unpleasantness from the stomach), or it may be troubled with worms and require Santonine with Podophyllin. 268 DISEASES OF CHILDREN. In some of these cases the disease is distinctly periodic, and quinine should be given in full antiperiodic doses. In other cases the reccurreuce of the disease ispreATented by the adminis- tration of Bromide of Ammonium 5'j. water %i\\, a teaspoonful every four hours. In still other cases the croup is the result of a suppressed eruption, frequently urticaria or hives, or it may arise from retro- cession of an eruption, and erythema, roseola, or even that which is popularly knoAvn as heat. These cases will be reached by the administration of small doses of Aconite Avith Belladonna, and sometimes by sponging the surface Avith hot Avater. (EDEMA GLOTTIDIS. CEdema glottidis, or asthenic laryngitis, may occur at any age, but is most frequent in childhood. It is not met with very fre- quently ; indeed, many physicians will practice a life-time Avithout seeing a case. Causes.—This disease seems to be dependent upon cold, but Avhy it should iiwade this particular part -we are unable to tell. As it occurs in feeble children, and therein manifesting a ten- dency to disease of the throat, it is probably OAving to debility of the tissues. Pathology.—The disease is undoubtedly inflammatory in its character, but the inflammation is subacute, and involves the submucous tissue. In its progress there is effusion into this, and it becomes swollen, and Avhere this tissue is loose, as the imvard surface of the epiglottis, and the upper portion of the larynx, it produces such engorgement as to obstruct the passage of air. As this distension is greatest in the epiglottis, the difficulty is much greater in inspiration than in expiration. Symptoms.—The disease commences Avith a continually in- creasing impediment to respiration, and a feeling of fullness and constriction, and continuous desire to clear the throat, as if the irritation were caused by some foreign body. The voice becomes hoarse, then croupal, and aftenvard sharp, stridulous, Avhispering, and is then lost entirely. There is a hoarse, convulsive cough, with fits of suffocation, causing great agony. (EDEMA CLOTTIDI3. 269 The most marked feature of the disease is, that Avhile inspira- tion is prolonged, stridulous, and exceedingly difficult, expiration is comparatively easy. This feature is so constant as to be path- ognomonic. There is no fever, but as the disease progresses the pulse be- comes more frequent, small, and irregular. The difficulty of breathing increases, the paroxysms of coughing and suffocation are more frequent, symptoms of asphyxia appear, the cerebral functions are disturbed, and at last death ensues from inability to inflate the lungs. Diagnosis.—The diagnosis in this disease will be readily made, if it is recollected that the difficulty is in inspiration, while expiration is comparatively free. In the later stages of the dis- ease, when it is likely to prove fatal, the diagnosis will be more difficult. Prognosis.—In the early stages of the disease, the prognosis is favorable ; but when symptoms of asphyxia begin to appear, it is doubtful. Treatment.—The treatment of this case Avill be Avholly different from that adopted in croup, being stimulant instead of relaxing. We Avould dry cup the throat and upper part of the back, and repeat it if the case Avas serious; applying to the throat and breast a cloth spread with lard and sprinkled with the compound powder of Lobelia and Capsicum, changing it tAvo or three times daily. A mustard foot-bath may be used Avith good effect, and repeated tAvo or three times, following it by the application of dry heat. We guard against coldness of the ex- tremities, which so frequently folloAvs the ordinary use of the foot-bath, and Avhich almost invariably increases the disease. If the pulse is frequent and small, Ave will give Aconite, com- bining with it Apocynum, as: R Tinct. Aconite gtt. ij. to gtt. v., Tinct. Apocynum gtt. iij. to gtt. xv., water $i\\, a teaspoonful every hour. Apocynum will act upon the bowels in quite small doses, but if the bowels are torpid the proportion of this remedy may be increased. Phytolacca is sometimes indicated by the soreness of the mouth and throat, and engorgement of the lym- phatic glands. Belladonna is a good remedy in some cases, the indication being the dullness and stupor, and inclination to sleep. In sonic cases stimulant doses of Lobelia, Avith some pleasant 270 DISEASES of children. aromatic to prevent nausea, may be prescribed. The following formula ansAvers well: Ity Tincture of Lobelia oij-, Compound Tincture of Lavender f§ss., Simple Syrup to 5ij.; a teaspoonful every hour, or, better, half teaspoonful every half hour. If at any time it should produce nausea the dose must be lessened. This may be aided by the use of stimulant inhalations with the spray apparatus. A very good inhalation may be formed by adding Carbolic Acid, grs. a\, to water 5i\\, or, Hydrochlorate of Ammonia, grs. x., to water 5iv.; or in place of them, lime water, of full strength, may be employed. Associated with these means, in a malarial country Ave Avould give quinine in stimulant doses, say half to one grain every three hours. It may be given alone, or, Avhat is better, associated Avith hydrastine. Sometimes Ave find a very troublesome cough, that greatly in- creases the patient's danger, by its interference Avith the respira- tory movement. Without the cough the child Avould get a suffi- cient supply of air, and its blood would be decarbonized; Avitji the cough it suffers from defective oxygenation and retained car- bonic acid. In this case the life of the patient may depend upon quieting the cough. For this purpose I Avould make the folloAV- ing prescription: T^ Sulphate of Morphia gr. j., Alum 5ss., Gum Arabic, White Sugar, aa. 5i.; mix and divide in tAventy parts. One of these may be placed upon the tongue, and allowed to dissolve, and be SAvalloAved without taking fluid, and repeated as often as may be necessary to quiet the irritation. BRONCHIAL CATARRH. This is one form of cold—that in which it principally affects the bronchial tubes—as in nasal catarrh it is principally confined to the cavities of the nose. It is of frequent occurrence in the fall and early winter, and in the changeable weather of spring. Sudden changes of temperature, or the barometric condition of the atmosphere, is a very common cause. Exposure to north or east Avinds, or too long or great exposure in cold weather, v/ill also cause it. Pathology.—The disease varies from simple irritation with determination of blood, to a slight grade of inflammatory action. In all cases there is a stage in which secretion is arrested. This BRONCHIAL CATARRH. 271 however, is short, and Avhen the patient is seen by the physician, increased secretion is a present condition. Symptoms.—The child manifests the usual symptoms of cold, and in addition has a cough, with some difficulty of respiration. It is noticed that it does not feel so Avell as common, that it does not move freely, or if eating, that its appetite is impaired. There is ahvays more or less febrile action for tAvo or three days, and sometimes the fever is so prominent for a day or tAvo that it ob- scures the symptoms of local disease. The physician notices in addition to all this, that there is a want of free respiratory movement, and an unnatural rattling sound in respiration. On auscultation we find the evidence of increased mucous secretion over all parts of the chest, in the moist bloAving sound (mucous rhonchus). After the third or fourth day, the febrile action passes aAvay, the difficulty of breathing goes with it, leaving but the cough, aud increased secretion, Avhich gradually declines until in from ten days to tAvo Aveeks, it has Avholly disappeared. Treatment.—In the earlier stage of the disease Ave give Aconite or Veratrum, according as the pulse is small or full, Avith such other 'remedies as may be indicated. If the patient seems to have pain in the chest, on coughing or in respiration, Bryonia is suggested. If the pulse is sharp, and there is rest- lessness with sudden starting in sleep, the remedy Avill be Rhus. If there is much mucous secretion, and rattling in bronchial tubes, with suppressed breathing, Lobelia is added to the seda- tive. In some cases the old prescription—1\/ Tinct. Lobelia 5j-, Comp. Tinct. Lavender 5'ij , Simple Syrup Sjss.—is a most excel- lent remedy ; it can be given in small doses, frequently repeated, just short of nausea, until the patient is relieved. If there is much oppression of the chest with difficult respira- tion, use the cloth spread Avith lard, and sprinkled with the compound poAvder of Lobelia and Capsicum, applying it to the entire anterior and lateral Avails of the chest, and changing tAvo or three times a day. 272 DISEASES OF CHILDREN. ASTHENIC BRONCHITIS. A form of bronchial disease is met with in young children, which Ave have been accustomed to describe under this head, though it does not express the conditions as well as Ave would wish. Causes.—The exciting cause of the disease is cold, from ex- posure, from sudden changes of temperature, or of the hygro- metric condition of the atmosphere. The predisposing' causes are such as impair the general health of the patient: bad air, insufficient diet, Avant of cleanliness and the condition heretofore described under the head of dyscrasias—bad blood and imperfect nutrition. Though*the disease most frequently occurs in such persons, it Avill occasionally be met with in children Avho have been healthy, and avIio have all the care and comforts that can be given them. Pathology.—The inflammation of the bronchial mucous membrane is of a Ioav grade, and is folloAved by relaxation and a sluggish circulation with increased secretion. It is this loss of irritability of the bronchial muscular fiber, Avith the greatly in- creased secretion, that is the principal source oC danger. Symptoms.—This is the peripneumonia notha of authors, and generally occurs in Aery young or old persons, or in those of exhausted constitution, or Avho have been liable to coughs with profuse Avatery expectoration. It usually commences with symp- toms of cold and oppression in the chest, with slight febrile reaction. The cough is severe, occurring in paroxysms; the breathing is oppressed, laborious and Avheezing; the expectora- tion, scanty at first, soon becomes abundant, thin and frothy • the pulse is quick, small, and irregular, the heat of the surface but little if any increased, the extremities generally bein Simple Syrup §jss., M.; half a teaspoonful every thirty minutes until the breathing becomes easier, then every hour. In all of these cases it is necessary that the child be kept quiet and Avarm; and I ahvays prefer that it be kept in the cradle or crib, rather than in the mother's or nurse's arms. Keep the ex- tremities Avarm—close attention to this, will in many cases be the difference betAveen a successful or fatal termination. Hot flannel to the loAver part of the body, with dry heat in the form of bottles of hot Avater, will fulfill this indication. In older children Avhen the pulse is frequent, I give small doses of Aconite to give strength to the circulation. It will be observed that as the pulse becomes less frequent under its influ- ence, it attains strength and volume. In some cases the dull- ness and hebetude, tending to coma, will be an unfavorable symptom. Here I would add Belladonna, using it in doses heretofore named. Other remedies may be indicated, for the disease presents many phases. I have-seen cases Avhere the hot sponge bath, stimulating the skin, or even Avhere- the addition of a small portion of hydrochlorate of ammonia to the hot Avater Avas an important means. Others are markedly benefited by the quinine inunction. We ahvays have the therapeutic maxim clearly before us, " that without reference to the name of the disease, whichever remedy is indicated is to be employed." ACUTE BRONCHITIS. Acute bronchitis is of frequent occurrence in childhood, and forms the larger part of those cases Avhich are knoAvn as lung fever, and winter fever. In general it does not present those acute features that are noticed in the sthenic bronchitis of the adult, but many cases Avill be quite severe. Causes.—Inflammation of the bronchial tubes arises from the same causes that produce inflammation in other tissues. Exposure to cold, especially to the north or east Avind, sudden changes of temperature, etc., are the common exciting causes. The predisposing causes are all such as impair the general health; and as a rule, it may be stated that such causes will not A.CUTE BRONCHITIS. 275 produce inflammation unless the vitality or resisting poAver of the system is loAvered from other causes. Pathology.—The inflammation is confined to the bronchial mucous membrane, and in some cases invoh'es but a portion of it, but in severe cases it extends to all the bronchial tubes. At first there is determination of blood, and the tissue is injected, SAvollen, and dry, but afterward there is impairment of the cir- culation and increased secretion. When children die of the disease, post-mortem examination sIioavs the mucous membrane thickened and softened, and the bronchial tubes more or less clogged Avith accumulated mucus and muco-pus. Symptoms.—For a day or tAvo the child has symptoms of cold, with some cough. This is succeeded by a chill, sometimes scarcely noticed by the mother, but lasting from one to four hours. FolloAving this, febrile reaction comes up briskly ; the surface becomes hot and dry, the pulse is hard and frequent, and the child irritable and restless; the urine is scanty and the boAvels constipated, the tongue having a pretty uniform Avhite coat. The fever gradually increases to the third or fourth day, remains stationary for from one to four days, and then declines as the inflammation passes off. With the first coming on of febrile reaction the attention Avill be attracted by the irritative cough, that repeats itself every few minutes. It is not yet the full bronchial cough, that is so marked a feature after the third day, but is half Avay betAveen this and the hacking cough of pneumonia. The^ougb is dry and the respiration dry and whistling, and Avhen the ear is applied over the chest, there is a marked sibi- lance or dry blowing sound. By the end of the second day Ave notice that there is slight secretion of a transparent, tenacious white mucus, streaked with blood. This is increased the third day, and by the fourth it commences to assume a yellowish, opaque appearance. Up to this time the secretion of mucus seems rather to increase the couch, as it is a source of irritation and is raised with difficulty. When secretion is fully established Ave have a moist, blowing sound, or mucous rhoncus, which is very marked. After the sixth day, the mucus becoming vcIIoav and opaque, it is raised with less effort, and the cough is not so hard or so frequent, and 276 DISEASES OF CHILDREN. respiration is much easier. From this time there is a gradual decline in all the symptoms, and the patient is convalescent from the seventh to the fourteenth day of the disease. Prognosis.—Though a severe disease, Ave do not look upon it as a fatal one, though occasionally from its intensity it becomes difficult to manage. If secretion commences, becomes opaque, easily expectorated, Avith an abatement of the fever, the case is progressing Avell ; but if symptoms of imperfect depuration of the blood are developed, with delirium, the case is a grave one. During the disease, if the sputa changes from an opaque to a glairy white mucus, we may be satisfied that the inflammation is redeveloped in its original intensity. Treatment.—The treatment Avill be directed to lessening the frequency of the pulse and temperature, relieving the irritation and stopping determination of blood to the bronchise and lungs, relieving irritation or other Avrongs of the nerve centers, and establishing secretion. It is Avell to have the subject thus clearly in mind that Ave may be able to make our diagnosis and select our remedies. Quite as essential is it that we know Avhat not to do, and what to keep friends from doing. We do not propose that the stomach or boAvels of our patient shall be irritated by cathartics or nau- seants, and Ave object to the teas and potions that friends are inclined to give or insist upon our giving. To control the pulse Ave administer Aconite, if the pulse is small and frequent (Aconite is the child's sedative), Veratrum if it has volume and is frequent. They are both good remedies, and relieve irritation of the lungs and bronchise as Avell as the general irritation Avhich gives the frequency of pulse. If the patient suffers pain, (this may be known by the expres- sion of the face and the cry,) Bryonia should be added to the sedatiA'e. If the patient has a persistent cough Avith whistling in the smaller bronchise, and further on, if there are bloAvin<» sounds with free secretion, Ipecac should be employed. If there is an oppressed respiration, with abundant mucous secretion after some days, Lobelia is the remedy. A very hot skin, but seem- ing almost on the point of breaking out into a perspiration, and a full, oppressed pulse, calls for Eupatorium perf. The remedies that relieA'e wrongs of the nerve centers are ACUTE BRONCHITIS. 277 suggested by symptoms that force themselves upon our notice. The extreme restlessness, sensitiveness to impressions, evidences of pain, sleeplessness, with flushed face, bright eyes, contracted pupils, and increased heat of the head, call for Gelseminum. The same restlessness and irritation, but with contraction of the frontal muscles, sharp pulse, and reddened papillae at tip of the tongue, call for Rhus. The dullness and inclination to sleep, want Belladonna. In addition to the remedies Avhich influence the pulse, and re- lieve irritation of the nerve centers, which also lessen the tem- perature, Ave employ baths to lessen the heat of the body and improve the functional activity of the skin. The bath may be soap and Avater, the alkaline bath (bicarbonate of potash is the best), the acid bath, or fatty inunction. The temperature of the bath is to be determined by the condition of the patient, as here- tofore named. If the temperature is high, and inflammation active, a cold pack may occasionally be used with great advantage—even an entire Avet-sheet pack is a good thing. In the majority of cases, hoAvever, a hot pack is best, and may consist of three or four thicknesses of flannel Avrung out of hot Avater, and applied to the chest OArer a single thickness of flannel which is alloAved to remain. Sometimes sponging the chest with hot Avater for a few minutes, and then covering it with flannel, exerts a good influ- ence. My favorite local application, hoAvever, and one that is ahvays safe, is the soft cloth spread with lard, and sprinkled with the Compound PoAA'der of Capsicum. This may be renewed tAvice a day, scraping the old off with a knife and respreading. If the irritation of the bronchise is so great as to cause much difficulty of respiration, or if the cough should be so harassing as to prevent sleep and aggravate the fever, we may relieve the patient by the use of inhalations. The steam atomizer is an ad- mirable apparatus in this case, but if not at hand Ave Avill impro- vise an inhaling apparatus out of a half gallon cup and a hot iron. The vapor of Avater alone is sufficient in most cases; or in some Ave may use an infusion of hops, of tansy, of poppy heads, or a small portion of tincture of opium may be added. The inhalation may be repeated as often as every one, tAvo or three hours, until the patient has relief. The plan laid doAvn I think much better than the old method by the use of nauseant expectorants, and while a case might 278 DISEASES OF CHILDREN. occasionally arise in the adult, Avhere I Avould use the old method, I do not think I Avould employ' it in the child. CHRONIC BRONCHITIS. We occasionally meet Avith a case that may be classified as chronic bronchitis, though it does not present all the symptoms of that disease in the adult. Like the disease in the adult, it is associated Avith an impairment of the general health, and may terminate in infantile phthisis. Causes.—The cause of this bronchial disease in the child is the frequent repetition of bronchial catarrh from cold. At first the patient recovers from the attack well, but as it continues to be repeated the recovery is tardy, and less and less perfect, until finally Ave have the condition of the respiratory organs under con- sideration. In other cases the disease is the sequel of measles. Pathology.—The disease is not strictly a chronic inflamma- tion, but rather a condition of the mucous membrane resembling that produced by such inflammation. The nutrition of the mu- cous tissue is impaired, the circulation is sluggish, the tissue thickened, and there is an increased mucous secretion Avhich clogs up the bronchial tubes. In the severer cases, the secretion is muco-pus, and may be in considerable quantity and quite ojfensive. Symptoms.—The child has lost flesh and strength, and has a pale or salloAV appearance. The pulse is feeble, the extremities become cold easily, the appetite and digestion are impaired, the boAvels irregular, and the child is fretful and peevish, as Ave should expect under the circumstances. Our attention is called to a bad cough, from which the child has suffered some Aveeks, and Avhich has been very intractable. We notice that it is loose and someAvhat IioIIoav, and that more or less mucous is brought up by the act of coughing, but gen- erally SAvalloAved. Applying the ear to the chest, Ave hear a very marked moist bloAving sound—indeed, when secretion is free, it had better be called a gurgling or rattling—as the air passes into and out of the lungs. As the disease progresses, the child becomes feebler, its appetite and digestion more impaired/ and the cough worse. It has chills CHRONIC BRONCHITIS. 279 folloAved by hectic fever, during Avhich it is irritable and restless, and finally the strength is so exhausted that it dies of inanition. Treatment.—The treatment of this case requires considerable care, and all harsh and unpleasant remedies should be avoided. There are tAvo principal objects in vieAV—to modify the irritation and lessen the cough ; and to improve the appetite and digestion, and thus get better nutrition and restore the structure of the pari affected. If both can be accomplished by one class of remedies it will be best, as the child's stomach is easily irritated, and Avill not tolerate too much medicine. Frequently Ave will attain the ob- ject by the use of Collinsonia alternated Avith tincture of muriate of iron and glycerine; it may be prescribed in the folloAving form: R Tincture of Collinsonia 5'j-, Simple Syrup Sij.; a half teaspoonful three times a day. The preparation of iron may some- times be changed for the compound syrup of the hypophosphites. Occasionally Ave may require something more for the relief of the cough, in the earlier part of the treatment. Here I like the action of an infusion of clover hay, SAvcctened and given as required. Or in [dace of this the Stillingia Liniment may bo given in doses of half to one drop on sugar, every three or four hours. When the disease has arisen from measles, the Drosera Avill be found a valuable remedy, in the proportion of gtt. :;. to gtt. xv. of the tincture to Avater o'y-; a teaspoonful four times a day. In some cases Veratrum and Bryonia seem to exert au excel- lent influence in quieting bronchial irritation, checking the cough, and improving the general health. In other cases Ave employ Arsenic, as—ty, Tinct. Veratrum, FoAvler's Solution of Arsenic, an. gtt. v., water §iv.; a teaspoonful every tAvo or three hours. Rumex is sometimes an excellent remedy for cough, gtt. v. to gtt. x. being added to Avater 5iv. and given in teaspoonful (Joses. If there is a very free secretion of mucus, with much rattling in the chest, Lobelia with Compound Tincture of Lavender may be employed, as heretofore named. For further information, the reader is referred to my Practice of Medicine, article "Cough." Inunction with quinine is au excellent measure in those cases in Avhich there is feeble innervation or impaired circulation. Generally fatty inunction serves a better purpose than the ordi- nary use of baths; the surface being rubbed freely with the hand or with flannel. 280 DISEASES OF CHILDREN. Exercise in the open air, the free admission of light and sun- shine to the room, and a nutritious diet-, are important aids to the cure. PNEUMONIA. Inflammation of the lungs is met Avith most frequently during the winter months, and like acute bronchitis it forms a portion of those cases knoAvn as lung or winter fever. In some localities it is a very common disease, but in others it is seldom met Avith. From Avhat I have noticed I should judge it to be most common in localities exposed to north and' east winds, or indeed to any winds, and rare in sheltered places, as byAvoods, hills, etc. Thus in Cincinnati, aAvay from the river, it is rarely met with, but on high grounds Ave occasionally see cases. On the prairies of Illi- nois, and in Northern Indiana, Ohio, and Xcav York, it is of fre- quent occurrence. Causes.—The common cause of inflammation of the lungs in children is cold, either from direct exposure, or from sudden alternations af temperature. Pathology.—In this case the inflammation is of the paren- chyma of the lung. In some it will progress as in the adult, embracing all of that part of the lung Avhich is the seat of inflam- mation. But in the majority of cases it is confined to the lobules, and is thus scattered through a large portion of one or both lungs, sound lobules being interspersed betAveen the inflamed ones. From this character of the disease it has received the name of lobular pneumonia. For the first tAvo or three days the lung presents the appear- ance of determination of blood, the capillaries being full, and the tissue consequently reddened; the lung still floats on water, though not so freely as the healthy tissue. From this time there is a continued increase in its density, the air-cells being effaced by the engorgement of the capillary vessels, and by exudation into the intercapillary spaces, and into the air-cells. This is the stage of red hepatization, am] is fully completed by the sixth day. Noav, in the majority of cases, resolution commences, and the circulation is gradually restored from the circumference to the center, the effused material being taken up as soon as the blood begins to flow freely. Thus the lung is free of both the arrested PNEUMONIA. 281 circulation and the effusion, and becomes again permeable to air. Resolution is usually complete by the ninth day. But should the inflammation run so high as to impair the vitality of the tissues, then the condition of gray hepatization may ensue. In this the effused material is formed into pus, and in a still further advanced stage, the tissues losing their vitality, soften and are likeAvise transformed. If Ave examine a lung: in this condition, Ave Avill find it soft and friable, and readily lacerated by the fingers. The cut surface presents a yelloAv mottled appearance, and Avhen pressure is made upon it an imperfect purulent fluid exudes. In a still further advanced stage small abscesses are formed in the lungs at the site of the diseased lobules. Symptoms.—Usually the child sIioavs symptoms of cold for two or three days before the attack, and is restless and fretful. In many cases the commencement of the inflammation is an- nounced by a persistent hacking cough, Avhich seems to arise from irritation of the throat or larynx. What is peculiar about this cough is, that it seems to be made by the child, and fre- quently it will be scolded for persisting to cough Avhen it seems to be unnecessary. Such a cough is ahvays annoying to the per- sons in the room for its persistency. Of course there are many cases in Avhich an ordinary cough folloAvs the iiwasion of the in- flammation, and does not precedent as described. In all cases there is a chill, but in most it is so mild that it is scarcely noticed by the parents. In the majority, febrile reaction comes up slowly, and for the first tAventy-four hours the child does not seem to have more fever than Avould attend an ordinary bad cold, but even in those cases it will be noticed that the cheeks are flushed, that there is too great dryness of skin, and sharpness and hardness of the pulse, for a slight disease. In other cases the fever comes up rapidly, and runs very high. By the third day of the disease, a casual observer Avould notice that the child Avas quite sick. The skin is hot and dry, the pulse frequent and hard, urine scanty, boAvels constipated, no appetite, a coated tongue, one or both cheeks flushed, and some difficulty in respiration. The cough is usually paroxysmal, and varies from the hacking cough first named to a deep bronchial cough. In some cases the child is irritable and restless, but in most lies quite still, even though it suffers, and sleeps with its eyes partly open. 282 DISEASES OF CHILDREN. With these symptoms but little changed, the disease continues to the sixth day, Avhen, in a majority of cases, Ave find an amend- ment. The skin is less dry and hot, the pulse softens and is less frequent, secretion is gradually established, the difficulty of respiration and cough passes aAvay, and by the ninth day the child is free from fever and convalescent. When it passes into the stage of gray hepatization, the pros- tration becomes alarming. The mind wanders, and in a short time coma comes on, and, gradually deepening, is attended with evidences of imperfect aeration of the blood, from Avhich the child dies. Occasionally a very severe case is met with, in Avhich evi- dences of asphyxia are manifested as red hepatization advances, and in which the disease will terminate fatally before the sixth day, on account of the extreme engorgement. And in very feeble children there is occasionally a case in which the deter- mination of blood is folloAved by congestion, and such engorge- ment of the lungs is produced in a few hours, that death results. This resembles the pulmonary apoplexy of the adult. Diagnosis.—The symptoms above named, cough and difficult respiration, point to the lungs as the seat of disease, while the febrile reaction evidences its inflammatory character. Ausculta- tion during the first three days detects a marked change in the respiratory murmur, Avhich is roughened and louder, and asso- ciated Avith a marked blowing sound, at first dry, aftenvard moist. From the third to the sixth day the respiratory murmur becomes less and less marked, until at last it is scarcely heard over the seat of inflammation, but is replaced by a moist bloAving sound (mucous rhoncus). With this change there is increasing dullness on percussion, though it is rarely so marked as in the adult. We have less evidence of diseased action from the sputa than in the adult, for children can rarely be induced to spit out the secretion removed by coughing. At first there is dryness of the mucous membrane; in tAvo or three days the secretion is Avhite, tenacious, and has the globular form so characteristic of the dis- ease in the adult; about the fifth day it acquires a reddish-broAvn tinge, but rarely has the rusty hue that is seen in the adult. After this time, if convalescence progresses, it becomes yelloAvish, and resembles the sputa of bronchitis. PNEUMONIA. 283 Prognosis.—The prognosis in the pneumonia of children is faA'orable, the mortality being but little increased over remittent fever. • This, of course, is supposing that the. patient has proper treatment and good nursing. Those cases that manifest symp- toms of asphyxia early, are to be regarded as unfavorable, as are those in Avhich the disease progresses unabated beyond the seventh to the ninth day. Treatment.—The treatment of pneumonia in the child should be quite simple, as it is not a case that will be benefited by or bear much medication. The indications are plain—to lessen the frequency and obtain a uniform circulation of the blood, to allay irritation of the lungs, and to establish secretion, and this is done in the order in which they are named. To accomplish the first object Ave prescribe the special seda- tives, Veratrum and Aconite, in the usual doses, repeated every hour. If the fever runs high, and the pulse is full and hard, the dose of the Veratrum may be doubled until it influences the pulse. All Ave expect of the remedy is that it Avill hold the febrile action and the inflammation in check, and after twenty- four or forty-eight hours Avill cause a gradual decline in both. That action of Veratrum Avhich brings the pulse doAvn in six or eight hours from one hundred and thirty beats per minute to eighty or seventy beats per minute, is not desirable, because it can not be maintained, and because it is opposed to nature's methods of cure. Again, Ave note the indications for other remedies Avhich may be added to the sedative solution or alternated with it. Bryonia is given if the child sIioavs evidences of pain in respiration or on eouahinsr : Rhus, if there is contraction of the facial muscles, and a sharp stroke to pulse, Avhich is small and frequent; Lobe- lia, if there is marked oppression in the chest, and difficult breathing; Gelseminum, if there are evidences of determination of blood to the brain; Belladonna, if the child is dull and in- clined to sleep a great deal; Eupatorium, if the pulse is full and oppressed, and perspiration is caused by coughing, notAvithstand- ing the heat of skin ; Phytolacca, if patient complains of sore mouth and throat; Baptisia, if the face is full and purplish, the tongue and lips sboAving the same color. When the tongue is dirty—a yelloAvish, glutinous coat—sul- phurous acid exerts an excellent influence, and Avill sometimes be 284 DISEASES OF CHILDREN. nearly all that the patient will require. Occasionally the sul- phite of soda is indicated, and more rarely the chlorate of pot- ash. A trituration of podophyllin (second decimal or first cen- tessimal), in doses short of an action upon the bowels, will give good results in those cases showing fullness of face and tissues generally, and especially fullness of veins, which should be noted. > Cathartics as a rule are contra-indicated, and if the boAvels are locked up, it is much better to use an enema to open them. Tavo, three or four days without an evacuation of the boAvels, is not commonly injurious, at least it is much better than the irritated stomach and intestinal canal from physic. Ipecacuanha exerts a specific action upon the respiratory ap- paratus, removing irritation and stopping determination of blood. It has been used alone Avith marked success, being given tritu- rated Avith sugar in doses just short of nausea, or Avith slight nausea for a feAV hours and just short of vomiting. I employ it in tincture and combine it Avith Aconite gtt. v. to gtt. x., to Avater 5iv. As the disease advances, if there be a very free secretion, with much rattling in the chest, and difficulty of breathing from obstructed bronchial tubes, the preparation of Lobelia with Comp. Tinct. of Lavender, as named under the head of asthenic laryngitis, Avill answer a most excellent purpose. In this case the cloth spread with lard and sprinkled with Compound PoAvder of Lobelia should not be neglected. To fulfill the second indication Ave apply a hot fomentation as heretofore named, or the "mush jacket;" or in young children, where this Avould be inconvenient, the cotton cloth spread Avith lard and sprinkled lightly with emetic powder. The mush jacket is made of corn mush of ordinary consistence, spread an inch thick on cloth large enough to cover the anterior and lateral portions of the chest, and covered Avith musquito-bar, netting, or other thin goods, to retain the poultice. It is applied hot, a thinkness of flannel being first laid over the chest, and changed tAvice daily ; the heat is retained by the thickness of the poultice, and by keeping the body Avarmly covered. The hot application should not be continued longer than the first day, and then if needed replaced by the Lobelia and Capsicum. In all cases the air of the room should be kept moist, and if the irritation of the lungs is great, with harassing cough, we may obtain much advantage from the use of inhalations of the PHTHISIS PULMONALIS. 285 vapor of Avater, of an infusion of hops, or tansy, or poppy heads, or of one part of vinegar to three of Avater. This not only gives present relief, but it aids the cure; indeed, I am not certain but that the disease could be very successfully treated by the use of inhalations alone, adding the sedative to the Avater employed. As a general rule, Ave Avill find the third indications of cure accomplished by the means already named. As soon as the pulse is brought under the influence of the sedatives there is a natural tendency to a re-establishment of secretion. At the commence- ment of the treatment the patient has a general bath with soap and Avater to cleanse the skin, and a hot foot-bath for its quiet- ing influence upon the nervous system. Further than this, I do not think bathing is beneficial, except sponging the surface under the cover, drying speedily and with friction. The child should be kept in the recumbent position in its cradle, crib, or bed, and should be kept pleasantly warm and free from all draughts and changes of temperature. If at any time during the progress of the disease, there is tendency to coldness of the extremities, apply dry heat, Avrapping the feet and legs in flannel. If the child needs a stimulant and tonic, I think Ave may ob- tain the best results from the inunction of quinine, as heretofore named. When the disease passes into the stage of gray hepatization, Ave can do nothing more than support the strength by the use of the bitter tonics, as they can be given, and such food as we can prevail upon the child to take. In some cases advantage might result from the use of sulphite of soda. PHTHISIS PULMONALIS. Infantile phthisis is generally acute, resembling the hasty con- sumption of the adult. In this form Ave meet Avith it at all ages from the first AATeeks of life to the age of five or six years. After this time, phthisis pulmonalis is of very rare occurrence, until the age of puberty is past. Causes.—The predisposing cause is a feeble vitality, mani- fested especially in the formation of blood and nutrition of tissue. In this sense infantile phthisis is ahvays hereditary, as it is hardly possible that a child possessing normal vital or formative poAver 28G DISEASES OF CHILDREN. should haA'e this disease, even under the most adverse circum- stances. The exciting causes are all such as still further loAver the vitality of the child. Diseases affecting the stomach and bowels, thus impairing digestion, or fiose which impair secretion, lower the vitality of the blood and its adaptation as a nutritive fluid. If uoav the child is exposed to the ordinary causes of cold, and irritation of the respiratory organs is set up Avith determination of blood, the imperfectly formed albumen Avill be throAvn out in the parenchyma of the lungs as tubercle. Pathology.—As above stated, a congenital defect of via- bility lies at the foundation of the disease, and as has been pre- viously stated, it is impossible for some children to live to adult years for this reason. This feeble viability is manifested in im- pairment of all the functions of the body, but especially in the formation of poor blood. This imperfect elaboration furnishes the material for tubercles, which only requires an arrest of secre- tion by which it is ordinarily removed, and a determination of blood to the lungs for its deposit in that tissue. Post-mortem examination sIioavs very extensive disease. In the early stage the lung is infiltrated Avith a yelloAV albuminoid material of cheesy consistence, and showing but very slight, if any, traces of organization. It resembles the lower form of yellow tubercle, as seen in the adult. This exudation does not Avholly prevent the entrance of air into the part diseased, for even when the deposit is extensive, some lobules Avill be found free. At a further advanced period Ave Avill find this material in every stage of breaking doAvn, from that in Avhich it has softened to the ordinary consistence of pus, to that in Avhich the tissue of the lung has yielded, giving rise to large and ragged abscesses, containing the debris of the lung and the tubercular material. Symptoms.—The disease frequently commences as a simple cold, manifested by coryza, slight cough, seemingly from irrita- tion of the throat, impaired appetite, chilly sensations in the morning, Avith febrile exacerbations in the after part of the dav. The child is restless and fretful, and does not sleep Avell durinf the day, at its usual times. These symptoms continue for a Aveek or ten days, the coryza disappearing, but the cough increases, the chills are more marked, and the febrile reaction higher. PHTHISIS PULMONALIS. 287 Prostration becomes marked after a feAV days, and the appetite is almost wholly lost. The patient is thirsty, and drinks often, especially at night, Avaking every hour or two. Its sleep is also disturbed, and it changes its position often, throwing off the cover, and frequently expressing its uneasiness in moaning and short cries. Thus Aveek after week Ave observe an increasing loss of flesh and strength, until the child is as much emaciated as in cholera infantum. And yet the cough is not very severe, neither is there much difficulty of respiration, or imperfection in the aera- tion of the blood. Still, these symptoms are sufficient to call our attention to the lungs as the seat of the disease. Quite fre- quently the blowing sound Avill be so marked that it is readily heard Avhen Ave sit down by the side of the child. Upon auscul- tation it is found to extend to every part of the lung tissues. Diagnosis.—The marked emaciation and debility is evidence that the disease, AvhateATer it may be, is one affecting the forma- tion of blood and nutrition of tissue. If in the summer, avc would suspect it to be one of the intestinal canal, but a careful examination determines that this is not the source of the lesion. The cough, some difficulty in respiration, and the blowing or rattling sounds heard Avhen near the child, cause us to make au examination of the chest. On percussion Ave usually find a dullness over the superior lobes of the lungs, sometimes quite marked. But over the mid- dle and loAver lobes the resonance is clear, except in cases Avith congestion, Avhen there is some dullness even here. On auscultation Ave find a uniform bloAving sound over the entire chest, with more or less mucous rattling, as there is more or less secretion. Though it seems louder in the sound lung, it does not mask the respiratory murmur which, is heard distinctly. In those parts of the lung infiltrated with tubercle, the bloAving sound is dull, as if deadened by passing through an infiltrated tissue, or the sounds are small, whistling, creeping in and out of the tissues, sometimes like a nest of mice. Not unfrequently the dry-crackling that so generally attends the same disease of the adult will be heard, though but for short periods. Prognosis.—The prognosis is unfavorable. The disease oc- curs in children of feeble viability, and avIio have little poAver to resist disease or of repair Avhen this is arrested. Still, in some 288 DISEASES OF CHILDREN. cases, an infantile phthisis may be arrested, and by a proper res- torative treatment, aided by good hygiene, a moderately good constitution may be developed in time. Treatment.—The treatment of this case can only be outlined, as the indications for remedies will vary, and here, as elseAvhere, Ave Avisli the right remedy for the conditions present, rather than a treatment for the name of the disease. With a frequent pulse and increased temperature, Ave think of Veratrum as a good basis of treatment. If there is pain in the chest, Bryonia is given for a feAV days, and is then replaced with Arsenic if the skin sIioavs atony; continuing in this Avay for a time, these remedies may be replaced with hypophosphite of lime alone, or Avith some preparation of malt given after meals. We can not, at first, use bitter tonics and restoratives by mouth Avith advantage, and Ave Avill therefore employ them endermically. The inunction of quinine, heretofore spoken of, will ansAver a very excellent purpose. Even simple fatty inunction will be found beneficial. If the parents can afford it as well as not, let the inunction be of good cod liver oil, with quinine in the pro- portion of 5>j- to the pint. Let the entire surface be thoroughly rubbed Avith this once or tAvice daily, using considerable friction. No exposure of the surface should be permitted at these times, but the child kept carefully covered. The fatty matter may be remoAred from the skin with a soft flannel. Washing with AA'ater is absolutely prohibited, except the face and hands. The same directions for diet should be given as in a case of cholera infantum, and if there is irritation of the stomach and boAA'els, the same remedies may be used to relieve it. As the child improves, Ave may put it upon the use of tincture of muriate of iron and glycerine, as heretofore named, and sometimes Ave may add a small portion of the tincture of Nux Vomica to it. Probably a better restorative in this case Avill be found in the compound syrup of the hypophosphites, which is not only very pleasant to the taste, but is easily appropriated. The dose for a child two years old will be one-third of a teaspoonful four times a day. Cod liver oil ansAvers a very good purpose Avhen it can be taken. But with the majority of children under six, we Avill find it impossible to give it. DENTITION. 289 As the child becomes stronger, it should be taken out of doors Avhen the Aveather is Avarm, and the air calm; and it should also be persuaded to use its limbs, and take moderate exercise. When it can not be taken out of doors, its chair or crib should be so placed that it may receive abundance of light, anil even sunshine, if not too bright. CHAPTER VII. DISEASES OP THE DIGESTIVE APPARATUS. The digestive apparatus embraces the mouth, the throat, the stomach, and small and large intestines. The diseases Ave have to study are those of the mucous membrane of these several parts, and of their functions. We take it for granted that dis- eases of mucous structure will demand a someAvhat similar treatment, no matter Avhat its location. If this vieAV is correct, Ave will have simplified the therapeutics of this class of diseases, and Avill also have made it more definite. DENTITION, AND ITS DERANGEMENTS. Dentition is usually regarded as the great trial of the health, if not of the life, of the child, and Ave find parents and even physicians speaking of it as if it Avere a morbid process, instead of a physiological development. It is true that during the cutting of the teeth there is occasional disturbance, sometimes of one function, sometimes of another, but more frequently of the digestive tract. But the majority of these are but indirectly influenced by dentition, and the cause should be sought elsewhere. The error is an important one, because it obscures real causes of disease, and prevents the direction of remedial agents for their remoA'al. And with some persons it leads to interference with the natural eruption of the teeth, which proves injurious. As a general rule, the child exhibits evidences of buccal ex- citement about the fourth or fifth month. Tftere is an increase of the salivary secretion, and it has a strong desire to bite or press its gums strongly against Avhatever is given it. 19 290 - DISEASES OF CHILDREN. This excitement continues to the eruption of the first teeth— the front incisors—Avhich occurs from the sixth to the eighth month. In some cases, the excitement becomes general, and there is restlessness and irritability of the nervous system, fever, derangement of digestion, and sometimes diarrhoea. The treatment of such a case is Arery simple. The child has a bath, and once or twice a day a hot foot-bath. We prescribe Aconite in the usual doses, and if there is much derangement of the stomach and bowels, small doses of an infusion of compound powder of rhubarb and potash, to produce a gentle laxative in- fluence upon the boAvels. Usually Avhen dentition is attended with such derangements, the subsequent cutting of the teeth will be attended with more irritation than the first. Especially is this the case in feeble children, at the eruption of the molars and canine teeth, during the second summer. But these cases need but the treatment just named, unless there is a distinct complication, which will be treated as noticed hereafter. Lancing the Gums.—Lancing the gums is an old practice, and is iioav somewhat out of vogue. When the lancet Avas the remedy for adult fevers and inflammation, lancing the gums Avas the remedy for all irritations supposed to arise from teething. Its use, therefore, while sometimes beneficial, Avas frequently injurious. The eruption of the teeth through the gums is not a sudden nor a forcible process. As the teeth attain increased size they press upon the gum, which is as gradually absorbed before them, and in the true physiological process there is no disturbance Avhatever. The lesions we notice result from the deterioration of the child, induced by our abnormal civilization. The cases in Avhich the gums may be cut to advantage are those in which there being the lesions of the nervous system and fever, that have been already noticed, there is marked swelling and lividity or duskiness of the gums, over the point Avhere the tooth is to make its appearance. In such cases, occasionally, prompt relief follows the incision of the gum, and the relief of its tension by the discharge of a small quantity of blood. It seems evident tharMt is the discharge of the blood which relieves the tension upon the parts, and in the same degree the irritation, and not the coming through of the tooth, as many persons think. DENTITION. 291 The tooth is cut none the quicker for the lancing of the 0< G VSTRODYNIA. I use the term gastrodynia to express the condition of pain in the stomach, Avhether the pain is the result of irritation of the gastric nerves, from cold, from irritative ingesta, or from spas- modic contraction of the muscular coat. In slight decree it is of very frequent occurrence, and is quite often seen in a severe form. With some children it is of daily recurrence, and is usually called colic by mothers and nurses. It not only causes much suffering to the child, but is source of very great annoy- ance to the parents; and Avhen the mother is in feeble health, it becomes a serious matter, and if possible must be removed. Causes.—The most common cause of pain in the stomach is indigestion. The child nurses well, and frequently thrives, but some portion of the food undergoes decomposition and proves irritant, or generates gas which unduly distends the stomach. In some of these cases there seems to be a peculiarly irritable condi- tion of the gastric nerves, so that a very slight cause is sufficient to produce pain. In other cases it results from cold, and in these there is fever;.and in others there is a real spasmodic action, or cramp of the stomach. Symptoms.—The child exhibits evidences of pain in its coun- tenance, is uneasy, and will not remain in one position, and has violent paroxysms of crying. In some cases the body is draAvu up, and the loAver extremities are flexed upon the abdomen. Occasionally there are eructations and some of the food is throAvn up, shoAving imperfect digestion ; but at other times the milk will be curded and sAveet, shoAving healthy digestion. In the majority of cases the pain is paroxysmal, lasting for five or ten minutes, during Avhich the child seems to suffer severely, and cries violently; it gradually abates until there is comparative ease, and as Ave are about to congratulate ourselves that the pain has Avholly passed away another paroxysm comes on suddenly. Thus it may continue for an hour or two, or for a considerable portion of a day. Treatment.—In many cases Ave find one or two drops of tincture Xux to a half glass of water, given in half teaspoonful doses, every fifteen minutes to one hour, will give speedy relief. 308 DISEASES OF CHILDREN. If there is irritation of the boAvels, also with griping pain, Tinct. Cblocynth gtt. j. to gtt. ij. to Avater 5iv., a teaspoonful every half- hour to hour will give speedy relief. In some cases Aconite may be used Avith both of these, and aids in relieving the pain* Dioscorea in infusion, the tincture gtt. v. to gtt. x., to Avater Siv., is a good remedy. Apis answers a good purpose Avhen the pain in the stomach is associated Avith an eruption like "heat," and Belladonna, if such an eruption has disappeared from the surface. The old remedies, after the folloAving formula, may sometimes be giA7en: T^ Tincture of Lobelia oj., Compound Tincture of Lav- ender 5iij-, Simple Syrup ojss. ; the dose will be from one-fourth to one teaspoonful, and may be repeated as often as necessary. Another excellent preparation is: R« Chloroform gtt. xx., Glycerine §ij., in doses of one-fourth to one teaspoonful, as often as required. When these attacks are of frequent occurrence in nursing children Ave may suspect a Avrong in the mother's diet or diges- tion, and this being looked after, avc will sometimes find that our little patient has more comfort. In other cases the pain is a symptom of infantile dyspepsia, and lime-Avater, phosphate of soda, or some of the simpler tonics, Avill giA'e permanent relief. The best local application, as a general rule, Avill be a hot dry flannel applied over the stomach and abdomen. Sometimes the use of the hot flannel to the spine Avill give speedier relief than when used over the stomach. In children of one year and older a mustard plaster may be used. GASTRIC IRRITATION. We are called to prescribe for cases in Avhich there is marked irritation of the stomach. It occurs as a complication of many acute diseases, and sometimes alone, there being no other disease present. In the first case it increases the severity of the primary disease, prevents the absorption of remedies, and the taking and digesting of food. It thus becomes, when severe, an unfavorable complication. Causes.—We can not determine, in many cases, any cause for this irritation. In some it depends upon imperfect digestion of food, in others from cold and arrested secretion. In acute dis- ease it is doubtless OAving in part to decomposition of food, taken before the disease Avas fairly announced. GASTRIC IRRITATION. 309 Symptoms.—Prominent among the symptoms is the occasional nausea, retching, and effort to vomit. The child is thirsty, and. desires drink frequently, but when any quantity is taken it is ejected by vomiting. If nursing, it Avants the breast frequently, and after nursing it throAvs up its milk. When the child is Aveaued, it will generally reject all food. If medicine is given, at least many kinds, it will be throAvn up after a time. Thus, in the treatment of acute disease, avc may be giving the sedatives, or any remedies, every hour; the child takes three or four doses, and then there is sickness of the stomach, and the Avhole is ejected. Thus, many times, the treat- ment Avill go on day after day Avithout any appreciable influence upon the disease, none of the medicine having gained entrance into the circulation. In this condition of irritation osmose is from the blood-vessels to the stomach, and of course there is no absorption either of food or of medicine. Irritation of the stomach, Avithout other disease may continue for several days, or in slight degree for tAvo or three weeks. Necessarily there is sympathetic disturbance of the nervous system, and of other functions, and digestion being arrested the child is much prostrated. There is an irritation of the stomach, arising from disease of the brain, that is of very serious import. This case is diagnosed by the contracted and pinched appearance of the countenance, the dullness of the eyes, and the increased frequency and hard- ness of the pulse (there are some exceptional cases in Avhich the pulse is small and Aveak). The skin,is dry, sometimes husky, the temperature of the trunk slightly increased, but the extremi- ties are cold. If the tongue is examined in irritation of the stomach, it Avill sometimes be found reddened, contracted, and pointed, in others pale and atonic ; in the one there is irritation with determination of blood, in the other atony. If coated, it will be with a white fur, confined to the center. Treatment.—When there is febrile reaction, or increase of temperature, I direct cold applications over the epigastrium. In the opposite cases, a sinapism or a spice plaster may be used. In all cases much benefit Avill folloAV the use of the hot foot-bath, which, if the extremities are inclined to be cold, maybe rendered stimulant by the addition of mustard or capsicum. 310 diseases of children. Internally, if the tongue is elongated and red, we may admin- ister small doses of Aconite and Ipecac, say : Jfy Tinct. Aconite gtt. j. to gtt. ij., Tinct. Ipecac gtt. v. water 51 v., a half teaspoon- ful every hour. If the pulse is sharp and the patient has frontal headache, the remedies will be Aconite and Rhus. In the second case, Avhen there is evidence of atony, the prescription will be: 1^ Tinct. Nux gtt. j. to gtt. ij. water 5i\\, a teaspoonful every half hour. Occasionally an infusion of our old fashioned compound poAvder of rhubarb given in small doses Avill give relief. In place of this, and better adapted to severe cases, is an infu- sion of the bark of the peach-tree. We take the young and green limbs of the present year's groAvth, scrape the bark off, cover it with boiling Avater, and Avhen cold it is ready for use. We giA*e it at first in doses of one-fourth to one-half teaspoonful every feAV minutes until the irritation has partially subsided ; aftenvards in teaspoonful doses for tAvo or three hours. Occasionally Ave will obtain benefit from the preparations of bismuth; either the subnitrate,carbonate, or liquor bismuth may be used. The first I generally prescribe Avith mint water, in doses of from one to three grains. When the irritation is very persistent, the boAvels being consti- pated, an enema of a Aveak salt water to move the bowels, Avill aid in giving relief. If the temperature is high the injection may be cold, if the patient is exhausted the injection should be hot. In these severe cases Ave are very careful in administering remedies and giving food after the irritation seems to have been subdued. GASTRITIS. Acute inflammation of the stomach is rarely met with in the child, and only, as I believe, from the administration of irritant medicines. Subacute inflammation, hoAvever, is met with quite frequently, and is sometimes very persistent. Caeses.—The causes of inflammation of the stomach arc tAvo- fohl. It may be produced by the ordinary causes of inflamma- tion in other organs, as from cold, arrested secretion, etc. It is also the result of irritant ingesta, or of such decomposition of food as gives rise to irritant products, or to irritant secretions. GASTRITIS. 311 Symptoms.—Subacute gastritis may occur as an idiopathic affection, or as a complication of some other disease. In the first case it is announced by nausea, retching, and vomiting, folloAving a short forming stage, in which for a feAV hours the child has been restless and uneasy, not caring for food, but wanting to drink freely. Occasionally there is a pretty Avcll-marked chill lasting for an hour or tAvo. The retching and vomiting are not constant, but come on at longer or shorter intervals, are quite violent and attended with much straining. When the stomach is thus relieved for the time being, the child seems to lie easily, and sometimes falls into a short sleep. Presently the thirst increases, it Avants drink con- tinually, and having taken but a small amount, A'omitinir asrain commences. There is always more or less fever. Usually it is paroxysmal, folloAving the course of the vomiting, coming up after this has stopped and gradually increasing until the nausea and vomiting commence. After the nausea and A'omitins: have continued to relaxation, the fever passes off, to re-appear again, as before named. In some cases the nausea and retching simply increase the irritation of the nervous system and the circulation, and there is no abatement of the febrile action. In some cases the irritation of the nervous system is A'ery great, and manifests itself in uneasiness and restlessness, crying and other evidences of suffering. In a few cases the irritation is of such character as to produce convulsions, which are usually very severe and intractable. Should the gastric irritation not be arrested, it Avill result in one of three Avays. In nervous irritation, occasionally convul- sions, and finally coma, gradually increasing until it proA'es fatal. In irritation of the intestinal canal, and diarrhoea, Avhich, running the usual course, terminates in the same manner as muco-enteritis. In an irritative feA^er, Avhich rapidly assumes typhoid symptoms, and proves one of the severest diseases Ave are called to treat. Treatment.— The treatment of an inflammation of the stomach is quite simple, and usually very successful. The first object is to so modify the irritation as to stop nausea and vomit- ing, for these perpetuate if they do not increase the irritation ; afterward we have time for the removal of the inflammation. The patient has a general bath if febrile reaction is high, fob 312 DISEASES OF CHILDREN. lowed by a hot-mustard foot-bath, continued for twenty-five to thirty minutes. In some cases a general hot bath, using salt in the Avater, will prove beneficial; if this be used, the applications to the epigastrium should also be hot. In the majority of cases, I prefer cloths Avrung out of cold water, over the stomach. In- stead of this, a sinapism made of three parts of flour to one of mustard, may be used. Internally I Avould prescribe an infusion of peach-tree bark, in doses of one-fourth to one-half teaspoonful, frequently repeated. The infusion is made of the bark of the limbs of the present season's groAvth. In place of this, bismuth with mint water may be employed, as named for irritation of the stomach. In some cases, those especially in which the inflammation is not high, Ave may use the compound powder of rhubarb in infusion. To modify the febrile action small doses of Aconite are em- ployed ; five drops to four ounces of Avater ; a teaspoonful every half hour or hour will be the proper quantity. If there is much irritation of the nervous system Ave may give the Gelseminum, in doses of from one to three drops, Avith the sedative. We find that these remedies not only ansAver their specific purpose, but they also have a beneficial influence in arresting gastric irritation. In some cases we find the boAvels inactive, and occasionally the gastric disease is increased by accumulations in the intestinal canal. As it is clearly out of place to give cathartics by mouth, we must depend upon enemas. A:i enema of salt watar Avill sometimes exert a marked influence in checking nausea and vomiting; not so much in gastritis, of course, as in simple irrita- tion of the stomach, yet its influence in this respect is beneficial. Simple enemata are used Avhen the object is to empty the loAver boAvels, but Avhen the small intestine is to bo reached, the enema should be of compound poAvder of Jalap, or of castor oil, in Avarm Avater. INFANTILE DY;JPEP,(JIA. To many persons the name infantile dyspepsia will sound singular, as they have been accustomed to think of dyspepsia as associated with a long-abused and v.'orii-out stomach. Yet dys- pepsia is a very common complaint Avith the child, almost as fre- quent as in the adult, though not so persistent. There are several causes of infantile dyspepsia, and Ave will obtain a better knowledge of the disease and of its therapeutic^ INFANTILE DYSPEPSIA. 313 if Ave study these. They have reference to the quality and quantity of the food, to the secretion of gastric juice, to the muscular action of the stomach, aud to the condition of the upper intestinal canal. , We find this disease most commonly in children avIio have other food than the mother's milk. Here the trouble is in the difficulty Avith Avhich the food is digested, and the imperfection of this process, in Avhich some portions undergo decomposition. This may be corrected in some cases, to a limited extent, by changing the food, by giving it in a less concentrated form, and in such manner that the secretion of saliva may be increased. Thus in a case Avhere the child Avas being fed on cow's milk, simply diluting the milk with one-fourth Avater has proved suc- cessful. Or, when it Avas fed with a spoon, or from a cup, the use of the bottle, so as to call for the act of sucking, Avould cause an increased Aoav of saliva, and the little patient avou.U1 be greatly benefited. A very common cause of infantile dyspepsia is over-feeding. This is the most common cause in nursing children, and depends not only upon the taking of too large a quantity at a time, but upon its too frequent nursing. In the one case the stomach is OArerdistended, and overworked, and gradually it loses its poAver of digestion, and evidences of dyspepsia are manifested. In the other case the stomach is alloAvcd no repose, in Avhich to regain its lost poAvers, or for its nutrition. The result is that its func- tion becomes gradually impaired. In another class of cases the dyspepsia is dependent upon a bad blood, from the many causes heretofore named for this de- terioration. The child is cachectic, lacks poAver in every direc- tion, and this, as well as other functions, are impaired. Dyspepsia is not ahvays a gastric lesion. The small intestines have as much to do with the digestion of food as the stomach, and a lesion here gives rise to dyspepsia. Generally this, so far as Ave can see, is a simple atony, at other times it is an irritation. , The atony is not only of the small intestine, but also of the liver, the pancreas, and indeed of all associated parts. In such cases the circulation of blood and the innervation are deficient; there is a Avant of normal stimulus. So in cases of irritation, the associated organs are involved, to a greater or less extent, and there is too much blood and innervation to these parts. There are cases in which a failure of poAver in the muscular 314 DISEASES OF CHILDREN. coat of the stomach is a cause of dyspepsia in infants, as Avell as adults. Others in Avhich there is a defect in the secretion of gastric juice; either in quantity or quality. These in the child are principally of an atonic character, and hence there Avill not be so much difficulty in the treatment as in the disease of the adult. Symptoms.—The symptoms of dyspepsia in the child vary greatly ; in some cases being Avell marked, in others obscure. Usually the child is uneasy after taking its food, and is fre- quently troubled with colic. Vomiting of the food is of common occurrence, and it the matters ejected are examined, the food Avill be found acid, smelling sour and sickly, or undergoing incipient decomposition. These changes in the matter ejected are pathog- nomonic; for in the vomiting which folloAvs mere repletion, in Avhich case the overloaded stomach takes this easy mode of re- lieving itself, the food is sAveet, the milk Avell curded, presenting evidences of a healthy condition of digestion. With this digestive lesion Ave notice that the child becomes pale, the tissues soft and flabby, the circulation feeble and the extremities cold. There is also, in most cases, very marked irri- tation of the nervous system, the child being restless, irritable, and fretful, and at night tosses about, aAvakes frequently, and Avants to drink. In some cases there is the same desire for food, even a ravenous appetite at times. In other cases the appetite sloAvly fails, and the child cries neither for food nor for the breast. When this form continues for any considerable time, the child becomes anaemic and much debilitated. The simplest division of these cases is into the irritative and atonic. In the first case the evidence of gastric irritation is prettv well marked. There is the red tongue, the irritability of the nervous system, the pinched face, and bright eyes, the harsh skin, and the greenish acrid discharges from the bowels. In the atonic form of dyspepsia, the tongue pale, a whitish pasty fur accumulates at its base, the breath has a sickly odor, the child is feeble and languid, and likes to remain in one position, the ' face is pallid, the eyes dull, the face expressionless, the skin soft, relaxed, and cool, the pulse soft and feeble, and the discharges from the boAvels light-colored. Diagnosis—The diagnosis Avill be made in part bv the symp- toms above-named, Avhich point to the stomach as the seat of a INFANTILE DY'SPEPSIA. 315 lesion, and in part by exclusion. The difference in the diagnosis betAveen the adult and the child is, that the first points out the location of the unpleasant sensations, Avhile in the second Ave have to determine this by careful observation. By making the ex- amination thorough Ave are enabled to exclude one organ after another until the evidence of the gastric lesion becomes positive. Prognosis.—The prognosis is not ahvays favorable. It will depend much upon the kind of food the child is taking; if nurs- ing, it is favorable; if fed on cow's milk or other food, it is un- favorable. It is generally grave in proportion to the change in the matters vomited ; if they are but little changed, or seem to be undergoing the process of digestion in a proper manner, Ave conclude that the lesion of the stomach is simple in its nature. But if they are undergoing decomposition, and have an unpleas- ant odor, the evidence of serious lesion is pretty strong. Treatment.—The first thing that engages the attention of the physician is the food of the child, for as avc have seen above, the lesion is frequently dependent upon a Avrong in this. If the child is being raised on coav's milk, or other artificial food, Ave Avill see that this is the best of the kind, and properly prepared and given. When the dyspepsia is persistent Ave will have to take into consideration the propriety of changing it. Liebig's food Avill answer a good purpose in many of such cases, when the child is being fed upon milk. The directions, heretofore given under the head of food for the child, may be studied with advantage. When the child is nursing Ave will inquire as to the mother's diet, for not unfrequently indiscretions upon her part Avill have caused, and may perpetuate, the disease. Usually it is the use of A'egetables and fruits in too large quantity that has first oc- casioned it. In some cases the dyspeptic lesion of the child de- pends upon a similar gastric lesion upon the part of the mother, and it is her imperfect digestion Avhich deranges its stomach. In case of indiscretions in diet, Ave Avill represent the import- ance of care in this regard ; and Avhen this is not so manifest it will be well to change the mother's food until Ave have discovered Avhat Avas giving rise to the trouble. When the mother suffers from dyspeptic symptoms, or has imperfect or feeble digestion, it will be proper to put her upon a course of treatment that Avill restore the functions of the stomach. 316 DISEASES OF CHILDREN. A very marked case of this kind came under my care in the earlier part of my practice. A lady had given birth to five children, of Avhich three had died of infantile dyspepsia. One was saved by Aveaning, and the fifth, at the age of three months, was suffering severely. I treated the mother for chronic gastritis, by the use of the irritating plaster over the'stomach, and an in- fusion of hydrastis taken internally, and as the irritation disap- peared added iron and phosphorus. As the gastric symptoms of the mother disappeared and her health improved, the child became better, and in a feAV weeks was doing as Avell as other children. In some cases Ave Avill have to take into consideration the propriety of Aveaning the child, as it becomes evident that the disease can not be controlled otherAvise'. In some, feeding the child Avith coav's milk is attended Avith benefit, though in others the child rapidly fails after it is put upon it. Liebig's food, when the child Avill take it, usually does well. When artificial food disagrees with the child it increases the pains in the boAvels, and is either vomited or is carried off by a diarrhoea. In all such cases the chances of saving the child is much better if a suitable Avet-nurse can be obtained, and this should be clearly stated to the parents at as early a period as possible. In some cases the employment of restoratives and tonics with the mother, and the use of Avell-cooked animal food, will be the best treatment for the child. Tincture of muriate of iron and glycerine, Avith the addition of tincture of Nux Vomica, if there is atony of the stomach, answers very well. Hydrastis, with same preparation of iron, is a good bitter and stomachic. The hypophosphites have proven serviceable in my practice, either singly or in the form of compound syrup of the hypophosphites. In some of the more simple forms of infantile dyspepsia Ave Avill find the administration of phosphate of soda in small doses, three or four times a day, either alone or with the food, will answer an excellent purpose (about ten grains daily for a child three to six months old). Common salt will also exert a marked beneficial effect with nursing children, in some of these cases. Where the dyspepsia is of the irritative form, I prescribe an infusion of peach bark, as heretofore named, and some preparation of bismuth. The subnitrate or subcarbonate in poAvder, or the liquor bismuth, in small doses. With these, and proper hygienic means, the irritation Avill have so abated in one or two Aveeks, the child can be put upon the use of Collinsonia and tincture of colic. 317 muriate of iron. Where there is evidently accumulations in the small intestine, an infusion of the compound poAvder of rhubarb, given to produce its laxative effect, may precede the other remedies. In some cases of irritative dyspepsia Ave will obtain much advantage from the use of small doses of Aconite, repeated every one or two hours for a day or two, and aftenvard at less frequent intervals. The Avet pack to the abdomen may also be resorted to in more acute cases with advantage. In the simpler forms of atonic dyspepsia, I put the child on the use of some simple bitter, as an infusion of Matricaria Chamo- milla, Virginia snake root, or the Panax Quinquefolia. In others I prescribe Collinsonia alternated with tincture of muriate of iron in the folloAving proportions: Xa/ Tincture of Collinsonia Sss., Simple Syrup Siijss.; half a teaspoonful three times a day. R Tincture of Muriate of Iron, 3'j-, Glycerine, Simple Syrup, aa. to Siv.; a teaspoonful three times a day. The tincture of Xux Vomica in small doses, or a solution of strychnia in doses of about the l-200th to the l-100th of a grain may be used with marked advantage. © In some of these cases Podophyllin, thoroughly triturated, will prove one of our best remedies. As named in the first part, it should be triturated in the proportion of one part to ten or tAventy of sugar; have Ipecac triturated in the same Avay, and combine them in equal parts, making poAvders of one-half to one grain. This may be given three or four times a day, and asso- ciated witli the tonics, as before named. COLIC. We may distinguish tAvo forms of colic in^children, the one being temporary and arising from slight indigestion, the other bearing a close relationship to the bilious colic of the adult, and due to spasmodic contraction of the muscular coat. The first form is of very frequent occurrence, and in some cases seems to be natural to the child. It comes on from the slightest causes, and lasting an hour or two, passes aAvay, and the child seems as well as ever. With many it Avill continue to recur frequently fov the first three or four months, and will then cease. The second form of colic is caused by cold, by indigestion, by some indiscretion in the diet of the mother, or occasionally by 318 DISEASES OF CHILDREN. mental excitement, from anger, fear, grief, etc. The child not only suffers much pain, but there is functional disturbance, and some fever. Symptoms.— In either form of colic the child is uneasy, changes its position frequently, bends its body in various direc- tions, and cries persistently. Simple crying, hoAvever prolonged, would not be evidence of colic, but with the contortions of the body/and frequent change of position, the diagnosis is pretty evident. It may continue but a feAV minutes, or for half an hour. When it lasts long it is remittent or paroxysmal. The second form of the disease presents the same evidences of pain, but it is of longer duration, continuous, and severer. I determine its character principally from contraction of the fea- tures Avhich expresses pain. The flexion of the trunk, and of the lower extremities upon the abdomen is more persistent. Treatment. —In many cases the colic is speedily relieved by the administration of Nux Vomica, as—Ia) Tinct. Nux gtt. ij.. wafer Siv.; a half teaspoonful every fifteen minutes or half hour. If the child is feverish, Aconite in the usual doses may be alter- nated with this. In other cases the indications will be stronger for Cohicynth, and I usually administer it as folloAvs : It Tinct. Colocynth gtt. ij., Tinct. Aconite gtt. iij., water Siv.; a teaspoon- ful every half hour. An infusion of Dioscorea, or of Epilobium, will sometimes give prompt relief, and sometimes the tincture Avill serve a good purpose. If the attack is very severe, and relief is not obtained in this way, aji enema of hot Avater (sometimes cold is better), or Avater to Avhich we have added grs. xx. of Compound PoAvder of Jalap and Senna may be used. Sponging the alxlomen Avith hot vrater, the general hot bath, hot packs to the abdomen, a cold pack, if the temperature of the child is increased, a sinapism, or the application of chloroform, will suggest themselves to the practitioner, and Avill be selected according to the indications. In some cases the prescription of Lobelia with Comp. Tinct. I*ivender may be used, more rarely chloroform may be given by mouth. If the pain is excessive chloroform may be used to produce partial anaesthesia and give relief. If Ave can not relieve the patient in any other Avay chloral may be given to relieve the pain until other means can be employed. DIARRHCEA. 319 If the child suffers from gastric irritation or dyspepsia, we will treat the case as has been named for those affections. And if OAving to errors or imprudence in the diet of the mother, avc will endeavor to have them corrected. DIARRHCEA. Simple diarrhoea is of very frequent occurrence with children, and Avill arise from any cause deranging the processes of digestion, or from cold. We recognize the same forms of the disease as in the adult; first, from irritation of the intestinal canal; second, from increased secretion of bile; third, from atony of the intestines; fourth, from congestion of the portal veins and determination of blood; fifth, from increased secretion of mucus; sixth, from imperfect digestion. A simpler classification, however, and more easily recognized in practice, is the tAvo forms, diarrhoea from irritation and diarrhoea from atony. Symptoms.—In diarrhoea from irritation the discharges from the bowels are dark-colored, usually a shade of green, or in some cases of a light or pea-green. They are sometimes acrid, so that Avhen they have continued for some time, they excoriate and chafe the child. Usually, the child manifests some uneasiness before having a stool, and there is some straining with it. Occasionally, there is febrile action, the skin being harsh and the temperature elevated. In diarrhoea from atony, the discharges are light-colored and Avaterv, and passed Avithout any pain or uneasiness. They are usually larger than in the other case, though the amount pf solid matter is not increased. Here, if it persists for some time, the child seems relaxed, the skin soft and cool, extremities cold, face pallid, and circulation enfeebled. In both cases the appetite is impaired if the diarrhoea con- tinues, and what food is taken is not well digested, consequently the patient loses strength and flesh as the disease progresses. Treatment.—The diarrhoea of irritation may be very fre- quently controlled by the use of Aconite alone, in the usual doses. Generally avc continue Ipecac Avith it in the following proportion : Ti Tinet. Aconite gtt. iij., Tinct. Ipecac gtt. a\, Avater Siv.; a teaspoonful every hour. The Euphorbia Hyperi- cifolia will sometimes prove a better remedy than Ipecac, and 320 DISEASES OF CHILDREN. may be substituted for it in about double the proportion. If the patient complains of uneasy sensations in the abdomen, Avith tormina and some tenesmus, the prescription might be: Ii Tinct. Aconite gtt. iij , Tinct. Colocynth gtt. ij., water §iv.; a teaspoonful every hour. In atonic diarrhoea avc frequently substitute Nux for the Aco- nite, as: Tjj Tinct. Nux Vomica gtt. iij., Tinct. Ipecac gtt. v., Avatcroiv.; a teaspoonful every hour. When there is evidence of irritant matters in the intestinal canal, an infusion of compound poAvder of rhubarb may be given to produce an action upon the bowels, and aftenvard in smaller doses until the diarrhoea ceases. Or, after obtaining this action, Ave may use the subnitrate of bismuth, in doses of one to three grains, every tAvo or three hours. In atonic diarrhoea, Ave may use the preparation of rhubarb, above named, to change the character of tire secretions; or in its place: R Neutralizing Cordial Sij., Chloroform ,>ss.; a tea- spoonful every hour. Podophyllin thoroughly triturated with prepared chalk, is an excellent remedy in these cases, Avhen given in minute doses, say the 1-40 of a grain. If an astringent is thought desirable, tannic acid with glycerine will ansAver a good purpose, and will be readily taken by the child. It may be dis- solved in the nronortion of 5j- to the ounce, and given in doses of one-fourth to one half teaspoonful. If the tongue is pallid, the patient should have bicarbonate of soda,or in some cases lime Avater, Avhatever else may be given. If the toiiguc is deep-red, an acid should be given, usually muriatic acid. If the tongue is red and dirty, the remedy Avill be sul- phurous acid. Leptandrin is an excellent remedy in those cases in Avhich there is evident torpor of the liver, and Avould be preferable to the Podophyllin, Avere it not that the dose has to be large, and the remedy is very unpleasant. Stimulants, especially the aro- matics, may be used in some of these cases, but as a general rule, they are not so beneficial as in the adult. MUCO-ENTT.RITIS. Subacute inflammation of the small intestine is most usually caused bv cold, though it may arise from irritating ingesta, or from decomposition of the food and the production of irritant MUCO- ENTERITIS. 321 material from this. The inflammation is confined mostly to the mucous membrane, the secretions of which are increased, and an increased peristaltic action having been set up, there is more or less diarrhoea. Symptoms.—The child is restless and uneasy, and has consid- erable fever. The discharges from the bowels are not at first very frequent, but they are preceded by pain, the child flexing the body and the lower extremities to remove the pressure. The discharges are attended with some tensenius, and in some cases the straining will be quite severe and prolonged. The stools vary in character; in nursing children they at first consist of curded milk, mixed with a greenish feculence, afterward they contain mucus, and are slimy and tenacious. In other cases the stools will be a green or biOAvnish .frothy material, mixed with mucus. As the disease progresses the discharges from the boAvels be- come more frequent, and are attended with greater uneasiness. They also contain more mucus, indeed sometimes seem to consist almost entirely of it. The febrile reaction also continues, and sometimes becomes quite severe. Generally it will run its course in from six to eight days, the fever ceases, the infhnnination of the bowels passes aAvay, and the diarrhoeal evacuations stop. Diagnosis.—We diagnose a muco-enteritis by the febrile reac- tion Avhich comes on Avith the diarrhoea, and by the tormina and tensenius Avhich attend the discharges. From dysentery it is distinguished by the feculence of the discharges. In some cases the diseases are associated, and we have a true dysenteric diarrhoea. * Treatment.—The treatment of this form of diarrhoea is very simple. We put the child upon the use of Tincture of Aconite gtt. ij. to gtt. v., Tinct. Ipecac gtt. v. to gtt. x., Avater Siv.; a teaspoonful every hour. In place of the Ipecac the Euphorbia may be used. If there is much griping pain, avc will sometimes find Colocynth, the best remedy, as—1^ Tinct. Aconite, Tinct. Colocynth aa. gtt. iij., Avater Siv.; a teaspoonful every hour. In some cases there will be nausea, not controlled with Aconite and Ipecac and in examining the patient Ave will note the ex- pressionless mouth, and the pallid atonic tongue, and Nux in small doses will be suggested until these symptoms have passed away. When the tongue is broad, pallid and dirty, the patient '21 322 DISEASES OF CHILDREN. has sulphite of soda ; if deep red, an acid is given. In some cases the marked periodicity in the disease calls for quinine, and it is given in the usual antiperiodic doses. Among the older means that may be suggested are the Avhite liquid physic, Avhen there is much tormina and tenesmus; tritu- rated Podophyllin, or the compound powder of rhubarb, Avhen the discharges are light-colored, and the boAvels tumid; bismuth, either in the form of sub-nitrate or liquor bismuth, or an infusion of Epilobium. In some cases Avhere the fever runs high, I have given the Veratrum- instead of Aconite, and where there Avas much irritation of the nervous system, adding Gelseminum. CHOLERA INFANTUM. Cholera infantum is a disease of the second year of childhood— a period which may be considered one of the climacterics of life, as there is iioav a change from the fluid food obtained from the mother, to the ordinary food of man. The change is a great one, but Avhen there is strong vitality and good development, it is made Avithout any appearance of disease. But if from any cause the child is enfeebled, or its development in other respects is tardy, it then suffers in the Avay Ave are about to describe. It is not easy to say what the exact pathology of this disease is. In one case it seems to be almost Avholly an irritation of the gastro-intestinal mucous membrane; in another it is an atonic condition, and a failure of poAver to digest food ; in another still, the intestinal lesion seems to be secondary, and depends upon a want of assimilation and nutritive poAver; and in others the lesion is principally of the nervous system. I conclude from all this, that the lesion is primarily one of the sympathetic system of nerves Avhich govern all the processes of vegetative life. In all cases there is debility, though in one it may be manifested in irritative action, and in the other in atony. Manv haATe urged dentition as the cause, but as this is a phys- iological process, except Avhen disturbed, avc Avould expect to find the disease only in cases of dental irritation, Avhereas Ave find it in children Avho have no teeth, Avho are not cutting teeth at the time the disease commences, avIio have all their deciduous teeth except the four last molars, or Avhen shewing no swelling, ten- derness or irritation of the gums. cholera infantum. 323 Cholera infantum usually occurs in the summer, making its appearance in May, June, or- July, and in the severer cases last- ing until frost and cool nights in the fall. A continuous high temperature always increases the severity of the disease, while a 'moist cool atmosphere gives relief. As a general rule, it is more severe on Ioav lands than on high ground, and is unfavor- ably influenced by the ordinary malarial causes. Symptoms.—A\e may divide the disease into two varieties, acute and chronic; the first bearing a very close resemblance to the cholera morbus of the adult, the second progressing slowly and occupying a period of Aveeks or even months. Acute cholera infantum is usually preceded for a day or tyvo by a slight diarrhoea, which gives the child but little uneasiness, and is scarcely noticed by the mother. But presently the child manifests an intense desire to drink and greedily takes Avhatever is offered. This causes nausea and vomiting, and the fluids are thrown up about as soon as taken. The diarrhoeal discharges also become more frequent, and arc large and exhausting. In a very short time the child is much prostrated, there is fre- quent retching and vomiting, especially Avhen any thing is taken upon the stomach. The thirst is a very marked feature, the child wanting water all the time, and crying for it Avhenever it sees a cup or glass; yet if even a tea-spoonful is taken, it is thrown up. The evacuations from the bowels have also increased in fre- quency. In some cases the skin is harsh or dry, and the pulse hard and increased in frequency.; in others the skin is soft and doughy, the extremities cold, and the pulse feeble and frequent. Occa- sionally the brain is affected, there being congestion or a low form of determination, or effusion. I recognize these cases by the extreme restlessness when there is determination, and a con- tinued rolling of the head from side to side, and stupor in the other cases. The disease may terminate fatally during the first twenty-four hours, or may continue for three or four days—the child recov- ering—or gradually pass into the chronic form. The chronic form of cholera infantum may folloAV the acute attack, as above described. But in a majority of cases it is pre- ceded for a Aveek or two by a simple diarrh e i, which, as it does not make the child sick, is alloAved to progress without attention. 324 DISEASES OF CHILDREN. The very gradual increase in the disease is probably the reason why au early treatment is not adopted. The disease develops by an increase of diarrhoea, and the ap- pearance of nausea and vomiting. The child has lost flesh and strength, its appetite is impaired, and it is thirsty, wanting to drink frequently and considerable quantities. As time passes, all the symptoms increase, but those that are cspeciallyfniarked are the intense thirst, irritability of the stomach, with frequent vomiting, especially Avhen drink or food is taken, frequent evac- uations from the boAvels, and great loss of flesh and strength. The discharges from the boAvels vary much in character in different cases, and even in the same case at different times. Sometimes they arc yelloAvish, with more or less stringy mucus mixed with them, shoAving disease of the mucous follicles ; at others they are greenish, and have a sour smell ; at others clayey ; again almost Avhite, and rarely a dark broAvn or black.* In febrile cholera infantum the skin is harsh, dry and con- stricted, and in some cases seeming to be draAvn upon the pa- tient like parchment. There is great irritability of the nervous system, the patient being restless and uneasy, never satisfied, always changing its position, wanting everything, satisfied Avith nothing, and especially restless and Avakeful at night. The child seems to be Avorse in the afterpart of the day and e\Tening, and frequently every other day. When the disease becomes very severe, it is impossible to keep the child in bed at night, the heat seems to torture it, and it is only satisfied Avhen laid where it can turn freely about, or Avhen carried from place to place. In the non-febrile form the skin is sqft, relaxed, and flabby, the extremities cool, the boAvels distended or pendulous, the tongue broad, flabby, and coated, and the pulse small, soft, and fluent. The child is not so restless as in the preceding case, seems stupid and dull Avhen nursed in a comfortable position, but Avants its *Dr GoldingBird made an analysis of the green evacuations of children, and found, contrary to Avhat was generally supposed, that they gave no indication of containing an excess of bile. He conceives that their color is due to the presence of altered blood, and that the state in which they are produced is analogous to that which exists in melsena, the portal system being generally in a congested state, In support of his views, he mentions that stools original'y of a yellow or orange color, often turn green on exposure to the air, an occurrence very unlike what takes place with matters containing bile, though it is an ascertained fact that blood, under the influence of several oxidating agents, acquires a green color. CHOLERA INFANTUM. 32-J own Avay. In both cases the appetite is alike impaired, there is the same nausea, the same desire for drink, and the same pros- tration of strength. We sometimes find the brain affected in those cases Avhere there is a continued moving of the head from side to side, the child sleeping with its eyes partly open, and rolling the eye- balls upAvard. If the pupils are so me av hat dilated and do not contract freelyr, upon exposure to light, I am satisfied there is congestion with effusion, and consider the patient's prospects very poor. Occasionally determination to the brain sets in, the head is hot, there is throbbing of the carotid arteries, contrac- tion of the pupils, and great restlessness and uneasiness. As the disease lasts for Aveeks, sometimes the Avhole summer, it does not present these active symptoms throughout. There are remissions and exacerbations ; for a few days the vomiting Avill cease, the appetite improve, and the diarrhooal discharges are less frequent—consequently there is a marked improvement in the child. Then, from some slight indiscretion in diet, or over-ex- ertion, but more frequently from alternations of temperature, there is another exacerbation. Diagnosis.—The acute attack is readily recognized by the sudden appearance of nausea, vomiting, and diarrhoea, the great prostration, and intense thirst. The chronic form, by its sIoav accession, and the same nausea and vomiting, the intense thirst, the persistent diarrhoea, and the impairment of digestion and nu- trition, as marked by the rapidly Avasting tissues. Prognosis.—The first element of prognosis Avith me is to de- termine the viability of the child, and I am guided in this by the depth of the base of the brain, as determined by the life line heretofore described. If the child has good viability, no matter hoAV severe the disease, I am hopeful, and give a favorable prog- nosis. But if the life line falls below half an inch the prognosis is very doubtful. The prognosis is less favorable when the brain becomes in- volved in the disease, presenting either irritation or congestion. Cases, also, which haAre been treated with irritant medicines, or by the persistent use of astringents, are difficult to manage. Treatment.—The treatment of the acute form Avill be much like that for cholera morbus of the adult. The objects are to 326 diseases of children. arrest the vomiting, to check the diarrhoea, and to restore tone to the system. To fulfill the first indication Ave have a large list of remedies, and, as is generally the case Avhere there are so many remedies, there are none very certain. I think this Avill apply, hoAvever, to the medicines in ordinary use, and not to specifics. I Avill name the first in the order in Avhich they are most commonly employed. fy, Rhubarb, Bicarbonate of Soda, Spearmint, aa. This, as Avill be recollected, I recommend in place of the ordinary neutralizing powder of the Dispensatory. When the patient is first seen, add ten grains of the powder to ten teaspoonfuls of cold Avater, and alloAV it to settle; giAC a teaspoonful every ten minutes. Add a teaspoonful of the poAvder to one-third teacupful (tAvo ounces) of boiling AA'ater; let it stand until cool, strain, SAveeten, and if the child is somcAvhat exhausted, add a teaspoonful of brandy. As soon as prepared give half teaspoonful doses every half hour, and as it is retained, increase the dose to a teaspoonful every hour, until it acts slightly upon the boAvels. The first doses will be throAvn up, but by repeating them it quiets the stomach and the nausea and vomiting cease; if not, after passing a reasonable length of time, select another remedy. An infusion of the bark of the young twigs of the peach tree is a very reliable remedy in these cases, and may be given in small doses, frequently repeated, until the object is accomplished. The subnitrate of. bismuth in mint Avater, Avill prove a good remedy in some cases; it is used in the ordinary doses. In those cases Avhere there is marked exhaustion, the extremi- ties being cold, stimulants ansAver a better purpose than other remedies. The compound tincture of Cajeput is a good remedy in these cases. If not convenient, a tincture of the essential oils of cinnamon, cloves, peppermint, etc., singly or in combination, may be employed ; or tincture of camphor may be used for the same purpose. Chlorodyne, the formula for which, is given in the first part, may sometimes be given with advantage, in doses of about one to tAvo drops. Chloroform may also be used, and Avill sometimes be tolerated when other remedies are not borne. Whatever is given, or Avhether anything is given, the nursing is a most important part of the treatment. Place the child in the recumbent position, and wrap the feet in dry, hot flannels, keeping a plate, stove lid, or "any heat-retaining article in con- tact Avith them, so as to keep a continued heat. If there is feeble CHOLERA INFANTUM. 327 circulation, and marked coldness of the extremities, the poAvdcrcd capsicum or mustard may be sprinkled upon these flannels. As an application over the stomach, I prefer the cold pack, either in the form of a Avet towel folded, Avhich may be renewed as often as may seem necessary, or an entire abdominal pack, which will remain for one or two hours, and will then be removed, the child rubbed thoroughly, and Avrapped in dry flannel. The recumbent position should be insisted upon. To quiet the thirst, I prefer giving small pieces of ice, or tying a piece in a cloth for the child to suck. If ice can not be had; then give cold Avater, a teaspoonful at a time, every feAV minutes. Sometimes a very little salt added to the water causes it to be retained better. When the vomiting is persistent, and the thirst excessive, I have employed an injection of salt Avater with good advantage. It is used in considerable quantity, and may be repeated when it passes aAvay. We-liave now to speak of specific remedies for this disease, and though they arc not cure-alls, they deserve attention. When the skin is hot and dry, the pulse hard, and other evidences of a febrile condition, Aconite is the remedy. I use it in the ordinary proportion of two drops to Avater four ounces, but give one- fourth of a teaspoonful every fifteen minutes. The directions above as to nursing, must be implicitly followed. In an ordinary case, I order Aconite and Ipecac alternately; they are prepared for use by adding two drops of Aconite and five drops of Ipecac to four ounces of water, and give a teaspoonful every hour. They may be a little slow but are very certain in their action. When the face is pallid, and the mouth expressionless, the tongue pallid and atonic, Xux Avill serve our purpose best. It is given in quite small doses, gtt. j. to gtt. ij. to Avater 5iv.; a tea- spoonful every fifteen minutes until the nausea is quieted. The Ipecac is added in the usual proportion, And the two are continued until the diarrhoea stops. It is a little singular, but there is in the market much so-called "fluid extract" of Xux Vomica, that has no bitterness, and of course is absolutely Avorthlcss. Such stuff is not recommended. In the acute form of the disease avc have accomplished the greater part of the cure, Avhcii avc have arrested the nausea and vomiting, and generally any simple remedy adapted to the case, 328 DISEASES OF CHILDREN. will be sufficient to arrest the diarrhoea. In my practice I depend almost Avholly upon the continued use of Aconite and Ipecac. In true cholera infantum (chronic) it is Avell to make the clas- sification of cases — irritative and atonic. Sometimes this is very readily done, as the symptoms are so marked, but in others Ave reach a half-Avay ground, a debatable land, and the classification can not be made. In some cases the irritation of the stomach is extreme, so that the child can take neither food nor medicine Avith advantage. Aconite and Ipecac in very small doses, with restrictions in drink, (thirst is extreme,) Avill frequently relieve the stomach. Some- times Euphorbia is substituted for the Ipecac, or if there is much tormina and straining at stool, Colocynth may be used. The dose of course must be very small. 1$ Tinct. Aconite, Tinct. Colo- cynth, aa. gtt. ij. water 5iv.; a teaspoonful every hour. (The medicine should be kept cool, and preparedtfresh every day.) If the tongue is pallid, the face expressionless, and salloAV or y el Ioav about the mouth, Nux Vomica Avill be the remedy to re- lieve the nausea. One or two drops may be added to a half glass of Avater, and given in doses of one teaspoonful every half hour or hour. Ipecac may be added in some cases to assist in relieving the nausea, or after a day or t\AO to control the diarrhoea. • The Compound Powder of Him barb, infusion of Peach bark, Bismuth, Hydrate of Chloral, and sometimes, but rarely, stimu- lants may be employed, as heretofore named. In some cases Ave find marked irritation of the brain, and indi- cations for Gelseminum. In others the patient is dull and stupid and Belladonna is Avanted. 'There are cases in Avhich the child is extremely restless, starts in his sleep, aAvakes frightened, cries out shrilly, and at the same time has a peculiar pinched expression about the eyes and base of the bra hi. The symptoms are char- acteristic, and the remedy is Rhus, and when thus indicated it Avill quiet irritation of tine stomach, and check the diarrhoea. There are cases in Avhich sulphurous acid becomes an excellent remedy; cases that require sulphite of soda; cases that Avant a simple alkali, bicarbonate of soda or lime Avater; and others that want muriatic acid. Here, as elseAvhere, the indications for rem- edies should be folloAved. Podophyllin thoroughly triturated Avith sugar of milk or loaf sugar, in minute doses, is sometimes an excellent remedy. Its use is in those cases in which there is atony of the stomach, and CHOLERA INFANTUM. 329 congestion of the liver and portal circle. Cases in which the tongue is broad, and coated, the abdomen SAvollen, the skin salioAy and the temperature loAvered. Leptandrin is used in these cases, but is not so easily taken by children, and owing to its nauseous taste, is not so we 11 tolerated by the stomach. In cases where there is any evidence of periodicity, usually manifested by increase of nausea and vomiting and diarrahoea, quinia may be employed with advantage. I prescribe it as I do in interniittents, every two hours, until three doses are taken, or one dose of two grains, at the time Avhen the patient is most free from nausea. In some cases its action is ATery decided—it checks the nausea and vomiting, lessens the thirst, allays the irritation of the nervous system, and indeed, seems to improve every func- tion ; and repeated for a few days, the patient is convalescent. In some cases minute doses of Arsenic Avith Veratrum will quiet the gastro-intestinal irritation, and strengthen digestion better than anything else. When there is a soft compressible pulse, a relaxed and pale skin, and cold extremities, I luu-e used the quinine inunction with benefit. I think in some very bad cases, it has given tone to the system, and so added to the patient's poAver to live, as to tide over the summer to frost, and convalescence. Fatty inunction alone, answers a very good purpose. When the skin is dry and harsh, it is the best means to soften it and place it in condition for secretion. When it is soft and relaxed, by adding a stimulant to it, and using it Avith friction, it is a good means to stimulate capillary circulation. I do not like the free bathing sometimes recommended, as there is not the poAver of re-action, without Avhich the use of Avater must do harm. If the child is bathed, let it be thoroughly and quickly washed with soap and Avater, or Avith salt and Avater, if the inunction is not practiced. In some cases of cholera infantum "a soft flannel bandage is applied to the abdomen, and gives as much relief as the medicine. A bag, a foot square, filled with good Fenugreek seed, sprinkled with oil of cloves, or some other of the essential oils, and quilted a half inch thick, and worn over the stomach, Avill give marked relief in some cases. It is after the order of the old fashioned spice plaster, but is better. Much will depend upon the diet of the child in some cases. As a general rule, the mother's milk is preferable, and the case 330 DISEASES OF CHILDREN. would be exceptional Avhere I Avould recommend that it be weaned; still there are such cases. When the child has been weaned, however, Ave Avill have to take this into consideration. The directions heretofore given will enable us to determine Avhether the milk in use is good. If Ave see reason to change this, Liebig's food Avill be found the best, Avhere it can be taken. Raw or rare cooked beef Avill sometimes agree well " ith a cjiild Avhen it has been unable to take other food. Pickled pork Will sometimes ansAver well, and be digested when the stomach Avill not tolerate lighter articles of food. The child's appetite may be gratified, and indeed it may be taken as a guide, with refer- ence to all such things as constitute the healthy food of the country, only excepting some vegetables and fruits. In regard to the latter, Ave have difficulty sometimes in determining Avhether any, or Avhat may be given Avith safety. As a general rule, ripe peaches and blackberries, fresh from the vines, Avill be the only ones we can give Avith safety. The excessive thirst is an annoying feature of the disease, and avc Avill be anxiously asked about gratifying it every time Ave see the patient. In some cases the child may have all the Avater it wants, even though it causes vomiting at first, for by giA'ing drink freely in this Avay the irritation of the stomach is overcome, These cases, I am sorry to say, are feAV. The rule of practice is. that the child must be restricted to smqll quantities of Avater until the disease is arrested ; it may be given frequently, however, and this is some alleviation of the thirst. In- other cases, Avhen the stomach refuses to tolerate water Ave order ice, and it may be given quite freely Avithout danger, and sometimes with benefit. Recollect the injection of salt Avater in these cases, and the ad- vantage that sometimes follows from the use of the Avet-pack. Convalescence must be managed with care, and indiscretions in diet avoided. I frequently put the little patient on the use of tincture of muriate of iron and glycerine, as heretofore named, and sometimes associate it Avith phosphate of soda, three grains, three times a day. TABES MESENTERIC A. Tuberculous disease of the intestinal canal is most usually met with in childhood, tliough occasional cases Avill be seen even up to the age of tAventy-five. It occurs only in those constitu- TABES MESENTERICA. 331 tions which Ave have before referred to as being tuberculous, and where, if the irritation had been of the lungs instead of the boAvels, it Avould have been phthisis. The pathology of the disease is Avell described by Habershon : " In disease of the mesenteric glands, a low organized product is effused into the glands themselves, probably because the chyli- fcrous ducts become entirely obliterated, and the structure of the gland destroyed. Their extensive disease prevents the absorption of chyle into the system. The glands share the disease in vari- ous stages and gradations ; in some, but scanty abnormal product is found, in others the whole gland is destroyed and very much enlarged, constituting a -whitish mass, the size of a pigeon's or hen's egg. The effused product consists of granular blastema, and imperfectly developed ccdls. The swollen and injected state of the glands less affected, appears to indicate that inflammation or hyperaemia is associated with the disease. The increase takes place by additions to the periphery of that already deposited, and degeneration occurs in the center from the scanty supply of nourishment afforded to the.central part. The gland sometimes appears to be enveloped by a firm, fibrinous cyst, which consists of inflammatory product better organized, having assumed the character of fibrous tissue, Avhile the center consists of calcareous deposit, the albuminous portion having been absorbed, and the organic onlv left. Degeneration of another character, however, takes place in the effused product, it is converted into a mass of granular molecules and highly refracting particles, constituting small, cheesy tubercles of a yelloAV color, or a softened and semi- diffluent mass. The lacteals betAveen the glands become enlarged and distended with similar strumous product, or avc can trace the distended ducts to the intestine, where they ramify on its surface, and at this part Ave generally find a cluster of tubercles and ulceration of the mucous membrane." Symptoms.—Tn children it is usually preceded by diarrhoea and gradually increasing prostration. The appetite is usually goo:l, sometimes ravenous, but the patient receives no apparent benefit. The bowels are sometimes tumid, hot and tender, at others very much shrunken ; the evacuations consisting of a thin mucus, greenish, and frequently resembling the Avashings of meat.' The countenance is contracted.and pinched, the eyes set far back in the head, and the skin peculiarly dry, wrinkled, and salloAV, 332 DISEASES OF CHILDREN. giving the child a prematurely aged appearance. It is restless, irritable and fretful, and presents many of the symptoms of cholera infantum. In the adult there may or may not be diarrhoea, frequently an alternation of diarrhoea and constipation, and sometimes severe pain. There is a marked marasmus, increasing day by day, though the appetite may be good, and the digestion seemingly well performed. The patient has an anxious expression of coun- tenance, a salloAV, wrinkled skin, contracted abdomen, and is uneasy, restless and irritable. In the latter stage diarrhoea some- times sets in, and carries the patient off quickly, or disease of the brain or lungs comes on to assist the tabes. In both cases the enlarged mesenteric glands can frequently be felt through the abdominal Avail. Diagnosis.— Tabes mesenterica is diagnosed with difficulty. The principal symptoms leading us to believe in strumous dis- ease of the mesentery are: the continuance of a good appetite, and seemingly good digestion, with continually increasing loss of strength and flesh, and the evidence of disordered boAvels, and in the latter stages feeling the enlarged mesenteric glands through the abdominal Avails. It Avill be seen that our diagnosis will have to be made principally by exclusion, a \rery common method, and possibly more correct than by direct symptoms. Prognosis.—The prognosis in Avell marked cases of this dis- ease is exceedingly unfavorable, as much so as any disease we are called to treat. In the earlier stages its progress may be arrested as it may also occasionally in the latter. Treatment.—A tonic and restorative treatment would seem to offer the best results in these cases. Yet we find that it does not prove so serviceable as some other means. The general inunction with quinine once a day., and the use of the Uvedalia ointment to the abdojnen is recommended. In some cases small doses of Arsenic exert a benefiofal influence as : 1^ Fowler's Solution gtt. x., Tinct. Veratrum gtt. v., water 5'iv.; a teaspoon- ful every three or four hours. Hypophosphitc of lime is a good remedy, as is the compound syrup of the hypophosphites ; cod-livcr oil has given very good results Avhen it could be taken Avell and digested. In some cases a good preparation of malt, taken after the foods, aids in digestion, and the child will improve on it. DYSENTERY. 333 Small doses of Ipecacuanha, alternated with Aconite, may be employed to relieve the irritation of the boAvels, and check diar- rhoea when it is present. Or, in place of these, we may use the extract of Hamamelis (Pond's), Avhich I think very highly of. The dose will be about ten drops four times a day. The use of Alnus, Rumex, Scrofularia, and others of our vege- table alteratives, has been recommended; but I think they will not prove so serviceable as the means above named. D Y S E N T F R Y. Inflammation of the large intestine in the child arises from the same causes, and presents somcAvhat similar symptoms to the same disease of the adult. It occurs in both the sporadic and epidemic form, though in some epidemics children are remarkably exempt from it. Indeed, as a general rule, we Avill find that dys- entery in the child is rarely the active inflammatory affection that avc are called to treat in the adult. Causes.—The common cause of sporadic dysentery is cold, though it may be produced by indigestible food, or such derange- ment of the digestive process as Avill permit the decomposition of food and formation of irritant products. Epidemic dysentery depends upon the influence of an animal poison ; Avhat it is avc do not knoAV, nor Avhy it acts upon this particular portion of the body. Pathology.—Dysentery is a true inflammation of some por- tion of the large intestine—a colitis. The inflammation may involve but a small portion of the intestine, and be confined to the mucous membrane, or it may involve the greater part or all, and extend to the muscular and peritoneal coats. There are some cases in children in which the inflammatory character is not marked, but rather an irritation of the mucous coat, Avith increased secretion, and of the muscular coat, with increased peristaltic movement. This form of the disease is not attended by fever, and may continue for Aveeks or months Avithout danger to life. Symptoms.—In acute sporadic dysentery of the child, it is first noticed that the boAvels are moving too frequently, and there is considerable straining at stool. The discharges, hoAvever, are 334 DISEASES OF CHILDREN. feculant, though small, but if noticed closely they Avill look slimy, and after a day has passed they Avill be almost pure mucus, or mucus tinged with blood. As the dysenteric character of the discharges becomes marked, febrile symptoms appear. The child is restless and uneasy, the skin is dry, the pulse is accelerated and hard, the appetite im- paired, and indeed all the functions of the body deranged. These symptoms vary greatly in different cases—in some the fever runs high, in others it is hardly noticed. But as the disease progresses the discharges become more fre- quent, every fifteen, ten, or even every five minutes; they are preceded by pain, and attended with tenesmus. This straining at stool is so marked a feature with the child, and so strongly expressed in its countenance, that it is an index to the character of the disease as soon as seen. Day by day the child loses strength, and the general and local disease seems to gain inten- sity, until the fifth or sixth day; then there is a gradual amend- ment, until convalescence is completely established. I speak of this as being the usual course of the disease Avhen not influ- enced by medicine. Epidemic dysentery presents the same symptoms that it does in the adult. Commencing Avith evidences of prostration, and impairment of the general health, there is usually a well marked chill, Avhich is followed by febrile reaction. This general dis- ease assumes so prominent a place at first, that it overshadows the local inflammation. Yet, at first, there is an irritation and increased activity of the boAvels, and with the development of the fever, the small mucous or bloody dysenteric evacuations be- come marked. It is not Avorth Avhile in this place to enter into a lengthy de- scription of the symptoms presented, as they are a continuation of those above described, avith a remittent or continued fever. As the disease progresses, it develops typhoid symptoms, both general and local, and in the severer cases it becomes a very grave affection. The dysenteric irritation referred to AArhen speaking of the causes of this disease, presents but a part of the symptoms of dysentery. The discharges are attended with straining, are small, and in some are wholly mucus, in others mucus mixed with feculant matter. They are also frequent, and in some cases it seems that the child can not stoop or be placed in ".constrained • DYSENTERY. 335 position Avithout an action of the boAvels. But the general health is less affected than Ave Avould suppose, not nearly so much in most cases as in ordinary diarrhoea. Still, as it continues for a longtime, it is a cause of much annoyance to both parents and physician. Diagnosis.—The diagnosis of dysentery is made with ease. No one could see the peculiar expression of countenance during the tenesmus, Avithout at once recognizing what Avas the matter, even if he had never seen a case of the disease. Prognosis.—The prognosis is favorable in the sporadic dys- entery of children, but in those epidemics that reach children the mortality is greater than in the adult. Treatment.—In the mild sporadic form of the disease, my practice resolves itself into the administration of Aconite with Ipecac in the usual doses. The general bath is used, and the hot foot-bath, and the child is kept still, and in some cases a cloth spread with lard or mutton suet is applied over the abdo: men. The treatment is very simple and very satisfactory, and I should be glad if all treatment Avere as much so. When there is persistent abdominal pain or tormina, I like the action of Colocynth, in the small doses heretofore named. In some cases Veratrum may be used, and if there is evidence of determination of blood Gelseminum is given Avith it. In some cases the broad pallid and dirty tongue calls for sul- phite of soda, and it is given in doses of from two to five grains every three hours until the tongue has cleaned. Sulphurous acid is an excellent remedy in typhoid dysentery, the tongue being red and full, and covered Avith a nasty glutinous coat. In the olden time, the Avhite liquid physic of our Dispensatory, held a prominent place in the treatment of dysentery. And it may yet be w^cd with advantage in some seasons. I advise that the proportion of acids be diminished as folloAvs: R Sulphate of soda 5viij., water 5xxiA\, Nitric acid, Muriatic acid, aa. .^ss. Mix. The dose for a child two or three years old Avill be' a teaspoonful every two hours, (with syrup), until it moves the bowels gently, then in smaller doses. In some cases olive oil may be used to move the upper intestine. If in a malarial region, Ave look carefully for periodicity, which AA'ill be found in many cases. Here quinine is an indispensable 336 DISEASES OF CHILDREN. remedy, the patient being prepared for it, and it is« given in the usual usually in familes of three or four." Symptoms.— With many if not all forms of worms, it is neces- sary that the bowels be in a condition to furnish a comfortable habitation. This condition is essentially one of Avant of tone, Avith, in many, increased seeretion of intestinal mucus. We observe in many cases that the child or person is poorly nourished, the muscles are soft and flabby, there is a loaded tongue, bad breath, and derangement of the secretions. We are not inclined to believe that this is the result of Avorms, but simply coincident Avith them, and in some cases the patient has Avhat is termed worm fever, usually of an intermittent character, the paroxysms occuring in the afternoon and evening, at which time Ave find the skin hot and dry, the pulse frequent, the head hot, and marked irritability and restlessness, and occasionally convulsions. Or the fever may be more obscure, the child is fretful and nervous, sleeps poorly, its breath is fetid, tongue coated, bowels irregular, abdomen tumid, is frequently picking its nose, the upper lip swells, a Avhite line appears around its mouth and it seems to be out of order generally. These are the symptoms of the first named varieties, though not nearly so avcII marked in the case of the ascaris vermicularis. Though seeming to be very plain, yet all these symptoms may be present and no worms; or Avorms present, and but few of these symptoms. The only certain evi- dence of worms is their presence in the feces, and even then Ave can not be certain but that all have passed. The ascaris vermi- cularis makes itself known bv an intolerable itching and crawl- ing sensation about the anus. At first it generally comes on after the little patient gets Avar in in bed, the irritation being so 344 DISEASES of children. great that sleep is impossible; at last, they are more or less troublesome all the time. The irritation is occasionally so great as to impair the health, and occasionally gives rise to convulsions. As regards the symptoms of tape-AVorm, they are very decep- tive. In one hundred cases recorded by Seeger, in sixty-eight instances nervous affections, or general or partial convulsions, occurred—epilepsy, hysteria, abdominal spasms, convulsive cough, dyspnoea, melancholy, and hypochondriasis ; in forty-two, vari- ous pains in the abdomen ; in thirty-three, disordered digestion and irregular states of the evacuations; in thirty-one, irregular appetite and voracity ; in nineteen, habitual or periodical hemi- cranias ; in seventeen, sudden colic; in sixteen, sensations of undulatory movements in the abdomen up to the chest; in fifteen* vertigo, delusions of the senses, and defects of speech ; and in eleven, shifting pains in various parts. The only definite evi- dence of the presence of tape-worm is the passage of portions of it Avith the feces, and as this usually occurs Avith this worm, the non-appearance of the joints in the evacuations during a consid- erable time, may be considered as good evidence that the worms do not exist in the intestinal canal. Treatment.—The treatment of the ascaris lumbricoides and trichocephalus will be very similar, the object being to remove the Avorms, and break up the predisposition to them by remov- ing the condition on which they depend. Very many vermifuge remedies have been recommended and used with success, so that the trouble will be, not that Ave have no remedies, but that Ave have too many. The old fashioned remedy, ".pink and senna" in infusion, seemed to be about as certain as any other agent, and I am satisfied that if it were as disgusting to the Avorm as it is to the child, it Avould readily leave its nest in the boAvels, rather than take the dose. Still it is not more nauseous than the oil of Avormseed, which is an ingredient of all the principal vermifuges, as—1^ Oleum Chenopodii ox., Oleum Terebinthinae J£ij., Oleum Rieinii Siij., Aqua Calcis .^x., Syrupus Limonis 5aj. ; Mix ; the dose being two teaspoonfuls three or four times a day. Kuchen meister recommends the santonine, and the santonate of soda> for the ascaris lumbricoides ; he considers it to be best adminis- tered in oil, in order to bring it into solution as readily as possi- ble, and thus combines it Avith castor oil, or sprinkles it on bread and butter, and folloAV it with Jalap and Senna. Troublesome intestinal avorms. 345 effects sometimes follow the administration of this remedy, as severe irritation of the nervous system, convulsions, tenesmus, bloody stools, and the minor disturbances, green or bnii.-u vision, and discoloration of the urine. The santonate of soda he gaA'e i in doses of from two to six grains on a Friday night, and the same dose on Saturday and Sunday mornings, facing; half an hour after this last powder, confection of Senna and Jalap is taken in sufficient doses to produce several fluid evacuations, the Avorms passing alive, and sometimes Avandering forth Avithout any opera- tion, the intestines having become unpleasant for them. I now employ a trituration of Santonine with Podophyllin in the following proportion—R Podophyllin gr. j. to ij., Santonine gr. x. to gr. xx., White Sugar oij.; triturate and make twenty powders. One of these may be given morning and night, until the object is accomplished. When there are no Avorms, but only the atonic condition of the mucous membrane Avith increased secretion of mucus, the patient will be benefited, and sometimes cured by the remedy. A judicious tonic course of medicine, the boAvels being kept regular, and the other secretions free, Avith an avoidance of all grease or indigestible food, the daily use of the bath, and exercise in the open air, are the only means by which we can break up the tendency to the formation of worms. Many remedies have been recommended for the ascaris vermi- cularis, but in my opinion all vermifuge medicines should be dis- carded. If the patient's bowels are irregular, proper means should be taken to overcome the difficulty, and if necessary a tonic and bracing treatment adopted. For the Avorms I have ahvays directed an injection of salt and cold Avater, in the pro- portion of a teaspoonful to half a teaenpful, and so far with in- variable success. Should this fail, Ave Avill be able to relieve the patient by the use of an aloetic purgative, as in the following formula: T^ Tincture of Aloes, Compound Tincture of Lavender, aa. Sss., Simple Syrup §j. ; a teaspoonful four times a day. Tape-Avorm is of A^ery rare occurrence in childhood, and is possibly never met with during the first tAvo or three years. The mildest treatment will be best here, and I would recommend the emulsion of jiumkin seed, or the oil of male fern. The emulsion is made by depriving tAvo ounces of the seed of their capsules, and beating them into a pulp, Avith sugar and Avater; this is the 346 DISEASES OF CHILDREN. dose for an adult, and is taken upon an empty stomach, in the morning; and is followed in from tAvo to four hours by a full dose of castor oil. The oil of male fern is also taken, fasting, the dose being from gtt. xx, to 5j- in mucilage of milk. The most effective means for the removal of tape-AVorm will be found in the Pomegranate bark, according to the directions of Prof. Locke, a full description of Avhich may be found in my Practice of Medicine. DISEASES OF THE LIVER In the olden time, diseases of the liA'er Avere the most promi- nent affections of both adults and children, and Avould occupy a conspicuous place in treatises upon the subject. But as Ave have learned more and theorized less, the liver has played a less im- portant part in pathology, and has received less attention from the therapeutist. We have reason to believe that the intra-uterine function of the liver is of more importance than its function after birth. For, of all the organs of the body, it alone had its complete de- velopment before birth, and in size was much larger than any other organ in proportion to the body. What its functions Ave re there, Ave are as much unable to say as Avhat its functions are in the adult; but of one thing we are convinced, that it is so admi- rably adapted to its office that it rarely suffers from serious disease. CONGESTION OF THE LIVER. We notice a singular disease, occurring during the first three or four months of infancy, in Avhich there is enlargement of the right hypoehondriuin and the epigastrium. It is known by nurses and old ladies as liver-grown, and they propose its remo- A'al by rubbing with some fatty material—generally goose-grease. That there is such enlargement there can be no doubt, and that it is relieved by these frictions is also certain, but Avhat the exact condition is, I have never been able to determine. The symp- toms would indicate congestion of the liver, hence I have given it that name. CONGESTION OF THE LIVER. 347 Symptoms.—For some days the child has been fretful and uneasy, seeming to suffer from indigestion and colic. The dis- charges from the bowels are more frequent, and have an un- healthy appearance, generally light-colored. At last the child is undoubtedly sick, has some fever, does not sleep well, is startled in its sleep and cries out as if in pain. It does not nurse well, and usually feels uneasy after taking the breast, and relieves itself by throAving up its milk. This has an unpleasant sour smell, and is not curded \s in healthy digestion. The symptoms named may continue for some weeks, the child losing flesh and becoming quite feeble; and I doubt not, though I have never observed it, that this condition might continue to a fatal termination. Diagnosis.—With the symptoms above given, Avhich resemble those of infantile dyspepsia, Ave Avill find a distinct enlargement of the right hypochondrium. A careful examination, Avith pal- pation, Avill show the liver to be really enlarged, as its outlines can be distinctly traced. TpiEATmknt.—As named above, the treatment of the nurse is usually quite successful, and this is simply the thorough rubbing of the part Avith some oily material. In the hands of an old lady, the treatment is very vigorous, with rubbing, kneading, and palpation, the child being turned from side to side, uoav on its abdomen, then on its back, and this continued for a quarter or half hour, and repeated every day, and sometimes tAvice a day. On first Avitnessing it I thought it pretty rough usage for a delicate and sick infant, and protested against it. But the old nurse insisted that doctors Ave re fools, and Avould have her oavu Avay, and the result justified her claim to be able to treat liver- grown, for the child made a quick recovery. I learned one lesson from this, that I have put in practice many times since Avith success—that torpid organs could be stim- ulated to action by passive movements, and their circulation and nutrition decidedly improved. This is the principle of the Swe- dish "movement cure," Avhich is claimed to be as well adapted to a dyspeptic stomach, as to an enfeebled limb. The remedies I Avould advise in this case are—1^ Tinct. Bel- ladonna, Tine. Aconite, aa. gtt. iij., Avater *\v.; one-fourth to one-half teaspoonful every hour. If it Avas somewhat chronic, haying lasted for some Aveeks, small doses of Xux might be N 348 DISEASES OF CHILDREN. given, or if there Avas still irritation, the tincture of Chionantbus in drop doses every three hours. If the child is feeble, and especially if suffering from a mala- rial influence, quinine inunction would be advisable. In all cases I Avould advise the thorough rubbing of the part, as first named. STRUMOUS ENLARGEMENT OF THE LIVER. This is not of frequent occurrence, but may be occasionally met with in the children of the poor in large cities, as the result of poor and scanty food, bad air, Avant of sunlight, Avant of clean- liness, proper clothing, Avarmth,and indeed all that Ave are accus- tomed to regard as the comforts of life. Rarely a case occurs in a family in good circumstances, from scrofula or bad blood, or from the depression of other sickness. Dr. Tanner observes "that a peculiar enlargement of this gland not unfrequently occurs in feeble and delicate children. The abdomen gradually enlarges, so that the little patient is said to be ' pot-bellied/ and on examination one or more Avell defined tumors are discovered. These tumors are formed by the enlarged liver, Avith perhaps an enlarged spleen; the increase in size in both cases being due to the interstitial deposit of albuminous matter. As this foreign matter is* soft, and has no tendency to con- tract like the lymph poured out in ordinary inflammation, it docs not much impede the passage of the blood through the liver, or the escape of bile through the ducts; and hence it very seldom giA^es rise to serious disturbance. Should the same material, hoAvever, become deposited in the structure of the kidneys, then the function of these glands becomes so completely interfered with that the cases cease to be amenable to treatment, and albu- minuria, ascites, and anasarca ensue, and death ultimately results." Symptoms.—The child has lost flesh in a very marked degree, though it is usually not so feeble as Ave should suppose by its ap- pearance. Its appetite is variable ; sometimes craving, especially for fruits, SAveets, pastry, and things it should not have ; at others it wants to eat but little. Digestion is accomplished tolerably well, so far as Ave can observe from any derangement of stomach or boAA'els, folloAving the taking of food. But it is imperfect in that the material is deteriorated during the digestive act, and can not make good blood or good tissue. ENLARGEMENT OF THE LIVER. 349 Generally, there is more or less derangement of the bowels, the discharges being too frequent, attended Avith uneasiness, and are light-colored. The urinary secretion is someAvhat scanty, highly colored, and sometimes presenting distinct evidence of the coloring matter of bile. The skin is generally sallow, relaxed, and hangs in folds, the circulation being sluggish, and secretion i m perfect. In the majority of cases there is slight febrile action in the after part of the day, and the child is restless and fretful at night, wanting to drink often. In some cases an unpleasant irritation of the nervous system, causing the child to be restless and fretful and sleeping badly, is the most unpleasant symptom. Diagnosis.—The distended abdomen, so large as compared Avith the general loss of flesh, and the distinct enlargement in the region of the liver, its lobes being felt as distinct tumors, is suffi- cient. In tabes mesenterica there is a somewhat similar enlarge- ment of the abdomen, but it is most prominent in the region of the umbilicus, and the nodulated glands may also be felt in the mesentery. Prognosis.—When of long duration, and attended Avith great marasmus, the prognosis is unfiworable. But if the child, has considerable strength, and digestion is not much impaired, we may expect favorable results from the use of remedies. Treatment.—I have much faith in ajudicious tonic and re- storative treatment, in all these cases, paying particular attention to the clothing, food, and that it has an abundant supply of sun- shine and fresh air.. The internal administration of Collinsonia and Hamamelis al- ternated, in the doses heretofore mimed, Avill be found to quiet irritation of the bowels, check the frequency of the discharges and change their character. Associated with this, I Avould give the tincture of muriate of iron Avith glycerine morning and night. Let the child be thoroughly rubbed tAvice a day Avith the quinia inunction, freeing the surface from any surplus material by rub- bing Avith clean flannel, and occasionally by washing Avith soap and AArater. This I consider one of the most important parts of the treatment. The child should be clothed in flannel throughout, both winter and summer, and in chilly or cold weather, especial care should 350 diseases of children. be used to keep if warm, and in an atmosphere of uniform tem- perature. The room where it sleeps should be thorougly venti- lated, and have a good supply of sunshine, and in addition the child should be carried in the open air. The food may be the same as recommended in cholera infantum, and should be carefully prepared. Sometimes more will depend upon this than upon the treatment. For a poor and bad blood must increase the disease, Avhile from good food, well digested, good blood is formed, capable of supplying the tissues, and giv- ing no Avaste for struma. JAUNDICE. We have two varieties of jaundice in childhood which require separate description. The first, or icterus neonatorum—the jaun- dice of infancy—is usually a very simple affection, and though of frequent occurrence, it passes away Avith simple treatment. The second variety resembles the jaundice of the adult, both in its pathology and symptoms, and while of rare occurrence it is sometimes a severe affection. Causks.—The causes of the first form are very obscure, and while occasionally it seems to arise front some irritation of the primce via;, in other cases there is no apparent cause for it. The second form of jaundice may be caused by cold, produc- ing congestion of the internal organs, and especially of the por- tal circle. Or it may be produced by a malarial poison, which, impairing the circulation of blood, causes congestion of the ab- dominal viscera. Pathology.—Jaundice is but a symptom of some lesion of the liver or of the blood. It consists in a change of the coloring material of the blood, and its being set free and deposited in the tissues ; or more frequently in the retention and absorption of the coloring matters of the bile, and their deposit in various structures, principally the skin and conjunctiva. Occasionally it is deposited in the deeper structures, as of the eye, giving rise to yelloAv vision ; in the nails, and in the internal organs. It is singular that the mildest and the severest form of jaun- dice are alike, in that they are dependent upon change in the coloring material of the blood. In icterus neonatorum I regard the coloring matter deposited in the skin, as arising from the natural retrograde metamorphosis of the red globules, but fail- jaundice. 351 ing to be removed, from some temporary inactivity of the excre- tory organs. All the symptoms point to this as the true condi- tion, for in the majority of eases, there is no lesion of the diges- tive canal or its associate organs, all their functions being car- ried on regularly and well; while in those cases in Avhich there is such irritation, it seems rather from arrest of excretion than from any other cause. In those extreme cases of jaundice, running a regular and very certain course to a fatal termination, the coloring material is changed hematine and not bile. In this respect it resembles the bronzed discoloration in Addison's disease (disease of the su- prarenal capsules). The other form of jaundice arises from—a, hypersecretion of bile; b, from congestion of the liver and portal system ; c, from chronic alterations of the structure of the liver, preventing se- secretion or the free discharge of bile ; d, from spasm or tempo- rary obstruction of the biliary ducts; e, from obliteration or compression of the biliary ducts or gall bladder;/, and lastly, from disease of the duodenum, partially or entirely occluding the ductus communis. Symptoms.—Icterus neonatorum is frequently attended at first by slight febrile action. Occasionally this is quite marked, and the child is restless and uneasy, and sleeps badly, continuing for from one to four or five days, in a remittent form ; it gradually passes away, and the secretions being restored, the child seems as well as ever, but for the yellow discoloration. It will be recol- lected that in the majority of cases the fever is not high, and passes off entirely by the end of the second day. The yellow discoloration very gradually fades, seeming to be removed more by the natural removal of tissue than by special absorption. Rarely continuing less than tAvo weeks, it may not be entirely removed for as much as three months. The other form of the disease rarely occurs during the first or even the second year. Usually, there is distention of the bow- els, colicky pains, constipation, the feces being clayey, pale, and scanty. The mouth is dry, has a bad taste, tongue coated, and sometimes nausea and pain in the head. The yellow tinge usu- ally makes its appearance in the eyes, and gradually extends to all parts of the body, the color being deepest in the' folds of the skin. *>'■>* diseases of children. For practical purposes, Ave may divide this variety into tAvo forms, the symptoms being distinctive and the'treatment different. in the one case the patient is irritable and restless, the skin is dry and harsh, the urine high-colored, the pulse hard and in- creased in frequency, and the temperature elevated. In some cases the patient complains of pain in the right hypochondria and in the shoulders, and sometimes in the small of the back. In the second case the tongue is broad, palid, and covered with a uniform yellowish white coat. The patient is dull and sluggish, and has an inclination to sleep. The bowels are swol- len, but not tender, the extremities cold, the skin inelastic, and the discoloration not bright, as in the preceding case, the pulse soft and oppressed. In the first form there was febrile action, in this the opposite state. Diagnosis.—The diagnosis of jaundice is easily made. The yelloAv discoloration is so unlike anything else met with, if we except Addison's disease, Avhich never occurs in childhood, that no mistake can be made. Icterus neonatorum occurs during the first few weeks of life, and may be determined by this. The pathological conditions, giving rise to jaundice proper, will be determined by the symptoms named above. Prognosis.—The prognosis of the jaundice of children is very favorable. While it is sometimes very persistent, especially the first form, there is but very little, if any danger, except from in- judicious medication. The second form yields readily to appro- priate treatment. Treatment.—For icterus neonatorum I should prescribe tinc- ture of Aconite in the usual doses, aiding it with the general bath, the general hot bath, or the hot foot-bath. When the fever de- clines I should direct that an infusion of Asclepias be given in addition. It Avill be recollected that saffron has been the reme- dy of old Avomen and nurses for centuries, and there is no doubt but that benefit has been obtained from it. Its action Avas dia- phoretic. The treatment I have named restores all the secre- tions, but acts especially upon the skin. In the first variety of jaundice proper, with fever, partial ar- rest of the secretions, and with an irritation and determination to the liver, I would advise the following course: Pot the pa- tient upon the use of tincture of Veratrum or Aconite, the usual jaundice. 353 doses, adding Gelseminum, if there is irritation of the urinary ap- paratus, and uneasiness in passing urine. Associated with this, the tincture of Chionanthus may be given in doses of from one to five drops every three hours, according to the age "of the pa- tient. The Chionanthus is as nearly a specific for jaundice as a remedy can be for a named disease. The patient should have the general bath and hot-foot bath, to aid the action of the seda- tives, and the wet pack to the right hypochondrium, or, better, an entire abdominal pack to relieve the irritation of the liver. This plan should be followed up, Avithout addition, until the pulse has lost its frequency and hardness, and the skin is be- coming soft and active, and urinary secretion more free. If need be we now add to this a solution of acetate of potash in doses proportioned to the age of the patient. We Avatch its action at first, that it does not irritate the kidneys, and as it acts kindly increase its quantity. We observe as the febrile action passes off, and the urinary secretion is re-established, that the discoloration commences to fade. The reason is obvious, as the urine is highly charged with coloring matter, so much so as to stain the linen. Indeed, in all cases of jaundice, the coloring material is principally removed by the kidneys, and not, as generally thought, by the liver. In the second form there is an atonic condition, Avith conges- tion of the 1 iver, and a failure on its part to remove the biliary material from the blood; or, having secreted it, it is prevented from passing to its usual destination by the engorgement of the viscus, and is re-absorbed into the circulation, and from thence deposited in the tissues. In this case Ave may giA'e mild cathar- tics, especially such remedies as act as special stimulants to the liver. Small doses of podophyllin and leptandrin, thoroughly triturated with sugar, or bitartrate of potash, may be given with advantage, until they have produced the desired effect. In place of this, small doses of Xux may be given, and the region of the liver thorougly rubbed with quinine and lard, or if there is marked fullness, or the patient has suffered with malarial disease the in- unction will be with ointment of Uvedalia. This is followed by the bitter tonics, hydrastine, quinine, or remedies of like character, and some pleasant preparation of iron. Stimulant baths with friction, are employed to obtain an equal circulation, and stimulant frictions to the region of the liveir, to excite it to action. 23 354 diseases of children. Having obtained these influences and restored the functions of the liver and intestinal canal, Ave have still to promote the re- moval of the coloring matter from the skin. This is accoin- plished, as in the preceding case, by the use of a saline diuretic, acetate of potash or citrate of potash being preferable. PERITONITIS. Peritonitis is of rare occurrence as an idiopathic disease, both in the adult and child. As a secondary disease it may arise du- ring the progress of fevers, or from diseases of the intestinal ca- nal, and is met with more frequently. Usually but a comparatively small portion of the peritoneum is involved in the disease ; in some, hoAvever, a large portion is involved, and the disease is consequently very severe. Causes.—The cause of idiopathic peritonitis is most com- monly cold and arrest of secretion. In febrile diseases it is difficult to determine Avhy a particular part is selected as the seat of the local disease, and Ave must be satisfied with the sim- ple knowledge of the fact. In diseases of the intestinal canal, or abdominal viscera, the peritonitis is an extension of the in- flammation of the part first diseased. We have still the excep- tional cases Avhere, from perforation of the intestinal canal or stomach by ulcers, there is an escape of their contents into the peritoneal cavity, and inflammation as the result. Pathology.—In inflammation of serous membranes the ex- udation is upon the free surface, and the change of structure noticed, is from organization and change in this. The inflamma- tion is usually active in its character, and the exudation plastic. We have as yet no reasonable theory Avhy this extremely thin and delicate membrane, into which nerves can scarcely be traced, and Avhich ordinarily has no sensation, becomes so exquisitely sensitive and painful. Post-mortem examination shows the peritoneum thickened and opaque, having lost its smooth and even appearance. The lymph thrown out is in every state of organization, from a thin film upon the surface to strong bands, which tie parts together, or agglutinate adjacent parts. In some cases there is an abundant serous fluid in the peritoneal cavity, at others more or less pus. PERITONITIS. 355 Symptoms.—In idiopathic peritonitis the inflammation is ush- ered in with a chill, followed by high febrile action. The sur- face is hot and dry, the pulse frequent, small and hard, with much irritation of the nervous system. The countenance has an anx- ious and restless expression, and is frequently contracted as if from severe pain. The thighs are flexed upon the abdomen, and the body flexed to take off the extension of the abdominal muscles. In all cases the abdomen is tense and hot, and more or less tympanitic. There is marked tenderness on pressure, even the weight of the covering producing pain in the severe cases, and slight movements elicit cries from suffering. As the disease approaches a fatal termination, the pulse be- comes very frequent, small, and thready ; the countenance is con- tracted and anxious, and the abdomen much distended, though there is less sensibility to pressure. Diagnosis.—The diagnosis of peritonitis is made from the symptoms of acute inflammation within the abdominal cavity, Avith tenderness on pressure, and tympanitis ; at the same time the fever being active, and the pulse frequent, and unnaturally small and hard. Prognosis.—The prognosis is not unfavorable, except in those cases in Avhich it is associated Avith some other severe lesion. Treatment.—The patient is put upon the use of Aconite or Veratrum, as the pulse is large or small, with Rhus, Bryonia, Asclepias, Viburnum, Colocynth, etc., according to special indi- cations. If the boAvels are loose, Ipecac or Euphorbia are com- bined with the Aconite. If there is the expressionless mouth Avith nausea and pain simulating colic, Xux may be alternated Avith Aconite. The hot foot-bath may be used at first, but in severe cases it is better to use hot bricks, Avrapped in cloths wrung out of vinegar and Avater. When Ave can depend upon good nursing Ave order hot hop fomentations to the boAvels, but if avc can not depend upon their being continuously and carefully applied, it Avill be better to order a mush poultice. If the pain is very severe, and is not controlled by the means named, enemas containing opium may be employed. Five to tAventv drops of tincture of opium may be used with tAvo table- 356 DISEASES OF CHILDREN. spoonfuls of starch Avater or mucilage, and will give great relief. I think it much better than to give opium by mouth, and Ave can not Avell resort to the hypodermic use of morphia, Avhich I prefer in this disease of the adult. HERNIA. Hernia, or rupture, in the child is of frequent occurrence, and may be through any of the natural openings in the abdominal Avail, or may be direct from the feebleness of the structures. Hernia is of more frequent occurrence in the male, the intestine passing doAvn through the inguinal canal. It is of rare occur- rence in the female through the femoral ring. Inguinal Hernia.— Inguinal hernia is of most frequent occurrence. In the majority of cases the boAvel passing through the internal abdominal ring, traverses the inguinal canal, passing through the external abdominal ring, and finally makes its Avay into the scrotum. Attention is draAvn to the child by its cries and evidence of severe suffering, and to the abdomen by its contortions, and by the loAver extremities being forcibly flexed upon it. A careful examination detects the enlargement in the inguinal region, and the hand placed upon it detects the succussion as the child cries. Direct inguinal hernials that form in which the boAvel is forced through the abdominal wall immediately aboArethe external ring, through Avhich it may pass, and descend into the scrotum, as in the preceding case. The distinction betAveen the tAvo is made by tracjng the course of the protrusion. In the first there is the oblique distension in the course of the inguinal canal, Avhile in the second the enlarge- ment ceases immediately above PouparPs ligament. Femoral Hernia.—In femoral hernia, the intestine forces its Avay under Poupart's ligament through the femoral ring, and passing up through the saphenous opening, the tumor is formed in the groin. If the hernia continues to increase, the boA\*el jiasses upAvard over Poupart's ligament, assuming very nearly the position of an inguinal hernia. The symptoms are the same as in the preceding ease, and it Avill be diagnosed by a careful examination. hernia. 357 Umbilical Hernia.—Umbilical hernia is of more frequent occurrence in the child than in the adult. This is OAving to im- perfect closure of the umbilicus, after the detachment of the cord, the intestine being forced through this natural opening. It varies in extent, being sometimes but slight, not larger than a good-sized cherry, but in other cases it may attain the size of an egg. The diagnosis is easily effected. The child suffers pain and cries severely; draws its feet upAvards, and contorts its body as if from volic. An examination of the abdomen detects the seat and character of the injury. Treatment.—A hernia being diagnosed, the first object of treatment is to return it. This is done by the taxis—pressure being made on the boAvel in the direction that it has passed down. This pressure should be gentle, yet continued, the Avhole protru- sion being Avell supported with the hand, Avhileone or tAvo fingers are engaged in dislodging and carrying upwards small portions of the gut. As a general rule, but little difficulty will be ex- perienced in replacement, if the pressure is Avell directed. If the taxis fails from the straining or resistance of the child, it should be brought under the influence of chloroform, Avhen pressure will readily reduce it. After reduction is effected, Ave will have to select an appropri- ate apparatus to prevent the reproducement of the hernia. For infants and young children, I prefer a well fitted bandage, with a soft pad large enough, and thick enough to give efficient sup- port. I think in the majority of cases a radical cure Avill folloAV its use. In children over tAvo years of age, the ordinary spring truss may be used. The hard pad is decidedly the best, and should be adapted to the injury, so as to excite the part and promote adhesion. 358 DISEASES OF CHILDREN. -, CHAPTER VIII. DISEASES OF THE URINARY APPARATUS. The urinary organs of the child do not suffer so frequently from disease as do those in the adult; yet when such diseases do occur, they are quite severe and treated Avith difficulty. The urinary secretion removes materials from the blood which are highly noxious Avhen retained, and diseases impairing this func- tion are ahvays folloAved by marked constitutional disturbance. ACUTE NEPHRITIS. Acute inflammation of the kidneys may be produced by cold, or may arise from other causes of inflammation, but in the ma- jority of cases it arises during the progress of eruptive fevers, especially scarlatina ; and is doubtless dependent on some action of the fever poison, with which Ave are unacquainted. It is pos- sible that the arrest of secretion from the skin in these cases throAvs an additional amount of work upon the kidneys, from the irritation of Avhich the inflammation arises. Symptoms.—Inflammation of the kidneys is announced by increased excitement of the nervous system, and an increase in all the febrile symptoms, if it occurs during the progress of an- other disease. The child passes urine frequently, but in very small quantity, and seems to suffer much at these times. In some cases the urine Avill be tinged with blood, sufficient to discolor the diaper. The pain and uneasiness are attended Avith contortions of the body, flexure of the limbs, and straining, so that it may be easily mistaken for colic. These symptoms, as well as the duration of the period of excite- ment, Avill vary as one or both kidneys are involved in the in- flammation. In the first ease they Avill not be so severe, and may last tAvo or three days, or even more ; but in the second they Avill not last longer than tAventy-four hours. Occasionally con- vulsions ensue early in the disease. ACUTE NEPHRITIS. 359 The second stage of an inflammation of the kidneys is that in which, from retention of urea, the nervous system is depressed, and coma results. A very short time is necessary for this change of symptoms (two to four hours); the nervous irritation passing off, the patient becoming dull, drowsy and comatose; this gradu- ally deepening until the patient dies. In the first stage the pulse is frequent and hard, the skin dry and harsh, the mouth and tongue dry, and the temperature quite high. In the second stage the pulse becomes small, its frequency still more increased, but it loses its hardness, the temperature of the surface is diminished, and the extremities become cold, yet the thermometer shows a higher temperature than before. In the severe cases the duration of the disease Avill not be more than from tAvo to four days, unless the patient is relieved. In mild cases it may continue a Aveek or more. Diagnosis.—The increased nervous excitement will attract our attention, and cause us to make a very close examination. The pain that the child suffers is undoubtedly in the abdomen, and Avould be mistaken for colic, Avere it not that it comes on in passing urine, and is very closely associated with this. The scanty urine, tinged with blood, passed a few drops at a time, and with straining and pain as named, is the most striking diag- nostic feature. Prognosis.—The prognosis is not favorable when both kid- neys are involved, unless the lesion is noticed early and prompt treatment is adopted. When but one is involved we expect a favorable termination. The prognosis is of course more favora- ble in the stage of excitement, than in that of depression and coma. Treatment.— In the first stage of the disease the child is put upon the use of Veratrum and Gelseminum in full doses, the ob- ject being to arrest the fever and inflammation at once. I think there are no remedies that will take the place of these, at least there are none that I would like to trust. T Avould give them in the following proportion : Rj Tincture of Veratrum gtt. v., Tincture of Gelseminum gtt. x. , Avater, Siv. The nurse is directed to give a teaspoonful every hour, until she observes an abatement of the fever, then reduce the dose one-half and continue. 360 diseases of children. In place of Gelseminum Ave sometimes employ Macrotys, as there is muscular pain or soreness, or Cannabis Indica, there being irritation of the urinary passages, even to the meatus urinarius. Bryonia is sometimes a good remedy if there is marked contrac- tion of the abdominal muscles; Belladonna if there is fullness of the abdomen with stupor and disposition to sleep, or if there has been retrocession of an eruption. Eryngium is a good remedy Avheu there is a constant desire to pass urine; Apocynuin Avhen the eye- lids are swollen and the feet oedematous, or the slightest evi- dence of dropsy. Cathartics are absolutely contra-indicated, as are diuretics, and diaphoretics are of no value until Ave have first obtained the in- fluence of the remedies named. As a local application I like the influence of the hot hop fomentation better than anything else. I order the application across the loins, the child lying upon the abdomen, but Avhen tired in this position it is placed upon its back, and the fomenta- tion applied over the loAver part of the abdomen. The child should always be kept in bed, betAveen blankets, and the action of the skin may be solicited by the use of hot bricks near the feet, Avrapped in Avet cloths. This treatment is persisted in until the febrile action is par- tially checked, and secretion of urine is increased, the patient meaiiAvhile being allowed as much fluid as desired, unless it causes nausea. As soon -as Ave have the patient fairly under the influence of the sedatives, Ave commence the administration of the milder vegetable diuretics, as haircap moss or mentha viridis, and continue them until the secretion is wholly restored. In the second stage of the disease the patient is suffering from uraemicpoisoning, and the treatment Avill be Avholly different. We give at once a brisk cathartic, as of jalap and bitartrate of potash, and if the case is one of emergency, Ave may aid its action by a cathartic enema. Dry cups are applied to the neck and over the loins, and a hot stimulant application over the kidneys folloAvs their use. Stim- ulants and heat are also applied to the extremities. The internal remedy that I rely upon with most confidence is Belladonna, Avhich maybe given in the following proportions: 1^/Tincture of Belladonna gtt. v., Tincture of Aconite gtt. v., water 5iv.; a teaspoonful every hour. If the reader can not make up his mind to the use of such small doses in such a grave CHRONIC NEPHRITIS. 361 affection, I Avould advise in its place a prompt and very thorough emetic, folloAved by the cathartic as first named. In the use of diuretics Ave Avill have to be very careful as the patient convalesces, for the kidneys are in a very irritable condi- tion, and a slight irritant is sufficient to arrest the Aoav of urine. I It is fortunate that the tincture of muriate of iron, in quite small doses, is a good tonic to the kidneys, as it is the restorative Ave most frequently employ. CHRONIC NEPHRITIS. Chronic nephritis is never met with during the first year, is very rare during the second, but is occasionally met with from this up to the sixth year. After this time it is hardly ever seen until the person has reached middle life. It is a very insidious disease, coming on slowly, and presents so feAV prominent symp- toms that in many cases it is not detected. Causes,—The causes of chronic nephritis are very obscure. It may arise from cold, from irritant diuretics, but probably is most frequently the result of some morbid condition of the blood, or change in the process of retrograde metamorphosis. We knoAV the irritant effect that the presence of the urates, triple phosphates and oxalates have on the bladder, and Ave can well imagine that their excretion by the kidneys may set up a sIoav process of in- flammation in these organs. Pathology.—The inflammation may be confined to one, or may affect both organs, or it may invoh'e but the cortical struc- ture of the kidney, the tubular remaining comparatively free. Post-mortem examination sIioavs the kidneys enlarged, with evidences of enfeebled circulation. The structure is softened and friable, and the capsule readily detached. In some cases there is a free deposit of a Avhite amorphous material. In others the inflammation has progressed to suppuration, and more or less of the structure has been destroyed by it. Symptoms.—The child has lost flesh and strength, in a marked degree ; its appetite is impaired, digestion feeble, the boAvels irreg- ular and the skin dry and harsh. Irritability and restlessness is a marked feature, and is sometimes developed to that extent that the child becomes a burden to itself and all around it. 362 diseases of children. If old enough to locate its sufferings it will complain of pain in the back and across the loAver part of the abdomen. Occasion- ally it experiences uneasiness before urinating, and sometimes after its discharge. Frequently, hoAvever, no complaint of this kind is made, and though the child undoubtedly suffers uneasi- ness and pain, it is of such a fugitive character that he can not locate it. These symptoms are constant, and gradually increase, but in addition there are exacerbations in the disease, coming on at in- tervals of two or three weeks. At these times the patient suffers from fever, the skin is dry and hot, the urine very scanty, the boAvels constipated, Avhile the face has a pinched and anxious ex- pression. It is evident at these times that the child suffers from pain in the back; and frequently the lameness is quite marked. Thus the disease progresses, until finally the periodic exacer- bation of the inflammation is much Avorse. The fever is active, Avith great excitation of the nervous system, .occasionally with convulsions. The urinary secretion being arrested, the symp- toms of uraemia are rapidly developed, and within twenty-four hours the patient is comatose, and by another day it terminates fatally. Diagnosis.—The diagnosis is principally made by exclusion. The examination is made with reference to disease of special parts, as of the brain, lungs, digestive apparatus, etc. One after another being excluded, we finally trace the diseased action to the kidneys, and the symptoms given above Avill be found suffi- cient to designate the character of the disease. Prognosis.—The prognosis is favorable in the early stage of the disease; but Avhen it has continued for some months, having lost flesh to a great degree, with frequent pulse, harsh dry skin, scanty high-colored urine, great irritability of the nervous system, with a pinched and anxious expression of countenance, the prog- nosis is doubtful. Treatment.—The treatment of this case is one of much diffi- culty, and Avill have to be varied from that Ave Avould use in the adult. As a general rule, I should give but few medicines, in- deed experience Avill teach that the stomach Avill not tolerate much, and that all irritants are injurious. albuminuria. 363 Small doses of Aconite with Gelseminum, Rhus, Bryonia, Apocynum, Eryngium, Cannabis Indica, or Agrimonia, as indi- cated, will serve the purpose Avell. Apocynum should be espe- cially noted as the remedy if there is the slightest evidence of oedema. Agrimonia is indicated by the pain which sometimes extends up into the hypochondria. If the child is nervous and - cries at every little thing Avith sobbing, small doses of Pulsatilla may be alternated Avith the other remedies. The child may have a hot salt-water bath every day, being rubbed Avith dry flannels afterward and clothed warm. Or. in place of this, Ave may use fatty inunction, rubbing the surface thoroughly. Inunction Avith quinine ansAvers an excellent pur- pose in some cases, especially those in Avhich there is a malarial influence. The best Icoal application for the child is the vinegar pack, applied upon going to bed. A flannel cloth, six inches Avide, is ■ Avrung out of tepid vinegar, and applied around the body at the loins, and this is again covered by a dry strip; it is removed on getting up, and the part thoroughly rubbed with flannel. As the severer symptoms pass away, the patient may have some of the tonic and astringent diuretics, if thought best, or it may be continued upon the remedies already named, at less fre- quent intervals. The compound syrup of the hypophosphites, some of the preparations of malt, occasionally iron, Collinsonia, Hydrangea, or Eryngium, or the quinine inunction, may be con- tinued to complete recovery. ALBUMINURIA. While albuminuria in the child is most frequently the sequel of the eruptive fevers, it, is occasionally seen from other causes. It is not dependent, hoAvever, on granular degeneration, or Bright's disease, in either of these cases, and is, therefore, a much less grave affection. Pathology.—It has been supposed that the albuminuria fol- loAving the eruptive fevers Avas dependent upon irritation, or a low grade of inflammation of the kidneys. While this may be the cause, to a certain extent, avc luwe reason to believe that the changes effected in the blood by the febrile poison is an im- portant element of the disease. 364 diseases of children. Post-mortem examination sIioavs the kidneys swollen, the glomeruli congested, and the tubuli uriniferi more or less loaded with albuminoid matter. Casts from the tubules may be de- tected in the urine during the progress of the disease. Symptoms.—Occurring almost ahvays after the eruptive fevers, on exposure to cold, by Avhich the surface is suddenly chilled, it commences generally with a Avell-defined chill; symptomatic fever folloAvs, the pulse being hard and frequent, the skin hot, dry, and constricted, the tongue coated Avhite, the mouth dry, frequently nausea and vomiting, boAvels constipated, pain in the back, and marked restlessness and nervous irritation. With these symptoms the patient complains of a sense of Aveight and constriction in the region of the kidneys, never, as is said, ex- tending to* or causing retraction of the testicles. The pain may be confined to one side, but one kidney being affected, or it may be equally in both sides. , With the occurrence of these symptoms the urine becomes scant, almost suppressed, and highly albuminous, of a reddish color, and occasionally bloody. Its specific gravity is almost ahvays above that of healthy urine, and it gives an acid reaction. When alloAved to rest, it deposits a filamentous substance, and when examined with the microscope it will present blood-glo- bules, mucus, epithelium, and in some cases complete casts of the urinary tubules. A dirty-Avhite sediment is frequently depos- ited from the urine, not unlike mucus, and easily diffused by agitation. The urine is frequently passed with difficulty, and sometimes Avith pain, the calls to urinate being frequent and dis- tressing. In the course of the second or third day dropsical symptoms make their appearance, most frequently as anasarca of the eye- lids, face, and at last of the Avhole body. The skin at this time is hot, and does not pit except upon firm pressure. If properly treated, in a majority of cases, Ave find that the symptoms are much mitigated in the first three or four days, and the disease terminates in recovery by the tAvelfth to the fifteenth day. In other cases coma comes on by the second, third, or fourth day, and the disease terminates fatally within the first week. Occa- sionally convulsions appear, and continue until the patient is exhausted. In other cases the disease seems to give Avay sIoavIv, until it reaches the chronic stage, in Avhich it continues. DIABETES. 365 Treatment.—If the temperature is above the normal stan- dard and the pulse is too frequent, we give Aconite with Apocy- num, (gtt. iij., gtt. v. to gtt. x., Avater §iv.) In some case-, fol- loAving the eruptive fevers, there has been something omitted from the treatment of the cases, and Ave endeavor to find it. It is possibly Belladonna, Rhus, Apis, Phytolacca, or Macrotys, but whatever it is, it should iioav be given if the indications still persist. In some cases the hydragogue cathartic, like jalap with bitar- trate of potash, is employed, to increase secretion by Avay of the boAvels, and reuuwe dropsical accumulations, but I prefer the more direct remedies, Apocynum and Aralia Hispida. If the dropsy is not reached by these remedies, Ave will some- times find the small dose of sulphate of manganese a good rem- edy. It may be given in the following proportion: I|* Sulphate of manganese gr. \\, Avhite sugar oj.; make twenty powders, and give one every three hours until it acts upon the bowels. The hot foot bath may be used, and dry cups, followed by hot fomentations, applied to the loins. If the case seems to be ur- gent, Ave may use the general hot-bath Avith advantage, continued for one or tAvo hours, the surface being rubbed dry, and the child clothed or Avrapped in flannel. In some cases quinine inunction ansAvers an excellent purpose, but sometimes the fatty matter seems to close the skin, and Ave arc obliged to have the child thoroughly Avashed with soap and Avater to remove it. In other cases the inactivity of the skin is relieved by a sponge bath of Ilydrochlorate of ammonia and water. DIABETES. I have never seen but one case of diabetes in children giving the evidence of sugar on analysis, and this Avas in quite small quantity, and for.a short time ; neither do I recollect seeing any such cases recorded. Diabetes insipidus, on the contrary, is met with quite as frequently in childhood as in the adult, and is some times very persistent. Causes.—The causes giving rise to this increased flow of urine arc very obscure. In some cases the exciting cause seems to be cold, but more frequently it will be found to be dependent upon, or at least associated Avith some disease of the nervous centers. 366 DISEASKS OF CHILDREN. Pathology.—I think, in all of these cases, there is an impair- ment of circulation, with tendency to congestion. The nervous system suffers first, and the enfeebled innervation seems to be one cause of the lesion of the kidneys. The condition of the kid- neys seems to be one of atony rather than excitation—one which permits the Avater of the blood to filter off, rather than increased activity of secretion. Indeed, in some cases, the patient suffers first the nervous irritation from retained urea, and aftenvard from ursemic coma. Occasionally there is the same profluvia from the boAvels, but in less degree. Symptoms.—It will have been noticed that the child has lost flesh rapidly for tAvo or three weeks, or may be, for as many months, and that it is becoming quite feeble; yet it has a pretty good appetite, and digestion is well performed, and the child does not complain of any particular suffering. If associated with diarrhoea, the loss of flesh and strength will be attributed to this. When Ave examine the patient, Ave find the pulse feeble, small, and soft, and somewhat increased in frequency; the surface is pale, cool, and wanting in tone, and the child suffers from cold feet and feeble circulation. The tongue and mucous membranes are pallid, but the tongue is not coated. Usually there are tAvo, three, or four fluid movements from the boAvels daily, but they are not large or unhealthy. Upon close inquiry, Ave will learn that the child passes Avater frequently at night, and the bedding is very Avet, and when the mother's attention is called to it, she Avill notice the frequent passage of large quantities of clear urine. If we examine a portion of the urine Ave Avill find it limpid, very light-colored, and of low specific gravity, frequently not more than 1008. I . have seen cases, in Avhich the child Avould urinate on an average every fifteen minutes during the day, and every half hour at night. In the severer cases the marasmus is as great as in the diabetes mellitus of the adult. In such cases the irritation of the nervous system is extreme, and the child suffers intensely from nervous excitement. In some eases it seems almost impossible for it to obtain sleep. Continuing on in this Avay for a short time, this is replaced by coma, and a feAV hours will terminate its life. Diagnosis.—The diagnosis of diabetes of the child will be easily made, if our attention is directed to the kidneys as the seat DIABETES. 367 of disease. This is the advantage of forming a habit to correct the diagnosis of every ease by exclusion; as each organ is thus passed under revieAV, it is almost impossible to fall into serious error. The frequent and abundant discharge of urine may have escaped notice until attention is draAvn to it, or the mother may have considered it an unimportant circumstance. Prognosis.—The prognosis is favorable in the majority of cases, as the disease yields readily to remedies. When it has continued for a considerable time, the child being Avasted almost to a skeleton, the nervous system being very irritable, the prog- nosis is unfavorable. Trkatmknt.—In the milder cases, the treatment is very sim- ple and direct. The child is put upon the use of—R^ Tincture of Belladonna gtt. v., Avater 5iv.; a teaspoonful every two hours. To restore the action of the skin, and at the same time, get its action as a tonic, I employ the quinine inunction once daily. When there is atony of the digestive apparatus, and torpor of the liver, minute doses of podophyllin may be given. The following combination will answer well: I$i Podophyllin gr.j., Hydrastine gr. v., white sugar gr. xx.; tritutate thoroughly and divide in twenty parts; one may be given in the morning and one at night. In some cases Ave may alternate the Belladonna with Hama- melis (Pond's extract), in doses of ten drops, giving each every four hours; and Avhen diarrhoea accompanies it, this may be con- trolled with Ipecac. As the disease is brought under the control of remedies, Ave may alternate them with the Collinsonia, tincture of phosphorus, Rhus Aromatica, and the tincture of muriate of iron, as a restor- ative. But if the patient gets along well, Ave will, in the major- ity of cases, find no cause for change. ISCHURIA. Ischuria, or arrested discharge of urine, is divided into tAvo varieties—ischuria renalis, suppression of urine, and ischuria vesicalis, retention of urine. Both of these should be regarded as but symptoms, as they may arise from various and Avidely differ- ent causes. 368 DISEASES OF CHILDREN. Suppression of Urine.—Suppression of urine may be the re- sult of an active inflammation of the kidneys, as Ave have already seen. But the cases that Avill come under our notice most fre- quently, depend upon exhaustion or enfeebled innervation of tlje kidney, or from congestion. It occurs most frequently during the progress of acute disease, especially in such as are attended Avith serious blood-poisoning. Symptoms.—The symptoms of suppression of urine vary in different cases. Where the suppression is partial, as is generally the case, Ave find the first evidence in great excitation of the nervous system, and an increase of the febrile symptoms. Not unfrequenfly, Ave Avill find the desire to pass urine increased, and the frequency of the effort, but small quantities passing, will first attract the attention. As it continues, the symptoms of the uraemic coma begin to be developed, the child is dull, has a tendency to sleep Avith its eyes partly open, and starts frequently from its sleep as if alarmed. Occasionally convulsions precede the coma, Avhich seem to be dependent upon it? Nausea and vomiting occasionally occur in the early part of the disease, and the irritability of the stomach is one of its most troublesome features. From the commencement of coma, Ave find it becoming deeper as time passes, until at last it is impossible to arouse the patient. The pulse is feeble and irregular, the ex- tremities cold, the features contracted and pinched, with occa- sionally more or less convulsive movement, until death ensues. Retention of Urine.—Retention of urine is most frequently due to paralysis of the bladder, though it may be produced by irritation of and contraction of the neck of the bladder or urethra, or in some rare eases, it is dependent upon the presence of a calculus. Retention from exhaustion of the muscular coat is of common occurrence in Ioav forms of disease, and is sometimes a source of much trouble. Retention from irritation of the urethra is attended Avith much pain, and a frequent desire to pass Avater. Symptoms.—In retention of urine occurring during the pro- gress of Ioav forms of fever and imflammation, it Avill be noticed that the prostration is much greater, and the symptoms more ischuria. 369 grave, than Avould have been anticipated in the ordinary pro- gress of the disease. Frequently the attention is drawn to the difficulty by the marked uneasiness of the child, and the move- ment of the hands to the region of the bladder. In retention from contraction of the neck of the bladder or urethra, there is the evident desire to pass urine, attended with straining and pain, out the Avant of power to overcome the ob- struction. Diagnosis.—Having learned that the urine has not been passed, we have to determine Avhether it is a suppression or re- tention. This may be determined in many cases, by the symp- toms above described, or by an examination of the bladder with the hand. If this is not satisfactory, a catheter may be intro- duced into the bladder. This, hoAvever, is attended with diffi- culty, and may generally be dispensed with. Treatment.—In the treatment of suppression of urine in the child, I rely more upon the use of hot fomentations across the loins, than on any other means. They should be assiduously employed, and continued until the desired result is produced. If the patient has feA'er, Tinct. Veratrum gtt. iij., Tinct. Gel- seminum gtt. x., Avater 5'\\\, a teaspoonful every hour, Avill be good treatment.* If the face is pinched and the patient is rest- less, starting in sleep, Rhus may be given with Aconite. If the patient is dull and Avants to sleep most of the time, Belladonna will be suggested. Apocynum ansAvers an excellent purpose, if there is a puffy condition of the eye-lids, or swollen feet. To relieve the system from the symptoms of uraemic poisoning, a cathartic may sometimes be given, if there are no circumstances > to contra-indicate it; jalap and bitartrate of potash will answer this purpose very well. As soon as urine commences to pass in small quantities, diure- tics may be administered, the remedy being selected to meet the condition of the patient, being demulcent, stimulant, or louic, as the case may require. In some cases, dry cups may precede the use of the hot fomentations, and Avill be found of much service. In the treatment of retention of urine in children, I prefer the use of santonine to any other remedy I have employed. I have. used it in doses of from one-fourth to one grain, triturated with su'vir, repeated every tAvo hours. This mav be assisted bv hot 24 370 diseases of children. fomentations applied over the bladder and genitals, or in some cases by a hot sitz bath. The use of diuretics is contra-indicated in this case, as they rather diminish than increase the power of the bladder to evacu- ate urine, while they certainly increase the distension. When the retention is dependent upon stricture of the urethra, or contraction from irritation, Ave will obtain the best results from an enema of equal parts of Lobelia and Gelseminum 5ss to Avater 5j. ENURESIS. Incontinence of urine is most commonly a disease of child- hood, though Ave occasionally meet with it in the adult, but usually as the result of injury, or from disease. In the child it varies from the slight form of nocturnal incontinence, to the severer cases in which the patient is Avholly unable to retain the urine, and it Aoavs aAvay all the time. Causes.:—The causes of incontinence are somewhat obscure. In some of the milder cases it seems to be a habit more than a disease. The severer cases folloAV the eruptive fevers, diseases of the nervous system, and occasionally diseases of the urinary ap- paratus. Pathology.—In some cases the incontinence is dependent upon an irritable condition of the mucous membrane of the bladder, slight distension of the viscus giving rise to involuntary muscular contractions and expulsion of urine. In other cases the muscular fiber is in an irritable condition, and contracts from slight excitement. In other cases, and by far the most numerous ones, the lesion is of the nervous system. In one it is of the spinal system, an atonic or feeble condition, and as the result of this, there is imperfect contraction of the circular fibers at the neck of the bladder, and the first portion of the urethra, Avhich serves the purpose of a sphincter. In the other it depends upon irritation of the lumbar spine, with involuntary contraction of the bladder from the disordered innervation. Symptoms.—The simplest form of the disease is that in Avhich the child wets the bed. Frequently, in these cases, the child drinks freely in the evening, and the bladder being distended at enuresis. 371 night, the urine is passed unconsciously, or under the influence of a dream. This may continue to the age of puberty, or even longer, becoming a source of very great annoyance and mortifi- cation. In other cases there is not onlyr the nocturnal incontinence, but there is a frequent desire to eA'acuate the bladder through the dayT, and if not promptly attended to, involuntary passage of urine occurs. , Then there is the severe form of the disease, in Avhich the person has no command over the passage of urine, but it dribbles aAvay continually, keeping the clothes soiled, and making it quite impossible to keep the child free from a disgusting urinous odor, irritating the surface about the parts, and requiring much care to prevent its suffering from cutaneous irritation. Treatment.—In the simpler forms of nocturnal incontinence, it is frequently sufficient to prevent the child's drinking in the evening, see that it passes urine before going to bed, and have it Avaked once in the night for the same purpose. What Ave Avant is to break up the habit of involuntary passage, and this may be done in the majority of cases in this Avay. In this, and other forms of the disease, Avhen there is no special lesion, I rely upon the Belladonna as a specific. I usually pre- scribe it in the following proportions. Rj Tincture of Bella- donna gtt. x., Avater i*>iv.; a teaspoonful three times a day. In se- vere cases, those dependent upon atony of the spinal cord, or consequent Avant of contraction of the sphincter fibres, the Bella- donna is our best remedy, and will give relief Avhen the person has been supposed incurable. Ergot has a A*ery similar influ- ence, and may sometimes be alternated with it. I Avould use it in the proportion of—R/ Tincture of Ergot gtt. xx., Avater §iv.; a teaspoonful four times a dav. The Rhus Aromatica has been highly recomended in these cases, and may be tried, though thus far I have not seen the marked results that have been described. In feeble children the syrup of iodide of iron has been given with advantage in doses of five or ten drops three times a day. Irritability of the bladdder should be treated by the use of Agrimonia, Hydrangea, or Collinsonia,combined with atonicand restorative treatment, as it is usually associated Avith impaired health. A Belladonna plaster applied over the bladder will give 372 DISEASES OF CHILDREN. present relief, but its continued use Avill sometimes produce un- pleasant symptoms. Frictions over the bladder with the lini- ment of Stillingia will answer a better purpose. In those rare cases in Avhich the incontinence is epileptic in its character, I Avould advise the bromide of ammonium alternated with Belladonna. URINARY CALCULI. Stone in the bladder is met with even during the first year of life, and from this up to adult age. It is not of as frequent occurrence in the child as in the adult, yet it is met with more frequently than many suppose. There is no doubt but that many children suffer for months, and finally lose their lives, without the detection of the lesion. Previous to the last quarter of a century we find but feAV cases of stone in the bladder of children recorded, and the cases of cutting for stone in children under six could be counted upon the fingers. In the last few years a large number of cases have been reported, with successful operations for their relief. One surgeon alone reports some thirty cases in ten years. We must, therefore, conclude that the disease Avas not recognized, as it is not probably of more frequent occurrence now than in the centuries past. KnoAving these facts, Ave will not allow ourselves to make the same error in diagnosis. If stone in the bladder in the child Avas incurable, this error in diagnosis Avould make less difference; but the experience of some of the most skillful surgeons sIioavs that the operation for its removal is much more successful than in the adult or aged. Pathology.—Urinary calculi may result from lesions of di- gestion, but mostly from lesions in the Avaste of tissue and retro- grade metamorphosis. All are composed of the normal elements of tissue, except in those rare cases in Avhich the material is furnished by maldigestion. The urinary organs do not seem at all at fault, indeed they perforin the additional function" of re- moving a material from the blood Avhich would prove injurious there. The calculous formations in childhood are principally of three kinds—uric acid and urates, oxedates, and phosphates. These may be deposited in the form of minute crystals, being Avashed URINARY CALCULI. 373 from the bladder by the floAV of urine, giving rise to no lesion but irritation of the bladder and urethra; or they may accumu- late and coalesce to form those masses of variable size, which Ave knoAV as calculi. The uric or lithic calculus is of a brownish mahogany color, oval or flattened in form, and finely tuberculated or smooth, though not polished. It is perfectly dissolved in caustic potash, and disappears with effervescence in hot nitric acid, the solution affording, when evaporated to dryness, a bright carmine residue. It becomes black and is gradually consumed before the bloAV-pipe, leaving a minute quantity of white alkaline ashes. Oxalic calculi are generally of a dark broAvn color, rough and tuberculated, hard, compact and imperfectly laminated. It is insoluble in the alkalies, dissolves sloAvly in nitric and hydro- chloric acids, if previously Avell broken up, and under the blow- pipe, expands and effloresces into a Avhite poAvder. Phosphalic calculi are of a lighter color, less clear and friable. Phosphate of lime more frequently forms layers with other mat- ter; Avhen it occurs alone, they are usually small, of a pale broAvn color, of a loosely laminated structure, not fusible with the blow- pipe,- but readily soluble in hydrochloric acid Avith effervescence. The amoniaco-magnesian calculus is of a Avhite color and friable, looking a good deal like a mass of chalk. It exhales an ammo- uiacal odor before the bloAV pipe, is not affected with caustic potash, but is easily dissolved in dilute acids. There is a form of phosphatic calculi that is fusible. It is white, extremely brittle, easily separated into layers, and leaves a Avhite dust on the fingers. It is not affected by caustic potash, is soluble in hydrochloric acid, and is melted into a transparent pearly glass under the bloAV-pipe. Symptoms.—The general symptoms attending the presence of urinary calculi in the child are pretty well marked. The appe- tite is irregular, digestion is impaired, and frequently there are well marked dyspeptic symptoms. The secretions are deranged, the skin being very susceptible to external impressions, at times dry and harsh, at others soft, relaxed and flabby, Avith cold ex- tremities. The boAvels are torpid and sluggish in most cases, but in some the irritation of the bladder extends to the boAvels, and there are frequent discharges. The patient is irritable and fret- ful, and extremely restless, and dissatisfied with everything done for it. 374 DISEASES OF CHILDREN. The local symptoms are sometimes very marked, in other cases the patient will have to be observed for some time before we have such evidence as Avill lead us to make the necessary exam- ination. There is some difficulty in passing Avater, but it is not constant, as at one time the urine may be evacuated Avithout any trouble ; at another time the urine will be stopped in its passage, with more or less pain and tenesmus. Occasionally at such times the urine will be stained with blood. As the case advances the difficulty in passing urine becomes more frequent, and is attended with greater suffering. The patient suffers from sense of Aveight and pain in the bladder, loins, and small of the back, sometimes so severely that the countenance presents that peculiar contracted anxious expression, which Ave observe in long-continued painful diseases. Progressing in this Avay the child becomes exhausted from the long continuance of suffering, and the functional derangements that follow it, and Avill succumb to this, or to some local disease of the pelvic viscera induced by the calculus. Diagnosis.—The uneasy sensations in the bladder, with diffi- culty in passing urine, point to the bladder as the seat of disease, while the long duration of it and its intractability Avould lead us to suspect the presense of a calculus. To determine this a sound is introduced into the bladder, and careful manipulation will detect its presence. Prognosis.—The prognosis may be regarded as favorable, Avhether Ave conclude to practice lithotrity or lithotomy—both these operations being successful in the young. Treatment.—Having determined upon an operation we prepare the patient for it as best Ave may, in the short time Ave have. I think it of advantage to keep the patient very still for a feAV days, giving small doses of Aconite and Gelseminum Avith some demulcent diuretic to relieve the irritation of the bladder. In some cases much relief will be obtained if the child lies upon its abdomen a portion of the time, as it removes the pressure from the base of the bladder. In the meaiiAvhile avc see that the stomach is placed in condi- tion to take and digest some food; and Ave may use the tincture IMPERFORATE URETHRA. 375 of muriate of iron and glycerine as a restoratiA'e. Quinine in- unctions will prove beneficial in some cases, giving strength to the nervous system. Lithotrity is preferred by many surgeons at the present time, as giving good results, notwithstanding the sinallness of the urethra. The calculi of children are generally more friable than in the adult, and arc much easier crushed, and the urethra may be dilated so as to admit a good sized instrument. Lithotomy is performed in the usual way, the lateral operation being preferred. Though it is not prudent to make the 1-arge incision permitted in the adult, but with a little care in its dila- tion with the finger, and in seizing the stone so as to present its smallest diameter, there will be no trouble in its extraction. The principal points in the after treatment are to keep the patient quiet, keep down the febrile action, and the stomach in condition to receive food. When the child has recovered from the operation, it should be put upon such a course of treatment as Avas named for dyscrasias. In addition to this tonic and alterative plan, it may be possi- ble to employ special means to antidote the tendency to calcu- lous formations. The information necessary for this will be found in my Avork on Practice, pp. 357 to 3G6 IMPERFORATE URETHRA. Rarely a case of imperforate urethra Avill be met with in the new-born child. The malformation Avill be brought to the phy- sician's notice by the child not passing urine, and suffering pain in consequence of it. An examination Avill determine the char- acter of the lesion. In other cases the urethra terminates by false openings in the upper or under surface of the penis—hypospadias and epispadias. These are rarely more than one inch from the meatus, frequently not more than half an inch. Treatment.—In imperforate urethra the difficulty may be remedied by passing a large exploring needle, or small trocar, through the meatus and carrying it upward until it reaches the free portion of the canal. A silver catheter being now intro- duced it is worn until the part heals. In hypospadias, and epispadias, though there is no danger to 376 DISEASES OF CHILDREN. life, I think that the malformation should be remedied in infancy, as it can be best done at this time and with the least danger. Open up the canal of the urethra in the manner above named and passing a catheter, retain it for the urine to pass through. Then freshen the edges of the artificial opening, and draAV them together with a silver suture. If, as in some cases, the canal really terminates with the false opening, I Avould operate by de- taching the skin at that part, if not too far up, bring it down to the glans and attach it Avith silver ligatures, retaining a catheter until the part had healed. P II Y M 0 S I S. The natural condition of the penis in the child is, with the elongated and contracted foreskin entirely covering the glans. It is only in exceptional cases that this is a source of trouble. In one of these cases an inflammation of the prepuce and glans is set up, and there is a free discharge of pus. Sometimes the inflammation runs high, and the prepuce is so swollen as to render the passage of urine very difficult and painful. This is really a case of infantile balanitis, and being difficult of cure, or recurring frequently, it may require removal of the prepuce. In the other case, the prepuce being quite long and much con- tracted, is irritated and inflamed by the urine, so as to be a source of very great anuoyance. I have seen two cases in which this Avas a source of serious disease, and there Avas but the one Avay for its removal, and that by removal of the prepuce. Treatment.—Circumcision is very readily performed in the child, and is not"attended Avith any danger. The method I would recommend is to take the foreskin betAveen the thumb and finger for half an inch, then drawing it down well to clear the glans penis, excise it with a bistoury, cutting toward the finger. But if afraid that you may wound the glans, draw down the pre- puce with the fingers, and have an assistant grasp it next the glans with a pair of dressing forceps, or the arms of a pair of scissors, then cut between the fingers and it. Retract the foreskin and apply a water dressing until the part heals. Some may make objection to circumcision, as was once the case in my practice. The mother declared she would not have her child made a Jew of, even though the penis had to be cut off. In this case, simple incision of the prepuce on a grooved director, urethritis 377 its entire length, retracting it over the glans, and retaining it with adhesive straps, Avas all that Avas required. PARAPIIYMOSIS. i Paraphymosis is the retraction of a tight prepuce above the glans penis It is occasionally met with in boys of from six to ten years, Avho have, out of curiosity, or prompted by those older, pushed the foreskin back and have not been able to return if. The glans becomes swollen and painful, and if the constric- tion continues long it may go on to inflammation and finally to sloughing. In many cases the application of cold Avater or ice for a short time Avill reduce the swelling and permit the foreskin to be draAvu doAvn. It is also claimed that if a couple of hairpins are used, pressing the bent end up under the prepuce on each side of the glans, the prepuce can be driuvn down over them. If this does not succeed, or if so long a time,has already elapsed that Ave do not think it prudent to try these means, we Avill incise the pre- puce and thus free it. This is easily accomplished by passing a grooved director under the foreskin on the dorsum of the penis, and cutting outward with a sharp-pointed bistoury. URETHRITIS. Urethritis in the child is of very unfrequent occurrence, yet occasionally a case will be met with. It is pretty difficult to determine the cause of the inflammation. Sometimes it is un- doubtedly venereal, and has been contracted from the clothing of some persons about the house affected Avith the disease, or some- times by being nursed by such .persons. The only case I ever met with Avas as marked a case of gonorrhoea as ever I saAV in the adult. The boy was about four years old, not yet in pants, and Avas nursed frequently' by an uncle who was suffering from the disease. Symptoms.—The child Avill complain of pain in passing urine, and if the disease is severe, Avill suffer intensely from this cause. • Upon examination, the prepuce will be found much SAvollen, the penis tender, and a more or less abundant discharge Avill pass from the urethra. 378 DISEASES OF CHILDREN. Treatment.—Of course, it is hardly possible to determine the cause of the difficulty, and avc Avill tieat it as a simple in- flammation. The parts should be kept scrupulously clean, and if the inflammation runs high, a Avarm hip-bath may be used once or tAvice during the day, and some soft poultice at night. Internally I Avould prescribe, Tfy Tincture of Canabis Indica, Tincture Veratrum, aa. gtt. v.", Avater Siv.; a teaspoonful every two hours. The bowels might be opened with a saline cathartic every three or four days, but active catharsis is to be avoided. HYDROCELE. Hydrocele is occasionally met with in young children, and gives rise to considerable alarm upon the part of the parents. In some cases it is congenital, the inguinal canal not having been closed after the descent of the testes. In these it may sometimes be associated with congenital hernia. Our attention having been called to the enlarged scrotum, Ave Avill endeavor to determine its cause by an examination. If the enlargement is. caused by the distension of the tunica vaginalis Avith Avater, palpation Avill detect the movement of the fluid, and Avhen the child cries Ave Avill find no movement communicated to the swollen scrotum. On the contrary, if a scrotal hernia exist, the movements of the diaphragm in the act of crying, Avill be communicated to the hand supporting the scrotum. In this ease also, there Avill be no movement from side to side, as when dis- tended with fluid. The diagnosis betAveen hydrocele and hema- tocele is readily effected in the child by the marked change of color in the last. Treatment.—In some cases Ave will be successful in removing the fluid and curing the disease by a stimulating application and compression. The use of a strong infusion of Hamamelis, with a Avell adjusted bandage, in the usual form of a suspensory band- age, was attended Avith success in one case that came under niv notice. Mayer's ointment Avould prove a good application, as Avould also a soft piece of leather, cut to fit the part and spread with our ordinary strengthening plaster. Tincture of iodine has been recommended as an application to the part, to stimulate ab- sorption, but I think it Avould be too irritating. If these means should not succeed, the scrotum mav be [nine- INFANTILE LEUCORRHCEA. 379 tured with an exploring needle or small trocar, and the fluid draAvn off. If iioav the part is supported by a well adjusted bandage, Ave may expect a radical cure. INFANTILE L E UC'ORR II (E A. A slight discharge from the vulva is not of unfrequent occur- rence in children from one to tAvelve years of age, but it is only in exceptional cases that it is severe, and produced by an active inflammation at first, but Avhich, as it declines, becomes chronic and very stubborn. These last are very troublesome cases, and are a source of great annoyance both to the physician and the family. Causes.—The slight discharge is the effect of cold, after over- exertion in the use of the loAvcr limbs, or occasionally from sit- ting on the damp ground, or a stone. This may also be a cause of the active inflammation, or it may be produced by acridity of the urine, irritating and excoriating the vulva, the inflammation arising in and extending from this part. In some cases it may arise from Avant of cleanliness, especially in those Avho are badly nourished. Then Ave have exceptional cases, in Avhich the inflammation is specific in its character, and is produced by contact with gonor- rhoea 1 virus. This may occur in a house Avhere some person has gonorrhoea, from sitting on the privy scat, or by the use of cloths impregnated with the virus. Pathology.—In the slight cases there is simply an increased circulation in the parts, and activity of the mucous follicles. Usually this is confined to the glands about the vulva, and the vulvo-vaginal glands. In the severer form, there is a well marked inflammation, in- volving the parts about the commencement of the vagina, the vulva, and sometimes extending up the entire length of the vaginal canal. The inflammation loses its active character after the first ten days, and the parts present a swollen, deep-red ap- pearance, bathed Avith muco-pus. There is no means of deter- mining from the appearance of the parts, Avhether it has arisen from gonorrhoeal virus, or not. Treatment.—The treatment is unsatisfactory in many cases, from the difficulty Ave experience in getting a proper application 380 DISEASES OF CHILDREN. of local remedies. Indeed, with the best assistance the mother can give, Ave make but sIoav progress. I put the child upon the use of Aconite with Cannabis Indica in the usual doses; or in place of the last Ave might give the Gel- seminum. The boAvels are gently opened by citrate of magnesia or phosphate of soda every two or three days. If the child is old enough to take it, she may use an infusion of equal parts of Althaea and Uva Ursi as a drink. I iioav use salicylic acid and borax or chlorate of potash as the local application, as—R/ Salicylic Acid, Borax (or Chlorate of Potash), aa. gr. xx., Avater Oj. This may be applied to the vulva only, or if the discharge is vaginal it may sometimes be used with a syringe. Bathing the parts with hot Avater alone (as hot as can be borne comfortably) Avill sometimes effect a cure. The hot bath may extend to the abdomen and spine. Perseverance in these means Avill relieve the acute inflamma- tion, and many times Avill effect a radical cure. But if a chronic discharge continues, Ave Avill obtain the best results from the local use of a solution of Sulphate of Hydrastia grs. iv., to Avater Siv. There are many other local remedies that have been used in this case, but they are the same as recommended for the adult, and for these the reader is referred to treatises on disease of Avomen. The general treatment in the chronic form of the disease, Avill be of a tonic and restorative character. Further than this, it is doubtful if any internal remedies can be used with benefit to the local disease. ONANISM. The practice of onanism is of very common occurrence after the twelfth year, or about the commencement of puberty. But at an earlier age than this, we will find occasional instances of the vice, which will give us much trouble. I have seen it as early as the second year, and in one case, the boy being in his fourth year, it had proven a cause of severe constitutional dis- turbance. It is difficult to determine the cause of the habit in children of this age, as the organs are yet undeveloped, and Ave are taught to believe that the venereal appetite is not present until the age of puberty. It is my impression that the habit of handling the parts, is sometimes attained at a very early age, and attended ONANISM. 381 with erections, is found pleasurable, and is repeated for this reason. I have noticed this occasionally, and even in this slight degree, if continued but for tAvo or three months, it will give rise to marked irritability of the nervous system and impaired health. In the severe cases Ave find the child has lost flesh and is much debilitated. There is marked depression of the nervous system, and the child has a furtive and uneasy look. It is easy to see that the mind is affected, that the child does not receive natural impressions, and that its reasoning power is impaired. Some- times it seems to suffer from* spinal disease, at others from disease of the loAver extremities, and again from disease of the brain. Some cases seem to be dependent upon inactivity of the stomach and bowels—dyspepsia—and treatment is direct- ed to this with the expectation of restoring the health and strength, by the use of bitter tonics and restoratives. I recognize the difficulty by the furtive uneasy look of the patient, and by the disposition to rub the thighs together, and move the loAver part of the body. In the milder cases, the child does not seem to appreciate but Avhat it is all right, and will carry the hand to the penis Avhile you are conversing with him. In the protracted cases, the chil 1 seems as much impressed with the offense as the adult, especially if he has been reproved for it; and practises it secretly Avhenever he has an opportunity. If the penis is examined in these cases, the prepuce will be found red and irritated, and occasionally the organ will be more developed than is usual at the age. If continued, the practice will lead to epilepsy, idiocy, or to such impairment of the general health that the child will die early of some cachectic disease. Treatment.—In the milder cases, those which have continued but a month or two, avc may break up the habit by close atten- tion and mild reproof. Gentle means are much better than harsh, persuasion than force, and if the matter is properly pre- sented to the parents, and they will take advice, Ave will get along with the patient well. When the habit is Avell-cstablished, I put it beyond the child's power to continue it, by vesicating the surface so that handling will be painful, and an erection impossible. Tincture of Canthar- ides, or Cantharidal Collodion Avill ansAver this purpose avcII. It 382 DISEASES OF CHILDREN. should always be applied Avithout the patient's knowing of the purpose for which it is used, Avhich can very readily be done, and it should be so repeated that for one or tAvo months the organ must remain at rest. In the meanwhile, by the use of tonics and restoratives, nutri- tious diet, baths, and exercise in the open air, Ave restore the general health, and at the end of a couple of months Ave find the habit broken and the health restored. If the difficulty should still continue circumcision is a most effectual remedy. If parents will not consent to the complete removal of the prepuce, it may be slit up on a grooved director, and the glans exposed. CHAPTER IX. DISEASES OF THE NERVOUS SYSTEM. Lesions of the nervous system exert a very important influence in disease, and we rarely find a case in which they do not form a part, and must be estimated in the diagnosis. They also exert a more or less marked influence on all pathological changes, and it is through the nervous system, to a considerable extent, that avc are enabled to modify and change the various processes of life. The nervous system of the child is peculiarly susceptible to the causes of disease, and as susceptible to the influence of reme- dies. Hence, minute doses of direct medicines are found prefera- ble to large doses of such as act in an indirect manner. It Avill be recollected that the nervous system is divisible into three parts—the brain, the spinal cord, and the sympathetic nervous system. The brain is the organ of the mind, and gives us conscious ex- istence, and from it the will calls into action the voluntary mus- cles brscrve its purposes. As a Avhole it is an element of Aveak- ness, and draws upon the vegetative functions for its life, rather than giving strength or aid to them. The popular opinion "that DISEASES OF THE NERVOUS SYSTEM. 383 a child may haA'e too much brain,'' like many such, is founded in fact. The large orain, as compared with the body, appropri- ates an excess of blood, nutritive material, and vital or formative power, and the remainder of the body suffers in consequence. It is essential to success, in some cases, to see that this morbid groAvth of the brain be arrested. This is accomplished by adopt- ing such a course of training as Avill develop the body and keep the mind at rest. The basilar portion of the brain is an expansion of the spinal cord, and influences vital processes. The tenacity of life and poAver of living depend, to a very considerable extent, upon its development and perfect condition. We have already seen that this poAver may be very closely estimated by a measurement de- termining the depth of the basilar portion of the brain. The spinal cord is the center of reflex action, or automatic movements. It carries on certain functions Avhen the Avill is in abeyance, and others that are but partially under the influence of the Avill. The functions of respiration, deglutition, defeca- tion, etc., and all the involuntary movements, are carried on un- der its control. Nerves from this source pass to all parts of the body, and Ave know that they may take complete control of all the voluntary functions, usurping the place of the brain. The sympathetic nervous system presides over the functions of vegetative life, controlling digestion, assimilation, blood-mak- ing, the circulation of the blood, nutrition, waste of tissue, secre- tion and excretion. Though the entire amount of gray nerve substance in the sympathetic ganglia of the body Avould not be the size of a pigeon's egg, it is probable there is no structure in the body, hoAvever minute, but Avhat receives nervous supply from this source. DETERMINATION OF BLOOD TO THE BRAIN. Determination of blood to the brain is of frequent occurrence in acute disease. We understand that determination is the result of irritation, but Ave can only account for this by the supposition that it folloAvs from the accelerated circulation and increase of temperature. The immature brain is very susceptible to irrita- tion, and but slight change in its vital condition is required to # induce it. 384 DISEASES OF CHILDREN. Symptoms.—Determination to the brain is announced by the increased restlessness sind irritability of the patient. The face is flushed, the eyes bright, the pupils contracted, and the bead hot- ter than usual. These symptoms gradually increase until they become very marked, the child suffering severely from it, and occasionally having convulsions. With determination to the brain all the other symptoms are increased. The pulse is more frequent, the temperature higher, greater arrest of the secretions, less disposition to sleep, and fur- ther impairment of the digestive organs. It may continue to increase until an inflammation is estab- lished, or after some days terminate in the opposite condition of congestion, from exhaustion of the irritability of the brain. Treatment.—The treatment of determination of blood to the brain in childhood is direct and certain. The use of Gelseminum, associated Avith the special sedatives, Avill meet the indications in almost every case. But the specific action of the remedy is only obtained from the one preparation—a tincture made from the green root; the most that is sold is Avholly Avorthless for any pur- pose in medicine. In this form I prescribe it in the folloAving proportions: Iy Tincture Gelseminum gtt. v. to gtt. x., Tinct. Aconite gtt. v., Avater Siv.; a teaspoonful everyone or two hours. If the features are contracted, expressive of pain, and the child starts in its sleep, and cries out shrilly, Rhus' will take the place of Gelseminum, in the proportion of gtt. v. to Avater oiv. With this treatment Ave employ the general bath and the hot foot-bath ; the last frequently repeated, and if the head is hot, it is sponged with Avarm Avater, and evaporation is promoted by fanning. Catharsis, counter-irritation, and ice to the scalp, should be avoided. CONGESTION OF THE BRAIN. Congestion is that condition in which there is excess of blood in a part, Avith its moATement impaired. It may arise from irri- tation of the brain at first, but usually depends upon some cause Avhich depresses the vitality of the organ. The circulation is feeble and sluggish, while the vessels are unduly distended, and necessarily the function of the organ is impaired. PITRENITIS. 385 Symptoms.—The child is dull and inactive, Avants to sleep much, and usually sleeps Avitli its eyes partially open. The dull- ness and hebetude are so marked that they cannot escape notice. As the disease progresses Ave find this condition increased; the c'.iild sleeps a considerable part of the time, but it is not so much sleep as stupor, and gradually this passes into coma, Avhich at last becomes so profound that the child can not be aroused from it. With this condition of the brain the Avhole system sympathizes, and there is atony Avith tendency to sluggish circulation, and consequent arrest of function in every part. Treatment.—This condition of the child, like the preceding, I prefer to treat with a specific, rather than to depend upon the ohl means—counter-irritation and catharsis. Belladonna is the remedy, and I would prescribe it in the folloAving form: Ia) Tincture of Belladonna gtt. v., Tincture Aconite gtt. ij. to gtt. a*., Avater .5iv., a teaspoonful every hour. I think the remedy Avill very rarely disappoint expectation, as I have successfully em- ployed it for this purpose for many years, and it has been used very extensively by others with like results. It may be aided by the use of the hot mustard foot-bath, con- tinued for thirty minutes at a time, and repeated two or three times a day, and in very severe cases by dry cups to the neck. When the condition is so marked, that it Avill evidently prove fatal if not speedily removed, I have been accustomed to employ a prompt and thorough emetic, and folloAV with the Belladonna. This treatment may be recommended in those very seA'ere cases sometimes met with in the eruptive fevers, in which the emetic will throw off the profound coma, and give freedom to the circu- lation and the respiration. I trust to the Belladonna to accom- plish this result in children under one year, and it has so far proved satisfactory. Still there are very many Avho will 'not have faith in such small doses of a single remedy, for the relief of so grave a condition. PURE NTTIS. Inflammation of the brain is of more frequent occurrence in childhood than in the adult. It is rarely an idiopathic disease, but when seen it is a complication of some other affection, usu- •2'j 386 diseases of children. ally a fever or inflammation. As it is preceded by determina- tion of blood, the symptoms of Avhich are Avell marked, and the remedies employed almost specific, an imflammation of the brain should be of very rare occurrence. Causes.—An inflammation of the brain may arise from any of the causes that Avould produce inflammation of any other organ or part; but, as Ave have seen above, such origin is very rare. Occurring, in a majority of cases, during the progress of an acute fever or inflammation, it is dependent upon an irrita- tion produced by the accelerated circulation and increase of heat. It occurs in such persons as have a natural irritability of the brain and nervous system. These changes prove sufficient to establish an irritation, which is folloAved by determination and inflammation. Pathology.—The inflammation may be confined to the dura mater and arachnoid—cerebral meningitis; or it may affect the substance of the brain itself—cerebritis. But it is impossible, by the symptoms presented, to determine the difference betAveen the two during life. The inflammation presents its usual features ; a first stage, in which there is an active circulation, thestructures being filled with blood, and presenting similar appearances to those seen in superficial imflammation ; and a second sta^e in Avhich there is stasis of blood and exudation into the connective tissue. Post-mortem examination sIioavs the scat of the lesion. If of the membranes, the dura mater and the arachnoid Avill be found injected in patches of greater or less extent. There is also an increased quantity of fluid, sometimes but little chano'ed at others more or lessviscid, or con tabling flocouli of coagulablelvniph. When the acute stage has continued for three or four days, avc sometimes find adhesions between the free surfaces. When the substance of the brain has been involved, the vesicles of the pia mater are distended, and on making an incision into the convo- lutions, the cut surface will present a more uniform red color than natural, and the puncta vasculosa are more numerous and larger. Symptoms.— The invasion of the disease is indicated by a sense of fullness and pain in the head, the integuments beino- suffused, and sometimes a marked sense of heat. Frequently phrenitis. 387 the patient complains of dullness, with confusion of ideas and forget fulness, and unquiet sleep. Extreme irritability and fret- fulness, with indisposition to sleep, and frequent startiugs dur- ing rest, the cry being sharp and quick, as if terrified, are the precursory symptoms in children. The disease is usually ush- ered in with a marked rigor or chill, continuing for an hour or tAvo, or sometimes for nearly a Avhole day. Following tins, there is in most cases high febrile reaction, the skin is hot and flushed, the pulse frequent and hard, tongue coated Avhite, bow- els constipated, and urine scanty and high-colored. The head is turgid and hot, the eyes more prominent and suffused, the pupils contracted and fixed, and a deep-seated, heavy pulsating and tensive pain in the head. As the disease progresses, the patient becomes more irritable and restless, the pain in the head increases, there is intolerance of light, ringing in the ears, and intolerance of sound, sleepless- ness and delirium. Up to the third or fourth day the fever is usu- ally continuous, though sometimes there is a slight remission in the forenoon, and the head symptoms increase or continue Avith- out abatement. A marked change is now observed, the acute sensibility gives Avay to torpor, and the delirium becomes low and muttering, or is replaced by coma. The pulse becomes fuller, softer, or sIoav, or in some cases very hard and frequent. The head and trunk are still hot, the face turgid and of a deeper color, or in some cases blanched mid contracted, the pupils dila- ted, the extremities cool, respiration difficult and sometimes stertorous, and more or less involuntary movement and starting of the tendons. The coma gradually becomes deeper, and the in- sensibility more marked; all the functions are feebly performed, the patient lies on his back, siips down to the foot of the bed, grasps at imaginary objects, and thus slowly sinks. According to Copland: "In some eases, particularly those in which the cer- ebral substance is early and generally inflamed and turgid, in- stead of phrenitic delirium, an apoplectic sopor, often preceded bv convulsions, quickly supervenes; with a sIoav pulse, stertor- ous, sIoav, or labored breathing, turgid or bloated countenance, startiugs of the tendons, involuntary evacuations, torpor of the senses, and flaccidity of the limits." Here the first stage is very short, or not noticed, and the disease passes rapidly to a fatal termination. In children avc frequently find inflammation of the brain 388 diseasks of children. making its appearance during the progress of other diseases. The head becomes hot, the face turgid, the pupils contracted, with great restlessness and constant movement of the head. Though not very marked on account of age, the child is evident- ly delirious, and the frequent movement of the head, and putting the hands up to it, shows that it suffers pain. In other cases the acute stage has passed Avithout notice, the face is blanched and contracted or Avhite and puffy, the pulse is small and very fre- quent, the extremities cool, boAvels loose, the operations being unnatural and offensive, there is continued movement of the head and restlessness, or a deep stupor or coma. Sometimes the symptoms will continue for three or four days, but at other times the disease will terminate fatally within forty-eight hours. Diagnosis.—It is not difficult in the most of cases to de- termine the presence of phrenitis. The heat and turgidity of the face and scalp, the deep-seated and tensive pain, contracted pu- pils, and the great irritability and restlessness, with, the high grade of fever, are sufficient for the diagnosis. In those other cases in Avhich coma, difficult respiration, full but oppressed pulse, coldness of the extremities, dilated pupils, etc., are the at- tendant symptoms, the diagnosis Avill be \Tery difficult, and if avc can not have the previous history of the case, almost im- possible. Prognosis.—In the first stage of the disease, the prognosis is usually favorable, if prompt measures are adopted for the arrest of the inflammation. In the second stage the lesions aresooreat that Ave Avill have to be guarded in our prognosis, though a con- siderable number will recover. Treatment.—If called to a case in the first stage of the disease, we have the patient thoroughly bathed with the alkaline wash, drying with brisk friction; this is folloAved by a hot mustard foot-bath, continued for half an hour, and both are repeated once or tAvice daily. Internally, I prescribe—Tfy Tinct. of Aconite gtt. v., Tinct, Gelseminum gtt. x , water Siv.; a teaspoonful every hour. If the fever runs high, I would add to this, Tinct. of Ve- ratrum gtt. x., for a few hours. To lessen the heat of the head, Ave direct that it be sponged Avith warm Avater and fanned, to produce evaporation. We will find quite Avarm Avater is very agreeable to the little patient, re- FHRENITIS. 389 lieving the excitation of the nervous system, and lessening the temperature. We never apply cloths Avrung out of cold Avater, as is the common practice, or bladders of pounded ice, as recom- mended in most Avorks. This is not nature's method for remov- ing surplus heat, as is the case with the plan first named. On the contrary, it is directly depressant in its first influence, and if not persistently applied there will be a corresponding reaction ; if, therefore, it is continued, the depression may cause death ; if suspended, tjie reaction is higher than before, and the patient in greater danger. I do not approve of the use of a cathartic in all cases, for while in some it will prove beneficial, in others it exerts an unfavorable influence. Never give a cathartic when the tongue is contracted, reddened around its border and Avhite in the center, or Avhen it is elongated and pointed. In this case it is quite certain to irri- tate the stomach and upper intestine, increasing the febrile action and the disease of the brain. It may, however, be used with good effect when the tongue is moist, somewhat broad, and tole- rably uniformly coated with a yellowish or grayish fur. I Avould prefer a small portion of jalap with a saline, as—li) Jalap grs. iij. to grs. v., Bitartrate of Potash gr. v. to grs. x. If the tongue is thus coated, sulphite of soda, in doses of tAvo to five grains, may be given every tAvo or three hours, until the tongue cleans. So soon as the influence of the special sedative is observed, Ave may prescribe a solution of acetate of potash, to be taken largely diluted with Avater. I usually give it as a drink, and as the child is thirsty it will be taken pretty freely. In some cases Rhus is a very important remedy, and replaces the Gelseminum. The indications are usually very clear : the pulse is sharp, the tissues about the eyes and base of brain con- tracted, with evident frontal headache, and the tongue sIioavs the red papillae at its tip. If the child is Avildly delirious, and clutches at its mouth and throat, Stramonium may be given Avith Veratrum, aa. gtt. \'., Avater 5iv.; a teaspoonful every hour. There is one point in the treatment that should not be ne- glected—keeping the child quiet—rest to the nervous system being essential to complete recovery. I prefer that the child shall re- main in the recumbent position in its crib or bed, Avith the room darkened, and as little noise as is possible. 390 DISEASES OF CHILDREN. In some cases there is extreme irritation of the stomach, and it becomes important that this should be relieved. The Aconite and Gelseminum will have to be in very small dose, and Ave may need to add portions of Aconite and Gelseminum to the water that Ave sponge the child's head with. If this is not sufficient to relieve the irritation, peach bark may be used, or a small portion of a Seidlitz poAvder may be given with the drink. If the tem- perature is high, cold packs may be used over the stomach and bowels; if the child is feeble, hot packs or sponging Avill be bet- ter. With a temperature of 105° I should think of an enema of of four to eight ounces of cold salt Avater; Avith cool extremities, the Avater should be as hot as the patient can bear it. In the second stage, the condition is Avholly changed. Instead of the active circulation and excitement of the brain, Ave have a stasis of blood and coma. Locally, I order dry cups to the neck, and sometimes to the spine, with the hot mustard foot-bath; the first being repeated if the case is severe, and the second used two or three times a day. Evaporating lotions are applied to the scalp, as sulphuric ether, alcohol, or cologne; sometimes a camphor or arnica lotion will ansAver the purpose Avell. Internally, I prescribe—R/ Tinct. Aconite gtt. v., Tinct Bel- ladonna gtt. x., Avater .>iv.; a teaspoonful every hour. Or if there is fullness of the fontanelles or swollen eyelids, avc might * 7 o add Tinct. Apocynum gtt. x. to Avater 5*1 v., and give in teaspoon- ful doses alternately with the Belladonna. If there is retention of urine, or sluggish passage, Santonine may be given in doses of one-fourth to one grain, as heretofore named. If there is the condition of the tongue named above as per- mitting the use of a cathartic, I should give—R/ Jalap grs. iij., Capsicum gr. L, Bitartrate of Potash, gr. x., and repeat it every four hours until it acted freely. To act upon the kidneys, I would prefer i§A\'eet spirits of nitre in doses often or fifteen drops, every two hours, as it is also an excellent stimulant. In some cases we Avill find quinine inunction to answer a very good purpose. If there is much prostration and feeble circula- tion in the skin, some rubefacient may be added to it, :\n one of the essential oils, or the oil of mustard in very small quantity. If the quinine is not used in this way, it may be given internally to the extent of two grains a day, during convalescence. ACUTE HYDROCEPHALUS. 391 A C U T J] II Y DHOC E PII A L 'C S. We use this term, for the want of a better one, to distinguish a certain class of cases in which the disease of the brain is a principal lesion, though the symptoms Avould indicate something else. The disease is confined almost entirely to children, occur-J ing most frequently from the ages of one to three years, and being, rare after twelve. It is very difficult to determine the cause, though Ave are of the opinion that it is frequently dependent upon irritation of the digestive apparatus, or upon any cause that will enfeeble the system. At the age of ten or tAvelve it is usually brought on by over mental exertion. Pathology.—The lesions observed in this disease are by no means constant. In some cases there is considerable effusion into the ventricles and the cavity of the arachnoid, but in others there is very little or none. Sometimes there is evidence of determina- tion of blood, and occasionally small patches of lymph or flocculi » in the effused fluid ; rarely the brain exhibits evidence of sIoav inflammation. "The nature of acute hydrocephalus/' says Dr. Bennet, "has been keenly disputed, and Avhether it be inflammatory or non- inflammatory, and should be treated with antiphlogistics or nu- trients, will be found to be discussed at great length in systematic Avorks and numerous monographs. The fact is, that the group of symptoms indicating the occurrence of water on the brain is altogether insufficient to prove the existence of this morbid pro- duct in acute cases. What avc observe are symptoms of excite- ment, gradually passing into those of depression, occasionally passing into paroxysms of pain, restlessness or screaming, alter- nately with droAvsiness and coma. These symptoms are com- mon to various lesions of the brain, and may be the result of congestion, or of this state terminating in effusion and frequently in exudation. Hence, Avhy sometimes after death Ave find no lesion Avhatever, at others more or less distension of the \Ten- tricles with serum, and very commonly, in addition, exudation at the base of the cranium. In every case, the symptoms are referable not so much to one or the other of these lesions as to something Avhich they all have.in common, and this undoubtedly is more or less pressure on various portions of the brain, causing, 40 392 DISEASES OF CHILDREN. first, irritation and then perversion of function, or so operating as to excite some parts and to depress others. In the great ma- jority of cases, the fluid distending the ventricles is more allied to the dropsies than exudations. Nay, even Avhen lymph is thrown out at the base of the brain, the amount of serum in the ventricles is altogether disproportioned to the quantity of coagu- lated fibrin deposited. Hence, I am disposed to think that even when evidence of so-called inflammation exists, still the fluid that distends the ventricles is owing to a mechanical obstruction of the vessels, causing dropsical effusion." Symptoms.—At an early age, avc find the disease commencing as an obscure remittent fever, the languor, or more properly stupor, being the most prominent symptom. The fever usually has an exacerbation in the afternoon, the child being restless and fretful at this time. Nausea and vomiting arc very frequently present, especially if there is irritation of the bowels, forming one variety of cholera infantum. In a longer or shorter time, usually not more than from two to ten days, the patient becomes almost entirely unconscious, though from the occasional glance of intelligence it is not believed by the parents. Still it is rest- less and uneasy, turning its head from side to side, putting its hands to its head, and uttering those sharp, piercing cries indic- ative of pain ; if the tongue can be seen, it Avill be found dry, its tip and edges red, and center covered with a white coat. The countenance is now pallid and pinched ; the eyes Avant expression, and are sunk in the head, the pupils generally dilated; the head is not above normal temperature, frequently dry, although the forehead is covered with a clammy perspiration. If there v as not diarrhoea at the commencement, there is now, the stools being of a dirty-yellowish or greenish color, mixed Avith slimy matter and having an offensive odor. A very common grouping of symptoms is thus reported in a clinical case by Dr. Bennet: "Unconsciousness of surrounding objects, not recognizing even her mother ; pupils not contractile to light; slight strabismus of right eye; frequently puts her hands to the head, which is rolled about uneasily ; continual grinding of the teeth, Ioav moaning, and occasional muttering. Tip of tongue, which is all that can be seen, very dry and of a scarlet color; loss of appetite; constant thirst ; vomiting; invol- untary discharge of feces and urine; on pressing the abdomen ACUTE HYDROCEPHALUS. 393 uneasiness evidently experienced, and moaning increased; skin hot and dry ; no eruption ; a small abscess at the back of the neck, Avith a sanious discharge ; action of the heart feeble and fluttering; pulse one hundred and forty, small, and occasionally intermittent. Breathing short and hurried ; no rales." These symptoms were developed in a child aged six, commencing four- teen days previously with diarrhoea. In older children the first symptoms will be a more or less severe headache, with intellectual stupor, the child being restless and uneasy, and passing bad nights ; an obscure fever may be recognized in the after part of the day, the skin being dry and husky, and the pulse frequent and hard. For davs, and even for tAvo or three weeks, the symptoms continue in this Avay, the child being occasionally better for a few hours or sometimes for a day or tAvo. Suddenly the pain in the head becomes intense; the face is pinched and expressive of great suffering ; the tongue is red at its tip and edges, dry, and its center covered with a- Avhite coat; the bowels constipated, or there is diarrhoea ; urine scanty; the pupils dilated, and immobile on exposure to light. The child does not like to be disturbed, is constantly dozing, tliough its nights are restless. The pulse may be either frequent and sharp, or in some cases sIoav and feeble. Very frequently there is nausea and vomiting, sometimes very persistent and intractable. These symptoms becoming very severe, deep coma results, from which the child never recovers, but tAvo or three days elapsing from its accession until the fatal termination. Diagnosis.—I diagnose this disease by the pinched expression of the countenance, CA'ery part seeming to be contracted, the dilatation of the pupil, the stupor and at the same time restless- ness of the patient. These symptoms may be confounded with the second stage of inflammation of the brain, but the prior symptoms are usually sufficient for the diagnosis. Prognosis.—It is very difficult to so describe this disease, that the reader may determine which cases Avill recover, and which Avill unaA'oidably prove fatal. Usually, if the child is still conscious, and there is not such marked contraction of the countenance, as to render it hippocratic, Ave may hope for a favorable result ; if the contrary is the case, it will in all proba- bility prove fatal. 394 DISKASES OF CHILDREN. Treatment.—The treatment Avill have to be much modified to suit each individual case; yet in every one it must be decidedly stimulant and sustaining. If there is continuous nausea, with evidence of morbid accumulations, the stomach should be re- lieved by the administration of a prompt emetic, very marked benefit folloAving its action. In other cases the nausea may be arrested by a sinapism over the epigastrium, and the administra- tion of an infusion of peach-tree bark, or compound poAvder of rhubarb and potassa. Injections of salt and water, an even tea- spoonful to four ounces of water, Avill sometimes prove very efficient in irritation of the stomach ; chloroform and glycerine may be used for the same purpose, and may aftenvards be con- tinued in doses of five drops every hour or tAvo, for its stimulant and at the same time soothing influence. If there is diarrhoea, it is the generally received opinion that it should be checked by the use of astringents ; but this is bad practice, as almost invari- ably on the arrest of the discharges, the coma becomes complete, and the child dies. Remedies should be very carefully selected in these cases. Aconite and Ipecac, in small doses, Avill sometimes quiet irrita- tion of the stomach and relieve this irritation. Gelseminum may be indicated as in inflammation of the brain. Belladonna is called for Avhen dullness and stupor become marked symptoms. Rhus Avill sometimes prove a most valuable remedy, there being a sharp frequent pulse, contraction about the eyes and base of the brain, sudden startiugs in sleep Avith shrill cry. With the relief of irritation of the stomach, and to a certain extent of the brain, Apocynum becomes a' prominent remedy, though it must be used in small doses. R/ Tinct. Aconite gtt. iij., Tinct. Apocynum gtt. v., Avater Siv.; a teaspoonful every one or tAvo hours. If indicated, Rhus or Belladonna should be substi- tuted for the Aconite. If the tongue is pallid and dirty, sulphate of soda should be given in doses of two to five grains every three hours. If red and dirty, sulphurous acid wi 11 be the remedy. If drvand harsh, the child's drink may be acidulated Avith muriatic acid, or it can have small portions of good sharp cider, or in some cases, of whey. The hot mustard foot-bath wi 11 be sufficient in some cases, if thoroughly used, but if the case is severe, I prefer a tub of water as hot as the child can bear it, and rendered stimu- lant by the addition of mustard or capsicum, into which T put the CHRONIC HYDROCEPHALUS. 395 child, letting it remain for half an hour, being Avell covered with a blanket. In place of this, sponging the surface with hot Avater, will ansAver a good purpose. Dry cupping to the neck, and even sometimes to the entire spine, is among our most important measures; sometimes the cups to the neck maybe scarified, espe- cially if there is much heat of the head. A sinapism to the neck and spine will sometimes answer the purpose, but is not as good as the cups, and I think not as useful as friction Avith strong salt and water hot. If the kidneys fail to act freely, I Avould admin- ister an infusion of hair-cap moss or of marsh-mallows, ■with a suitable portion of acetate of potash or sweet spirits of nitre. CHRONIC HYDROCEPHALUS. Dropsy of the brain is almost exclusively a disease of child- hood, and occurs most frequently before the third year. It is difficult to determine the causes that give rise to the effusion of water from the arachnoid, but as it occurs almost invariably in children of feeble vitality, and in families whose children die during infancy of acute hydrocephalus, cholera infantum, or this, we are led to believe that it depends upon hereditary debility. The exciting cause may be the exanthemata, Avhooping cough, disease of the boAvels, or inflammatory disease, or it may arise from depression, produced by cold hud other causes. Symptoms.—The symptoms A-ary very greatly, the disease running a tolerably rapid course in some cases, and a very slow one in others. The child usually complains of its head, if it can talk, or moves it from side to side, putting its hands to it fre- quently. The face is pallid and contracted, or in some cases puffy and Avithout expression ; the circulation is feeble, the extremities being cold, and the surface easily chilled; the appetite is irregu- lar, sometimes good, at others very poor, and digestion seems to be feeble; the boAvels are torpid and constipated, tliough some- times irregular. As the disease progresses, we notice that the child is very stupid, and that at times it has difficulty in con- trolling the voluntary muscles ; there may be temporary or per- manent strabismus, and an iiiA-oluntary rolling about of the eves, Avith a dilated and fixed pupil. Occasionally avc observe a marked irritability of the stomach, that is with difficulty controlled, and in some cases an extreme 396 DISEASES OF CHILDREN. irritability and restlessness, though the intellectual functions are greatly impaired. As the disease progresses the torpor becomes deeper, and the child does not exhibit the symptoms of pain above named. The pulse is iioav seen to be getting perceptibly weaker, and occasionally irregular ; the hands are tremulous and unsteady, and frequently raised to the back of the head. When the child sleeps, its eyes are half open, and the eyeballs are con- stantly moving and usually draAvn upAvard. When the torpor is not so great, the child is in some cases constantly picking its nose or lips, and is extremely irritable, having paroxysms of rage from the slightest supposed offense. The disease may con- tinue this Avayfor months, or in some rare cases for years, finally terminating fatally by the development of some ataxic disease, or of acute hydrocephalus, or with a gradually developed maras- mus. Diagnosis.—In very young children, and sometimes up to the age of three years, there Avill be found a perceptible enlarge- ment and distension of the fontanelles, and separation of the sutures, and the child's head is appreciably larger. After this, Ave are guided entirely by the general symptoms above named. Prognosis.—The prognosis is usually unfavorable, though some eases may be cured, and in others life may be prolonged for a considerable period. Cases*are recorded in Avhich the persons lived to adult age, and in four cases to twenty-seven, thirty-two, forty-five and fifty-four years. Post-Moutem-Examination.—If the disease has been of long duration, the bones of the cranium will be found thin and transparent, and occasionally separated from each other by very considerable intervals. The effused fluid is found in the sac of the arachnoid, and in the ventricles; if in the ventricles to a great extent, the convolutions are unfolded, and the medullary and cineritious substances can Avith difficulty be distinguished. * The brain is often denser than usual, and is not diminished in Aveight. Treatment.—I am satisfied that the greatest success in the treatment of dropsy will follow the use of specific remedies, and especially in the case under consideration. The remedy I prefer in this case is the Apocynum cannibinum—its substitute, Aralia hispida. I prescribe the first in the folloAving form : 1$. Tinct. SPINAL MENINGITIS. 397 Apocynum gtt. x., Avater .^iv ; give a teaspoonful every tAvo or three hours. The Aralia I have used in infusion, associated with the tonics named below. A number of cases of hydrocephalus cured by Apocynum are on record, and I have had three cases in my practice which have recovered under its use. After the use of these means for some days, their influence in removing the accumulation being observed, Ave put the patient upon the use of tonics, alternating them. As a tonic, some of the preparations of hydrastia answer the best purpose, and Avhen there is constipation of the boAvels, may be given Avith podophyllin in small doses ; the combination of these remedies heretofore given may be employed. The Collin- sonia canadensis is a favorite remedy in my practice, especially in cases where there is irritation of the nervous system, and avc may associate with it the Ptelea, Cornus, Euonymus, or other remedies of this class. Rye Avhiskey and cod-liver oil are excellent when the stomach bears them kindly, and should it reject the oil, its place may be supplied by sweet cream or beef-suet. The child should have a daily salt-Avater bath ; sometimes the entire bath will be best, and may be used either Avarm or cold, th;* first being generally preferable, or the sponge-bath may be u-ieil; in either case it should be followed Avith brisk friction. The child should be taken out in the open air every day, being Avarmly clad in flannel. If possible it should be removed to a high locality in the country, Avhere it can have pure airand sun- shine, exercise and pure milk. SPINAL MENINGITIS. Inflammation of the meninges of the spinal column is not an uncommon disease, tliough sometimes, from the obscurity of its symptoms, it may be mistaken for other affections. It occurs in two forms, as a distinct sporadic inflammation, and as an epi- demic or endemic fever, Avhich involves the spinal cord. It is in the last named cases that mistakes in diagnosis are most usu- ally made. The causes of this affection are those which give rise to other inflammations, as cold, sudden changes of tempera- ture, injuries, and especially a sudden chilling of the surface after active exertion. It occurs most frequently in the young and vigorous, and is very rare after middle life. » 398 DISEASES OF CHILDREN. Symptoms.—Spinal meningitis usually commences with a well-marked chill, lasting for several hours, though sometimes with a severe rigor of considerable duration. I have seen cases in which the chill Avas of twenty-four hour's duration, the later [tart of it being alternated Avith flushes of heat. FolloAving this there is marked febrile reaction, with hot, dry skin, hard and frequent pulse, tongue coated Avhite, the edges and tip being red, constipation of the boAvels, and scanty and high-colored urine. The patient complains greatly of pain in the back, which is so increased on movement, that he dislikes to change his posi- tion for any purpose; though in some cases, Avhen not so severe, they are constantly shifting their position to give thein ease. By the second or third day the fever usually becomes high, the pulse running some thirty or forty beats higher than in health, the skin being very dry and constricted, and the irrita- bility and restlessness marked. These symptoms may be so pro- minent as to completely overshadoAV the symptoms of spinal in- flammation, the patient not even complaining of pain, unless his attention is directly called to it. It will be noticed, hoAvever, that the slightest movement or changing the position of the body gives rise to pain, and when the attention is thus draAvn to it the soreness of the spine will be continually noticed. Deep pressure usually elicits tenderness, and sometimes the sensibility is so ex- quisite that the patient cannot bear to be touched. As the disease progresses, the feA'er assumes an irritative or typhoid type. The tongue soon becomes broAvn, and sordes ap- pear on the teeth. Typhomania occurs about the sixth or sev- enth day, and is frequently attended Avith looseness of the bowels. Sometimes there is marked irritation of the brain and delirium, at others a stupor which soon passes into deep coma. As the local disease progresses, it is found that the loAver extremities are subject to involuntary movement, and that the patient has but partial command over them ; and that the bladder and rectum are evacuated Avithout the knowledge of the patient, or there is retention of urine without the power of discharging it. At last, in severe cases, paralysis of the parts beloAv the seat of inflamma- tion is complete. The fever is usually continued, though some- times remittent, and is invariably ataxic, presenting well marked typhoid symptoms, with the exception of diarrhoea, by the tenth to the twelfth day. It is usually protracted, lasting from tAvo to eight or ten weeks. SPINAL MENINGITIS. 399 Diagnosis.—"We diagnose inflammation of the spinal cord by the marked tenderness of the spine and inability to move, the constant pain in the back, Avith the severe attendant ftwer. It is almost impossible to overlook these local symptoms, and yet in nianv cases they have been disregarded, to the great detriment of the patient. Prognosis.—The prognosis is usually favorable, if treatment is commenced in time, but is unfavorable after it has made prog- gress for scA*eral days, in many cases terminating fatally, or in paralysis. Post-Mortem Examination.—In some cases there is marked evidence of determination of blood to the membranes, and en- largement of the vessels. Sometimes the membranes are thick- encd, and fragments of organized lymph on the free surface; there may also be flocculi in the fluid of the spinal cord, Avhich is increased in quantity. In other cases the disease seems to be confined to the pia-mater and the substance of the cord, the for- mer being slightly reddened, and sometimes thickened, and the latter softened, sometimes so much as to have lost all traces of organization. Treatment.—The treatment of this disease will vary accord- ing to the indications. In some cases Aconite or Veratrum, with Gelseminum, will be the remedy, and as the pulse and tempera- ture come d >avh, Ave find the symptoms of spinal irritation re- duced, in other cases the indications for Rhus Avill be marked, and it will be associated Avith Aconite. Bryonia is indicated by the steady pain in the spine, with possibly a flushing of the right cheek. Macrotys will be indicated by muscular pain, as in other cases; Sticta by the pain in shoulders and neck to the occiput; Phytolacca by soreness of the mouth and throat, and fullness of cervical glands. In some cases, the attack being sudden and seA'ere, and the patient suffering from nausea or disgust for food, drink, or medi- cine, avc find a full, dirty tongue, and conclude that the treat ment had best be commenced Avith an emetic. The Acetous Emetic Tincture acts Avell, but in many cases Ave Avould prefer Ipecac in doses of tAvo or three grains every fifteen minutes to free emesis. With a broad, pallid and dirty tongue, sulphite of soda will be indicated in the usual doses. If the tongue is red, and covered with a glutinous yellow coat (like fecal material) 400 diseases of children. sulphurous acid is the remedy. When the face is full and pur- plish, like one who has been exposed to severe cold, Baptisia is given. When the temperature is high Ave may sometimes obtain ex- cellent results from the cold Avet-sheet pack. It requires a little courage to use»it, for both child and parents are afraid;- still, if avc have a severe case, and the stomach is irritable, so that avc do not see our Avay clearly Avith other remedies, Ave Avill use it. If the case is severe, and there is marked impairment of the skin Avith exhaustion, I think Avell of the hot-blanket pack. In place of this, rapid sponging of the surface Avith hot water ansAvers well, (it should be done before a fire, and the surface protected against chill by a blanket.) Any part that the patient complains of may be thus sponged. The local applications to the spine (if Ave use any) Avill vary Avith the case. Sometimes dry cups give relief. In other cases hot spongings, or hot packs, hot bran, or a bag of hot salt, to the part, is of benefit. I do not have much faith in liniments, and am inclined to believe that rest is better than the rubbings. As the inflammation passes aAvay the child may have some of the simpler bitters, quinine inunctions, the hypophosphites, cod- liver oil, or some of the preparations of malt. CURVATURE OF THE SPINE. Curvature of the spine occurs most generally in the youno- and is rare after the age of twenty-five. In all cases it is the result of enfeebled vitality, either congenital or induced by des- titution, over mental exertion, or sexual excitement. In some cases this manifests itself in the form of scrofula or tuberculosis and in such case avc may expect disease of the bones. Tavo va- rieties of curvature are met with, lateral and posterior, both oc- curring most frequently in the dorsal region, though at last always compensated by curvature of the lumbar and cervical portions. Lateral curvature may be dependent upon affections of the muscles, as hypertrophy, atrophy, spasmodic contraction or inflammation; upon general debility, the body not being suffi- ciently strong to support itself in the erect position ; upon obli- quity of the pelvis, the result of injury or disease of the lower extremities; upon altered capacity of one side of the chest ; upoi rachitis or softening of the bones, or defective development of CURVATURE OF THE SPINE. 401 the vertebra. Posterior curvature is most generally dependent upon disease of the bodies of the vertebra, though in some cases it undoubtedly results from debility, and the habit of throwim' the head and shoulders -forward in sitting and walking; in the last case being very mild. Practically we have to study the case, first, with reference as to Avhether it depends upon disease of the muscles or bones ; second, Avhether its continuance depends upon determination of blood or upon feeble circulation; and third, as regards the general health, Avhether there is simple debility from imperfect digestion and assimilation, or a scrofulous or tubercu- lar cachexia. The success of the treatment will depend upon accurate diagnosis as regards these points, as in many respects it must differ in different cases. Symptoms.—The symptoms of curvature of the spine vary greatly in different cases, in some being very marked, and in others obscure. Usually the child's health is noticed to he fee- ble, its appetite variable, and digestion and assimilation imper- fect. It may or may not complain of pain in the back, but it Avill be noticed that the back is weak, and that it makes unusual efforts to rest it. In lateral curvature, the disease is most usu- ally dependent upon local debility of the erector muscles of the spine, and there is frequently no complaint, except from Aveak- ness of the back, and the symptoms of general debility above named. If partially owing to spasmodic action, pain Avould be a constant attendant, though usually there Avould be no tender- ness on pressure. If the result of disease of the bones, as in most cases of posterior curvature, in addition to more or less pain, there will be tenderness on deep pressure. In these cases the disease of the bone causes irritation of the spinal.cord, and avc have the symptoms heretofore named. Diagnosis.—An examination of the spine Avill determine the existence of curvature, and it is usually not difficult to de- termine Avhich is the primary and which is the curvature of com- pensation. In almost all cases of lateral curvature Ave will find the fault to exist principally in the muscles at first, though as the disease progresses, irritation is frequently developed, result- ing in spasmodic action, and finally in atrophy or softening of the bones; hence spinal tenderness will usually result in the lat- ter part of the disease, and not at is commencement. In poste- 2d 402 DISEASES OF CHILDREN. rior curvature, Ave sometimes have the most marked evidence of scrofulous cachexia, and in most cases Ave have marked general debility. It wiLI be recollected that the disease of the bodies of the vertebra may be a true inflammation, or result from deposit of tubercles and scrofulous material, or may be simple softening from rachitis. In the first case the pain will be marked and de- cided, in the second there is simple irritation and aching of the part, Avith tenderness on pressure; and in the last Ave will have the previous curvature and deformity of the legs and pelvis, in addition to the absence of pain and tenderness, to aid us in the diagnosis. Mr. Solly believed that softening of the bones might be entirely local, and might be dependent upon nervous exhaustion ; in such case the symptoms Avould be obscure. Prognosis.—In lateral curvature a favorable prognosis may be given in many cases, the deformity being nearly entirely re- moved, or it maybe simply arrested, the body so accommodating itself to it as to giATe rise to but little subsequent trouble. In posterior curvature the best results usually obtainable is to stop the disease and prevent further curvature. It is true that in some eases Ave may partially correct the deformity, but in a large majority the attempt is attended with injury rather than benefit. If there has been destruction of the bodies of the vertebra the best result is anchylosis of the bones and of course permanence of the curvature; and if this is prevented by instruments for extension, the life of the patient will almost surely be sacrificed. Treatment.—In all forms of spinal curvature attention to the general health is one of the most important points in the treatment. Those bitter tonics that improve the tone of the stomach, and give the patient a good appetite and poAver of di- gestion are applicable. For the selection of these remedies, the reader is referred to the first part of this Avork, "restoratives," which will enable him to select the best remedy. If there is disease of the bones assuming the form of softening, phosphoric acid has been recommended; and from the little experience I have had with it, I am inclined to believe that it Avill generally be found advantageous ; Ave Avould commence its administration in doses of tAvo drops of the dilute acid, four or five times a dav, and increase it if deemed best. Phosphate of soda may be given with the food in such quantities as will keep the boAvels soluble. CURVATURE OF THE SPINE. 403 Simple lime Avater is sometimes useful, and children will improve Avhen it is added to their milk. Even common salt becomes au important remedy avIicu children have not had it in sufficient quantity (bottle babies), and added to their milk there is a deci- ded improvement. Hypophosphitc of lime, the compound syrup of the hypophosphites, and some of the phosphates, may also be thought of. Occasionally veratrum and arsenic in small doses Avill improve the appetite, digestion and bloodmaking. When the symptoms Avould lead us to believe there was scrof- ulous disease of the bones, the ATegetable alteratives may be brought into requisition. A combination of yellow dock and tag alder, with small portions of acetate of potash has ansAvered my purpose Avell. If there is great irritability of the nervous system I Avould substitute the bromide of ammonium for the prepara- tions of potassa. These remedies should not take the place of tonics and restoratives, but should be associated with them in such manner as that normal digestion and assimilation shall be the first object in v'icav. A nutritious and easily digested diet should be prescribed, and frequently a small amount of malt liquor is advisable. The sponge bath should be used daily, sometimes of simple water, salt and Avater, or stimulants, as cap- sicum or mustard, or the mineral acid baths, or of a decoction of the bitter tonics and astringents. If there is simple loss of muscular poAver, as in many cases of lataral curvature we would recommend open air exercise, and fric- tion of the spine with cold salt Avater, and sometimes the use of elec- tricity. These are the only cases in Avhich exercise is permissible, and then it should be so regulated as not to prove exhaustive. Sir B. Brodie recommends that the muscles of the back be strength- ened by climbing and other exercises, for which, in delicate girls, friction or shampooing for an hour or two daily might be sub- stituted; and the patient should lie down for a part or a Avhole of the time she Avas not engaged in exercise. Mechanical support may be used in these cases, but it should always permit free movement. If in any case there is irritation and pain, with ten- derness on pressure, the child should maintain the recumbent position, and especially is this the case in posterior curvature. Rest is all-important in these cases, until the disease is entirely arrested, and though it will sometimes seem as if the child could not bear the continued confinement, Ave Avill find that it absolute- ly improves in every respect, while maintaining the nfost perfect 404 DISEASES OF CHILDREN. quiet. Counter-irritation is of niuch importance in these cases, but we must be careful not to carry it so far as to unduly irritate the nervous system, or induce debility by the excessive discharge. The irritating plaster is a favorite application, and av'i.11 .usually be found the best of any. It may, in severe cases, be replaced by the issue, and in others by two, three or four small setons, as ( common surgeons' silk, passed through a fold of the skin on i each side of the spine. In cases of the diseases of the bones, Dr. Pirrie remarks, "That any attempt to remove the curvature Avould be injudicious. Anchylosis is the only favorable termination to be hoped for, and therefore the object to be aimed at in treatment should be to [dace the patient under circumstances most likely to conduce to that result. With that vieAV, it is indispensable, first to keep the patient in a recumbent position, so as to remove from the diseased parts the pressure of the superimposed Avcight, and to preserve the parts in a state of perfect quietude in that position ; and secondly, to use all means, judicious and available in the cir- cumstances of the case, for maintaining the general health. One particular advantage Avhich results from preserving the parts at rest in the horizontal position, is that the removal of the irrita- tion caused by the superincumbent weight froni the diseased parts diminishes the danger of the formation of abscess, Avhich is a most unpromising occurrence, and must induce the gloomiest apprehensions as to the ultimate result." A most excellent means of attaining perfect rest is afforded by a common camp cot, Avith the head elevated about a foot, and covered Avith a soft hair mattress; tAvo crutches softly padded, should pass from the foot up to the arm-pits, and an india-rubber webbing attached to the arms of these to support the trunk. In this apparatus there is constant gentle extension ; the body is supported by the Avebbing, the patient lying on the back, or face doAviiAvard, as seems best suited to the case. For full description the reader Avould do Avell to consult Bigg on Deformities, the second volume containing most explicit descriptions of apparatus and well-drawn wood-cuts. EPILEPSY. 405 EPILEPSY. • Epilepsy is one of the most serious of the diseases of the nerv- ous.system, not because of its fatality, for it runs a very chronic course, but because there is no tendency to spontaneous arrest, and meplicine has heretofore had very little influence upon" it. One of the most distressing features of the disease is,, that it grad- ually impairs the mind, until the person, once bright and of sound mind, becomes a driveling idiot or a raving maniac. The disease usually commences in childhood, most frequently be- tween the ages of six and tAvelve. The causes of epilepsy are various, and not very well under- stood. They may be divided into intrinsic and extrinsic, in the first case existing in the cerebro-spinal nervous centers, or their immediate surroundings, and in the second existing at a distance, and affecting the spinal cord through the nerves. Of the first, Ave may instance inflammation and determination of blood to the cerebro-spinal centers, disease of the meninges and of the boAV- els, and injuries of the bones, giving rise to compression ; or con- tinued irritation, as by the presence of a spicula pressing the nerve-substance. Derangements of the blood may sometimes give rise to epilepsy, as in the retention of the solids of the urine and other changes that Ave are not cognizant of. By an extrinsic cause, Ave understand one in Avhich the irritation being set up at a distance is propagated along the nerve trunks to the spinal cord, where, setting up an irritation, it manifests itself through the excito-motprvvsystem of neiwes. The most simple instance of this action is Avitnessed in the case of cramps of the muscles of the extremities from irritation of the intestinal canal, as in cholera morbus, and in the case of infantile convulsions from teething or from gastro-intestinal irritation. Epilepsy may in this way arise from irritation of the stomach from crude indiges- tible food, from Avorms, from irritation of the boAvels, the kid- neys, or bladder, or genital organs. The cause being sufficient to set the disease going, may disappear entirely in a feAV days or Aveeks, and yet the epileptic attacks continue. It Avould seem that Avhen this abnormal action is once set up, the tendency to its continuance is the same as in healthy functions; but Avhy this is Ave know not, and neither can Ave give any probable theory. As regards the pathology of epilepsy, we are much in the dark. 406 DISEASES OF CHILDREN. In some cases it Avould seem to be dependent on a too free circu- lation of blood in the nervous centers—determination of blood; in other cases upon a sluggish circulation—congestion; and in still others, upon some defect in nutrition. There are cases in which it is very manifest that the condition of the blood is the exciting cause of the epileptiform seizure, though we must still imagine an unnatural irritability of the nerve centers to be so impressed. Thus, I have seen cases in Avhich every convulsion Avas preceded by deficient secretion of urine ; and so long as this secretion could be maintained in the normal condition, so long would the patient be free from its seizure. Cases in Avhich the disease is dependent upon the amount and character of the men- strual discharge, have come under the notice of almost every one. Experience, hoAvever, has proven to me, that epilepsy is eminently a disease of debility of the nervous system, even in cases in which there seems to be the most evident symptoms of irritation and determination of blood. Dr. Radcliffe has Avritten a most interesting paper on the pathology of convulsions, and draAvs the folloAving conclusions: "1st. The epileptic and epileptiform paroxysm is not unfre- quently preceded by signs of defective respiration. 2d. It is usually accompanied by a state of unmistakable suffocation. 3d. The condition of respiration during convulsion is one Avhich supports the notion that the convulsion is connected with de- pressed and not with exalted vital action. 4th. In the chronic form of convulsive disorders, the inter-paroxysmal condition is usually marked by evident signs of feeble circulation. 5th. The epileptic and epileptiform paroxysm is usually if not invariably preceded bv signs of failure in the circulation. 6th. In the fullv developed paroxysm, the pulse is sometimes aroused to a con- siderable degree of activity, not because the arteries are receiving a largely increased supply of red blood, but because they are then laboring under a load of black blood, as they are found to labor during suffocation. 7th. Convulsion is never co-incident witli a state of active febrile excitement of the circulation. 8th. Epileptiform convulsion is a direct consequence of sudden and copious loss of blood. 9th. The condition of the circulation during convulsion is one which supports the notion that the convulsion is connected with depressed and not Avith exalted vital action." 9 EPILEPSY. 407 It is of but little use to try to study the original cause in many cases of epilepsy, for as has been remarked, it has possibly passed aAvay months before our examination. There is ahvays, however, an exciting caus^ which it is necessary to determine, if possible, as upon its removal, the success of our treatment will in great measure depend. I have knoAvn it to be a failure of excretion, an imperfection in digestion, derangement of the menstrual function, excessive mental emotion, and not unfre- quently excessive sexual excitement. Symptoms.—In some cases there are brief premonitory symp- toms of the approaching seizure, and rarely, the patient has no- tice of it for hours. The sensations differ in different cases: sometimes a sense of Aveight and oppression in the head, with giddiness and loss of voluntary poAver ; in others, a coldness pass- ing from the feet upAvards, and terminating in the epileptic seiz- ure when it reaches the head. In the more protracted cases, there is usually a marked dullness and hebetude, noticed by the friends, and the patient feels a loss of consciousness that is very unpleasant. In an attack of epilepsy the patient becomes suddenly uncon- scious and falls to the floor, or wherever he may be situated. Involuntary movement from spasmodic; contraction and relaxa- tion, is characteristic of the disease, and may be very intense or mild. If severe, the limbs are thrown in various positions, the trunk contorted, and the features remarkably changed. First one group of muscles contract and then another, so that parts are kept in constant movement. The lower jaw and tongue be- ing also affected, Ave find that usually the latter organ is severely bitten, if means are not taken to avoid it. The patient usually froths at the mouth ; respiration is normal in frequency, and the pulse but little changed, except that it is smaller and feebler. The countenance is not only distorted by the convulsion, but in some cases is turgid and purplish, or almost black. Frequently the urine, and sometimes the feces, are passed involuntarily dur- ing its continuance. The duration of the epileptic seizure is very variable, some- times lasting but a feAV seconds, and at others for fifteen or twenty minutes. The patient may have but one attack at a time, or they may succeed one another at short intervals, until quite a large number ha\*e passed. When the attack ceases, the patient 408 DISEASES OF CHILDREN. becomes completely relaxed, and usually falls into a deep, coma- tose sieep, from Avhich it is almost impossible to arouse him for an hour or 'two. The frequency of their recurrence varies in different cases; in some they do not appear oftener than once a month ; in others every Aveek, or almost every day. Sometimes thev are so distinctly periodic that the return can be closely cal- culated, but at others they are very erratic in their course. In many cases there are slight seizures during the. intervals betAAreen the principal attacks; in these the patient seems to lose conscious- ness for but a moment, and stares vacantly at persons present; passing 'off, he has no recollection of it, nor of the epileptic attack. Diagnosis.—We diagnose epilepsy from apoplexy by the fact that in the first there is continual spasmodic action, Avhile in the last there is not the slightest motion ; in the one there is frothing at the mouth, in the other it occurs but rarely ; in apoplexy the respiration is slow and stertorous, and the pulse full and sloAAr, Avhile in epilepsy respiration is of usual frequency Avithout ster- tor, and the pulse is small and frequent. We diagnose it from hysteria by the previous history of the case, and by the fact that Ave are able to determine that there is not complete loss of con- sciousness in the latter case. Prognosis.—So. far as regards the cure of the disease, the prognosis is unfavorable, unless the means here •recommended prove more serviceable than those heretofore used. But, as be- fore remarked, it runs a course of years, and the patient dies finally of some other affection in a great many cases. Post-Mortem Examination.—In a majority of cases the scalpel reveals no lesion to account for the severe disturbance of the system during life, and what lesions are found generally have no relation to the epileptic affection. In some cases the evidence of sIoav inflammatory action is found in the brain or spinal cord, or, in rare cases, a morbid growth in the nervous substance, or from the meninges or bones, is observed, and in others a change of structure, usually softening, has occurred. These, hoAvever, form but a small fraction of the cases. In other instances some organ, as the stomach, kidneys, uterus, etc., is found diseased, and as the epilepsy made its first appearance Avith the symptoms of these diseases, Ave have good reasons to believe that they acted as exciting causes. epilepsy. 409 Treatmknt.—The treatment in the^e cases is of two kinds: that for the arrest of the paroxysm, and that for the radical cure of the disease. If called to see a person suffering from an attack of epilepsy, Ave would place the patient in such a position that he Avould not be likely to injure himself, and. if the convulsive action Avas severe, get a friend to hold a cork or piece of soft wood between the teeth.to prevent .bjting the tongue. Usually this is all that ismecessary, except in cases Avhere the patient has a succession of attacks. In these cases, as soon as the first par- oxysm commences passing- off", avc may administer the compound tincture of Lobelia and.Capsicum in half-teaspoon ful doses every five or ten minutes, until-nausea is .induced,, which, in a large majority of cases, will,prevent a return of the convulsion; or avo may use the tincture of Gelseminum for the same purpose, giving it in doses of from ten to twenty drops, or even half a drachm of the common tincture, every ten or fifteen minutes, un- til the full relaxant influence of the remedy is produced. A com- bination of sulphuric ether, liquor ammonia, and tincture of asa- fetida may be used for the same purpose, but it is not as efficient as the preceding measures. If need be, stimulant applications may be made to the loAver extremities and.to the spine, but usu- ally this is not necessary. As regards a radical cure, Ave may attempt it in all cases in which there is no structural lesion of the spinal cord or brain, or their enclosures, to account for the disease. If there is, the case becomes one for the surgeon rather than the .physician, though operations thus far have proven very unsuccessful. If we can detect any lesion of function, especially if it seem to bear a rela- tion to the epileptic seizure, Ave would employ remedies for its removal. Thus, in rare cases, a cure will result from the removal of Avorms, and relief of irritation of the intestinal canal; from the relief of menstrual irregularity; by establishing and maintaining free secretion of the kidneys, Avhen functional lesion of these organs has been prominent, etc. In some cases the disease ap- pears to be dependent upon spinal irritation and determination of blood, and occasionally a cure may be effected by the use of the irritating plaster to the spine, the administration of tincture of Gelseminum and the use of those other measures recommended under the head of spinal irritation. Belladonna, ergot, and mix vomica may be used Avhen there seems to be feeble circulation in the nervous substance and tendency to congestion, manifested 410 DISEASES OF CHILDREN. by symptoms of paralysis, or a feeling of deadness, coldness, or tingling as if the part were asleep. In a large majority of cases, however, there is no lesion that would seem sufficient to occasion the epileptic seizure ; and even where there is, and Ave have removed it, and restored all the functions of the system, the nervous disease Avill still continue. Here our treatment will be, to a great extent, empirical; it is true Ave correct all lesions of function, and try to get the sys- tem in as healthy a condition as possible, but after this Ave give remedies simply because they have proven efficient in other cases. I have employed the bromide of ammonium in my prac- tice, Avith the most marked success, sometimes using it alone, and at others in combination with other remedies. I prescribe it in the proportion of half an ounce of the salt to four ounces of water, of which the dose is half a teaspoonful four or five times a day. If we are to expect success, the remedy must be perse- vered with, and if the quantity named is not sufficient, it should be increased to such an extent as to hold the paroxysms in check. After twenty years experience, I can still recommend the bromide of ammonium, especially in early life, having cured scores'of cases Avith it. Do not substitute bromide of potash for it, for this remedy has a Avidely different field. If the patient is stout, has a vigorous circulation, and suffers from excitement of the reproductive organs, bromide of potassium is the remedy. Some most persistent cases have yielded to this treatment, and I am in hopes that it Avill prove curative in many of these distress- ing cases. All undue excitement must be avoided in epilepsy, the sufferer leading the most regular life. Some employment should be fur- nished that Avould amuse the mind, and keep it normally active, but much mental exertion is injurious; novel reading, -or any- thing in which the mind becomes deeply absorbed, proves hurt- ful. Above all things else, excessive sexual excitement is most injurious, either as solitary vice or irritation of the organs from disease, and it Avill become the practitioner's duty to examine into the case Avith reference to this matter, and give the neces- sary advice and treatment. CONVULSIONS. 411 CONVULSIONS. Convulsions occur far more frequently during childhood than after puberty, though they may be occasionally noticed at all ages. The causes giving rise to them are various. Sometimes they are produced by disease of the brain and spinal cord, as in determination, inflammation, and some obscure structural lesions; at others they arise from an external irritation, it being trans- mitted to the spinal cord, and giving rise to excited reflex action. According to Dr. Marshall Hall, convulsions are dependent upon irritation of the true spinal system, and though this occurs in some cases from causes acting directly upon the nervous system, it more frequently depends upon an irritation of some distant part transmitted to the spinal cord through the nerves. Thus, Ave find convulsions arising in this Avay during dentition, from crude or acrid ingesta, from irritation of the stomach or bowels, from the irritation produced by Avorms, and from inflammation of internal organs, or disease of the surface, attended with great irritation and pain. Symptoms.—If convulsions occur during disease, they are generally preceded by tolerably Avell-markedsymptoms, by Avhich the close observer may anticipate their approach ; and though not ahvays constant it is well to give them due consideration. The most marked of these is a sudden, jerking, involuntary movement of the extremities, and quick grasping movement of the hands. This Avill be observed as Avell Avhen the child sleeps as Avhen aAvake, and is sometimes increased by motion. Usually the child sleeps with its eyes partly open, and Ave ob- serve that the globe of the eye is drawn upward and rolled about, and this involuntary movement of the eye may be fre- quently noticed Avhen aAvake. With these symptoms there may be excitement of the nervous system, manifested by restlessness, fits of crying in children, and sleeplessness ; or Ave may have the reverse, the patient being dull, impassible and somnolent. The attack is always sudden, the patient losing consciousness, and being to a great extent insensible. The convulsion is usu- ally very marked, but in some cases Ave find it slight or entirely absent, the patient being rigid and remaining in one position. Respiration is labored, in many cases very markedly so, and in 412 DISEASES OF CHILDREN. the.^e the countenance is turgid and purple, and the features distorted. The pulse is very frequent and small, or it is soft, feeble and small, and but little increased in frequency. In the severer cases, deglutition is almost impossible, and from the fall- ing backward of the tongue respiration is snoring. These symp- toms may continue for a moment or tAvo to fifteen minutes, or half an hour, in the milder cases terminating in a return of con- sciousness, but the severer in a deep sopor, from 'which the patient can .'not be aroused. One convulsion may terminate the attack, biit in many eases one succeeds another' for from one to twenty-four hours, The. interval betAveen the spasms is fre- quently marked by nothing more than a relaxation of the entire system, ami restoration of the poAver of deglutition, the patient being in a semi-comatose condition, and totally unconscious. Children haying convulsions once, are usually more liable to them than others, and they Avill frequently come on from slight causes. Diagnosis.—The diagnosis of convulsions is very easy, there being no possible chance of mistaking the symptoms. The sudden loss of consciousness, convulsive movement, difficult res- piration, and frequent, small pulse, can not be confounded with any other disease. It is true that Ave can not distinguish between simple convulsions and epilepsy, except by the lapse of time. Prognosis.—The prognosis is usually favorable, though it is very difficult in some cases to arrest the convulsive action. Oc- casionally cases Avill be seen that Avill prove, fatal in spite of treatment. 4 Post-Mortem Examination.—The scalpel reveals no con- stant lesion to account for the symptoms. When there has been determination to or inflammation of the brain, Ave of course will find the evidence of these lesions. But when the disease has arisen from an extrinsic irritation, there is not the slightest evidence of disease of the nerves. Treatment.—Our primary object is to arrest the spasmodic movement which is so alarming to the friends, and, no matter hoAv often seen, to some extent so to the practitioner. Calmness and decision are very important requisites in this case, as all around the patient is excitement, and a hundred expedients to benefit the sufferer are proposed. CONVULSIONS. 413 A quick examination of the patient Avill enable us to clasify our cases into tAvo groups, and select the appropriate remedy. In the one there is marked vascular excitement, Avith irritation and determination of blood to the brain and spinal cord; in the other the circulation is feeble, and the condition is one of atony. In the first case the remedies are sedative, in the second they are stimulant. If the convulsion passes off so that remedies can be given by mouth, Ave will add to a half glass of water Tinct. of Aconite or Veratrum (as indicated) gtt. v., Tinct. of Gelseminum gtt. x. to gtt. xxx., and give a teaspoonful every ten or fifteen minutes, until the convulsions are arrested, then less frequently. If there is a markedly pinched expression about the eyes or base of the brain, Rhus will take the place of Gelseminum. It is especially indicated by sudden startiugs and a shrill cry (cry encephalique). If the patient has been suffering from severe pain, and the convulsions have come On during a paroxysm of it, Ave Avould give—I$s. Hydrate of Chloral oij., syrup, Avater, aa. ry., a half teaspoonful or teaspoonful sufficiently often to arrest the convulsions. Sometimes the single dose will be sufficient, some- times the child will require as niuch as a half ounce of the mixture. When the patient is full blopded,and the face and neck are full or red, Bromide of Potassium may be added to the mixture. Asafoetida is a remedy Avhen there has been irritation of the stomach and intestinal canal, with gaseous accumulation. It is a stimulant, and ought to be classed with the second group, but the gastro-intestinal irritation is the best indication. Of the second group of remedies (.stimulants), Lobelia will take the first place. It is indicated by an oppressed circulation and respiration, fullness of tissue, and Avant of expression, when the convulsion has passed off. Frequently Ave prescribe from our pocket-case— ^ Tinct. Lobelia Seed gtt. x. to gtt. xx., water 5iv.; a teaspoonful every fifteen minutes until the convul- sions have ceased. If Ave have it at hand, the old-fashioned Comp. Tincture of Lobelia and Capsicum may be given in doses of half to one teaspoonful, to nausea and vomiting. Sulphuric ether is a good remedy in these cases, and may be given in doses often drops on sugar or in mucilage, and repeated frequently. It may also be used as an anaesthetic. Chloroform may occasionally be given internally in doses of 414 DISEASES OF CHILDREN. ten drops, but I prefer to use it by inhalation. If the convul- sions are severe, Avith but little interval between them for the administration of medicines, or if, OAving to their severity, Ave can not see the indications for remedies, chloroform should be used by inhalation to the extent of complete arrest of convulsive action, and continued until Ave are satisfied that Ave have the case Avell in hanJ. The indicated remedies should be given as soon as the patient can sAvalloAv them. One of the best, if not the very best remedy to prevent a re- currence of convulsions Avhen they have been arrested, is the bromide of ammonium. For children I usually prescribe it 3>j- to Avater 5iv., and give teaspoonful doses as often as may be re- quired (usually every three or four hours). It may be givTen for the arrest of convulsions in some cases with most excellent results. When children are inclined to convulsions the preparation of bromide of ammonium should be kept in the house, and its ad- ministration directed Avhen the child sIioavs the slightest symp- toms of convulsive action. As convulsions of childhood will sometimes run into confirmed epilepsy, Ave can not be too much on our guard. I prescribe the remedy under consideration, and insist that there shall never be any neglect to administer it if indicated. If a hot foot bath can be rightly used, it Avill be of advantage in many cases; there must be a bucket of Avater, so that the legs may be immersed to the knees; it must be as hot as the child can bear it, and hot water must be added every ten minutes to keep up the temperature, and both child and bucket must be sur- rounded by a blanket or shaAvl. Thirty minutes is the least time for using^the hot foot bath. The sitz bath may sometimes be employed Avith the same pre- cautions, and even a general bath. When, hoAvever, there is need of stimulating the skin, the hot blanket pack may be used, or the child may be rapidly sponged with hot water. When the temperature is very high, and the head hot, an enema of five or six ounces of cold Avater, Avith a teaspoonful of tincture of lobelia may be given. If there is marked prostration hot Avater may be used for this injection and Compound Tinct. of Lobelia and Capsicum added. If we are satisfied that the convulsions are due to irritant or crude ingesta, an emetic may be given at once. Ten grains of Ipecac, any preparation of Lobelia, or even salt Avater, will CHOREA. 415 ansAver our purpose. If Ave have reason to believe that there is irritant material in the intestinal canal, use an enema of Avarm Avater to Avhich Ave have added compound powder of jalap and senna oss. in the treatment of disease avc Avant to notice the symptoms of convulsions Avhen they first appear, that remedies may be selected to remove them. "Au ounce of prevention is Avorth a pound of cure," at least it saves us much trouble. Gelsemi- num, Belladonna, Rhus, Lobelia, Apis, Veratrum, Bromide of Ammonium, as indicated, Avill usually relieve the nervous irrita- tion. The rule may be repeated—"the indicated remedy is the remedy to prevent convulsions." CHOREA This affection, knoAvn commonly as St. Vitus' Dance, occurs most generally about the age of puberty, though it sometimes appears as early as the sixth or eighth year, and as late as the thirteenth, and in some cases later than this. It is confined principally to the female sex, but in rare cases it is met Avith in the male. Most generally it is associated Avith some derange- ment of the sexual organs, and it is not unfrequently associated Avith hysteria. We usually find it in persons of feeble health, and precocious mental development, but in some cases, in persons of the opposite character, in which it may be induced by torpor of the liver and boAvels, deranged secretion of the skin and kid- neys, and from close confinement or sedentary occupations. The modern disease received its name, doubtless, from the dancing manias of the middle ages. The "dancing plague" or St. Vitus' dance, commenced in Strasburg, in 1418, and is thus described by Burton : "Chorus Sanctce Viti, the lascivious dance, as Paracelsus calls it, because they that are taken with it can do nothing but dance till they are dead or cured. It is so called for that the parties avc re wont to go to St. Vitus for help, and after they had danced there a while they were certainly freed. 'Tis strange to hear how long they will dance, and i:i Avhat manner, over stools, forms, tables; even great-bellied Avomen sometimes (and yet never hurt their children) Avill dance so lotig that they can stir neither hand nor foot, but seem to be quite dead. One in red clothes they can pot abide; music 416 DISEASES OF CHILDREN. above all things they love ; and therefore magistrates in Ger- many Avill hire musicians to play to them, and some lusty, sturdy companions to dance Avith them." Another form of the dancing mania, termed St. John's dance, commenced in 1374, and extended over the greater portion of Europe. "At Cologne the number possessed amounted to more than five hundred, and at Metz the streets are said to have been filled with eleven hundred dancers. Peasants left their ploAVS, mechanics their Avorkshops, houseAvives their domestic duties, to join the wild revels, and this rich commercial city became the scene of the most ominous disorder; secret desires Avere excited and tAvo often found opportunities for wild enjoyment; numer- ous beggars, stimulated bv Aice and misery, availed themselves of this new complaint to gain a temporary livelihood. Girls and and boys quitted their parents, and servants their masters, to amuse themselves at the dances of those possessed, and greedily imbibed the poison of mental infection. Above a hundred un- married Avomen Avere seen roving about in consecrated and mi- consecrated places, and the consequences Avere soon perceived ; gangs of idle vagabonds, who understood Iioav to imitate to the life the gestures and convulsions of those really affected, roved from place to place seeking maintenance and adventures, and thus, Avherever they Avent spreading this disgusting spasmodic disease like a plague; for in maladies of this kind,' the suscepti- ble are infected as easily by the appearance as the reality." (Hecker.) This gives the origin of the name of the affection Ave are now considering, and though there is no similarity between the ancient and modern St. Vitus' dance, the description just given illustrates the case Avith which nervous affections of this kind may be propagated. And it is a fact, proven by numerous in- stances in hospital practice, that attacks of hysteria, epilepsy, and chorea, Avill be excited by witnessing the malady in another. As regards the pathology of the affection, avc must conclude that there is an irritation of the true spinal cord, arising some- times from debility, and at others from extrinsic causes of irri- tation. In either case the excitation of the nervous system is indicative of debility, rather than strength, and in many cases is based upon feeble nutrition of the nerve substance. • CHOREA. 417 Symptoms.—The first CA'idences of chorea are occasional invol- untary movements of the hands and the facial muscles, and an inability to sit quietly in one position. Very frequently the fingers are quickly and involuntarily moved, and when the pa- tient uses the hands it is with a quick unnatural movement. As the disease progresses the involuntary movements become continuous, some part of the body being constantly in motion, and the movements arc now very much exaggerated. If the v CO patient attempts to do anything, she seems to have but partial control over her muscles, and while they are being directed to the end intended, they are going through a succession of move- ments entirely independent. So great is this, sometimes, that the patient can not sit still, nor even keep the hands quiet for a moment, and her Avalking is irregular from the same cause. The facial muscles are sometimes very much involved, and the attempt to speak, or give expression to the emotions, is folloAved by various contortions of the couutenance, which would be laughable were they not connected Avith so serious a malady. Sometimes it is almost impossible for the patient to express her- self intelligibly, owing to spasmodic action of the muscles of the mouth and of the larynx. As before remarked, the general health is usually impaired previous to the commencement of the disease, and this becomes more marked as it progresses; symptoms of anaemia are of com- mon occurrence, the skin being blanched, the pulse feeble, the lips and gums pale, variable appetite, imperfect digestion and constipation of the boAvels. The mind is more or less affected, the patient being low spirited, and desiring solitude, the counte- nance being pale, languid and vacant. In some instances con- firmed chlorosis will be developed during the progress of the disease. It Avill be noticed, that the child has no disposition to play or to take exercise, and does not desire to associate with others, but prefers rather to get Avhere her infirmity will not be noticed ; the sensitiveness in this respect being sometimes very great. Diagnosis.—Chorea is marked by such distinctive symptoms that it is easily recognized, the continual partly voluntary and partly involuntary movements not being observed in any other disease. Prognosis.—Though in some cases very obstinate, the disease is almost ahvays curable. It may last for tAvo or three Aveeks, 27 418 DISEASES OF CHILDREN. or as many months, and in some rare cases for years. Usually it disappears as the general health is improved. Post-Mortem Examination.—In fatal cases the evidences of anaemia are usually very marked, the tissues being very pale, soft and flaccid. The different organs have been found more or less diseased, but these Ave re complications and bore no relation to the spasmodic action. We Avould expect to find lesions of the brain and spinal cord; but except in those cases terminating in general convulsions, or in inflammation, no change of structure has been noticed. Treatment.—Various plans of treatment have been adopted, and many remedies used as specifics in this affection, and as is usual, Ave find that Avhere the means are so abundant they are not very efficient. We bad much better adopt a rational plan of treatment, by correcting any dyscrasia, and getting a normal performance of the various functions of the body, rather than depend upon any one remedy, no matter how highly it is praised. The disease is intimately related to rheumatism in many cases and the remedies Avill be selected from the class of anti-rheu- matics, to Avhich the reader is referred. Macrotys probably stands first on the list, as it has probably benefited more patients than any other remedy. In some cases it is given alone, in others it may be combined with Aconite or Veratrum, in others with Va- lerian, and in still others Avith Arsenic. One of the best prepa- rations I have ever used is—ty Tinct. Macrotys Sss., Tinct. Valerian §iss., in doses of five to tAventy drops every three hours. With Arsenic the prescription Avill be—1^ Tinct. Macrotys 5j-, Fowlers Solution of Arsenic 5ss., AvaterSiv.; a teaspoonful every four hours. Sticta, Bryonia, Apocynum, and Colchicum, have all been used Avith good results, as has the iodide of potassium Avhen the tongue is broad and of a bluish pallor. If the disease is associatetl with amenorrhoea, or irregularity of the menstrual function, this must be attended to. In some cases the emmenagogue pill of the Dispensatory Avill prove use- ful, both as a cathartic and for its action on the uterus. The Avild ginger is another agent that Avill prove useful in some of these cases. The Macrotys, or Cimicifuga, has already been named as a remedy in cases Avhere the patient complains of Avan- dering pains in various parts of the body, or pain in the back CHOREA. 419 and limbs. We sometimes associate it with Valerian or Scutel- laria, and sometimes Avith the bitter tonics. The extract of Indian hemp has been employed Avith benefit, in doses of half a grain three times a day, and good results are said to have attended the administration of small doses of Stramonium. The sulphate and oxide of zinc have been prescribed oftener possibly than any other agents, and Ave must believe, from the favorable reports given, that they have an action in these cases ; these remedies may be given, commencing with half-grain doses four times a day, and gradually increased until five or ten grains are admin- istered. If there is tenderness on pressure over the spinal cord, coun- ter-irritation will often prove very efficient, and the same will be the case Avhen there is tenderness over the epigastrium. Electricity has been frequently resorted to in chorea, and the reports of its action differ materially. When passed through the limbs it is not only useless, but sometimes positively injuri- ous; but Avhen applied to the spine it is almost ahvays beneficial. The common electro-magnetic battery may be employed, the negative pole being applied to the sacrum, and the positive passed baclvAvard and forward over the spine. The better plan, hoAvever, is to insulate the patient, and by the old-fashioned electric machine, charge the patient and withdraAV the spark from the back. In one case I have employed the bromide of ammonium in addition to a tonic treatment, and seemingly' with marked benefit. Very much will depend upon the home management of the patient. All causes of irritation must be carefully avoided, and she should be encouraged to take suitable exercise, and try to control the involuntary movements. Out-door exercise, pleasant company, and something to constantly occupy the mind Avith, exert an important influence, and it will sometimes be found that Avhere the patient is allowed to have her oavii way, if not decidedly improper, she will get along better. In some cases the disease results, in both male and female, from sexual excita- tion and onanism; this should be looked into, and if reasonable evidence exists, means should be employed to put a stop to it. The manner of doing this Avill have to be left to the discretion of the physician, and Avill vary in different cases. 420 DISEASES of children. TRISMUS NASCENTIUM. Infantile tetanus is of very rare occurrence, and a physician may be in practice a lifetime Avithout seeing a case. It occurs most frequently in the children of the poor, especially in badly ventilated dAvellings, and when the mother and child have had insufficient food, clothing, etc., and a Avant of cleanliness. That it does not always depend upon these conditions, I have evidence in one case that came to my kuoAvledge, in a family in comfort- able circumstances. Causes.—The conditions above named may be considered as predisposing causes. The exciting cause is an unhealthy in- flammation of the navel; the disease is, therefore, really trau- matic tetanus. Pathology.—The tetanic convulsion is dependent upon irri- tation of the spinal cord and excess of reflex action. Post-mortem examination sIioavs an inflammatory condition of the unbilical vessels, and of the peritoneum about the umbilicus and reflected upon the artery and veins. Examination of the spine sIioavs in- jection of the arachnoid and pia mater, with effusion of serum, lymph, and sometimes of blood. Symptoms.—The disease may make its appearance in a day or two after birth, but more frequently about the ninth day. The child is observed to be restless and fretful, sleeps badly, and has paroxysms of crying which seem like colic. It moves the loAver extremities in a peculiar manner, does not nurse well, and has greenish and slimy discharges from the boAvels. These symptoms continuing for a time, it is attacked with convulsions, which are, hoAvever, very irregular. "These con- vulsive motions recur at uncertain intervals, and produce vari- ous effects. Sometimes the agitation is very great; the mouth foams; the thumbs are rivited into the palms of the hands; the jaws are locked from the commencement, so as to prevent the action of sucking and SAvallowing ; any attempt to Avet the mouth or fauces, or to administer the medicines, seems to aggravate the spasms; and the face becomes turgid and of a livid hue as do most other parts of the body. From this latter circumstance nurses speak of this form as the 'black fits.' The conflict lasts from eight to thirty hours, and in some rare instances to about night terrors. 421 forty hours; when the poAvers of nature seem to sink exhausted and overpowered by their own exertions." Treatment.—Put the child upon the use of Veratrum and Gelseminum in full doses, as—1^. Tincture of Veratrum gtt. v., Tincture of Gelseininum 5ss., Avater 5ij.; a teaspoonful every hour. As it is not very easy to give the entire teaspoonful at once, it may be given in smaller doses through the hour, or the quantity of Avater may be lessened. When the disease is very persistent I should not hesitate to double or even quadruple the quantities of the remedies named. Locally the application of a Avarm emollient poultice to the abdomen over the umbilicus Avill be found beneficial. Ulmus fulva, flaxseed, or anything of a similar character may be used ; or in place of these, application of a cloth spread with the mild zinc ointment will answer a good purpose. NIGHT TERRORS. We are consulted occasionally with regard to the sudden waking of the child at night, manifesting every evidence of ter- ror. Generally it AA'akes Avith a piercing scream, and starts up in bed Avith affright, and it is some minutes before it can be assured that it is safe, and quieted. There may be but one paroxysm through the night, but occasionally there Avill be tAvo or three. In some cases it will also occur Avhen the child sleeps in the daytime. Many persons think that this groAvs out of frights from play- mates or servants, or fearful stories about ghosts, giants, robbers, etc., which are so frequently told -to children. While this gives rise to a morbid fear, manifesting itself especially after dark, but also folloAving the person in the day, it has little or nothing to do with this case. In this there is an irritation of the brain Avith determination of blood, and the night terrors are similar in their cause to con- vulsions and epilepsy, the first being of the cerebrum—the intel- lectual portion, the second of the spinal cord—or of automatic movement. The use of small doses of Aconite with Rhus, given in the after- noon and evening, Avill frequently remove the unpleasantness. In some cases the indications are very clear for Gelseminum and 422 diseases of children. Ave use it in place of Rhus. In other cases there is an irritation of the skin associated with the unpleasant dreams, and Apis or Belladonna will come in play. If the child is nervous and sobs in its sleep, Pulsatilla Avill be the remedy, and it may be given three or four times daily. In some cases Ave will find a torpid condition of the boAvels, which Avill require the administration of a mild cathartic. In some, very small doses of podophyllin, thoroughly triturated and combined with hydrastia, will be found to ansAver the purpose well. A tonic and restorative treatment Avill almost ahvays be neces- sary. Here I would put the child upon the use of our common prescription : T^. Tincture of Muriate of Iron 5ss., Glycerine 5ij.; a teaspoonful three times a day ; or the compound syrup of the hypophosphites. PARALYSIS. Infantile paralysis is a very different disease from that Ave are called to treat in the adult. We are accustomed to think of paralysis as a loss of motion or sensation ; in this case there is but diminution of one or both. In slight degree it is met with quite frequently, and I have no doubt that it is often overlooked, or attributed to something else. Causes.—It is very difficult to determine the causes of infan- tile paralysis. In most cases I believe there is a congenital fee- bleness of the nerve centers, and afterward from imperfect nutri- tion the disease is developed. In other cases it is the result of injury to the spine, usually from bad nursing or from a fall. Pathology.—The pathology of the disease is pretty clearly stated above—enfeeblement of the nerve centers and impaired nutrition. I do not think that I have seen evidence of any other lesion in the cases I have examined. Symptoms.—In the majority of eases avc will first notice the difficulty in feebleness of the lower extremities, and an imperfect command over them. Usually one side is principally affected and the disease seems to be of one or more articulations. I have noticed it oftenest in the hip, and from the eversion of the toes, and shortening of the limb, ha\'e felt confident there Avas a paralysis. 423 dislocation. Careful examination, hoAvever, could detect no lesion. In other cases the Avhole pelvis seemed to be affected, having no strength to support the body, giving a very feeble point of action for the muscles of the extremities. More rarely Ave see cases of paralysis of the upper extremities, yet they are easily recognized by the sameness of the symptoms. The mother thinks the child's arm has been dislocated, or has been injured in some Avay, and attributes the loss of poAver to this. On first looking at the arm, avc suspect a dislocation, its position is so unnatural and its movements so feeble, but an ex- amination sIioavs the bones in their proper place. Facial paralysis is still more rare, but cases are on record. Paralysis of the third pair of nerves, causing falling of the upper eyelid, or ptosis, is occasionally seen. Again, a single muscle may be affected, as Avhen from paralysis of a sterno-mastoid Ave have torticollis. Treatment.-—Of course the treatment Avill be, to some extent, dependent upon the cause, and a careful examination Avill be in- stituted to determine the lesion which has given rise to it. If from irritation of the stomach and intestinal canal, this should be removed, and means employed to restore digestion. If Avorms are thought to be present, the Podophyllin and Santonine may be given. If from irritation of the urinary apparatus, this must be relieved. Outside of these Avrongs, which may be the cause of paralysis, Ave look to the nerve centers for the Avrong, and here Ave Avill be guided by the special indications for remedies. Xux vomica Avill frequently be indicated, there being evidences of an enfeebled circulation. With flushed face and contracted pupils the patient Avill have Gelseminum, usually with one of the sedatives. If the patient is dull and inclined to sleep, Belladonna will be given ; and with sluggish muscular action, Ergot. Rhus is indicated by the sharp pulse, frontal headache, and red papillae of tongue; Bryonia by the corded pulse, and flushed right cheek; Macrotys by muscular pain and soreness. Inunction Avith quinine has been of marked benefit, in these cases ; even friction with a fatty matter (lard) is of advantage. Brisk friction to the spine and the part affected, Avith stilt ami water, using the open hand, is good. In some cases the use of Avater is injurious, and I direct dry friction Avith flannel or silk ; 424 DISEASES OF CHILDREN. this is especially useful in cases in Avhich there seems a deficiency of electricity. Benefit is derived from the moderate use of electricity, passing the current doAvinvard from the spine through the muscles. The Voltaic electricity, used by the method called " Faradization," I believe to possess the'most active curative properties. The child should be taken into the open air, and have an abun- dant supply of light, and even sunlight, Avhere it passes most of its time. It should also be instructed to call the paralyzed parts into action as much as possible, and control their movements. Practice in this direction is often attended with the happiest results. CHAPTER X. DISEASES OF THE EYES. The eye is one of the most important organs of the body, and though its diseases do not endanger life, their favorable termina- tion is as anxiously Avatched for by both patient and friends as that of the more grave maladies. As regards the pathology of these affections, Ave will find it the same as in other portions of the body, and, as a general rule, the same treatment Avill be ap- plicable. Inflammation of the structures of the eye is the same disease as inflammation of any other part of the body, differing only as regards the peculiarity of structure and function of the parts. And in the treatment of this affection the same general principles apply in the one case as in the other. So it is in all other diseases, and he Avho properly understands the pathology and nature of the affection need be at no loss for appropriate treatment. The organ of sight, it will be recollected, consists of tAvo parts, the eye itself and its appendages, the latter being tAvo palpebra or lids, the conjunctiva or investing membrane, the lachrymal apparatus, the muscles moving the eye, and the cellular and adi- pose tissues Avhich form its bed. Each of these parts mav be diseased, but some of them so rarely that it is hardly Avorth while OPHTHALMIA NEONATORUM. 425 to notice them in this place. The globe of the eye is composed of three tunics—the external, composed of the sclerotic and cor- nea ; the middle, of the choroid; and the internal, the retina or expansion of the optic nerve. It has a muscular septum divid- ing it into tAvo parts—the iris; and it has three humors possess- ing different degrees of density—the aqueous, the vitreous, and the crystalline lens. OPHTHALMIA NEONATORUM. The sore eyes of the newly born child vary very greatly in character, from simple conjunctivitis to that grave inflammation which, involving structure after structure, destroys the organ in a few days. Causes.—In some cases it is the result of aAvkAvard Avashing, either from the irritation of soap in the eye or rubbing; these are ahvays mild and of short duration. In others the conjunc- tivitis arises from exposure to a bright light, which induces irri- tation ; and in some it is caused by cold. The severer cases are thought to arise from the introduction of purulent matter into the eyes from the soft parts of the mother while the child's head Avas passing through the vagina. The severest inflammation of the eyes knoAvn, is caused by inocula- tion Avith gonorrheal virus, and Ave have abundant evidence that other purulent discharges from the vagina are quite as virulent. Pathology.—In the milder cases the inflammation is confined to the conjunctiva, and is but little more than determination of blood. In the seATerer eases the inflammation is at first of the conjurctiva, but of very active character, impairing the vitality of the tissues, and giving rise to free suppuration. In many cases it gives rise to separation of tissues, producing phlyctenida, and extending to the cornea, causes ulceration. In still severer cases it extends to the deep-seated structures of the eye, causing softening, suppuration, and other lesions that destroy the organ. Symptoms.—In the milder cases the eyes are observed to be injected, and the child dislikes to expose them to a strong light. In a feAV days a tehacious secretion accumulates at the margin of the lids, and agglutinates them together. The eyes may remain sore in this Avay for a Aveek or tAvo, occasionally causing the child to be restless and fretful. 426 DISEASES OF CHILDREN. Iii the severer form of the disease, the eyes are noticed to be i-ed, and the lids much SAVollen,and from the first the child seems to suffer much pain in them, and keeps them tightly closed the most of the time. By the second day all these symptoms are increased, the SAvelling being very marked, and when the eyelids are separated, the entire surface is seen to be involved in the inflammation, the conjunctiva being injected and thickened. By the third or fourth day, there is a free discharge of yellowish purulent matter from the eye, and the intolerance of light is extreme. When the lids are opened the conjunctiva is seen to be much SAvollen, and many times the chemosis is so great that the cornea can hardly be seen. Continuing in this Avay, the disease may run its course to the destruction of the eye in three or four days, or, as in the major- ity of cases, it will last as many Aveeks, and the child will sloAvly recover. Treatment.—I have great faith in the value of internal rem- edies in disease of the eyes, though the proper local means should not be neglected. Prepare for the child Aconite in the usual doses, Avith Gelseminum, Rhus, Belladonna, Phytolacca, or Apis, as may be indicated. The child may also be medicated through the mother, if her health is impaired. Not unfrequently the unpleasant coating upon the tongue, the bad breath, and imper- fect digestion, Avill call for sulphite of soda or sulphurous acid. The eyes should be kept free from the discharge (clean) by Avashing them every tAvo or three hours with Avarm water, to which may sometimes be added a small portion of salt. In some cases the Avater may be used as hot as it can be borne. To thor- oughly cleanse the eye, the lids may be opened and the water ■allowed to trickle through, to Avash the pus aAvay. A lotion of Aconite or Veratrum (3j. to Sj.) applied above and around the eyes, and sometimes to the lids, Avill give relief. In cases of moderate severity a collyrium may be made by adding Tinct. Belladonna or Gelseminum to water. Or in a more advanced stage a solution of atropia may be emploved (gr. I to Avater ;5j.), or an infusion of Baptisia filtered, or a solu- tion of Hydrastia (Berberin), grs. ij. to water Sj. If the case is very serious, and the eye is "endangered, nitric acid may be applied to the surface of the lids (everted), using a pine pencil. I think it preferable to the nitrate of silver Avhich is so commonly used in these cases. DISEASES OF THE EYE. 427 DISEASES OF THE APPENDAGES OF THE EYE. The eyelids may be the subject of phlegmonous inflammation, usually associated with erysipelas. They are swollen and livid, and very painful, and occasionally the inflammation extends to the cellular tissue of the orbit. It may terminate in resolution or suppuration, the pain being severe and throbbing Avhen pus has formed, and the constitutional symptoms tolerably well marked. If the inflammation is dependent upon erysipelas, Ave may apply equal parts of tincture of muriate of iron and glyce- rine, every two or three hours, keeping a cloth Avet Avith the same over it; if from other causes, a poultice of equal parts of Hydras- tis and Ulmus, or cloths dipped in a decoction of Cornus, Avith a small portion of tincture of Aconite. The boAvels maybe moved Avith any simple laxative, and if necessary, a diaphoretic and diuretic given. If suppuration occurs, the abscess should be carefully opened as soon as it is detected, as if it remains it in- creases in size, and sometimes causes great destruction. Furuncle, or boils of the eyelid, are of very frequent occurrence, and sometimes occasion much suffering. Occasionally they pass through their stages rapidly, a Aveek sufficing for their removal, but in other cases they are very chronic. When formed on the edge of the eyelid, they are called styes, and are smaller but not less painful. They require but little attention, except in such cases as would be injured by the continued pain and restlessness produced by them. In such cases they may be incised, and if pus has not yet formed, touched freely with a crystal of sulphate of zinc, and a poultice applied. In such cases lime Avater may be given Avith benefit, to prevent the recurrence of them. The general health is also improved. In place of lime water Ave may employ sulphide of lime in doses of one eighth of a grain four times a day. Ptosis, or falling of the upper eyelid, is caused by paralysis of the third pair of nerves, or by disease affecting the eyelid, or the levator muscle. In cases of paralysis, it may be relieved some- times by the use of electricity or local stimulant applications and the proper internal remedies; failing in this and in the cases not dependent upon paralysis, a surgical operation is demanded. Entropium or inversion of the eyelids, and ectropium or eversion, are only remediable by surgical operations. 428 DISEASES OF CHILDREN. Trichiasis, or inversion of the eyelashes, is popularly known as "wild hairs in the eye," and is often a source of great irrita- tion or inflammation. The trouble is OAvingto a misdirection of the cilia, a portion of them being turned iiiAvard, so as to come in contact with the eye. The cause is usually easily detected by turning the patient's eye to a strong light and slightly raising the lid, the faulty hairs being seen to pass inward to the con- junctiva. They are usually of a light color, smaller and much more flexible than the normal ones, and for these reasons are sometimes detected Avith difficulty. In cases of partial trichiasis the treatment is easy, and consists simply in removing the of- fending cilia with a pair of forceps. I can yet feel the mortifi- cation I once experienced, in Avhich, after treating a ease of "sore eyes" for tAvo weeks, the patient Avas cured in forty-eight hours by an old woman removing these faulty hairs. In severe cases this Avill not ansAver, a surgical operation being necessary. DISEASES OF THE LACHRYMAL APPARATUS. The lachrymal gland is so protected Avithin the orbit that it is rarely the seat of disease. Inflammation sometimes occurs, and is marked byr pain in the region of the gland and dryness of the eye from arrest of secretion. When the inflammation subsides there is usually too free secretion and epiphora, but this soon sub- sides. It should be treated as any other inflammation. Inflammation of the lachrymal sac is of frequent occurrence, and requires care in its management. It makes its appearance usually as a diffused, erysipelatous-like redness and SAvelling of the parts near the internal canthus, with deep-seated pain, and more or less irritation of the conjunctiva, increased lachrvmation and passage of the tears over the eyelid. The inflammation con- tinuing for some days, the parts become much swollen and very painful, and at last pus having formed, it discharges through the integument. In some cases the pus finds its Avay through the lachrymal canals by pressure, and the inflammation becomes chronic, but Avithout the formation of a fistula. Usually there is closure of the nasal duct, which remains permanent unless an operation is undertaken for its removal, though sometimes the closure of the nasal duct is the primary affection, the inflamma- tion of the lachrymal sac being caused by it. DISEASES OF THE EYE. 429 The child should have the right internal treatment as for any other disease, in the use of Aconite or Veratrum, with Phyto- lacca, Rhus, Gelseininum, Belladonna, or Avhatever remedy' may be indicated. If uoav the part is penciled with TiiiGture Aconite or Tincture Veratrum in the first stage, or has a Avet dressing of Ri Salicylic Acid, Borax, aa., gr. x., Avater Siv., if suppuration is threatened, Ave usually get along Avell. In some cases the deep redness will indicate Tincture Muriate of Iron 5j., Glycerine Sss., applied to the part. If pus forms, au incision should be early made for its removal, thus preventing change of the lachrymal sac, and especially distension, and permanent closure of the nasal duct. An injection of ten or tAventy grains of sesqui-carbonate of potash to the ounce of Avater, will uoav assist very much in effecting a speedy cure. As soon as the inflammation subsides, if the nasal duct seems closed, a style should be inserted. Closure of the nasal duct, producing fistula lachrymalis, fre- quently results from the above inflammation, though it may be produced by injuries of the bones or soft parts, or an extension of inflammation to its mucous lining from the nose, or from the conjunctiva. In a majority of cases there is a fistulous opening over the lachrymal sac, or a continuous suppuration and dis- charge of pus at the internal eanthns, through the puncta, Avith more or less frequent attacks of acute inflammation of the sac, and discharge through the integument. In some of these cases a fungous-looking mass of considerable size is found upon the site of the lachrymal sac, Avhich is constantly discharging pus mixed with tears. This and the constant floAving of the tears over the eyelid, is very unpleasant, and occasionally it keeps up continuous irritation of the eye, and causes imperfect vision. The disease is only cured by an operation, which consists in opening the lachrymal sac and introducing a silver style made for the purpose. The usual means to relieve irritation are then made use of, and the style retained until there is evidence of the free passage of tears and restoration of the mucous membrane lining the duct, when it is removed, and the external opening allowed to heal. The puncta or canaliculi may be obstructed from inflammatory action, and occasionally from other causes. In these eases there is also the overflow of tears and irritation of the lid. If it is produced by inflammation, the means heretofore named may be used to arrest it. If from other causes an Auel's probe may 430 DISEASES OF CHILDREN. be passed into the puncta and through the canaliculi into the sac, with the result of removing the obstruction. The caruncula lachrymalis is sometimes the seat of inflamma- tion very similar to that in ophthalmia tarsi, and by displace- ment of the puncta will produce Avatering of the eye. It some- times gives rise to considerable uneasines and pain. It may be treated in the same manner as the other inflammations named, but Avhen persistent is best removed by the use of the mild zinc ointment, or ophthalmic ointment. Occasionally they are the subject of chronic enlargement, forming a red, soft, tuberculated tumor, of considerable size, Avhich bleeds readily on pressure. It may be occasionally removed by the application of a saturated solution of tannic acid, or the solid nitrate of silver, but in many cases Avill have to be excised, one-half or more being cut aAvay, the remainder disappears. PTERYGIUM. This is strictly a disease of the conjunctiva, and consists of a thickening of a circumscribed portion of it extending between the internal canthus and the cornea, though occasionally it is found on the temporal side. It is divided into tAvo kinds, the membranous and fleshy, both kinds being triangular, with the apex toAvard the cornea. It commences from without, and grows imvard, occasioning but little disturbance until it reaches the cornea. If it commences to involve the conjunctiva-cornea, it gives rise to irritation, and may be attended with serious conse- quences. It may be arrested by cauterizing with nitrate of silver, nitric acid, or other escharotics, but the easiest plan is to dissect off the half next the cornea, when the* remainder Avill generally disappear Avithout trouble. OPHTHALMIA TARSI. Inflammation of the edges of the eyelids is noticed more fre- quently in children than in the adult, and is frequently associated Avith some depraved habit of body, as scrofula. When primary it may be the result of cold, smoke, impure air, or filthiness • but it is most usually a sequence of catarrhal ophthalmia or scrofu- lous conjunctivitis. The disease is located in the edvay, as may also carbonic acid gas. With throbbing pain in the ear, Ave are satisfied that suppura- tion has occurred, and sometimes an inspection of the meatus Avill sIioav the yellowish color of pus. The little abscess should be at once opened with a sharp-pointed bistoury, Avhen Ave Avill have immediate relief. If the disease is of the middle ear, and the pain becomes tensive and throbbing, Ave may be satisfied of the presence of pus. An examination of the car will show the membrana tympani pushed outAvard (coua'cx) and blanched and yelloAvish. If it is iioav incised Avithasmall tenotome, or small, sharp-pointed bistoury, the escape of a drop or tAvo of pus gives relief. In place of destroy- ing the tympanic membrane by incision, we frequently preserve it, for the continuous presence of pus would cause its entire de- struction, and sometimes the destruction of the internal mem- brana, whilst if the pus is discharged, the inflammation ceases, and the wound closes up, the membrane shoAving but a slight cicatrix. 442 diseases of children. If the disease seems to extend to the mastoid portion of the bone, I should apply a blister immediately over it, and follow it Avith the irritating plaster. In some cases, suppuration having undoubtedly taken place, and dangerous symptoms occurring, it becomes necessary to open into the mastoid cells through the bone, in order to permit the escape of pus. O T 0 R R II (E A . Purulent discharges from the ear may be occasioned by chronic inflammation of the external meatus, or disease of the bony canal, or it may proceed from chronic inflammation of the tym- panum, or disease of adjacent parts, the membrana tympani having been ruptured or destroyed, so as to permit its escape. In either case there is more or less deafness, uneasiness in the ear, and an offensive discharge. The most frequent causes of otorrhcea are inflammation attending the eruptive fevers, injuries, the direct action of cold, and chronic inflammation resulting from acute attack. Some families seem to have a predisposition to this affection, the majority of their children having such dis- charge. In such cases it is almost ahvays associated with scrofula and feeble vitality. Otorrhcea from disease of the external auditory meatus is the most frequent form of the affection, and might properly be called chronic catarrh. It is of frequent occurrence after scarlet fever and measles, and is often seen in infancy or up to the age of tAvo or three years, becoming more rare as Ave advance to adult age, except in the cases named. It is true, that the disease com- mencing at the age of tAvo or three years may continue through life, but this is not very common when the patient has sufficient vitality to reach adult age. Further than the discharge from the ears of an offensive purulent matter, and some dullness of hearing, there are no prominent symptoms, if we except the al- most invariable cachectic appearance of the child. On examin- ing the car, Ave Avill find the bone in a carious condition. When the hearing is much affected, Ave Avill find the membrana tympani opaque, and its dermoid layer thick and vascular. In some cases the discharge is produced by a small polypoid formation in the ear, and in others by a hardened cerumen. Otorrhcea from disease of the middle ear occurs only when the membrana tympani has been destroyed or ruptured and mav OTORRHEA. 443 arise from chronic inflammation of the lining membrane, disease of the ossicles, or disease of the bony Avails. It is most generally the sequence of acute inflammation, Avhich terminating in sup- puration, the membrana tympani gives way, and the inflamma- tion gradually assumes the chronic form. There is always deaf- ness, sometimes but slight, at others marked. There may not be pain or unpleasant sensations in the ear, though usually if there is but a slight opening in the membrana tympani it occasionally becomes closed, and dizziness, ringing in the ear, etc., result from the pressure of the retained secretion. The condition of the tympanum varies greatly; in some cases there is but slight change of structure, in others the ossicles be- come diseased, and are east off, the mastoid cells and eustachian tube are affected to some extent, and the hearing is nearly en- tirely destroyed. It may occasionally terminate fatally by an extension of the inflammation to the membranes of the brain. Treatment.—In all cases it becomes necessary to pay atten- tion to the general health, for as long as the child or adult con- tinues cachectic, or sIioavs evidence of a Avrong of the blood, it is almost impossible to arrest the discharge. The use of lime water, sulphite of soda if there is eczema, sulphurous acid, cod liver oil, arsenic, iodide of potash, Donovan's Solution, Phyto- laca, and some of the vegetable alterat'wes, are suggested. It is impossible to name a remedy Avhich will be good in all cases, for here, as in other diseases, the remedy will be selected according to the special indications in the case. Prominent among external applications in all forms of this affection, except Avhen occassioned by a foreign body lodging in the ear, or a polypoid growth, is counter-irritation over the mas- toid process. It should rarely be neglected, but pursued stead- ily until the cure is complete. The best agent that I have em- ployed is the cantharides, Avhich may be repeated sufficiently often to keep up a continued influence. In common chronic inflammation of the external meatus, Avashing the car out thoroughly with tepid Avater, and dropping three or four drops of—ly Tinct of muriate of iron 5'j., glyce- rine Sj-, iuto the ear once or tAvice daily, will effect a cure in one or two Aveeks. In place of this, nitric acid gtt. x., to Avater and glycerine aa. Sss., may be employed witli advantage. A Aveak solution of thymol, of sulphate of zinc, or acetate of lead, 444 DISF.ASES of children. from four to ten grains to the ounce of Avater, may be used in some cases. ify Chlorate of potassa, gr. xx., glycerine Sss., water Sj., also forms a good application. An infusion of Hama- melis, Hydrastis, Cornus, Geranium, Sage, etc., is found use- ful in some cases. Occasionally I have employed oxide of zinc gr. x., rubbed up with glycerine Sss., adding a small portion of morphia if necessary, to relieve irritation. Failures in these cases will frequently depend upon a faulty use of local means. When injections are used they do not reach the affected surfaces. In place of the syringe, a# long camel's hair pencil may be used to clean the ear first, and afterward to carry the local remedy close to the membrana tympani if neces- sary. This Avill be readily done by twirling the pencil betAveen the fingers as it is introduced. In some cases the brown citrine ointment, with one to three parts of cod liver oil or simple cerate (according to the soreness), may be applied to the entire diseased surface by twisting a soft piece of cotton cloth, smearing it with the ointment, and tAvist- kig it as it is pressed into the meatus. In other severe cases, nitric acid applied lightly with the pine pencil, will be found a most excellent plan of treatment. If the tympanic cavity is the seat of disease, we will pay espe- cial attention to the general health, and keep up continuous counter-irritation near the ear. Cleanliness is of prime impor- tance, and hence the ear should be thoroughly Avashed out, once or tAvice daily. This may be followed by some of the lotions above named, being careful that they are brought iu contact with the diseased surface. If the discharge is produced by accumulations of hardened cerumen acting as a foreign body, this should be softened and removed with a scoop. If from a polypus, and it is not red and vascular, it may frequently be removed by the application of a saturated solution of tannin, or the careful application of chloride of zinc. The best plan, hoAvever, in all cases, is to catch it Avith a strong pair of ring forceps, and detach and remove it. DEAFNESS. Partial loss of hearing depends upon various causes, some of Avhich are remediable ; total deafness depends upon disease of the internal ear, and if of any considerable duration is incurable. DEAFNESS. 445 We Avish, therefore, in this place, to inquire into the causes of partial deafness, and see how far they are amenable to treatment. We may sum them up, as: 1st, from disease of the external meatus; 2d, from-disease of the membrana tympani; 3, from disease of the tympanum ; and, 4th, from disease of the eusta- chian tube. Diseases of the internal ear are beyond our poAvers of diagnosis, though Ave are able occasionally to determine with considerable certainty that the deafness is dependent upon par- tial paralysis—Ave call this nervous deafness. The ear-specu- lum should always be used, so as to make an accurate diagnosis. I. The external meatus suffering from cnronic inflammation will give rise to hardness of hearing, as Ave have already seen. In other cases the lining membrane is thickened and dry, and in addition, the ceruminous glands seem to pour out a very in- spissated secretion, Avhich desiccating sometimes fills up the bot- tom of the meatus. In this case avc Avould use injections of tepid Avater and the scoop, to thoroughly cleanse the ear, and then use the lotion of tincture of muriate of iron and glycerine, heretofore mentioned. The lotion of thymol and glycerine may also be used in these cases. If there is irritation of the struc- tures, much benefit will be derived from counter-irritation over the ear. Polypi obstructing the meatus should be removed, as before mentioned. 2. A condition of chronic inflammation of the membrana tympani, giving rise to a fleshy vascular appearance Avhen ex- amined Avith the speculum, is sometimes a cause of deafness; quite frequently it is associated with catarrhal inflammation of the meatus, though it may persist afterAvard. An injection of a decoction of Cornus and Hydrastis, and the local application with a camel's hair pencil of the oxide of zinc, morphia, and glyce- rine, heretofore named, is usually sufficient. Counter-irritation over the mastoid process is also employed. Relaxation of the membrana tympani is not of frequent occurrence, but may occa- sionally be met with as a cause of deafness. It is readily de- termined by the use of the speculum, the membrane being re- markably concave on its external face, and is diagnosed from the same appearance resulting from closure of the eustachian tube, by its being throAvn outward by SAvalloAving with closed nostrils. Por.d's Hamamelis and glycerine, equal parts, make a good local application. Tincture muriate of iron oj- to glyce- rine Sj. maybe used in sojne cases, and a solution of Hydrastia, 446 DISEASES OF CHILDREN. gr. ij. to rose-Avater Sj-, will give tone to the structures in others. Perforation of the membrana tympani is a frequent cause of deafness, and is readily detected with the speculum. It seems, hoAvever, that the deafness depends in part upon thickening of the mucous membrane of the tympanic cavity, for when this is marked, the patient can hardly hear at all, while in other cases the deafness is but slight. We should therefore endeavor to re- move all irritation by the use of counter-irritants and appropri- ate local applications, and we will then have placed the patient in the best condition for the use of the artificial membrana tym- pani; this is formecTout of vulcanized rubber, and has been very successfully employed. 3. Various changes in the tympanic cavity, resulting from in- flammation, may be the cause of deafness, but there is only one, so far as Ave know, that can be reached by remedial measures. We have already noticed that a chronic inflammation of these structures might continue for years, attended with secretion ; and examination shoAvs us in some cases, a thickening of the lining membrane, with increased vascularity. In these cases, the persistent use of counter-irritation and the local means here- tofore named will do much toAvard the relief of the deafness. 4. Obstruction of the eustachian tube ahvays gives rise to partial deafness, though, as the causes are usually temporary, the deafness is not of long duration. Dr. Toynbee notices three points of obstruction : 1, at its faucial orifice, a thickening or relaxation of the mucous membrane ; 2, at its tympanic orifice, from thickening of the mucous membrane, or a deposit of fibrin ; 3, in the middle part of the tube, from a collection of mucus, a stric- ture of the osseous or cartilaginous portions, or membranous bands connecting the Avails. If the eustachian tube is impervious, Ave will find the membrana tympani sunken in, of a dull, leaden hue, and its surface unnaturally glossy, and SAvalloAving Avith the nose closed or forcible expiration will not have any effect on it. If the patient has had disease of the tonsils, fauces, or poste- rior nares, Ave may reasonably suppose that the disease has been caused by this, and is at the faucial extremity of the tube. The inflammation sometimes extends to the mucous membrane lining the tube, and its tumefaction causes the disease. In other eases the SAvelling of the mucous membrane at the termination of the tube, is the cause of it, and in another, class it results from re- DEAFNESS. 447 taxation. In these cases, appropriate measures to relieve in- flammatory engorgement in the one instance, and to remove the atony and relaxation in the other, should be adopted. The ori- fice of the eustachian tube may be reached through the mouth or inferior meatus of the nose, and local applications may be made with a probang or syringe. In some cases it is proposed to remove obstructions by means of a probe passed into the eustachian tube, but no permanent benefit results from it. We may, however, introduce a catheter, for the purpose of using an injection into the tube, using the same remedies that would be indicated in other situations, as, for instance, those recommended in otorrhcea. Xera'ous Deafness.—Toynbee remarks that "As some cases of deafness dependent upon the derangement of the nervous apparatus connected with the organs of hearing appear to be caused by the condition of the brain generally, or of that part in intimate relation Avith the acoustic nerve, it has seemed desira- ble to divide the nervous diseases of the ear into two classes; to the first of Avhich belong those cases where the special nervous apparatus of the organ is alone affected ; to the second, those where the brain, conjointly Avith the ear, seems to be injured. The first class may be divided into diseases arising from : 1, concussion ; 2, the application of cold ; 3, various poisons, as that of typhus, scarlet, or rheumatic fevers, of measles and mumps, of gout, of an accumulation of bile in the blood, and of quinine in large doses. And the second into diseases arising from: 1, excess of mental excitement; 2, physical debility. In the first class of cases there is not unfrequently ringing and singing in the ears, with other morbid sounds, and sometimes a feeling of giddiness and unsteadiness extremely unpleasant. From its commencement there is frequently a continuous in- crease in the deafness; but in other cases it remains the same, and in still others there is gradual improvement. It is gener- ally conceded that in very many cases there i-s congestion of the nervous apparatus of the internal ear, though if it continues for a considerable time it will very likely terminate in structural change. The treatment Avill vary in these cases, in some the remedies being selected from those Avhich influence the nervous system di- rectly, in others from those which influence the blood, and in 418 DISEASES of children. still others from those Avhich influence Avaste and excretion. Of the first class Ave find marked benefit from Rhus, Bryonia, Sticta, Belladonna, Apocynum, Bromide of Potash, Bromide of Ammo- nium, etc. Of the second, FoAvler's Soiution of Arsenic, Cod liver Oil, Donovan's Solution, Phytolacca, Alnus. The third class Avill embrace the alkaline diureties, and remedies that increase secretion from skin and boAvels. Persistent counter-irritation over the mastoid portion of the temporal bone, Avith cantharides, or the irritating plaster, is one of the most important parts of the treatment. These measures, folloAved up for months, will occasionally produce the most marked benefit, the hearing being sometimes completely re- stored; but in other cases no benefit results. In the second class of cases Ave will have more or less evidence of cerebral disturbance, though frequently the symptoms a^e im- perfectly marked. No treatment can be laid doAvn for these cases, as the symptoms are so variable and changing. They should be treated on general principles, and we Avill sometimes be agreeably surprised at a favorable termination in cases which had seemed hopeless; and not unfrequently Ave Avill fail when Ave seemed to have the best chance of success. CHAPTER XII. DISEASES OF THE SKIN. Difficult of classification in all cases, avc find diseases of the skin doubly so in the child. True, some cases are so well de- fined that the merest tyro Avill assign them their proper place ; but others are obscure from the first, and more become so as they progress. Probably, the simplest classification is that adopted by Cazenave, into eight orders. The following brief description of each will enable the reader to classify many cases : Exanthemata.—This term is applied to patches of a reddish color, varying in intensity, size and form, disappearing under pressure of the finger, and terminating in delitescence, resolu- tion or desquamation. diseases of the skin. 449 Vesiculce.—A vesicle is a slight elevation of the epidermis, containing a serous and transparent fluid, Avhich, however, is oc- casionally opaque or sero-purulent. The A'esicle may terminate in absorption of the fluid, slight desquamation, excoriation, or the formation of small, thin incrustations. Bullae.— Generally speaking bullae differ from vesiculae merely in size; they are small superficial tumors caused by effusion of serum underneath the epidermis. Pustulce.—This term should be strictly confined to circum- scribed collections of pus on the surface of the inflamed mucous layer. The contents of the pustules in drying produce scales, and they may be followed by chronic induration, or byr red in- flamed surfaces, or sometimes by slight excoriation. Papulce.—These are small elevations, which are solid, resist- ing, and never contain any trace of fluid ; they may likeAvise give rise to ulceration, but generally terminate in resolution and furfuraceous desquamations. Squamoz.—The term squamae is applied to the scales of thick- ened, dry, whitish, friable, and degenerated epidermis, which cover minute papular elevations of the skin ; they are easily de- tached, and may be reproduced for an indefinite length of time by successive desquamations. Tuberculce.—These are small hard tumors more or less promi- nent, circumscribed inform, and persistent; they may become ulcerated at the summit, or suppurate partially. In this defini- tion Ave consider tubercles as elementary lesions, and not those which appear after abscesses. Maculaz—Are permanent changes in color, in certain points of the skin, or of the Avhole cutaneous envelope, but unattended with any general derangement of the health. ORDER I.-EXANTHEMATA. The general characteristics of this order are Avell marked at first, though in the progress of the disease they may so change that they will approximate some of the others. They always commence with redness of the skin, which is effaced for the moment by pressure, returning as soon as this is removed. Some of them, as erysipelas, rubeola and scarlatina, are attended 29 450 diseases of children. with marked constitutional disturbance, and in the last tAvo, as Ave have already seen, the cutaneous disease is associated with disease of the throat and respiratory apparatus, and in all three of the diseases named there is in some cases marked lesion of the blood. ERYTHEMA. Erythema is one of the mildest of the exanthemata, and usu- ally is not accompanied Avith febrile action, though in the severer cases there is arrest of secretion and some constitutional disturbance. It may be produced from mechanical irritation of the skin, but the most frequent causes are cold and arrest of cutaneous secretion, or gastric and intestinal derangements. Symptoms.—The disease appears in the form of patches of variable size, of a light, superficial red color, readily effaced by pressure, and most frequently on the face, chest and limbs. In some eases they spread so as to cover a considerable portion of the body, but this is not frequent. One form, termed erythema nodosum, is preceded by slight constitutional disturbance, and comes out in oval, red patches, from half an inch to an inch in diameter, most generally on the lower extremities. When more fully developed they are slightly elevated above the adjacent skin, and in a feAV days form small, red, painful tumors, which seem inclined to suppurate, and in severer cases give a suspicious sense of fluctuation, but at last disappear Avithout any change of structure. The first form may last but a few hours, or in rare cases it may continue tAvo or three Aveeks ; the second usu- sually continues for from three to six days. Before the eruption makes its appearance the child is some- times quite sick, and the febrile action is marked, and if there is a sudden retrocession, Ave sometimes find the child restless and uneasy, with nausea, pain in the head, and frequent pulse. Treatment.—Usually Ave put the patient upon the use of small doses of Aconite, with Belladonna if the eruption is not out freely; Rhus if there is frontal pain, starting? in sleep and red papillae on tip of tongue; Apis if there is itchino- of the sur- face ; Gelseminum if the face is flushed and the patient restless • Apocynum if the eyelids are SAvollen. The surface should be bathed with a Aveek solution of carbon- ate of potash, (alkaline bath,) and in some eases Ave Avould use the ROSEOLA. 451 warm foot-bath. In the second form of the disease, I have usu- ally prescribed a gentle laxative, Avith a solution of acetate of potash, and very small doses of Aconite. The use of the alkaline bath gives great relief, and it may sometimes be repeated several times a day. In some rare cases there seems to be a tendency to excoriation, and in such cases I would advise a lotion of—by Glycerine, Sj , Chlorate of Potash gr. xx., rose water Sij.; mix. Or the part may be dusted with poAvdered subnitrate of bismuth. roseola. Roseola, or rose rash, is a mild exanthematous eruption, con- tinuing from one to six or seven days, and attended by more or less febrile action. The causes are obscure, though arrest of secretion and gastro-intestinal irritation, are the most frequent. It sometimes occurs as an epidemic, especially in Avarm seasons, and sporadically, from over-heating the body, severe exercise, etc Four varieties have been distinguished : R. infantilis, R. aestiva, R. autumnalis, and R. annulata. Symptoms.—Roseola infantilis, as its name indicates, is usually met Avith in young children, and arises form gastro intestinal irritation, or from dentition. It comes out in the form of deep rosy-red patches about one-fourth of an inch in diameter, and circular in form. When severe, they are very much croAvded together so as to give a general red appearance to the surface, but yet each one is Avell defined. They may continue for several days, or Aranish and reappear for several days. Usually the fever is but slight, but the child sho\Ars symptoms of irritation, being cross and fretful. Roseola ozstiva is usually ushered in by marked febrile action, and in children delirium or convulsions sometimes supervene. The eruption usually appears about the third or fourth day on the face and neck, anemphigus being flat. Ecthyma resembles it most in some cases, and it will be difficult to distinguish betAveen them in its later stages, but the hard and inflamed base, irregular scabs, and superficial excoria- tions, are usually sufficiently diagnostic. Treatment.—The treatment in this disease, as in the pre- ceding, should be strictly tonic, arrest of the skin disease depend- ing to a great extent upon the restoration of the general health. I have obtained the best results from the administration of Fowler's Solution of Arsenic with Phytolacca as heretofore named. Cases will be found requiring Rhus, Apis, Corvdalis and Alnus, and either of these may be associated or alternated with Arsenic. When the tongue is pallid and dirty, Sulphite of Soda may be given in the usual doses, and continued for some Aveeks. Occasionally Sulphurous Acid will be indicated. In rare cases Donovan's Solution of Arsenic Avill prove better than Fowler's. If there is much derangement of the stomach, Ave frequently derive benefit from an emetic, and in many cases excretion needs to be stimulated with small doses of the alkaline diuretics. Associated with these means, the patient should have a daily bath of salt and water, or in some cases of a decoction of Cornus or Hydrastis. The diet should be nutritious, and exercise should be taken in the open air. When the local affection is very persistent, we may dress the ulcer with three parts of glycerine, and one of tincture of muri- ate of iron; or with the mild zinc ointment, black salve or an ointment made of the inner bark of the elder. Sometimes a de- coction of equal parts of Cornus, Alnus and Rumex, answers an ecthyma. 469 excellent purpose, or the tinctures of the same agents may be used. Salicylic Acid with Borax (5j. of each to water Oj.) is a good dressing; or Thymol grs. ij, to grs. iv., to Avater Sj., may be employed with good results. Wheu the ulcers are very per- sistent, they may be cauterized with a saturated solution of chloride of zinc, or a paste made Avith this and Hydrastis; and after the slough is cast off, the part usually heals kindly with any simple dressing. ORDER IV.-PUSTUL.E. This order is distinguished by the formation of small eleva- tions containing pus, and hence termed pustule They are almost invariably situated on an inflamed base, which usually precedes the eruption, though in some cases the inflammation comes on after the appearance of the eruption, and is more or less diffused. The diseases included under this order are both acute and chronic, tAvo of them, variola and vaccinia, heretofore described, being eminently contagious, and one, porrigo, being propagated by contact: The others seem to depend upon some unknown internal cause. ecthyma. Ecthyma may be divided into the two forms, acute and chronic, the first occurring most frequently in children and young persons, the second in the adult, though sometimes in children. Symptoms.—In the acute form, it is usually preceded by lassi- tude and indisposition, and its appearance is frequently marked with slight chills and febrile action, tt makes its appearance in the shape of red, circumscribed, inflamed spots, Avhich soon suppurate at their apices. In some cases the eruption is attended with pain, the inflammation being quite severe, but in others it is simply a sense of stiffness. Some of the pustules terminate by resolution, Avhile others are succeeded by a thick, adherent scab, Avhich, in falling off, leaves a deep-red mark, and in some cases a cicatrix. It usually lasts for one or tAvo Aveeks. In chronic ecthyma there is a successive appearance of the eruption, sometimes for months, the general health being much depressed. It may present the same character as that just de- scribed, or it may become confluent in large suppurating stir- 470 DISEASES OF CHILDREN. faces. A variety termed ecthyma caebecticum, occurs in old persons, and those Avho have broken their systems doAvn byr in- temperance. "The skin is inflamed and more SAvollen than in the common forms of the disease. It assumes a deepened color, and in about six or eight days the cuticle is raised over the pus- tules, is blackish and infiltrated with blood. It soon bursts and forms a thick, dark scab, raised at the center; the edges are hard, callous, and more or less inflamed. The scabs are very adherent and do not become detached for several Aveeks, some- times for months. If they fall accidentally, an unhealthy ulcer- ation ensues, and the scab is Avith difficulty removed. Some- times febrile symptoms precede or accompany the eruption, but they generally disappear with the disease."—(Cazenave.) • Diagnosis.—Ecthyma is usually recognized with ease by the hard and inflamed base, suppuration commencing on the surface, and not deep as in furunculi, acne, and sycosis, Avhich are most frequently mistaken for it, but in these the base is hard, not in- flamed, and the pustules are small and slowly developed. Treatment.—In the acute form of the disease Ave give the special sedative, Aconite or Veratrum, using the warm bath with glycerine soap. In some cases Rhus will be indicated, in others Apis, and in still others Phytolacca. If the tongue is broad and pallid, sulphite of soda will be found an admirable remedy, and Avill sometimes effect a speedy cure. If the tongue is red, with brownish coat doAvn the center, sulphurous acid Avill be given. In the chronic form of the disease, the patient may have Foav- ler's Solution, with Phytolacca, or cod-liver oil ; or, if congenital syphilis is suspected, Donovan's Solution, or iodide of potassium is indicated. In some cases the old combination of aa. Alnus, Rumex, and Quercus, in infusion, may be given internally, and used as a local application. If the eruption is very perverse, a local application of brown citrine ointment one part, with cod oil or simple cerate two or three parts, may be used. It needs to be used with care, but it is very certain in its action. In some eases a dry dressing is preferable, and the part is dusted Avith subnitrate of bismuth. diseases of the skin. 471 PORRIGO. Porrigo, or tinea, is a disease of the scalp, and is generally known by the name of scald-head. It is undoubtedly contain- ous, and is propagated from one to another byr contact; hence Jhe necessity for care in the use of articles of clothing, combs, baushes, toAvels, etc. Two varieties are distinguished : P. favosa, or tinea capitis, and P. scutulata, or tinea annularis. Porrigo favosa commences Avith an eruption of minute, round, yelloAv pustules, which seem to be imbedded in the skin. At first they are distinct, and situated on a hard base, but as the disease progresses they become confluent, the entire scalp being inflamed or indurated. In a short time after their formation, the yellowish fluid begins to concrete, and Avhen they are distinct forms a scab Avith a marked depression in the center, but Avhen close together they form one large scab. If this is allowed to remain, it becomes thick, whitish, and brittle; if removed, slight erosions are seen under it, and it is not re-formed, except by the appearance of a ucav crop of pustules. " This affection is never accompanied with febrile symptoms, but a troublesome and annoying itching is often present during its progress, which is aggravated by want of cleanliness. A number of lice are often, seen under the scabs, causing the pa- tients to scratch themselves, and by this means* increase the in- flammation. In these cases there is a strong, disagreeable odor, similar to that of cat's urine, given off from the head. After the head is cleansed from the scabs the odor becomes sickening. The excoriations on the surface, Avhich often reach to the hair- bulbs, and thus produce baldness, are not covered with the reg- ular cup-shaped favus pustules, but a reddish and fetid sanies oozes out, Avhich concretes into irregular-shaped scabs. Fresh pustules, however, soon appear, which give rise to fresh favus scabs. Small subcutaneous abscesses may sometimes appear, accompanied with sympathetic engorgement of the lymphatic glands of the neck. It has been remarked that the gnnvth of those persons avIio have been affected with porrigo is often ar- rested, and the development of the mental as Avell as the physi- cal powers is slow and imperfect. The duration of the disease is very variable and uncertain ; and the hair, Avhen reproduced, is rarely the same as the original either in color or consistence." (Cazenave.) 472 DISEASES OF CHILDREN. Porrigo scutulata commences with the appearance of red cir- cular patches, upon which small yellow pustules are soon devel- oped. Each pustule has a hair passing through it, and has the same cupped appearance as in the preceding variety ; and they appear more frequently upon the circumference of the spot than at its center. The scabs increase in thickness for some time, and when removed a large furfiiraceous patch with an uneven surface is left, from which the hair frequently falls off. It spreads by spontaneous development, or by inoculation of other parts by scratching; marked and sometimes intense itching attending the eruption. Like the preceding affection, its duration is variable, but if allowed to run its course it would probably continue for years, resulting in permanent baldness. Diagnosis.—The presence of the small, rounded, yellow pus- tule, depressed in its center, is the diagnostic feature of both forms. Porrigo scutulata is determined by the appearance of the eruption in circular patches, though when these are numer- ous, they are so crowded together as to cover the entire surface, and the distinction then betAveen this and porrigo favosa can not be made out. Treatment.—Cleanliness is of great; importance in this affec- tion, and to secure it avc would have the hair cut close, and the head frequently washed with eastile soap and water. It may be necessary at first to soften the incrustations by continuous emollient applications, or in some cases with poultices, usino- soap and Avater freely in the meantime. Having thus exposed the scalp Ave Avould apply—fy Oxalic Acid, grs. x. to grs. xx., Creosote gr. x., water Sij.; M., and follow it in half an hour with free inunction of mild zinc ointment. The ointment of iodide of sulphur is a very efficient remedy, and should when used be gently rubbed over the parts night and morning, the scalp being kept perfectly clean by the use of soap and water. A nicer application and a more effectual one will be found in broAvn citrine ointment one part, simple cerate two parts. The head may be thoroughly cleansed Avith a solution of salicylic acid and borax (aa. 5j- to Avater Oj.,) and the ointment then carefully applied. As regards internal remedies, Ave will find it necessary to give the vegetable alteratives heretofore named, associated with some ' LICHEN. 473 preparation of potash, as the iodide, acetate, carbonate, etc. Sulphite of soda is an admirable remedy in some cases, and sul- phurous acid is occasionally indicated. Usually the bitter tonics and iron will be required to some extent, and occasionally cod- liver oil will prove beneficial. ORDER V.-PAPULJ1. This order is characterized by small, firm, solid elevations of the skin, ahvays attended with more or less itching, and never contain plis or serum, though occasionally from irritation these surfaces become ulcerated and covered with incrustations. They are developed Avithout any appreciable cause, are rarely attended with febrile symptoms, and are not contagious. They are most generally chronic, but sometimes acute. Tavo diseases are in eluded under this order—lichen and prurigo. LICHEN. Lichen appears as small, hard elevations, but slightly red, or of the color of the skin, and attended with severe pruritus. We may distinguish three forms : L. simplex, L. agrius, L. urticatus. Litchen simplext comes out in the form of small and aggregated papulae, being attended with severe itching, and sometimes burn- ing. It most frequently appears on the face and arms, and the neck and breast, though it may extend to all parts of the body. They remain stationary for three or four days ; Avhen the redness gradually declines, there is slight furfuraceous desquamation, and the disease terminates in seven or eight days, unless there is a new eruption. In many cases it continues for Aveeks or months by the appearance of successive crops of papulae. Litchen urticatus usually appears suddenly in the form of large and numerous papulae, attended with a burning, distressing pru- ritus. It appears most frequently on the face, neck, and ex- tremities, and is irregular and transitory, subsiding and reap- pearing with great rapidity. "The papulae are clustered, and they are either white or surrounded by a faint-red areola ; some- times thev are prominent, and considerably inflamed, and at first bear considerable resemblance to flea-bites." When scratched or otherAvise irritated, they frequently bleed, and dark scabs form on their surface. The eruption m&y disappear with one 474 diseases of children. crop of papulae, but it is occasionally very obstinate, lasting for months, by their success'iA'e reproduction. Lichen agrius may appear spontaneously, or it may succeed lichen simplex. When it appears spontaneously, the papulae are very small, red, accumulated, inflamed and developed on an erythematous surface of limited extent, which is generally attended with heat and painful tension. Instead of subsiding on the fourth or fifth day, they continue increasing; slight ulcera- tions form on their apices, whence issues a sero-purulent fluid, which concretes and forms yellowish, prominent crusts, soft and slightly adherent. These incrustations fall off', and are then re- placed by thin scaly scabs. Sometimes the redness diminishes, the inflammation disappears, slight desquamation ensues, and the disease terminates about the tAvelfth or fifteenth day. But frequently the discharge continues, and neAV crusts are formed, by Avhich the disease is prolonged considerably. The itching which accompanies it is often so intense that the patient seeks the hardest substances to rub himself with, and thus invariably aggravates the pruritus. It may continue in this manner for several Aveeks, or it may pass into the chronic state, Avhen the scaly incrustations disappear, and are succeeded by slight exfoli- ation, and the skin is often considerably hypertrophied. This form may last for months.—(Cazenave.) A peculiar form of disease has prevailed extensively in the Western country, for the last tAventy years, knoAvn as Illinois itch, soldiers' itch, etc., presenting many of the characteristics above named. Its symptoms seem so variable, that it is difficult to classify it, as it sometimes resembles eczema, and at others im- petigo, and in others, again, it presents to some extent the characteristics of all three. It appears most generally upon the wrists and hands first, and then extends to various parts of the body, and is remarkably persistent and annoying. Diagnosis.—The diagnosis of litchen is very difficult, as it may be mistaken for eczema, porrigo, scabies, or impetigo but it may usually be determined by the presence of some of the characteristic papulae. Treatment.—Lichen agrius is more difficult to manage and no remedy seems to answer in all cases. In some, I have had very good success Avith glycerine and tincture of muriate of iron PRURIGO. 475 in the proportion three parts of the first to one of the last, given internally in teaspoonful doses four times a day. A lotion of muriate of ammonia has been frequently employed, composed of—R Hydrochlorate of Ammonia Sj-, vinegar Siv., Avater Oj., and applied freely to the affected parts. In some cases the in- ternal administration of the compound tincture of Corydalis, with iodide of potassium, and a Avash of a decoction of equal parts of Cornus,'Alnus, and Rumex, has answered a good purpose. In other cases a lotion of—Ij* Glycerine Sij.; Oxide of Zinc, 5ss., Morphia grs. a-., Rose-Avater Siv., has ansAvered an excellent purpose, as has the ointment of elder and the mild zinc oint- ment. In other cases, good results Avill be obtained by the internal use of sulphur, and its local employment as a bath, Avash, or ointment. PRURIGO. Several varieties of this disease arc described, but many of them are named, not from any prominent difference of symptoms but more on account of their location. The disease is character- ized by the appearance of papulae, usually larger than those of lichen, and Avithout discoloration of the skin, which are attended by A*ery severe pruritus, and sometimes burning. Three varie- ties may be named, P. mitis, P. formicans, P. senilis. Prurigo mitis is the mildest form of the disease, and is usually acute. The papulie are slightly prominent, but very small, and accompanied with intense itching. In prurigo formicans the papulae arc much larger, and flattened, and distinct, and accom- panied with an intolerable pruritus, Avhich increases at night, and by the Avarmth of the bed. If not irritated by scratching, they frequently disappear in the course of one or two weeks, but frequently the skin is torn in the efforts for relief, and the part bleeds, and a dark thin scab is formed on its surface. It may continue for a considerable time by continued development of the eruption. In old people, or in Aveakly children, the papulte are frequently large and prominent, and- the skin becomes thickened and inflamed ; vesicles, pustules, and boils form, and beiiv opened by scratching give rise to unpleasant excoriations and superficial ulcers, and a most intense burning and itching. It may thus last i'»r months, or even years. Prurigo may attack any part of the body, but is most severe Avhen it attacks the "cnitial or»a:i-:, or is situatei". around the anus. 476 diseases of children. Diagnosis.—Prurigo may be distinguished from lichen by its larger papulae, and the dark incrustations Avhich are sometimes formed on them; from scabies by the accumulated vesicles of the latter, and their rose-colored base. It may be associated with lichen, scabies, eczema, impetigo and..ecthyma, and in such cases the diagnosis Avill of course be difficult. Treatmknt.—In the milder forms of the disease, the re- moval of any internal irritation, and soothing local applications, are all that is required. Frequently it is desirable to keep the bowels open Avith a saline purgative, and give an alkaline diure- tic, Avith some gentle diaphoretic. As a local application, the glycerine lotion Avill ansAver a very good purpose; or Ave may Use it with chloroform, adding ten or fifteen drops of it to each ounce of the lotion. A solution of borax ansAvers a very good purpose, as—T^ Borax 5ij-> Morphia gr. v., Rose-Avater Syj- A decoction of Hydrastis or Cornus, with borax and morphia, is frequently beneficial. N^EVUS MATEBNI. It is generally supposed, and I think Avith truth, that certain impressions made upon the mother's mind during pregnancy will affect the groAvth and structure of the child, and in some manner deform it. It is true that Ave can not account in a rational man- ner for any such occurrence, but the instances are so numerous that Ave can not dispute the connection betAveen the impression and the mark. Very frequently Ave find Avomen making anxious inquiry with regard to the matter, as they are strongly impressed that they haAre received some shock or sudden impression Avhich will mark or deform the child. As it is so rarely that nsevi result from * these impressions, AA'e are safe in giving such assurance to the prospective mother as Avill quiet her fears. Numerous instances are related to prove the relation between the impression on the mother's mind and the deformity of the child. The severest case of the kind that ever came under my observation Avas a child born Avith a hand so completely deformed as to be useless, and Avhich Avas attributed to the mother's Avit- nessing the dressing of a hand that had been crushed in a thresh- ing machine. In another case the child had a vascular naevus N.EA'US MATERNI. 477 on the cheek, immediately beloAV the eye. The mother attributed the mark to her husband's throwing a cherry at her, which, strik- ing upon the same part of the cheek, burst, and not only star- tled her at the time, but firmly impressed her mind that the child would be marked. The deformities and distortions, that are rarely met with, may frequently be remedied by the surgeon, as in talipes, hair-lip, cleft-palate, etc., but Ave Avill not attempt to describe them here. The most common form of mother's mark is a discoloration of the skin, from an increase in the size of the blood-vessels. It may be located upon any part, and usually increases in size as the child jji'oavs. In some cases it is so large at birth that it is useless to interfere, as Avhere it involves one-fourth, or sometimes one-half of the face. In other cases it is but the size of a five or ten cent piece, and frequently not larger than a grain of Avheat. There is much difference in the rapidity of groAvth. In some it is very sIoav, so that the spot will not have doubled in size to adult years; in others it groAVS rapidly, and will have doubled its size the first month. In the first operative interference is not so necessary, and maybe postponed; in the second the naevus should be removed as early as possible. The vascularity Agarics in different cases. In some it is a true anastomotic aneurism, occasionally distinctly pulsating. In these much care should be used to prevent hemorrhage in any opera- tion that may be undertaken. In others the disease is Avholly confined to the capillaries, and the operation outside of the spot Avill not cause greater hemor- rhage than for any other purpose. • The bright vivid coloration is met with in those cases Avhere the arterial capillaries are involved ; the purplish discoloration Avhere the veins are dilated. We rarely meet with a case upon the skin Avhere the growth is such as to form a red tumor, projecting from the skin. But when it is at the junction of the skin and mucous membrane, as on the lip, or wholly of the mucous membrane, as sometimes of the tongue or mouth, and occasionally about the reproductive organs, avc frequently find it assuming the form of an erectile tumor. Occasionally the structure gives Avay in such cases, and there is profuse hemorrhage. 478 DISEASES OF CHILDREN. Treatment.—A great many plans of treatment have been recommended for naevus. The most commonly adopted are by excision, strangulation by ligature, and removal with escharotics. Where the growth is not markedly vascular, the smaller capil- laries being alone involved, the best plan is to excise the growth. Where the tissues are loose, or when the groAvth is oblong or oval in form, the edges may be draAvn together with silver sutures, and union obtained without any scar. If the surgeon fears hemorrhage, he inserts his ligatures before operating. The needle is carried through the sound skin, and beneath the naevus, drawing the Avire through and clipping it at proper length. Enough are inserted in this Avay to insure an arrest of bleeding. Strangulation by ligature is performed by transfixing the base of the growth one or more times, and tying it in separate parts so tightly as to cut off the circulation. Probably nitric acid is the best caustic for the removal of naevi. Sir B. Brodic remarked : "Caustics may be used Avith advantage in congenital tumors, naevi, etc. Little vascular spots on child- ren's faces are an object of anxiety. If you look at these, you will see one large vessel and several branches supplying them. You may destroy them in the folloAving manner: Take a glass pen [a pine stick pointed ansAvers the same purpose] Avhich will hold n.itric acid, and apply it to the principal vessel, puncture it, and insert into the puncture a fine point of potassa fusa ; a mo- ment's touch Avill be sufficient to destroy the vessel; if the po- tassa extends further than you intended, apply vinegar. You may thirs obliterate the vessel Avithout leaving a scar. There are some congenital naevi abounding in the skin, formed by an intricate mesh of vessels; the skin is elevated and of a mulberry color. If these are of a large size, they must be destroyed by ligature or the knife; if of smaller size you may use caustics not unprofitable. The nitric acid is the best application; this makes a slouch, the blood coagulates and the parts become in- durated. This is only applied Avhen naevi are of small size. In subcutaneous naevi, which are not of the same color but purple caustics may be applied to effect their destruction, Avhether of a large or small size ; the great object is to destroy them with caustics rather than the ligature. These naevi have been cured by application of vaccine matter, which acts by producing a 51 njevus maternt. 479 slough. You may cure these subcutaneous ncevi upon the same principle; puncture them Avith a finely-pointed lancet, then having a probe armed with nitrate of silver, intrrduce it into the puncture—the caustic presently causes sloughii.g, and the vessels are obliterated." Lately the removal of naevi by the use of hypodermic injec- tions into the groAvth, has been strongly recommended. The solution of per-sulphate of iron has been employed in this Avay, and it is claimed Avith great success. One fatal case, however, has been reported, in Avhich the death Avas evidently due to the injection. When the nsevus is quite superficial, its removal may be at- tempted by the use of a strong tincture of iodine. A very good formula is—Ta) Tincture of Iodine (to saturation), Aqua Ammo- nia, aa. Sj. ; let it stand in a well-corked bottle for a Aveek, and it is ready for use. Apply this daily Avith a camel's-hair brush, and the nsevus Avill gradually yield. I NDE X. Action (f remedies....................... 21 Acids................................57, 104, 9G Acid, hydrochloric...................57, 96 sulphurous........................9", 101 nitric........ ..........................10p Acetate of potash........................ 84 Acetous tincture of Lobelia............ 71 Aconite............................42, 56, 62 iEther....................................... 3C Agrimonia.................................. 86 Ague........................................m Air.......................................55, 112 Alkaline salts.............................. 58 Aloes......................................... 84 Alteratives................................. 52 Albuminuria.............................3G3 Albugo .....................................435 Alstonia...... ............................. 107 Ammonium carb.......................... 39 bromide of............................ 31 Amygdalis................................. 73 Antierysipelatous .....................109 Anti_ riodies...............................105 Antirheumatics..........................102 Antiseptics..................................10C Antispasmodics........................... 26 Antizymotics............................... 95 Analysis of disease........... Anus, prolapse of............■ Appendages of the eyes..... Apis............................... Apocynum.............................'9, 103 Aphthae...................................294 Arsenic.................................95> 108 Ascaris.................................... Jl- Asafcetida......................;........... 40 21 338 427 Baths .................................. 51, 88 alkaline sponge..................52, 89 acid sponge.......................52, 89 coidpack...........................5!, 89 hot pack ...........................51, 90 hot foot................................ 90 hot sponge............................. 01 hot....................................... 91 inunction............................. 91 stimulant.............................. 53 tonic .................................. 53 Baptisia..................................57, 98 Belladonna.........................28, 85, 94 llenzoato i f lithia........................ 87 Bites and stings..........................240 Bryonia ......................30, 57, 63, 103 Bromide of ammonium................. 31 Bronchial catarrh........................270 Bronchitis, asthenic....................270 acute...................... ...........274 chronic................................278 Breast pump...............................124 Brain, dropsy of.........................395 inflammation of....................385 determination to.....................383 congestion of. ......................384 Ai Camphor............ ....................... 30 Care after birth..........................119 94 111 ' Catarrh, bronchial........................270 Care of the teeth..........................255 Cancrum oris.....-........................298 Caruneulalachrymalis..................430 Carbolic acid.............................. 101 Calculi.....................................372 I Cathartics.................................... 72 ,......178 Asthenic bronchitis.....................270' Cerebro-spinal meningitis. (481) 482 INDEX. Chloroform................................ 3(1 Chamomilla............................75, 115 Chronic catarrh...........................240 bronchitis.............................lit hydrocephalus.-.....................395 pharyngitis...........................2C5 nephritis..............................36; Chloral hydrate........................... 38 Chlorate of potash..................98, 11C Chloride of lead...........................102 lime...»................................101 Cholera infantum........................322 Chlorinated soda........................ 10] Chorea.......................................415 Chionanthus............................... 70 Ciielidonium.............................. 77 Chafing.......................................123 Circulation, derangements of......... 41 remedies influencing............... 41 Cinchonidia................................107 Cla- sification of remedies.............. 25 of disease...............................140 of fevers..............................142 Clothing the child........................120 Compound powder of rhubarb....... 74 Cod-liver oil.............................. 60 Constituents of milk.....................120 Congestive fever...........................12;; Continued fever ..........................127 Coryza......................................245 Colic.........................................317 Constipation..........................v....336 Congestion of the liver..................346 of the brain..........................384 Convulsions.................•..............410 Conjunctivitis............................432 Cornea, opacity of........................435 Cold pack.................................. 51 Colocynth................................. 75 Consumption.............................. 285 Cow-pox.....................................201 Cough........................................243 i Croup, mucous.............................257 pseudo-membranous...............261 spasmodic.........................'.....266 Cuprum.....................................117 Curvature of spine.......................400 D Digestive apparatus..................... 20 diseases of.............. ..............289 remedies for........................... 69 dentition...................................292 derangements of.....................289 Determination to the brain ...........383 Deafness...................................444 Direct medication........................ 21 Diaphoretics............................... 87 Diuretics.................................. 82 Digitalis............................... ..... 46 Diphtheria..................................183 Difficulties in nursing the child......124 Dioscorea.................................... 78 Discovery of vaccination...............202 Diarrhoea..................................319 Diabetes........ ..........................365 Diseases of the liver.....................346 nervous system......................382 eyes.....................................424 appendages of the eyes............427 ears......................................436 skin....................................448 Dysentery...................................333 Dyscrasias..................................232 Ear, foreign bodies in..................438 inflammation of.....................439 Earache......................................438 Ear, examination of......................437 Eczema.............................,.........458 Ecthyma.... ................................469 Emetics........................................ 70 Epilepsy.....................................405 Enuresis......................................370 Enteritis....................................320 Eryngium................................... 85 Ergot......................................... 35 Erythema....................................45 q Erysipelas.................................455 Eruptive fevers...........................190 Eupatorium....................45( 64j 85j 93 Euphorbia........................;......66j 75 Excretory apparatus......................... Exercise................................55f 112 Exanthemata..............................449 W Febrile diseases...........................l40 Fever, pathology of.................... j4i classification of...................... ^42 intermittent........................144 masked. .149 remittent.................... ........i4g INDEX. 483 Fever, sIoav infantile.....................156 congestive...........................160 continued..............................164 typhoid.................................167 spotted...............................172 eruptive...............................190 Febricula...................................142 Ferro-cyanide of potassium........... 40 Fistula lachrymalis.....................429 Form of remedies......................... 22 Food.......................................... 54 rules forgiving..................... 114 Liebig's..............................125 for the child........................124 Foreign bodies in the ear...............438 Furuncle....................................427 G- Gastrodynia.................................307 Gastric irritation......................... 308 Gastrit's..................................310- Gastric intermittent......................146 Gangrenous stomatitis...................298 Gelseminum........................27, 44, 85 Grindelia.................................... 68 Government, moral......................132 Gums, lancing..............................290 H Hamamelis............................48, 175 Hernia.......................................356 Herpes.......................................461 Hives..................... ....................453 Hot pack.................................... 51 Hot foot-bath............................... 90 Hot bath................................... 91 How to wean the child..................128 Hydrastis.................................... 78 Hydrochloric acid.................. ..... 96 Hypophosphites............................ 69 Hydrangea................................ 86 Hydrocele................................. 378 Hydrocephalus, acute....................391 Icterus neonatorum......................352 Imperforate urethra....................375 Intermittent fever........................144 nervous.................................145 gastric..................................146 inflammatory........................146 masked.................................149 Inoculation.................................201 Infantile syphilus.......................234 dyspepsia.............................312 Intestinal worms........................340 Infantile leucorrhcea....................3 7'.) Inflammation of the lungs....... .....23.> Infantile therapeutics.................... 17 Irritation, avoidance of. ................ 18 Ipecacuanha........................63, 71, 74 Iron..................................110, 110 Iris............................................ 8 1 Iron, sulphate of....... .................101 Ischuria......................................367 Itch..........................................463 Illinois..................................474 .T Jaundice........ ..........................350 Jenner Dr................................. 202 Kidneys inflammation of..............358 L Lachrymal apparatus....................428 sac, inflammation....................428 puncta.................................428 Lancing the gums........................290 Lesions of bloodmaldng................ Leptandra ................................ 80 Leucoma.....................................435 Leucorrhcea infantile....................37!) Lichen.................. ....................473 Light.........................................112 Life line..!.................................137 Lime.........................................118 Liebig's food..............................125 Liver, diseases of........................ 346 congestion of.........................346 strumous diseases of...............348 Lithotrily..................................375 Lithotomy...................................375 Local applications to loins............368 Lobelia.....................32, 46, 63, 71, 74 Lumbricoid worms......................342 Lycopus.................................46, 65 Lymph vaccine...........................254 M Macrotys....................................103 Manganese sulph....................... 80 Malignant measles........................209 scarlet fever..........................214 484 INDEX. Malignant sore throat...................302 Malt.......................................... 80 Medication direct............ ............ 21 Medicines, classification of............ 25 Mental impressions......................133 Mentha viridis...... ..................... 83 Medicines Avhich influence the ner- vous system........................... 18 Medicines afterbirth...................123 Medicine, dose of........................ 24 Measles.....................................20-1 sequela;................................210 Meningitis.................................397 Milk..........................................126 Milaria.......................................458 Milk scall....................................458 Moral government....................... 132 Muco-enteritis ............,............. 320 Mumps......................................223 7NT Narcotics................................. 38 N a> v us ma tern i............................4 76 Nepeta cataria............................. 93 Nervous system...........................382 Nephritis, acute..........................3;8 Nettle-rash ...............................453 chronic............. ...................3G1 Nervous system, disease of........... 382 Nebula.......................................435 Nitric acid................................. 62 Nipple shields............................124 Nitre, spirits of............................ 47 Night terrors .............................421 Nurse, Avet...................................127 NTux vomica......................33, 61, 76 Nursing, difficulties in..................126 bottles................................126 Nursery limp.............................12t> O Objections to weaning................. 129 Obstruction of the puncta..............428 Oedema glottidis.............. ...........268 (Enothora...............................'.. 40 Oil, cod-liver.............................. 60 One thing at a time..................... 22 Onanism...................................380 Opium...................................... 38 Ophthalmia neonatorum...............425 Ophthalmia tarsi...............-.........430 Opacity of the cornea....................435 Otitis ................................:.......439 Otorrhea.............. .......... .........442 Oxide of zinc............................... 81 Paraphymosis..............................377 Paralysis....................................42 2 Papula?....................................473 Pathology................................13-1 Parotitis.............................. .....223 Permanganate of potash...............102 Percussion..................................244 Peritonitis..................................354 Pemphigus..................................466 Pepsin........................................ 81 Pertussis.................................221 Phosphate of soda........................ 72 Phosphorus...................39, 59, 67, 116 Phytolocca........................64. 99, 104 Phisiological marriage..................135 Physical diagnosis........................242 Phthisis....................................285 Phymosis................................T.377 Phrenitis..............................^...385 Pharyngitis.................................250 Pleasant remedies.................j..... 24 Pneumonia.................................280 Podophyllin ...........................48 77 Potash, acetate of............ .....*...... 84 permanganate of...................102 chlorate of....................+..... gg Porrigo..............................4~ ......471 Poisonous bites................f,........240 Preservation of lymph ^..jf............207 Prurigo....................5*.............475 Prolapsus ani.............................333 Pseudo-membranous croup ..... .....261 Ptosis .......................................427 Pulsatilla................................ 30 Pulse.........................................139 Q Quinia.......................34, 60, 106, 115 Qu'in*y.......................................253 R Remedies, form of. 22 pleasant......................... 2„ Restoratives....................... Rest.................. Respiration........,.................13 ...111 ... 18 7, 140 INDEX. 485 Respiratory apparatus, remedies for 62 Rest necessary............................ 18 Reasons for weaning.....................128 Regular habits.............................131 Remittent fever...........................149 with diseases of the brain........151 with diseases of the lungs........152 slow..................................156 Respiratory apparatus, diseases of...242 Retention of the urine................. 367 Rumex....................................... 68 Rhubarb................................... 73 Rhus Tox..............29, 45, 57, 94, 111 Rhus Aroma. .............................. 8G Rheum ..................................... 73 Roseola..'...................................451 infantilis,..............................451 aestiva................................451 annulata.............................452 Rubeola...,.................................207 maligna........................•......209 sequelae of......... ...................210 Rupia.......................................467 swplex..............................467 prominens..........................467 escharotica............................468 « Santonine............................. 81, 84 Salieyli| acid.........................61, 103 Salicin.J;.................................... 62 Sanginawia.............. .................. 05 nitrfce of.............................. 66 Scillffl....lL................................ 67 Scarlatina.\^.........................212 simplex-.^B^........................213 anginosa .„/!.................... ...213 maligna...............................214 sequelae.............................. ..216 scald head...........................471 Scrofula...................................225 Scabies.....................................463 Sedatives................................... 83 action of............................. 83 Senega....................................... 94 Second dentition........................294 Serpentaria................................. 93 Silica.........................................117 Skin, remedies for.........................87 diseases of............................448 Sleeping.....................................130 Slow infantile remittent.............156 Small-pox...................................192 Soda........................ .................118 Sore throat..................................300 malignant.............................302 chronic................................305 Spotted fever..............................172 Spurious vaccination....................205 Sputa........................................244 Spasmodic croup..........................266 Spinal meningitis........................397 St. Vitus' Dance.........................415 Spine, curvature of.......................4C0 Sticta...................................07, 104 Stimulants................................488 Stillingia.................................... 65 Stings.......................................240 Stomatitis simplex.......................293 ulcerata................................297 gangrenous...........................298 Strumous liver.............................348 Sulphur.................................94, 116 Sulphite of soda.....................98, 111 Sweet spirits of nitre................... 47 Syphilis from vaccination..............206 Syphilis, infantile........................234 X Tabes mesenterica....................... 330 Tamia........................................342 Test for milk.............................125 Tetter.........................................459 Temperature................................137 Teeth, care of..............................291 Tinctures preferred...................... 23 Tincture of iron...........................110 Thymol......................................100 Tonics ....................... ..............115 Tonsillitis....................................253 Trismus nascentium.....................420 Trichiasis..................:.................428 Typhoid fever............................167 U Ulceration of the umbilicus..........122 Ulcerated sore mouth....................297 Umbilical hernia.......................257 Urethritis.................... .............377 Urine, suppression of...................367 retention of..........................368 Urinary calculi...........................377 Urethra, imperforate...................375 486 INDEX. Urinary apparatus, diseases of.......358 remedies for........................... 82 Urticaria...................................453 Urine, incontinence of..................370 Uvedalia...................................109 Variola.......................................192 Varioloid....................................200 Vaccine disease.........................201 Vaccination................................203 Vaccine, discovery of...................202 vesicle.................................204 Vaccination, spurious............ 204, 205 syphilis from.........................206 Vesiculae.....................................458 Veratrum....................43, 56, 63, 111 Viability...................................137 W Warm water............................... 92 Warm drinks ............................ 92 Washing the child.................... ...119 how often..............................121 Wet-sheet pack.......................... 51 Weaning the child .....................128 reasons for..........................128 objections to..........................129 how to.................................129 Wet-nurse........*..........................127 Whooping cough..........................221 Worms, intestinal.......................340 long round...........................342 thread..................................342 tape......................................342 * Z Zinc oxide................................... 81 Zymosis.......................................85 *t>d 5 i960 Ct v .;/l ■■/,••:;:>.Jin , -■■:{:.;. iv:-^ • : ■' ■ V; ^r« it* ..,,■■' j \'.,-' \-;v\>ih «' ,-.::iWii - i'i'i:::^'!! 1 ' f ■ ■;:s;::i;?^;i:wii .-r:; ::j|p!| i j! ■'mmmM ' «=¥* Mil! 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